ACEM Fellowship examination 2015 and beyond…

buzz lightyearThe first Fellowship examination next year introduces several new assessment tools; these are extended matching questions (EMQs), and revamped SAQs and SCEs. The details of these are gradually being released, but so far  just outlines and a few sample questions. These changes mandate that candidates and their coaches adopt a new approach to FE preparation, and most sites (including this one) and trainers will predominantly have examination materials that reflect the current examination written formats.  These aren’t totally useless to review and use as the required body of knowledge to be assessed hasn’t changed, but I am advising the candidates in my group to practise in the new formats exclusively from now.

The first half of the written examination will be a 180 minutes of MCQs and EMQs, (numbers of each yet to be announced), and this is likely to not be too time pressured. All prospective candidates should practise examples of both MCQs – many of the former are available on this site and others, but the latter are harder to find as they’re basically being written now. I’ll be progressively posting those that are written in our group, and I’ll outline below where others can be found.

In regard to the new SAQs, it has been confirmed that the initial format for the 2015.1 FE paper will be 180 minutes, 30 questions x 6 minutes, all equally weighted for marking. (DEMT forum by Chair FEC) There will be a variety of topic areas examined, and the number of questions within each individual question will range from 3 to 5 (as per the ACEM website examples), depending on complexity. This will be a very difficult written examination to complete in 180 minutes, and the format places a massive premium on sticking to time and moving on each 6 minutes. That being said, it will not be likely that many (? any) questions will require answers in depth or complex calculations, so I think this signals a change in the written examination to more breadth than depth.

This site will progressively change over the next six months with old material being updated and new material added. I’ll be leaving the weeks of the tutorial programme arranged in broad topic areas as in the old curriculum, as this seems to me as good as any other model for now.

Many other hospital EDs, coaches and sites will also be publishing new material. Two others I am aware of so far, and can recommend are:

a) Improving care in ED  (Auckland)  and

b) Medinuggets  (Melbourne)

Many more will emerge in the next six months, so share their links around widely to help all the candidates and their coaches in the lead up to the 2015.1 FE.

ACEM logo

ICE 015

A 22 year old woman with a past history of a seizure disorder presents to the ED with a 3 day history of progressive rash and fever. The rash began as macules and papules on the chest and neck and has now become blistered and eroded and involves the mouth and eyes. Her temperature is 390C and she feels miserable

 

Stevens Johnson Syndrome

 

Describe the features of the rash

  • What is the likely diagnosis ?
  • Suggest possible underlying aetiologies
  • How should this patient be managed?

 

The rash is widespread and in many forms (blisters, vesicles, erosions macules and papules). There is definite involvement of the oral mucosa and we are told that the eyes are involved as well. Although not seen, it is fair to assume up to 20% of body surface area is involved.

This is likely to be Stevens-Johnson Syndrome (previously known as erythema multiforme “many-forms” major) a disease with an immunological basis, on an overlapping continuum from the mild form (erythema multiforme) to the most severe (toxic epidermal necrolysis).

The common causes of these syndromes are:

Drugs – antibiotics esp sulphonamides, antiepileptics, NSAIDs, allopurinol

Infections – mycoplasma, herpes simplex, HIV

Haematological malignancies – lymphoma, leukaemia

The severe forms are often caused by drugs and can be life threatening.

Immediately stop any potential causative drugs.

This patient should definitely be admitted to hospital and preferably under the care of a dermatologist. If the disease becomes more severe or progressive care in a burns unit is required. The ED treatment is largely that of burns: dressings, pain relief, volume replacement and temperature maintenance.

 

More information:

Dermnet.nz

Whonamedit

 

Thanks to NEJM.org for use of image

 ICE Ian's Clinical Emergencies

RSR 003

 

Surf’s up!!  Time to enjoy another literature surf from Associate Professor Michael Ragg.
Check out his take on the studies below, and the abstract summary RSR 003

 

surfing at torquay

 

 

 

 

 

 

 

3waveHigh versus Low Blood-Pressure Target in Patients with Septic Shock [1]

My take is that we don’t need to chase a higher MAP on patients in septic shock, as those with a MAP of 65-70 did just as well from a mortality & serious adverse events point of view.

3wave

Mortality Related to Severe Sepsis in Australia and NZ, 2000-2012  [2]

Important paper showing mortality from severe sepsis & septic shock in Australia and NZ has reduced from 35% to 18% over the last 12 years. Mortality <5.

3waveDipstick Screening for Urinary Tract Infection in Febrile Infants [3]

So in a nutshell, urine dipstick had a NPV of 98.7% for UTIs and PPV of only 66.8%. Clinically, good for ruling out UTIs but not so good for ruling in. So a completely clear dipstick urine may be helpful in excluding the diagnosis

3wave
Transradial Coronary Catheterization and Intervention, Allen Test Results [4]

So in this study of 942 patients undergoing radial artery catheterization, the Allen’s test essentially made no difference and there were no hand ischaemic complications. Has not proved it but certainly is suggesting we need more research to prove whether doing an Allen’s Test is a waste of time

3wave
Time to epinephrine after in-hospital arrest with non-shockable rhythms [5]

So in 25,000 odd patients who had in-hospital cardiac arrest, the longer the delay to the first dose of adrenaline, the worse the outcome. Getting adrenaline earlier improved ROSC, survival in hospital and neurologically intact survival.

 

2waveFibrinolysis for Patients with Intermediate-Risk Pulmonary Embolism   [6]

2waveTime to Ambulance-Based Thrombolysis in Acute Ischemic Stroke [7]

2waveLorazepam vs Diazepam for Pediatric Status Epilepticus [8]

2waveAblation vs Antiarrhythmic Drugs for AF (RAAFT-2) [9]

2waveRV Dilatation on Bedside Echo Performed by EPs aids Diagnosis of PE [10]

2waveSystolic BP and outcome in adults with out-of-hospital cardiac arrest [11]

2wave8.0-cm needle at 4th AAL for tension pneumothorax [12]

 

1waveComparison of new oral anticoagulants with warfarin in patients with AF [13]

1waveAlbumin Replacement in Patients with Severe Sepsis or Septic Shock  [14]

1waveDoor-to-Needle Times for TPA, and Outcomes in Acute Ischemic Stroke [15]

1waveRF Ablation vs Endoscopic Surveillance for Barrett Esophagus [16]

1waveSternotomy or Drainage for a Hemopericardium After Penetrating Trauma  [17]

1waveEfficacy of ultrasound-guided radial artery catheterization [18]

1waveUltrasonography/MRI Versus CT for Diagnosing Appendicitis  [19]

1waveMajor Bleeding in Patients With AF Receiving Apixaban or Warfarin [20]

1waveThe Use of Digoxin in Patients With Worsening Chronic Heart Failure [21]

 

References

  1. Asfar P. et al, High versus Low Blood-Pressure Target in Patients with Septic Shock.
    N Engl J Med 2014; 370:1583-1593 April 24, 2014DOI: 10.1056/NEJMoa1312173
  2. Kaukonen K-M et al, Mortality Related to Severe Sepsis and Septic Shock Among Critically Ill Patients in Australia and New Zealand. 2000-2012JAMA. 2014;311(13):1308-1316. doi:10.1001/jama.2014.2637.
  3. Glissmeyer EW et al, Dipstick Screening for Urinary Tract Infection in Febrile Infants Pediatrics.
    Vol.133,No.5,May1,2014 pp. e1121 -e1127
  4. Valmigili M et al, Transradial Coronary Catheterization and Intervention Across the Whole Spectrum of Allen Test Results.
    J Am Coll Cardiol. 2014;63(18):1833-1841. doi:10.1016/j.jacc.2013.12.043
  5. Donnino MW et al, Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry.
    BMJ
    2014; 348 doi: http://dx.doi.org/10.1136/bmj.g3028
  6. Meyer g et al, Fibrinolysis for Patients with Intermediate-Risk Pulmonary Embolism.
    N Engl J Med 2014; 370:1402-1411 April 10, 2014DOI: 10.1056/NEJMoa1302097
  7. Ebinger M et al, Effect of the Use of Ambulance-Based Thrombolysis on Time to Thrombolysis in Acute Ischemic Stroke: A Randomized Clinical Trial
    JAMA. 2014;311(16):1622-1631. doi:10.1001/jama.2014.2850
  8. Chamberlain JM et al, Lorazepam vs Diazepam for Pediatric Status Epilepticus.
    JAMA. 2014;311(16):1652-1660. doi:10.1001/jama.2014.2625.
  9. Morillo CA et al, Radiofrequency Ablation vs Antiarrhythmic Drugs as First-Line Treatment of Paroxysmal Atrial Fibrillation (RAAFT-2): A Randomized Trial.
    JAMA. 2014;311(7):692-700. doi:10.1001/jama.2014.467
  10. Dresden S et al, Right Ventricular Dilatation on Bedside Echocardiography Performed by Emergency Physicians Aids in the Diagnosis of Pulmonary Embolism.
    Ann Emerg Med. 2014 Jan;63(1):16-24. doi: 10.1016/j.annemergmed.2013.08.016. Epub 2013 Sep 27. PubMed PMID: 24075286
  11. Bray JE et al, The association between systolic blood pressure on arrival at hospital and outcome in adults surviving from out-of-hospital cardiac arrests of presumed cardiac aetiology.
    Resuscitation. 2014 Apr;85(4):509-15. doi: 10.1016/j.resuscitation.2013.12.005
  12. Change SJ et al, Evaluation of 8.0-cm needle at the fourth anterior axillary line for needle chest decompression of tension pneumothorax.
    J Trauma Acute Care Surg. 2014 Apr;76(4):1029-34
  13. Ruff CT et al,  Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials.
    The Lancet, Volume 383, Issue 9921, Pages 955 – 962, 15 March
  14. Caironi P et al, Albumin Replacement in Patients with Severe Sepsis or Septic Shock.
    N Engl J Med 2014; 370:1412-1421April 10, 2014DOI: 10.1056/NEJMoa1305727
  15. Door-to-Needle Times for Tissue Plasminogen Activator Administration and Clinical Outcomes in Acute Ischemic Stroke Before and After a Quality Improvement Initiative.
    JAMA. 2014;311(16):1632-1640. doi:10.1001/jama.2014.3203
  16. Nadine Phoa K et al, Radiofrequency Ablation vs Endoscopic Surveillance for Patients With Barrett Esophagus and Low-Grade Dysplasia : A Randomized Clinical Trial.
    JAMA. 2014;311(12):1209-1217. doi:10.1001/jama.2014.2511
  17. Nicol A et al, Sternotomy or Drainage for a Hemopericardium After Penetrating Trauma: A Randomized Controlled Trial.
    Annals of Surgery: March 2014 – Volume 259 – Issue 3 – p 438–442
  18. Wan-Jie Gu et al, Efficacy of ultrasound-guided radial artery catheterization: a systematic review and meta-analysis of randomized controlled trials.
    Critical Care 2014, 18:R93  doi:10.1186/cc13862
  19. Aspelund G et al,  Ultrasonography/MRI Versus CT for Diagnosing Appendicitis
    Published online March 3, 2014  doi: 10.1542/peds.2013-2128
  20. Hylek EM et al, Major Bleeding in Patients With Atrial Fibrillation Receiving Apixaban or Warfarin The ARISTOTLE Trial.
    J Am Coll Cardiol. 2014;63(20):2141-2147. doi:10.1016/j.jacc.2014.02.549
  21. Ambrosy AP et al, The Use of Digoxin in Patients With Worsening Chronic Heart Failure. Reconsidering an Old Drug to Reduce Hospital Admissions.
    J Am Coll Cardiol. 2014;63(18):1823-1832. doi:10.1016/j.jacc.2014.01.051 

 

 

Orthopaedic SAQ

A new style of SAQ is to appear in 2015 in the written ACEM Fellowship examination.

Here’s an example of how this kind of SAQ might look, based upon the few appearing under the tab “2015 onwards”on the ACEM website so far. Bear in mind that ACEM is still to release details about this new written assessment modality especially its final format in terms of numbers, types and scope. Currently it states “up to 30 questions in 180 minutes”

A 68 year old man is brought to your ED by ambulance with left leg pain after sustaining a fall at a nearby rehabilitation hospital two hours earlier. He is an inpatient there for rehabilitation after surgery on a fractured left femur sustained in a fall in his home two months earlier.

 On arrival, he is alert with normal vital signs, and an Xray is performed

femur 3

1. What is your interpretation of his Xray?

This Xray of the distal left femur and knee joint demonstrates a comminuted fracture of the distal femur and broken metal plate midway through its length. There is some evidence of callus medially but fracture lines look new or un-united. Comparison with the previous films is important to clarify this. The distal component of the fracture is slightly angulated medially relative to the proximal femoral shaft. The knee appears osteoarthritic with narrowed joint space, and there appears to be some soft tissue swelling? haematoma.

 Interpretation: this is a major complication/re-fracture of a recently ORIF-ed femoral fracture with metal plate failure. He requires urgent admission and revision of the procedure, likely with use of an intramedullary rod.

 2. Describe five methods of analgesia appropriate in this setting

  1. Intravenous titrated opiate analgesia, eg Morphine 2.5 mg increments
  2. Femoral nerve blockade with Ropivacaine +/- ongoing infusion
  3. Oral analgesics eg Paracetamol and Oxycodone
  4. Inhaled Nitrous oxide, eg during splint or traction application
  5. Splintage and elevation, eg Zimmer splint or distal traction to limit movement

 

3. List four additional management priorities in this man

 

  1. Full secondary trauma survey to detect other injuries from this fall, especially head and spine.  ? head strike/LOC/neck or spinal pain
  2. Urgent Orthopaedic review for planning of operative approach. Keep fasted with maintenance fluids until timing of this known. Consent to be obtained by Orthopaedic team.
  3. Seek and treat medical precipitants for multiple falls, eg arrhythmia, sepsis, metabolic, and medication related. Will require at least ECG, blood tests, CXR, and referral to physicians for pre-operative assessment
  4. Explanation to patient and family. Notify Rehabilitation hospital of admission.

 

ICE 014

A 24 year old woman presents to ED with a 12 hour history of shortness of breath and left sided pleuritic chest pain. She has no significant past medical history and is on no regular medications. Her vital signs are normal.

  • Describe and interpret her chest X-Ray
  • What treatment is required ?
  • What follow up management and advice is needed ?

CXR

The CXR shows a large left sided pneumothorax. The rim of lung is visible about 3cm from the chest wall at the lung apex and 2cm from the mid/upper zone laterally. There is no obvious underlying lung abnormality or chest wall trauma, and no displacement of midline structures that can indicate tension. Estimating pneumothorax size is well known to be difficult, with only broad estimates generally possible unless volume is formally measured with a CT scan (and this isn’t usually needed). As a rule, if the lung rim is only visible at the apex it is small (< 2 cm), if visible and larger than this it is large or complete.

The most appropriate management for spontaneous pneumothoraces of this size (and indeed of any size) is an area that generates substantial debate. Opinions will range from just observe and await spontaneous resolution at one extreme to insertion of a large bore intercostal catheter connected to underwater seal drainage at the other extreme. Unfortunately the evidence on which to base treatment for spontaneous pneumothorax is weak. What is clear is that needle aspiration and small intercostal catheters can be effective and the only absolute indications for drainage are significant underlying lung disease or respiratory compromise.

A follow up CXR (timed to document expected complete re-inflation) is useful. Consider issues like flying, diving and advice re smoking cessation.

More information:

Pleural disease 2010 pneumothorax

Life in the Fast Lane

 ICE Ian's Clinical Emergencies

RSR 002

 

Here’s the latest literature surf from Associate Professor Michael Ragg.
Check out his take on the studies below, and the PDF summary RSR 002

tahiti surf

3waveEarly cardiac cath improved survival in cardiac arrest without STEMI [1]

I have given this paper published in Resuscitation ‘3 waves’  as it supports our push to get these patients to the cath lab even if the ECG does not show a STEMI. An impressive reduction in the risk of death.

3waveEndovascular or open repair for ruptured AAA: outcomes from IMPROVE [2]

So basically in 613 patients in 30 different vascular units, there were no statistically significant differences between endovascular and open management of ruptured AAAs in terms of 30 day mortality.

3waveTargeted Temperature Management at 33 C versus 36 C after Cardiac Arrest [3]

A potential game changer ?  Why are we cooling patients? Or is it saying just don’t let them get warm ( > 37.5C). Most definitely worth a read, my take is to continue doing what we do now and await expert consensus. There has been much discussion about this paper in relation to the clinically relevant benefit of preventing the development of fever as well the impact of healthcare workers not being blinded during the study.

2waveUltrasonography by emergency physicians for proximal lower extremity DVT   [4]

2wavePrehospital Mild Hypothermia on Survival of Adults With Cardiac Arrest    [5]

2waveMeta-analysis of myocardial infarction from oral direct thrombin inhibitors      [6]

2waveSaline Versus Plasma-Lyte A in Initial Resuscitation of Trauma Patients      [7]

2waveLimited transthoracic echocardiogram (LTTE) as a monitoring tool in trauma      [8]

2waveInduced Hypothermia in Severe Bacterial Meningitis      [9]

2waveColloids v Crystalloids for hypovolaemic shock      [10]

1waveHyperglycemic Control in Pediatric Intensive Care [11]

1waveMechanical Compressions and Defibrillation vs CPR in Cardiac Arrest  [12]

1waveOutpatient Versus Hospital Management for Uncomplicated Diverticulitis [13]

1waveHES Reduces Coagulation and Increases Blood Loss During Major Surgery [14]

1waveChest compression depth and survival in out-of-hospital cardiac arrest  [15]

1wavePelvic fracture management with a pelvic “blush” on early CT [16]

 

 

References

1. Hollenbeck R. et al   Early cardiac catheterization is associated with improved survival in comatose survivors of cardiac arrest without STEMI. Resuscitation Volume 85, Issue 1, Pages 85-95, January 2014 doi:10.1016/j.resuscitation.2013.07.027

2. IMPROVE trial investigators Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial  BMJ 2014;348:(Published 13 January 2014) doi: http://dx.doi.org/10.1136/bmj.f7661

3. Neilsen M., et al Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest N Engl J Med 2013; 369:2197-2206 December 5 2013  DOI: 10.1056/NEJMoa1310519

4. Crowhurst T, Dunn R  Sensitivity and specificity of three-point compression ultrasonography performed by emergency physicians for proximal lower extremity deep venous thrombosis  Emergency Medicine Australasia  Volume 25, Issue 6, pages 588–596, December 2013 doi:  10.1111/1742-6723.12155

5. Kim F. et al Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurological Status Among Adults With Cardiac Arrest : A Randomized Clinical Trial  JAMA. 2014;311(1):45-52. doi:10.1001/jama.2013.282173

6.  Artang R. et al  Meta-analysis of randomized controlled trials on risk of myocardial infarction from the use of oral direct thrombin inhibitors  Am J Cardiol. 2013 Dec 15;112(12):1973-9 http://dx.doi.org/10.1016/j.amjcard.2013.08.027

7. Young et al  Saline Versus Plasma-Lyte A in Initial Resuscitation of Trauma Patients: A Randomized Trial  Annals Surg 2014 February 2014 – Volume 259 – Issue 2, doi: 10.1097/SLA.0b013e318295feba

8.  Ferrada P et al,  Findings of a randomized controlled trial using limited transthoracic echocardiogram (LTTE) as a hemodynamic monitoring tool in the trauma bay.  Journal of Trauma and Acute Care Surgery. 76(1):31-38, January 2014. doi: 10.1097/TA.0b013e3182a74ad9

9.  Mourvillier B et al   Induced Hypothermia in Severe Bacterial Meningitis: A Randomized Clinical Trial  JAMA. 2013;310(20):2174-2183  doi: 10.1001/jama.2013.280506

10.  Annane D et al, Effects of Fluid Resuscitation With Colloids vs Crystalloids on Mortality in Critically Ill Patients Presenting With Hypovolemic Shock  The CRISTAL Randomized Trial JAMA. 2013;310(17):1809-1817. doi:10.1001/jama.2013.280502

11.  MacRae D et al A Randomized Trial of Hyperglycemic Control in Pediatric Intensive Care.  N Engl J Med 2014; 370:107-118 DOI: 10.1056/NEJMoa1302564

12. Rubertsson S et al, Mechanical Chest Compressions and Simultaneous Defibrillation vs Conventional Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest : The LINC Randomized Trial  JAMA. 2014;311(1):53-61. doi:10.1001/jama.2013.282538

13  Biondo S et al  Outpatient Versus Hospitalization Management for Uncomplicated Diverticulitis: A Prospective, Multicenter Randomized Clinical Trial (DIVER Trial)  Annals surg January 2014 Vol 259, Issue 1, p 38-44 doi: 10.1097/SLA.0b013e3182965a11

14.  Rasmussen, K, et al  Hydroxyethyl Starch Reduces Coagulation Competence and Increases Blood Loss During Major Surgery: Results From a Randomized Controlled Trial  Annals of Surgery. 259(2):249-254, February 2014. doi: 10.1097/SLA.0000000000000267

15:  Vadeboncouer T et al,  Chest compression depth and survival in out-of-hospital cardiac arrest Resuscitation Volume 85, Issue 2, Pages 182-188, February 2014 doi:10.1016/j.resuscitation.2013.10.002

16.  Verbeek D. et al ,  Management of pelvic ring fracture patients with a pelvic “blush” on early computed tomography, Journal of Trauma and Acute Care Surgery. 76(2):374-379, February 2014 , doi: 10.1097/TA.0000000000000094