MODULE 22 short answer questions
saq 1.
You are called to the resuscitation room to assist your colleague in managing a labouring mother. She is at term, and fully dilated. Your colleague assigns you to manage the newly born infant, while she will continue to manage the third stage of labour.
Question 1. What three things will you assess initially in this newborn? (3 marks)
Must include:
Tone
Heart Rate
Respiratory rate
Question 2. The child remains floppy and listless after the cord is cut. What actions will you take next? (1 mark)
Must include
- gentle stimulation by rubbing and warming
Question 3. After this action the child remains cyanosed and apnoeic with insufficient respiratory effort. What are your actions now? (3 marks)
Must include components (1 mark each)
- ventilation with BVM or T-piece
- on Air not O2
- aim for O2 sats of 90% at 10 minutes (or other end point appropriate from targeted pre-ductal saturations table)
Question 4. After this action the child’s heart rate continues to drop, and reaches 50 beats per minute. What are your actions now? (4 marks)
Must include:
Commence CPR rate 3 compressions to one breath
Aim rate of 90 compressions/30 breaths per minute
Plus (for 1 marks each)
Use of two finger or thumb technique
Increase in FiO2 administered to as high a fraction as possible
Question 1. What three things will you assess initially in this newborn? (3 marks)
Must include:
Tone
Heart Rate
Respiratory rate
Question 2. The child remains floppy and listless after the cord is cut. What actions will you take next? (1 mark)
Must include
- gentle stimulation by rubbing and warming
Question 3. After this action the child remains cyanosed and apnoeic with insufficient respiratory effort. What are your actions now? (3 marks)
Must include components (1 mark each)
- ventilation with BVM or T-piece
- on Air not O2
- aim for O2 sats of 90% at 10 minutes (or other end point appropriate from targeted pre-ductal saturations table)
Question 4. After this action the child’s heart rate continues to drop, and reaches 50 beats per minute. What are your actions now? (4 marks)
Must include:
Commence CPR rate 3 compressions to one breath
Aim rate of 90 compressions/30 breaths per minute
Plus (for 1 marks each)
Use of two finger or thumb technique
Increase in FiO2 administered to as high a fraction as possible
saq 2.
A 4 year old boy presents to your department with a fever and progressive petechial rash. He has become increasingly obtunded and unresponsive over the course of the morning.
On arrival his vital signs are:
HR 166 /min
BP 72/41 mmHg
Cap refill 6 seconds
RR 38 /min
Sats 99% RA
T 39.6 oC
BSL 6.7 mmol/L
Question 1. A clinical image of the rash is shown. What are the important features and likely diagnosis? (3 marks
On arrival his vital signs are:
HR 166 /min
BP 72/41 mmHg
Cap refill 6 seconds
RR 38 /min
Sats 99% RA
T 39.6 oC
BSL 6.7 mmol/L
Question 1. A clinical image of the rash is shown. What are the important features and likely diagnosis? (3 marks
Must include: (1 mark each theme)
Diffuse irregular purpuric rash
Visible on both legs and hand
Must specify one of three diagnoses for 1 mark.
- Disseminated intravascular coagulation
OR Pupura Fulminans
OR meningococcal sepsis
Question 2. What immediate treatment will you administer? (3 marks)
Must include (require details for marks, 1 mark each):
Crystalloid bolus 20ml/kg repeated for a cap refill 2 sec or other reasonable endpoint (SBP >85mmHg, HR < 120 etc)
Dexamethasone 0.15mg/kg
High dose cephalosporin
- ceftriaxone 50-100mg/kg IV
- cefotaxime 50mg/kg
Question 3. The child continues to deteriorate. His GCS has dropped to 6, and despite 60ml/kg of intravenous normal saline as a child his systolic blood pressure remains 75mmHg. Give 4 actions you will now undertake? (5 marks)
Must include:
Start inotropes: either 0.05-0.1mcg/kg.min of adrenaline or noradrenaline titrated to BP >80 (1 mark)
Rapid sequence intubation: size 5 tube, 14cm at lips, ketamine 0.5-1.5mg/kg and rocuronium (1.2mg/kg) (0.5 marks each detail, no marks for “RSI alone”).
And 1 marks each for
- counsel parents RE gravity of prognosis and intubation
- referral to PICU.
Diffuse irregular purpuric rash
Visible on both legs and hand
Must specify one of three diagnoses for 1 mark.
- Disseminated intravascular coagulation
OR Pupura Fulminans
OR meningococcal sepsis
Question 2. What immediate treatment will you administer? (3 marks)
Must include (require details for marks, 1 mark each):
Crystalloid bolus 20ml/kg repeated for a cap refill 2 sec or other reasonable endpoint (SBP >85mmHg, HR < 120 etc)
Dexamethasone 0.15mg/kg
High dose cephalosporin
- ceftriaxone 50-100mg/kg IV
- cefotaxime 50mg/kg
Question 3. The child continues to deteriorate. His GCS has dropped to 6, and despite 60ml/kg of intravenous normal saline as a child his systolic blood pressure remains 75mmHg. Give 4 actions you will now undertake? (5 marks)
Must include:
Start inotropes: either 0.05-0.1mcg/kg.min of adrenaline or noradrenaline titrated to BP >80 (1 mark)
Rapid sequence intubation: size 5 tube, 14cm at lips, ketamine 0.5-1.5mg/kg and rocuronium (1.2mg/kg) (0.5 marks each detail, no marks for “RSI alone”).
And 1 marks each for
- counsel parents RE gravity of prognosis and intubation
- referral to PICU.
saq 3.
)A 2 year old child is brought in to your emergency department after taking an overdose of his grandmother’s doxepin tablets. Shortly after arriving at triage he becomes floppy and unwell. He is transferred to the resus room, where he is found to be pulseless.
Question 1. Describe your immediate actions. (3 marks)
Must include
- commence CPR at a rate of 15 breaths:2 compressions
- attach defibrillator
- call for the resus team
Question 2.
The defibrillator shows the following rhythm. What is the rhythm, and what will your actions be? (3 marks)
Question 1. Describe your immediate actions. (3 marks)
Must include
- commence CPR at a rate of 15 breaths:2 compressions
- attach defibrillator
- call for the resus team
Question 2.
The defibrillator shows the following rhythm. What is the rhythm, and what will your actions be? (3 marks)
Must include:
- diagnosis of monomorphic VT
- administer 4J/kg shock
- recheck rhythm in 2 minutes
Question 3. What are the doses of adrenaline and amiodarone for this patient? (2 marks)
Must include (based on estimated weight of 12kg)
- adrenaline 120mcg (10mck/kg IV)
- amiodarone 60mg (5mcg/kg IV)
Question 4. The patient recovers output, and their ECG taken immediately after this is shown below. What is the major abnormality, and what medication will you administer? (2 marks)
Must include:
- pathologically wide QRS complex
- indication for either 3ml/kg of 3% NaCl or 0.5-1.0ml/Kg of 8.4% NaHCO3
- diagnosis of monomorphic VT
- administer 4J/kg shock
- recheck rhythm in 2 minutes
Question 3. What are the doses of adrenaline and amiodarone for this patient? (2 marks)
Must include (based on estimated weight of 12kg)
- adrenaline 120mcg (10mck/kg IV)
- amiodarone 60mg (5mcg/kg IV)
Question 4. The patient recovers output, and their ECG taken immediately after this is shown below. What is the major abnormality, and what medication will you administer? (2 marks)
Must include:
- pathologically wide QRS complex
- indication for either 3ml/kg of 3% NaCl or 0.5-1.0ml/Kg of 8.4% NaHCO3
saq 4.
An 11 year old boy presents with his mother to the emergency department. She complains that he has been progressively more dyspnoeic over the prior four days, and attributes this to asthma, which his brother also suffers from. She has been trying him on his brother’s ventolin puffer, 6 puffs every two hours for the last 8 hours, without any improvement.
On arrival his vital signs are:
HR 162 /min
BP 82/40 mmHg
RR 42 /min
Sats 99% RA
T 37.9 oC
Capillary refill 4 seconds centrally
Question 1.
An urgent arterial blood gas is taken in resus. What do the results show and what is the likely diagnosis? (5 marks)
pH 6.99
pO2 119 mmHg
pCO2 17 mmHg
HCO3- 6 mmol/L
Na+ 128 mmol/L
K+ 2.2 mmol/L
Cl- 92 mmol/L
BSL 26.3 mmol/L
Must include: (1 mark each)
Life threatening metabolic acidosis
Mild hyperoxaemia or Aa gradient 10.
Severe hyperglycaemia
Raised Anion gap
Plus (1 mark)
Likely diagnosis DKA
Question 2.
Correct the sodium for the glucose. (1 mark)
Answer: Na+ corrected = 128 +(26.3-5)/3 = 128 + 7 = 135 mmol/L
Question 3.
What treatment will you administer in resus (4 marks).
Must include: (1 mark each, must include details)
-start insulin infusion between 1.5IU and 3.3 IU/hr ( roughly 0.05-0.1 IU/kg.hr based on expected weight 33kg)
-administer fluid bolus 300 - 600ml either NaCl 0.9% or Hartmanns reassessed against cap refill/Hr/BP
-sepsis cover: 50mg/kg ceftriaxone or similar
-early and aggressive K+ replacement, e.g. 10mmol KCl in 100ml over 30/60 then reassess K+ by VBG.
On arrival his vital signs are:
HR 162 /min
BP 82/40 mmHg
RR 42 /min
Sats 99% RA
T 37.9 oC
Capillary refill 4 seconds centrally
Question 1.
An urgent arterial blood gas is taken in resus. What do the results show and what is the likely diagnosis? (5 marks)
pH 6.99
pO2 119 mmHg
pCO2 17 mmHg
HCO3- 6 mmol/L
Na+ 128 mmol/L
K+ 2.2 mmol/L
Cl- 92 mmol/L
BSL 26.3 mmol/L
Must include: (1 mark each)
Life threatening metabolic acidosis
Mild hyperoxaemia or Aa gradient 10.
Severe hyperglycaemia
Raised Anion gap
Plus (1 mark)
Likely diagnosis DKA
Question 2.
Correct the sodium for the glucose. (1 mark)
Answer: Na+ corrected = 128 +(26.3-5)/3 = 128 + 7 = 135 mmol/L
Question 3.
What treatment will you administer in resus (4 marks).
Must include: (1 mark each, must include details)
-start insulin infusion between 1.5IU and 3.3 IU/hr ( roughly 0.05-0.1 IU/kg.hr based on expected weight 33kg)
-administer fluid bolus 300 - 600ml either NaCl 0.9% or Hartmanns reassessed against cap refill/Hr/BP
-sepsis cover: 50mg/kg ceftriaxone or similar
-early and aggressive K+ replacement, e.g. 10mmol KCl in 100ml over 30/60 then reassess K+ by VBG.
SAQ 5.
A 7 year old boy presents to the emergency department complaining of abdominal pain, pain in both shoulders, both hips and his left knee, and a rash to both lower limbs.
A clinical image of the rash is shown below.
A clinical image of the rash is shown below.
Question 1. Give a list of four differentials for the rash. (4 marks)
Must include (1 marks each)
-Henoch Schonlein Purpura
-TTP
And then others from (1 marks each up to 2 mark)
-DIC/pupura fulminans/meningococcaemia
-Non specific vasculitis
-Erythema Multiforme
-Stevens Johnson Syndrome
-Drug Rash
-SLE
-Rickettsial infection
Question 2. Give 5 features will you look for on examination? (5 marks)
Must include (1 mark each)
-fever
-distribution over rest of body/involvement of mucous membranes
-nature of lesions - purpura versus blanching, palpable/impalpable
Plus any of other reasonable statements (1 marks each up to 2 mark)
-hepatosplenomegaly
-mucosal involvement
-lymph node involvement
-examination of the shoulder
Question 3. List 5 investigations will you order and the indications for each? (10 marks)
Must include (1 mark each for test and indication)
-FBC: platelet count
-urinalysis: proteinuria is a complication of HSP
-Renal function: renal involvement of disease
Then others from (1 marks each for test and indication)
-Coagulation screen: ?DIC
-Inflammatory markers
-LFTs: liver involvement
-Blood/urine cultures if febrile
Must include (1 marks each)
-Henoch Schonlein Purpura
-TTP
And then others from (1 marks each up to 2 mark)
-DIC/pupura fulminans/meningococcaemia
-Non specific vasculitis
-Erythema Multiforme
-Stevens Johnson Syndrome
-Drug Rash
-SLE
-Rickettsial infection
Question 2. Give 5 features will you look for on examination? (5 marks)
Must include (1 mark each)
-fever
-distribution over rest of body/involvement of mucous membranes
-nature of lesions - purpura versus blanching, palpable/impalpable
Plus any of other reasonable statements (1 marks each up to 2 mark)
-hepatosplenomegaly
-mucosal involvement
-lymph node involvement
-examination of the shoulder
Question 3. List 5 investigations will you order and the indications for each? (10 marks)
Must include (1 mark each for test and indication)
-FBC: platelet count
-urinalysis: proteinuria is a complication of HSP
-Renal function: renal involvement of disease
Then others from (1 marks each for test and indication)
-Coagulation screen: ?DIC
-Inflammatory markers
-LFTs: liver involvement
-Blood/urine cultures if febrile