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MODULE 20 short answer questions

saq 1.

A 4 year old child presents to the emergency department after ingesting 4 of his grandmother’s 60mg modified release gliclazide tablets 30 minutes previously. This was a witnessed ingestion, and no other tablets were taken. The child is currently well. It is 4pm
 
His vital signs are:
HR          110         /min
BP           93/66     mmHg
RR           26           /min
T              36.7        oC
GSC        15
 
Question 1. (3 marks)
 
The child has been in your department for 2 hours. At this stage the resident looking after the child informs you that the BSL is 5.6mmol/L.
 
Outline your disposition considerations.
 
Must include
  • Potential for delayed hypoglycaemia (up to 8 hours)
  • Therefore requires an extended period of observation.
  • As this will end at midnight, and overnight admission is appropriate
 
Question 2. (6 marks)
 
An hour later your resident informs you that the paediatrics registrar told her that as the child was well at 3 hours with a normal BSL he could be discharged. Subsequently the resident discharged the child.
 
What actions will you take?
 
Must include:
  • Recall of the child to the department immediately
  • Discussion with paeds consultant to ensure child is admitted with an appropriate monitoring regime
  • Quality assurance issues including education and procedure:
    • ED resident
    • Paeds registrar
  • Explanation and disclosure of events and rationale for recall to mother
  • Apology for inconvenience.
 
Question 3.
 
The child returns 2 hours later (7 hours after the original overdose). He is drowsy and partially responsive.
 
What investigation will you order?
 
Must include:
Immediate BSL
 
Question 4. (4 marks)
 
The BSL returns at 1.6. Give two alternatives to managing this toxic ingestion.
 
Must include: (1 mark for each drug, 1 mark for either correct outright dose or weight based dose)
5ml/kg 10% dextrose (80ml for 4yo) bolus repeat for BSL >5.0
1mcg/kg bolus then0.5-1.0mcg/kg (8-16 mcg) per hour infusion of octreotide
 

saq 2.

A 19 year old man presents to your ED after a fire at the factory he works at. He has no major injuries, but is complaining of severe dyspnoea.
 
His vital signs are:
 
HR          136         /min
BP           167/99  mmHg
RR           46           /min
Sats        100%     60% O2
T              37.1        oC
 
A primary survey in resus indicates that there is no mechanical injury. An urgent arterial blood gas is taken and the results are shown below.
 
FiO2                       0.6
 
pH                          6.95
pO2                        445         mmHg
PCO2                     17           mmHg
HCO3-                   6
 
Na+                        149         mmol/L
Cl-                           113         mmol/L
 
Lactate                 10.2        mmol/L
 
Question 1. (6 marks)
 
Describe the major acid base disturbances present and provide calculations to substantiate your answer.
 
Must include:
  • Metabolic acidosis (1 mark) with respiratory compensation (1 mark)
  • Expect CO2 for HCO3 6 = 8+1.5x6 = 17mmHg (1 mark)
  • Anion gap = 30, delta ratio = 1.0 (1 mark each)
  • Therefore Dx RAGMA (1 mark)
 
 
Question 2. (2 marks)
 
Your registrar suggests the patient may have a chemical pneumonitis from smoke inhalation. Comment on this in light of the ABG findings.
 
Must include:
Aa gradient = 450 – 1.25x17 – 445 = <0
Implies no V/Q mismatch, and therefore no ARDS/pneumonitis
 
Question 3. (2 marks)
 
What is the likely diagnosis and why?

Normoxic tissue hypoxia in the setting of a fire implies cyanide toxicity
 
Question 4. (2 marks)
 
Give 2 treatment options for this patient.
 
Must include:
 
12.5g sodium thiosulfate IV
2.5g hydroxocobalamin over 15 minutes, then repeated after 15-30 minutes
 

saq 3.

Two patients present to your department after an industrial accident at their factory. Their factory specialises in glass etching, and a vat of hydrofluoric acid tipped over and splashed them.
 
Question 1. (3 marks)
 
List risk factors for systemic toxicity in hydrofluoric acid burns.
 
Must include:
  • Any exposure to 50% HF solution
  • Exposure of >5% total body surface area to any concentration HF
  • Inhalation or ingestion of HF
 
Question 2. (3 marks)
 
The first patient has sustained burns to the fingers of his left hand. He states the HF solution they were using was 21%. He is complaining of severe pain.
 
Give 3 options for managing this patient’s burn.
 
Must include:
  1. Use of 2.5% calcium gluconate gel in a glove
  2. Biers block with infusion of calcium gluconate
  3. Intra-arterial infusion of calcium gluconate
 
Question 3. (5 marks)
 
The second patient received a large splash of HF to the face. On arrival to the ED with the ambulance he suffers a cardiac arrest. He is wheeled into your resus room covered in vomit.
 
Outline the important steps you will take as part of your ALS efforts.
 
Must include:
  • Use of PPE for all staff: risk of secondary exposure to HF in vomit (1 mark)
  • Institution of ALS (1 mark)
  • Secure the airway – facial/inhalational burn (1 mark)
  • Treat specifically for HF toxicity: 60ml calcium gluconate or 20ml calcium chloride repeated each cycle of CPR until cardiac output is re-established. (2 marks)

saq 4.

A patient is brought into your hospital after collapsing at a local beach.
 
Question 1. (16 marks)
 
List six organisms that may have been responsible for envenomation of this patient. For each, list the
major mechanisms of toxicity.
 
Must include:
(1 mark for each organism, 1 mark for each feature)
 
Box jellyfish
  • Large tentacle marks/severe pain at sting site
  • Neurotoxic/paralysis
 
Irukandji
  • Severe back pain
  • Symptoms of autonomic instability: sweating, hypertension, vomiting
 
Sea Snake
  • Paralysis
  • Mytotoxicity
 
Blue ringed octopus
  • Isolated Neurotoxicity
 
Cone shells
  • Isolated Neurotoxicity
 
Stone fish
  • Severe pain
  • Cardiotoxic venom

SAQ 5.

A 45 year old butcher is brought to your department unconscious after an apparent suicide attempt. He was found in his butcher store kitchen with an open packet of curing salt, and had left a suicide note.
 
His vital signs are:
 
HR          110         /min
BP           96/45     mmhg
RR           29           /min
O2 sats 86%        RA
T              36.7        oC
 
On arrival an arterial blood gas is taken in the resuscitation room. The results are shown below.
 
pH          7.10
PO2        105         mmHg
CO2        32           mmHg
HCO3-   16           mmol/L
O2 sat  95%
 
Na+        145         mmol/L
Cl-           109         mmol/L
 
Lactate 5.2          mmol/L
 
Your registrar notes a brown appearance to the patient’s blood.
 
Question 1. (5 marks)
 
What are the major disturbances in the arterial blood gas? Provide calculations to substantiate your answer.
 
Must include:
  • Raised anion gap metabolic acidosis with respiratory compensation
  • Expect CO2 = 32
  • AG = 20
  • DR = 1.0
 
Question 2. (2 marks)
 
What is the likely diagnosis and how will you confirm it?
 
Must include:
Methaemoglobinaemia: check a methemoglobin saturation level
(note, curing salt contains nitrites, and this patient has a low O2 sat compared to his O2 tension)
 
Question 3. (3 marks)

Give 2 therapies will you institute for this patient
 
Must include:
  • High flow oxygen (1 mark)
  • Administration of methylene blue 1-2mg/kg over 3-5 minutes, (1 mark) repeated at 30minutes, for normalisation of sats/respiration  (1 mark)