SAQ Trauma 014

FACEM SAQ Exam 2011.1 – Question 4

• The overall pass rate for this question was 56/82 (68.3%)
• Pass Criteria
  • The candidate must address the pros and cons of in-department sedation Vs in theatre GA. This should be at specialist standard with most of the multiple considerations outlined below mentioned:
    • Consideration to parental input, preferences, acceptability, consent and requests to access private care.
    • Consider department status, capabilities, staffing numbers and level, and orthopaedic access.
    • Accepted standard for orthopaedic manipulation in hospital/region.
    • Neurovascular status (although compromise is unlikely in this scenario).
  • The candidate must competently address the pros and cons of a GA.
  • The candidate must competently address the pros and cons of the commonly used paediatric dissociative procedural sedative – ketamine (either IV, IM or both);
  • Given the time limit on the question the candidate must competently address the pros and cons of at least 2 other relevant agents/techniques such that it puts them into perspective with GA, ketamine and this age specific scenario.
  • For points 2, 3 & 4 “competently” would be defined as most of the following points (relevant to each drug/technique) being addressed accurately such that safe knowledge and practice is conveyed. (Items with an * should be addressed for each).
    • Need for fasting*
    • Mode of administration/need for IV access*
    • Age appropriate*
    • Parental/child acceptability
    • Type of sedation +- analgesia
    • Depth of sedation
    • Antidotes available Vs not available
    • Antiemetic action
    • Protection of airway
    • Side effects specific to each agent
    • Contraindications specific to each agent –allergies
    • Combining agents – analgesic/sedative, ketamine /other
    • Training or credentialing needed for staff
    • Impact on ED-staff number, time and use of appropriate space
    • Onset/offset
    • Duration of procedure
    • LOS in ED and/or hospital
    • Cost
    • Ease of manipulation
  • Safe practice in the ED must be conveyed at all times – unsafe practice or options deemed to be unsafe in any part of the answer (i.e. deep sedation without mention of staffing/facilities/fasting consideration) would not be accepted as a pass regardless of the standard of the rest of the paper.
  • The candidate could discuss local anaesthetic techniques such as haematoma block, Biers block or axillary block. However the examiners felt that these techniques are not age appropriate. Failure to indicate this clearly and/or preference these techniques would be considered a fail.

• Features of unsuccessful answers
  • Paucity of pros and cons for ketamine and/or GA or not even mentioning these options at all
  • No consideration to paediatric specific and departmental issues
  • Poor hand writing and/or disorganised answers such that there was a paucity of detail and lack of consultant knowledge conveyed