TEST 1 answers.

As promised, our marking scheme/answers to roadblock one are reproduced below.

Well done to all those who got them submitted for marking!

Question 1.

Question 1. (5 marks)
 
What is the evidence for the use of tranexamic acid empirically in this patient?
 
Must include:
  • CRASH-2 trial in trauma patients
  • All cause mortality decreased from 16% to 14.5% (NNT 66) (0.5 marks given if numbers are wrong but statement included)
  • Exsanguination mortality decreased from 5.7% to 4.9% NNT 125 (0.5 marks given if numbers are wrong but statement included)
 
Plus any from:
  • No increase in adverse events
  • Subgroup analysis shows needs to be given 3 hours from injury
  • Questionable external validity/generalization to Australia

Question 2. (5 marks)

Give the 2 primary disturbances present and justify your answer. 
 
Must include:
  • Primary respiratory and metabolic acidosis
  • Neither CO2 or HCO3- correct for each other
  • For CO2 expect HCO3 ~26mmol/L acutely
  • For HCO3 expect CO2 23mmHg

Question 3. (8 marks)
 
Based on the VBG results use the following table to list two major pathologic processes you are concerned about, and three injuries which may contribute to each.

1. Respiratory failure: Pulmonary Contusion, (Tension) pneumothorax, Haemothorax
2. Major haemorrhage: Liver laceration, Spleen laceration, Renal injury, Massive haemothorax, (or any other reasonable cause of major bleeding)

Question 4. (4 marks)
 
The patient is taken to CT scan, and a copy of the image is reproduced in the “props” booklet.
 
What are the major abnormalities present?
 
Must include:
  • Complete rupture of the left kidney
  • Large left retroperitoneal haematoma
  • Compressed liver and bowel (intra-abdominal compartment syndrome)
  • Posterior rib fracture

Question 5. (1 mark).

What grade of kidney injury is this (1 mark)?
 
Must include: five.

Question 6.  (4 marks)
 
Give 4 indications for operative management of this patient.
 
Must include
-grade 5 injury is an indication for surgery
-non viable kidney (no contrast enhancement)
-requires surgical control of life threatening haemorrhage
-decompression of probable abdominal compartment syndrome
-free air on CT suggesting intercurrent bowel perforation (may be present on other slices) 

Question 7. (5 marks)
 
Give 5 elements important in a massive transfusion protocol.
 
Must include:
 
  • PRC:FFP:Plt 1:1:1
  • administration of cryoprecipitate
  • administration of Calcium for normal ionized serum Ca++
  • administration of tranexamic acid 1g stat
  • administration of warmed products

Question 8. (6 marks)
 
Give 6 endpoints you would use to judge the efficacy of your transfusion
 
Must include:
 
  • Normalization of haemodynamics (SBP >90, HR 100)
  • Capillary refill time approaching 2 seconds
  • Urine output >0.5ml/kg.hr
  • Lactate clearance of 50%/resolution of metabolic acidosis
  • Maintenance of normal haemostatics (INR as close to 1 as possible, normal TEG profile if available)
  • A normal clinical state, particularly normal mentation.

Question 9. (2 marks)
 
Is there any evidence for the use of low BP targets (permissive hypotension) in trauma?
 
Must include:
- there is one american RCT of penetrating trauma victims (1 mark) that shows a survival benefit (1 mark) in this population for permissive hypotension.

Question 2.

Question 1. (2 marks)
 
Give 2 differential diagnoses for this presentation.
 
Must include:
  1. Preterm Labour (critical answer)
    1. And any of
      1. Braxton Hicks contraction
      2. Placental abruption
Question 2. (8 marks)
 
Using the table below outline 4 features (not inclusive of vital signs) you will assess on clinical examination and the rationale for each.

Cervical dilation. Necessary criteria for diagnosis of preterm labour, cervix dilation >3-4cm increases change of preterm delivery
Cervical effacement. Helps to distinguish preterm labour from Braxton-Hicks contractions.
Membranes. PPROM is associated with increased chance of increased delivery and indicates antibiotics, eg ampicillin 2g tds – qid due to risk of chorioamnionitis.
Bleeding. Significant PPH is an absolute contraindication to tocolysis.
Foetal Heart Rate. Assess foetal viability.
Foetal lie and position. Check gestational age, movements RE foetal wellbeing.

 
Question 3. (5 marks)
 
Your examination indicates that preterm labour is in progress without any major complications to further medication administration.
 
Give 5 steps in management you will now institute.
 
Must include:
 
Liaison with on call obstetric service & retrieval service (critical answer)
Administration of betamethasone 11.4mg IM (critical answer)
Tocolysis: nifedipine 20mg repeated at 30 minutes then 20mg q4-6 hours (critical answer, note salbutamol will also be acceptable)
Administration of GBS prophylaxis:  benzylpenicillin 2.4g IV or ampicillin 2g IV
Foetal neuroprotection: discussion RE use of magnesium sulphate 4g IV then 1g per hour with O&G 

Question 4. (4 marks)
 
List 4 contraindications to tocolytic therapy in patients with preterm labour.
 
Must include:
  1. Gestation >34 weeks
  2. Gestation <24 weeks
  3. Placental insufficiency/abruption
  4. Eclampsia
  5. Foetal distress or death in utero
  6. Chorioamnionitis
  7. Advanced labour: cervical dilation >4cm

Question 3.

Question 1. (4 marks)
List 4 differential diagnoses for this presentation.
 
Must include
  1. Testicular torsion (critical answer)
  2. Then any of:
    1. Inguinal hernia
    2. Appendicitis
    3. UTI
    4. Epididymo-orchitis
    5. Torsion of an appendix testis
 
Question  2. (3 marks)
What further features on examination would support a diagnosis of testicular torsion?
 
Must include:
  1. High riding testis on the affected side
  2. Transverse lie of affected testis
  3. Loss of the cremasteric reflex

Question 3. (6 marks)
 
Your resident  who has primary care of the patient returns to you and asks you to approve an ultrasound of the testicle.
 Using the table below outline of two issues in this case which may limit the utility of ultrasound in this patient.

Time criticality (1 mark): Absolute ischaemic time= 6 hours. (1 mark), This patient is already at 4 hours. (1 mark), Ultrasound risks delaying definitive care/salvage
Diagnostic yield (1 mark): Surgical exploration, not ultrasound, is definitive care (1 mark)
Ultrasound has variable sensitivity (82-100%) depending on a variety of factors, and specifically may miss intermittent torsion (1 mark)

Question 4. (2 marks)
 
Your resident returns to you to say the surgical registrar is refusing to see the patient until an ultrasound is performed. At this stage the patient has been in your department 45 minutes.
 
Outline your next actions.
 
Must include:
  • Escalation to the on call consultant surgeon
  • Clear documentation of referral times and referral process

question 4.

Question 1. (3 marks)
 
Her ECG is reproduced in the “props” booklet.  
 
Give 3 abnormalities which relate to this lady’s presentation.
 
Must include:
  • Sinus bradycardia (rate 42)
  • J waves/osbourne waves
  • Plus
  • Shivering artefact (Seen beset between 2nd and 3rd beat)
  • Downsloping ST segments ?digitalis effect
 
(Note I make the QT corrected by Bazet’s formula 334ms (based on RR 1.48ms and QT 400ms) therefore prolonged QT is NOT an acceptable answer.)

Question 2.  (4 marks)
 
The resident brings you a venous blood gas.

Give 2 acid-base disturbances present and provide 2 derived values to support your answer.

Raised anion gap metabolic acidosis
Non anion gap metabolic acidosis
 
Derived value 1: ANION GAP = 145 – 14 – 114 = 17
Derived value 2: DELTA RATIO = (17-12)/(24 – 14) = 5/10 = 0.5

Question 3. (12 marks)
 
Using the table below list 6 investigations you will perform now in this patient. Give a justification for each.

Must include:
Blood sugar – altered LOC (critical error)
 
And may include any of:
Creatine Kinase – long lie syndrome
Renal function – renal failure (NAGMA)
Lactate – tissue underperfusion/sepsis in view of RAGMA
Urinalysis - ?UTI, also myoglobinura (long lie syndrome)
CT Brain - ?intracerebral event as cause of LOC
FBC – check Hb ?occult bleed eg GI as cause of LOC. (Note: check WCC ?sepsis is NOT a valid answer.)
INR – patient is warfarinized, check level
Digoxin level - ?digitalis toxicity
CXR – injuries from fall/aspiration
Troponin - ?ACS

Question 4. Give 4 methods which you will use to actively rewarm this patient. (4 marks)
 
Options:
  • Warming blankets (BAIR HUGGER)
  • Warmed humidified O2
  • Warmed IV fluids through a fluid warmer
  • Irrigation of bladder with warmed saline via 3 way irrigation catheter

Note, although peritoneal and thoracic lavage, as well as ECMO and haemodialysis are described in the literature as possibilities, they are not indicated in THIS patient.

Question 5.

Question 1.  (2 marks)
 
Describe the important findings in the image.
 
Must include:
Complete avulsion of the right great toenail
Intact nail bed underneath

Question 2. (5 marks)
 
Describe your technique to anaesthetise this patient to exam and treat him?
 
Must include:
  • Digital nerve block with 1% lignocaine
  • Aseptic technique
  • Infiltration either side of proximal phalanx aiming to anaesthetize digital nerves
  • Infiltration of the dorsal surface of the toe above the MCP joint (critical mark)
  • Use of adjunct analgesia (inhaled NO)

Question 3.
 
The patient has the injured toenail with him. (6 marks)
 
Describe the treatment you will provide including your disposition management.
 
Must include:
Irrigation and cleaning of the wound
Clean and wash toenail
Reimplant toenail under nail fold
Secure with tissue adhesive or sutures and dress
Ensure tetanus vaccine is up to date
Discharge with appropriate analgesia paracetamol/ibuprofen etc

Question 6.

Question 1.  (3 marks)
 
What are the important findings on the CT image?
 
Must Include: (1 mark each)
Substantial amounts of free fluid separating liver/spleen from abdominal wall
Air fluid level in this area
Other small areas of pneumoperitoneum
Plus any of:
  • dilated stomach with fluid filling
  • apparent pneumatosis anterior stomach wall
  • normally enhancing aorta
  • normal liver
  • normal spleen

Question 2. (4 marks)
 
Give 4 differential diagnoses?
 
Must include (1 mark each)
  • perforated DU or gastric ulcer
  • mesenteric ischaemia (drug user, pneumatosis)
 
Others from:
  • perforated appendix
  • perforated diverticulum
  • perinonitis due to seeding from IVDU
  • other reasonable diagnoses

Question 3. (8 marks)

Describe your immediate management.
 
Must include:
  • administration of broad spectrum Abx (2 marks: must specific drugs and doses for any mark):
    • either ceftriaxone 1g and 500mg metronidazole
    • or gentamicin 5-mg/kg, ampicillin 1g and metronidazole 500mg
  • fluid resuscitation (1 mark for dose, 1 mark for endpoints)
    • 20ml/kg repeated for SBP >90 or N HR
  • appropriate analgesia (1 mark must specify drug and dose for any score)
    • morphine 0.1mg/kg or fentanyl 10mcg/kg titrated to pain
  • insertion of IDC to monitor UO >0.5ml/kg (1 mark for IDC and 1 mark for endpoint)
  • early referral to surgery for laparotomy (1 mark)
  • keep NBM (1 mark).

question 7.

Question 1. (6 marks)
 
What pathology tests will you perform on this patient and why? 
 
Must include: (1 mark for each test and indication)
  • lipase: exclude pancreatitis
  • LFTs: evaluate hepatic/obstructive picture and serum bilirubin
  • blood gas + lactate: evaluate degree of sepsis
 
Note, candidates should not need to perform a full blood count to diagnose infection!

Question 2. (8 marks)
 
Selected pathology is shown below. Describe the results and their implications.  

Must include: 
Findings: (1 marks each)      
  • Significant acidaemia
  • Metabolic acidosis
  • Respiratory compensation
  • Hyperlactataemia
  • Elevation of cholestatic enzymes out of proportion to transaminases
  • Primarily conjugated hyperbilirubinaemia
 
Implications: (1 mark for each statement)
  • biliary obstruction/ascending cholangitis
  • complicated by severe sepsis/septic shock

 Question 3. (3 marks)

What are the advantages of ultrasound over CT in imaging this patient?
 
Must include: (1 mark)
visualize biliary tree including obstruction
 
Plus (any of, each up to 1 mark)
  • no radiation
  • quicker/bedside test
  • does not require contrast
  • or other reasonable statement

Question 8.

Question 1. (5 marks)
 
For each category listed below give the requested number of features you will examine for and the injuries they may represent.
 
PUPIL:
  • irregularity: globe rupture
  • hyphema
EYE MOVEMENTS
  • pain with eye movement: orbital fracture/muscle entrapment
  • diplopia: EOM entrapment
LIP
  • parasthesiae: injury to the infraorbital nerve secondary to maxillary fracture

Question 2. (2 marks)
 
A CT scan of the patient’s face is shown in the props booklet.
 
What are the two major abnormalities?
 
Must include:
  • herniation of periorbital fat through inferior orbital floor
  • fracture of the inferior orbital floor

Question 3. (4 marks)
​
What are the indications for surgery in this fracture?
 
Must include:
  • enopthalmos >2mm on imaging
  • diplopia
  • >50% fracture of the orbital floor
  • Extraoccular muscle entrapment

question 9.

Question 1. (3 marks)
 
His ECG is shown on page 10 of the supplementary information booklet. Give 2 major abnormalities and a likely diagnosis.
 
ST/J point depression
Upsloping pattern into tented T waves
ST elevation aVR
 
LAD occlusion/De-winter’s T waves

Question 2. (6 marks)
 
Explain three issues you would consider in determining whether to send this patient for primary PCI or use thrombolysis in the ED.
 
1. TIME TO REPERFUSION: Ilcor guidelines 2015: if <120minutes PCI is preferred, otherwise lysis on site should be provided
2. NATURE OF INFARCT: this is an anterior STEMI. PCI if available is much more effective (3% mortality v 10%)
3. STABILITY OF PATIENT FOR TRANSFER: cardiogenic shock is an indication for PCI, but risks of safe transport must be balanced against need for reperfusion.

Question 3. (6 marks)
 
Logistic factors prevent the timely transfer of the patient to the PCI facility and a decision is taken in consultation with cardiology to deliver primary thrombolysis. List the medications in sequence that you will give to achieve this.
 
1. Recombinant tPA:
a) Tenecteplase on weight based dose (>90mg/kg 50mg scaled down)
b) Alteplase r-tPA, given in weight dependent dose as an accelerated infusion
>67kg – 100mg; 15mg bolus, 50mg over 30min, 35mg over 60min
<65kg – 15mg bolus, 0.75mg/kg over 30min, 0.5mg/kg over 60min
2. Co-administer heparin - 60U/kg bolus then 12U/kg/hr infusion OR clexane 30mg IV then 1IU/kg s/c post lysis.
3. Antiplatelet agents: aspirin 300mg, clopidogrel 300-600mg, or other (e.g. ticagrelor as per local protocol).

 
Question 4. (1 mark)
 
One hour after lysis the patient is pain free and the ST segments have resolved. What is your time frame for transferring them to a PCI centre?
 
Transport to PCI centre should be within 3-24hrs as per ILCOR guidelines

question 10.

Question 1. (4 marks)
 
His initial xrays are shown on page 11 of the supplementary examination booklet.
 
Must include
Transverse fractures of the distal radius and ulnar
30+ degrees angulation (with either volar displacement of the proximal segment or dorsal displacement of the distal segment)
Extrusion of the radius past the skin margin ie an OPEN fracture
No foreign bodies seen

Question 2. (8 marks)
 
Using the table on the following page list 4 structures which may be damaged in association with this orthopaedic injury, and give a clinical sign you will assess for to evaluate the structure.

Ulnar artery: Pale/pulseless hand or direct vision of arterial injury
Radial artery: Pale/pulseless hand or direct vision of arterial injury
Median Nerve: Loss of thenar eminence movement, numbness in nerve distribution, loss of lateral two lumbricals movement
Flexor tendons: Direct visualisation of severed tendons, loss of flexion of DIPs and PIPs

Question 3. (4 marks)
 
Give four (4) interventions or consultations you will undertake as part of your management.
 
Must include:
  • Appropriate opiate analgesia 0.1mg/kg morphine or equivalent
  • Administration of appropriate antibiotics eg cefazolin 1g IV
  • Administration of tetanus if required
  • Urgent orthopaedic consultation for washout in OT