ACEM Fellowship Examination Emergency Medicine Practice Questions SAQ

Transcription

1 ACEM Fellwship Examinatin Emergency Medicine Practice Questins SAQ SAQ Questin 1 (16 minutes) a) List the pssible causes f the child s death (30%) b) Describe in detail yur verall management f this situatin with particular reference t management f the parents frm their time f arrival in the Emergency Department (70%) SAQ Questin 2 (16 minutes) a) Outline the Legal Issues surrunding D nt Resuscitate rders (30%) b) Prir t yu discussing the situatin with the upset family the patient suffers a Cardiac Arrest. Describe yur management. (70%)

2 ACEM Fellwship Examinatin Emergency Medicine Practice Questins VAQ Questin 1 A 69-year-ld lady presents t the Emergency Department (ED) with a histry f sudden cllapse. She is brught in by ambulance and has a GCS f 7 n arrival in the ED. Triage ATS Categry 1 Observatins: Bld Pressure 66/30 Respiratry Rate 8/min Heart Rate 40 Oxygen Saturatins 89% (n 15 litres by Hudsn Mask) a) Describe and interpret the patient s Electrcardigram. (50%) b) Shrtly after arrival the patient suffers a Cardiac Arrest. Outline yur management pririties and the mdificatins yu wuld apply t the standard Cardiac Arrest algrithm (50%) (ECG n next page)

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4 ACEM Fellwship Examinatin Emergency Medicine Practice Questins VAQ Questin 2 A 48-year-ld man presents t the Emergency Department (ED) with a histry f Cardiac Arrest at the lcal supermarket. CPR was started by bystanders immediately. He received 2 DC Shcks by the ambulance paramedics and has a Return f Spntaneus Circulatin (ROSC) prir t arrival in the ED Triage ATS Categry 1 GCS 6 Observatins: Bld Pressure 78/50 Respiratry Rate 15/min (spntaneus) Heart Rate 75 Temperature 36.1 degrees Oxygen Saturatins 99% (n 10 litres by Hudsn Mask) a) Describe and interpret the patient s Electrcardigram. (50%) b) Outline yur management pririties (50%) (ECG n next page)

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6 Ntes General Pints Always questins n Resuscitatin 2012:2 paper asked fr a Summary f the 2010 changes in the SAQ paper Latest Australia and New Zealand Guidelines are fund at Defibrillatin Effectiveness is dependent n Trans-thracic Impedance. T minimise impedance use 10-13cm pads, 5kg pressure, Defibrillatin in Expiratin and the Use f Paste with lder defibrillatin paddles CPR Cardiac Pump and Thracic Pump Theries t explain efficacy Recent trend tward minimsing interruptins in CPR cmpressins. An effective pressure head takes time t build up with Chest Cmpressins and therefre effective CPR depends n minimising delays and interruptins At mst, gd CPR prvides 20% f nrmal cardiac utput Cardiac Arrest Prgnsis Out f Hspital 0-21%, 8% verall. In hspital 13.8% (Camern) Outcme is better in witnessed arrest, early CPR, VT, VF and defibrillatin time Larsen et al (1993) 5.5% reduced survival per minute (cmpsite data) Survival is quted as up t 67% if BLS/ALS measures are prvided early (Camern) When t stp cntrversial (generally >20mins f asystle and lw ETCO2) Evidence Based Resuscitatin COSTR Cnsensus n Scientific Treatment Recmmendatins Unifrm Reprting (Utstein Methd) has imprved accuracy f data In terms f Public Health Hands nly CPR may be mre effective in terms f teaching and educatin. The SOS Kant (2007) and Arizna Studies demnstrated imprved survival in the Chest Cmpressins nly patients cmpared t the ABC patients With AED Ontari study (Stiell et al) demnstrated a survival benefit in public places. AEDs in the hme have nt been shwn t imprve utcme 2010 Guideline Changes In Paediatrics: Intrasseus Lines are emphasised: Indicatins Unable t btain IV access in an emergency/cardiac arrest. Cmplicatins f IO Bne (Grwth Plate) Injury, Cellulitis, Fracture, Cmpartment Syndrme, Extravasatin f Drugs, Ostemyelitis. Cntraindicatins f IO Fracture, Infectin Atrpine is n lnger given during cardiac arrest in the new prtcls LMA favured. ETT and ETT drugs are less favured. ETCO2 is encuraged

7 Pst Cardiac Arrest Care Tpical: Recent Changes and Key Papers in 2002 shwing benefit f Therapeutic Hypthermia Cling Therapeutic Hypthermia cnsider limited targeted temperature management Passive and Active measures shuld be cnsidered: 3 deg saline given IV ICE t grins and axilla End Pints f cling aim fr 32-33C Pst Drwning care is als tpical fr the FACEM exam Key article - Stub et al Circulatin This article and ther similar cmmentary n the subject suggests cling the patient as well as ptimum fluid, BP and supprtive care management: Fluids are generally thught t be a gd thing pst cardiac arrest BP aim fr relatively High BP MAP >75 Avid Hyperxia Avid Hyperventilatin Arrange Catheter Lab ASAP, Cnsider IABP and AICD Check ECG fr QT, Brugada, T wave changes Gd Supprtive Care ICU Referral Dcument Neurlgical Signs Prir t Intubatin and Ventilatin BSL mnitring and cntrl Angigraphy is warranted in many pst cardiac arrest patients even withut classic features f a STEMI n the ECG