CIA

Question 1

RECOGNITION OF THE CRITICALLY ILL PATIENT: Describe the use and limitations of risk scoring systems for common critical illnesses such as GI bleeding, pancreatitis, and trauma.

Answer 1

GI bleeding - Glawgow Blatchford

Pancreatitis - Ranson

Trauma - Revised trauma score (GCS, BP and RR)

AF - CHADVASC

Question 2

RECOGNITION OF THE CRITICALLY ILL PATIENT: Define the various grades of shock and their effects on the major organ systems

Answer 2

Shock: Describes circulatory failure that results in inadequate organ perfusion

Effects on major organ systems

Renal: Reduced urine output

Cerebral: Reduced consciousness

Cardiovascular: Increased HR with eventual reduction, eventual reduction in BP

Respiratory: Elevated RR

Question 3

RECOGNITION OF THE CRITICALLY ILL PATIENT: Distinguish between hypovolaemic, septic, cardiogenic and anaphylactic shock

Question 4

RECOGNITION OF THE CRITICALLY ILL PATIENT: Recognise acute severe exacerbation of COPD

Answer 4

Hx: Productive cough, general malaise, fever, chest pain, worsening dyspnoea

Examination: Widespread crackles, focal consolidation, reduced breath sounds

Investigations:

• CXR: Consolidation
• ABG: Acute on chronic type 2 respiratory failure. ABG in ‘health’ would show type 2 respiratory failure with metabolic compensation, allowing pH to be maintained within the normal range. In an acute exacerbation CO2 will increase and compensation will not be enough to keep pH within the normal range.

Question 5

RECOGNITION OF THE CRITICALLY ILL PATIENT: Recognise clinical features in patients at risk of cardio-respiratory arrest (ILS)

Answer 5

• Respiratory rate < 8
• Obstructed airway
• Cardiac arrest reversible causes: 4Hs and 4 Ts (hypothermia, hypoxia, hypovolaemia, hypokalaemia/hyperkalaemia & tamponade, tension pneumothorax, thrombosis, toxins)

Question 6

MANAGEMENT OF THE CRITICALLY ILL PATIENT: Describe the reasons for patient’s admission to ITU/HDU and the situations when it is inappropriate to refer a pt to ITU/HDU

Answer 6

Reasons for referral:

• Unable to maintain own airway
• Unable to maintain own BP

Inappropriate to refer:

• Ceiling of care set at ward based care
• Co-morbidities limit benefits

Question 7

SKILLS IN MANAGING THE CRITICALLY ILL PATIENT: Safely prescribe and administer Emergency anti-microbial therapy in a variety of critical illness situations: meningitis, community and hospital acquired pneumonia, urinary sepsis, and abdominal sepsis.

Answer 7

Meningitis: Ceftriaxone

CAP: Co-amoxiclav

HAP:

• PO Co-amoxiclav for low severity
• IV Piperacillin with tazo for severe infections

Urinary sepsis: Metronidazole

Abdominal sepsis: Cefuroxime and metronidazole

Question 8

Discuss the basic principles of emergency treatment of haemorrhagic shock; outline steps to be taken in fluid therapy of victims of haemorrhagic shock.

Question 9

Identify each of the following common life threatening chest injuries (ATOMFC) and discuss their pathophysiology: Airways injuries, Tension pneumothorax, Open pneumothorax, Massive haemothorax, Flail chest, Cardiac tamponade

Question 10

Describe the following potentially life threatening injuries and outline their initial management: pulmonary contusion, aortic disruption, tracheobronchial disruption, oesophageal disruption, diaphragmatic disruption, myocardial contusion

Question 11

Outline diagnostic and supportive therapeutic actions for abdominal trauma including the indications and contra-indications for FAST (focused assessment with sonography for trauma).

Question 12

Discuss the general management and initial investigation of the unconscious traumatised patient

Question 13

Describe the pathology of head injury, classifying into focal and diffuse. Describe the delayed complications that can follow head injury, classifying into focal and diffuse, and outline the basic principles of rehabilitation in those with cognitive impairment

Question 14

Describe the main causes, pathophysiological mechanisms and effects of increased intracranial pressure

Question 15

Outline the therapeutic interventions that, when initiated in the early phases of management, can help to reverse or delay undesirable effects of raised intracranial pressure.

Question 16

Specify the principles of acute management of the patient with spine or spinal cord injury.

Question 17

Discuss the aetiology, presentation and emergency management of a compartment syndrome.

Question 18

SKILLS IN EMERGENCY MEDICINE

• Conduct an initial assessment and management survey on a patient with multiple injuries, using the correct sequence of priorities and explanation of the management techniques for primary treatment and stabilisation.
• Conduct a neurological examination and determine the Glasgow Coma Scale on a patient with head trauma.
• Demonstrate the ability to immobilise the spine on a patient with a back injury.
• Demonstrate the ability to immobilise a fractured limb.
• Interpret the CXR in a patient with severe closed chest trauma.
• Interpret the pelvis and cervical spine radiographs in a trauma patient.
• Observe the performance of a FAST scan in a trauma patient and understand the interpretation of the results.

Question 19

BURNS: List and differentiate the categories of burn injury; thermal, chemical, electrical, cold and irradiation

Answer 19

Thermal: Due to direct contact with a hot object/vapour.

Chemical: Alkali substances tend to cause worse burns. Can penetrate the skin and be difficult to remove

Electrical: Severity depends upon the strength of voltage and duration of contact

Cold:

Irradiation: May occur due to exposure to X-rays, UV radiation (sun)

Question 20

BURNS: Classify the depth of burn injury

Answer 20

Superficial burn: Erythema, branches

↓

Superficial partial thickness burn: Blistered, blanches, painful

↓

Deep partial thickness burn: cherry red, blistered, no blanching, dull sensation

↓

Full thickness burn: white, does not blanch, no sensation

Question 21

BURNS: Describe and apply the rules of nine

(which areas correspond to 9%)

Answer 21

1% = palm and fingers

Question 22

BURNS: List the causes, symptoms and signs of inhalation injury

Answer 22

Causes:

• Inhalation of smoke

Signs and symptoms:

• Wheeze/stridor
• Dyspnoea
• Cough with discoloured sputum
• Hoarseness of voice

Question 23

BURNS: Outline the fluid resuscitation of burns patients, including composition, volume and timing of fluid.

Answer 23

*The greatest loss of plasma occurs in the first 12 hours following the burn

Burns of > 15% in adults, 10% in children, warrant the need for fluid resuscitation.

Crystalloid fluids are used,

The Parkland formula is used to calculate fluid requirements within the first 24 hours:

• 4ml x total burn surface area/TBSA (%) x body weight (kg)
• 50% of the calculate volume should be given in the first 8 hours
• The remainder should be given over the next 16 hours
• Catheterisation to monitor urine output is also required

Question 24

BURNS: List the other management steps in the initial 24 hours following a burn injury, including general support, wound management and antibiotics.

Answer 24

• Analgesia: Opioids
• Fluids
• Systemic abx if there is evidence of invasive infection
• Wound management
  
  • Partial thickness burn: Use non-adherent dressing. Hands should be covered with sulfadazine cream (sulphonamide abx) and placed in a sealed polythene bag
  • Full thickness burn: Total excision of the burn is required. Smaller burns may close primary but larger ones require grafts
    *

Question 25

BURNS: Discuss the methods used to prepare a full thickness burn for grafting and the factors relevant to the successful take if the graft on the wound surface.

Answer 25

* Grafting should be performed within 5/7 of the burn * Must be free of infection * Autograft split skin grafts provide the best covering

Question 26

BURNS: Identify patients who require specialised burns centre management.

Answer 26

* Full thickness circumferential burns (as can restrict blood flow to the rest of the limb) * Burns to the hands * Burns **\> 30% total body area** * **Partial thickness burns \> 10%** * Chemical or electrical injuries * Associated inhalation injury * Extremes of age

Question 27

BURNS: Define the maximum extent to which a patient can be burned and still be managed on an outpatient basis.

Answer 27

* Adults with partial thickness burn \< 10% * Children with partial thickness burn \< 5% * Full thickness burn \<1% Outpatient management involves analgesia, blister deroofing and dressing with a paraffin gauze. Referral to a burns centre must be made if the burn does not heal within 3/52.

Question 28

EMERGENCY MEDICINE: * Describe the immediate assessment and management of acute presentations of Cardiac arrest and life threatening arrhythmias * Describe the immediate assessment and management of acute presentations of the unconscious patient * Describe the immediate assessment and management of Myocardial infarction and acute coronary syndrome * Describe the immediate assessment and management of acute presentations of The breathless patient including asthma, COPD and pulmonary oedema * Describe the immediate assessment and management of acute presentations of Cerebrovascular accident * Describe the immediate assessment and management of acute presentations of Diabetic complications – hypoglycaemia, hyperglycaemia, DKA and HHS * Describe the immediate assessment and management of acute presentations of generalised and focal seizures * Describe the immediate assessment and management of acute presentations of severe sepsis * Describe the immediate assessment and management of acute presentations of Anaphylaxis

Question 29

ANAESTHETICS - PRE-OPERATIVE ASSESSMENT: Describe the ASA classification and methods used to classify urgency of operation.

Answer 29

ASA (American Society of Anaesthesiologists) physical status classification system is used to establish a patients functional capacity. Provides a simple scale for describing a person's fitness for anaesthetic.

Question 30

ANAESTHETICS - PRE-OPERATIVE ASSESSMENT: Specify appropriate starvation for food and clear fluids

Answer 30

Food - 6 hours Clear fluids - 2 hours

Question 31

ANAESTHETICS - PRE-OPERATIVE ASSESSMENT: Describe the principles of management of the diabetic patient presenting for surgery

Answer 31

**Pre-operative** * Minimise pre-operative fasting times - first on operating list * Well controlled DM with tablets or diet → medication omitted on the day of surgery and check BM regularly * ​Metformin must be stopped 48hrs before due to risk of lactic acidosis * Poorly controlled or on insulin → variable rate infusion required * Potassium supplementation may also be provided * IV maintenance fluids of 0.18% NaCl with glucose 4% **Peri-operative** * Regular monitoring of glucose levels * Consider insulin if BM \> 10mmol/L **Post-operative** * Regular monitoring of BM and vital signs

Question 32

ANAESTHETICS - PERI-OPERATIVE CARE: Describe causes of postoperative nausea and vomiting (PONV)

Answer 32

* Abdominal, gynae or ENT procedure * Long duration of surgery, GA, use of inhalation agents * Post-operative pain, opioid analgesia, dehydration or hypotension

Question 33

ANAESTHETICS - PERI-OPERATIVE CARE: Describe indications, contra-indications and doses for commonly used drugs for PONV: antihistamines (e.g. cyclizine), 5HT3 antagonists (e.g. ondansetron), Dopamine antagonists (e.g. droperidol), Dexamethasone

Answer 33

Question 34

ANAESTHETICS - PERI-OPERATIVE CARE: Recognize and manage a patient with an obstructed airway (also covered in critical illness attachment): Undertake appropriate head / neck positioning, sizes and insert an appropriate oropharyngeal (Guedel) airway

Answer 34

* Head tilt, chin lift with jaw thrust * Guedel sizing - from angle of the jaw to the mouth. Align the coloured area with the teeth * Nasopharyngeal airway and i-gels may also be considered as alternatives