CICM SAQ 2013.2 Q13

Questions

13.1 A 52-year-old female was admitted the previous night with an altered level of consciousness  that improved rapidly with administration of glucose.

She is referred to ICU the next day with confusion, ataxia and a worsening level of consciousness. Her CT head is normal.

The blood sugar level in the morning is 8 mmol/L on a 5% Dextrose infusion at 80 mL/hr. Her full blood count from the previous night is available as follows:

  • a) List two likely causes of the coagulation abnormalities.
  • b) State how you would correct the coagulopathy and give your reasoning.

13.2 A 44-year-old male presents with dyspnoea and is diagnosed as having multiple pulmonary emboli on a computerised tomography pulmonary angiogram (CTPA). He is commenced on  1000 units of heparin per hour IVI after a 5000 unit intravenous bolus. During the night his  heparin infusion has steadily increased to 1500 units per hour.

These blood results are from the following morning:

  • a) Give two reasons for the relatively low APTT despite heparin therapy.
  • b) List four causes for an increased predisposition to venous thromboembolic disease.

13.3 A 52-year-old female was admitted the previous night with an altered level of consciousness that improved rapidly with administration of glucose.

She is referred to ICU the next day with confusion, ataxia and a worsening level of consciousness. Her CT head is normal.

The blood sugar level in the morning is 8 mmol/L on a 5% Dextrose infusion at 80 mL/hr. Her  full blood count from the previous night is available as follows:

  • a) What is the likely cause of her confusional state?
  • b) What specific treatment would you prescribe for this?

Answers

Answer and interpretation

13.1

a) List two likely causes of the coagulation abnormalities.

  • Haemodilution with inadequate replacement of blood and clotting factors
  • DIC

b) State how you would correct the coagulopathy and give your reasoning.

  • Ensure patient is normothermic amd correct acidosis
  • Platelets to increase platelet count
  • FFP to replace factors II, V, VII, IX, X, and XI.
  • Cryoprecipitate to replace factor VIII, and fibrinogen if FFP does not reverse INR.
  • Consider tranexamic acid and/or Activated Factor 7
  • Exclude on-going surgical haemorrhage

13.2

a) Give two reasons for the relatively low APTT despite heparin therapy.

  • ATIII deficiency
  • Increased heparin clearance
  • Increased heparin binding proteins
  • Technical problems such as drug preparation error, disconnected IV line, pump problem, extravasated IV cannula

b) List four causes for an increased predisposition to venous thromboembolic disease.

  • Protein C def
  • Protein S def
  • AT III def
  • Malignancy
  • Factor V Leiden Lupus anticoagulant
  • Immobility
  • Smoking
  • Cardiac failure
  • Local venous obstruction
  • Surgery
  • Trauma
  • Obesity

13.3

a) What is the likely cause of her confusional state?

  • Wernicke encephalopathy.

b) What specific treatment would you prescribe for this?

  • Thiamine 100 mg IV daily.
Exams LITFL ACEM 700

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Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

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