FCEM(SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain Reg No 1955/000003/08

Final Examination for the Fellowship of the College of Emergency Medicine of South Africa 20 August 2012 Paper 1 (3 hours)

All questions are to be answered. Each question to be answered in a separate book (or books if more than one is required for the one answer)

Question 1: Please note, for question 1: The complete PAEDIATRIC SATS CHART is attached as APPENDIX A. 1.1 You are the consultant in charge of the triage section of your emergency centre (EC). Look at the table of the Triage Early Warning Score (TEWS) used for younger children. Bear in mind that the higher the score the more urgent the triage category assigned to the child.

1.1.1. For a baby of 6-months-old a) b) c) Do you agree with the normal range given for the respiratory rate (RR)? Motivate your answer. (3) Do you agree with the normal range given for heart rate (HR)? Motivate your answer. (3) Write short notes on the limitations of triage systems and how these can be addressed with your triage staff. (4)

1.1.2. What would the SATS triage category be of a 2-year-old boy who ingested his mothers antidepressive tablets? He has normal mobility, RR = 35; HR = 125; Temp = 36; AVPU = P. Motivate your answer. (2) 1.1.3 Explain what is meant with the following triage errors and explain the implicatons of each a) Overtriage. (2) b) Undertriage. (2) 1.2 You are treating a child with a sickle cell crisis in your emergency centre. The parents request that you to explain the cause of the disease to them. a) How would you describe the genetic basis of sickle cell disease to the parents? (2) b) What is the aetiology of an aplastic crisis? (2) A 2-year-old boy present to your emergency centre. His parents complain that the child in crying when he passes urine. On examination you find that his penile foreskin is red, warm and swollen a) What is the most likely diagnosis? (2) b) How should this condition be managed? (2) c) Would a circumcision be indicated? (1) [25]

1.3

Question 2: A 90-year-old lady presents to your emergency centre with Pneumonia. She is confused and hypoxic. Her family states that she requires assistance for all ADLs (Activities of daily living). 2.1 Describe a scoring system for rating the severity of pneumonia and describe the management of each category. (8) List 3 common pathogenic organisms for community acquired pneumonia. (3)

2.2 2.3

Discuss your approach to end-of-life care and decision making with the patient and family (10) Write short notes on Advanced Directives (living wills). (4) [25]

2.4

Question 3: You are a leading consultant in emergency medicine and regularly work well together with specialists in other clinical disciplines in a major tertiary academic hospital. The hospital clinical manager requests help with designing a hospital resuscitation policy for in-hospital ward patients and all patients presenting to the emergency centre. 3.1. 3.2 Describe what legal mandates you would wish to consult in drafting the policy. (4)

Describe what ethical issues may be of concern in designing the resuscitation policy. (7)

3.3

3.4

Outline a draft resuscitation policy, detailing what resources you would wish to include and a list of patient categories that the resuscitation policy would address. (7) Write short notes on determining brain stem death and certifying death (7) [25]

Question 4: Emergency Ultrasound is a useful diagnostic tool in the emergency centre. 4.1 4.2 4.3 4.4 4.5 What does the abbreviation EFAST stand for? What probe is commonly used for EFAST? List the areas that are examined during the EFAST assessment? What is the clinical significance of a positive EFAST scan in trauma? (2) (2) (5) (2)

What is the next step in a stable blunt abdominal trauma patient with a positive EFAST? (4) Discuss the sensitivity and specificity of the EFAST in blunt abdominal trauma? List 10 other uses for ultrasound for emergency medicine (5) (5) [25]

4.6 4.7

Question 5: A 23-year-old female patient presents to the emergency centre complaining of pain and swelling of her thighs, of two days duration. It is not responsive to NSAIDs and steroids prescribed by her general practitioner. She reports travelling over 300km to your emergency centre in a taxi and had undertaken vigorous exercise at a gymnasium recently. She is otherwise healthy and uses an oestrogen contraceptive for family planning. Her vital signs are normal and physical examination is unremarkable, save for tenderness and swelling of both thighs with limitation of passive knee and hip flexion and extension. 5.1 5.2 List 5 potential causes of this patients problem and for each cause one specific test to rule out and one test to confirm the diagnosis. (10) Discuss non traumatic rhabdomyolysis under the headings: aetiology, diagnosis, associated abnormalities and complications, and management strategies; indicate reasons for each. (10) Discuss the use of urinary alkanisation of relevance to emergency medicine. (5) [25]

5.3

Question 6: A 27-year-old presents after being punched in the face. His left eye is swollen shut and he is tender over his left zygoma. He complains of decreased vision in his left eye. 6.1 6.2 6.3 Discuss the potential causes of vision loss in this patient and how you would diagnose these. (10) Describe the LeFort classification system for midface fracture. (7) Write short notes on the pharmacological management of acute glaucoma including drug indications and dosages. (8) [25]

APPENDIX A:

FCEM(SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain Reg No 1955/000003/08

Final Examination for the Fellowship of the College of Emergency Medicine of South Africa 21 August 2012 Paper 2 (3 hours)

All questions are to be answered. Each question to be answered in a separate book (or books if more than one is required for the one answer)

Question 1 A randomised, double-blind, multi-centre trial comparing vasopressin and adrenaline in patients with cardiac arrest presenting to or in the emergency centre, was carried out by Ong et al. In table 1 of the research publication the demographics and characteristics of study participants in the adrenalin and vasopressin groups are compared. See the extract from the table below:
Table 1: Demographics and characteristics of study participants. Variables: Adrenaline group, Vasopressin n = 353 group, n = 374 Age (years), mean (SD) 64.9 (15.4) 64.6 (14.2) Age (years), median (range) 66.3 (14.6 99.3) 65.4 (25.2-95.9) Medical history, n (%) 247 (70.0) 288 (77.0) With medical history Ischaemic heart disease/other 131 (37.1) 134 (36.8) evident structural heart disease 110 (31.2) 121 (32.4) Diabetes mellitus Chronic obstructive pulmonary 27 (7.7) 37 (9.9) disease/asthma 42 (11.9) 39 (10.4) Cerebrovascular accident. 88 (24.9) 73 (19.5) Hyperlipidemia 167 (47.3) 190 (50.8) Hypertension 26 (7.4) 30 (8.0) Chronic renal failure 25 (7.1) 30 (8.0) Cancer

p Value:

0.75

0.09 0.15 0.23 0.16 0.15 0.02 0.22 0.22 0.22

1.1 1.2 1.3 1.4 1.5 1.6

How should one calculate the mean age of a group of patients? (2) How should one determine the median age of an uneven number of patients (e.g. the Adrenaline group) (2) What was the total number of patients that was involved in this study? (1) What does SD stand for and what is it used for? (2) What was the age of the eldest patient in the Vasopressin group? (1) Explain the following terms: p value, Null Hypothesis, Alternative Hypothesis. (3)

1.7 1.8 1.9

How do you interpret the p-value for Cancer? Does this mean that the null hypothesis should be accepted or rejected for this characteristic? (3) Are there any of the characteristics where there is a statistically significant difference between the two groups? Motivate your answer. (3) Explain the following research study designs a) Case-control studies. b) Cohort studies. c) Controlled trials with crossover design.

Indicate which of the above study designs are best used to identify aetiology and risk factors for a disease, and which are best used to evaluate treatment. Also state whether they are prospective or retrospective in design. (8) [25] Question 2 2.1 You arrive as the first responder on the scene of a bus accident involving 2 additional motor vehicles. Describe the essential components of communicating this incident to the emergency medical services control centre. (8) How would you prepare a safe landing zone for the emergency response helicopter? (8) Describe, using a flow chat or table, the system of triage you would initially use in a mass casualty incident with limited resources. (9) [25]

2.2 2.3

Question 3 3.1 A 70-year-old man presents with chest pain. His chest x-ray demonstrates a widened mediastinum. a) List 5 other radiological features suggestive of Aortic Dissection (5) b) In the form of a table, list the sensitivity, specificity and contraindications of the special investigations available to confirm the diagnosis of Aortic Dissection. (8) c) How would you manage this patient, if his vital signs are BP 190/110 and HR 90? (6) Write short notes on the pathophysiology and causes of methaemoglobinaemia. (6) [25]

3.2

Question 4 4.1 Write short notes on the following fractures/dislocations a) Monteggia. b) Colles. c) Jones. d) Hangmans. e) Bennetts. (10) 4.2 4.3 Discuss the classification of open fractures. List 3 ways to stabilise an unstable pelvic fracture in an emergency centre. (12) (3) [25]

Question 5

5.1

Sodium Bicarbonate is a commonly used drug in the emergency centre. a) List indications, precautions and adverse effects for using sodium bicarbonate in emergency medicine, specifying the dosing schedule for each indication.(5) b) List contraindications against the use of bicarbonate in emergency medicine. (5) c) List signs of hypokalemia, including ECG findings where appropriate, under the following headings: neurologic, gastrointestinal, cardiovascular, renal and general. . (9) Write short notes on the following cardiac biomarkers a) Pro BNP. b) Ischemia Modified Albumin.

5.2

(3) (3) [25]

Question 6 6.1 Discuss the concept of damage control resuscitation under the following headings a) Permissive hypotension. (3) b) Isotonic crystalloids vs. hypertonic saline. (4) c) Blood and coagulation factor based resuscitation strategy. (2) d) Cryoprecipitate and Recombinant factor VIIA. (4) e) Tranexamic acid. (2) Copy the table, and indicate the antidotes to the poisons given below

6.2

Table: Poisons and antidotes Poison: Paracetamol Bleech Cyanide Datura stramonium (Jimson weed) Carbamates

Antidote:

(5) 6.3. Write short notes on rabies, including the following a) Case fatality rate vs. mortality rate. b) Prophylaxis c) Virology

(2) (2) (1) [25]