OSCE

Question

Shortly after intubating a patient your machine begins alarming for high airway pressures. What is your assessment and management of this patient?

Answer

I'm considering equipment issues, ventilator, circuit or tube, patient issues, namely breath stacking, bronchospasm, tension, pneumothorax. So in practice what we'll do is first disconnect the patient from the circuit and allow full expiration to treat breath stacking. Then I'm going to bag the patient. If they're easy to bag, and then we've got good end tidal CO2 and they're sat so fine, then the issue is lying with ventilator or circuit. I'll continue bagging whilst troubleshooting the circuit. If the patient's difficult to bag, then the issue lies with the tube or it's a patient issue. So first thing I'll do is pass the suction catheter down to confirm that the tube is patent. Then we'll use a combination of physical examination and PO CUS to seek and treat patient issues. So we're going to assess for bronchospasm, do the asthma and anaphylaxis and treat accordingly. I'll look for a tension pneumothorax and do finger phorocos tomy if present. Other things we'll be examining and thinking for will be lung collapse, consolidation, pulmonary edema, pleural fusion, whilst looking at chest wall issues and potentially coughing.

Question

What is your basic intubation plan for a potential difficult airway?

Answer

I'll manage this patient in the resuscitation room with full non-invasive monitoring. I'll assemble my full team and brief the team on our anticipated difficulties. We will optimize the patient's oxygenation, ventilation, perfusion and positioning prior to induction. My induction agent will be ketamine 0.5 milligrams per kilo, rocuronium 1.6 milligrams per kilo. My equipment will include the difficult intubation, difficult airway trolley, including video laryngoscope, ETT, Bougie, superglottic air way, BVM and the surgical airway kit. Prior to induction I will use the air way checklist and verbalize my plan to the team, including critical desat uration points. Plan A, video laryngoscope with Bougie. Plan B, superglottic airway , plus or minus and BVM. Plan C, front of neck access. After we have intubated the patient, post intubation care will include confirming ETT placement with n-tidal CO2, chest auscultation and chest x-ray. Ongoing ventilation with a lung protective strategy. Ongoing sedation with propofol titrated. We'll also place an NG and this patient's disposition will be intensive care unit.

Question

A patient with a tracheostomy is in your resource room with respiratory distress. Outline your immediate management.

Answer

First I'll apply 100% oxygen to both the face and over the tracheostomy site. I'll ask the patient if this is a tracheostomy or a larynge ctomy. And then I'll remove the inner cannula and other vices such as humidifier, speaking valve. Then I'll attempt to pass the suction catheter down the outer cannula and attempt to suction. If the suction catheter does not pass, or we do not have end tidal, then I will deflate the cuff and remove the tracheostomy tube. If the upper airway is patent, that is they had a tracheost omy rather than a laryngectomy, then I will manage it as any other difficult airway except I'll have an assistant holding, occluding the stoma. So now I'll use bag valve mask, superglottic or prepare for intubation to maintain oxygenation. If they do not have a patent airway, so if it's a laryngect omy, then I'll ventilate via the stoma using a paediatric face mask or a size 2 LMA. And then my next step will be to replace the tracheostomy tube or intubate the stoma. Bye.

Question

Post intubation your patient has become severely hypot ensive. What is your assessment and management?

Answer

In post-induction hypertension my goal is to restore end- organ perfusion with supportive and specific care. I'll be considering issues second to the ventilation, breath stacking, tension pneumophorex, issues second to the induction agent, anaphylaxis. Progress of disease state, so hypovolemia, metabolic acidosis, sepsis, tamponade, arrhythmia. In practice the first thing I'll do is disconnect the patient from the ventilator allowing a full expiration to treat breath stacking. At the same time I'll request nursing staff give a 10 ml per kilo bolus of normal saline. Next I'll bag the patient with 100% FiO2 taking note of end tidal. At this time we will be using a combination of physical examination and POCUS to rapidly seek and treat life threats. So firstly anaphylaxis if difficult to bag, wheeze, rash I'll give 0.5 milligrams of iamadrenaline. If there's evidence on tension clinical or POCUS evidence of tension pneumophorex finger for acostomy. If there's if there is sepsis noradrenaline infusion we'll do repeat ECG and check pulse considering shock or pacing. I'll also do echo looking at tamponade or PE. At this point we'll also do a VBG specifically looking to treat metabolic acidosis or electrolyte abnormalities.

Question

What is your ventilation strategy for an asthmatic patient?

Answer

My goal is to prevent breath stacking and I'll accept a degree of hypercapnia. My respite will be low 6 to 10, total volume 6 mls per kilo , IED ratio 1 to 5. I'm going to have a high in spiritual flow rate up to 100 litres per minute. Peep of 0 to 5. I'll start FiO2 at 1 but titrate down aiming SATS 90% I'll keep this patient fairly heavily sedated with a ket amine infusion.

Question

A patient is in your recess room with a bleeding trachea. Outline your management.

Answer

In this I'm well patient my goal will be to stop the bleeding, reassess it and also ensure the airway is secure. When I manage this patient in the resource room I will be team leader. My team will include ENT plus or minus anaesthetics. Everybody will be in PPE. For the team at the head and neck, first job will be the suction to clear any clots. If there's visible bleeding at the side of the stoma, direct pressure. Otherwise, slowly hyper inflate the cuff to 60mm of mercury . If there's ongoing bleeding despite this, I have an assistant apply external pressure at the sternal notch, attempting to externally compress the abnominate artery. If there's ongoing bleeding, intubate. This will be a difficult intubation. You may need to go lower for the cuff to be deep to the source of bleeding. Post intubation consider a finger through the stoma to put pressure on the abnominate artery with a thumb in the sternal notch as well. The other general resuscitation will be oxygen over mouth and trachea. Massive transfusion at a 1 to 1 to 1 ratio of cacrobod cells, FFP and platelets. Reverse anequigalopathy. This patient's disposition will be theater with ENT, plus or minus vascular surgery. If there's a trachea abnominate, fistula.

Question

You attend the emergency bell. The handover is an eight- year-old about to go to theatre for a query open supercondylar fracture. They've just started kefazol and they're hypoxic. Sats of 80 percent, hypot ensive, blood pressure not recordable but have radial pulse. They are alert but confused. Cap refill is five. What is your management of this anaphylaxis?

Answer

My priorities are to concurrently cease the causative agent , so stop the Keflazolid, and ideally not use that line. We're gonna move the patient to resus and assemble a team. And administer iamadrenaline, 0.1 mil per kilo of one in 10,000. And then I'm going to be repeating that every five minutes targeting a cap refill less than two. And I apply 15 liters via non-rebreather. I'll give this child a 20 mil per kilo bolus of normal saline targeting cap refill less than two. I'll position them supine. Ongoing treatment will be guided by response. If they're still shocked after two doses of adrenaline, I'm gonna commence a peripheral adrenaline infusion at 0.05 micrograms per kilo per minute, titrating to the resolution of the anaphylaxis symptoms. If they're unconscious or at rest, we will intubate and give ALS dose of adrenaline. My post resus care will be, I'll give hydrocortisone four milligrams per kilo, antihistamine. I'm gonna ensure that theaters are aware, theaters and author aware of this event. And I'm going to debrief with staff and open disclosure to the patient and family.

Question

You're in a tertiary centre managing a 65-year-old man. He is presented in cardiogenic shock in the setting of ROSC in the community post-EVF arrest. His ECG shows an inferior STEMI with RV involvement, adverse heart block, and occasional ectopics. His current obs are heart rate 55, blood pressure 80/40, respirate 18, setting 96% on 6 litres. He is GCS 13 and combative. So far he has had aspirin and heparin. Road STEMI has been activated and the CAF lab will be ready for this patient in 15 minutes. How will you manage/intubate this patient?

Answer

I will continue managing this patient in the resource room with full non-invasive monitoring. I'll assemble a team, including a second senior airway operator. I'll brief the team. This will be a physiological difficult intubation due to the patient being in cardiogenic shock. He's at risk of an arrest on induction if not properly optimized first. Our goal will be to do a safe intubation and transfer this patient to the cath lab in a timely manner. We'll optimize his oxygenation and ventilation with BVM and PEEP at 100% FiO2. As well, we'll use Y-ball nasal prongs with 15 liters of oxygen. I'll optimize his circulation. So optimizing preload, consider 10 mil per kilobolus of normal saline if there's no signs of pulmonary edema. We'll be giving this patient a peripheral adrenaline inf usion, aiming for a main arterial pressure of 65 and heart rate of 60. Optimize his conduction, so correct any hyper or hyperkal emia. And we'll also consider-- we'll do transcutaneous pacing if the patient becomes more Brady, so heart rate less than 50. My equipment includes video laryngoscope, size 8 tube, BG, superglottic airway, BVM, surgical airway kit. My induction agent will be low dose ketamine, 0.5 milligrams per kilo, high dose roc uranium. Prior to induction, we'll utilize the airway checklist, and I'll verbalize the airway plan. Plan A, video laryngoscope, BG, regardless of U. B, superglottic airway, BVM. C, front of neck access. Post-intubation care, we will confirm tube placement, entit le CO2, chest auscultation, chest x-ray. We'll be ventilating using a lung protective strategy. Ongoing sedation with fentanyl and midazolam infusion starting at 50 microns, 50 milligrams. Then our priority will be to package and have this patient transferred to ICU or-- sorry, transferred to the cath lab with ICU or anesthetics.

Question

You're a consultant in a tertiary sensor. You have a five- year-old with asthma who is hypoxic and drowsy despite subut amol, ipatropium, magnesium. You have made the decision to intubate this patient. How will you intubate this patient?

Answer

I'll manage this patient in recess with full non-invasive monitoring. I'll be assembling my team. If I have a second experienced airway operator I'll continue team leadership. Otherwise I'll hand over team leadership during the period intubation period and I'll manage the airway. I'll also be allocating a senior staff member to be with the family. I'll brief my team that this is going to be a physiologically difficult intubation and particularly difficult ventilation. Prior to induction we're going to optimise the patient's ventilation and oxygenation so we're going to use BiPAP with 100% FiO2. If that's unavailable then we're going to use a pediatric BVM with PEEP plus 15 litres of oxygen through high-flow nasal cannula. We'll also be continuing maximal medical asthma treatment so commence amyophilin for a dedicated line consider IV salbutamol, consider IM adrenaline. Again prior to induction we're going to ready our equipment and verbalise the airway plan. I'm going to be using the Monash book plus an airway checklist. My induction agent will be ketamine a milligram per kilo, rocuronium one milligram per kilo. Plan A we're going to use a size 3 video laryngoscope with a size 5 cuff tube. Plan B will be supraglottic airway, BVM. Plan C needle crike. My post induction care will be confirming tube placement with n-tidal CO2, chest auscult ation and chest X-ray. For ventilation we're going to be aiming to avoid breath stacking. I'm going to have a respiratory rate of 10, tidal volume 6 mls per kilo, IE ratio of 1 to 5, and a spiritual flow rate of 70 litres per minute, PEEP of 0. I'll be starting FiO2 at 1 and then we'll titrate down to aim sats at 90%. I 'm going to continue my ongoing sedation will be with ketamine infusion otherwise we will continue to treat the asthma medically and this child will need ongoing management in PQ.

Question

What is your full airway plan for a difficult airway? You have three minutes.

Answer

I'll manage this patient in the resource room with full non -invasive monitoring. I'll assemble a team including a second experienced airway operator and any other relevant specialists. I will brief the team ensuring we have a shared mental model on why this is a difficult physiological or anatomical airway. If I am intervening the patient I will be handing over the team leadership role to another facem so that situational awareness is maintained. I'll optimize the patient for their oxygenation and ventilation. I'll give them a hundred percent FiO2 via bag valve mask as well as have high flow nasal prongs prior to and during intubation. For perfusion we'll make sure we've got dual IV access and ensure adequate preload with 10 mil per kiloboluses of normal saline plus consider push dose adrenaline or other inotropes aiming for a mean arterial pressure of 65. Regarding positioning I'll have this patient sitting up at 45 degrees ramped to a tragus in line with their sternal notch . My induction drugs will be low dose ketamine 0.5 milligrams per kilo high dose rocuronium 1.6 milligrams per kilo. My equipment will include dual suction , video laryngoscope, Bougie ET tubes, superglottic airway, typical airway cont rol, containing the surgical airway kit. Prior to induction I will run through the intubation checklist with the team and verbalize my airway plan including critical to saturation points and whether or not I will be bagging through the apnea period. Plan A will be video laryngoscope, Plan B superglottic air way, Plan C front of neck access. Regarding post intubation care I'll first confirm tube placement with end tidal CO2, chest auscultation and chest x-ray. I 'll employ a lung protective ventilation strategy so my initial settings will be tidal volume of 6 mils per kilo, respiratory rate of 12, FiO2 of 1 and PEEP of 5. Ongoing sedation will start with a propofol infusion titrating up from 0.5 milligrams per kilo per hour. Following this I will be readdressing the patient's circulation and continue to treat any underlying conditions. Other core tasks will include placement of nasogastric tube, ensure the patient's covered including eye care. This patient will require ongoing care in the intensive care unit.

Question

You have a patient that you intubated for reduced GCS six hours ago. ICU is full. Since intubation the patient has had a normal CT brain and bloods and you've been informed by their partner that they had ingested five mils of juice / GHB. What is your assessment of this patient for suitability for extubation in ED? If suitable, what is your management of the extubation?

Answer

So they must have resolution of the issue requiring intub ation. It must not have been a difficult intubation. They must have normal physiology, so SATs over 95% on FO2 less than 40, low PEEP, not requiring, no high respirate, normal tidal volume. Their circulation must be normal and unsupported, so normal intensive, not tacky. And then we'll check that they're ready for sedation, so we're going to ensure that the patient's not paralysed, turn sedatives off and then perform a spontaneous breathing trial, so minimise vent assistance, and then confirm that the patient's able to follow commands . I'd also ensure that the department is in a suitable time and place for the patient to be extubated, so not overnight, and we need to have safe staffing. If all of these are met, then I'll prepare for intubation, extubation. So I will extubate the patient in the resource room. Staff needs to be a full team, including airway nurse. Equipment was the same for intubation, so we need to prepare for laryngospasm and potential need for re-intubation. So I have all equipment out, ready, checked. Then to do the extubation, I will provide positive pressure , single positive pressure, deflate the balloon, and then as the patient exhales or coughs, remove the ETT, then suction. My post-intubation care, extubation care, will be observing them in resus, start them on six litres via Hudson and observe for respiratory distress or laryngospasm and prepare to manage these.

Question

Shortly after intubating a 20 year old asthmatic patient their stats have dropped to 60%. What is your management?

Answer

In this patient I'm concerned the tube displacement or obstruction, ventilator or equipment issues, as well as patient problems. The first thing I will do is disconnect the patient from the ventilator and allow a full expiration assessing for and treating breath stacking. Second I'm going to ventilate this patient with BVM at a hundred percent FiO2. I'll be firstly a) looking at end tidal CO2 to confirm that there is no tube dislodge ment. If there is no end tidal CO2 I will remove the tube, ventilate the patient and when improved re-intubate. If the patient then b) I'll be feeling for lung compliance. If the patient is stiff to back I'll be concerned for bronchostasm , second asthma and anaphylaxis and will treat accordingly. If the patient is easy to back but with no chest movement I'll be concerned for circuit leak or tube displacement. Third if there is minimal chest movement I will then pass a suction catheter down the tube to exclude tube obstruction. If obstructed I will re-intubate this patient. Fourth we will perform focus physical exam and POCUS to seek and treat potential patient problems. Tension pneumothorax, anaphylaxis, asthma progression or looking for a rest or other pathology.

Question

What is your airway plan for difficult intubation? Say it in under one minute.

Answer

Manage this patient in recess with full non-invasive monitoring. Assemble and brief the team. Optimise the patient's physiology and positioning. My induction drugs are ketamine, 0.5 mg/kg, and rocuronium, 1.6 mg/kg. Prior to induction, I will run through my intubation checklist, verbalise my airway plan as Plan A, video laryngoscope, Bougie ET tube. B, supraglottic airway with BVM. C, front of neck access. Post intubation, I will confirm tube placement with entile CO2, auscultation, and chest x-ray. I'll place the patient on lung protective ventilation. We will give ongoing sedation with propofol infusion, and this patient will require ongoing care in the intensive care unit.

Question

Your patient presents with preeclampsia. What is your management?

Answer

My priority is to manage the hypertension, prevent eclamps ia and expedite timely safe delivery of baby and placenta. I'll commence treatment if the systolic blood pressure is greater than 160. If there's seizure or severe hypertension I'll give magnesium sulfate 5 grams or 20 mill imoles IV and do an infusion of 1 to 2 grams per hour monitoring for hypermag nesium toxicity specifically dowsiness, respiratory depressant, loss of deep tendon reflexes. If toxicity develops I'll give 10 mils to 10% calcium gluc onate. For control of the hypertension I'll give 20 milligrams of libetalol IV over two minutes then repeat 10 minutely aiming for blood pressure approximately 140. My other management is I will have early CTG monitoring for fetal distress and I'll be immediate consult with obstetrics. Also be giving consider giving IV dexamethasone for lung maturity and early delivery.

Question

What is your management of hypertensive bradycardia? See ya.

Answer

I'll assume team leader. Our priorities will be to maintain a patent airway, apply oxygen and assist breathing as needed. We'll get ECG to identify rhythm, as well as I want a blood pressure and oxygen saturations. We'll establish IV access, dual IV access, and at this point get a VBG, specifically looking for hyperkalemia or hypoglycemia. Then, my supportive care will be, I will prepare transcutaneous pacing, as well as draw up an adrenaline infusion. Whilst these are getting started, I will give 600 milligrams IV atropine, which I may repeat a total of three milligrams. Then I'll start an adrenaline infusion, starting at five mics per minute. If this is ineffective, I'll be starting transcutaneous pacing, starting at 70 milliamps at a rate of 60, aiming for electrical and mechanical capture. After the supportive care, I'll continue to look for specific causes. So that's the hyperkalemia, as I said earlier. Other causes I'll be thinking of include underlying isch emia, so ACS requiring cath lab, toxidromes, so specifically beta blocker, calcium channel blocker, digoxin, and organophosphate. These patients will often require either cardiology or ICU input.

Question

Your patient is presented with tachycardia hypertension due to PR bleeding. He is on Dabigatran. What is your management?

Answer

This patient is in hemorrhagic shock. My priority is to res uscitate, reverse the coagulopathy and expedite definitive care. I'll team lead the management of this patient in the resource room. I'll call for massive transfusion protocol. I'll get early involvement with haematology, surgical and interventional radiology. As a team we'll resuscitate this patient. We'll go through massive transfusion protocol. So we'll use transf used warm balanced blood products in a one-to-one-to-one ratio of red blood cells, F FP and platelets, targeting a mean arterial pressure of 65, pH greater than 7 .2, lactate less than 4. We'll be reversing the coagulopathy early. In consultation with haematology I will administer Iterusisumab, 5 grams of IV and 1 gram of T XA. Following resuscitation and reversal of the coagulopathy, my goal will be to expedite definitive care, surgical or interventional radiology.

Question

What is your management of a patient presenting with query aortic dissection?

Answer

My priority will be to control blood pressure, stop the bleeding, and replace folium with balanced blood products. I'll manage the patient in the resource room with early consult of cardiothoracics. My initial treatment in ED will be to establish large-bore IV access, get oxygen on the patient, aiming sets above 90. I'll be giving IV fentanyl, 25 mics, five minutely, aiming for a decrease in pain and to decrease sympathetic output. I'll give IV libidolol, 20 milligrams IV, repeating 10 minutely, aiming for a heart rate 60/80, and right arms to stop blood pressure 100 to 120. My second agent will be sodium nitroproside at 0.3 mics per kilo per minute. I'll also be activating the massive transfusion protocol, giving him balanced blood products and correcting coagulopathy. In terms of investigations, my priority will be to CT angio . If it's a Stanford A ascending only, surgical repair with cardiothoracics. If B, it's going to be medical management with potential vascular surgery. At the bedside, I'll also be doing an echo to rule in dissection and looking for pericardial effusion such as tamponade. I'll be doing a VBG, rhodium coag as part of my massive transfusion protocol. ECG, which will be nonspecific, but maybe signs of inferior ischemia and chest x-ray may show some metastomal whiting.

Question

What is the clinical manifestation and treatment of patient with sodium valproate toxicity?

Answer

The resuscitation is supportive with airway protection. Risk stratification is if coma is concerning, so more than a thousand milligrams per kilo. Other clinical features is essentially CNS decreased conscious state for cardiac hypotension and tachycardia as well as prolonged QT . It has decontamination, there's role for activated charcoal as well as whole bowel irrigation and hyaluronidalysis for enhanced elimination.

Question

assessment and management of chlorpromazine or prochlorper azine overdose

Answer

This is a high-risk ingestion for children. One tablet may cause toxicity. Clinical features is an agitated delirium or can move to coma seizures. Tachycardia, hypotension, QRS prolongation for cardiovascular and they have anti-cholinergic effects. There's also a risk of neuro leptic malignant syndrome. Care is supportive including fluid, activated charcoal. If there is extraperitoneal side effects there is a role for benestro pin 1 to 2 milligrams IV.

Question

Patient presents with significant TCO overdose. What is your management?

Answer

My key interventions will be sodium bicarb as the antidote and intubation with hyperventilation. In basic order, I want to manage this patient in the resusc itator room with myself as the team leader. I want IV, we need IV, our priorities, our first priorities will be getting IV access and ECG with ongoing monitoring as well as a VPG. Then if there's indications such as seizure, arrhythmia, widen QRS, then we'll be giving sodium bicarb at a dose of 1 ml per kilo of 8.4% over 2 minutes. And I'm going to be repeating that every 5 minutes, up to every 5 minutes, aiming for a pH in the 7.5 to 7.55. My next priority will be managing hypotension and I'll be giving a 20 ml per kilo bolus of normal saline. Ongoing hypotension I will treat with noradrenaline. Our next priority will be intubating this patient, which I 'll do in my standard way, but with the only difference, with addition of a bolus of sodium bicarb prior to induction. Once intubated, we're going to have a high minute volume, again targeting a serum pH of 7.5. My next priorities will be a decontamination, so 50 grams via NG, and then this patient I will manage in the intensive care unit. Thank you.

Question

What are the clinical features and treatment for a patient presenting with a carbamazepine overdose?

Answer

In a pediatric overdose, this is a one pill can kill medication. It can cause CNS cardiovascular anticholinergics. So at CNS it causes drowsiness, ataxia, it can cause sedation and seizures, as well as coma. Cardiovascular hypotension, it can also lead to sodium channel blockade, which you would treat with the one mL per kilo sodium bicar b as you would with a sodium channel overdose. Otherwise there is a role for activated charcoal and the treatment is supportive fluids, intubation.

Question

What is the approach to SSRR toxicity?

Answer

By themselves, SSR overdoses are usually fairly benign. Sateleprem, S-sateleprem, associated with dose-dependent QT prolongation and are at risk for torsades. These resus is primarily supportive and specific treatment for torsades. They might present with nausea, vomiting, but CNS depression and coma not common. And serotonin toxicity is very rare following an isolated SSRI ingestion. There is a role for charcoal.

Question

Patient is presenting with a potential arsenic overdose. What are the features and management?

Answer

Ingestion causes severe GI symptoms that may progress to hy povolemic shock arrhythmias and multi-organ failure. There is a role in terms of management, aggressive fluid replacement resuscitation, as well as targeted chelatone therapy. Decontamination is removing of clothing, washing with soap and water, GI decontamination such as whole bowel irrigation in discussion with clinical toxicology.

Audio

What is your assessment and management of patient presenting with iron overdose?

Question

Assessment and management of beta blocker overdose.

Answer

My assessment will be start by taking a history of what was taken, knowing that sotolol causes and cause torsades, propranolol acts more as a sodium channel blocker. Of note in children this is a one pill can kill medication in the toddler. The key clinical features is bradycardia hypertension and AV blockade. Other features are hypoglycemia and hyperkalemia. My management is graduated so I get IV access and I give a fluid bolus of 20 mls per kilo of normal saline. I also will then start atropine 600 milligram bolus, sorry 600 microgram bolus and begin an adrenaline infusion so adding 6 milligrams of adrenaline in 100 mls of sodium chloride and then giving at 5 micrograms per minute. My next step will be high dose euglycemic therapy and I can also consider electrical pacing. Failing this there may be a role for extra corporal life support such as ECO.

Question

Discuss urinary alkalisation.

Answer

Useful for significant salicylate toxicity. Should be done in the ICU. Patients should have urinary catheters. To give it, I add 150 ml of sodium bicarb to 850 ml of 5% dextrose and I give it 200 ml per hour. Every hour, check urine, pH as well as a VBG checking for the urine and pH, aiming for a pH of 7.5 and on VBG ensuring that the serum pH is not greater than 7.5 and checking potassium as this will need correcting also. My key therapeutic endpoints is improving symptoms and as well as you can look at two down trending salicylate concentrations.

Question

What is your management of prolonged QT and toxicology?

Answer

It can be caused by multiple different drugs, antipsychotics, Sotolol, and some antidepressants, antihistamines, hydroxychloroquine. You can use a QT normogram. If patients are at risk, monitor them. Correct electrolytes. So ensure potassium is greater than four, calcium greater than two, magnesium greater than one. If patients go into Torsades, they should all get 10 millimoles of MagSulfate. Other options is overdrive pacing, using adrenaline or isoprenolone, or overdrive electrical pacing, so aiming for a heart rate of 80 to 100.

Question

What is your risk assessment and management of salicylate poisoning?

Answer

Risk assessment is based on dose, with 500mg per kilo being potentially lethal. Of note, 1ml of oil of wintergreen is equivalent to 1400mg of aspirin. Generally patients will present with GI symptoms, tinnitus, nausea, vomiting, a higher overdose, seizures, metabolic acidosis with mixed acid-base disturbance, multi-organ failure. The management, the mainstays, fluid resuscitation, urinary alkalisation and there is a role for decontamination with charcoal. I'll talk more about urinary alkalisation, I'll talk about separately.

Question

What is your assessment and measurement of digoxin poisoning?

Answer

Clinical features include increased automaticity, so the patient gets ventricular ectopics by Jamanese tachyarrhythmias. They also get bradydysarrhythmi as, so slow AF, AV block. Hyperkalemia is also a marker of toxicity. Otherwise, it can have GI symptoms as well as CNS, left edilium confusion. The management, aside from supportive, is digoxin, in the cardiac arrest, 5 vials IV, or in not arrest, 2 vials IV over 30 minutes in 100 ml of saline. Hyperkalemia is treated normally, including with calcium. If the patient is in a br adyarrhythmia, atropine. If they're in a tachyarrhythmia, magsulfate. There is a role for activated charcoal as well as enhanced elimination multidose activated charcoal.

Question

What is the antidote for cyanide poisoning? thing.

Answer

I-droxocobalamin and sodium thiosulfate

Question

What is the management of dapsone overdose?

Answer

Resus along conventional means the antidote is methylene blue 1mg/kg.

Question

What are the features and management of a cotyopine overdose?

Answer

Primarily tachycardia, CNS depression and hypotension, including also prolonged QT but with minimal no reports of torsades. Seizures are rare. The mainstay of treatment is supportive care. There is a role for activated charcoal.

Question

What is your risk assessment, clinical features and management of caffeine toxicity? toxicity.

Answer

Clinical and Futures, CNS, Anxiety, Agitation, Seizures, Cardiovascular, Tachycardia, Hypotension, Tachyarrhythmias including SVT, VT, VF, Metabolic, Respir atory Alkalosis, Metabolic Acidosis as well as Hypokalemia, Management, Aggressive Supportive Care is the mainstay for seizures and agitation, benzodiazepam, stazepam, for arrhythmias consider Esmolol, there is a role for activated charcoal, enhanced elimination is a role for multi-dose activated charcoal as well as hemodialysis.

Question

Your patient presents confused after deliberately ingesting ethylene glycol. What is your assessment and management?

Answer

This is a potentially high risk exposure. Assessment and management will be happening in parallel as patients likely to require early intubation, NGF and ICU for hemodialysis. Starting with reassess, we're going to be managing ABC along conventional lines, but I anticipate a need for early intubation. This will be a physiologically difficult intubation due to the metabolic acidosis. In light of this, I'll consider giving sodium bicarb 8.4% prior to induction if the patient's acidotic. And we're going to bag the patient through the apnea period and following intubation we're going to hyperventilate this patient, so in the least matching their prior minute volume. In terms of risk assessment, we're going to look at the amount, any co-ingestions, and if it would have been deliberate is very concerning on examination, taxius, third speech and drows iness. I'll examine for flank pain, indicating acute renal failure. Key investigations are going to be a VBG, and on that I'm anticipating a high and on-gap metabolic acidosis with an osmol gap, as well as hypokalcemia. Other investigations is we'll do renal EUC for assessing for acute renal failure. We'll do ethanol level for co-ingestion, screening ECG and paracetamol, given that this is deliberate, and then also urine microscopy looking for calcium oxalate crystals, which is pathogammonic of ethylene glycol. There's no role for decontamination. As I alluded to before, our enhanced elimination and definitive care will be hemodialysis. The antidote, so following intubation, I'll give nasogastric ethanol, so essentially four shots of food , our local protocol, but for example four shots of vodka in the first hour, followed by one shot hourly after that. Other options are IV ethanol or formepazole, which is not widely available. Disposition, these high-risk patients will require ICU, ongoing follow-up with mental health, as well as follow-up for potential cranial neuropathy, cranial neuropathies.

Question

What do you anticipate with an antihistamine overdose?

Answer

In severe tox you can have an anti-cholinergic delirium as well as sodium channel blockade arrhythmias.

Question

What is the management of Paraquat ingestion?

Answer

Priority is decontamination and that takes priority over resuscitation or transfer. Transfer the hospital, 50 grams activated charcoal, otherwise food, soil mixed with water as a slurry. Other options is no oxygen unless that's less than 90%. There's a role for hemodialysis, most beneficial within the first four hours. Maybe a role for NAC, prednisolone or indexamethasone. But generally anything greater than 50 milligrams per kilo is death.

Question

What is your assessment and management of a patient presenting with a overdose of metformin? woman.

Answer

So the main things that it can does not cause hypoglycemia, but can cause a lactic acidosis which is potentially profound. Patients will present non-specifically, but we can become t achycardic hypotensive. The supportive care, there is a role for activated charcoal . And there is a potential role for hemodialysis, lactate greater than 20.

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What is your risk assessment and management of isoniazid overdose?

Answer

Suspect in seizures that are refractory. The maximum dose is 5 grams in adults.

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What is your risk assessment and management of a patient with hydrofluoric acid?

Answer

causes severe pain and tissue damage. Large exposure can cause life-threatening fluorosis, which can cause ARDS, hyperkalemia, hypomagnesia, seizures, hypertension, cardiac arrest. Your management in the resource room for hypocalcemia, so if there's a prolonged QT, arrhythmia, seizures, or hypotension, give 30 mils of calcium gluconate over five to 10 minutes, as well as IV magnesium sulfate. These patients need VBGs and aggressively managed hyperkalemia. For domal exposure, you can do calcium gluconate gel, subcutaneous infiltration, not at the fingers. There's also a role for calcium gluconate BS block. Calcium gluconate BS block.

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What is the risk assessment and management of a patient presenting with baclofen overdose?

Answer

1 25mg tablet can produce a coma in a toddler. Presents for profound, prolonged coma, respiratory depression as well as seizure. It can be due to intrafecal administration. It may mimic brain death with fixed dilated pupils. The management is aggressive supportive care, including intubation, midazolam for seizures. Thank you for watching.

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What is the presentation and management of amphetamine toxicity?

Answer

Agitation, you can get hyperthermia, multi-organ failure, t achycardia, hypertension, you can also get SIADH. Management is primarily supportive. I treat with IV midazolam, 5mg aliquots. For hyperthermia, temperature above 40 is a key indication for intubation. If seizures, treat per normal lines but check for hyponatremia and also CT brain to exclude intercranial hemorrhage. If there's ACS, avoid beta blockers.

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What is the risk assessment and management of ethylene gly col toxicity?

Answer

Intentional or pediatric is high lethality. Patients present with ataxia, then increasing acidosis, then increased respiratory rate, tachycardia hypotension, then later progressive acidosis, renal failure , seizures, coma, death, the management, risk stratification can calculate the osmolarity, the antidote is FNL, also consider 8.4% sodium bicarb aiming for a pH if pH is less than 7.3. It's also options for hemodialysis.

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What is the specific treatment for hydrofluoric acid exposure?

Answer

For systemic toxicity, administer 30mL of calcium gluconate over 5 minutes, also 10mL of IV magnesium sulfate over 10 minutes, and treat any hyperkalemia aggressively. For dermal exposure, first start with calcium gluconate gel , which you can make with 10mL of 10% calcium gluconate in 30mL of lubricating gel. For non-hand exposure areas, subcutaneous infiltration of 10% calcium gluconate. You can also do a Beer's Block technique with calcium gluc onate. For inhalation, 1mL of calcium gluconate in 3mL of saline via a nib.

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What is your assessment and management of a patient presenting with calcium channel blocker overdose?

Answer

On history, a dose of 3 times usual dose can equate to serious toxicity. More than 10 tablets life threatening. And this is pills with one pill can kill a toddler. If modified release, symptoms can be delayed up to 12 hours . I'm concerned patients can present with bradycardia, hypot ension, first degree heart block. They may also, pulmonary edema may progress to refractory shock and death. They can also become hyperglycemic. My management. This is potentially life threatening. I will manage in resus using a team based approach. Managing the bradycardia. I will commence atropine and give up to every 5 minutes up to 3 doses. I will load them with crystalloid. I will give the antidote of 30 mls of calcium gluconate over 5 minutes. Repeat that 3 times in the first hour. And then consider an infusion aiming to keep my ionized calcium between 1.5 and 2 mls per liter. My other options will be an adrenaline infusion. High dose euglycemic insulin therapy. And I would also consider, if refractory, consider ECMO and lipid emulsion. To go back to my high dose insulin euglycemic therapy. I give 50 mls of 50% dextrose. Then start an infusion of 100 mls of 10% dextrose per hour. Then I start insulin. So I will give 1 unit per kilo as a bolus and 1 unit per kilo per hour. Aiming to maintain glucose between 5 and 11. And aiming to maintain potassium between 2.8 and 3.3.

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Assessment and management of hydroxychloroquine overdose. you

Answer

So this is Plaquenil. It can cause rapid onset life-threatening cardiovascular and neurological toxicity when ingested. So hypotension and can cause QRS and QT prolongation. Ventricular arrhythmias, hypokalemia, CNS, seizures, coma. The management is fluid bolus and adrenaline, 5 mics per minute. Treatment of electrolyte abnormalities, so they have QT prolongation. Aim to manage hypokalemia and there is a role for decontamination with 50 grams of activated charcoal.

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What is your assessment and management of local and acidic toxic...

Answer

So often this is due to accidental IV administration. Patients present with dizziness, perioral numbness, tinnitus, and this can progress to seizure, arrest. The management is primarily supportive care, with attention to airway. So I give all my patients oxygen. I treat seizures with IV midazolam. If there's evidence of widened QRS, I give sodium bicarb, one mil per kilo, aiming for a pH of 7.5. If in severe cases, lipid emulsion therapy, or intralipid. So I give one mil per kilo of 20%, and this can be embolised in consultation with a clinical toxicologist.

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What is your assessment and management of Colchicine overdose?

Answer

0.1 milligram per kilo has potential for toxicity including death. The management your first priority is decontamination otherwise it's with activated charcoal otherwise it's aggressive fluid resuscitation and ionot ropic support there's a role for hemodialysis you

Question

Outline your newborn life support in under 60 seconds.

Answer

I'll assume team leadership, call for help, try stimulate and put on a susseter. If the heart rate is below 100 or the infant's apnea gas ping, start positive pressure ventilation. If after a minute the heart rate is between 60 and 100, continue to optimise ventilation and oxygenation. If below 60, start CPR 3 to 1 with 100% FO 2, then at the same time gain IV access, give IV adrenaline, also intubate the infant and they will go to PICU or NICU.

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A newborn has been delivered in your ED and looks unwell. What is your approach?

Answer

Call for help including neonatal services, move the infant to the resuscitator, open the dryer and stimulate the patient, open the airway. If the heart rate is below 100 or there is gasp, gasp sneer or apnea, then provide positive pressure ventilation with 21% FiO2. If the heart rate, so after one minute, if the heart rate is still below 100 then I'll consider increasing my pressures and providing oxygen as well as considering L MA, laryngeal mask. If heart rate below 60 then I will commence three chest compressions for each breath giving 100% oxygen and looking at gaining air way, so intubation or LMA and gaining IV or umbilical access. I'll reassess if the heart rate is still below 60 then give IV adrenaline 10 micrograms per kilo and also consider fluid bolus 10 mils per kilo.

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What is your management of a child that has arrested in your department?

Answer

Ensure good quality CPR. Two breaths to 15 compressions. Compressions at a rate of 100 to 120 at one-third of the chest. Minimize interrupt ions. Confirm by direct observation as well as waveform capnography. At the first then assess rhythm when possible. If it's shockable, four joules per kilo then continue CPR. Non-shockable, continue CPR. If it is a non-shockable rhythm, give 10 mics per kilo adrenaline immediately then every second loop . If it is shockable, adrenaline after the second shock then every second loop and amiodarone five milligrams per kilo after a total of three shocks. During CPR, reverse consider and correct the four H's and T's but specifically address I want the patient with hypoxia is most common, ideally intubated, 100 % FIO2. They should have IV access with 20 ml per kilobolus of saline, fluid free running. At time of access they should have a VBG looking for hyper-hypokalemia and other metabolic disturbances. They also need to be checked for temperature ensuring not hypo or hyperthermic. They need bedside echo looking for signs of new tension pneumothorax, cardiac tamp onade or PE. Otherwise we need to take history for toxins. Other things that are important is to include, ideally have the parents in the room with a senior practitioner looking after them or being with them.