MediNuggets

Nuggets of wisdom for those with an interest in ED / Critical Care hit counter

[medinuggets-blog]

Dr Edward Reje's New Exam Verdict

The 2015 FACEM Exam So here it is.  The unofficial review of the New 2015 FACEM Exam. Guest blogger Dr Edward Reje gives his view of the examination in the form of an open letter. We accept no liab...

[medinuggets-blog]

Chest pain - Shared Decision Making

This is a link to Amal Mattu's shared decision making document for chest pain. Well worth a look. 

From the Hippo EM crew: 

http://blog.hippoem.com/?utm_source=EMRAP-mailing-list&utm_medium=email&utm_campaign=EMRAP--email--EM%253ARAP--15-02-18

[medinuggets-blog]

This is an excellent referenced table of the specificity and sensitivities of various methods of cardiac stress testing.........

[medinuggets-blog]

[medinuggets-blog]

Clear guidance from AHA on management of AF.....

[medinuggets-blog]

FACEM 2015 - Study Notes

The following study material is not meant to act as an exhaustive guide as to what to study (if only......) but purely represents material I have found useful to cover syllabus material.

Disclaimer: The material below is neither exhaustive nor definitive. Although measure are taken to ensure its accuracy it does not replace primary resources such as textbooks.

Study Material is ordered as per tjdogma fellowship exam study programme

1. Resuscitation

2. CVS 1

3. Trauma 1

4. Anaesthesia

5. Toxicology 1

6. CVS 2

Cardiac Pacemakers (powerpoint presentation)

ECG in toxicology (powerpoint presentation)

7. Trauma 2

8. Psychiatry

TJ Dogma's notes

9. Respiratory

Asthma severity assessment (BTS 2011)

BTS / SIGN Asthma Guidelines 2009

TJ Dogma's notes

10. Surgery (abdominal & urology)

11. Toxicology 2

QT interval notes

TJ Dogma's notes

12. Neurology & Immunology

13. Revision week 1

14. Disaster/Pre-hospital & Opthalmology

15. Orthopaedics 1 (Fractures)

Tor's Summary of Eponymous Fractures

Salter Harris # Classification

16. Renal / Metabolic / Endocrine

Sodium derangements (inc SIADH)

Hyponatraemia - Systematic Review of Guidelines (Nagler 2014)

Causes of a NAGMA

17. Orthopaedics 2 (Dislocations) / Rheumatology

TJ Dogma's notes

ShoulderDislocation.net (Dr Neil Cunningham - worth a look!)

18. Gastrointestinal & Infectious Diseases (ID)

ID - TJ Dogma's notes

19. Paediatrics

Head injury decision rules - 1. RCH Melbourne 2. St Emlyn's 3. Don't forget the bubbles

20. ENT & Obstetrics and Gynaecology

TJ Dogma's notes

21. Haematology / Oncology / Environmental

22. Administration / Education

23. Burns / Wound Management / Neurology / Vascular / Dermatology

24. Revision Week 2

..................Exam..................

[medinuggets-blog]

FACEM 2015 - Practice Exams & Study PEARLS....

The following are a few study PEARLS including mnemonics and study tips (mostly acting as an aide-memoire for me!).....

2014.2 FACEM Exam Feedback (to candidates who did not pass).....worth a read!

ACEM 2014 FE exam report

ACEM DEMT forum SAQs (late 2014 with answers)

ACEM DEMT forum SAQs (no answers)

ACEM FE SAQ committee questions (late 2014 with answers)

ACEM 2014 FE exam report

Adelaide 2015.1 practice SAQs (with answers)

Adelaide 2015.1 practice SAQs (no answers)

Auckland 2015.1 practice SAQs

2015.1 Victorian Fellowship Practice Exam (Monash) - Answers and Feedback in dropbox

Paediatric SAQ Exam - APEM 2015.1

PA Hospital (QLD) 2015.1 practice SAQs (with answers)

PA Hospital (QLD) 2015.1 practice SAQs (no answers)

WA SAQ pool - 2015.1

Age/4 +4 equation & Quick Calculation of the A/a gradient:

Some absolute pearls from Nickson.....

Toxicology:

Tricyclic antidepressant ECG (blockade of fast sodium channels):

Exam answer: "QRSD >100ms and RBBB of terminal QRS"

RBBB of terminal QRS manifest by: R wave >3mm in aVR / R/S ratio >0.7 in aVR

Measure QRSD in lead II (this is where the studies measured it!)

QRSD >100ms predictor of seizure

QRSD >160ms predictor of ventricular arrythmia

Multi-dose activated charcoal (MDAC) - mneumonic 

Useful for drugs undergoing enterohepatic recirculation

Carbamazapine (Charcoal)

Dapsone (Does)

Phenobarbitone (Pretty)

Quinine (Quality)

Theophylline (Toxicology)

Antidote challenge - think you know your Toxicology.....try the Life in the Fast Lane antidote challenge

[medinuggets-blog]

Algorithm for the treatment of maxillofacial and dental infections.

From an excellent 2014 review article in EMA: DeAngelis et al

[medinuggets-blog]

New Oral Anticoagulants (NOAC) - 2014 Australian Consensus Guidelines

Ever wondered what to do with your patients on Dabigatran (PRADAXA); Rivaroxaban (XARELTO); Apixaban (ELIQUIS).......

Prescribing

Laboratory measurements

Peri-operative management

Emergency bleeding management

Switching anticoagulants

See the 2014 Australian Consensus Guidelines on NOACs

As to be expected in the desert of evidence in this area, these are largely consensus guidelines, however they give an excellent current best evidence approach.

[medinuggets-blog]

Ebola Virus - the ICN Guide

Excellent summary for the resuscitationist by ICN:

EBOLA....what you need to know

[medinuggets-blog]

PE or NOT PE..........is this really the question.......

This is a recent Algorithm proposed by Mr PE Jeffery Kline

I'm still not sold.....I tend to agree with the EM Nerd....and SMART EM

[medinuggets-blog]

FACEM 2015 - ECG SAQs

The following ECG SAQ's have been structured in a 'best guess' format for the new ACEM fellowship exam for 2015.

Disclaimer: We have no idea if this is near the mark or not! The answers may be INCORRECT! Please email me if you have a better answer, know more or have any suggestions!!

ECG case 1

A 49 year old woman presents with a 24 hour history of intermittent retrosternal chest pain. She has a past medical history of hypertension and obesity.  On examination, she appears well.

 Q1. What are the primary abnormalities on this ECG? (2 marks)

best answer

Q2. What is the most likely diagnosis? What factors on the ECG favour your most likely diagnosis? (4 marks)

best answer

Q3. What life threatening diagnosis must be considered? What factors on the ECG make this less likely? (4 marks)

best answer

Reference:

Amal Mattu’s lecture

Life in the fast lane

[medinuggets-blog]

...This is the best pictorial display of US guided fascia iliaca block I have found.....Good work!

[medinuggets-blog]

FACEM 2015 - Blood Gas SAQs

The following blood gas SAQ's have been structured in a 'best guess' format for the new ACEM fellowship exam for 2015.

Disclaimer: We have no idea if this is near the mark or not! The answers may be INCORRECT! Please email me if you have a better answer, know more or have any suggestions!!

ABG case 1

A 79 year old woman living independently at home is brought in by ambulance with a GCS of 11/15 and a 5 day history of cough and epigastric pain treated by the GP with oral antibiotics and analgesia. She has a past medical history of hypertension and type 2 diabetes (diet controlled).

Vital signs:

Temp 35.2

HR 85

RR 8

BP 130/75

BSL 7.8

O2 Saturations 85% on 15L via NRB

ABG:

pH 7.15

pCO2 97

HC03 34

pO2 64 (non-rebreather @ 15L)

Glucose 7.9

K+ 3.8

Na+ 126

Cl 91

Albumin 26

Hb 146

Lactate 1.0

Q1. What is the primary acid-base disturbance?

Best answer

Q2. Are there any secondary acid-base disturbances (if so, please explain)?

Best answer

Q3. Interpret her respiratory disturbance (explain your answer).

Best answer

Q4. What other electrolyte abnormalities are present?

Best answer

Q5. What is your interpretation and immediate management of this patient’s condition?

Best answer

ABG case 2

A 30 year old female has been brought into ED after taking an overdose of an unknown substance three hours previously. The ambulance officers report that she is confused and reporting ringing in her ears.

Vital signs:

HR 112

BP 99/62

RR 34

Sats 100%

T 37.8

GCS 14

ABG:

FiO2 0.21

pH 7.6                                    

Na 135 mmol/L

pO2 115 mmHg

K 5.6

pCO2 20mmHg                                  

Cl 98

HCO3 18 mmol/L

Glucose 5.8

BE -4                                      

Lactate 0.6           

Urea 4.5                                                          

Creatinine 60

Q1. What is the acid/base imbalance?                                     (3 marks)

Best answer

Q2. Comment on the electrolyte disturbances                         (1 mark)

Best answer

Q3. What is you interpretation of this ABG                               (2 marks)

Best answer

Q4. How would you manage this patient?                                 (4 marks)

Best answer

ABG case 3

A 26 y/o asthmatic with a history of ICU admissions presents to your department in acute respiratory distress. She has been treated by her GP for 2 days with bronchodilators and glucocorticoids.

Vital signs:

HR 120

BP 112/70

RR 30

Sats 92%

T 37.2

 ABG:

FiO2 0.4                                                     

Na 142

pH 7.32                                                     

K 3.2

pO 65                                                     

Cl 88

pCO2 48

HCO3 18                                                     

Gluc 10.2

BE -6                                                     

Lac 3.6

Q1. What is the primary acid base disturbance?                       (1 mark)

Best answer

Q2. What secondary acid-base disturbance(s) exists?              (2 marks)

Best answer

Q3. Comment on the oxygenation and qualify your answer      (2 marks)

Best answer

Q4. What other features of this ABG which would be concerning? (2 marks)

Best answer

Q5. What are the management priorities in this patient?          (3 marks)

Best answer

ABG case 4

A 73 y/o female is brought in to your ED.

Vital signs:

GCS 12

BP 100/70

RR 10

Sats 97% RA

Temp 37.2

 ABG:                                      

Na 137

pH 7.35                                                    

K 4.6

pO2 113                                       

Cl 98

pCO2 50

HCO3 24                                                  

Gluc 72

Urea 28.7                                                   

Q1. What is the primary diagnosis? Why?

Best answer

Q2. What parameters would you use to decide ICU disposition?

Best answer

Q3. What are the key management priorities?

Best answer

Q4. After 4hours repeat bloods show Na 113 and Glucose of 60, what fluid should be used for ongoing maintenance?

Best answer

[medinuggets-blog]

ECG Differential Diagnoses

I like Amal Mattu’s approach to considering differential diagnoses when looking at an ECG……BOTH from the patient’s presenting complaint AND the ECG findings

 (NOTE: these are not meant to be exhaustive lists BUT if you have more / a better list please let me know!)

ECG differential diagnoses by PRESENTING COMPLAINT:

  Syncope (also see syncope ECG)

Common:

ACS

Dysrhythmias

AV blocks

DON’T MISS:

WPW (short PR / delta waves)

Brugada (RBBB / STE V1-3)  see http://tmblr.co/Zls-wvHV_74y

Wellen’s (TWI & biphasic T chest leads) see http://tmblr.co/Zls-wvIaievG

HOCM (high voltage / deep & narrow Q’s lateral leads)

Long QTc

Rare….9. Short QTc 10. Arrythmogenic RV dysplasia

    ECG differential diagnoses by ECG FINDINGS:

  T-wave inversion

Anterior ischaemia

Posterior MI

PE

SAH (or other intra cerebral pathology)

LVH / LV strain

Myocarditis / pericarditis

3rd degree heart block

Wellen’s syndrome

  Axis deviation

“RAD RALPH the LAD from VILLA” (mnemonic)

Right axis deviation (the RAD above)

Right ventricular hypertrophy

Anterolateral MI

Left Posterior Hemiblock

Left axis deviation (the LAD above)

Ventricular tachycardia

Inferior MI

Left ventricular hypertrophy

Left Anterior hemiblock

  ST elevation

MI

LV aneurysm

Benign early repolarisation

Pericarditis

Bundle branch block

Brugada syndrome

  Broad QRS

Bundle branch block

Ventricular ectopic

Hyperkalaemia

Toxins / drugs

Pacemaker

[medinuggets-blog]

FACEM 2015 - Clinical Photograph (VAQ) Interpretation

The following is a structured approach to written questions on clinical photographs for the FACEM exam.

Additional resources:

VAQ tips - edexam

Clinical photograph Questions:

Life in the fast lane

Structured approach to CXR interpretation:

Cover each of the following headings in order

Suggest ABC approach

  A. Clinical photo primary survey

(Only if there is an obvious life threat – if not move on to secondary survey)

Comment on the MOST obvious abnormality AND its severity

Obstructive angio-oedema. This is an airway emergency.

Make a ‘motherhood statement’ on any life threat identified

i.e. “This is an airway emergency….transfer to resus area”

  B. CXR secondary survey (ALL clinical photos)

ABCD’s

Point out and address life / limb threats not already mentioned

Consider / describe important aspects of photograph

Patient factors

Age

Sex

Race

How ill they appear

Disease factors

Surrounds

Equipment / monitoring

Drugs

Environment

Staff / personnel if present

  C. Interpret and Synthesise

Consider leaving space to do this at the START of your answer

Make a ‘motherhood statement’ (i.e. this is a potentially unwell patient who should be managed in a resuscitation cubicle)

What is the differential diagnosis (DDx)? (remember this is a consultant level answer – make it specific and relevant!)

What other information is required (and not already provided in the question) to rank the DDx?

Injury mechanism

Blood gas

Level of consciousness 

Medications

Assessment

Further management implications?

Direct to theatre?

Prognosis

Indications for specific emergent Rx

Disposition

Functional implication (particularly orthopaedic injuries)

Occupation

Handedness

Age

[medinuggets-blog]

Potassium correction for pH (expected K+)

Use the following formula (really just 'rules of thumb') to calculate the expected K+ in patients with a pH OTHER than 7.4.

1. Acidaemia (pH <7.4)

Each 0.1 pH fall below 7.4 expect K+ to rise by 0.5mmol (above 5mmol/L)

OR 0.1 pH decrease = 0.5 K+ increase

EXAMPLE - K+ 4.0 & pH = 7.2 - Expected K+ = 5.0 + (2 x 0.5) = 6.0mmol/L - patient is relatively hypokalaemic

 2. Alkalaemia (pH >7.4)

Each 0.1 pH rise below 7.4 expect K+ to fall by 0.5mmol (below 5mmol/L)

OR 0.1 pH increase = 0.5 K+ decrease

EXAMPLE - K+ 2.2 & pH = 7.58 - Expected K+ = 5.0 - (2 x 0.5) = 4.0 mmol/L - patient is relatively hypokalaemic