NUSH’s EMED REVISION VERBATIM

Question 1: When performing ETT in a patient with severe head injury:

a) RSI is a process whereby sedative agents are administered in large doses to achieve and maintain unconsciousness
False because we want to secure the airway (but patient isn’t in cardiac arrest if not it would be a crash arrest; in RSI you cannot ventilate the patient satisfactorily. In RSI,
we use small, titrated doses not GA.
- RSI small weight adjusted doses, not large doses administered
- Pre-oxygenation: high flow O2 NRM, BVM, BVM with +ve pressure ventilation à done by leaving a nasal prong on the entire procedure at 6L even when bagging
(apneic ventilation) even when baggingà a normal patient can maintain O2 sat for at least 8 minutes before it starts to drop to <90%. So if you push up before ETT,
even if you have difficulty, you have a buffer of 8 minutes.
- Starting: if patient O2 >95%, pre-oxygenation can be 2-3 mins of non-rebreather mask. If patient cannot maintain through non-re-breather, can put a bag-valve mask
(ambu bag) without squeezing à can achieve a tight seal. If the patient really cannot maintain, you need to ventilate the patient with Ambu bag and PPV.
-
b) Atropine 0.01-0.02 mg/kg BW is indicated in Paediatric patients <6 years as pre-treatment
- lignocaine
True. Not used on a routine basis, but can be used (anti-parasympatholytic which dries up secretions, blunt
- opioids (fentanyl à analgesia, amnesia also)
the vagal response in paediatrics patients when manipulating the airway). Not used routinely in adults. In
- atropine (dry up secretions)
Paeds, now normally used for babies <1 year of age.
- de-fasciculating dose of non-depolarizing agent (if
patient has NM disease, hyperkalemia, muscle
Pre-treatment: Pre-oxygenate, lignocaine and atropine à trying to make the situation as favourable as
breakdown à rocornoium etc the defasciculating dose is
possible (secretions, raised ICP). Commonly used drugs are LOAD:
10% of the usual dose that you would give to decrease
Paralysis of the patient
fasciculations)
Crash intubation à intubate without drugs as patient alr apneic
 
c) Lignocaine IV (1.5 mg/kg BW) is sometimes given before intubation to lower raised ICP
We do use lignocaine, and it has been shown to lower raised ICP. E.g: right pupil blown, intracranial bleed à acceptable to pre-treat with lignocaine; decreases HR and
MAP as well as ICP (just like atropine, it is a pre-treatment before the paralytic agent).
- Prevents raise in ICP associated with laryngeal stimulation

d) Suspicion of C spine injury is an indication for Nasotracheal intubation

Look à retracted mandible, subcutaneous emphysema, short neck big tongue
Epidural haematoma GCS<8, suspect C-spine injury without X-ray. If a patient has a neck
injury, can intubate but must use manual in-line immobilization with the help of an assistant. Evaluate à 3 fingers between teeth (inter alveolar), hyomental (3 fingers), 2
This will prevent you from unnecessarily flexing the neck. fingers (thyrohyoid)
Mallampati à can use a tongue depressor and quickly look in. (1- can see clear
Don’t put in a nasotracheal tube in a head injury cos if it’s a base of skull fracture à if the beyond uvula, 2- uvula touching posterior part of tongue, 3- base of tongue, 4-
cribiform plate is fractured, the tube potentially may go into the brain. Used mainly in short can’t see beyond posterior pharynx)
procedures, patients are usually semi-conscious. Obstruction: loose teeth, dentures, bilateral mandibular-rami fracture (tongue
Additionlly, nasotracheal intubation is a BLIND PROCEDURE and must assume it’s above looses support), stridor (15% of airway left à just secure airway any way you can!),
vocal cords. blunt trauma to neck (say cannot swallow saliva), hot potato voice
Neck mobility à neck surgery, Ankylosing spondilitis
e) Vercuronium IV (0.05-0.1 mg/kg BW) can be used to maintain paralysis and relaxation after
intubation
True. Not used because we have better and safer drugs; still available overseas. It is a non-depolarizing, long-acting muscle relaxing paralytic agent. We can give
propofol, fentanyl as analgesia, benzodiazepines to maintain.
- Prolonged paralysis
- Other drugs: atracurium, rocuronium (used in hyperkalemia cos won’t cause hyperK unlike succ, less fasciculation than succ à only downside is that you must use
oxygenation for longer)
- Induction agents: Propofol, ethomidate, ketamine, midazolam (drops BP)
NUSH’s EMED REVISION VERBATIM

Question Two: A car driver is brought to the ED after sustaining obvious chest trauma in a high-speed road traffic accident. BP is 75/62 mmHg, HR 131/min and RR 27/min with an O2
saturation of 81% on 100% )2 via a non-rebreather mask
Summary: this patient is in shock.

a) Fluid resuscitation using 1L of a crystalloid solution like lactated ringers solution should be commenced
Hypovolemic shock as initial diagnosis/ obstructive shock cos of tension pneumothorax or cardiac tamponade
Yes: first line is crystalloids. But now can have permissive hypotension.
No evidence that one crystalloid is better than the others. In a severely shocked patient with metabolic acidosis may want to switch to normal saline.
Do not use colloids as a first line treatment à 1) cost 2) we can get to bloods much easier but it won’t kill the patient to give colloids
Crystalloids à colloids à bloods

b) The patient should be intubated immediately because of severe hypoxia

False in this question à we haven’t ruled out a tension pneumothorax. May be the cause of the patient’s hypoxemia! If not get PEA
Chest trauma with shock: intubation before needle decompression can convert simple to tension pneumothorax, or worsen a pre-existing tension pneumothorax!

c) Skull, cervical spine, chest and abdo X-rays should be done after intial stabilization of the patient
Routine series: skull has no use! Abodominal X-ray has no use.
Do lateral C-spine, chest and pelvis instead

d) A flail segment in the chest wall is detected clinically by paradoxical movement of the abdominal wall  
The whole segment is flailed à can be detected clinically by paradoxical movement of the chest wall (not abdominal
wall!)
Flail segments of fracture of 2 or more continuous ribs at 2 or more sites.
Expires à flail segment balloons out
WHAT TO DO IN A FLAIL SEGMENT: treat underlying injury

e) If cardiac tamponade is suspected a pericardiocentesis is indicated because as little as 15 ml of blood can cause
haemodynamic compromise.
You need rapid accumulation of 100-150 mls à cardiac tamponade can occur but NOT with 15 mls!
Normally we already have 20-50 mls

Question 3: 21 year old girl seen 2 hours after consuming 32 tablets of 500 mg Paracetamol

a) Although she has not taken a toxic dose, empirical N-acetyl cysteine therapy should be commenced
- Should be commenced BUT she has taken a toxic dose!
- N-acetylcysteine is relatively safe so even if she dramas and lies that she took 32 rather than 5, if the history suggests a potential toxic overdose, can still treat àstart
NAC. Do liver function, PT INR, Paracetamol level (using the Rumack-Matthew normogram after 4 hours, but even after 2 hours we will take the Paracet level)
- NAC can cause anaphalactoid reaction: peri-orbital edema, rashes, wheezing etc à just slow down infusion, it won’t kill them
- NAC is IV: 1st dose is 150 mg/kgBW diluted in 200mls 5% dextrose run over 15 minutes. 2nd dose is 50mg/kgBW in 500 ml 5% dextrose over 4 hours. Last dse is 100mg/kgBW
diluted in 1L 5% dextrose run over 16 hours.
- Toxic dose is 140 mg/kg BW
140 mg x 50 kg = 7.0 gm (14 tablets) à she has taken 16g!
NUSH’s EMED REVISION VERBATIM

b) Activated charcoal 50 g should be administered

- 1g/ kg body weight
- Best given within 1 hour of ingestion, in large toxic dose can give within 4 hours (since gastric emptying takes 4 hour)
- In this patient, no point doing gastric lavage à 1 hour is the cut-off
- Contraindications to activated charcoal: ileus, iron, lithium, heavy metals, acid and alkali à later patient puke

c) N-acetyl cysteine works by helping to promote free radical propagation (NAPQI)

- False! NAPQI is what causes liver failure
MODES OF EXCRETION:
- NAC acts as gluthathione to handle NAPQI
- Glucoronidation
- NAC prevents further NAPQI formation, not propagate it’s formation
- Sulphation
- acts as a gluthathione precursor, increase the amount of gluthathione, substitute for gluthathione,
- NAPQI à normally handed by gluthathione (decreased in
promotes sulphation (has sulphur molecule!), increases capacity to detoxify NAPQI (may increase
sepsis, malignancy, pregnancy, cP450 inducer à all increased
microcirculation in the liver à can even give if the patient has gone into frank liver failure if presented after
risk of toxicity)
like 5 days)à therefore decrease NAPQI!
- Excreted Unchanged
 
d) The ECG is an important diagnostic tool in the evaluation of severe acetaminophen poisoning
- Won’t have cardiac toxicity

e) Renal failure is an important complication that may result

- Can get both liver and renal failure (25% of those who get liver failure from Paracet overdose will have some form of acute tubular necrosis)
- Renal tubule formation of NAPQI by cP450 in severe paracetamol overdose

Question Four: A 63-year-old female presents with fever and abdominal pain
a) Acute appendicitis is highly unlikely in view of her age
- Of course can get appendicitis
- Difference in presentation: present much more atypically/non-specifically, OR may present as a frank peritonitis from DDX:
the word GO! -­‐ Gallbladder sepsis
- Higher mortality because can have perforation -­‐ Appendicitis
- Can present with constipation/colic/UTI à have a low threshold for a CT abdomen because of the difficulty in -­‐ Pancreatitis
assessing such patients -­‐ UTI
-­‐ DKA
b) An urgent cholecystectomy may be indicated for cholecystitis -­‐ - Gangrenous bowel
- True
- Gallbladder empyema/Pneumotosis à patient obviously not reacting to abx therapy
- Not something done straight away à 24-48 hours à patient going into shock à remove infected bowel

c) A serum amylase level of 1250 IU/L is indicative of acute pancreatitis

- True!

d) If there is associated jaundice, ascending cholangitis from biliary calculi is the likely cause
- Fever, abdominal pain and jaundice = Charcot’s triad!
- Surgical jaundice!
NUSH’s EMED REVISION VERBATIM
e) A UTI is diagnosed by the presence of at lease >100 organisms/ml
- Need much more than that! If not every female will have UTI!
- Need about 100,000 WBC!

Question Five: A 54-year-old male presents with AF

a) Atrial fibrillation is characterized by the presence of P waves of multiple morphologies

- NO P WAVES FULL STOP!
- Fibrillatory baseline
- P waves of multiple morphologies: multifocal atrial tachycardia à P waves of 3 or more morphologies

b) IV Verapamil 1 mg/3 min can be used to control rapid heart rate

- Slow down the ventricular response wait à give as an infusion to a maximum of 30mg
- Controlling rate not so much rhythm
- IV diltiazem 2.5 mg/3 min: max of 50 mg
- IV amiodarone 150 mg x 20 minutes, repeat if HR>100
- STABLE PATIENTS, no contraindications such as poor EF, hypotensive, in frank heart failure
- If in heart failure à IV amiodarone (slower à 300 mg x40 mins), IV digoxin 0.5 mg/30min
- If digoxin doesn’t work, not working fast enough, recent 2D echo was done over the past month and shows that there is no thrombus à can give amiadorone (if not
risk of mural thrombus in the left atrium)

c) If the patient is unstable with chronic AF, IV heparin should be commenced first followed by cardioversion within 24 hours
- Possible workflow if you going to cardiovert à semi-elective synchronized cardioversion!

d) Thyrotoxicosis is possible etiology

- Still possible

e) If left untreated, the rhythm may degenerate to ventricular fib

- No!
- AF can degenerate to precipitating reduce CO, cerebral hypoperfusion

Question Six: A severely asthmatic patient with possible anaphylaxis was given four repeat salbutamol nebulizations without much improvement. You are considering administering
IM Adrenaline 0.3 mg
a) It has no value in the modern treatment of acute asthma/anaphylaxis
- Has possible value in asthma, if there is a possible anaphylactic component àpush comes to shove can use
- Not what we use normally

b) It is absolutely contraindicated if the patient’s BP is 160/112 mmHg and the HR is 131/min

- false: tachycardia and hypertension could be caused by bronchospasm
- may be relieved by adrenaline! à special situation

c) If the patient is currently on B2 blockers that would make the administration of IM adrenaline much safer
- THIS IS UNSAFE!
NUSH’s EMED REVISION VERBATIM
d) It is better to administer the adrenaline intravenously
- IM is the preferred route
- Give in frank anaphylactic shock, cardiac arrest, PEA à can give IV
- If not run risk of tachyarrythmias!

e) Adrenaline can cause tachyarrythmias like ventricular fib for which it is actually contraindicated as treatment
- Doesn’t make sense
- Adrenaline lowers the threshold for more successful defibrillation

Question Seven: 18 y/o male motorcyclists is wheeled into your consultation room after complaining of severe pain, swelling and deformity in his right lower leg following a collision
with a car four hours later

a) An x-ray of the tight leg is indicated to exclude any underlying fracture

- True!

b) If the patient’s dorsalis pedis pulse is diminished and barely palpable this represents early compartment syndrome
- late sign  
- Pain out of proportion, pressure (pressà scream in pain), pallor, parasthesia à late are paralysis, perishingly cold, pulselessness (vvvv.
Late)

c) The most sensitive sign for compartment syndrome developing in this patuent is the loss of deep pain sensation
- 2 point discrimination or vibration à much more sensitive (discriminate 2 points 1.5 cm apart)
- Deep pain is a late sign!

d) Fasciotomy is the treatment of choice if the compartmental pressure is more than 35 mmHg
- relieving pressure and edema
- muscles are swollen à bulging out due to the rise in intracompartmental pressure

e) Fasciotomy is best performed after 4 hours to allow the edema to settle first
- DO NOT WAIT

Question Eight: A 41-year-old firefighter is evacuated from the scene of a devastating fire with 32% BSA burns
a) Second degree burns can be differentiated from 3rd degree burns by the presence of blistering, erythema and pain
- True

b) Respiratory burns is heralded by the appearance of stridor

- Yes. Also singing of eyelash, nasal hair
- Patient coughing out sooty sputum
- Hoarseness of voice
- Erythema/edema developing in the mouth

c) Fluid resuscitation using the parkland formula should be initiated

- 4ml Hartmann’s/ % BSA Burnt/ kg BW
NUSH’s EMED REVISION VERBATIM
- Half of fluids x 8 hours, other half over 16 hours
- Normal maintainence fluids

d) Urine output must be maintained at 10-20 mls

- 50-100 mls per hour: prevent precipitation myoglobinuria (myoglobin in renal tubules)
- As high as possible!

e) If morphine that is given for pain relief causes repsi depression, IV narcan can be administered slowly in increments
- Can give in severe burns as indication for morphine is higher
- Often such pain, not survivable à palliative

Question Nine: The causes of status epilepticus

a) Familial Hyperlipidemia à No
b) SLE à yes
c) Hypokalemia à no Sodium and calcium are the ones that cause status
d) Post hypoxic brain injury à yes - Most common are hypernatremia and Hypercalcemia!
e) Hypercalcemia à yes

Question Ten: Elderly lady bring in her 62 year old husband with insulin dependent diabetes and complains that he appears confused
a) If bedside capillary BSL 25 mmol/L, DKA is confirmed
- BSL> 250 mg/dl, Ph <7.3, bicarb < 18, Ketonuria +3, serum B-hydroxybutyrate
- confusion may be due to anything
b) HHNK are more common in insulin dependent diabetics - confusion may be due to many things!
- true

c) A bedside capillary blood sugar level of 2.6 mmols/L can explain patient’s clinical presentation
- true

d) If the bedside blood sugar level is 33 mmols/L, in addition to IV insulin therapy, an urgent CT of brain is indicated to rule out a concomitant intracranial infarct/bleed
- only if not responding, obvious neurological symptoms
- correct all endocrine abnormalities first!

e) If the patient has a bedside blood sugar level of 28 mmol/L and a pH of 7.21 and a bicarb level of 12 mmol/L on ABG analysis, 100 mls IV sodium bicarb 8.4% should be
infused as rapidly as possible
- this is DKA!
- BUT this is not indicated
- And if you have to give sodium bicarb à give it slowly

Question 11: the following are accepted drugs in the initial management of a patient with acute cardiogenic pulmonary edema?
a) IV bumetanide 2 mg à true. Loop diuretic.
b) Aspirin 300 mg PO à NOT for APOR
c) IV morphine 10 mg
d) IV nitroprusside 5 ug/kg/min
e) IV digoxin 0.5 mg slow loading dose
NUSH’s EMED REVISION VERBATIM
Question 12: A 35-year-old male is being triaged by the nurse with a fever of 6 days duration and abdominal pain on the day of consultation
a) Jaundice and diahorrea are often present with typhoid fever à nope
b) Dengue fever is associated with haemoconcentration and hepatomegaly à true
c) Malaria can cause spontaneous splenic rupture à true
d) Leukocytosis is characteristically seen in malaria à parasite so not really expected
e) Mesenteric adenitis is a possible etiology for his presentation àless likely

Question 13: A 21-year-old male presents with suddent LS chest pain and breathlessness
a) The presence of hyperresonance and decreased breath sounds on the left chest suggest a left sides pneumothorax
b) Inspiratory chest x-ray should be ordered to rule out a pneumothorax à expiratory film shows small pneumothorax better
c) A tension pneumothorax develops due to the presence of a one-way valve leading from the lung parenchyma to the pleural cavity à correct definition
d) A chest tube should be inserted in the left 5th intercostal space at the mid axillary line if there is a pneumothorax with 60% lung collapse
e) To ascertain the correct intercostal space for the insertion of the thoracotomy tube, the landmark is the sternal notch which signifies the 2nd intercostal pace on either side
à NOT sternal notch! Manubriosternal angle!

Question14: 41 year old male consruction worker has accidentally fallen from a height of 3 metres whlst working off a metal scaffolding. He complains of pain in both lower limbs
and there is no apparent head injury
a) Bilateral calcaneal fractures should be carefully excluded à yes
b) Spinal X rays should be ordered if there is a mild pain over lumbar vertebral region
- vertical fracture: calcaneum à pylon fracture (dome of talus impacts on distal tibia and then distal tibia splits) à tibial plateau fracture w dislocated knee à hip à
lumbar spine (L4/L5, T12, L1)
- vertical shearing fractures: AP pelvis (open-book)

c) Fractures in the knee region are highly characteristic of vertical impact injuries to the lower limb à true
d) If the blood pressure is 82/54 mmHg and HR is 125/min, spinal shock must be excluded
- This patiet is in haemorragic/hypovolemic shock, not spinal shock à check chest etc
- May be in neurogenic shock, but the haemorragic shock is more acutely life threatening

e) Fractures of the pelvis are unlikely if there is no direct trauma to the pelvis
- vertical shearing à can still cause trauma

Question 15: A 3 year old boy was brought in by his mother after his arm was pulled suddenly as he tripped along the pavement. The child
complains of pain in the right elbow
Pulled elbow: radial head subluxes out of the annular ligament since the radial head not well developed.

a) X-rays are indicated to rule out supracondylar fracture à no need!

b) It is common for the brachial artery to be injured in these type of injuries
c) Treatment is usually conservative for this injury à true.
d) A long elbow plaster cast is mandated for proper healing of the elbow ligaments à not needed! Ligaments will heal by
themselves
e) Forcible supination of the forearm cal relieve the child’s pain à THIS IS THE TREATMENT!  
NUSH’s EMED REVISION VERBATIM

Question 16: A 55 year old male car driver is brought in to the ER with obvious bruising and tenderness over the abdomen. His BP is 80/62 mmHg and his HR is 132/min
a) A diagnostic peritoneal lavage is mandatory à no need because we have FAST etc. But if you do a DPL and it’s positive for blood à can send to the lab to count the
number of RBC!
b) A positive DPL is indicated by the presence of more than 1000 RBC in the lavage effluent à must be 100,000 to be positive
c) Fluid resuscitation with colloids and blood followed by laparotomy is highly likely à true given the abdominal trauma with shock!
d) A CT san of the abdomen is the first radiological investigation of choice à no. we do u/s first
e) A bedside u/s of the abdomen can easily detect a large retroperitoneal haematoma à WRONG. We cannot see retroperitoneal, only intraperitoneal (retroperitoneal
needs CT abdo)

Question 17: An elderly male alcoholic presents with epigastric pain and vomiting and is in hypovolemic shock

a) Pancreatitis is a possible cause for this presentation

- Indeed

b) The grey turner sign is depicted by bruising over the umbilicus

- This is Cullen’s!
- Grey-Turner can be everywhere theoretically if there is very bad bruising à including the umbilicus!
- But both are due to seepage of blood into retroperitoneal space  

c) Serum amylase would be elevated even when serum lipase is within normal limits
- Amylase goes up and down first (3-4 days before normalizing).
- Lipase occurs early but takes about 7 days to come down: more sensitive and specific ‘i
- If amylase is elevated, lipase should be elevated too!

d) The Ranson score include measuring the pO2 on an arterial blood gas: if lower than 90 mmHg indicated
- Wrong: pO2< 60
Ranson: predictor of mortality/ severity - 0-2: minimal mortality
If haematocrit falls >10%, - 3-5: 10-20% mortality
BUN increased >1.8 mg/dl - >5: 50% mortality rate, systemic
Calcium drops <2mmol/L complications
pO2 drops <60
Base deficit >4 mEq/L à option of surgical clearance of dead and necrotic tissue!
Estimated fluid loss sequestrated >6L

e) IV Morphine 1-2 mg in incremental doses is the analgesic of choice to relieve the patient’s pain!
- Pethidine vs morphine: what is important is less impact of sphincter of Oddi à Pethidine is the analgesis of choice!
NUSH’s EMED REVISION VERBATIM
Question 18: A 22 year old male patient presents with a puncture wound over the right middle finger after accidentally sustaining an injury
by paint gun
Pain does not correspond to site and size of injury!
a) Gangrene and amputation are possible complications à if paint tracks up the fascial sheath
b) Pain in the affected finger corresponds to the size and site of injury
c) An X-ray of the affected finger is unlikely to reveal subcutaneous foreign material à pain is radio-opaque
d) Treatment of the affected finger under local anaesthesia is mandatory as soon as possible à patient must be admitted, done
under regional or even general anesthesia
e) An acute inflammatory response is the underlying pathophysiology of injury

Question 19: A 83 year old female patient slips and falls at home sustaining pain over the right hip region
a) If the right leg is shortened and internally rotated, it indicates a fracture in the neck of the femur à shortened and externally rotated!
b) A posterior dislocated in the right hip is probably and is indicated by the affected limb being flexed, adducted and internally rotated à Which elderly will fall and get a
posterior dislocation? Need a LOT OF FORCE! Though this is the correct positioning.
c) Avascular necrosis of the head of the femur is associated with disruption of blood supply within the ligament teres à disruption of retinacular and capsular vessels along
neck of femur
d) An intertrochanteric fracture is usually treated conservatively by Russel’s traction for 6 weeks à never done anymore. Just do surgery (IT fracture not conservative!)
e) A long above-knee plaster cast is indicated for temporary immobilization of a fracture in the neck of femur à NOT conservative management unless patient refuses
surgery. And anyway you don’t put a cast! This is not a hip spica!!!

Question 20: A patient has been bitten by a cobra, on the right ankle
a) One of the earliest signs of significant envenomation is ptosis
- Cobra venom is a neurotoxin, oculofacial/CN involvement is possible.
- Diplopia, opthalmoplegia, ptosis!

b) A tourniquet should be placed proximal to the bite immediately on arrival in the EMD
- Do a compression bandage but not a tourniquet cos of risk to vascular status

c) Cobra venom contains mainly haemolysins

- Vipers and rattlesnakes! Not cobras.
- Limbs will swell, edema, oozing, coagulation problems
- Compartment syndrome

d) The bite wound should be incised and thoroughly cleaned with hydrogen peroxide
- Will damage wound more
- Don’t go and damage tissues by using strong cleansing agent

e) Cobra anti-venin is indicated fro serious evenomation but should be preceded by an intradermal skin test for hypersensitivity
- No need to do if clearly evenomated à systemic and local signs
- BE READY TO INTERVENE IF PATIENT BECOMES ANAPHYLACTIC à steroids etc
- but if you going to do this in a borderline situation when you don’t know if patient really envenomated and you’re scared patient will die of anaphylaxis à PROF
SURESH STATES THAT THIS IS CONTROVERSIAL.
- Works like a mantoux test!