Haem. ~ Short Answer

Question 1.

A 72 year old man is brought to the Emergency Department by ambulance with a 2 hour history of epistaxis. He is on warfarin for atrial fibrillation

 

A.) Describe your approach to his warfarin reversal if:

i. He has ongoing profuse bleeding with an INR of 2.3 and vitals of HR 126 bpm, BP 87/53 mmHg, RR 22, O2 sats 96% 15 L NRB?

Show Answer

  • Cease warfarin
  • Vit K 5-10 mg IV
  • AND Prothrombinex-VF 50 IU/kg IV
  • And FFP 150-300 ml
  • If Prothrombinex unavailable give FFP 15 ml/kg

(4 marks)

ii. He has ongoing bleeding with an INR of 2.3 and vitals of HR 78, BP 135/79, RR 12, O2 sats 96% RA?

Show Answer

  • Cease warfarin
  • Vit K 5-10 mg IV
  • And Prothrombinex-VF 35-50 IU/kg according to INR
  • If Prothrombinex unavailable give FP 15 mg/kg

(3 marks)

iii. His bleeding has stopped prior to arrival in ED and for the next 4 hours in ED with an INR of 2.3?

Show Answer

  • Omit warfarin, repeat INR following day and adjust dose to maintain INR in target range

(2 marks)

 

B.) For patients that are not bleeding but present to the ED with a high INR what is the recommendation for their warfarin management if:

i. INR > therapeutic range but < 4.5

Show Answer

  • If INR less that 10% above therapeutic range then no change, observation only
  • Lower or omit next dose and resume at a lower dose when INR approaches therapeutic range

(2 marks)

ii. INR 4.5-10

Show Answer

  • Cease warfarin
  • Consider reasons for elevated INR
  • If bleeding risk is high consider Vit K 1-2 mg PO or 0.5-1.0 IV
  • Measure INR within 24 hours
  • Resume at reduced dose once INR approaches therapeutic range

(4 marks)

iii. INR > 10

Show Answer

  • Cease warfarin therapy
  • Give 3-5 mg Vit K PO or IV
  • Measure INR in 12-24 hr and monitor daily or every second day for next week
  • Resume at reduced dose once INR approaches therapeutic range
  • If bleeding risk high:
    • Consider Prothrombinex 15-30 IU/kg
    • Measure INR 12-24 hr and monitor closely over next week
    • Resume at reduced dose once INR approaches therapeutic range

(5 marks)

 

 C.) What is the main difference between Prothrombinex and FFP?

Show Answer

  • Prothrombinex contains coagulation factors II, IX, X and low levels of II
  • FFP contains all coagulation factors

(2 marks)

Author: J Haire

Ref: An update of consensus guidelines for warfarin reversal; Tran HA et al; MJA 2013; 198 (4): 198-199


 

Question 2.

A 68 year old lady with rheumatoid arthritis presents with an acutely painful knee. She is currently on low dose prednisolone and non-steroidal anti-inflammatory agents. OBS: 37.9’C, Sats 96% RA, GCS 15, HR 100, sBP 150/85

 

A.) What are your differential diagnoses?

Show Answer

  • Septic arthritis
  • Rheumatoid flare-up
  • Gout
  • Pseudogout
  • Reactive arthritis
  • Traumatic haemarthrosis
  • Osteomyelitis
  • Prepatellar bursitis

 

(6 marks)

 

 B.) Which diagnosis must be ruled out first in this patient and why?

Show Answer

  • Septic arthritis
  • Febrile, tachycardic
  • Immunocompromised and rheumatoid are risk factors

(3 marks)

 

C.) What features on history would indicate septic arthritis?

Show Answer

  • Very painful joint developing rapidly
  • Very painful to move joint
  • Joint swelling
  • Fevers

(3 marks)

 

D.) What features on physical exam would indicate septic arthritis?

Show Answer

  • Hot swollen joint
  • Restriction of movement

(2 marks)

 

E.) What investigation is essential in making the diagnosis of septic arthritis, how do you interpret it and how sensitive is it?

Show Answer

  • Traditional teaching is joint aspirate with > 50, 000 WBC cells/mm3 indicates septic arthritis
  • Confirmed by growth on culture
  • Poor Se 64%

(3 marks)

 

F.) Is there another test you can do on the aspirate to help with your diagnosis?

Show Answer

  • Synovial lactate
    • > 10 mmol/L very high likelihood ratio
    • < 2 unlikely but no value can rule it out

(2 marks)

 

G.) Her joint aspirate returns with 35, 000 WBC cell/mm3. How would you manage her?

Show Answer

  • Very clinically suspicious for septic arthritis and immunocompromised
  • Consult orthopaedics
  • Can either:
    • Washout in OT
    • Give IV antibiotics and wait for culture results

(3 marks)

Author: J Haire

Ref: Tintinalli p.1930-33


 

Question 3.

A 47 year old man with a history of hypertension and depression has presented to your emergency department following deliberate self-poisoning approximately 3hrs ago with 20 x 240mg slow release verapamil tablets.

His initial vital signs are: GCS 15, HR 50 /min, BP 115 / 70, RR 16 /min, SaO2 99% room air.

 

A.) List the steps in a risk assessment-based approach to poisoning?

Show Answer

  • Resuscitation
    • Airway
    • Breathing
    • Circulation
    • Detect and correct
      • Hypoglycaemia
      • Seizures
      • Hyper/hypothermia
    • Emergency antidote administration
  • Risk assessment
    • Agent
    • Dose
    • Time since ingestion
    • Clinical features and course
    • Patient factors
  • Supportive care and monitoring
  • Investigations
    • Screening ECG and paracetamol level
    • Specific
  • Decontamination
  • Enhanced elimination
  • Antidotes
  • Disposition

 

(10 marks)

 

B.) What is your risk assessment of this patient?

Show Answer

  • Likely to get life-threatening toxicity
  • Delayed onset as slow release tablets i.e. onset can be delayed 12-16 hours and peaks beyond 24 hours
  • Already bradycardic

(3 marks)

 

C.) What clinical effects will this overdose have?

Show Answer

  • CVS
    • Bradycardia
    • Heart block
    • Hypotension
    • Refractory shock and death
    • Myocardial ischaemia, CVA, non-occlusive mesenteric ischaemia can occur
  • CNS
    • Seizures rare
    • Coma usually means co-ingestant
  • Metabolic
    • Hyperglycaemia
    • Lactic acidosis
    • If severe

(6 marks)

 

 D.) What investigations will you perform and why?

Show Answer

  • Serial ECGs
    • Presentation, 8, 12, 18 and 24 hrs
    • Looking for bradycardia and heart block
  • BSL screening
  • Paracetamol level screening
  • U&Es; Ca, lactate, blood gases baseline
  • CXR if suspect aspiration

 

(3 marks)

 

 E.) What would your initial management be?

Show Answer

  • Activated charcoal
    • Within 4 hours of slow release
  • Whole bowel irrigation
    • If cooperative and not established toxicity (if HR does not deteriorate) and present within 4 hours of ingestion of slow release formulation and > 10 tablets

(4 marks)

 

12 hours later he deteriorates. His vitals are now HR 35, BP 78/52, O2 sats 96% RA, RR 12.

 

 F.) What is your management now?

Show Answer

  • Early intubation and ventilation
  • Early invasive BP monitoring
  • Graduated approach to hypotension
    • Fluids 10-20 ml/kg boluses
    • Calcium
      • 60 ml Ca gluconate 10% or 20 ml 10% CaCl over 15 mins
      • Boluses repeated up to 3 times
      • Then infusion to maintain Ca level > 2.0 mmol/L
    • Bradycardia
      • Atropine 0.6 mg every 2 mins to 3 mg
    • Bradycardia and hypotension
      • Catecholamine infusion
    • High-dose insulin
      • Glucose 25g (50 mls 50%) then 1 IU/kg short-acting insulin
      • Then glucose 25g/hr + insulin 0.5 IU/kg/hr
      • Titrate glucose to maintain normal BSL
    • Metabolic acidosis
      • 50 – 100 mmol Na HCO3
    • AV block
      • Cardiac ventricular pacing
      • Keep rate at 60 bpm or less
      • May not help and hard to get capture
    • Cardiopulmonary bypass

(10 marks)

 

 G.) Are there any enhanced elimination techniques that would be useful?

Show Answer

  • No

(1 mark)

 

H.) How do you perform whole bowel irrigation?

Show Answer

  • One on one nursing + will need a commode
  • Use PEG-ELS
  • NGT
  • Activated charcoal 50 g via NGT
  • PEG solution at 2L/hr via NGT
  • Metoclopramide to minimise vomiting and increase gastric emptying
  • Continue irrigation until effluent clear
  • Watch for abdominal distension or loss of bowel sounds – stop if this occurs

(7 marks)

Author: J Haire

Ref: Toxicology Handbook p. 23; 186-9; 399


 

Question 4.

A 28 year old gas worker is brought to your emergency department having been injured in an explosion at work. On arrival in the emergency department he has the following vital signs: GCS 10, HR 120 /min, BP 125 / 75.

 

A.) What mechanisms of injury may this patient may have been exposed to?

Show Answer

  • Blast injuries
  • Blunt trauma
  • Penetrating trauma
  • Burns
  • Toxins

(5 marks)

 

 B.) What are the 4 types of blast effects?

Show Answer

  • Primary
    • Direct effect of blast pressure on tissue
    • Effects air-filled structures
    • g. barotrauma to lungs
  • Secondary
    • Collateral damage from flying debris
  • Tertiary
    • From victim being propelled through air and striking stationary objects
  • Quaternary
    • Burns, smoke inhalation, chemic agent release

(4 marks)

 

C.) List 4 important factors that influence the degree of injury in bomb blasts.

Show Answer

  • Distance of victim from explosion
    • 3m from bomb 8 x more pressure effect than if 6m
  • Enclosed vs open space
  • Surrounding environment
    • Blast waves reflected by solid surfaces i.e. increased effect if standing next to a wall
  • Quantity of explosive
  • Type of explosive
    • High-grade explosives with high-pressure gases produce very high pressure waves
  • Embedded shrapnel

 

(4 marks)

 

D.) What are the most important injuries to assess for in a blast victim?

Show Answer

  • Pulmonary barotrauma
    • Pulmonary contusion
    • Pneumothorax
    • Haemothorax
    • Pneumomediastinum
    • Air-embolism causing neurological symptoms

(4 marks)

 

 E.) How does blast injury effect the ears

Show Answer

  • Tympanic membrane rupture
  • Dislodgement of ossicles

(2 marks)

 

F.) Patients that have been exposed to a blast injury, have a ruptured tympanic membrane but are otherwise asymptomatic require what management?

Show Answer

  • CXR for pulmonary barotrauma
  • Observation for 4-6 hours
  • Discharge advice re development of pulmonary contusion

(3 marks)

Author: J Haire

Ref: Tintinalli p.38-41


 

 

Question 5.

A 69 year old woman is sent to your emergency department by her LMO after a one day febrile illness. Her chest X-ray reveals lobar pneumonia. Blood tests are performed.

Her observations are:

HR

120 /min

BP

110/60

mmHg supine

Temp

38.5

Celsius

SaO2

90

%RA

 

Reference Range

Haemoglobin

63

gm/L 115 – 160
WCC

0.60

x 109/L

4 – 11

Platelets

8

x 109/L

150 – 400

Red cell count

1.99

x 1012/L

3.80 – 5.80

Haematocrit

0.18

0.37-0.47

Mean Cell Volume

92

fL

80 – 100

Neutrophils

0.38 x 109/L

2.0 – 7.5

 

A.) Describe the main abnormalities in her blood test

Show Answer

  • Critically low Hb and Hct – severe anaemia
  • Normocytic anaemia
  • Critical leukopaenia and neutropaenia
  • Critical thrombocytopaenia

(5 marks)

 

B.) What is the overall description of the blood test?

Show Answer

  • Severe pancytopaenia

(1 mark)

 

 C.) What is the differential diagnosis for this blood disorder?

Show Answer

  • Critical illness
  • Chronic illness
    • SLE
    • Rheumatoid
    • Felty’s syndrome
  • Drugs
    • Chemotherapy
    • Radiotherapy
  • Deficiencies
    • Vit B12
    • Folic acid
  • Malignancy
    • Myeloproliferative disorders
    • Multiple myeloma
    • Paroxysmal nocturnal haemoglobinuria
  • Infection
    • Parvovirus
    • CMV
    • HIV
    • Hep B & C
    • EBV
    • Brucellosis
    • Leishamaniasis

(6 marks)

 

D.) What antibiotics would you initiate?

Show Answer

  • Community acquired pneumonia with neutropaenia
    • Ceftriaxone
    • Or Ticarcillin/clavulanate OR piperacillin/tazobactam

(2 marks)

Author: J Haire

 


Question 6.

An 80 year old woman presents short of breath.

 Haema & Rheuma Photo 1 Short Answer

A.) Describe the abnormalities in this picture

Show Answer

  • Ulnar deviation and volar subluxation pf MCPJs
  • Swan-neck deformity of fingers
  • Z deformity thumb
  • Erythema MCPJs and DIPJs
  • Heberden’s nodes fingers

(5 marks)

 

B.) What is the diagnosis?

Show Answer

  • Rheumatoid arthritis
  • Heberden’s nodes indicating OA

(2 marks)

 

C.) List 8 of the extra-articular manifestations of the primary disorder in this patient.

Show Answer

  • Extra-articular manifestations of rheumatoid arthritis
    • Atlanto-axial subluxation
    • Temperomandibular joint arthritis with decreased mouth opening
    • Pulmonary
      • Interstitial fibrosis
      • Nodules
      • Pleural effusions
    • Heart disease
      • AR
      • MR
      • Pericarditis
    • Rheumatic nodules
      • Joints
      • Heart valves
    • Nerve entrapment
    • Vasculitis
    • Ocular
      • Keratoconjunctivitis (Sjogrens)
      • Uveitis
      • Episcleritis
    • Splenomegaly
    • Enlarged LNs
    • Renal vasculitis
    • Tenosynovitis
    • Muscular atrophy

(8 marks)

Author: J Haire

Ref: Dunn4th Ed p.854


 

Question 7.

A 25 year old man presents after a two day illness of fever and vomiting. The following investigations have been performed.

 

FIO2                 0.4

pH                    7.80                 (7.35-7.45)

PCO2               15mmHg         (35-45)

PO2                 192mmHg       (75-100)

HCO3               23mmHg         (22-33)

Base excess     10.1                 (-3.0 – +3.0)

O2 sat              99.7%              (95-98%)

Na+                  119mmol/L     (135-145)

K+                    2.5mmol/L      (3.2-4.5)

Cl-                    65mmol/L       (100-110)

Urea                10.3mmol/L    (3.0-8.0)

Creatinine       0.187mmol/L  (0.07-0.12)

Glucose           4.5mmol/L      (3.0-7.8)

 

 A.) Describe the acid-base abnormalities in this blood gas

Show Answer

  • Respiratory alkalosis
  • Metabolic alkalosis
    • HCO3 is in the normal range
    • Would expect it to be decreased to compensate for respiratory alkalosis
      • For every ? pCO2 by 10 the HCO3 should ? by 2 if acute and 4 if chronic
      • Decreased by 20 so HCO3 should be 20 mmol/L if acute and 18 if chronic
    • AG Metabolic acidosis
      • Anion gap
      • = 119 – (65 + 23) = 31 = raised
    • Triple disturbance

(6 marks)

 

 B.) Comment on the rest of the blood gas

Show Answer

  • Raised A-a gradient so degree of shunt
  • Severe hyponatraemia
  • Severe hyochloraemia
  • Critical hypokalaemia
  • Urea slightly raised
  • Cr normal
  • BSL normal

(7 marks)

 

 C.) What is the most likely cause?

Show Answer

  • Triple acid disturbance caused by salicylate poisoning
  • Rest of picture by vomiting

(2 marks; reasonable explanation)

 

D.) Are there any other possibilities?

Show Answer

  • Sepsis secondary to pulmonary infection + vomiting

(1 mark; reasonable explanation)

Author: J Haire

 


 

Question 8.

A 62 year old, previously well woman is referred to your emergency department with a letter from her doctor that states:

“She has a 6 week history of increasing lethargy, malaise, weight gain and peripheral oedema.  BP 180/120.  See electrolyte results enclosed.  She is currently taking no medication.”

 

Serum biochemical results

Reference Range

Na+                  151                  mmol/L                       (134-146)

K+                     2                      mmol/L                       (3.4-5)

Cl                    98                    mmol/L                       (98-106)

Bicarbonate    40                    mmol/L                       (22-28)

Urea                5.8                   mmol/L                       (3-8)

Creatinine       0.06                 mmol/L                       (0.06 – 0.12)

Glucose                       16                    mmol/L                       (3.5-5.5)

 

 A.) Describe the abnormalities in these bloods

Show Answer

  • Moderate hypernatraemia
  • Critical hypokalaemia
  • Cl low-normal
  • Metabolic alkalosis
  • Normal renal function
  • Moderately high BSL but patient not acidotic

(6 marks)

 

 B.) What is the most likely diagnosis?

Show Answer

  • Adrenocorticoid excess (mineralocorticoid)

(1 mark)

 

 C.) What is the differential diagnosis for this condition?

Show Answer

  • Primary hyperaldosteronism
    • Adrenal hyperplasia
      • Idiopathic
      • Congenital
    • Adrenal adenoma (Conn’s)
  • Secondary hyperaldosteronism
    • Response to activation of renin-angiotensin system
    • Accelerated phase of HTN
    • Primary hyper-reninism
    • Decreased blood flow or perfusion pressure e.g. renal A stenosis
    • Underlying oedematous disorder
  • Bartter’s syndrome
    • Unlikely as usually normal BP and no oedema
  • Cushing’s syndrome
    • iatrogenic
      • Corticosteroids
    • Cushing’s disease
      • ACTH production from pituitary adenoma
    • Paraneoplastic Cushing’s (ACTH production e.g. oat cell lung Ca)
    • Adrenal hyperplasia
    • Adrenal adenoma or carcinoma
    • CRH secreting tumour e.g. pancreatic

(6 marks)

Author: J Haire

Ref: Dunn p 241-2


 

 

 

 

 

 

 

 

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