FCEM(SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain Reg No 1955/000003/08

Final Examination for the Fellowship of the College of Emergency Medicine of South Africa

31 August 2011 Paper 1 (3 hours)

All questions are to be answered. Each question to be answered in a separate book (or books if more than one is required for the one answer) Al die vrae moet beantwoord word. Elke vraag moet in n aparte boek (of boeke indien meer as een nodig is vir n vraag) geskryf word

a) b) c)

d)

Define the condition Status Epilepticus. (2) Define the condition Refractory Status Epilepticus. (2) Write short notes on the dosage and method of administration of the following medications for the management of Refractory Status Epilepticus i) Midazolam. (4) ii) Propofol. (4) iii) Levetiracetam. (4) iv) Valproic Acid. (4) v) Thiopental. (4) What is the dose of intravenous phenytoin in epilepsy? (1) [25] Discuss the difference between Rapid Sequence Intubation and Rapid Sequence Airway techniques. (5) Discuss the difference between Rapid Sequence Intubation and Delayed Sequence Intubation techniques. (8) What is the dose of sugammadex (Bridion) when used in the emergency department? (2) Tabulate the current rabies post-exposure prophylaxis protocol in a non-previously immunised patient. (10) [25] Describe the Wells criteria for pulmonary embolism. (4) Discuss the advantages and disadvantages of risk factor scoring systems for pulmonary embolism in your clinical practice. (3) Describe the potential chest x-ray findings in a patient with a pulmonary embolism. (3) Compare and contrast the following diagnostic strategies for pulmonary embolism in terms of indication, sensitivity, specificity, predictive values and limitations i) Duplex ultrasound. ii) D-dimer. iii) Ventilation/Perfusion (V/Q) scanning. iv) CT pulmonary angiography. (12) What is a paradoxical pulmonary embolism? (1) Write short notes on Lemierres syndrome. (2) [25]

a) b) c) d)

a) b) c) d)

e) f)

PTO Page 2 Question 4...

a)

b) c)

A 29-year-old female patient presents to your emergency department complaining of epistaxis and easy bruising. On full blood count it is noted that her platelet count is 12 000/mm3. Tabulate the differences between idiopathic thrombocytopaenic purpura (ITP) and thrombotic thrombocytopaenic purpura (TTP) with regards to i) Clinical presentation, including demographics and any other accompanying signs or symptoms. (5) ii) Management of a patient with each condition. (8) Name 4 drugs that may cause thrombocytopaenia. (2) Regarding acute chest pain syndrome in sickle cell disease, describe i) The clinical presentation. (3) ii) The presumed underlying pathophysiology. (3) iii) How to manage such a patient. (4) [25] Your hospital has a high rate of ventilator-associated pneumonia. Discuss strategies that should be implemented to prevent ventilator-associated pneumonia. (10) Discuss the differences in the paediatric patients cervical spine and explain how they alter injury patterns and interpretation of investigations. (12) You need to suture the wound of a patient who claims to be allergic to lignocaine. How would you manage this problem? (3) [25] Synchronised cardioversion is usually effective in terminating lethal tachyarrhythmias in unstable patients. Detail your approach to the unstable patient who is refractory to synchronised cardioversion. (7) Discuss in detail the specific management of digitalis toxicity in the presence of the following complications (Digoxin-specific Fab fragment therapy is not available) i) Life-threatening hypokalaemia. (3) ii) Life-threatening hyperkalaemia. (4) iii) Symptomatic bradycardia. (2) iv) Stable ventricular tachycardia. (3) v) Unstable ventricular tachycardia. (3) vi) Ventricular fibrillation. (3) [25]

a) b) c)

a)

b)

FCEM(SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain Reg No 1955/000003/08

Final Examination for the Fellowship of the College of Emergency Medicine of South Africa

1 September 2011 Paper 2 (3 hours)

All questions are to be answered. Each question to be answered in a separate book (or books if more than one is required for the one answer) Al die vrae moet beantwoord word. Elke vraag moet in n aparte boek (of boeke indien meer as een nodig is vir n vraag) geskryf word

a) b) c) d) e) f)

What is the Pritchards regimen (high dose) for eclamptic seizure management? What is the Zuspan regimen (low dose) for eclamptic seizure management? Describe the technique of humeral intraosseous infusion. Describe the technique of sternal intraosseous infusion. Briefly discuss pain during intraosseous intravenous access. What are the constituent factors that are found in a unit of cryoprecipitate?

(4) (4) (4) (6) (4) (3) [25]

a) A young adult patient with a life-threatening asthma attack deteriorates into cardiac arrest after full medical treatment i) Describe the specifics relating to management of this patients airway. (5) ii) Describe the specifics relating to ventilation of this patient. (5) iii) Describe the specifics relating to chest compression in this patient. (5) b) A young male is brought into the emergency department having been contaminated in a radiation accident nearby. Answer the following questions related to this patient i) How would you externally decontaminate the patient using common items found in the emergency department, excluding the use of water? (4) ii) What is your further management if the dosimeter indicates a radiation level of 0.01Sv? (2) iii) What is the radiation level encountered by undergoing a chest x-ray? (2) iv) What is the radiation level encountered by undergoing a chest CT scan? (2) [25] a) Discuss the use of non-invasive ventilation in the emergency department. b) Define the following as related to mechanical ventilation i) Synchronised intermittent mandatory ventilation. ii) Volume-controlled ventilation. iii) Pressure-controlled ventilation. iv) Controlled manual ventilation. v) Pressure support. c) Discuss the indications, dose, contra-indications and side-effects of tranexamic acid. (8) (2) (2) (2) (2) (2) (7) [25]

a) A 45-year-old male patient presents with epigastric pain of 2 days duration i) Discuss in detail laboratory tests available for the diagnosis of pancreatitis. Include in your answer approximate sensitivities and specificities of each, what may cause false positive results, as well as the period in which a positive result would be found. (9)

ii) The patient has a gastroscopy and is found to have a peptic ulcer. List the pharmacological treatment options available for the management of this patient. For each type of drug, explain its mechanism of action and rationale for use. (12) b) Write short notes on the iliotibial band syndrome. (4) [25] 5 a) A 24 year old, 32-week pregnant patient presents to your emergency department having overdosed on her iron tablets. i) Approximately what dose of elemental iron is associated with toxicity and morbidity or mortality when taken as a single ingestion? (2) ii) Discuss the investigations available to estimate the severity of overdose. Include in your answer any limitations to their use when managing this patient. (10) iii) Discuss the detailed management of this patient. Include in your discussion the indications for antidote administration and its dose. (9) iv) On further questioning, she admits to her reason for overdose being a physical altercation with her boyfriend. She is rhesus negative. Discuss the use of Rho(D) Immune Globulin treatment (RhoGAM) in this patient as well as any blood tests that may help you manage this patients potential Rhesus problem. (4) [25] a) Write short notes on the clinical recognition, electrocardiographic findings (if any) and specific emergency management of the following i) Malignant hypercalcaemia due to multiple myeloma. (5) ii) Hypermagnesaemia due to antacid overdose. (5) iii) Hypovolaemic hypernatraemia. (5) iv) Hypophosphataemia. (5) b) Discuss the role of 3% hypertonic saline in the emergency department. (5) [25]