Procedures & Skills

A 34-year-old male pedestrian is brought to the emergency department after being struck by a car. He is unresponsive with a GCS of 6, has a boggy scalp haematoma, and his left pupil is 5 mm and sluggish. Vital signs are heart rate 128/min, blood pressure 82/48 mmHg, respiratory rate 28/min with gurgling, and SpO2 91% on a non-rebreather mask. There is a tender, distended abdomen and an obvious open femur fracture. Two large-bore cannulae are inserted, blood is sent for group and hold, and the massive transfusion protocol is activated while CT is arranged. The emergency physician prepares for rapid sequence intubation to protect the airway and optimise oxygenation prior to imaging. Given his haemorrhagic shock and suspected traumatic brain injury, which induction agent is most appropriate?

A 40-year-old man presents to the emergency department after falling from his bicycle onto a gravel path. He has a 3 cm full-thickness laceration through the lateral aspect of his left eyebrow, with irregular edges but no active bleeding. He denies visual disturbance and there is no periorbital bruising. On examination, visual acuity is normal, pupils are equal and reactive, extraocular movements are full and painless, and there is no diplopia or globe tenderness. The supraorbital rim is palpated and is smooth without step deformity, and sensation over the forehead and upper eyelid is intact. He is systemically well, vaccinated against tetanus within the last five years, and has no other injuries. Regarding the technique for repairing this eyebrow laceration, which of the following statements is INCORRECT?

A 58-year-old man presents to the emergency department with three days of progressive right knee swelling and pain, denying any trauma. He has a background of osteoarthritis but no prior joint infections. On examination his temperature is 37.8°C, heart rate 92/min, and blood pressure 128/76 mmHg. The knee is warm, tense, and diffusely swollen with a positive bulge sign and reduced active range of motion; there is no overlying cellulitis. Point-of-care ultrasound demonstrates a large anechoic collection in the suprapatellar recess with synovial thickening. You plan an ultrasound-guided diagnostic and therapeutic arthrocentesis to exclude septic arthritis. Which needle approach is most appropriate?

A 3-year-old boy is brought to the emergency department by his mother after she saw him place a small plastic bead into his right nostril approximately one hour ago. He is otherwise well, with normal vital signs and no respiratory distress. On examination he is crying, thrashing his head from side to side and will not tolerate examination of the nose despite distraction techniques. A shiny round bead is glimpsed just inside the right nasal vestibule, partially obscured by mucus and swelling. Two brief attempts using a nasal speculum and alligator forceps have failed because the child will not stay still, and the object appears to have moved slightly further into the nasal cavity. Which of the following approaches is BEST avoided in this scenario?

In a busy emergency department resuscitation bay, an experienced registered nurse is drawing up intravenous adrenaline and insulin infusions for two critically unwell patients simultaneously. During preparation she is interrupted three times in ten minutes — once by a colleague asking for supplies, once by a phone call, and once by a doctor requesting a verbal update. Shortly afterwards, a tenfold dosing error is narrowly intercepted by a second nurse during an independent check. The department's medication safety committee reviews the incident and wishes to implement a systems-based intervention to reduce interruptions during high-risk drug preparation. Which of the following strategies is most effective in reducing this hazard?

A 52-year-old fisherman presents to the emergency department three days after sustaining a laceration to his left hand while cleaning a fish caught on a coral reef. He initially cleaned the wound at home but did not seek medical care. He now reports increasing pain, redness and swelling around the wound, with a low-grade fever. He has a history of alcoholic liver disease. On examination his temperature is 38.2°C, heart rate 104 bpm and blood pressure 118/72 mmHg. The wound edges are erythematous and tender with a small amount of purulent discharge; there is surrounding cellulitis extending 4 cm from the wound margin, and no crepitus or bullae are noted. Plain radiograph of the hand shows no retained foreign body or gas. Which of the following best describes the appropriate empirical antimicrobial approach for this wound?