Download Toxicology VAQ`s

VAQ 1
A 14 year old girl is being assessed in your ED for possible envenomation after a
snake bite.
a. Outline the components of the test shown in this photograph, briefly
explaining its method of use.
b. What are the limitations of this test?
50%
50%
2005.1 VAQ 3
A patient is being assessed in your emergency department following an overdose of
paracetamol. You are told the paracetamol level is 100 micrograms/ml (630
micromol/L) and are given a paracetamol nomogram.
What factors do you need to consider or determine in order to interpret this result?
(100%)
FACEM VAQ Exam 2005.1 – Question 3

The overall pass rate for this question was 31 / 44 (70.5%).

The picture is of a paracetamol nomogram with 2 “treatment” lines.

A high level of knowledge was expected in answers to this question on a topic that is
frequently encountered in emergency practice.

An awareness of the validity of the nomogram with its derivation from a study of single
ingestions at a known time was expected as well as an understanding of the meaning of the 2
treatment lines.

The result also needed interpretation in the context of patient factors such as age, comorbidities, co-ingestants, paracetamol formulation, multidosing etc.

Failing answers did not consider enough variables in interpretation of the result and did not
mention the nomogram validity.
A 77 year old man presents to your emergency department feeling generally unwell
for several days. He is noted to have a pulse rate of 36 beats / minute and is
normotensive.
Arterial blood gases and serum biochemical tests are performed
Question
a.
Describe and interpret the results of his investigations.
(70%)
b.
Outline your treatment of his raised digoxin level
(30%)
FACEM VAQ Exam 2007.2 – Question 3

The overall pass rate for this question was 57/77 (74.0%).

The examiners felt that this was an excellent set of clinical data on which to base a question.
Good answers identified all the major abnormalities plus discussed specific treatments including
dialysis, use of digoxin Fab fragments and avoided the use of calcium for the hyperkalemia in the
presence of digoxin toxicity
A previously well 2 year old boy is brought to your Emergency Department by his
mother after he ingested 1.8 g of liquid Paracetamol at 0700 that morning. Serum
biochemical investigations were performed four hours after the ingestion; it is now
1200. He is asymptomatic with normal vital signs.
a.
b.
Discuss the utility of the nomogram shown below in this patient
Outline your disposition
Serum biochemistry results
Normal Range
Paracetamol
30
mg/L
<20
ALT
10
U/L
<24
(50%)
(50%)
FACEM VAQ Exam 2009.1 – Question 5

The overall pass rate for this question was 48/81 (59.3%)

The examiners felt that this was a good question requiring core EM knowledge.

They were disappointed with the standard of replies.

Pass criteria were to recognise that the nomogram was reliable in a situation of a known
ingestion dose at a specific time and that the ingested dose was sub-toxic.

Fail criteria were treatment with NAC and admission based on the nomogram results.
A
30 year old female is brought to your ED by ambulance following a suspected drug
overdose. Her observations are: BP 90/60 mmHg (supine), RR 20/min, SaO2 99%
(room air) and GCS 14.
Question
a. Describe and interpret her ECG
b. Outline your initial management in the ED.
(50%)
(50%)
FACEM VAQ Exam 2006.1 – Question 1

The overall pass rate for this question was 30/40 (75%).

The ECG given shows a broad complex tachycardia

Examiners expected that the ECG description would specify the rate of 130, broad QRS and
prolonged QT likely to be TCA overdose (or other Na channel blocking agent).

Initial management needed to focus on the need for bicarbonate/alkanisation and a low
threshold for definitive airway management because of the high risk of rapid deterioration.

Failing answers misinterpreted the ECG, including being unable to estimate the rate. Some
missed the clues about a toxicological cause and assumed this was a primary cardiac problem.

Others did not mention TCAs as a possible cause and saw no role for the use of bicarbonate.
A 32 year old woman is brought to your emergency department by her friend who
believes her to have taken a deliberate overdose earlier that morning. The patient is
drowsy and denies this. Her observations are normal.
Question
a.
b.
Describe and interpret her ECG
What drugs would you consider as potential ingestants?
(50%)
(50%)
FACEM VAQ Exam 2008.1 – Question 6

ECG showing markedly prolonged QT interval.

The overall pass rate for this question was 54/62 (87.1%)

The examiners felt that this was a basic question on a core ECG area that should have been
well handled by most well prepared candidates.

Despite this, a large number of candidates failed to diagnose the prolonged QT/QTc and/or
failed to realise its significance.

Failed candidates tended to provide an incorrect or non specific list of potentially causative
drugs.
A 35 year old man is brought to your Emergency Department following two
seizures. His observations are:
GCS
BP
8
75/40
Describe and interpret his ECG
/min
mmHg supine
(100%)
FACEM VAQ Exam 2009.1 – Question 7

The overall pass rate for this question was 52/81 (64.2%)

ECG showing regular broad complex tachycardia with widened QRS and abnormal terminal R
wave in aVR.

Again the examiners were disappointed with the response to this straight forward question.

Pass criteria were identifying the abnormalities listed plus considering toxic ingestion
(especially Tricyclic Antidepressant Overdose (TCA)) as a cause in this scenario.

Fail criteria were absence of the above.
A 46 year old man is brought to your emergency department
by ambulance following an overdose of unknown
medications. He has had a brief generalized seizure en
route.
On arrival his observations are:
Question
a. Describe and interpret his ECG
a. Outline your treatment
(50
%)
(50
%)
Answer
Answer and Interpretation
FACEM VAQ Exam 2011.1 – Question 7
The overall pass rate for this question was 68/82
(82.9%)
Pass Criteria
Part A
Rate, Axis, Rhythm, R Prime AVR ,
Interpretation – consistent with Na
Channel Blockade
also that QRS upper limit or slightly
prolonged,
QT almost half the RR along with
examples gave extra marks
Part B
Mx in resus area, treatment with
NaHCo3 and the doses,
Fluid Mx for hypotension and
Benzodiazepines for seizures.
Use of RSI to assist is accepted but was
felt that in this Stem was secondary to above
Features of unsuccessful answers
Lack of detail & precision or systematic approach
to part A
Inadequate management – focus was NaHCo3 is
the antidote and 1st line treatment.
No titration or endpoints – to pH 7.55 & QRS , and
no detail in doses or utalising cardioversion in Mx