Resus. & Anaes. 2 ~ Short Answer

Question 1.

A 58 year old man presents with a displaced fracture of the wrist that will need to be reduced.

A.) List 4 options for providing anaesthesia to reduce his fracture.

Show Answer

  • Regional – IV Regional anaesthesia or Biers block
  • Regional – Haematoma block
  • Regional – Nerve block e.g. Axillary nerve block
  • Procedural sedation – Ketamine
  • Procedural sedation – Propofol
  • General anaesthetic in theatre

4 marks

B.) What issues will you consider in deciding which anaesthetic option to use?

Show Answer

  • Resource factors
    • How busy the ED is
    • Availability of staff
    • Skill mix of staff
  • Patient factors
    • Ability to tolerate regional approach
    • Fitness for procedural sedation
    • Patient choice

4 marks (4 factors)

C.) What are the pros and cons of IV regional anaesthesia (Biers block)?

Show Answer

Pros

  • Effective
  • Often well tolerated
  • No risk of sedation

Cons

  • May fail
  • Risk of IV local anaesthetic and LA toxicity
  • Poor tolerance of pressure cuff

4 marks (2 each)

D.) What are the pros and cons of procedural sedation?

Show Answer

Pros

  • Effective
  • Safe
  • Amnesic
  • Analgesic

Cons

  • Risk of airway loss
  • Risk of CVS collapse
  • Risk of intubation
  • Risk of aspiration
  • Failure to provide adequate analgesia/amnesia

6 marks (3 each)

Author: J Haire

 


 

Question 2.

A 47 year old man is brought to the emergency department with fever, throat pain and difficulty swallowing.

xray

 

A.) Describe the abnormalities in this x-ray

Show Answer

  • Significant pre-vertebral soft tissue swelling C1 to C6
  • Neck held in extension
  • Epiglottis and arytenoids possibly swollen

2 marks

B.) What is the differential diagnosis?

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  • Retropharyngeal abscess
  • Epiglottitis
  • Bacterial tracheitis
  • Malignancy e.g. lymphoma

(3 marks)

 C.) What further steps could be taken to make a diagnosis and how?

Show Answer

  • CT neck soft tissues but likely will need intubation
  • Indirect laryngoscopy by ENT

2 marks

D.) List the main features of management in this man

Show Answer

  • Control of airway if needed
  • Antibiotics
  • Sepsis management
    • Fluids
    • Vasopressors
  • Surgical drainage of collection if present

4 marks

E.) Which antibiotics would you give and why?

Show Answer

Ceftriaxone (3rd Gen Cephalosporin) to cover Haemophilus influenzae and Streptococcus pneumoniae

F.) What would be your indications for intubation in this man?

  • Signs of airway compromise
    • Stridor
    • Increased work of breathing
    • Change in phonation
    • Other causes of airway compromise e.g. Decreased LOC secondary to sepsis

3 marks

G.) List your options for intubation in order of preference in this patient.

Show Answer

  • Gaseous induction in OT with ENT standing by to do surgical airway
  • Awake fibreoptic intubation by anaesthetics in ED with ENT standing by to do surgical airway
  • RSI in ED with anaesthetic and ENT support
  • RSI in ED with another consultant ready to do surgical airway

3 marks (options need justification and need to be safe)

Author: J Haire

 

 

6 Comments:

  1. These questions and your website are fantastic, thank you. Out of curiosity were these particular questions written with a 6 minute per question0 timeframe in mind?

    Cheers

    • Thanks Tim, I hope you continue to find some usefulness out of the site as it expands it’s content.
      Specifically the questions are based on the framework provided by ACEM on how to write Questions for the new format examination and are actually produced in the main by FACEM’s who have sat or are sitting on the Fellowship Examination committee. I am not certain that they are always expected to be in the 6 minute form.

  2. Thanks Tim, for providing the useful resource.

    • Not too sure who you mean by Tim. This website is basically designed, maintained and provided for you by a couple of FACEMs – Ric Todhunter (myself), Dean Powell and Julia Haire. Anyway thanks for the sentiment.
      Ric

  3. Thanks Ric,Dean and Julia,
    Great resource.
    this website has been quite useful to me in the studies.

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