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

Final Examination for the Fellowship of the College of Emergency Medicine of South Africa 20 August 2012 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)

Question 1: Please note, for question 1: The complete PAEDIATRIC SATS CHART is attached as APPENDIX A. 1.1 You are the consultant in charge of the triage section of your emergency centre (EC). Look at the table of the Triage Early Warning Score (TEWS) used for younger children. Bear in mind that the higher the score the more urgent the triage category assigned to the child.

1.1.1. For a baby of 6-months-old a) b) c) Do you agree with the normal range given for the respiratory rate (RR)? Motivate your answer. (3) Do you agree with the normal range given for heart rate (HR)? Motivate your answer. (3) Write short notes on the limitations of triage systems and how these can be addressed with your triage staff. (4)

3 Explain what is meant with the following triage errors and explain the implicatons of each a) Overtriage. What would the SATS triage category be of a 2-year-old boy who ingested his mothers antidepressive tablets? He has normal mobility. On examination you find that his penile foreskin is red. warm and swollen a) What is the most likely diagnosis? (2) b) How should this condition be managed? (2) c) Would a circumcision be indicated? (1) [25] 1.2 2. RR = 35. The hospital clinical manager requests help with designing a hospital resuscitation policy for in-hospital ward patients and all patients presenting to the emergency centre.2 Describe what legal mandates you would wish to consult in drafting the policy. (2) 1.3 Question 2: A 90-year-old lady presents to your emergency centre with Pneumonia.1. 2. (7) .1.4 Question 3: You are a leading consultant in emergency medicine and regularly work well together with specialists in other clinical disciplines in a major tertiary academic hospital. (3) 2. The parents request that you to explain the cause of the disease to them. 3.2. (4) Describe what ethical issues may be of concern in designing the resuscitation policy.1 Describe a scoring system for rating the severity of pneumonia and describe the management of each category. (2) 1. (4) [25] 2. (2) b) Undertriage. She is confused and hypoxic. a) How would you describe the genetic basis of sickle cell disease to the parents? (2) b) What is the aetiology of an aplastic crisis? (2) A 2-year-old boy present to your emergency centre. (8) List 3 common pathogenic organisms for community acquired pneumonia.2 You are treating a child with a sickle cell crisis in your emergency centre. Her family states that she requires assistance for all ADLs (Activities of daily living). 3.1. Temp = 36.3 Discuss your approach to end-of-life care and decision making with the patient and family (10) Write short notes on Advanced Directives (living wills). Motivate your answer. His parents complain that the child in crying when he passes urine. AVPU = P. HR = 125.1.

3 4. indicate reasons for each. (10) Discuss the use of urinary alkanisation of relevance to emergency medicine.4 4.1 5. (10) Discuss non traumatic rhabdomyolysis under the headings: aetiology.2 4.5 What does the abbreviation EFAST stand for? What probe is commonly used for EFAST? List the areas that are examined during the EFAST assessment? What is the clinical significance of a positive EFAST scan in trauma? (2) (2) (5) (2) What is the next step in a stable blunt abdominal trauma patient with a positive EFAST? (4) Discuss the sensitivity and specificity of the EFAST in blunt abdominal trauma? List 10 other uses for ultrasound for emergency medicine (5) (5) [25] 4. It is not responsive to NSAIDs and steroids prescribed by her general practitioner. 5. (10) Describe the LeFort classification system for midface fracture.1 4. He complains of decreased vision in his left eye. save for tenderness and swelling of both thighs with limitation of passive knee and hip flexion and extension.3 3.3. detailing what resources you would wish to include and a list of patient categories that the resuscitation policy would address. (8) [25] . and management strategies.1 6. of two days duration. His left eye is swollen shut and he is tender over his left zygoma.3 Discuss the potential causes of vision loss in this patient and how you would diagnose these.4 Outline a draft resuscitation policy.2 List 5 potential causes of this patient’s problem and for each cause one specific test to rule out and one test to confirm the diagnosis. (7) Write short notes on the pharmacological management of acute glaucoma including drug indications and dosages.7 Question 5: A 23-year-old female patient presents to the emergency centre complaining of pain and swelling of her thighs. (7) Write short notes on determining “brain stem death” and “certifying death” (7) [25] Question 4: Emergency Ultrasound is a useful diagnostic tool in the emergency centre. 4. (5) [25] 5.3 Question 6: A 27-year-old presents after being punched in the face. Her vital signs are normal and physical examination is unremarkable. She is otherwise healthy and uses an oestrogen contraceptive for family planning.2 6. 6. diagnosis. She reports travelling over 300km to your emergency centre in a taxi and had undertaken vigorous exercise at a gymnasium recently.6 4. associated abnormalities and complications.


2-95.3) 190 (50.9) disease/asthma 42 (11. In table 1 of the research publication the demographics and characteristics of study participants in the adrenalin and vasopressin groups are compared.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 21 August 2012 Paper 2 (3 hours) All questions are to be answered. Vasopressin n = 353 group.2) 121 (32. Variables: Adrenaline group.5 1.22 0.4) Diabetes mellitus Chronic obstructive pulmonary 27 (7.2) Age (years).3 1.4) 30 (8.8) Hypertension 26 (7.0) 288 (77.0) Chronic renal failure 25 (7.6 (14.75 0.9) Medical history.22 1.g.4) Cerebrovascular accident.2 1. median (range) 66. See the extract from the table below: Table 1: Demographics and characteristics of study participants.9 (15. (3) . n = 374 Age (years).09 0. Null Hypothesis.15 0.9) 39 (10.0) Cancer p – Value: 0.5) Hyperlipidemia 167 (47. the Adrenaline group) (2) What was the total number of patients that was involved in this study? (1) What does SD stand for and what is it used for? (2) What was the age of the eldest patient in the Vasopressin group? (1) Explain the following terms: p – value.6 – 99.1 1.4 1. mean (SD) 64. double-blind.02 0.3) 65.1) 30 (8.4 (25.1) 134 (36.9) 73 (19. multi-centre trial comparing vasopressin and adrenaline in patients with cardiac arrest presenting to or in the emergency centre.22 0.23 0.15 0. was carried out by Ong et al.7) 37 (9.3 (14.0) With medical history Ischaemic heart disease/other 131 (37. Alternative Hypothesis.8) evident structural heart disease 110 (31.16 0.6 How should one calculate the mean age of a group of patients? (2) How should one determine the median age of an uneven number of patients (e. n (%) 247 (70.4) 64. 88 (24. Each question to be answered in a separate book (or books if more than one is required for the one answer) Question 1 A randomised.

Indicate which of the above study designs are best used to identify aetiology and risk factors for a disease. a) List 5 other radiological features suggestive of Aortic Dissection (5) b) In the form of a table.3 Discuss the classification of open fractures. using a flow chat or table.2 2. List 3 ways to stabilise an unstable pelvic fracture in an emergency centre.1 You arrive as the first responder on the scene of a bus accident involving 2 additional motor vehicles. list the sensitivity.7 1. d) Hangmans. b) Colles. the system of triage you would initially use in a mass casualty incident with limited resources. (3) Explain the following research study designs a) Case-control studies. and which are best used to evaluate treatment.1 A 70-year-old man presents with chest pain.9 How do you interpret the p-value for Cancer? Does this mean that the null hypothesis should be accepted or rejected for this characteristic? (3) Are there any of the characteristics where there is a statistically significant difference between the two groups? Motivate your answer. c) Jones.8 1. Describe the essential components of communicating this incident to the emergency medical services control centre. (10) 4. (8) c) How would you manage this patient.3 Question 3 3. Also state whether they are prospective or retrospective in design.1.2 4. (6) [25] 3. His chest x-ray demonstrates a widened mediastinum. if his vital signs are BP 190/110 and HR 90? (6) Write short notes on the pathophysiology and causes of methaemoglobinaemia. specificity and contraindications of the special investigations available to confirm the diagnosis of Aortic Dissection. (12) (3) [25] Question 5 . (9) [25] 2. e) Bennetts. b) Cohort studies. c) Controlled trials with crossover design. (8) [25] Question 2 2. (8) How would you prepare a safe landing zone for the emergency response helicopter? (8) Describe.2 Question 4 4.1 Write short notes on the following fractures/dislocations a) Monteggia.

specifying the dosing schedule for each indication.1 Discuss the concept of damage control resuscitation under the following headings a) Permissive hypotension. and indicate the antidotes to the poisons given below 6. (4) c) Blood and coagulation factor based resuscitation strategy.3. including the following a) Case fatality rate vs. . (4) e) Tranexamic acid. b) Ischemia Modified Albumin. renal and general. mortality rate. (2) d) Cryoprecipitate and Recombinant factor VIIA. cardiovascular. including ECG findings where appropriate.2 (3) (3) [25] Question 6 6. Write short notes on rabies. 5.5.(5) b) List contraindications against the use of bicarbonate in emergency medicine. (3) b) Isotonic crystalloids vs.1 Sodium Bicarbonate is a commonly used drug in the emergency centre.2 Table: Poisons and antidotes Poison: Paracetamol Bleech Cyanide Datura stramonium (Jimson weed) Carbamates Antidote: (5) 6. precautions and adverse effects for using sodium bicarbonate in emergency medicine. gastrointestinal. (5) c) List signs of hypokalemia. (2) Copy the table. hypertonic saline. under the following headings: neurologic. a) List indications. (9) Write short notes on the following cardiac biomarkers a) Pro BNP. b) Prophylaxis c) Virology (2) (2) (1) [25] .