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Emergency Department Presentation and Management Scenarios: ABG Abnormalities, Chest Trauma, Lip Laceration Repair

Explore three clinical scenarios in an emergency department setting: ABG interpretation for an 82-year-old lady, chest trauma assessment for a 55-year-old man, and lip laceration repair in a 27-year-old man. Learn about differential diagnoses, treatment considerations, and management strategies.

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Emergency Department Presentation and Management Scenarios: ABG Abnormalities, Chest Trauma, Lip Laceration Repair

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  1. SHORT ANSWER QUESTIONS Oct 2007

  2. Question 1 pH 7.399 (7.34 – 7.44) pCO2 34.7 (35.3 - 41.4) pO2 60.3 BE -3.2 cHCO3- 20.9 (22 – 25)

  3. An 82 year old lady comes into the department following a collapse. She was discharged from hospital 3 weeks beforefollowing a fall and a fractured neck of femur. • What three abnormalities are present on the ABG? (3) • Hypoxia • Hypocapnia • Compensated respiratory alkalosis • Give 4 components of the Wells PE score? (4) • Suspected DVT 3.0 • Alternative diagnosis less likely than PE 3.0 • Heart rate >100 beats per minute 1.5 • Immobilization or surgery in the previous four weeks 1.5 • Previous DVT or PE 1.5 • Haemoptysis 1.0 • Malignancy (on treatment, treated in the past 6/12, or palliative) 1.0

  4. What is the mechanism of action of mainstay of long-term treatment? (3) • Inhibition of hepatic (1) production of • Vitamin K (1) dependant factors • II, VII, IX, X (1) of the clotting cascade

  5. Question 2

  6. A 55 year old man is brought into the department following a fall downstairs onto the banister post. He is talking with a RR32, O2 Saturations 93% on air, P110 and BP 150/98 • Give three abnormalities shown on the chest xRay (3) • Surgical Emphysema • Pneumomediastinum • Right sided Pneumothorax • Right sided rib fractures 3-8

  7. Give three immediate treatments that you would consider? (3) • Oxygen • Chest tube thoracostomy / drain • Analgesia - opiates • Analgesia – intercostal block Give four other complications that you would be concerned about? (4) • Haemothorax • Lung Contusion • Flail segment • Tension Pneumothorax • Liver injury

  8. Question 3

  9. A 27 year old man presents one evening with an injury to the upper lip following a fight. You decide that you wish to repair it. • Describe a method of anaesthesia appropriate to the task (4) • Maxillary nerve block (or sup alveolar) • At the mucobuccal fold of the 2nd Molar between maxilla and lip (1), insert the needle at a forty five degree angle (1) in a posterior, superior, medial direction (1). Orientate the bevel toward the bone. Advance the needle to c. 3cm (1). Aspirate then rotate the needle one quarter turn, and aspirate again (1). If aspiration in both directions is clear, slowly inject the anaesthetic (1) • OR Local anaesthesia • Clean the area of skin around the wound. Injection of lignocaine (1) with a small bore / 22G (1) needle into the skin parallel to the wound edges (1) taking care to aspirate (1) first to ensure no injection into vessels. Both sides of the wound should be anaesthetised (1)

  10. Describe the normal tetanus toxoid immunisation schedule (1) • 2 months, 4 months, 6 months, 4yrs, 15-17yrs • What two other diseases does the DTP protect against? (1) • Diphtheria, Pertussis • Give 4 alternative methods to immunisation for minimising the risk of tetanus developing? (4) • Wound toilet / irrigation • Wound debridement • Antibiotics • Immunoglobulin

  11. Question 4

  12. An 82 yr old man with a PMHx of oesophageal cancer comes to the department complaining of a headache 2 /52 ago, with subsequent confusion and difficulty walking. This is his CT scan • Give three differential diagnoses, taking into account the history and the scan? (3) • Metastatic Ca • Intra-parenchymal, cerebellar bleeds • Hydrocephalus • Bleed into tumour

  13. Give three features that help distinguish Central vertigo from Vestibular causes? (4) • Other neurological signs • Vertical or Rotational nystagmus • Inability to suppress nystagmus with visual fixation • Gaze over-/ under-shoot • Sudden onset • Headache

  14. Give three physical signs of a cerebellar pathology (3) • Past-pointing • Wide-based gait / ataxia • Dysdiadochokinesia • Intention tremor • Scanning speech • Dysrhythmia • . Give one drug treatment that you would consider for a vestibular cause? ( ½ ) • Prochlorperazine • What class of drug is it? ( ½ ) • Phenothiazine / Dopamine antagonist

  15. Question 5

  16. A 24 yr old comes into the department complaining of a rash on her legs that she noticed that morning. She is otherwise well • What is the most likely cause? (1) • Erythema Nodosum • Give two differential diagnoses? (2) • Urticaria • Insect bites • Erysipelas (Strep pyogenes) • Bruising • Thrombocytopaenia / platelet disorder • Henoch-Schönlein Purpura

  17. What is the mechanism behind it? (2) • Delayed hypersensitivity reaction (1) in the subcutaneous fat layer (1) • Immune complex deposition in IBD (1) • Panniculitis (1)

  18. Name six causes? (3: ½ mark each) • Sarcoid • Streptococcal infections • IBD • Connective tissue diseases – SLE, RA • TB • Coccidiomycosis • Pregnancy • Lymphoma • Salmonella / Yersinia

  19. What specific investigations should be done in the department? (2) • Pregnancy test • ASO or throat swab (if pus) • CxR • Urine dip

  20. Question 6 • A 66 yr old patient is brought into the department, having been found on the floor. There is no sign of injury and he is febrile • What is the definition of Sepsis? (4) • At least 2 out of (1) • Pyrexial >38ºC or <36 ( ½ ) • Tachycardic >90 ( ½ ) • RR >20 ( ½ ) • WBC >12 or <4 x 103( ½ ) • Plus documented or presumed source of infection (1)

  21. Give three possible sources of infection? (3) • Urine • Chest – pneumonia, empyema • Brain – meningo-encephalitis • Skin – cellulitis, fasciitis • Intra-abdominal

  22. Assuming that his airway and breathing are not compromised, give six immediate management options for this gentleman (3 – ½ mark each) • Oxygen • IV Fluids • Early antibiotics • Source control • Appropriate monitoring – BP, CVP, • Investigations - Hct, Lactate • Referral to HDU / ITU

  23. Question 7

  24. A 47 yr old lady is brought into resus with the above ECG. She has developed palpitations while on the treadmill at the gym. What are your first actions? (2) • Assess the patient – airway and Breathing • Oxygen • Monitoring or obs (single point)

  25. P 285, BP unrecordable - she is sweaty, pale, and getting drowsy. What is the preferred treatment option? Electrical Cardioversion (½) – synchronised (½) What are the indications for this option? (4) • Shock (BP<90) • Pulmonary oedema • Reduced conscious level • Chest pain

  26. Your treatment is successful, she is awake and thanking you. What are you going to do for her next? (3) • Record post-shock ECG • Refer to CCU / cardiology • Amiodarone infusion • Consider cause - angiogram

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