VAQ 035
VAQ 035
A 29 year old female patient is brought into the Emergency Department by ambulance. She is complaining of weakness, lethargy and palpitations. She denies any previous illness and claims she does not take any medications.
On examination you find a drowsy, very thin young female. Her blood pressure is 100/60 mm mercury and has a pulse rate of 90 beats per minute. Apart from cachexia and generalised weakness (3/5 to 4/5 in all muscle groups) there are no physical abnormalities found. Her ECG is reproduced.
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(a) Describe the ECG findings.
(b) What are the possible causes of this ECG?
(c) Outline your initial management.
A 38 year old man presents to your ED with 2 days of chest pain.
His vital signs are normal, and he has no positive IHD risk factors.
a) Describe and interpret the ECG (50%)
How would you further investigate this man? (50%)
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A 38 year old man collapses while playing squash. He spontaneously recovers during transport by ambulance. He has no known past medical problems. His observations are: BP 120/70, GCS 15, O2 sat 100% on 6L/min. An ECG is shown.
Question
|a. |Describe this ECG. |(50%) |
|b. |Outline this patient’s disposition and explain why. |(50%) |
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FACEM VAQ Exam 2003.1 – Question 1
• The overall pass rate for this question was 64 / 83 (77.1%).
• ECG showed atrial flutter with variable block.
• The examiners expected an accurate description of the rhythm and a plan to admit to a monitored bed with justifications for doing so (such as unstable rhythm or high grade block).
• Failures were due to ECG misinterpretation or giving a treatment plan when disposition and why was asked for.
2003.2 VAQ 7
This 23 year old man complains of palpitations and dizziness. His blood pressure is 70/50.
Question
|a. |Describe the ECG. |(50%) |
|b. |How would you manage this man. |(50%) |
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FACEM VAQ Exam 2003.2 – Question 7
• Overall pass rate for this question was 42 / 82 (51.2%).
• An ECG showing a rapid, regular tachycardia with borderline QRS width is shown.
• Examiners felt that this was a good ECG demonstrating a problem that was important for an emergency physician to be able to interpret and manage.
• It was expected that the ECG description would include a synthesis and mention of the factors that could be used to differentiate VT from PSVT with aberrancy.
• Management was expected to include the use of cardioversion in this unstable patient.
• Extra points were given for treating any underlying causes. Failures occurred due to use of inappropriate therapies such as verapamil or an unstructured approach to the ECG with VT not included in the differential.
2007.1 VAQ 7
A 49 year old woman presents to your emergency department with central chest pain.
His observations are:
| |HR |110/70 |mmHg supine |
| |02 |90 |% RA |
Question
|a. |Describe and interpret her ECG |(50%) |
|b. |Outline your disposition considerations |(50%) |
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FACEM VAQ Exam 2007.1 – Question 7
• Overall pass rate for this question was 32/55 (58.2%).
• ECG showed widespread T wave inversion, concave up ST elevation and PR depression inviting in this clinical context a discussion re a number of differentials.
• This was viewed as a difficult but relevant ECG which was satisfactorily interpreted by most candidates.
• The discussion re echocardiography was generally superficial and was the major reason for poor scores.
A 78 year old man is brought to your emergency department after being found on the floor of his home. His only past medical history is of congestive cardiac failure, and he is unable to remember his medications.
An ECG has been taken.
Question
|a. |Describe and interpret her ECG |(100%) |
| |
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FACEM VAQ Exam 2006.2 – Question 1
• The overall pass rate for this question was 41/57 (71.9%).
• ECG showing Mobitz type 2 AV block ( 2:1 ) with RBBB and R axis deviation.
• The examiners felt that this question was not well done by the candidates overall, especially as this was regarded as a straight forward ECG.
• In order to pass, candidates needed to exhibit a systematic approach to ECG interpretation and identify pass/fail criteria of 2:1 AV Block, Right BBB and Right Axis Deviation plus a number of secondary changes.
• Better candidates were able to put the ECG findings into the given clinical context. Candidates who scored poorly failed to meet the basic pass/fail criteria above.
2005.2 VAQ
A 40 year old man presents to the emergency department with a history of chest pain two hours previously. He is now pain free.
Question
|a. |Describe and interpret her ECG |(50%) |
|b. |What investigations does this man need and why? |(50%) |
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FACEM VAQ Exam 2005.2 – Question 7
• Overall pass rate for this question was 36/56 (64.3%).
• The ECG provided shows a change from broad to narrow complex rhythm across the ECG and ST/T changes suggesting a proximal LAD stenosis.
• The key to this question was to recognize ECG changes strongly indicative of a proximal left coronary stenosis which was visible in the second half of the ECG when the broad complex rhythm was no longer present.
• Candidates who failed did not appreciate the clinical significance of the ECG changes and the presumed site of stenosis, and therefore did not make clear the need for early angiography.
A 70 year old man presents to the emergency department with presyncopal symptoms and central chest pain for the first time.
Question
|a. |Describe and interpret her ECG |(50%) |
|b. |Outline your management |(50%) |
[pic]
FACEM VAQ Exam 2007.2 – Question 1
• The overall pass rate for this question was 32/77 (41.6%).
• ECG showed Atrial Fibrillation with ST/T changes and a non specific interventricular conduction defect.
• The examiners felt that this was an appropriate standard ECG with multiple abnormalities.
• The management question was also thought relevant. Time may have been an issue with the interpretation of a complex ECG plus a number of management options.
• Candidates who did not pass this question erroneously or incompletely analysed the ECG or suggested inappropriate management strategies such as cardioversion or use of Beta Blockers or Nitrates.
Question 7 continued.
A 74 year old woman presents to the ED with several days of lethargy, nausea, vomiting and near syncope.
Her past medical history includes hypertension, cardiac failure, atrial fibrillation, and chronic renal insufficiency. She takes multiple medications, but is unable to provide a list.
She is lethargic but easily roused. Her systolic blood pressure is 85 by palpation.
An immediate venous blood gas reveals the following results:
Na 129
K 6.4
a) Describe this ECG.
b) Outline your management.
A sixty year old woman presents with a history of multiple episodes of pre-syncope.
a) Describe and interpret her ECG.
b) Outline your management.
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a.
b. Describe and Interpret ECG
• 12 lead ECG
• Regular rhythm
• LAD
• Ventricular rate 33 ( ventricular escape rhythm)
• Atrial rate 96
• No relationship btw p wave and QRS complexes
• QRS wide (> 140msec), RBBB
• ? ST-T seqment depression < 1mm V2-V5)
• No evidence Inferior AMI, hypothermia , significant electrolyte disturbance (K+)
• SUMMARY Complete heart block , no evidence myocardial infarction, consider drug overdose ( B-blocker, Ca Channel blocker, TCA –NB bradycardia terminal sign ) or electrolyte disturbance. Note underlying RBBB and LAD (LAHB). In view of multiple syncope pt likely requires definitive PPM.
c. Outline your management.
• Resus cubicle
• Team approach
• Full physiological monitoring
• Manage ABC:
• Airway opening manouvers if ACS, hypoxia or upper airway obstruction
o Care with cervical spine if suspect injury from syncope)
• High flow O2 via mask, BVM if requires support
• 2x large bore IV access, 500ml bolus N/Saline if BP < 100
• Specific treatment
o Atropine 0.6mg IV up to 2-3mg
o Adrenaline 10 mcg iv boluses then infusion
o Consider isoprenaline ( 20 mcg IV boluses and infusion)
o TC pacing - may require analgesia and sedation to tolerate
o Urgent consult cardiology
o TV pacing / PPM
• Manage cause / complications
o Seek and treat under lying causes eg NonSTEMI, OD
o Correct any electrolyte disturbance
o Manage complications
o Asystolic arrest
o APO/ cardiogenic shock
• Disposition - Admission to CCU / ICU ( if related drug OD)
• Communication - Explanation / reassurance patient and family
3. A 75 year old man presents with a history of chest pain and light headedness.
He has a GCS of 14/15, BP 90/70 and RR 20. Sp02 is 97% on room air.
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a) Describe his ECG.
b) Outline your management.
There’s more below – the document won’t let me delete the next 2 blank pages – sorry!
Question 4
A 74 year-old man presents with recurrent syncopal episodes. An ECG is taken on arrival.
[pic]
a. Describe and interpret the ECG (50%)
b. Outline the key features in your examination of this patient (50%)
Question 7
A 26 year-old woman with a history of systemic lupus erythematosus presents with a 2-week history of lethargy and intermittent atypical chest pain.
On examination, she looks not unwell. Afebrile, BP 130/80. An ECG on arrival is taken.
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a) Describe and interpret the ECG (50%).
b) List and justify your other investigations in this patient (50%)
A 74 year old woman with previous hypertension and type II diabetes presents with epigastric pain and distended abdomen. She is breathless.
Her observations are as follows: SaO2 85% on room air, NIBP 90/55mmHg, Respiratory Rate 24/min and Temperature of 37.5oC.
Question
|a. |Describe and interpret her ECG |(50%) |
|b. |List the treatment for this woman |(50%) |
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FACEM VAQ Exam 2004.1 – Question 1
• The overall pass rate for this question was 59 / 69 (85.5%).
• An ECG demonstrating extensive ST elevation AMI is shown.
• Examiners expected that the ECG would be correctly interpreted as showing an inferoposterolateral infarct with the possibility of right ventricular involvement.
• It was expected that the ECG would be interpreted in light of the presented scenario with a number of pressing clinical issues such as hypoxia, cardiogenic shock and the potential for an abdominal cause or complication such as ischaemic gut.
• The treatment needed then to address all of these issues and was not just that of a simple infarct.
• The commonest cause for failure was the lack of appreciation of the presence of shock and the urgent need for its treatment. Some candidates were not able to appreciate the extent of the infarct shown on the ECG.
A 25 year old man is brought to the emergency department complaining of chest pain for 48 hours.
Question
|a. |Describe his ECG. |(50%) |
|b. |List the possible causes. |(50%) |
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FACEM VAQ Exam 2004.2 – Question 3
• The overall pass rate for this question was 55 / 64 (85.9%).
• His ECG shows widespread ST segment changes.
• Examiners expected that description would highlight that the ECG was typical for an AMI but in a patient of an atypical age.
• The description should have included relevant negative findings and be done in a systematic manner.
• Failing answers had inadequate descriptions, didn’t mention AMI or focused on diagnoses not supported by the ECG (e.g. WPW syndrome).
A 50 year old man presents with shortness of breath and sharp central chest pain of 24 hours duration. He has no past medical history and is on no medication.
Question
|a. |Describe and interpret his ECG |(100%) |
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FACEM VAQ Exam 2008.2 – Question 6
• ECG showing narrow complex tachycardia with electrical alternans.
• The overall pass rate for this question was 46/81 (56.8%).
• Both examiners felt that this was a good question, poorly answered by many candidates.
• High level answers showed a structured approach to ECG interpretation and stated conclusions within the clinical context.
• Poor answers failed to calculate rate, identify alternans or interpret within context.
A 30 year old female is brought to your ED by ambulance following a suspected drug overdose. Her observations are: BP 90/60 mmHg (supine), RR 20/min, SaO2 99% (room air) and GCS 14.
Question
|a. |Describe and interpret her ECG |(50%) |
|b. |Outline your initial management in the ED. |(50%) |
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FACEM VAQ Exam 2006.1 – Question 1
• The overall pass rate for this question was 30/40 (75%).
• The ECG given shows a broad complex tachycardia
• Examiners expected that the ECG description would specify the rate of 130, broad QRS and prolonged QT likely to be TCA overdose (or other Na channel blocking agent).
• Initial management needed to focus on the need for bicarbonate/alkanisation and a low threshold for definitive airway management because of the high risk of rapid deterioration.
• Failing answers misinterpreted the ECG, including being unable to estimate the rate. Some missed the clues about a toxicological cause and assumed this was a primary cardiac problem.
• Others did not mention TCAs as a possible cause and saw no role for the use of bicarbonate.
A 72 year old man presents by ambulance to your ED with onset of tachycardia and shortness of breath.
Question
|a. |Describe and interpret her ECG |(100%) |
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FACEM VAQ Exam 2006.1 – Question 8
• Overall pass rate for this question was 25/40 (62.5%).
• The ECG given shows a regular, narrow complex tachycardia with widespread ischaemic changes
• The examiners noted that with the limited clinical information given and the number of ECG abnormalities present a reasonably broad range of possibilities need to be considered in the interpretation.
• The description needed to note the tachycardia which was atrial in origin and associated with significant ischaemic changes.
• The interpretation should have noted that this was likely to be a clinical situation requiring urgent treatment or referral.
• Failures were due to basic errors of description (often including findings that were not present) or due to providing very limited differentials.
A 78 year old man is brought to your emergency department after collapsing at the local shopping centre that morning. He is now alert with no memory of the event. His observations are normal.
Question
|a. |Describe and interpret his ECG |(50%) |
|b. |Outline the investigations prompted by his ECG |(50%) |
[pic]FACEM VAQ Exam 2008.1 – Question 1
• ECG showing showing intermittently paced rhythm with underlying complete heart block.
• The overall pass rate for this question was 49/62 (79.0%).
• The examiners felt that this was an excellent question and prop which tested appropriate knowledge.
• Good answers in part a) described the presence of a pacemaker, underlying high level heart block and intermittent pacemaker failure.
• Satisfactory answers to part b) had to include a discussion of the investigation of a failing pacemaker.
• Poor answers failed to identify the presence of a pacemaker and its intermittent failure.
A 32 year old woman is brought to your emergency department by her friend who believes her to have taken a deliberate overdose earlier that morning. The patient is drowsy and denies this. Her observations are normal.
Question
|a. |Describe and interpret her ECG |(50%) |
|b. |What drugs would you consider as potential ingestants? |(50%) |
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FACEM VAQ Exam 2008.1 – Question 6
• ECG showing markedly prolonged QT interval.
• The overall pass rate for this question was 54/62 (87.1%)
• The examiners felt that this was a basic question on a core ECG area that should have been well handled by most well prepared candidates.
• Despite this, a large number of candidates failed to diagnose the prolonged QT/QTc and/or failed to realise its significance.
• Failed candidates tended to provide an incorrect or non specific list of potentially causative drugs.
A 49 year old woman presents to your emergency department with central chest pain.
His observations are:
| |HR |110/70 |mmHg supine |
| |02 |90 |% RA |
Question
|a. |Describe and interpret her ECG |(50%) |
|b. |Outline your disposition considerations |(50%) |
[pic]
FACEM VAQ Exam 2007.1 – Question 7
• Overall pass rate for this question was 32/55 (58.2%).
• ECG showed widespread T wave inversion, concave up ST elevation and PR depression inviting in this clinical context a discussion re a number of differentials.
• This was viewed as a difficult but relevant ECG which was satisfactorily interpreted by most candidates.
• The discussion re echocardiography was generally superficial and was the major reason for poor scores.
A 64 year old woman presents with acute chest pain, dyspnoea at rest and palpitations.
His observations are:
| |HR |96 |/min |
| |BP |90/65 |mmHg supine |
| |Sa02 |89 |%via Hudson mask (6 L/min) |
| |Temp |37 |Celsius |
| | | | |
Question
|a. |Describe and interpret her ECG |(50%) |
|b. |List your treatment priorities. |(50%) |
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FACEM VAQ Exam 2006.2 – Question 7
• Overall pass rate for this question was 40/57 (70.2%).
• ECG showing paced rhythm.
• The examiners felt this was a challenging question and was an excellent discriminator.
Pass/fail criteria were a reassured description of paced rhythm and comprehensive approach to hypotension in the setting of paced rhythm
An 80 year old woman presents to your emergency department with palpitations and breathlessness for three days. She had undergone coronary bypass grafting two weeks earlier.
Question
|a. |Describe and interpret her ECG |(50%) |
|b. |List the possible causes of her breathlessness. |(50%) |
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FACEM VAQ Exam 2005.2 – Question 6
• Overall pass rate for this question was 45/56 (80.4%).
• The ECG provided shows a narrow complex tachycardia with electrical alternans.
• Examiners noted that better answers correctly diagnosed the electrical alternans but it was still possible to pass by noting that this was a narrow complex rhythm of which possible causes included a pericardial effusion post surgery
• It was incorrect to call the rhythm atrial fibrillation. It was expected that the list of possible causes for her breathlessness would be structured so as to highlight the important or likely causes in this particular patient.
A 70 year old man presents to the emergency department with presyncopal symptoms and central chest pain for the first time.
Question
|a. |Describe and interpret her ECG |(50%) |
|b. |Outline your management |(50%) |
[pic]
FACEM VAQ Exam 2007.2 – Question 1
• The overall pass rate for this question was 32/77 (41.6%).
• ECG showed Atrial Fibrillation with ST/T changes and a non specific interventricular conduction defect.
• The examiners felt that this was an appropriate standard ECG with multiple abnormalities.
• The management question was also thought relevant. Time may have been an issue with the interpretation of a complex ECG plus a number of management options.
• Candidates who did not pass this question erroneously or incompletely analysed the ECG or suggested inappropriate management strategies such as cardioversion or use of Beta Blockers or Nitrates.
A 68 year old man presents with one hour of rapid palpitations.
Two ECGs are shown – ECG 1 and 2 are before and after his anti-arrhythmic drug treatment respectively.
Question
|a. |Describe and interpret ECG 1 |(50%) |
|b. |Describe and interpret ECG 2 |(50%) |
| |
ECG 1
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ECG 2
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• ECG 1 showed a narrow complex tachycardia with widespread ST segment depression
• ECG 2 showed an ectopic atrial rhythm with 2:1 AV nodal conduction with almost complete resolution of the ST segment changes.
• Overall pass rate for this question was 37/77 (48.1%)
• The examiners felt that the ECGs were both of a suitable standard for this level of testing. ECG 1 was largely well completed by most candidates. Many candidates failed to identify the nodal block and the ectopic atrial focus.
A 72 year old woman is brought to your Emergency Department after a syncopal episode.
|a. |Describe and interpret her ECG |(50%) |
|b. |Outline your disposition considerations |(50%) |
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FACEM VAQ Exam 2009.1 – Question 1
• The overall pass rate for this question was 26/81 (32.1%)
• ECG showing first degree heart block, left axis deviation and RBBB.
• The examiner pair felt that this was a core EM scenario that was done very poorly by the majority of candidates.
• Pass criteria were to identify the ECG features above plus appreciate the conduction implications of this in the presence of syncope with need for monitoring and potentially pacing.
A 35 year old man is brought to your Emergency Department following two seizures. His observations are:
| |GCS |8 |/min |
| |BP |75/40 |mmHg supine |
| | | | |
| | | | |
| |Describe and interpret his ECG |(100%) |
FACEM VAQ Exam 2009.1 – Question 7
• The overall pass rate for this question was 52/81 (64.2%)
• ECG showing regular broad complex tachycardia with widened QRS and abnormal terminal R wave in aVR.
• Again the examiners were disappointed with the response to this straight forward question.
• Pass criteria were identifying the abnormalities listed plus considering toxic ingestion (especially Tricyclic Antidepressant Overdose (TCA)) as a cause in this scenario.
• Fail criteria were absence of the above.
VAQ 6
A 50 year old man presents with shortness of breath and sharp central chest pain of 24 hours
duration. He has no past medical history and is on no medication.
His observations are:
BP 110/80 mmHg supine
Temperature 37.9oC
O2 saturation 97% room air
[pic]
Describe and interpret his ECG. (100%)
The overall pass rate for this question was 46/81 (56.8%)
Both examiners felt that this was a good question, poorly answered by many candidates. High level
answers showed a structured approach to ECG interpretation and stated conclusions within the
clinical context. Poor answers failed to calculate rate, identify alternans or interpret within context.
VAQ 1
A 70 year old man presents to the emergency department with presyncopal symptoms and central chest pain for the first time.
His observations are:
BP 90/70 mmHg supine
O2 saturation 95% room air
[pic]
a. Describe and interpret his ECG. (50%)
b. Outline your management. (50%)
The overall pass rate for this question was 32/77 (41.6%).
The examiners felt that this was an appropriate standard ECG with multiple abnormalities. The management question was also thought relevant. Time may have been an issue with the interpretation of a complex ECG plus a number of management options. Candidates who did not pass this question erroneously or incompletely analysed the ECG or suggested inappropriate management strategies such as cardioversion or use of Beta Blockers or Nitrates.
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