MODULE 21 short answer questions
saq 1.
A 26 year old woman presents to your costal hospital feeling generally unwell. She reports that she has been out with a local scuba diving boat, and has performed 3 dives for the day.
Question 1. (2 marks)
How is decompression illness diagnosed?
Must include:
Question 2. (6 marks)
List 6 symptoms you will ask about.
Must include any of
Question 3. (2 marks)
What is the difference between AGE and DCS?
Arterial gas embolism occurs due to the occlusion of blood vessels by gas bubbles in the bloodstream. It usually manifests acutely with isolated neurological symptoms.
Decompression sickness requires saturation of the blood with nitrogen and presents with systemic symptoms.
Question 4. (3 marks)
How will you manage this patient?
Must include: (1 mark each)
Plus reasonable symptomatic management (0.5 marks each point to maximum 1)
Question 5. (1 mark)
The nearest recompression chamber is 240km away, and the only available platform is a helicopter. What is the major disadvantage of a helicopter in this situation?
Must include:
Question 1. (2 marks)
How is decompression illness diagnosed?
Must include:
- clinical diagnosis based on typical symptoms
- proved by therapeutic recompression alleviating symptoms
Question 2. (6 marks)
List 6 symptoms you will ask about.
Must include any of
- weakness/malaise/sweating/numbness
- joint and muscle pain
- confusion and mental status changes
- eye symptoms: scotomata, diplopia, visual loss
- ear symptoms: deafness/tinnitus
- dyspnoea
- chest or abdominal pain of indistinct nature
- neurological: headache, parasthesiae, paralysis
Question 3. (2 marks)
What is the difference between AGE and DCS?
Arterial gas embolism occurs due to the occlusion of blood vessels by gas bubbles in the bloodstream. It usually manifests acutely with isolated neurological symptoms.
Decompression sickness requires saturation of the blood with nitrogen and presents with systemic symptoms.
Question 4. (3 marks)
How will you manage this patient?
Must include: (1 mark each)
- Hi flow O2 via mask
- Transfer to a hyperbaric chamber
Plus reasonable symptomatic management (0.5 marks each point to maximum 1)
- IV crystalloid
- Analgesia
- Antiemetics etc
Question 5. (1 mark)
The nearest recompression chamber is 240km away, and the only available platform is a helicopter. What is the major disadvantage of a helicopter in this situation?
Must include:
- helicopter cannot be pressurized, therefore must fly at sea level.
saq 2.
A 19 year old man is brought in by the ambulance after being found immersed in the sea. He had been snorkelling with friends, and was noted missing for 5 minutes, after which he was found face down unresponsive in the water.
On arrival his vital signs are:
HR 113 /min
BP 135/55 mmHg
RR 26 /min
T 35.2 oC
Sats 91% 15L NRB (FiO2 .60)
GCS E2M5V1 (8)
The ambulance report that he has had an altered LOC during their treatment, but has never lost cardiac output.
Question 1. (4 marks)
List 4 indicators of adverse prognosis in near drowning.
Must include:
Question 2. (4 marks)
Give 4 potential indications for RSI in this patient.
Must include
Question 3. (6 marks)
An arterial blood gas taken shortly after the patient’s arrival is shown below. Describe and interpret the results.
pH 7.22
PCO2 55 mmHg
PO2 70 mmHg
HCO3- 16 mmol/L
Lactate 4.6 mmol/L
Must include:
On arrival his vital signs are:
HR 113 /min
BP 135/55 mmHg
RR 26 /min
T 35.2 oC
Sats 91% 15L NRB (FiO2 .60)
GCS E2M5V1 (8)
The ambulance report that he has had an altered LOC during their treatment, but has never lost cardiac output.
Question 1. (4 marks)
List 4 indicators of adverse prognosis in near drowning.
Must include:
- immersion >10 minutes
- core temperature <30oC on arrival
- CPR required on scene
- pH <7.0 on arrival
- altered LOC
- no initial resuscitation efforts, despite them being subsequently required
Question 2. (4 marks)
Give 4 potential indications for RSI in this patient.
Must include
- altered level of consciousness
- profound hypoxia
- hypercapnoeic respiratory failure
- airway obstruction
Question 3. (6 marks)
An arterial blood gas taken shortly after the patient’s arrival is shown below. Describe and interpret the results.
pH 7.22
PCO2 55 mmHg
PO2 70 mmHg
HCO3- 16 mmol/L
Lactate 4.6 mmol/L
Must include:
- combined respiratory (1 mark) and metabolic acidosis (1 mark)
- hyperlactataemia (1 mark) suggest tissue hypoxia (1 mark)
- profound hypoxia (1 marks) or Aa gradient approx 310mmHg (1 mark)
- Suggests V/Q mismatch due to ARDS/aspiration (1 mark)
saq 3.
A 42 year old man is brought to your hospital by the ambulance. He has collapsed while running a local marathon. On arrival to the ED his vital signs are:
HR 138 /min
BP 88/55 mmHg
T 42.6 oC
RR 33 /min
Sats 99% RA
Initial pathology is shown below.
Hb 192 mg/dL
WCC 26.3 x109/L
Plt 190 x109/L
Na 157 mmol/L
K 6.1 mmol/L
Urea 29.1 mmol/L
Creatinine 300 umol/L
CK 36210 IU/L
Question 1. (10 marks)
What are the major abnormalities, and what diagnoses do they each suggest?
Elevated haemoglobin – haemoconcentration
Leucocytosis – acute inflammatory response
Hyperkalaemia – rhabdomyolysis
High CK - rhabdomyolysis
Raised urea and creatinine – acute renal failure
Question 2. (4 marks)
What initial treatment will you institute?
Must include:
Question 3. (1 mark)
If this patient requires rapid sequence intubation, what agent will you use for paralysis if any?
Must include:
HR 138 /min
BP 88/55 mmHg
T 42.6 oC
RR 33 /min
Sats 99% RA
Initial pathology is shown below.
Hb 192 mg/dL
WCC 26.3 x109/L
Plt 190 x109/L
Na 157 mmol/L
K 6.1 mmol/L
Urea 29.1 mmol/L
Creatinine 300 umol/L
CK 36210 IU/L
Question 1. (10 marks)
What are the major abnormalities, and what diagnoses do they each suggest?
Elevated haemoglobin – haemoconcentration
Leucocytosis – acute inflammatory response
Hyperkalaemia – rhabdomyolysis
High CK - rhabdomyolysis
Raised urea and creatinine – acute renal failure
Question 2. (4 marks)
What initial treatment will you institute?
Must include:
- rehydration with cool normal saline 20ml/kg for urine output 1-2ml/kg
- other active cooling: fans for convection, cold packs groin and armpits
- Calcium chloride, HCO3- and insulin/dextrose if ECG changes of hyperkalaemia
- Other supportive care: analgesia (paracetamol 1g), ondansetron 4-8mg IV
Question 3. (1 mark)
If this patient requires rapid sequence intubation, what agent will you use for paralysis if any?
Must include:
- rocuronium: suxamethonium is contraindicated in the context of hyperthermia and hyperkalaemia.
saq 4.
A 19 year old woman is brought in by the ambulance from a local nightclub. She has had a seizure on the dance floor.
Her vital signs on arrival are:
BP 165/99 mmHg
HR 132 /min
RR 30 /min
Sats 99% RA
T 41.0 oC
GCS E2V2M4 (8)
Question 1. (5 marks)
List 5 differential diagnoses.
Must include
Plus other reasonable from
Question 2. (4 marks)
Give 4 features on examination that would make you suspect sympathomimmetic toxicity?
Must include:
Question 3. (3 marks)
A friend of the patient arrives in the hospital and admits that the patient had taken illicit drugs thinking they were ecstasy. What treatment will you administer?
Must include
plus any mark for reasonable supportive care – maintenance of BSL, correction of electrolytes etc.
Her vital signs on arrival are:
BP 165/99 mmHg
HR 132 /min
RR 30 /min
Sats 99% RA
T 41.0 oC
GCS E2V2M4 (8)
Question 1. (5 marks)
List 5 differential diagnoses.
Must include
- epileptic seizure
- drug use (methamphetamines, ecstasy)
- CNS sepsis
- hypoglycaemia
Plus other reasonable from
- hyponatraemia
- head injury
- arrhythmia
Question 2. (4 marks)
Give 4 features on examination that would make you suspect sympathomimmetic toxicity?
Must include:
- mydriasis
- diaphoresis
- tachycardia
- hypertension
- agitation
Question 3. (3 marks)
A friend of the patient arrives in the hospital and admits that the patient had taken illicit drugs thinking they were ecstasy. What treatment will you administer?
Must include
- active cooling: 20ml/kg cool NaCl 0.9% and cold packs to groin/axillae
- diazepam 5-10mg PO or 2-5mg IV for control of temperature and hypertension
plus any mark for reasonable supportive care – maintenance of BSL, correction of electrolytes etc.
SAQ 5.
A 25 year old man presents to your hospital in the South Island of New Zealand. He has just returned from a day of skiing in the local ski field (altitude 2585m to 3100m).
The patient is complaining of significant headache, and abdominal cramps.
Question 1. (4 marks)
List 4 differential diagnoses.
Must include:
plus any other reasonable differentials.
Question 2. (4 marks)
What are the criteria for diagnosis of acute mountain sickness?
Must include:
Lake Louise consensus criteria:
PLUS (one of)
Question 3. (4 marks)
What treatment options are available for acute mountain sickness in this patient?
Must include:
The patient is complaining of significant headache, and abdominal cramps.
Question 1. (4 marks)
List 4 differential diagnoses.
Must include:
- acute mountain sickness/altitude illness
- concussion/head injury
plus any other reasonable differentials.
Question 2. (4 marks)
What are the criteria for diagnosis of acute mountain sickness?
Must include:
Lake Louise consensus criteria:
- ascent to altitude above 2500m
- headache
PLUS (one of)
- gastrointestinal symptoms (cramps, nausea, diarrhoea)
- constitutional (fatigue, lightheadness, dizziness)
- insomnia
Question 3. (4 marks)
What treatment options are available for acute mountain sickness in this patient?
Must include:
- descent to 500-1000m below the altitude at which the illness occurred (definitive)
- IV dexamethasone 8mg: works 2-4 hours to relieve Sx
- High flow O2 for symptomatic relief
- Acetazolamide 500mg PO, works 12-24 hours to aid acclimatization, but does not cure AMS