UNIVERSITYHOSPITAL,GEELONG

FELLOWSHIPWRITTENEXAMINATIONWEEK11–TRIALSHORTANSWERQUESTIONSSuggestedanswersPLEASELETTOMKNOWOFANYERRORS/OTHEROPTIONSFORANSWERSPleasedonotsimplychangethisdocument-itisnotthemastercopy!

Question1(18marks)A65yearoldmalepresentswithsymptomssuggestiveofrightrenalcolicforthispatient.

a. Statesix(6)aimsintheuseofradiologicalinvestigationforthispatient.(6marks)• Confirmdiagnosis(highsensitivity97%andspecificity96%forureterolithiasisas>90%stonesopaque)• Detectcalculisite• Detectnumbercalculi• Detectcalculisite• Detectcalculisize(indicatelikelihoodspontaneouspassageorneedforurologicalintervention)• Detecthighgradeobstruction(CTKUB/US<48/24-hydronephrosis,hydroureter,perinephricstranding,lowdensity

kidneysuggestiveoedema)• DeterminevisibilityonKUB(toallowlessradiationforfollowup,useofUralifunseen)• Ruleoutothersignificantcauses(egAAArupture,diverticulitis,pyelonephritis)

~10%ofCTKUBsshowanalternativeDx

b. Listthree(3)typesofuretericcalculithathavedifferentchemicalcomposition.Providetwo(2)clinicalorepidemiologicalfeaturesforeachtypeofcalculi.(9marks)

Calculitype Feature

CalciumcompoundOxalatepredominantly(lesscommonlyPO4)

• Majority(70-80%)• UsuallyradioopaqueonplainKUB• Usuallyidiopathicoridiopathichypercalcuriain10%• Prevention:↑U/O>2-3L/day• Thiazides↓urinaryconcentration

Infection/Triplephosphate/Struvite(Ca,Mg,NH4)

• Femalepredominance• HighurinarypHfromureasplittingorganismsthatcreate

ammonium• Cangrowrapidly(esppregnancy)-Staghorncalculi• Rxlithotripsy(renacidininfusion)

Uricacid/Urate • 10%allstones• RadiolucentonplainKUB• UrinepH<6• “passageofgravel”describedbypatient• Prevention:allopurinol• Prevention:↑U/O>2-3L/day

Cysteine • ~1%ofallstones• MostlikelycalculitocauseESRF• AssociatedwithCystinuria(autosomalrecessiveinheritance)• Especiallyconsiderinyoungwithstones

ThepatientisconfirmedtohaveasinglerenalcalculionCTKUB.Thisishisfirstepisodeofrenalcalculi.

c. Whatistheroleofmedicalexpulsivetherapyinhismanagement?Statethree(3)pointsinyouranswer.(3marks)• Antispasmoticagents:

§ αblockertherapy(Tamsulosin)→αreceptorsaremorecommoninthedistalureter• somesupportbutconflictingdataon5-10mmcalculi

§ CaCB→nifedipine§ phosphodiesterasetype5inhibitor(Tadalafil)

o mayreducesymptoms&timetostonepassage(existingdataconflicting)• Alkalinizationtherapy

o UralmayassistinUricacidstonedissolution AdditionalQ:Q:Completethetablebelowthatrelatescalculisizeandspontaneouspassagerate.(4marks)

Diameter(mm) Passagerate(%)4 905 805-8 15>8 5

“List”=1-3words“State”=shortstatement/phrase/clause

ClickontheimagesbelowtovieweachentirePDF(&print/saveifnecessary)

Question2(12marks)A25yearoldEmergencyDepartmentnursesustainsaneedlestickfromaknownpatientintheEmergencyDepartment.Thedetailsoftheexposureareobtainedanddocumented.

a. Otherthandetailsoftheexposure,listsix(6)keyfeaturesinhistorythatyouwouldseekfromthisnurse.(6marks)• Hasfirstaidbeenperformed?• HepBvaccinationstatus-immunisationdateandpostimmunisationtitre• PriorPEP/Hxoftreatment• Pregnancyrisk/contraception/lactation• MedicalHistory• Medicationuse• Allergies• PsychiatricHx• Drug/alcoholHx• RecentHIV/HepB/HepCtesting

ThesourceisidentifiedashavingHepatitisB,HepatitisCandHIV.

b. Listtheapproximateriskoftransmissionofeachvirusforthispatient.(3marks)

Virus Riskoftransmission(%)

HepatitisB 3 HepatitisC 30 HIV 0.3

c. Completethetablebelow,listingthetimecourseofrequiredserologicaltestingforthispatient.(3marks)

Test Timeframeoftest/s

HepatitisB BaselineHepatitisC Baseline

3monthsHIV Baseline

4-6weeks3 months

PossiblealternativeQ:(discussasagroup).Listfive(5)keystepsinthemanagementofthispatient.• Firstaid

o skin:washexposedareawithsoapandwatero eye:removecontactlenses,irrigationwithcopiouswaterorsaline

o oralmucous/membrane:spitoutcontaminatingmaterial,rinsemouthwithwaterseveraltimes• Counselling

o riskasswithspecificexposureo efficacyandSEsofPEP(vomiting)o riskreductionstrategies(safesex,don’tdonate,nopregnancy)o followupo stressleave

• Referforfollowupo testing4-6weeksand3mths,psychologicalsupport,stressleave

• HepBimmunisation/Ig• PEP

o truvada(combodrug)andraltegravirfor28days(2vs3drugscontroversial,2drugsbettertoleratedwithnoevidenceoflessefficacy)

o preferablywithin2hrsbutupto72o consultIDo indicated:HIV+vepersonnotonRx,HIV+veonRxbutwithmeasurableviralload,nootherinfoavailablebutareknown

tobeHIV+ve

Question3(12marks)

a. Completethechartbelowdemonstratingthepercentageofburnestimationinaninfantfortheareasindicatedwithabox.(7marks)

A35yearoldmanisbroughtintoyouremergencydepartmentwithextensiveburnstohisupperbodyfollowingahousefire.

b. Statethree(3)indicationsforemergencyescharotomy.(3marks)• Circumferentiallimbinjurieswithevidenceofdistalneurovascularcompromise• Chestwallinjurieswithimpairedventilation• Circumferentialneckinjuries

c. Assuming adequate analgesia and sedation, consent and explanation, list two (2) steps in the

procedureoflimbescharotomy.(2marks)• LinearincisionVolaraspect-oftenonlyonesiderequired,cutdowntosubcutaneousfat• Upperlimbextendingtodorsumofhand/lateralaspectofdigitsor1cmaboveand1cmbelow

areaburn

Additional Q:Q:Assumingadequateanalgesiaandsedation,consentandexplanation,listfour(4)stepsintheprocedureofchestescharotomy.(4marks)

• Lateralincisiononeithersideo Anterioraxillarylineo Fromlevel2ndribtolowermarginribcage

• Joinlateralincisionswith2transverseincisionso Superioratlevelofthemanubriosternaljointo Inferiorincisionatthelowerborderoftheribcage

• Floatingsquareresults

Question4(12marks)A76yearoldwomanpresentstoyouremergencydepartmentwithonehourofseverechestpain.AnECGistaken-refertothepropsbooklet-page1.

a. Statefour(4)abnormalfindingsinthisECG.(4marks)• STEaVR3mm,V11mm(ieaVR>V1)• STDI,II2mmaVL,aVF1mm,V3-6-3/5/5/3mm• Rate102-110-sinusTach• QT>600msec

b. WhatisthesignificanceoftheseECGchangesforthispatient?Satefour(4)pointsinyouranswer.(4

marks)• LMain/Triplevesseldisease• Highlikelihoodcardiovascularcompromise• Highmorbidity/mortality(upto70%)• RequiresurgentearlyPCI• Respondspoorlytonon-invasiveRx

ThecardiologyregistrardoesnotagreewithyourassessmentofthisECGandits’significance.

c. Statefour(4)piecesofinformationfromabedsideECHOthatwouldsupportyourcase.(4marks)

• Globalwallmotionabnormalities• Papillarymmrupture/valveincompetence• Absenceofpericardialfluid• AbsenceofLVaneurysm• AbsenceoffeaturestosupportPE

Question5(12marks)

A52yearoldItalianwomanpresentstoyouremergencydepartmentwithgraduallyincreasingbreathlessnessoverthelast3days.Itis1weeksinceherlastchemotherapytreatmentforcancer.Shehasaportocathinsitu.Herobservationsonarrivalare:BP130/60 mmHg PR110/minRR28/minTemp37.8°COxygensaturation90%Roomair

Refertothepropsbookletforlargerimage

a. Otherthantheportocath,list(4)abnormalitiesshowninthisX-ray.(4marks)• OpacificationLlungfield• Rnecksurgicalclips• Raxillasurgicalclips• Asymmetricbreastshadow• MediastinalshifttoR• PatchychangesRlung

HerFBEshowsnormalHbandplateletcounts.HerWCCis1.5(ref4-11)andherneutrophilcountis0.4(ref2.0-7.5).b. Stateyourantibioticchoice/s.(2mark)NB:Dosesandroutenotrequested

Antibioticchoice:1. piperacillin-tazobactam4.5gIVQ8h(Q6hifsepticshock/criticallyill)

ORcefepime2g(child:50mg/kgupto2g)IVq8hORceftazidime2g(child:50mg/kgupto2g)IVq8h)

2. vancomycin15mg/kgmax500mgIVq6h

c. Statetwo(2)pointstojustifyyourchoice/s.(2marks)Justification:1. FebrileneutropenianecessitatingboardspectrumantibioticcoveringPseudomonas(Bacteraemiadue

toPseudomonasaeruginosaoccursrelativelyinfrequentlybut,becausemorbidityandmortalityarehigh,empiricalregimenscoverthismicroorganism)

2. AddVancomycinifvasculardevicepossiblesourceofsepsis• addVancomycinforsuspectedMRSAif

o patienthasseveresepsis/septicshocko knowntobecolonisedwithmethicillin-resistantStaphylococcusaureus(MRSA)o clinicalevidenceofacatheter-relatedinfectioninaunitwithahighincidenceofMRSAinfectiono feverpersistsat48hours

Considerthefollowing:• changingtoMeropenemforsuspectedESBL• addantifungal(e.g.voriconazole)if:

§ suspectedfungalinfection(e.g.candida,aspergillus,mucormycosis)§ feverspersistinhigh-riskpatientsbeyond96hoursofantibacterialtherapy(seekexpertadvice)

• addCo-trimoxazoleforsuspectedPCP• addacyclovir/ganciclovirforsuspectedHSVorCMVinfections

d. OtherthanU+EandLFT,listsix(4)keyinvestigationsthatyouwouldorderforthispatientintheemergencydepartment.(4

marks)• bloodculturesperipheral:identifyorganismwithsensitivitiesguidingongoingantibioticregiment• bloodculturesCVC:identifyorganismwithsensitivitiesguidingongoingantibioticregiment• SputumMCS:identifyorganismwithsensitivitiesguidingongoingantibioticregiment• Ca• BedsidetransthoracicECHO:excludevalvularvegetations• ECG• Swabanyskinlesion:identifyorganismwithsensitivitiesguidingongoingantibioticregiment

Question6(12marks)A65yearoldmanpresentswithabdominaldistensionandpain.ThepatientisnotedtohavefreefluidonanEmergencyDepartmentscreeningultrasound.

Anaspirateofperitonealfluidisperformed.

Appearance darkbrownWhitebloodcellcount 1500Polymorphcount 1000Glucose 0.1 mg/DlLDH 450 Albumin 36 g/dLSerumAlbumin 34 g/dL

a. Statethemostlikelydiagnosis.(1mark)• Bacterialperitonitis(eitherspontaneousorsecondary)

b. Listfive(5)likelycausesforthiscondition.(5marks)• Spontaneousbacterialperitonitis

o CLDwithasciteso Nephroticsyndromeo Peritonealdialysis

• Secondarybacterialperitonitiso Ascites+appxo Ascites+pancreatitiso Ascites+perfviscuso Ascites+diverticulitis

c. Listthree(3)keypathologicalinvestigationsthatyouwouldperformintheemergencydepartment.

Stateone(1)justificationforyourchoice.(6marks)

Investigation(3marks)

Justification(3marks)

Bloodcultures +vein50%Guideantibioticuse

LFT ↓AlbuminasacauseoflowascitesEvidenceofsyntheticimpairmentsuggestschronicliverdisease

Clotting Priortoascitictap

FBE WCC>15and>75%neutrophils +/-or L shift supports the likelihoodSBP

Lipase >3normalsuggestspancreatitisasacauseofascites

Initialasciticfluidtests—Theroutinetestsorderedonasciticfluidsamplesincludeananalysisoftheappearance,serum-to-ascitesalbumingradient,cellcountanddifferential,culture,andtotalprotein.Appearance—Thegrossappearanceoftheasciticfluidcanbehelpfulinthedifferentialdiagnosis.Clearfluidistypicallyseeninthesettingofcirrhosis,turbidorcloudyfluidinthesettingofinfection,milkyfluidinthesettingofchylousascites,andbloodyfluidinthesettingofmalignancyoratraumaticparacentesis.●Clear–Uncomplicatedascitesinthesettingofcirrhosisisusuallytranslucentyellow;itcanbecompletelyclearifthebilirubinisnormalandtheproteinconcentrationisverylow.●Turbidorcloudy–Spontaneouslyinfectedfluidisfrequentlyturbidorcloudy.Astudyof916samplesdemonstratedthatan"abnormalasciticfluidappearance"asdefinedashazy,cloudy,orbloodywas98percentsensitive,butonly23percentspecificindetectingspontaneousbacterialperitonitis.●Opalescent–Infrequently,asciticfluidinthesettingofcirrhosisis"opalescent"andhasaslightlyelevatedtriglycerideconcentration.Thispeculiaritydoesnotseemtohaveclinicalsignificanceexcepttoexplaintheopalescence,whichcanbemisinterpretedas"pus."●Milky–Milkyfluidusuallyhasatriglycerideconcentrationthatexceedstheserumconcentration,isgreaterthan200mg/dL(2.26mmol/L),andisoftengreaterthan1000mg/dL(11.3mmol/L);suchspecimensarereferredtoas"chylousascites"[41].Astudyperformedinatertiaryreferralcenterreportedthatmalignancywasthemostcommoncauseofchylousascites;however,thisprobablyrepresentedselectionbias[41].Bycontrast,aprospectivestudyperformedinlargegeneralhospitalsdocumentedthatcirrhosiscaused10timesasmanycasesofchylousascitesasmalignancy[40].Approximately1outof200patients(0.5percent)withcirrhosishaschylousascitesintheabsenceofcancer.

●Pinkorbloody(andcorrectedneutrophilcount)–Pinkfluidusuallyhasaredcellconcentrationof>10,000permm3.Franklybloodyfluidhasaredcellcountoftensofthousandspermm3.Mostbloodysamplesareduetoa"traumatictap"withtrivialleakageofsubcutaneousbloodduringthetap.Inthissetting,thefluidisheterogeneouslybloodywithclearanceoftheredcolorduringthetapandclottingofthespecimenifthesampleisnotpromptlyplacedintotheanticoagulanttube.Ifthefluidappearstobehomogeneouslybloody,thebleedingprobablyoccurredlongbeforethecurrenttapwithsubsequentclotlysisanddistributionoftheredcellsthroughouttheabdominalcavity.Arapidrepeatparacentesisenteringtheothersideoftheabdomencanconfirmthatthefluidishomogeneouslybloody.Thedifferentialdiagnosisinthissettingisbloodyascitesduetocirrhosis,leakageofbloodfromapuncturedcollateral(eg,fromaprevioustap),ormalignancy[56,57].Ofsamplesobtainedfrompatientswithcirrhosis,approximately5percentwerebloodyinonestudy[56].Ofthebloodysamples,41percentwere"spontaneous"andprobablyrelatedtobloodylymph,34percentwereduetobleedinghepatocellularcarcinoma,22percentduetotraumatictap,and3percentduetotuberculousperitonitis[56].Carefulparacentesistechniqueminimizestheriskofpuncturingacollateralveinorartery.(See"Diagnosticandtherapeuticabdominalparacentesis".)Ascitesisbloodyinapproximately50percentofpatientswithhepatocellularcarcinoma[56-58]andin22percentofmalignancy-relatedascitesoverall[58].Patientswithhepatocellularcarcinomacandevelopmassiveintra-abdominalbleedingwithhemodynamicinstabilityandrapiddeath;embolizationofthebleedingvesselbyaninterventionalradiologistcanbeeffectiveinstoppingthebleeding[57,59].Suchpatientsrarelyqualifyforlivertransplantationduetoadvancedtumorstageandintraperitonealspread.(See"Malignancy-relatedascites".)Contrarytopopularbelief,tuberculousperitonitisisrarelybloody[56].(See"Tuberculousperitonitis".)●Brown–Deeplyjaundicedpatientshavebrownasciticfluidwithabilirubinconcentrationapproximately40percentoftheserumvalue[60].Iftheasciticfluidisasbrownasmolassesandthebilirubinconcentrationisgreaterthantheserumvalue,thepatientlikelyhasarupturedgallbladderorperforatedduodenalulcer[60].Serum-to-ascitesalbumingradient—Theserum-to-ascitesalbumingradient(SAAG)accuratelyidentifiesthepresenceofportalhypertensionandismoreusefulthantheprotein-basedexudate/transudateconcept(table3andtable6andalgorithm1)[40,61].TheSAAGiseasilycalculatedbysubtractingtheasciticfluidalbuminvaluefromtheserumalbuminvalue,whichshouldbeobtainedthesameday.TheSAAGgenerallydoesnotneedtoberepeatedaftertheinitialmeasurement.●Thepresenceofagradient≥1.1g/dL(≥11g/L)predictsthatthepatienthasportalhypertensionwith97percentaccuracy[40].●Agradient<1.1g/dL(<11g/L)indicatesthatthepatientdoesnothaveportalhypertension[40].TheSAAGwillbeelevatedwithanydisorderleadingtoportalhypertensionandisnotspecifictoascitesduetocirrhosis(table6).Othertestingmaybeneededtodifferentiatecirrhoticfromnoncirrhoticportalhypertension.Additionaltestingwilldependupontheclinicalsettingandmayincludeanevaluationforheartfailure,hepaticmetastases,orBudd-Chiarisyndrome.Patientswithascitesduetoheartfailurecannarrowtheirgradientduringdiuresis,whereastheSAAGinthesettingofcirrhosisremainsstableunlessbloodpressureorportalpressuredecreasessignificantly.Cellcountanddifferential—Thecellcountwithdifferentialisthesinglemostusefultestperformedonasciticfluidtoevaluateforinfectionandshouldbeorderedoneveryspecimen,includingtherapeuticparacentesisspecimens(ie,aparacentesisbeingperformedaspartofthetreatmentofascites).Asciticfluidinfectionisareversiblecauseofdeteriorationandapreventablecauseofdeathinpatientswithcirrhosisandascites.Thekeytosurvivalisearlydetectionandtreatment[52,62].Thecellcountshouldbeavailablewithinonehour,whiletheculturetakesseveralhourstodays[63,64].Antibiotictreatmentshouldbeconsideredinanypatientwithacorrectedneutrophilcount≥250/mm3[52,62,64].Thefluidshouldbesubmittedtothelabinatubecontainingananticoagulanttoavoidclotting(usuallyEDTA—"purpletop"tube).Rapidturn-aroundmayrequirea"stat"order.Somelaboratoriesprioritizeroutineperipheralbloodtestsovertheprocessingofasciticfluidcellcounts,andacallshouldbeplacedtothelaboratoryiftheresultisnotrapidlyavailable.Iftheresultsaredelayedoriftheclinicianfailstofollow-uponthecellcountinatimelymanner,infectionmaynotbediagnoseduntilisatanadvanced,andpossiblyfatal,stage.Thewhitebloodcellandneutrophilcountsneedtobecorrectedinpatientswithbloodysamples.Onewhitebloodcellshouldbesubtractedfromthewhitebloodcellcountforevery750redbloodcellstoyieldthe"correctedwhitebloodcellcount,"andoneneutrophilshouldbesubtractedfromtheabsoluteneutrophilcountforevery250redbloodcellstoyieldthe"correctedneutrophilcount"[65].Inbloodyascites,thecorrectedneutrophilcountisfrequently<0duetoremotehemorrhagewithlysisofneutrophils.(See'Appearance'aboveand"Spontaneousbacterialperitonitisinadults:Diagnosis".)Totalproteinconcentration—Asciticfluidcanbeclassifiedasanexudateifthetotalproteinconcentrationis≥2.5or3g/dLandatransudateifitisbelowthiscutoff.However,theexudate/transudatesystemofasciticfluidclassificationhasbeenreplacedbytheSAAG,whichisamoreusefulmeasurefordeterminingwhetherportalhypertensionispresent[40].(See'Serum-to-ascitesalbumingradient'above.)

Despiteitsproblems,theasciticfluidtotalproteinconcentrationremainsofsomevalue.Thisparameterdoesnotchangewithdevelopmentofspontaneousbacterialperitonitis(SBP),andpatientswithavaluelessthan1g/dLhaveahighriskofSBP[66,67].SelectiveintestinaldecontaminationmayhelppreventSBPinpatientswithlowproteinascites[68].(See"Spontaneousbacterialperitonitisinadults:Treatmentandprophylaxis",sectionon'Prophylaxis'.)Measurementoftotalprotein,glucose,andlactatedehydrogenase(LDH)inascitesmayalsobeofvalueindistinguishingSBPfrombowelperforationintoascites[69,70].Patientswithasciticfluidthathasacorrectedneutrophilcount≥250cells/mm3andmeetstwooutofthefollowingthreecriteriaareunlikelytohaveSBPandwarrantimmediateevaluationtodetermineifbowelperforationintoasciteshasoccurred[69,70]:●Totalprotein>1g/dL●Glucose<50mg/dL(2.8mmol/L)●LDHgreaterthantheupperlimitofnormalforserumThetotalproteinconcentrationmayalsohelpdifferentiateuncomplicatedascitesfromcirrhosisfromcardiacascites,bothofwhichhaveaSAAG≥1.1g/dL(≥11g/L).Inthecaseofascitesfromcirrhosis,thetotalproteinis<2.5g/dL(<25g/L),whereasincardiacascitesitis≥2.5g/dL(≥25g/L).Inpatientswithnephroticascites,theSAAGis<1.1g/dL(<11g/L),andthetotalproteinintheascitesof<2.5g/dL(<25g/L).Otherasciticfluidtests—Othertestsshouldbeorderedinappropriatesettings(table3andalgorithm1)[52].Theseadditionaltestsmaybeperformedwiththeinitialparacentesisifthereisclinicalsuspicionforaparticulardisorder,ortheymaybeperformedonasubsequentparacentesisbasedontheresultsofinitialtesting.Asageneralrule,thesetestsaremostusefulwhenthereissuspicionofsomethingotherthansterileascitesduetocirrhosis.●Culture—Culturesofasciticfluidshouldbeobtainedonspecimensfrompatientswhoarebeingadmittedtothehospitalwithascitesandthosewhodeterioratewithfever,abdominalpain,azotemia,acidosis,orconfusion[52].Bycomparison,therapeuticparacentesissamplesinpatientswithoutsymptomsofinfectiondonotneedtobecultured[71,72].Anadequatevolumeofasciticfluid(generally10mLperbottle,buttheamountvariesaccordingtothemanufacturerofthebottle)shouldbeinoculatedintoaerobicandanaerobicbloodculturebottlesatthebedside;thismethodismoresensitivefordetectingbacterialgrowthinasciticfluidthanconventionalculturemethods[63].Bedsideinoculationofthebloodculturebottlesispreferabletodelayedinoculationofthebottlesinthemicrobiologylaboratory[73].(See"Spontaneousbacterialperitonitisinadults:Diagnosis".)●Glucoseconcentration–Theasciticfluidglucoseconcentrationissimilartothatinserumunlessglucoseisbeingconsumedintheperitonealcavitybywhitebloodcellsorbacteria[66].Malignantcellsalsoconsumeglucose;thus,theconcentrationofglucosemaybelowinperitonealcarcinomatosis[58].Inthesettingofbowelperforation(eg,perforatedulcerordiverticulum)intoasciticfluid,glucosemaybeundetectable[69,70].●Lactatedehydrogenaseconcentration–Becauselactatedehydrogenase(LDH)isamuchlargermoleculethanglucose,itentersasciticfluidlessreadily[74].Theasciticfluid/serum(AF/S)ratioofLDHisapproximately0.4inuncomplicatedascitesduetocirrhosis.InSBP,theasciticfluidLDHlevelrisessuchthatthemeanratioapproaches1.0[66].IftheLDHratioismorethan1.0,LDHisbeingproducedinorreleasedintotheperitonealcavity,usuallybecauseofinfection,bowelperforation,ortumor.

●Gramstain–AlthoughaGramstainofasciticfluidisfrequentlyorderedwhenSBPissuspected,carefulinspectionofthecentrifugedsedimentof50mLofascitesisonly10percentsensitiveinvisualizingbacteriainearlydetectedSBP[63,75],andaGramstainofuncentrifugedfluidispositiveinonly7percent[63].Inonereport,aGramstainwaspositiveinonly31of796fluidsamples;sensitivityandspecificityforSBPwereestimatedtobe10and98percent,respectively[75].Choiceofantibioticswaschangedinonlyonepatient,while16of31positivesamplesoccurredinpatientswithoutSBPandwerethoughttohaverepresentedcontaminants.

Approximately10,000bacteria/mLarerequiredfordetectionbyGramstain,whilethemedianconcentrationofbacteriainSBPisonlyoneorganism/mL[63].Thus,aGramstainofasciticfluidisanalogoustoaGramstainofbloodinbacteremia;itisonlypositivewhenthereisanenormouscolonycount.TheGramstainismosthelpfulinrulinginfreeperforationofthebowelintoascites,inwhichcasesheetsofmultiplebacterialformscanbeseen(picture1).AsyringeortubeoffluidmustbesubmittedtothelaboratoryinadditiontotheculturebottleswhenrequestingaGramstain.

●Amylaseconcentration–Themeanasciticfluidamylaseconcentrationisabout40int.unit/Linuncomplicatedascitesduetocirrhosis,andtheAF/Sratioofamylaseisapproximately0.4[76].Theasciticfluidamylaseconcentrationrisesabovethislevelinthesettingofpancreatitisorbowelperforationintoascites[70,76].Inpancreaticascites,theasciticfluidamylaseconcentrationisapproximately2000int.unit/L,andtheAF/Sratioisapproximately6.0[76].(See"Chylous,bloody,andpancreaticascites".)

●Testsfortuberculousperitonitis–Avarietyoftestshavebeenusedforthedetectionoftuberculousperitonitis.Whenthereishighsuspicionoftuberculousperitonitis,peritoneoscopywithmycobacterialcultureandhistologyofabiopsiedtubercleisthemostrapidroutetothediagnosis.(See"Tuberculousperitonitis".)

•Directsmear–Thedirectsmearofasciticfluidhasonly0to2percentsensitivityfordetectingmycobacteria[77].WehavenotencounteredasingletruepositiveasciticfluidMycobacterialsmear.

•Culture–Whenoneliteroffluidiscultured,sensitivityforMycobacteriareportedlyreaches62to83percent[77,78].However,mostlaboratoriescanonlyprocess50mLofasciticfluidforMycobacterialculture.

•Peritoneoscopy–Peritoneoscopywithcultureofabiopsyspecimenhasasensitivityfordetectingtuberculousperitonitisthatapproaches100percent[79].FluidandtissuecanbesentforPCRfortuberculosis[80].

•Cellcount–Tuberculousperitonitiscanmimictheculture-negativevariantofSBP,butmononuclearcellsusuallypredominateintuberculosis.(See"Spontaneousbacterialperitonitisvariants".)

•Adenosinedeaminase–Adenosinedeaminaseisapurine-degradingenzymethatisnecessaryforthematurationanddifferentiationoflymphoidcells.Adenosinedeaminaseactivityofasciticfluidhasbeenproposedasausefulnon-culturemethodofdetectingtuberculousperitonitis;however,patientswithtuberculousperitonitiswhoalsohavecirrhosisusuallyhavefalselylowvalues[79].ThistestisusefulincountriessuchasIndia,butitisofverylimitedutilityintheUnitedStatesbecausemostpatientsintheUnitedStateswithtuberculousperitonitisalsohavecirrhosis[79].

●Cytology–Almost100percentofpatientswithperitonealcarcinomatosiswillhavepositiveasciticfluidcytologyduetothepresenceofviablemalignantcellsexfoliatingintotheasciticfluid[58].However,onlyabouttwo-thirdsofpatientswithmalignancy-relatedasciteshaveperitonealcarcinomatosis.Theremainingpatientshavemassivelivermetastases,chylousascitesduetolymphoma,orhepatocellularcarcinoma;thesepatientsusuallyhavenegativecytology[58].Asaresult,theoverallsensitivityofcytologysmearsforthedetectionofmalignantascitesis58to75percent[81,82].Hepatomasrarelymetastasizetotheperitoneum[83,84].(See"Malignancy-relatedascites".)

Somecytologylaboratoriespreferthatspecimensbesubmittedinalcoholfixative,whileotherspreferfreshunfixedspecimens.Itisbesttocoordinatethiswiththelocallaboratorytomaximizethesensitivityofthecytology.

●Carcinoembryonicantigenconcentration–Measurementofcarcinoembryonicantigen(CEA)inasciticfluidhasbeenproposedasahelpfultestindetectingmalignancy-relatedascites[85].However,thestudythatvalidatedCEAwassmallanddidnotsubgrouppatientsbasedonthetypeofcancer.CEAmaybeofsomeutilityinasciticfluidanalysis,butitsprecisevalueremainsunclear.

●Triglycerideconcentration–Atriglycerideconcentrationshouldbeobtainedonasciticfluidthatismilky.Chylousasciteshasatriglyceridecontentgreaterthan200mg/dL(2.26mmol/L)andusuallygreaterthan1000mg/dL(11.3mmol/L)[41,55].

●Bilirubinconcentration–Thebilirubinconcentrationshouldbemeasuredinpatientswithbrownascites.Asmentionedabove,anasciticfluidbilirubinvaluegreaterthantheserumsuggestsbowelorbiliaryperforationintoascites[60].(See'Appearance'above.)

●Serumpro-brainnatriureticpeptideconcentration–Measurementofpro-brainnatriureticpeptideinserumcanhelpdistinguishasciticfluidduetocirrhosisfromasciticfluidduetoheartfailure.Inonereport,medianvaluesweresignificantlyhigherinheartfailurecomparedwithcirrhosis,withverylittleoverlap(6100versus166pg/mL).Patientswithbothheartfailureandcirrhosishavevaluesintheheartfailurerange[86].

●Uselesstests–Sometestsofasciticfluidappeartobeuseless.TheseincludepH,lactate,and"humoraltestsofmalignancy"suchasfibronectin,cholesterol,andmanyothers[64,87].

Question7(12marks)

a. Listfour(4)drugsforwhichmultipledosecharcoalmaybeofbenefit.(4marks)• Carbamazepine• Quinine• Theophylline• Phenobarbitone• Dapsone

b. Listfour(4)drugsforwhichcharcoalisnotindicated,independentofthetimeofingestion.(4marks)

• Ethanol• Isopropylalcohol• Ethyleneglycol• Methanol• Lithium• Iron• Potassium• Lead• Arsenic• Mercury• Acids• Alkali

c. List four(4)drugsforwhichhaemodialysis is theeliminationmethodofchoice inthemanagementofseveretoxicityoverdose.(4marks)

• Ethyleneglycol• Methanol• Theophylline• Salicylate• Lithium• Phenobarbitone• Metformin• SodiumValproate• Carbamazepine• Potassiumsaltoverdoses

AdditionalQ:

Q:Listfour(4)indicationsforcharcoaluseinparacetamolpoisoning.(4marks) • <2/24instandardrelease• <4/24orModifiedrelease• <4/24inOD>30g• <24/24inOD>30gofmodifiedrelease

Question8(8marks)A34yearoldwomanpresentstoyouremergencydepartmentwithahistoryofabdominalpain,vomitinganddiarrhoeafortwoweeks.Anarterialbloodgashasbeenperformedandisshowninthepropsbooklet.

a. Providetwo(2)calculationstohelpyoutointerprettheseresults.(2marks)

Derivedvalue1: AG=12NAGMADerivedvalue2: expectedCO2=26+/-2respacidosis

b. Usingthescenarioandthederivedvalues,definetheprimaryacid/baseabnormality/s.(2marks)• NAGMA

c. Usingthescenarioandthederivedvalues,definethesecondaryacid/baseabnormality/s.(2marks)

• Respiratoryacidosis

d. Stateone(1)unifyingexplanationfortheseresults.(2marks)• NAGMAduetodiarrhoeaand/orrenalfailuresecondarytopre-renalcausesi.e.dehydration• HypoKduetoGUlosseswithhyperClsecondarytoelectricalequilibriumorNSresuscitation• Rest acidosis due to altered conscious state and/or fatigue 2° hypoventilation or aspiration or

respiratorymuscleweaknesssecondarytoHypoK

Question9(18marks)A20yearoldfemalepresentsafteramarineenvenomation.

a. Listtwo(2)historicalfindingsthatareconsistentwithBoxJellyfishenvenomation.(2marks)• Tentaclesseen• Stingimmediatelyintenselypainful• Arrestonbeach

b. Listtwo(2)examinationfindingsthatareconsistentwithBoxJellyfishenvenomation.(2marks)

• Screaming• Irrationalbehaviour• Wheals/vesicles/red-brownwhiplikemarks• HT• Tachycardia• Musclespasm/paralysis

c. Listtwo(2)historicalfindingsthatareconsistentwithIrukandjienvenomation.(2marks)

• Nostinger/jellyfishseen• Pain-notinitiallysevere• Notentaclesseen• Skinerythema-nowheal• Systemicsymptomsdelayed30min-2/24• Muscleaches/spasm• Headache• Sweating,restlessness,agitation• N/V• Respiratorydifficulty• Weakness• Collapse• Feelingof“impendingdoom”

d. Listthree(3)examinationfindingsthatareconsistentwithIrukandjienvenomation.(3marks)

• Sweating• HT• Tachycardia• CCF/APO

e. Completethetablebelow,listingtheroleofeachmanagementmodality.(10marks)

Boxjellyfish Irukandji

Mainstayoftreatment ProlongedACLSifarrest AntiHTRoleofapplicationofice N NRoleofvinegarapplication Y N/Ydifferentrecommended

textsdisagree!!Roleofpressureimmobilisation

N N

Roleofantivenom Controversial N

ThisresourceisproducedfortheuseofUniversityHospital,GeelongEmergencystaffforpreparationfortheEmergencyMedicineFellowshipwrittenexam.Allcarehasbeentakentoensureaccurateanduptodatecontent.Pleasecontactmewithanysuggestions,concernsorquestions.DrTomReade(StaffSpecialist,UniversityHospital,GeelongEmergencyDepartment)Email:tomre@barwonhealth.org.au November2017

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