ROADBLOCK II answers.
The answer guide for Roadblock II is below. Comments/questions as per usual via the VSG please.
Question 1.
i. (5 marks)
Other than the vital signs, give five (5) signs of pneumothorax that you will assess this patient for on clinical examination.
ii. (3 marks)
The patient’s chest xray is shown on page 2 of the supplementary exam information booklet.
What is the major finding?
iii. (12 marks)
Give 4 options for managing this patient’s pneumothorax in the ED, and an advantage and disadvantage for each.
Other than the vital signs, give five (5) signs of pneumothorax that you will assess this patient for on clinical examination.
- Decreased breath sounds
- Increased resonance
- Decreased fremitus
- Decreased expansion
- Hyper-resonant percussion note
- Signs of tension: tracheal deviation
ii. (3 marks)
The patient’s chest xray is shown on page 2 of the supplementary exam information booklet.
What is the major finding?
- Right pneumothorax (1 mark)
- A reasonable comment RE size – discontinuous with apex and lateral chest wall but maintains continuity with diaphragm (2 marks)
iii. (12 marks)
Give 4 options for managing this patient’s pneumothorax in the ED, and an advantage and disadvantage for each.
|
OPTION
1. Conservative Mx 2. Needle aspiration 3. Pigtail catheter 4. Tube Thoracotomy |
PRO
Non invasive, allows discharge home No indwelling chest catheter, 75% success rate Less invasive than traditional tube thoracostomy, allows pt to be mobile/dioscharged with Heimlich valve Not compromised if bleeding occurs Can use for pleurodesis Traditional "gold standard" |
CON
Slow resolution, not supported by guidelines May fail and create need for ICC ay obstruct if bleeding occurs. Does not allow secondary therapy Very invasive compared to other therapies |
Question 2.
Give 7 pieces of information you will seek from the notifier.
M – whether a major incident has been declared
E – the exact location
T – the type or nature of the event
H – the hazards present
A – the access available to the site
N – the number of casualties involved
E – what emergency services are involved
ii. (2 marks)
In the context of disaster medicine, define a major incident.
Must include:
An event where the care needs of patients are likely to exceed the available medical resources.
iii. (6 marks)
Give three priorities you now have, and state your action(s) to enact them.
Must include any reasonable from the following:
Activate the hospital disaster response: notify the on call executive member to activate
Create capacity in the ED: expedite any discharges, move admissions to the ward
Prepare equipment: open disaster packs/mass triage tools
Secure the department: contact security and media liason
Brief staff and assume command: as per the incident plan, assign teams and areas
M – whether a major incident has been declared
E – the exact location
T – the type or nature of the event
H – the hazards present
A – the access available to the site
N – the number of casualties involved
E – what emergency services are involved
ii. (2 marks)
In the context of disaster medicine, define a major incident.
Must include:
An event where the care needs of patients are likely to exceed the available medical resources.
iii. (6 marks)
Give three priorities you now have, and state your action(s) to enact them.
Must include any reasonable from the following:
Activate the hospital disaster response: notify the on call executive member to activate
Create capacity in the ED: expedite any discharges, move admissions to the ward
Prepare equipment: open disaster packs/mass triage tools
Secure the department: contact security and media liason
Brief staff and assume command: as per the incident plan, assign teams and areas
Question 3.
i. (3 marks)
The patient’s ECG on arrival is shown on page 3 of the supplementary information booklet.
Give 3 abnormalities seen.
Wide QRS
1ST degree HB
R’ wave in AVR
Note, the QT is not prolonged
ii. (6 marks)
The patient has a blood gas in resus and the results are shown on page 4 of the supplementary information booklet. Give three acid base disturbances present and indicate if they are primary or secondary.
Primary respiratory acidosis
Primary metabolic acidosis
Isolated RAGMA as confirmed by AG 20 and DR 1.
iii. (3 marks)
List 3 classes of drugs which may cause similar derangements to this on an ECG.
Note, this is a list of drugs which cause sodium channel blockade, not QRS prolongation!
Must include TCAs
Others from:
Class 1A or !C antiarrythmics
Antimalarials
Propranolol
Carbemazepine
Quinine
The patient’s ECG on arrival is shown on page 3 of the supplementary information booklet.
Give 3 abnormalities seen.
Wide QRS
1ST degree HB
R’ wave in AVR
Note, the QT is not prolonged
ii. (6 marks)
The patient has a blood gas in resus and the results are shown on page 4 of the supplementary information booklet. Give three acid base disturbances present and indicate if they are primary or secondary.
Primary respiratory acidosis
Primary metabolic acidosis
Isolated RAGMA as confirmed by AG 20 and DR 1.
iii. (3 marks)
List 3 classes of drugs which may cause similar derangements to this on an ECG.
Note, this is a list of drugs which cause sodium channel blockade, not QRS prolongation!
Must include TCAs
Others from:
Class 1A or !C antiarrythmics
Antimalarials
Propranolol
Carbemazepine
Quinine
question 4.
i. (14 marks)
Describe your management.
i) What is considered a lethal dose of propranolol?
>1g
(ii) List 5 potential clinical features of this overdose
Bradycardia, hypotension, AV nodal Block, hyperkalaemia, Coma, Seizures, hyper/hypo glycaemia
(ii) In the course of your management, the patient develops a ventricular arrhythmia
(a) List 3 potential treatments
Na bicarb IV 100mEq
Hyperventilation if intubated
Lignocaine
(b) List 2 drugs that must be avoided
amiodarone
Class Ia-procainamide
Class Ic Flecainide
will also accept phenytoin for seizures
(iv) The patient’s blood pressure remains low. What would you use to correct this- give 5 alternatives:
crystalloid
adrenaline
isoprenaline
atropine
high dose insulin
Describe your management.
i) What is considered a lethal dose of propranolol?
>1g
(ii) List 5 potential clinical features of this overdose
Bradycardia, hypotension, AV nodal Block, hyperkalaemia, Coma, Seizures, hyper/hypo glycaemia
(ii) In the course of your management, the patient develops a ventricular arrhythmia
(a) List 3 potential treatments
Na bicarb IV 100mEq
Hyperventilation if intubated
Lignocaine
(b) List 2 drugs that must be avoided
amiodarone
Class Ia-procainamide
Class Ic Flecainide
will also accept phenytoin for seizures
(iv) The patient’s blood pressure remains low. What would you use to correct this- give 5 alternatives:
crystalloid
adrenaline
isoprenaline
atropine
high dose insulin
Question 5.
i. (5 marks)
Describe the photo and give 3 differentials.
Must include swollen and erythematous knee
Include differential of septic arthritis
Plus any 2 of gout, pseudogout, reactive arthritis, osteoarthritis, haemarthrosis
ii. (5 marks)
Describe your procedure for aspirating this joint.
Reasonable description of procedure including:
Note, ultrasound guidance is acceptable replacement of patella as landmark
iii. (6 marks)
(a)What is the diagnosis?
Must include: septic arthritis
(b) give 3 management steps you will enact
must include:
administration of appropriate Abx
urgent orthopaedic consultation
analgesia of some form with appropriate details (e.g. morphine 0.1mg/kg titrated)
Describe the photo and give 3 differentials.
Must include swollen and erythematous knee
Include differential of septic arthritis
Plus any 2 of gout, pseudogout, reactive arthritis, osteoarthritis, haemarthrosis
ii. (5 marks)
Describe your procedure for aspirating this joint.
Reasonable description of procedure including:
- Consent
- Aseptic technique
- Infiltration under medial or lateral border of patella
- Needle inserted and aspirated until fluid flashback
- Some form of analgesia – local or nitrous
Note, ultrasound guidance is acceptable replacement of patella as landmark
iii. (6 marks)
(a)What is the diagnosis?
Must include: septic arthritis
(b) give 3 management steps you will enact
must include:
administration of appropriate Abx
urgent orthopaedic consultation
analgesia of some form with appropriate details (e.g. morphine 0.1mg/kg titrated)
Question 6.
i. (9 marks)
Give 3 induction agents (or combinations of agents you would consider using in this child and specify an advantage and disadvantage of each.
Give 3 induction agents (or combinations of agents you would consider using in this child and specify an advantage and disadvantage of each.
|
AGENT
1. Ketamine 1.5mg/kg 2. Propofol 0.5-1mg/kg 3. Thiopentone 3mg/kg 4. Fentanyl and midazolam |
PRO
Maintains BP and respiratory function No effect on ICP, antiemetic, readily available No effect on ICP Neuroprotective Cardiac stable |
CON
Emergence phenomenon Note Increase in ICP is NOT an acceptable disadvantage, as this is dogma that is not currently valid Risk of allergy (eggs/soybeans) May induce hypotension May induce hypotension and promote secondary ischaemic injury 2 drugs: more complex induction |
ii. (3 marks)
Give three anatomic differences compared to an adult that you will need to consider when intubating this child.
Any of:
iii. (7 marks)
List and describe the equipment you will require for this intubation.
Must include:
Appropriate laryngoscope – straight/curved blade 2.0
ETT appropriately sized – 5 (cuffed or uncuffed)
Suction
BVM
LMA 2 and guedels
Bougie/stylet
Monitoring: ETCO2 and sats probe
Give three anatomic differences compared to an adult that you will need to consider when intubating this child.
Any of:
- small mandible
- large head (neck already flexed)
- tongue large
- larynx high
- funnelled shaped with anterior angulation
- epiglottis long and stiff
- vocal cords angled
- narrowest portion = circoid cartilage
- small diameter of airways -> higher resistance to air flow.
- highly compliant -> kink
- trachea short & in line with right bronchus.
- increased chance of airway blockage
iii. (7 marks)
List and describe the equipment you will require for this intubation.
Must include:
Appropriate laryngoscope – straight/curved blade 2.0
ETT appropriately sized – 5 (cuffed or uncuffed)
Suction
BVM
LMA 2 and guedels
Bougie/stylet
Monitoring: ETCO2 and sats probe
question 7.
The patient is taken to CT scan and the image is shown on page 7 of the supplementary information booklet.
i. (4 marks)
Describe the image findings and 2 implications
Must include:
Implies
ii. (10 marks)
Social work brings the patient’s mother in from the waiting room where she has just arrived. She has a black eye.
(a)List 3 immediate concerns
Must include
(b)List 3 important elements in the history you need to obtain from mother
How did mother get black eye?
Abuse by non- coping parent of child? Or abuse by father of both mother and child.
Other children involved
Is there a safe place for the family?
(c)Assuming your concerns are verified outline the actions you will take to manage this case:
1.Manage injured child – intubation, hypoerosmolar therapy, expedite transfer to NSx OT
2.Manage mother/other children – s/work
3.Medico-legal reporting requirements: mandatory child safety notification, clear documentation of all injuries and events
i. (4 marks)
Describe the image findings and 2 implications
Must include:
- large extradural haematoma
- midline shift or compression of the ventricles
Implies
- severe raised ICP/imminent coning
- this is a life threatening neurosurgical emergency
ii. (10 marks)
Social work brings the patient’s mother in from the waiting room where she has just arrived. She has a black eye.
(a)List 3 immediate concerns
Must include
- Urgent need for Nsx for patient
- Welfare of mother
- Welfare of other children (NAI must be mentioned somewhere)
(b)List 3 important elements in the history you need to obtain from mother
How did mother get black eye?
Abuse by non- coping parent of child? Or abuse by father of both mother and child.
Other children involved
Is there a safe place for the family?
(c)Assuming your concerns are verified outline the actions you will take to manage this case:
1.Manage injured child – intubation, hypoerosmolar therapy, expedite transfer to NSx OT
2.Manage mother/other children – s/work
3.Medico-legal reporting requirements: mandatory child safety notification, clear documentation of all injuries and events
Question 8.
i. (6 marks)
What symptoms would suggest acute decompression illness?
Any from:
ii. (5 marks)
A provisional diagnosis of acute decompression illness is made. The nearest decompression chamber is 450km away. Outline your preparations for retrieval.
Must include:
iii. (15 marks)
A provisional diagnosis of acute decompression illness is made. The nearest decompression chamber is 450km away.
Give three options for transporting this patient and 2 pros and 2 cons for each
What symptoms would suggest acute decompression illness?
Any from:
- General symptoms of profound fatigue or heaviness, weakness, sweating, malaise, or anorexia
- Musculoskeletal symptoms of joint pain, tendonitis, crepitus, back pain, or heaviness of extremities
- Mental-status symptoms of confusion, unconsciousness, changes in personality
- Eye and ear symptoms of scotomata (negative then positive), diplopia, tunnel vision, blurring, extraocular motor paresis, tinnitus, or partial hearing loss
- Skin symptoms of pruritus or mottling
- Pulmonary symptoms of dyspnea, nonproductive cough, or hemoptysis
- Cardiac symptoms of inspiratory, substernal, or sharp or burning chest pain
- Gastrointestinal symptoms of girdle abdominal pain, fecal incontinence, nausea, or vomiting
- Genitourinary symptoms of urinary incontinence or urinary retention
- Neurologic symptoms of paresthesia (general or over a joint), paresis, paralysis, migrainous headache, vertigo, dysarthria, or ataxia
- Lymphatic symptoms of edema
ii. (5 marks)
A provisional diagnosis of acute decompression illness is made. The nearest decompression chamber is 450km away. Outline your preparations for retrieval.
Must include:
- Communication: retrieval service and receiving hospital
- Notification of patient/family of transfer
- Secure all lines/medical equipment
- Copy all documentation to transport with patient
- Draw up spare drugs/infusions
iii. (15 marks)
A provisional diagnosis of acute decompression illness is made. The nearest decompression chamber is 450km away.
Give three options for transporting this patient and 2 pros and 2 cons for each
|
PLATFORM
1. ROAD 2. ROTARY WING 3. FIXED WING |
PRO
No pressure issues Easily available Point to point transfer Fast over 450km Fastest in the air, cabin compressible to sea level |
CON
SLOW, shorter range (not really suitable for 450km) Cannot be compressed Vibrations may worsen decompression illness Needs to add road leg either side, which adds significantly to time Needs available landing strip |
question 9.
i. (5 marks)
Describe the ECG.
Tachycardia
RBBB pattern
Prominent R wave V1-V3
TWI V1-3
Narrow QRS complex
ii. (5 marks)
What are the normal features of a paediatric ECG compared to that of an adult?
As above, because of a relatively larger right ventricle
ii. (2 marks)
How will you manage this child on the basis of this ECG?
Analgesia for the toothache
No specific management is required as this is a normal ECG
Describe the ECG.
Tachycardia
RBBB pattern
Prominent R wave V1-V3
TWI V1-3
Narrow QRS complex
ii. (5 marks)
What are the normal features of a paediatric ECG compared to that of an adult?
As above, because of a relatively larger right ventricle
ii. (2 marks)
How will you manage this child on the basis of this ECG?
Analgesia for the toothache
No specific management is required as this is a normal ECG
question 10.
A 20 year old man presents to your department concerned that he has been bitten by a snake. He did not actually see the snake, but felt a sharp bite on his right ankle during a bushwalk.
i. (9 marks)
Give three features of snake envenomation and for each two symptoms or signs you will seek in this patient.
Anticoagulation
ii. (7 marks)
The patient’s coagulation profile returns from the laboratory. He has no other symptoms or signs on exam.
The results are shown on page 9 of the supplementary information boolet. Describe them and outline your further treatment.
Must include:
- high INR
- low fibrinogen
- high d-dimer
- indicates a VICC
Therefore
- antivenin is indicated.
- treat 1 vial antivenin 100ml NaCl 0.9% over 30 minutes and reassess clinical state
- guided by VDK or use polyvalent antivenin
i. (9 marks)
Give three features of snake envenomation and for each two symptoms or signs you will seek in this patient.
Anticoagulation
- Easy bleeding puncture sites/gums etc
- Bruising ++
- Muscle pain
- Dark urine
- Descending paralysis – ptosis, diplopia etc
- Weakness, voice changes, difficulty swallowing
ii. (7 marks)
The patient’s coagulation profile returns from the laboratory. He has no other symptoms or signs on exam.
The results are shown on page 9 of the supplementary information boolet. Describe them and outline your further treatment.
Must include:
- high INR
- low fibrinogen
- high d-dimer
- indicates a VICC
Therefore
- antivenin is indicated.
- treat 1 vial antivenin 100ml NaCl 0.9% over 30 minutes and reassess clinical state
- guided by VDK or use polyvalent antivenin