ICE 016

The previous evening, a 59 year old man experienced an hour long episode of chest pain which resolved spontaneously. He has had no further chest pain, but encouraged by his family he presents to ED the next morning. A bedside cardiac troponin test is negative. This is his ECG taken at the same time.

ECG 1Describe his ECG

What do the ECG findings signify ?

How should this patient be managed?


The ECG shows sinus rhythm at 60 /minute, with abnormal ST/T wave changes in V1 through V5 but most marked in leads V2, V3 & V4. There are biphasic T waves in V2 & V3 with the negative component of the T wave being deeply so. In V4 there is very deep T wave inversion.

These particular ECG findings are called a Type 1 Wellens’ pattern. (The other and more common Type 2 Wellens’ pattern with only deep T inversion in V2 – V4 is shown in the ECG underneath this answer) Wellens’ pattern ECGs very likely signify severe stenosis of the left anterior descending coronary artery. They were only first described as an ECG syndrome in the early 1980s and named after the author of the first publication on it. At other times it has been called Wellens’ sign or Wellens’ warning. The last name emphasises the usual clinical course, which is to progress to full occlusion and a completed anterior infarct unless intervention occurs.

This patient should be admitted, not sent for outpatient follow-up. Stress testing should be avoided as it may precipitate a completed infarct. Antiplatelet agents and heparin should be commenced but the key intervention is early coronary angiography/angioplasty.


Wellens type 2 ECG

ECG 2More information on Wellens syndrome: LITFL

 ICE Ian's Clinical Emergencies

2015 ACEM Fellowship Short Answer Question (SAQ)

The new format Short Answer Question (SAQ) will be introduced in the first written ACEM Fellowship examination in February 2015. The ACEM website has included an unchanged outline under the “2015 Onwards” tab for some time, but recently some detailed information has emerged on the DEMT online forum and in the Trainee e-bulletin. To aid dissemination of this, here are the ACEM released sample questions and associated comments from the ACEM Fellowship Examination Committee (FEC).

Firstly, a summary of the SAQ format for the first examination of 2015

  • 30 questions in one paper over 180 minutes*
  • All questions of 6 minutes duration*
  • A single question may have between 2 and 5 parts or sections requiring responses
  • Answer booklet to be provided with spaces for specific number of responses required

(* Has only been guaranteed for the 2015.1 FE, different formats may apply thereafter)

New information

  1. Around Australia and New Zealand, there are many individuals creating questions and resources for the new formats required from 2015, and many of these have been uploaded for free sharing and use on the ACEM DEMT e-forum. (Additionally, there are many sites like this one, with material for free use by trainees and their coaches. All material on tjdogma is part of the FOAMed world, and I encourage readers to use and share it as they wish)

Recently the College collated this material into a single document and released it via the DEMT forum (although it may find its way on to ACEM website at some stage in the future)

ACEM_SAQ_ example_items_DEMT_Discussion_Group

This was released with the following statement:

Here are around 110 SAQ questions in a single collated document. We hope that this will be useful when working with your trainees and helping them to prepare for the new exam format.

There are also some EMQs at the end of this document too that have been submitted.

Please note:

  • X-rays, clinical images and ECGs are reproduced in this document without owner’s consent

  • There are some questions in the document without model answers

  • Items have been briefly reviewed and some typographical errors amended and small changes to increase consistency provided. Detailed quality assurance by the exam sub-committees has not been undertaken.

  1. Shortly thereafter, a second document was released directly from the SAQ subcommittee of FEC, with six questions and suggested answers. These are currently the most accurate representation of what we can expect in 2015.

SAQ Examples New exam format_SAQ_SCv2

This statement accompanied the release:

Dear DEMT’s

Here is a sample of six questions that are equivalent in structure and length to what your candidates sitting 2015:1 can expect. Bear in mind that they have not been workshop-ed and therefore may not be considered ‘exam ready’ but hopefully they give the flavour of the new format exam.

On behalf of the SAQ subcommittee, I apologise that we cannot provide more samples at this time. Our focus has been on ensuring a high quality exam for 2015:1 and given the short turn around time between old and new format exams and meeting printing and quality assurance deadlines, we have been time poor.
We have not been involved in setting the standard for the 2015:1 exam: that will be done by an independent group between now and the time of the exam.

I recommend the following guidelines to assist your candidates.

Answer the question asked (if asked for four options – give four but be mindful of what would be most relevant to the topic being examined). Extra credit will not be given for listing five! If asked to list, the answers will mostly be words or short phrases. Detailed explanation will not be expected.

Keep to the six minutes per question. The standard setting will be based on this time allocation.

To prepare candidates I recommend picking topics to examine and look for ‘packets’ of information that may be the answer to a question. Then come up with the most appropriate question to have the candidate give you that information. Much smaller topics can be examined in this way.

The terms used in the exam are unchanged however you can expect that rather than have an assessment question, the question will focus on x features of history or x diagnoses with supportive investigations. Rather than use ‘discuss’, the question will ask for x pros and cons for the topic. Management features will be very specific with no scope for long-winded descriptions and formulaic responses.

David Cruse

Chair: ACEM SAQ Sub-committee

To finish, I wish to highlight some points arising from these releases – this is entirely my personal assessment of this information:

  • number of responses – note the emphasis on the number of responses to a given question. The provided booklet will contain preformatted space for the number of responses requested. Additional responses will not be marked. If there are more correct responses to a question than spaces provided, the candidate should answer with the most important/likely/encountered in practice.
  • time – it will be exceptionally hard to complete this paper to time. Note that within some of the released questions there were as many as 22 components to a full response to all options within the question. It is vitally important that candidates practice multiple back to back questions like these strictly to time to try and prepare for this both physically and mentally.
  • detail – please note that last comment “Management features will be very specific with no scope for long winded descriptions and formulaic responses”   This is the major change that all candidates must understand and comply with if they wish to be successful. The new format demands and will reward broad superficial responses, not depth, explanation or justification.
  • defined question wording – thus far it has been stated that the current list of defined words such as interpret, describe, list etc will still be used as before. I believe there will definitely be a move towards subsections of these, so asking history, examination, or investigations specifically rather than assessment for example.
  • standard setting – there is a SAQ standard setting meeting scheduled for examiners in February, so currently I’m unclear exactly how this will officially play out. But if it echoes the ACEM MCQ standard setting process, a group of examiners will work through FEC provided SAQs and determine the standard of response we would expect from a borderline pass candidate. That is, how would a candidate at that level be expected to perform on that question in six minutes? The data from this exercise is then collated and used to determine the pass requirement for each question and then to that specific SAQ examination collection of questions overall.
  • pass requirement – so what will the definition of a pass be for the SAQ section? No information released on this as yet. In the past it was 5 out of 8 SAQs passed, with a total of 40 marks or more. With the above standard setting process applied, it will vary (but only a little probably) from examination to examination. I guess like so many other details on the new formats, we’ll have to wait and see…

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:



Thanks to 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.


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

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

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]



  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.
    2014; 348 doi:
  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