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Josh's RC Questions > Acute Care/ED SAQ > Flashcards

Acute Care/ED SAQ Flashcards

1
Q
  1. A 15 year old male collapses while playing basketball. CPR is initiated, emergency responders intubate the patient. You see the following rhythm strip:
    [Vfib]
    A. What does the rhythm show?
    B. What are TWO treatments you should institute?
    C. What is your compression ratio per minute?
    D. What is your ventilation ratio per minute?
A

A. Ventricular fibrillation
B.

  1. Defibrillation: first shock 2J/kg, second shock 4J/kg. Then >=4J/kg, max 10J/kg
  2. Obtain IV/IO access and give epinephrine

C. 100 bpm
D. 10 breaths per min

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2
Q
  1. A boy is involved in an MVC. He was intubated by the ED doctor. He now develops bradycardia, hypertension and a dilated pupil. List 4 steps in your treatment
A
  1. Elevate head of the bed up to 30 degrees with head in the midline position
  2. Hyperventilate to pCO2 25-30
  3. Give 3% NS 5mL/kg
  4. Sedation and analgesia. Avoid ketamine b/c of increased ICP
  5. Do CT head once stable
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3
Q
  1. A three year old boy is brought to the emergency room after extrication from a house fire. He was found in a smoky room.
    a) What three clinical features would make you think the has upper airway inhalational injury?
    b) What is your immediate intervention?
A

A.

  1. Soot in the nares, mouth or carbonaceous sputum
  2. Singed eyebrow or facial hair
  3. Stridor, WOB, tachypnea

B. Intubate

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4
Q

Table given with medications. Write “increase” “decrease” or “none” for effect of the following on (a) contractility, (b) PVR, (c) SVR

A. Epi 0.05 mcg/kg/min
low
B. Epi 0.5 mcg/kg/min
intermediate
C. Dopamine 20 mcg/kg/min
D. Dobutamine

A

Epi 0.05mcg/kg/min (low dose) - B2>a, B1

a) contractility - increase - B1
b) PVR - no effect
c) SVR - decrease - B2

Epi 0.5mcg/kg/min (intermed dose)- a>B2, B1

a) contractility - increase
b) PVR - increase
c) SVR - increase -a

Dopamine 20mcg/kg/min - a,B1

a) contractility - increase
b) PVR - increase
c) SVR - increase

Dobutamine - B1, B2

a) contractility - increase
b) PVR - none
c) SVR - decrease

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5
Q
  1. Kid with Methanol toxicity. Na 140, K 4, Cl 96, Bicarb 11, BUN 11, Glucose 4, Serum osmolarity–396
    a) Calculate anion gap. Show calculations:
    b) If anything, What would you expect of the osmolar gap?
    c) What is the long term complication of methanol toxicity
    d) What is one med to treat methanol toxicity
A

A) Na - (HCO3 + Cl) = 140 - (11 + 96) = 140 - 107 = 33
B) High >10
Calculated osmolarity = 2(140) + 4 +11 = 280 + 15 = 295
OG = measured - calculated = 396-295 = 101!
c) Ocular toxicity/blindness
d) Fomepizole

High Osmolar gap
PIE ME
P - polyethylene glycol, propylene glycol
I - isopropyl alcohol (no acidosis)
E - ethanol
M - methanol, mannitol
E - ethylene glycol

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6
Q

2 patients have arrived at the same time in the ED:
Patient 1 – 8yo boy with asthma attack, resp distress and tracheal tug. RR 36 PCO2 28.
Patient 2 – 8yo boy with asthma attack, resp distress and tracheal tug. RR 20 PCO2 38.
(no other info was given)
Which patient do you see first? (2 points)
Explain your choice (2 points)

A

Patient 2

Lower RR and “normal” pCO2 indicates that this patient is in impending respiratory failure and tiring out.
Compensated asthmatic should have tachypnea and hyperventilation with low pCO2

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7
Q

A 4 year old boy fell off a park bench onto concrete a few hours ago. He did not lose consciousness but vomited a few times since. His GCS in the ER is 14.
a. What are 5 indications for a CT head in this patient?

A

Mild TBI = CATCH rules

GCS 13-15 in previous 24H and witnessed LOC, amnesia, witnessed disorientation, persistent irritability (in <2yo), or persistent vomiting (>1X) AND

WIGS

  1. Worsening h/A
  2. Irritability on exam
  3. GCS <15 after 2H of observation
  4. Suspected depressed skull #
  5. Any sign of basal skull #
  6. Large, boggy scalp hematoma
  7. Dangerous mechanism
    • MVC
    • Fall from 3ft or 5 stairs
    • Fall from bike without helmet

Absolute indications

  • Focal neurological exam
  • Suspected open or depressed skull # or widened or diastatic skull # on Xray

Relative indications

  • GCS <14 at any point from time of initial assessment onward OR GCS <15 at 2H aftr injury
  • Clinical deterioration over 4-6H of observation in ED
  • Sz at time of event or later
  • known coagulopathy
  • Projectile (gunshot or metal fragment)
  • Plus the ones in CATCH
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8
Q
  1. A child was at a restaurant 1.5 hours ago and had a hamburger + drink. Shortly thereafter, he was noted to be drooling and not tolerating his own secretions at all. You do an X-ray and find a Twoonie stuck in the upper 1/3 of his esophagus. You consult GI/surgery for urgent scope + removal.
    a. How soon is the soonest you can safely proceed with the removal as per anesthesia
    b. What are 3 indications for urgent removal of an esophageal foreign body?
A

a)Aspiration risk anyway, since not handling secretions, go now

  • If tolerating secretions. NPO now. 8H post last meal, so in another 6.5H
    • clear fluids okay up until procedure
    • breast milk 4H
    • formula 6H
    • solid food 8H

b)

  1. Battery
  2. Sharp foreign body
  3. Any signs of resp compromise, esophageal perforation, or complete esophageal obstructions
  4. Two magnets
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9
Q
  1. Kid comes into ED not using his arm after mom pulled hard to get his sweater off.
    a. What is the diagnosis (be specific)
    b. What is the anatomic abnormality/finding
    c. How will you reduce it? guidelines given his NPO status?
A

A. Nursemaid elbow
B. Subluxation of the annular ligament (wraps around ulna, radial head, and proximal ulna)
C. Reduce by rotating forearm into supination while holding pressure over radial head

  • feel palpable click
  • recovers immediately
  • no need to immobilize

Do not need NPO because surgery rarely indicated, even if irreducible (tend to resolve spontaneously over days to weeks)

Usually in <5yo
Produces immediate pain + limited supination
Normal flexion + extension, typically no swelling

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10
Q
  1. 16 year old boy had femur fracture following skateboarding (poor kid!). Now in a cast with traction, and on day 4 develops respiratory distress, with oxygen sat 84%. Name 2 likely causes. What 1 investigation would you do?
A

A. Likely causes

  1. Fat embolism
  2. pneumonia
  3. PE
  4. Pneumothorax
  5. Atelectasis

B. spiral CT chest

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11
Q
  1. 2 yo girl was bitten by a dog in the playground and has an open wound on her right thumb. What are FIVE things to do in her management. She is fully immunized.
A
  1. Examine for neurovascular damage
  2. Clean the wound with saline. Leave open to drain
  3. Start amoxicillin-clavulin (3-5d for ppx or 7-10d for Tx of infected looking tissue)
  4. Report dog to public health. Determine if dog is rapid. If unsure, can give rabies vaccine and immunoglobulin
  5. Pain control. Consider local anesthesia.

Note: do not need tetanus Ig if she is fully immunized and received 3 doses of tetanus, even for “all other wounds”

  1. Contaminated with dirt, soil, feces, saliva (animal bites)
  2. Deep puncture
  3. Avulsion
  4. Injury due to missile, crush, burn, frostbite

When is ABx prophylaxis indicated? Also reasons for leaving wounds open.

  1. Deep puncture wounds (esp cat bites)
  2. Mod-severe wounds due to crush injury
  3. Wounds in areas of underlying venous +/ lymphatic compromise
  4. Wounds on hand(s), genitalia, face, or in close proximity to bone or joint (esp hand and prosthetic joints)
  5. Wounds requiring closure
  6. Bite wounds in compromised hosts (immunocompromised, functional/anatomical asplenia)
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12
Q
  1. Child in status for a while, ABC stable, IV inserted. What ONE thing do you do initially? What are FOUR other steps if step one doesn’t stop the seizure.
A

A. Lorazepam 0.1mg/kg IV
B.
1. Give Second dose of lorazepam 0.1mg/kg IV within 5min
2. If still seizing, give Fosphenytoin load 20mg/kg IV
3. If still hasn’t stopped in 5min, Phenobarbital load 20mg/kg IV
4. Consult PICU + Neuro, midazolam infusion
5. Check glucose if not mentioned in stem. Start thinking about causes of the seizure.

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13
Q
  1. 16 yo girl with an MVA. Was intubated at the scene because GCS 6. HR 142, BP 85/54, Sa O2 94% on 50% fio2. PERL and 4 mm. What are the two likely causes of her presentation? List three things you would do for her immediate management
A

A. Likely causes

  1. Diffuse axonal injury
  2. Intracranial hemorrhage

B. Immediate management

  1. Activate trauma code. Do trauma survey. Ensure that she is in a C-spine collar.
  2. Establish IV/IO. Give NS 20mL/kg, reassess response and repeat as necessary. Consider inotropic support. Aggressively manage the hypotension.
  3. Order blood.
  4. CT of areas of suspected injury
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14
Q
  1. A. Name two things you would see on an EKG that would make you think of hyperkalemia.

B. What are three treatments you would start if you confirmed hyperkalemia causing EKG changes.

A

A. ECG findings of hyperkalemia

  1. Peaked T waves
  2. Increased PR interval >200ms. Eventual loss of P wave
  3. Widened QRS >120ms
  4. Sine wave pattern
  5. V fib

B Management

  1. Stop all sources of additional potassium
  2. Ventolin nebs
  3. Insulin (with glucose)
  4. Calcium carbonate (stabilize heart cell membranes, prevent arrhythmias)
  5. Bicarbonate (causes K to move into cells; most effective if metabolic acidosis)
  6. Loop diuretic - furosemide (renal excretion of K)
  7. Kayexelate (exchanges Na on resin for K, K excreted)
  8. Dialysis
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15
Q
  1. Kid with concussion, name 3 advice you would give
A
  1. Complete cognitive and physical rest. Follow graduated return to learn and return to play guidelines.
  2. Must return to learn and have 7-10d Sx free and fully back to school before starting return to play.
  3. Each step should take at least 24H. If any Sx, need to rest for at least 24-48H before trying again at last step without Sx
  4. Antiemetics + analgesia for supportive management
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16
Q
  1. Given a scenario of a child, give the 3 components of GCS and calculate the score
A

Child

  • E
    • 4: opens spontaneously
    • 3: opens to voice
    • 2: opens to pain
    • 1: no opening
  • V
    • 5: oriented
    • 4: confused
    • 3: inappropriate sounds
    • 2: incomprehensible sounds
    • 1: no speech
  • M
    • 6: follows commands
    • 5: localizes to pain
    • 4: withdrawal to pain
    • 3: decorticate (flexion posturing) to pain
    • 2: decerebrate (extension posturing) to pain
    • 1: no movement

Infants

  • E: same
  • V
    • 5: cooes, babbles
    • 4: irritable, cries
    • 3: cries to pain
    • 2: moans to pain
    • 1: no sounds
  • M
    • 6: moving spontaneously + purposefully
    • 5: withdrawals in response to touch
    • 4: withdrawals in response to pain
    • 3: flexion decorticate to pain
    • 2: extension decerebrate to pain
    • 1: no movement
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17
Q
  1. Boy from a burning fire has high level of lactic acidosis, besides severe hypoxemia, name 3 other causes of the lactic acidosis?
A
  1. Tissue hypoperfusion after burns
  2. Cyanide
  3. Carbon monoxide toxicity
  4. Hypovolemic shock due to increased fluid losses after burns
  5. Sepsis (more prone to infection after burns)
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18
Q
  1. Boy from trauma, with cushing’s vitals
    a) What mode of ventilation would you use?
    b) Explain why?
A

A. Conventional ventilation. SIMV-PRVC
B. Volume guarantee method to ensure tight CO2 control (35-40). Ensure no obstruction to venous drainage. Ensure adequate PEEP + FiO2 to maintain oxygenation (SpO2 >94%)

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19
Q
  1. 3 things you can tell the team to ensure quality CPR
A
  1. Push hard = 1/3 AP diameter (5cm children, 4cm infants)
  2. Push fast = 30:2 if 1 rescuer, if child with 2 rescuers then 15:2. 100-120bpm
  3. Allow for recoil
  4. Minimize breaks in compressions
  5. Avoid excessive ventilations. Give rescue breaths over 1s, should result in visible chest rise

Note:

  • If EtCO2, aim for >10-15
  • ROSC identified when rises abruptly to 40
  • Arterial waveform if have art line. Can use for feedback on hand position + chest compression depth.
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20
Q
  1. Teen with trauma from sport 2 days ago, presents with erythema around the umbilicus and epigastric pain
    a) Name 2 diagnoses
    b) Name 2 tests
A

A. 2 diagnoses

  1. Splenic laceration
  2. Pancreatic injury

B. 2 tests

  1. CT abdomen
  2. Bloodwork: lipase, amylase, liver enzymes, CBC
  • Cullen’s sign: periumbilical ecchymosis
  • Grey Turner’s sign: flank ecchymosis (blood tracking subcutaneously from retroperitoneal or intraperitoneal source)
  • Non-specific findings that suggest retroperitoneal bleeding in setting of pancreatic necrosis
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21
Q
  1. Patient presents in DKA with a glucose of 21, pH 7.1 and HCO3 9. He is started on treatment with NS + 40 meq/L of KCl at an appropriate rate. One hour later repeat blood work consists of Glucose 9.3, pH 7.2, HCO3 10. What change in management would you make (if any)? (1 line)
A
  1. Start insulin 0.1 units/kg/hr IV (if not already on it)
  2. Add D5W as BG <15. Can change to D5NS+40mEq/L of KCl depending on lytes. Monitor for hyperchloremic metabolic acidosis
  • Goal of serum osmol change by no more than 2-3 mmol/hr decrease
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22
Q
  1. 12 yo boy collapses on a school field while playing sports, brought to the ER. A EKG is given – shows a wide complex tachycardia (V.fib/V.tach). CPR is initiated. The patient is intubated and has an IV.
    a. What 3 most important medications/interventions in the first 5 minutes of ER care?
    b. What is the rate of chest compressions in this patient?
    c. What is the rate of ventilation?
A

a) A. Most important interventions

  1. Good quality CPR
  2. Adequate ventilation + oxygenation
  3. Defibrillation: first shock 2J/kg, second shock 4J/kg
  4. Epinephrine 0.01mg/kg (0.1mL/kg of 0.1 mg/mL)
  5. 100 bpm
  6. 10 breaths per min
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23
Q
  1. MVC and head injury – BP 100/60 and HR falls from 110 to 70 – management
A
  1. Elevate HOB to 30 deg
  2. Keep head in midline
  3. Intubate with RSI
  4. Hyperventilate to pCO2 25-30
  5. 3% NS 5mL/kg
  6. Sedation, analgesia, muscle relaxant. Avoid ketamine b/c may increase ICP
  7. Avoid hypoxemia
  8. Maintain ventilation with PCO2 35-40
  9. Aggressively manage hypotension
  10. Maintain normothermia
  11. Get CT once stable
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24
Q
  1. Description of child with Necrotizing fasciitis lower leg- some respiratory distress. Already started IV fluids and oxygen. 5 additional things in the management.
A
  1. Cardioresp monitors and cycle BP cuff. Monitor ABCs
  2. Stat plastics/ortho consult - surgical emergency that requires early debridement
  3. Start braod spectrum antibiotics: vanco + piptazo + clinda
  4. NPO
  5. Pain management

Resp distress

  • CXR/CT?
  • Intubate?
25
Q
  1. 15 yo boy had a deep laceration on his left shin 3 days ago. Over the last 24 hrs, he has noticed swelling of his left calf, and with lots of pain. His vital signs: temp 39.6 degrees, O2 sats 92%, HR 120, RR 25. You have already given him oxygen and IV bolus.

A. What is the most likely diagnosis?
B. What other treatment modalities would you provide? List 4.

A

A. Necrotizing fascitis

B.

  1. Cardiorespiratory monitors, cycle BPs
  2. Stat consult to Gen Surg/Plastics. Nec fasc is surgical emergency that requires urgent debridement. Put NPO
  3. BCx and start broad spectrum ABx: Piptazo, Vanco, + clinda
  4. Bolus NS 20mL/kg fluids because tachycardic, then maintenance fluids
  5. Pain management + antipyretic
26
Q
  1. 9 year old boy fell from a tree [picture of an epidural bleed shown on CT scan]. List 3 immediate management issues.
A
  1. 1Ensure C-spine precautions, head of bed up to 30-45 deg, head in midline
  2. Assess airway in context of GCS and ability to protect + maintain patency
  3. Treat hypotension aggressively. Maintain adequate ventilation and oxygenation.
  4. Consult Neurosurgery
  5. CBC + diff, coags, cross and type
27
Q
  1. A child is involved in a house fire. Name 4 things (physical exam findings) that would give you a low threshold for urgent intubation.
A
  1. Soot on nares or oropharynx
  2. Carbonaceous sputum
  3. Stridor or resp distress
  4. Singed facial hair
28
Q
  1. Boy being transferred to hospital with a closed head injury. What are 4 factors that worsen outcome in post-traumatic brain injury.
A
  1. Hypotension
  2. Hypoxemia
  3. Seizures
  4. Increased ICP
  5. Hyperthermia

CPS: “An important goal of stabilization is to avoid secondary injury to the traumatized brain from hypoxia, hypotension, hyperthermia or raised intracranial pressure”

If they mean what are poor prognostic signs? (as per CPS)

  1. GCS ≤5 at presentation
  2. ↑ICP
  3. presence + severity of other injuries
  4. pre-injury ADHD
  5. Low SES
29
Q
  1. You attend your child’s baseball game. One of the other children takes a ball in the mouth and tooth gets knocked out. What 2 immediate things could you do to save the tooth?
A
  1. Handle the tooth carefully by the crown. Rinse tooth of debris by washing gently in saline or tap water (don’t scrub it or try to sterilize it)
  2. Place tooth back into socket (ideally within 15min or later if stored in cold milk)
30
Q
  1. A kid presents with a 2-3 day history of feeling ill, nausea and vomiting. In ER, blood glucose is 2.9, Na 131, K 5.3, normal CBC. What one serious condition should you think of?
A

Adrenal insufficiency

  • Hypoglycemia
  • Hyponatremia
  • Hyperkalemia
31
Q
  1. Patient in ER with her first presentation of DKA. 11 years old (30kg). HCO3 11, pH 7.11, BG 40, Na 130, K 4.3. Write orders: What fluid? What rate? Insulin order?
A
  1. NS. If has voided, can add 40mEq/L of KCl (b/c K is normal). 7-10mL/kg over 1h = 300mL/hr
  2. Insulin 0.1 units/kg/hr. Start after 1-2H of fluids

DKA

  • BG >11
  • Ketones
  • Acidosis (pH <7.25 or bicarb <17)
32
Q
  1. A child with gastroenteritis, tachycardic, normal respirations, decreased urine output, irritable but not lethargic (20kg).

A. What fluid would you use for resus?

B. How much would you give?

C. Over how long a period (rate)?

A

A. ORS
B. Moderately dehydrated, so 100mL/kg over 4H = 2000mL
C. 500mL/hr

Note:
Moderate = 10% dehydrated
= 20kg x 10% x 1000mL/kg = 2000mL

33
Q
  1. Clinical signs/symptoms of tension pneumothorax: Where would you insert a needle and what size needle? Heimlich or flutter valve?
A

A. 2nd intercostal space, mid clavicular line, above the 3rd rib
B. Large bore IV catheter (connected to large syringe via 3 way stopcock). 14 or 15 G angiocatheter, 5cm needle.
C. Heimlich valve = flutter valve
- one way valve used to help remove air from a pneumothorax
- Chest tube attached to drainage system that contains a one-way valve mechanism to allow air + fluid to exit, but prevents air or fluid from entering the pleural cavity from the outside

34
Q
  1. 3 y.o. ingested 6 tablets of SSRI. What do you advise? What is the treatment of SSRI overdose?
A
  1. Call poison control to review case
  2. Monitor for signs of serotonin syndrome
  3. ECG to r/o QTc prolongation
  4. ABCs + observation until Sx resolve
  5. Screening bloodwork for signs of renal injury, electrolyte disturbances, rhabdomyolysis
  6. Counsel around keeping all Rx + OTC meds locked at home

Tx

  1. Supportive: benzo, IVF, NPO, may need to intubate
  2. Cyproheptadine
35
Q
  1. What is the first line treatment of child with pulseless VT?
A

CPR
Defibrillation shock 2J/kg

36
Q
  1. 16 y.o. female on surgical ward in traction for femur fracture and splenic rupture. Sudden onset chest pain, cough, O2 sats 84%.
    A) Three most likely causes of sudden distress:
    b) Three investigations to confirm diagnosis.
A

A.

  1. Fat embolism
  2. PE
  3. Pneumothorax

B.

  1. CXR
  2. spiral CT chest
  3. ECG
37
Q

Indications for intubation in a trauma patient

A
  1. GCS <8 or not protecting airway or signs of airway obstruction
  2. Need to go to OR for operative management
  3. Need diagnostic test with risk of deterioration during that time
  4. Need transfer to a trauma centre
38
Q
  1. Child submerged in icy water 6 min. T 28, VSA, CPR started early. Stop at 15 minutes. Why or why not and justify.
A

No. Resuscitative effects until T32-34C. If the victim continues to have no effective cardiac rhythm and remains unresponsive to aggressive CPR, then resuscitative efforts may be discontinued.

Hypothermia has been associated with good recovery/neurological outcomes.

39
Q
  1. 4 ‘medical reasons’ why brain dead patient may not be able to be an organ donor
A
  1. Active disseminated TB
  2. Severe untreated systemic sepsis
  3. Active or uncontrolled hematologic malignancy
  4. Active CMV infection
  5. Active Hep B or C infection
40
Q
  1. Child with HA, nausea, father admitted with CO poisoning. What is your first management?
A
  • Give 100% O2
  • Draw carboxyhemoglobin
  • Consider hyperbaric O2
  • Assess for cyanide poisoning
41
Q
  1. List four signs of Jimson Weed toxicity
A

Anticholinergic

  • Dry as a bone
  • Hot as a hare
  • Mad as a hatter
  • Red as a beet
  • Blind as a bat
  • Elevated temperature
  • Tachycardia
  • Tachypnea
  • Increased BP
  • Agitation
  • Mydriasis
  • Flushed
42
Q
  1. A kid in status asthmaticus. Not responding to continuous inhaled ventolin, atrovent, or IV steroids. What are 4 additional medications to consider?
A
  1. Magnesium sulfate
  2. IV salbutamol
  3. IV aminophylline
  4. Heliox
  5. Consider intubation
43
Q
  1. A trauma patient is brought to the emergency room by paramedics. They have him on maintenance fluids. He is 3 years old and his heart rate is 160 with a blood pressure of 60/40. Would you change his fluid management and why?
A

Give NS bolus 20mL/kg IV push. Reassess afterwards and repeat if needed. He is in decompensated shock. Consider pressors by 60mL/kg

Given his history of trauma, order blood with CBC to look for anemia. Examine for signs of bleeding. Call trauma code to activate blood bank for early pRBC

44
Q
  1. Cranial trauma. Three signs of high ICP.
A
  1. Bradycardia
  2. Hypertension
  3. Irregular respiration rate
45
Q
  1. What are four indications for admission in a burn patient?
A
  1. Inhalational injury
  2. TBSA >10%
  3. Burn to face, hands, feet, genitalia, erineum, major joints
  4. 3rd degree/full thickness burns
46
Q
  1. A boy was brought to the PICU after a near drowning. What are four factors that predict a poor prognosis.
A
  1. Submersion >5min
  2. Failure to respond to CPR in 25min
  3. Absence of pupillary responses in ED
  4. Hyperglycemia in ED
  5. Do not regain consciousness in 24-48H
47
Q
  1. A 4 year old has varicella. He presents to his GP with severe thigh pain and a purple rash over his thigh. He looks unwell. The GP who is two hours away calls you for advice.
    What do you think the diagnosis is? What are four pieces of advice you would give the GP with regards to this patients’ management?
A

A. Necrotizing fasciitis
B.
1. Transfer to nearest hospital with surgery. Stat ortho consult for urgent surgical debridement within 48H. Keep NPO
2. Establish IV/IO access (not over affected limb). Since pt looks unwell, give NS bolus and monitor effect
3. Start broadspectrum antibiotics: pip-tazo + vanco + clinda
4. Monitor vitals
5. Manage pain
6. Start acyclovir for varicella

48
Q
  1. A 4yo boy fell from a tree and is complaining of severe left shoulder pain. He has a normal shoulder and chest X-ray. His blood pressure is 70/40 and his heart rate is 130.
    a) What is his diagnosis?
    b) What investigation would you do?
A

A. Uncompensated hemorrhagic shock due to splenic rupture
B. CT abdo wtih IV contrast. Needs to be stable before this and if still unstable after fluid resuscitation, go straight to OR

49
Q
  1. Pictures of CT head with concave epidural bleed (see below)
    a) What is the diagnosis (epidural bleed)
    b) What are 3 things for management?
A

A) Epidural bleed
B)
1. Monitors. Head of bed at 30-45 deg, head in midline, C-spine. Monitor for signs of increased ICP
2. Consider rapid sequence intubation depending on GCS and airway status
3. Neurosurgery consult

  1. CBC + diff, coags, cross + type
50
Q
  1. 6 m.o. infant with HR 114, RR 32, BP 85/60 – are there any abnormalities?
A

Normal

51
Q
  1. 14 year-old was raped by a university student earlier that evening at a party – now presents to your ER. List 5 things you would do in your management.
A
  1. Assess ABCDEs
  2. Call CAS. Ask if she’d like to speak with police.
  3. History ideally taken by clinician trained in forensic interviewing. Use open ended questions
  4. Physical exam with goals to
    a) not cause added trauma
    b) find injuries that need immediate attention
    c) address pt concerns about physical health
    d) detect signs of STIs
    e) collect forensic evidence (if consented)
    - when possible, reassure pt that they are healthy after exam
    5) Consider lab testing
  • urine and blood for toxins
  • U/A
  • preg test
  • Hep B screen, Syphillis, HSV titres, HIV
  • Oropharynx culture for gonorrhea
  • Rectal, urethral (male) + cervical (female) culture for gonorrhea + chlamydia
  1. Give prophylactic antibiotics (prevent infection if <72H from assault: CFTX 250mg IMx1 AND azithromycin 1g PO x1dose) + HIV PEP
  2. Give emergency contraception
  3. Forensic evidence - sexual assault kit (with consent)
  4. Urgent psychiatry/psychology referral for counselling. Ensure follow up with PCP
  5. Make sure she is safe to go home.
52
Q
  1. Child admitted with bronchiolitis, with low urine output, Na 128, K 3.3
    a) What is the most likely diagnosis?
    b) What is the one change you would make to his IV fluids
A

A. SIADH
B. Restrict fluids (limit to 1L/m2/24hr)

53
Q
  1. Mother calls you because her 4 year-old daughter has taken a bottle of ibuprofen (estimated dose 400 mg/kg). You tell her to come to the ER. Name 3 lab tests you will do.
A
  1. Serum acetaminophen + salicylate levels
  2. Lytes, BUN, Cr, lactate, gas, glucose
  3. CBC + diff

Ibuprofen

  • Mild to moderate overdose <400mg/kg: GIB, renal dysfunction, problems with platelet response to injury
  • Large overdose >400mg/kg: neurotoxicity, hypothermia, hypotension, metabolic acidosis
54
Q
  1. Hyperkalemia:
    a) List 3 features on ECG
    b) List 3 options for treatment
A

A. ECG

  1. Peaked T waves
  2. Prolonged PR
  3. Prolonged QRS

B. Tx

  1. Ventolin neb
  2. Insulin
  3. Kayexelate
  4. Lasix
  5. Dialysis
  6. Stop all sources of K
55
Q
  1. Child with signs of anaphylaxis after the transition to cow milk formula.
    A) Most important medication in the immediate management and route?
    B) When can the patient go home (i.e. how long does she need to be observed)?
    C) List 4 preventative recommendations for the non acute management.
A

A. Epinephrine 0.01mg/kg (1mg/mL) IM

B. Need to observe at least 4-6H, but counsel that biphasic reaction can occur within up to 72H

C.

  1. MedicAlert bracelet
  2. Carry epi pen at all times
  3. Avoid known triggers
  4. Refer to allergy to identify/confirm triggers
  5. Education + provide pt resources
  6. Can prescribe 3d course of PO H1 + H2 antihistamines (cetirizine + ranitidine) and oral corticosteroids
56
Q
  1. List 6 clinical signs of early hypovolemic shock in a 3 year old who is dehydrated.
A
  1. Tachycardia
  2. Prolonged capillary refill
  3. Decreased peripheral pulses
  4. Decreased skin turgor
  5. Sunken eyes
  6. Dry mucous membranes
  7. Irritability (but not lethargic)
  8. Decreased urine output
  9. Decreased tears
57
Q
  1. List 3 clinical signs of increased ICP in an 8 month old baby with vomiting for 5 days.
A
  1. Bulging fontanelle
  2. Papilledema
  3. Unequal pupils
  4. Sunsetting eyes
  5. Bradycardia
  6. Hypertension
  7. Altered respiratory rate
  8. Apneic spells
58
Q
  1. 15 year old with hypertensive emergency. List two medications that you can use to lower BP acutely. For each medication, list one side-effect (not including hypotension).
A
  1. Labetolol - hypoglycemia
  2. Hydralazine - H/A
  3. Nicardipine - reflex tachycardia
  4. Nifedipine: flushing

Hypertensive emergency

  • Acute severe symptoamtic elevation in BP WITH evidence of potentially life-threatening Sx or target organ damage
    *

Josh's RC Questions (39 decks)

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