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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:
  • 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:
  • 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:
  • 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
  • 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:
  • 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