FACEM VAQ Exam 2010.2 – Question 6

• The overall pass rate for this question was 67/92 (72.8%)
• Pass Criteria
  • Identify both pneumothorax and pleural effusion on right side.
  • Consider Boerhaave’s syndrome as a possible diagnosis in the interpretation.
  • Important treatment features expected to include were supplementary oxygen, IV fluid resuscitation, appropriate IV antibiotics, an appropriate size intercostal catheter, and urgent surgical referral
• Features of unsuccessful answers
  • Failure to consider Boerhaave’s syndrome, missing important areas of treatment such as IV fluids, IV antibiotics, small bore catheter drainage, inappropriate referral

FACEM VAQ Exam 2009.2 – Question 2

• The overall pass rate for this question was 53/67 (79.1%).
• Chest X-ray showing large cavitating lesion in right hemithorax with soft tissue density in lowerzone laterally.
• Pass criteria: A satisfactory description with consideration of an infective cause including less usual organismssuch as TB and / or fungi and/or aspiration.
• Fail criteria: Failure to recognise the cavitating nature of the main lesion.Failure to consider unusual organisms.

The chest X-ray demonstrates a dense alveolar infiltrate involving the lateral aspect of the left mid-zone.

Devices:

• right IJ central line
• left IJ vascath (dialysis catheter)
• nasogastric tube
• endotracheal tube

The left IJ vascath is in too far.

Central lines and vascaths should not be inserted beyond the superior extent of the pericardial reflection (which corresponds to the take off of the right main bronchus) because beyond this point they can erode through the superior vena cava or the right atrium / ventricle leading to pericardial tamponade and death.

A chest drain has been inserted draining the left pleural effusion and the vascath has been pulled back to an appropriate position.

The overwhelming evidence here points to a diagnosis of Streptococcus pyogenes pneumonia, bacteraemia and empyema!

The clinical history suggests the possibility of a bacterial infection complicating influenza and, indeed, this turned out to be the case:

Influenza may predispose to invasive group A Strep disease (at least it does in mice)

In a series of 2079 cases .of invasive group A Strep infection, the case fatality rate was 38% for pneumonia, compared with 26% for patients with necrotizing fasciitis.

There is extensive mediastinal emphysema and bilateral pleural effusions.

Boerhaave syndrome or so-called ‘spontaneous’ rupture of the oesophagus.

Often it is not really spontaneous as it occurs with vomiting.

Herman Boerhaave (1668-1738) described the condition in 1724, in a classic example of clinicopathological correlation, when faced with the case of the Grand Admiral of the Dutch Fleet, a roast duck and three litres of juniper beer…

Legend has it that letters Boerhaave received bore no address and were simply mailed “To the Greatest Physician in the World”.
- from Tan SY, Hu M. Hermann Boerhaave (1668-1738): 18th century teacher extraordinaire. Singapore Med J. 2004 Jan;45(1):3-5. PMID: 14976574

“A middle-aged man presenting with sudden-onset severe chest or epigastric pain, often radiating to the back or shoulder, after repeated episodes of retching or vomiting in association with over-indulgence in food and alcohol.”

Most presentations of Boerhaave’s syndrome are atypical and the diagnosis often requires a high index of suspicion – usually an “oesophogram” of some sort is required.

In about 1 in 4 cases there is no history of vomiting!

The Mackler triad consists of:

1. vomiting
2. lower thoracic pain
3. subcutaneous emphysema

Although it supposedly defines the classic features of Boerhaarve’s syndrome it is probably not worth knowing because it is rarely found and is of negligible clinical utility in the real world.

This a a highly lethal condition – it is essentially 100% fatal if left untreated. Overall mortality is about 30%.

The cornerstones of management are:

• aggressive resuscitation
• early surgical intervention
• broad-spectrum antibiotics

Resuscitation should be followed by prompt surgical intervention (call the thoracic surgeons!). The time between onset of symptoms and surgery is the greatest predictor of patient survival.

• best outcomes if surgery is performed <12 hours from onset.
• mortality probably increases to ~50% at 24 hours, and to ~90% at 48 hours.

Empirical antibiotics are indicated and should be broad spectrum to cover gram positives (including enterococcus), gram negatives and anaerobes. Some also advocate antifungal cover with fluconazole in initial empirical treatment as Candida is commonly grown from drain fluid in these patients (sometimes I give this and sometimes I don’t and I’m not sure whether doing this is a good idea or not).

Conservative management (i.e. without surgery) may be appropriate in some situations:

• presentation >48 hours
• debilitated premorbid condition
• a contained rupture, with minimal symptoms and negligible clinical evidence of sepsis.

Although there is little consensus for the management of this rare condition, one suggested treatment algorithm is:

FACEM VAQ Exam 2003.1 – Question 8

• Overall pass rate for this question was 65 / 83 (78.3%).
• This question also posed problems with image quality which made answering and marking difficult for candidates and examiners alike.
• Examiners noted that answers rarely had a systematic approach for describing the X-ray and for listing causes of fluid in the pleural space.

FACEM VAQ Exam 2003.2 – Question 4

• Overall pass rate for this question was 57 / 82 (69.5%)
• A CXR showing dentures overlying the mediastinum with probable air in the neck soft tissues.
• The examiners felt that this was an extremely good question that tested candidates’ diagnostic ability, perception, common sense and knowledge.
• Nevertheless it could be passed largely by considering the possibility of oesophageal perforation due to a foreign body.
• Common errors included not considering oesophageal perforation, indicating tracheal perforation more likely, thinking the denture wires to be sternotomy wires, use of barium in diagnostic studies and failure to include a preoperative workup in investigations.

FACEM VAQ Exam 2004.1 – Question 6

• Overall pass rate for this question was 57 / 69 (82.6%).
• A CXR demonstrating a right main intubation is shown.
• Examiners expected that the right main bronchus intubation would be recognized and were surprised that some candidates interpreted the xray as showing a pneumothorax.
• The question was an opportunity for candidates to demonstrate practical paediatric resuscitation knowledge.
• It was expected that the answer in b) would include resorting to BVM with an Fi02 of 1.0 while other steps were being taken to improve oxygenation.

FACEM VAQ Exam 2006.1 – Question 5

• The overall pass rate for this question was 35/40 (87.5%).
• The CXR given shows extensive, bilateral pulmonary infiltrates
• It was expected that the candidates would be able to describe the CXR accurately and demonstrate that they are able to interpret the CXR in a systematic way, noting major positives and negatives,and including lung fields, cardiac size and borders, bone, diaphragms etc.
• It was also expected that the candidate could interpret the CXR sensibly in the clinical context (Down’s syndrome, dry cough) that was given, form a reasonable differential diagnosis, recognizing that the most likely diagnosis was infection, types of infection likely (both typical and atypical organisms), with other possibilities less likely.

FACEM VAQ Exam 2007.1 – Question 6

• Overall pass rate for this question was 39/55 (70.9%).
• X-ray showed a large left pleural effusion, multiple discrete lung parenchymal lesions typical of metastatic lung disease and a portocath.
• This was a high discrimination question in the opinion of the examiners.
• Good responses provided a good description of the radiograph and a reasoned discussion of the possible diagnoses.
• Candidates failed because of poor use of x-ray descriptives, lack of a systematic technique and vague/ inadequate differentials.

FACEM VAQ Exam 2007.2 – Question 2

• The overall pass rate for this question was 38/77 (49.4%).
• Chest X-ray showed mediastinal and subcutaneous emphysema.
• The examiners felt that this was an easy question poorly answered by many candidates.
• Satisfactory answers systematically described the image and interpreted it in the light of the clinical scenario. Management required knowledge of the supportive care of this condition and safe disposition of a drug affected patient.
• Unsatisfactory answers failed to address the above or suggested the inappropriate insertion of an intercostal catheter.