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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”
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Question2
I) Listfour(4)criticaldiagnosesyouwouldconsiderand(one(1)riskfactorthatisassociatedwitheachofthesediagnoses.Differentials
a. MIb. Dissectionc. AAAd. PEe. Otherreasonabledifferentials
II) BrieflydescribetheEchostillimageintermsofdiagnosisandcomplications(3marks)i. Thoracicaorticaneurysm
i. StanfordAii. NoEffusioniii. PossibleCoronaryArteryInvolvement
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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
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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
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- 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