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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