Question 1 - Microsoft



MEMBERSHIP EXAMINATION

JUNE/JULY 2005

VETERINARY EMERGENCY & CRITICAL CARE

PAPER 1

THEORY

Perusal time: 15 minutes

Time allowed: TWO (2) Hours after perusal

Answer FOUR (4) from the six questions only.

All questions are of equal value

Subsections of Questions are of equal value unless stated otherwise

You should allocate 30 minutes

to EACH of the FOUR (4) questions you answer

PAPER ONE – VETERINARY EMERGENCY AND CRITICAL CARE– 2005

Answer FOUR (4) from the six questions only.

1. “The arterial partial pressure of oxygen (PaO2) is the best measure of the oxygenating efficiency of the lungs, and the arterial partial pressure of carbon dioxide (PaCO2) is the best measure of the ventilatory status of a patient.”

Discuss this statement.

Your answer should include comparisons with other methods of evaluating pulmonary function in the critically ill – physical examination, haemoglobin saturation with oxygen (SaO2), capnography (end tidal carbon dioxide).

Your answer should briefly explain the differences and advantages over PvO2 (venous partial pressure of oxygen) and PvCO2 (venous partial pressure of carbon dioxide).

Your answer should also include normal ranges for each method discussed and when medical intervention is necessary.

(25 marks)

2. ANSWER EITHER PART A OR PART B

PART A

Oncological emergencies constitute any critical situation occurring in the cancer patient as a direct or indirect cause of the tumour itself, or as a secondary consequence of cancer therapy.

Choose THREE (3) of the following acute oncological emergencies and write notes on the pathogenesis, clinical manifestations and immediate treatment for each one:

i) Mast cell tumour degranulation causing local and systemic signs.

ii) Acute tumour lysis syndrome.

iii) Tumour rupture of both haemangiosarcoma of the spleen and haemangiosarcoma of the right atrium.

iv) Haematologic toxicity from chemotherapy. (25 marks)

Continued over PART B, Question 2, Paper 1, Vet. Emergency & Critical Care 2005

Continued PART B, Question 2, Paper 1, Vet. Emergency & Critical Care 2005

2. PART B

Some of the most commonly encountered oncological emergencies clinically manifest as a constellation of unique symptoms, often referred to as paraneoplastic syndromes. Choose TWO (2) of the following paraneoplastic syndromes and write notes on the pathogenesis, aetiology, clinical manifestations, diagnosis and treatment for each one:

i. Hypercalcaemia.

ii. Hypoglycaemia.

iii. Hyperviscosity syndrome secondary to hyperglobulinaemia.

(25 marks)

3. The GIT (Gastrointestinal tract) has been called “The motor of multiple organ failure.”

a) Discuss the importance of the GIT in critical illness by outlining the pathogenesis of bacterial translocation (movement of viable enteric bacteria across the endothelial barrier to the mesenteric lymph nodes & other distant sites). (15 marks)

b) Bacterial translocation is largely prevented by the preservation of an intact mucosal barrier. Discuss the therapeutic measures that need to be employed in a critical patient to prevent bacterial translocation. (10 marks)

4. ANSWER BOTH PARTS TO THIS QUESTION

PART A

i. What factors determine Central Venous Pressure (CVP)? (3 marks)

ii. Does CVP measure circulatory volume? (1.5 marks)

iii. What is the proper placement for the catheter used for

measuring CVP? (3 marks)

iv. Describe a set-up for measuring CVP. (3 marks)

v. What is the ideal CVP measurement? (normal animal

and critically ill patient) (2 marks)

Continued over PART B, Question 4, Paper 1, Vet. Emergency & Critical Care 2005

Continued PART B, Question 4, Paper 1, Vet. Emergency & Critical Care 2005

4. PART B

i. What does an Ultrasonic Doppler Flow Detector measure, and what principle does it use? (4 marks)

ii. Describe briefly the method of how you place the apparatus on a small cat (a 4kg Domestic Short Hair) and a large dog (a 55kg Mastiff Cross) and interpret its measurements. (4 marks)

iii. Name TWO (2) uses for this device in the trauma patient with severe degloving injuries to a limb. (2 marks)

iv. Hypotensive resuscitation in the haemorrhaging patient has been said to improve survival if pressures are not normalized until the patient is ready to go to surgery. What is Hypotensive resuscitation? (2.5 marks)

5. ANSWER EITHER PART A OR PART B of this question

PART A

Discuss the pathophysiology of the hypermetabolism that occurs following major injury or the onset of severe illness. (25 marks)

OR

PART B

i. Discuss the pathophysiology of poor tissue perfusion. (8 marks)

ii. Discuss compensatory mechanisms initiated by poor perfusion.

(8 marks)

iii. Discuss how the patients’ response to poor perfusion can be measured by physical examination. (5 marks)

iv. Outline the first priority in the treatment of poor perfusion. (4 marks)

Continued over, Paper 1, Vet. Emergency & Critical Care 2005

Continued Paper 1, Vet. Emergency & Critical Care 2005

6. a) Discuss the mechanisms of Primary and Secondary Haemostasis.

(8 marks)

b) Discuss your diagnostic approach to a coagulopathic canine patient using signalment and history, physical examination and haemostatic tests. (10 marks)

c) For EACH of the following six (6) indications for blood component therapy:

i. Anaemia

ii. Thrombocytopaenia

iii. Thrombopathia

iv. Coagulopathies

v. von Willebrand’s Disease

vi. Haemophilia A

List your first (1st) and second (2nd) choice component from the following five broad categories:

A. FWB

B. SWB

C. PRBC’s

D. FFP

E. Platelet-rich Plasma

(4 marks)

d) List which tests you would find most useful to monitor each of the following therapeutic interventions (3 marks)

i. Vitamin K therapy for rodenticide toxicity.

ii. Heparin therapy for thromboembolic disease.

iii. Fresh Frozen Plasma for von Willebrand’s disease.

END OF PAPER

MEMBERSHIP EXAMINATION

JUNE/JULY 2005

VETERINARY EMERGENCY & CRITICAL CARE

PAPER 2

CLINICAL

Perusal time: 15 minutes

Time allowed: TWO (2) Hours after perusal

Answer FOUR (4) from the six questions only.

All questions are of equal value.

Subsections of Questions are of equal value unless stated otherwise

You should allocate 30 minutes

to EACH of the FOUR (4) questions you answer

PAPER TWO – VETERINARY EMERGENCY AND CRITICAL CARE– 2005

Answer FOUR (4) from the six questions only.

1. a. List at least TWO (2) conditions or situations that may underlie the following causes of hypotension:

i. Low venous return (2 marks)

ii. Poor diastolic function (2 marks)

iii. Poor systolic function (contractility) (2 marks)

iv. Impaired systolic efficiency (2 marks)

v. Low systemic vascular resistance (2 marks)

b. Compare and contrast EACH of the following drugs in the treatment

of hypotension:

i. Dobutamine (3¾ marks)

ii. Dopamine (3¾ marks)

iii. Adrenaline (3¾ marks)

iv. Vasopressin (3¾ marks)

2. An 8-year-old spayed female terrier cross (6kg body weight) presents with a half day history of anorexia and vomiting, and a sudden profuse bloody diarrhoea which has not stopped after a few hours.

Examination revealed:

Mentation – depressed but responsive

Rectal Temperature 38.0’C

Heart Rate 180 bpm

Mucous membranes muddy brown colour

Capillary Refill Time 2-3 seconds

Abdominal palpation revealed “squashy fluidy feel” mid-abdominal area

Rectal examination showed much mucous with thick bloody (‘strawberry jam’) faeces

PCV 68% TP 80 g/L BUN 6.4 mmol/L Glucose 4.4 mmol/L

a) What is your differential diagnosis?

b) List the possible aetiologies.

c) Briefly describe your favorite theory on the pathogenesis.

d) Tabulate a treatment protocol.

e) List the possible complications.

Continued over, Paper 2, Vet. Emergency & Critical Care 2005

Continued Paper 2, Vet. Emergency & Critical Care 2005

3. ANSWER THREE (3) OF THE FOLLOWING:

a) A 9-week old puppy (weight 5kg) is admitted for surgery with signs of diarrhoea for 5 days and vomiting for 2 days. Radiographs show an intussusception. What is your general approach to this puppy with regard to supportive measures and achieving general anaesthesia?

b) A lean geriatric cat (weight 3.5kg) presented with sudden onset of laboured breathing. A diaphragmatic hernia was confirmed on radiographs and there was a partially filled stomach in the thoracic cavity. You decided to perform a surgical repair of the hernia after initial stabilization of the cat. What were the principal complicating factors concerning the anaesthesia of this cat? Design your anaesthetic protocol for this case.

c) A 12-year-old Irish Setter (obese weight of 45kg) is presented as an emergency for inspiratory dyspnoea. A presumptive diagnosis of laryngeal paralysis is made. The patient needs to be anaesthetized for tracheal cannulisation. Which complicating factors need to be considered? What would be your anaesthetic approach?

d) An adult Great Dane (~60 kg) with a Gastric Dilatation/Volvulus is presented for emergency surgery. Following stabilization with oxygen, fluids, and support therapy, percutaneous puncture of the distended stomach was done to relieve gastric tympani. What concerns do you have regarding selection of anaesthetic agents for this dog? What anaesthetic agents would you use?

4. Answer only TWO (2) of this question’s three parts (PART A, PART B, PART C). You must answer ALL subsections of the two selected Parts.

PART A

An 8-year-old Golden Retriever is presented for acute collapse. The dog has pale mucous membranes and muffled heart sounds; the femoral pulses are weak. Thoracic radiographs show a globoid cardiac silhouette and increased interstitial densities in the lungs. An echocardiograph shows a hypoechoic area between the heart and the pericardium, with restricted filling of the right and left ventricles during diastole.

i) What is the most likely cause of the acute collapse? (2 marks)

ii) What emergency procedure is required for stabilization of

this patient & how is it safely performed? (6½ marks)

iii) What is the reason for giving intravenous fluids during

this procedure? (2 marks)

iv) What other areas may be ultrasounded to aid in the

diagnosis? (2 marks)

Continued Over/Part B & C, Question 4, Vet. Emergency & Critical Care Paper 2, 2005

Continued/Part B & C, Question 4, Vet. Emergency & Critical Care Paper 2, 2005

PART B

An 18-month-old Cattle Dog Cross presents collapsed. Heart Rate 80; weak femoral pulses and no dorsal pedal pulse; Capillary Refill Time 2 seconds; Mucous Membranes gray; 10-12% dehydrated; Na+ 130 mEq/L; Cl- 98 mEq/L; K+ 8.2 mEq/L. An ECG shows tall spiked T waves; prolonged PR interval; widened QRS complexes & a decrease in amplitude and a widening of the P wave.

i) What fluid choice and what rate of administration would you use?

(2 marks)

ii) What is an unusual finding in this patient that is >10% dehydrated?

(2 marks)

iii) What is the likely diagnosis and what is the cause of the electrolyte disturbance? (2 marks)

iv) List possible causes of hyperkalaemia. (3 marks)

v) Outline a treatment plan for life threatening hyperkalaemia. (3½ marks)

PART C

On the morning of an early summer day, a 5-year-old male German Shorthaired Pointer played unattended in the backyard garden. During the following six hours the right side of the dog’s face became swollen. The dog developed marked urticaria and became lethargic, unable to walk and vomited several times.

i) What is your presumptive diagnosis? (1½ marks)

ii) What pathological mechanism is involved? (2 marks)

iii) Name TWO (2) other possible causes of this syndrome. (2 marks)

iv) What is the treatment protocol? (4 marks)

v) What clinical signs would you expect if this was a

similar situation in a cat? (3 marks)

Continued over, Paper 2, Vet. Emergency & Critical Care 2005

Continued Paper 2, Vet. Emergency & Critical Care 2005

5. It is often lifesaving to have protocols readily available for the management of common emergency problems. These cannot be all-inclusive as the monitoring orders need to be amended according to individual patient requirements.

Tabulate a protocol for THREE (3) of the following six (6) emergency situations, assuming the patient will be in your care for 2-3 days.

i. Hyperglycaemic diabetic crisis.

- A protocol for rehydration & lowering of the blood glucose and osmolality in the diabetic patient in a hyperglycaemic crisis.

- In this situation, list the underlying problems (associated diseases) that you should look for.

ii Ethylene glycol (EG) toxicity.

- Your protocol should allow for handling the acute ingestion of EG before signs of intoxication have occurred (>1 hour) as well as the profoundly intoxicated patient

- Briefly list adjustments you would make to your protocol if you had everything available to you to manage this syndrome (eg. What tests/ treatments are available overseas that we can’t readily use?)

- How does the management of cats differ from the management of dogs?

iii. Head injured patient

- For this problem, please outline prognostic indicators.

iv. Serotonin syndrome in a dog that was observed to ingest a large number of antidepressant tablets.

- List the factors influencing prognosis.

- List potential complications.

v. Feline Urethral Obstruction

- Also list complications that you need to monitor for.

vi. Status Epilepticus, the refractory seizuring canine patient.

- List adjustments for the similar situation in a feline patient.

Continued over, Paper 2, Vet. Emergency & Critical Care 2005

Continued Paper 2, Vet. Emergency & Critical Care 2005

6. Write notes on THREE (3) of the following controversial topics in critical care:

a. The role of heparin in treating DIC in the septic patient.

b. Thrombolytic therapy for aortic thromboembolism in cats.

c. Antibiotic therapy in wound management.

d. The PIRO classification scheme for sepsis as being more precise than the SIRS classification.

e. The anion gap and its use as an aid in differentiating the causes of metabolic acidosis & in identifying mixed acid-base disturbances.

f. The use of corticosteroids in haemorrhagic shock and septic shock.

g. The best drugs for Cardiopulmonary Resuscitation (CPR) – Adrenaline versus Vasopressin.

h. The use of Low Dose Dopamine for the treatment & prevention of Acute Renal Failure (ARF) in the canine and feline patient.

END OF PAPER

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