Resuscitation SAQ’s
Resuscitation SAQ’s
With regard to intravenous regional anaesthesia of the upper limb:
• List the indications
• List the contra-indications
• List the potential toxic effects of LA agents and how to minimise them in this context
• List the indications:
• Closed forearm fractures needing reduction
• List the contra-indications:
• Unco-operative patient
• 93%)
C IV access x 2
Fluid resus: early goal directed therapy in sepsis (Rivers et al, NEJM, 2001)
Goals
MAP 65 – 90 vasoactive agent
CVP 8 – 12 IV fluid
ScvO2 > 70% BTF to get Hct > 30%
Dobutamine
I&V to decrease O2 consumpn
Shown to decrease in-hospital mortality
Therefore: early aggressive fluid resuscitation within the first 6h
D monitor GCS, pupils
Monitor BSL
2. Specific treatment
IV antibiotics:
Community acquired pneumonia –
Benzylpenicillin 2.4g load then 1.2g qid iv
Erythromycin 500mg tds iv
Also consider:
?aspiration/pseudomonas – ceftriaxone
?staph – flucloxacillin
NB. Avoid aminoglycosides
Tetracyclines
Beta blockers
Morphine
Pethidine
Antiarrhythmics IA, IB
- cause prolonged NMJ block
3. Treatment of complications
Coagulopathy, DIC – FFP, platelets, cryoppt
Renal dysfunction – IV fluid, monitor UO, +/- hemodialysis
Liver dysfunction
Cerebral compromise
SUPPORTIVE CARE
Myasthenia –
a. Cholinergic crisis
therapy induced
bronchorrhea
generalized weakness
withhold therapy
b. Myasthenic crisis
resp and pharyngeal paresis
often early in Rx or post thymectomy
Cholinesterase inhibitors:
- neostigmine 2.5mg
- pyridostigmine 60mg tabs 1-3tabs 2-4x/day
both life-threatening - 4% mortality
edrophonium test will distinguish
- myasthenic crisis → improves
- cholinergic crisis → worsens (resp deterioration, cardiac dysrhythmia)
Prednisone 100mg/d
Cytotoxics, plasmapheresis
Chest physio
Analgesics, antiemetics
Nebulisers
Bronchoscopy and toilet
DISPOSAL
ICU – monitor gas exchange, hemodynamics, renal function
Input from intensivist, respiratory physician
GENERAL ANAESTHETIC
Issues
Resistant to depolarizing agent – double dose
Sensitive to non-depolarizing agent – don’t use
Little resp reserve – desaturates quickly
Elective intubation:
Fasted – OT - anaesthetist
Gas induction
High dose suxamethonium
?awake fibreoptic intubation
Emergent intubation:
1. RSI
pre-oxygenate
sedate with thiopentone or fent/midaz
cricoid
quick check that can ventilate with bag and mask
high dose suxamethonium 200mg
2. Awake intubation
pre-oxygenate – sedate – laryngoscopy – cophenylcaine spray to cords – ETT
Maintenance of GA:
Sedate with propofol or midaz only
AVOID ongoing paralysis - spontaneous breathing with PEEP & PS
SAQ 108
A term baby is delivered in an ambulance at the entrance to your ED. The child has no palpable cardiac output, no spontaneous respirations and is generally cyanosed at one minute of age. There is meconium in the baby's mouth. Outline your management.
INTRO
This is a time critical situation with immediate threat to life of newborn.
Significant factors to consider
1-Baby- est weight 3.5KG
-Asphyxia –Apgar between 1-3 at 1 minute nil CO or resp effort –CPR needed
-meconium aspiration-associated complications aspiration,pneumothoraces, pulmonary hypertension
2-Mother-second patient issues-
- Medical- maternal conditions leading to asphyxia of infant ie, APH , Also likely needs to complete third stage
-Psychological-unexpected life threat to her newborn infant- ideally separate staff member assigned to support.
3 -Father-psychosocial
4-Staff ,ambulance, nursing and medical need for de-brief post resuscitation
I would call for help-paediatrics, midwife/obstetrics, and social worker.
Two teams
Team 1 baby
Neonatal resuscitiaire overhead heater, timing device to start, full non invasive monitoring
If the baby was still hypotonic with no respiratory effort I would
Intubate 3.5 ETT baby and extubate suctioning simultaneously with meconium aspirator device.
AIRWAY
I would then immediately re-intubate and confirm ETT placement –Direct vision tube through cords, ETT CO2 (unreliable whilst no CO), bilateral air entry, ventilation aiming for chest wall rise and hopefully improvement in heart rate and colour.
BREATHING
If after 5 breaths with good chest rise there is no improvement of HR > 60BPM team member to commence chest compressions.
CIRCULATION
Chest compressions hand encircling technique thumbs in midline on sternum just below inter-nipple line aim for compression third depth of chest.
3 compressions to 1 ventilation once HR and palpable output > 60bpm and rising compressions can cease.
If no response to above measure and lung inflation and adequate ventilation confirmed would administer 10mcg/kg of adrenaline 0.35mls 1 in 10,000 via IO/Umbilical venous catheter. Continue in cycles every 3-5minutes.
History of volume loss re APH would give 10mls /kg of N.saline
DISABILITY
Dextrostix- BSL 100, PR < 100, UO >= 1ml/kg/hr, normal acid-base status.
• no response to saline then packed cells, 2 units initially ?response.
• Urgent surgical assessment required from outset and failure to respond to fluid resuscitation in absence of obvious cause (haemopneumothorax, peripheral fractures, pelvic fractures) indicates laparotomy.
• Unstable pelvic fractures = pelvic binder or sheet tie
• Major pelvic fractures + shock = DPL/DPA/or FAST to clarify need for laparotomy and use of ex-fix and/or angiography as per orthopods
• External haemorrhage control.
• Warm fluids to 37C
Disability:
• Neurosurgical lesion suspected = neurosurgical r/v, CT if able. Supportive management along standard lines for head injury.
• Spinal cord injury = immobilisation, orthopaedic review re reduction of dislocations or decompressive surgery, methylprednisolone depending on local practices
Other management of identified injuries or ingestions along standard lines
Supportive care:
• Analgesia – morphine in aliquots of 2.5 mg IV
• Antiemetic as indicated
• NGT as indicated
• Maintain normothermia
• Counsel relatives/friends
Disposition:
• OT as indicated
• Likely to require HDU or ICU level monitoring in view of conscious state, hypotension, likely injuries. Certainly necessary if intubated.
• Will need psychiatric input and assessment to clarify situation and ensure safety once recovering.
1. A 12 month old infant is brought to your ED after being found submerged and unresponsive in a local home swimming pool. CPR is in progress, and there has been no return of spontaneous circulation.
(a) Describe the technique you use to establish an intraosseous line. (70%)
(b) What are the complications of an intraosseous line (30%)
2. Describe the factors you use to decide the time to discontinue resuscitation of out of hospital cardiac arrest.
3. SAQ 1 2006/1
4. a. Outline the evidence for therapeutic hypothermia in post cardiac arrest patients. (30%)
5. b. Describe a protocol for therapeutic hypothermia in your ED. (70%)
6. SAQ 7 2006/1
7. A 55 year old man presents to triage complaining of throat tightness, itch, generalised erythema and
8. lip swelling whilst eating at a local Thai restaurant.
9. a. Outline your history and examination of this patient. (50%)
10. b. Describe your management of this patient. (50%)
11.
12.
13. SAQ 4 2007/1
14. Compare and contrast the cardiac arrest algorithm for asystole between adults and children older than one year. (100%)
FACEM SAQ Exam 2007.1 – Question 4
. The overall pass rate for this question was 22/55 (40.0%).
. Pass Criteria
. The examiners felt that this was an excellent core knowledge question on a topic recently overviewed in widely discussed concensus statements (ILCOR/AHA/ARC).
. It was thought to have been overall answered very poorly by most candidates.
. Good responses identified the differences in pathophysiology (and hence, priorities) in children, highlighted the potential reversible causes and exhibited knowledge of the recently published algorithms in this area.
. Features of unsuccessful answers
Common errors in answering this question were incorrect drug doses, incorrect CPR ratios/rates, failure to mention intraosseous vascular access techniques and disregard of the differing pathophysiology.
15. SAQ 3 2007/2
16. A 72 year old man presents to the emergency department with a two day history of abdominal pain. A CT scan undertaken to investigate recent weight loss and jaundice shows a pancreatic mass lesion.
17. On examination, he is confused and jaundiced with maximal tenderness in the right upper quadrant.
18. His observations are:
19. Temp 39.8oC
20. PR 120 per min
21. BP 100/65 mmHg
22. RR 22 per min
23. O2 Sat 98% on oxygen 6 LPM
24. Describe your management. (100%)
25.
26. SAQ 5 2007/2
27. Discuss the pharmacological options available (including dosages and modes of delivery) to treat anaphylaxis in the emergency department. (100%)
28.
29. SAQ 6 2007/2
30. A 58 year old patient who is undergoing Continuous Ambulatory Peritoneal Dialysis for end stage renal disease presents with a 6 hour history of severe abdominal pain and vomiting.
31. His observations are:
32. Temp 38.8oC
33. PR 110 per min
34. BP 150/90 mmHg
35. RR 22 per min
36. O2 Sat 98% on oxygen 6 LPM
37. Describe your assessment. (100%)
Discuss the strategies available in the event of a failed orotracheal intubation.
~ You are preparing to semi-urgently intubate a patient
a.) outline how you assess the likelihood of this being a difficult intubation b.) describe your approach to managing a potentially difficult intubation.
7. An 86 year-old woman is brought in by ambulance from her nursing home. She was found unconscious in her room, 12 hours after being seen to be her usual self.
Preliminary findings:
GCS 3 (tolerating oro-pharyngeal airway)
BP 200/110 mmHg
HR 50 bpm
Temp 31 deg C
Outline your approach to this case (100%).
Issues
• Immediate control of critically unwell patient – assume team leadership, and establish order and direction early
• Preliminary assessment:
o Immediate life threats
o Cause of coma – stroke, incl ICH
o Complications of coma – hypothermia, hypoglycaemia, other
• Preliminary management
o Airway support
o Rewarming
o Metabolic correction (eg hypoglycaemia)
• Ongoing:
o CT Brain – with our without ETT
o End of Life Consideration - depends on more info from NOK, NH, GP etc
o Palliative care is paramount. Additional Rx beyond this is subject to multiple factors, including time.
o Appropriate disposition
• Liaison with family / NOK is crucial
SAQ 2
Discuss the use of non-invasive ventilation in the emergency department. (100%)
The overall pass rate for this question was 39/67 (58.2%).
Pass criteria
Primary rationale for CPAP is correction of hypoxaemia versus correction of hypercarbia for
BiPAP
Understanding of the physiologic advantages of these therapies – both decrease work of breathing
and improve V/Q matching
Specific concerns re risk of aspiration
Specific concerns re patient tolerability / acceptability
Technical / nursing load and demands created by both therapies
SAQ 4
Compare and contrast the cardiac arrest algorithm for asystole between adults and children older than one year. (100%)
The overall pass rate for this question was 22/55 (40.0%).
The examiners felt that this was an excellent core knowledge question on a topic recently overviewed in widely discussed concensus statements (ILCOR/AHA/ARC). It was thought to have been overall answered very poorly by most candidates. Good responses identified the differences in pathophysiology (and hence, priorities) in children, highlighted the potential reversible causes and exhibited knowledge of the recently published algorithms in this area. Common errors in answering this question were incorrect drug doses, incorrect CPR ratios/rates, failure to mention intraosseous vascular access techniques and disregard of the differing pathophysiology.
SAQ 6
A 62 year old man with known chronic renal failure presents with respiratory failure, secondary to
pulmonary oedema. Oxygen saturation is 89% on 100% oxygen utilizing bi-level positive airway
pressure (BiPAP). His observations are:
Glasgow Coma Score 14
Temperature 37.0oC
Respiratory Rate 32 /min
Systolic blood pressure 90 mmHg
Electrocardiograph Rate of 105 /min with a regular broad complex rhythm.
An urgent Potassium level of 8.7 mmol/L (Reference Range: 3.5-4.9 mmol/L) has been recorded.
Discuss rapid sequence induction in this man. (100%)
The overall pass rate for this question was 23/56 (41.1%).
Examiners noted that this was a challenging question that required far more than a simple
description of an RSI template. In particular as a discuss question it required consideration of
whether RSI was appropriate at all, alternative approaches, the clinical context of a patient with life
threatening hyperkalaemia and the pros and cons of elements of RSI such as drugs, posture,
haemodynamics etc.
SAQ 2
Discuss the role of adrenaline and vasopressin in cardiac arrest.
The overall pass rate for this question was 33 / 64 (51.6%).
It was expected that a good answer would explain the current place of both drugs in resuscitation
guidelines but with an appreciation of the limited evidence for the efficacy of either. As a discuss
question a solid list of pros and cons was expected with this being a good opportunity to discuss
some of the quality of evidence issues. Failing answers lacked pros and cons, had limited detail and
made incorrect assertions regarding the role of the drugs.
2008.2 SAQ 4
Compare and contrast propofol and ketamine for procedural sedation in the emergency department. (100%)
SAQ 4
Describe a detailed protocol for the use of propofol in the emergency department.
The overall pass rate for this question was 22 / 44 (50%).
The expectation was that candidates would provide substantial detail in this answer on a topic in
which they could reasonably be expected to have a high level of knowledge. Although technical
issues such as pharmacology, dosing, indications were clearly required this in itself was not
sufficient to pass. Since the question asked for a detailed protocol examiners expected that more
managerial issues such as consent, credentialing of staff and audit would be addressed.
2. What features would you want in a patient trolley (bed) for a resuscitation area? Justify your answer.
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