UNIVERSITYHOSPITAL,GEELONGFELLOWSHIPWRITTENEXAMINATION

WEEK21–TRIALSHORTANSWERQUESTIONSSuggestedanswersPLEASELETTOMKNOWOFANYERRORS/OTHEROPTIONSFORANSWERSPleasedonotsimplychangethisdocument-itisnotthemastercopy!

Question1(18marks)YouarestandingattheTriagedeskofyourEmergencyDepartment.AdistressedmanpresentstotheTriagedeskcarryinghis5yearoldson.Hestatesthathewitnessedhissonbeingbittenontherightthighbyasnake,about30minutesearlier.Thechildisconsciousandalert.Younoteasmallbruisedareaonthechild’srightthigh.Thechildisplacedinaresuscitationcubiclewithfullexternalmonitoringapplied.

a. Statethree(3)key,immediatestepsinyourmanagementofthischild.(3marks)Boldrequired1markeach,4thmarkanyofotheroptions

• Keepchildimmobile-Mandatory• Pressurebandagetorightlowerlimb-Mandatory• Splintrightlowerlimb-Mandatory• ObtainIVaccess(drawbloodforpathology)• Reassurefather

b. Listtwo(2)symptomsandtwo(2)signsthatwouldbeconsistentwithenvenomationinthischild.(4marks)

i) Symptoms:-Headache -Abdopain -Vomiting

-Myalgia-Diarrhoea-Sweating

ii) Signs: -Neurotoxic-cranialnerves/peripheralfocalsigns/respiratoryfatigue -Coagulopathic-bruising,bleeding-Hypotension/circulatoryfailure-Lymphadenopathy-Muscletenderness

c. Stateyourpreferredtechnique(iebitesiteorurineorblood)tocollectasampleforVenomdetection.Statetwo(2)justificationsforchoice.(3marks)

• SkinJustification:• Bestaccuracy(iehighestsensitivityandspecificity)• BothUrineandbloodhaveunacceptableFalse+verate• Urinefalse-veinmassiveenvenomation• Bloodfalse-verateunacceptable

AnFBEandU+Earetaken.d. Listthree(3)otherkey,bloodteststhatyouwouldperformforthispatient.(3marks)

• Coagulationscreen-INR,APTTo Fibrinogen(partofacoagulationscreen,butusuallyrequiresseparateordering)o DDimer(partofacoagulationscreen,butusuallyrequiresseparateordering)

• Bloodfilm• CK• LDH• LFT

e. Completethetablebelow.Stateone(1)justificationforeachchoice.(6marks)

Managementstep JustificationAntivenomtype Polyvalent

Monovalent-areaspecificIfsevereenvenomation-untilVDKconfirmsMonovalentfollowingVDK/areaspecificchoice

Antivenomdose 1amppolyvalent Child=adult1ampouleRepeat/Totaldosecontroversial-seekexperthelp

Likelihoodofserumsickness

Increaseriskvsadult Child>riskthanadult↑inlinewithamountofantivenom-espifpolyvalentgiven(>10%)

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

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Clinical pathway: Snake bite envenomation in Victoria This clinical pathway applies ONLY to community-acquired snake bites in patients who are not snake handlers. Specific advice regarding bites in snake handlers and from exotic snakes should be obtained from a clinical toxicologist (e.g. Poisons Centre 13 11 26).

Clinical patterns Snake Coagulopathy Neurotoxicity Myotoxicity Systemic

symptoms Cardiovascular effects

TMA Antivenom

Brown VICC Rare and mild - <50% Collapse (33%)

Cardiac arrest (5%)

10% Brown

Tiger VICC Uncommon Uncommon Common Rare 5% Tiger

Red-bellied black

Anticoagulant - Uncommon Common - - Tiger

VICC = Venom-induced consumptive coagulopathy (abnormal INR, fibrinogen very low, d-dimer high) Anticoagulant = aPPT 1.5–2.5 x normal ± minor elevation INR. D-dimer and fibrinogen usually normal TMA = thrombotic microangiography. Fragmented red blood cells on blood film, thrombocytopenia and a rising creatinine

Indications for antivenom: seek advice from a clinical toxicologist (e.g. Poisons Centre 13 11 26)

• Neurotoxic paralysis (e.g. ptosis, ophthalmoplegia, limb weakness, respiratory effects)

• Significant coagulopathy (e.g. unclottable blood, INR>1.3, prolonged bleeding from wounds and venepunctures)

• History of unconsciousness, collapse, convulsions or cardiac arrest

There are a number of relative indications for antivenom that require expert interpretation. It is strongly recommended that significant systemic symptoms or any abnormality of INR, APTT, fibrinogen, d-dimer, full blood count (leucocytosis, evidence of TMA) or CK >1000 is discussed with a clinical toxicologist to determine if antivenom is required.

Choice of antivenom: seek advice from a clinical toxicologist (e.g. Poisons Centre 13 11 26)

If there is a delay in contacting a clinical toxicologist and there is clear indication for antivenom, administer 1 vial of tiger snake antivenom and 1 vial of brown snake antivenom.

It is strongly recommended that all cases of envenomation be discussed with a toxicologist to guide treatment and appropriate disposition.

Prepare to manage anaphylactoid reactions Tick if completed

• Critical care area with monitoring • IV line in situ • Further IV fluids available • Adrenaline available

Preparation and administration of antivenom Tick if completed

• Dilute in 100–500mls of isotonic saline • Administer over 15-30 minutes

• Release pressure bandage immobilisation after antivenom has been administered

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Monitor progress: seek advice from a clinical toxicologist (e.g. Poisons Centre 13 11 26)

Tick if completed

Monitor, investigate and treat for complications such as occult bleeding, electrolyte abnormality (e.g. hyperkalaemia, developing renal impairment)

6 hours post anti-venom: INR, APPT, fibrinogen, d-dimer, EUC, CK and FBE If not improving/unsure, seek advice from a clinical toxicologist (e.g Poisons centre 13 11 26)

12 hours post anti-venom: INR, APPT, fibrinogen, d-dimer, EUC, CK and FBE

If not improving/ unsure, seek advice from a clinical toxicologist (e.g Poisons centre 13 11 26)

NOTE: Coagulopathy may not begin to improve until about 12 hours. Persistent coagulopathy is not an indication for additional antivenom. Seek advice if concerned.

Daily thereafter until resolved: INR, APPT, fibrinogen, d-dimer, EUC, CK and FBE

Location List criteria

ED observation unit

Ward

ICU/ HDU

Transfer

Criteria for discharge during daytime (do not discharge at night): seek advice from a clinical toxicologist (e.g. Poisons Centre 13 11 26)

Uncomplicated myotoxicity and mild neurotoxicity Once clinical features are resolving and blood tests, at least 12 hours post antivenom, are normalising

VICC INR, APTT, creatinine and platelet count normalising

Discharge advice Tick if completed

Explanation of the risk of serum sickness (~30%) characterised by flu-like symptoms, fever, myalgia, arthralgia and rash developing 4–14 days post antivenom

Letter to GP including advice regarding recognition and treatment of serum sickness

Notes for participating emergency departments: 1. Snake venom detection kit use: This is a decision for individual health services based on local resources and experience. The role of snake venom detection kits in bites occurring in the community within Victoria who are not snake handlers is controversial, because of the narrow range of snakes that might be involved and a significant misclassification rate of tiger snake venom as brown snake venom. Use of the kits requires training and results need to be interpreted in the light of all clinical and laboratory data. If health services decide to include the use of a snake venom detection kit in their pathway, it should be inserted under the ‘Choice of anti-venom’ section along with a strong recommendation/ requirement that the results are discussed with a clinical toxicologist. 2. Disposition criteria: Each health service should decide its own disposition criteria, taking into account resources, expertise and clinical risk. These should be clearly documented in the pathway.

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Question2(12marks)A25yearoldmalepresentsviaambulancetoyourruralemergencydepartment.Hefellfromamotorbikeandcomplainsofneckpain.Aftercompleteexaminationandinvestigation,heisfoundtohaveanisolatedneckinjury.Observations: GCS15

a. Statethree(3)abnormalfindingsshowninthisXray.(3marks)

• Anteriorteardrop#C5• Posteriorteardrop#C5• LossofcontinuityofposteriorspinallineayC5-6• Retrolisthesisofinfero-posteriorC5

Itisdeterminedthatthepatientrequirestransferbyroadambulancetoatraumacentre150kmaway.

b. Statesix(6)preparationsfortransferthatarespecificforthisinjury.(6marks)• Completespinalimmobilisation• IDC• XRimages-hardcopy/CD• Antiemetic• Analgesia• Airway:

§ secureonlyifptnon-compliantwithspinalimmobilisation/drugaffected/othersignificantinjuries

• Steroidsonlyafterdiscussionwithreferralcentre• Communicationwithdestinationtominimisepatientbedtransfers• Keepwarm:atriskofhypothermia

Yoususpectaspinalinjury.

c. Listone(1)proandtwo(2)consforusingsteroidsforthispatient.(3marks) Pros:

• Minormotorbenefit-insmalltrials(needstobegivenearly)• Forpartialinjuriesonly

Cons:• Usenotuniversallyaccepted-needadvicefromspecialistunit• Insufficientevidenceofbenefittorecommendroutineuse• Complications:

§ Infection§ GIbleed

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Question3(12marks) YouareworkinginamixedemergencydepartmentinanoutersuburbanhospitalwithaninpatientPaediatricservice.An11montholdfemaledevelopedarashovera48hrperiod.Therashispresentovertheentirebody,sparingthepalmsandsoles.

a. Whatisthediagnosis?(1mark)• Toxicepidermalnecrolysis

b. Listthree(3)likelyunderlyingcausesforthiscondition(eachcausetobeadifferentaetiology

type). (3marks)• Drugs-sulphonamides,carbamazepine,phenobarbital,lamotrigine,aspirin/NSAIDS• Infections-underlyingHIV,mycoplasma,CMV• Vaccination• Contrastmedium• Externalchemicalexposure• Herbalmedicines• Food• UVtherapy• Systemicdiseases-egSLE• Malignancies-leukaemia,lymphoma

c. Whatisyourpreferreddispositionforthispatient?Statetwo(2)pointsinyouranswer.(2marks)

• UrgenttransfertoaTertiarypaediatriccentre(1)withICUandBurnsunit(1)• EarlyOpthalmologicalreferral• Earlygynaecologicreferral

d. Justifyyourpreferreddispositionforthispatient.Statetwo(2)pointsofjustificationforyour

choice.(2marks)• prognosisisbetterforpatientstransferredpromptlytoaburncareunitorintensive

careunit• managedlargelyasamajorburn• EarlyOpthalmologicalreferral-eyeinflammationcanevolvequicklyinthefirstfew

daysoftheillness• Earlygyanecologicreferral-shouldbeperformedinallfemalepatientswithSJS/TEN.

Thegoaloftreatmentofvaginalinvolvementisdecreasingtheformationofadhesionsandlabialagglutination

e. Otherthandispositionarrangements,listfour(4)keystepsmanagementofthiscondition.(4marks)

• Withdraw/treatincitingagent• Nonadherentdressings• Analgesia• Fluidmanagementasperburns• Infectionprevention-Sterilehandling,antisepticsolutions• Eyecare-lubrication

NB: ProphylacticAbsarenotrecommended• Topicalsteroidsuseiscontroversial• Iguseiscontroversial

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Stevens-Johnsonsyndrome(SJS)andtoxicepidermalnecrolysis(TEN)areseveremucocutaneousreactions,mostcommonlytriggeredbymedications,characterizedbyextensivenecrosisanddetachmentoftheepidermis.Accordingtoawidelyacceptedclassification,SJSandTENareconsideredvariantsofadiseasecontinuumandaredistinguishedchieflybyseverity,baseduponthepercentageofbodysurfaceinvolvedwithblistersanderosions

● SJSisthelessseverecondition,inwhichskindetachmentis<10%ofthebodysurface(pictureA1-C).Mucousmembranesareaffectedinover90%ofpatients,usuallyattwoormoredistinctsites(ocular,oral,andgenital).

● TENinvolvesdetachmentof>30%ofthebodysurfaceareaMucousmembranesareinvolvedinthemajorityofcases.● SJS/TENoverlapdescribespatientswithskindetachmentof10to30%ofbodysurfacearea.● “Dunn”definesErythemamultiformaemajorasinterchangeablewithSJS.

TheincidenceofSJS/TENisapproximately100-foldhigheramongHIV-infectedindividualsthaninthegeneralpopulation.TheoverallmortalityrateamongpatientswithSJS/TENisapproximately30%,rangingfromapproximately10%forSJStomorethan30%forTEN.Mortalitycontinuestoincreaseuptooneyearafterdiseaseonset.Clinicalfeatures:

• Fever,oftenexceeding39°C,andinfluenza-likesymptomsprecedebyonetothreedaysthedevelopmentofmucocutaneouslesions.Photophobiaandconjunctivalitchingorburning,andpainonswallowingmaybeearlysymptomsofmucosalinvolvement.Malaise,myalgia,andarthralgiaarepresentinmostpatients.

• Insomepatients,anexanthematouseruptioncanbetheheraldingsignofSJS/TEN.SignsandsymptomsthatshouldalertthecliniciantothepossibilityofStevens-Johnsonsyndrome/toxicepidermalnecrolysis(SJS/TEN)includefever>38°Cmucositis,skintenderness,andblistering.

• Cutaneouslesions—Theskinlesionstypicallybeginwithill-defined,coalescingerythematousmaculeswithpurpuriccenters,althoughmanycasesofSJS/TENmaypresentwithdiffuseerythema).Theskinisoftentendertothetouchandskinpaincanbeprominentandoutofproportiontothecutaneousfindings.Lesionsstartonthefaceandthoraxbeforespreadingtootherareasandaresymmetricallydistributed.Thescalpistypicallyspared,andpalmsandsolesarerarelyinvolved.Atypicaltargetlesionswithdarkercentersmaybepresent.Asthediseaseprogresses,vesiclesandbullaeformandwithindaystheskinbeginstoslough.

• Nikolskysign(ie,theabilitytoextendtheareaofsuperficialsloughingbyapplyinggentlelateralpressureonthesurfaceoftheskinatanapparentlyuninvolvedsite)maybepositive.TheAsboe-Hansensignor"bullaspreadsign"(alateralextensionofbullaewithpressure)mayalsobepresent.Theultimateappearanceoftheskinhasbeenlikenedtothatofextensivethermalinjury.

• Mucosallesions—Mucosalinvolvementoccursinapproximately90%ofcasesofSJS/TENandcanprecedeorfollowtheskineruption.Painfulcrustsanderosionsmayoccuronanymucosalsurface.

• Oral—Theoralmucosaandthevermilionborderarealmostinvariablyinvolved,withpainfulhaemorrhagicerosionscoveredwithagreyish-whitemembraneStomatitisandmucositisleadtoimpairedoralintakewithconsequentmalnutritionanddehydration.

• Ocular—Ocularinvolvementisreportedinapproximately80%ofpatients.Themostcommonchangeintheeyesisasevereconjunctivitiswithapurulentdischargebutbullaemaydevelop.Cornealulcerationisfrequent,andanterioruveitisorpanophthalmitismayoccur.Painandphotophobiaareaccompanyingsymptoms.Theeyechangesoftenregresscompletely,butscarringwiththedevelopmentofsynechiaebetweentheeyelidsandconjunctivamaybelatesequelae.

• Urogenital—Urethritisdevelopsinuptotwo-thirdsofpatients,andmayleadtourinaryretention.Genitalerosionsarefrequent.Inwomen,vulvovaginalinvolvementmaypresentwitherosiveandulcerativevaginitis,vulvarbullae,andvaginalsynechiae,andmayleadtolong-termanatomicsequelae.Theseincludelabialandvaginaladhesionsandstenosis,obstructedurinarystreamandurinaryretention,recurrentcystitis,orhematocolpos.Vulvovaginaladenosis(presenceofmetaplasticcervicalorendometrialglandularepitheliuminthevulvaorvagina)alsohasbeenreportedinwomenwithSJS/TEN.

• Pharyngealmucosaisaffectedinnearlyallpatients;tracheal,bronchial,andoesophagealmembranesarelessfrequentlyinvolved.Intestinalinvolvementisrare.

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Question4(12marks)

Clinicalhandoverintheemergencydepartmentcanbeperformedusingseveraltechniques.

a. Listone(1)proandone(1)conforeachofthetechniquesofhandoverlistedbelow.(6marks)

Handovertechnique Pros Cons

Paper/whiteboard • Freefromunnecessaryinfo

• Confidentiality

• (Acceptability)

• Not-Easeofuse

• Easytoloseinfo

• Errorsofinfoduplication

• Notrailofrecordchanging

Electronic • Rapiddata

• Flexiblesetup/WRsetting

• Avoidsinfodoublingup

• AccessIxatsametime

• Soundproof/privatearea

• ReliesonITinfrastructure

• Infoscopemaybelimitedbyfunctionality

• Needselectricity

• Systemcrashesinfoloss/tracking

Wardround/bedside • Directptviewing

• Immediateinfo/obs

• Ptsatisfaction

• DirectptquestioningPainetc

• Allowsprovisionofsymptomcare

• Timeconsuming

• Confidentiality

• Spaceforentireteamtomove

• Potentialthreattostaffsafety

• Uncomfortableforpatients

b. Assumingappropriatestaffparticipation,listsix(6)otherimportantcomponentstoamorninghandoverwardround.(6marks).

• Safehandoverofpatientsseen• Ongoingmanagementofsickpatients• Identifysalientissueswitheachpt• Managementplanshouldbeclear• Teachingandsupportwhereappropriate• Delegateamstaffmembertoeachpt• Handoverofshortstayadmittedpts• Debriefanyproblemsovernight• Ensurenightstaffdocumentationiscomplete

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Question5(10marks)

A21yearoldmanpresentsfollowinganassaultwithapainfulrighteye

a. Statefour(4)abnormalfindingsshowninthisCTscan.(4marks)• RBlowout#• Rtrappedinfrectus• Rmaxilliarysinusblood• Lmaxilliarysinusitis• AirinRorbit

b. List(6)associatedexaminationfindingsthatyouwouldexpecttobeassociatedwiththisinjury.

(6mark)• Periocularbruising• Infraorbitalnumbness• Inabilitytolookup/upwardgazepalsy• Painoneyemovement• Tendernesstoorbitalrim• Facialsubcutaneousemphysema

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

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Question6(12marks)An82yearoldwomanpresentstoyouremergencydepartmentwith10hoursofabdominalpain.Yourclinicalassessmentleadstoaclinicaldiagnosisofmesentericischaemia.

a. Listthree(3)optionsfordefinitiveimaginginthispatient.Stateone(1)relevantproandone(1)conforeachoftheseoptions.(9marks)

NB:youonlyhave1choiceforeachsomakeita“goody”.Makeitclinicallyrelevant.

Imagingoption Pro Con

CTabdo+contrast• Mostsensitiveformesenteric

venousthrombosis• Candefineembolicvs

thrombotic-arterialandvenousocclusion

• DxotherDx

• riskofcontrastnephropathy• Sensitivityandspecificitycanbeaslow

as64%and92%• contrastallergies

Angiography• Specificandgoldstandard• Diagnosticandtherapeutic• Goodresolutionofbowelwall

oedema• Identifythetypeofocclusion,site

ofocclusionandstateofcollateralcirculation

• Limitedavailability• Radiocontrast• Invasive

MRI/MRA• Detailedinformationofthe

vasculature• Candefineembolicvsthrombotic

• Limitedresolutionofbowelgas• Availability• Outofdepartment• Timeforprocedureandinterpretation

NB:US–Limitedvalueinacutesetting.Usefulinchronicstate,assessingvascularflow-87%and98%sensitivityinidentifyingceliacandSMAstenosisrespectivelyAdiagnosisofmesentericischaemiaissupportedbyyourchosenimaging.

b. Statethree(3)factorsthatmayaffectadecisionregardingoperativetreatmentforthispatient.(3marks)• Criticaldecision:100%mortalitywithoutsurgery;timecriticalifoptforit• Patient’swishes

o Advancedirectiveso Patientpotentiallyunfittodecide,evenifcomposmentispre-morbidly

• NextofKin:o Medicalpowerofattorneyifapplicableo Choicemustbeinformedandnotcoerced

• Co-morbidities:o PremorbidQOLo Complicationsofcurrentillness–egacidaemia,shocko Otherillness–heighteningrisksofperioperativemorbidity/mortalityo Otherrisks:egcurrentwarfarinorantiplatelettherapy

• Clinicalprogress-Responsetoinitialresuscitation• Currentresources-AvailabilityofurgentsurgicalservicesandICU,andtheiropinion.If

unavailable,ptunlikelytobesuitablefortransfer

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Question7(11marks)

A3weekoldboyisbroughttoemergencywithfrequentvomitingovera24hourperiod.

Arterialbloodgas,serumandurinebiochemistry ReferencerangeFiO2 0.21pH 7.54 7.35-7.45pCO2 50 mmHg 35-45PO2 62 mmHg 80-95Bicarbonate 41 mmHg 22-28Baseexcess +10 -3-+3O2saturation 99 %>95Na+ 131 mmol/l 134-146K+ 2.1 mmol/l 3.4-5.0Cl- 66 mmol/l 98-106Bicarbonate 45 mmol/l 22-28Urea 10.5 mmol/l 2.5-6.4Creatinine 0.05 mmol/l 0.05-0.1Glucose 3.4 mmol/l 3.5-5.5UrinespotNa 22 mmol/lK 28 mmol/l Cl <10 mmol/l

a. Provideone(1)calculationtohelpyoutointerprettheseresults. (1mark)

• Derivedvalue1:ExpectedpCO2=PCO2=0.9xHCO3-+9=49.7

b. Whatisthesignificanceofthiscalculationfinding?(1mark)• Appropriaterespiratorycomponent-metabolicalkalosisonly,norespcomponent

c. Whatisthemostlikelydiagnosis?(1mark)

• Pyloricstenosis

d. Listfour(4)investigationfindingsfromthesebloodteststosupportthisdiagnosis.(4marks)• Severemetabolicalkalosis-pH7.52andBicarbonate45• Severehypochloraemia• Severehypokalaemia• ElevatedUr:Cr-suggestingdehydration• Otherslessgood:

o Mildhyponatraemiao Urinarysodiumlowo IncreasedurinaryKlosso DecreasedurinaryClo Nearnormalglucose

e. Listtwo(2)urgent,keyinvestigationsthatyouwouldorderforthispatient.Stateone(1)justificationfor

eachchoice.(4marks)

Investigation(2marks)

Justification(2marks)

US Accuracycloseto100%(ieSensitivityandspecificitynear100%)“doughnut”or“null’seye”onX-sectionofpyloricchannel

Urine/Septicscreen Excludeinfectionascauseofvomiting

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Question8(18marks)

A25yearoldwomanpresentsfollowingadeliberateaspirinoverdose.

a. Completethetablebelowtodemonstrateyourdoserelatedriskassessment.(10marks)

Doserangemg/kg Clinicaleffects Acid/basedisturbance

<150mg/kg Minimalsymptoms(nofurtheranswerrequired)

Nil(nofurtheranswerrequired)

150-300mg/kg HyperpnoeaTinnitus,decreasedhearingCNSagitationNauseavomiting

Respalkalosis

>300mg/kg AlteredmentalstateSeizure

HAGMetabolicacidosis

>500mg/kg Potentiallylethal Acidaemia

b. Whatistheroleofserumsalicylatelevels?Statethree(3)pointsinyouranswer.(3marks)

• Poorcorrelationbetweenlevelsandseverityoftoxicity• Seriallevelsevery2-4hrsusefultoidentifyongoing/delayedabsorption(tablet

bezoar/SRtablets)• Veryhighlevelsmaybeusedasanindicationfordialysis• Lowerlevelisaconcerninchronicpoisoningorelderly• ↑levelspostcharcoalisanindicationforrepeateddosingofcharcoal

c. Whatistheroleofdecontaminationinthispoisoning?Statetwo(2)pointsinyouranswer.(2

marks)• Effective• >150mg/kg:Oralcharcoalupto8/24• >300mg/kgNGTafterairwaysecured• Repeateddoseifserumlevelsrising

d. Whatistheroleofenhancedeliminationinthispoisoning?Statethree(3)pointsinyouranswer.

(3marks) • Urinaryalkalinisationforsymptomatic• Haemodialysisrarelyrequiredifdecontaminationandurinaryalkalinisation

implementedearly• Indicatedif:

o Urinaryalkalinisationnotfeasibleo ↑serumlevelsdespitedecontamination&urinaryalkalinisationo Severetoxicity(alteredmentalstate,acidaemia,ARF)o Veryhighsalicylatelevels

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Question9(11marks)An18montholdgirlpresentswithrespiratorydistressandpallor.

a. WhatisthediagnosisbasedonthisECG?(1mark)

• SVT

b. Statefour(4)featuresshowninthisECGthatsupportthisdiagnosis.(4marks)• Regular• Narrowcomplex• Tachycardia:Rate230-270(acceptablerange)• Absentpwaves

c. Statesix(6)immediatestepsinyourmanagement,demonstratingyourescalationuntilthis

conditionisadequatelytreated.(6marks)NB:shockissuggestedbypresentation-SOB&pallor

• Consent/explanationtoparents• Vagalmanoeuvre-Icetoface/invertupsidedown/headinbucketofwater(!)• IfrapidIVaccessavailable-IVadenosine0.1mg/kg• RepeatIVadenosine0.2mg/kgthen0.3mg/kg(+/-0.4mg/kg)• IfIVaccessdelayed/failureofIVadenosine-IMsedation(egKetamine4mg/kg)&

DCR-dose0.5-1J/Kg• RepeatDCR2mg/kg

NB:NOTverapamil-(CI<1yr)

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