WestmeadSAQ–“General”–TimeAllowed40mins

SUGGESTEDANSWERS–ShortGeneralSAQ

Question1

OcularTrauma

i) HyphaemaCase(inBlackpatient)

https://www.optocase.com/archives/hyphema.aspx

Thisa“Grade1”

Grade1-LayeredbloodoccupyinglessthanonethirdoftheanteriorchamberGrade2-BloodfillingonethirdtoonehalfoftheanteriorchamberGrade3-LayeredbloodfillingonehalftolessthantotaloftheanteriorchamberGrade4-Totalclottedblood,oftenreferredtoasblackballor8-ballhyphema

ii) EXAMLOOKINGFORCOMPLICATIONS• Inspection• Pressures• Visualacuity(outof20or60).• Fundoscopy+/-redreflex.• Extraocularmovements• RAPD/Pupils• DetailedSlitLampExam

InvestigationswouldincludeCoag/FBCinpatientofthisB/gbutquestionisaboutExaminationfindingnotinvestigations

Complications:

Raisedintra-ocularpressure(canleadtoopticatrophyandglaucoma)CornealstainingCornealopacificationSecondaryiritisVisionlossRe-bleedingHaemorrhageCataracts

iii) Re-bleedingisthemajorconcern=longtimevisualdeficit•Haemophilia•Sicklecelldisease•Sicklecelltrait•Idiopathicthrombocytopeniapurpura(ITP)Otherreasonablecauseof“rebleeding”

Question2

I) Listfour(4)criticaldiagnosesyouwouldconsiderand(one(1)riskfactorthatisassociatedwitheachofthesediagnoses.Differentials

a. MIb. Dissectionc. AAAd. PEe. Otherreasonabledifferentials

II) BrieflydescribetheEchostillimageintermsofdiagnosisandcomplications(3marks)i. Thoracicaorticaneurysm

i. StanfordAii. NoEffusioniii. PossibleCoronaryArteryInvolvement

Question3

AFibulaFracture(singleviewXR)–significantmechanism

?Partofamaisoneuveinjortibialplateauinj

Complications–Arterialinj,PeronealNerve,Compartment,OtherFractures(Missed)

- Ligamentousinjuryisalsopossible

SuggestfurtherXRfilms

MayneedCT

MayneedMRI

Question4

PreptheDepartment–People,Area,Equipment,Drugs,Sendforhelp(?internaldisaster)

ECGinOleanderPoisoning

39%normal-oftenhavevaryingAVblocks

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3004167

ECG

ClassicallygetAVblocksandAF

ThisECG-nopwave,bradycardia,reversetick,borderlinewidecomplexes(?escaperhythm)

Diagnosis-?OleanderPoisoning

Miverva

DigiBindIndications(LITFL)

Acutedigoxintoxicity

• cardiacarrest• life-threateningdysrhythmia• K>5mM• >10mgingested(adult),>4mgingested(child)• >15nMlevel(>12ng/mL)

Chronicdigoxintoxicity

• cardiacarrest• life-threateningdysrhythmia• dysrhythmiaorincreasedautomaticityunlikelytobetoleratedforaprolongedperiod• significantgastrointestinalsymptoms• symptomsofdigoxintoxicityandcoexistentrenalfailure

Otherlife-threateningcardiacglycosidetoxicities:

• oleanderpoisoning• canetoadpoisoning(bufotoxin)• Chinesemedicines(e.g.ChanSu,DanShenandLu-Shen-Wan)

Question5

AHypertensiveCrisis

i) 3featuresassociatedwithMalignantHypertension

VisualChanges

Headache

EndOrganDamage

AbsoluteNumber

SecondaryCauses(Endocrine,Renal)

ii) 4causes

COMMONCAUSES

- AcuteRenalFailure

- AorticCoarctation- AorticDissection- ChronicRenalFailure- Eclampsiainfemales- Hypercalcemia- Hyperthyroidism- Pheochromocytoma- RenalArteryStenosis- SubarachnoidHemorrhage

Needtolist4reasonablecausesofmalignanthypertension

iii) Discusshowyouwouldmanagethispatient’sbloodpressureintheED.(3marks)

Approach–Avoidloweringtooquickly:

“Overzealousreductionofbloodpressurecanresultinorganhypoperfusion,andtargetorgandamagecanbemissedwithoutathoroughevaluation.Properlydiagnosinghypertensiveemergencyandurgencyisessentialtopropertriageandtreatment

Allpatientsshouldbecarefullyassessedforsecondarycausesofhypertension”

BPonbotharms,ArterialLine,Analgesia,Medications,Titrationofmeds

DRUGEXAMPLES:

Drug PROS CONS Dosing

SodiumNitroprusside

PRO–EffectiveArterialDilatorCAVEAT-PotentiallyToxic(Cyanide)

CON–MayincreaseheartrateShouldbe‘covered’Unfamiliarity

Infusion0.5–3mcg/kg/min

Esmolol PRO-Veryshortacting(estergroup)Easilytitrated

CON-ObstructiveLungDisease

Bolustheninfusion

GTN PRO–Effective-Lowersbloodpressure–avenodilator

CON–MayincreaseheartrateTachyphylaxis

Infusion5–200mcg/min

Other OtherBetaBlockers,Nicardipine,Analgesia