10. Answer: A
Advance care planning in a health care context can be described as the process by which an individual sets out their wishes for medical care in the event that they are unable to make decisions themselves. In addition, advance care planning can set out who they would like to assist in medical decision making such as family or close friends. Advance care planning has been shown in multiple studies as being valuable to patients and their families. Additionally, randomised controlled trials have shown significant improvement in several outcomes; decreased utilisation of healthcare and cost, increased satisfaction with care, decreased use of hospital resources, improved concordance with wishes. However, these trials have not been of sufficient rigour and size to evaluate whether advance care planning improves quality of end‐of‐life care such as by measures of individual comfort.
Weathers E, O’Caoimh R, Cornally N, Fitzgerald C, Kearns T, Coffey A et al. Advance care planning: A systematic review of randomised controlled trials conducted with older adults. Maturitas. 2016;91: 101–109.
https://pubmed.ncbi.nlm.nih.gov/27451328/
11. Answer: C
Necrotising fasciitis is a rapidly progressive infection of the fascia, with secondary widespread necrosis of the subcutaneous tissues. The frequency of necrotising fasciitis has been increasing because of an increase in immunocompromised patients with diabetes, peripheral vascular disease, alcoholism, organ transplants, and neutropenia. The causative bacteria may be aerobic, anaerobic, or mixed flora. The three most important types are as follows:
Type I, or polymicrobial
Type II, or group A streptococcal
Type III gas gangrene, or clostridial myonecrosis
The reported mortality in patients with necrotising fasciitis has ranged from 20% to as high as 80%. Early diagnosis is key and requires a high index of suspicion as the initial lesion is often trivial. In many cases of necrotising fasciitis, antecedent trauma or surgery can be identified. Necrotising fasciitis requires urgent surgical intervention, and the urgent initiation of broad spectrum antibiotics. Admission to the intensive care unit is likely required, as these patients are usually profoundly shocked.
While caring for critically ill patients with necrotising fasciitis the following complications should be close monitored:
Capillary leak syndrome: Circulating bacterial toxins and host cytokines cause diffuse endothelial damage. Intravenous fluid requirements may be extremely high (10 to 12 litres of normal saline per day). Profound hypoalbuminaemia is also common, and replacement with albumin is needed to maintain oncotic pressure.
Intravascular haemolysis: Bacterial haemolysins cause striking and rapid reductions in the haematocrit in the absence of DIC. Thus, the haematocrit may be a better indicator of the need for transfusion than the haemoglobin level.
Stress cardiomyopathy: necrotising fasciitis especially caused by streptococcal infection can cause global hypokinesia, severe systolic heart failure, low cardiac output. This cardiomyopathy is reversible, fully resolving in 3 to 24 months after infection.
Posterior reversible encephalopathy syndrome (PRES) is a clinico‐radiological syndrome characterised by headache, visual disturbances, seizures and altered consciousness. It is most commonly associated with accelerated and malignant hypertension. It can also be associated with eclampsia/preeclampsia, HUS, TTP, drug toxicity and very rarely sepsis. CT or/and MRI of the brain commonly show vasogenic oedema within the occipital and parietal regions, The oedema is usually symmetrical. PRES can be found in a non‐posterior distribution, mainly in watershed areas, including within the frontal, inferior temporal, cerebellar, and brainstem regions. Both cortical and subcortical locations are affected.
Stevens D, Bryant A. Necrotizing Soft‐Tissue Infections. New England Journal of Medicine. 2017;377(23):2253–2265.
https://www.nejm.org/doi/10.1056/NEJMra1600673
12. Answer: B
The updated paracetamol overdose management guidelines in 2019 recommend a two‐bag N‐acetylcysteine (NAC) infusion regimen (200 mg/kg over 4 hours, then 100 mg/kg over 16 hours) instead of the previous three‐bag regimen since they have similar efficacy and the two‐bag regimen has less adverse reactions. All patients with risks of hepatotoxicity secondary to paracetamol overdoses should receive NAC treatment. In patients with massive paracetamol overdoses which result in blood paracetamol level more than double the nomogram line should receive increased doses of NAC. In patients whose time of ingestion is unclear, it may be worthwhile to commence NAC infusion regardless given the unlikelihood of harm associated with the treatment.
The nomogram is only validated for a single ingestion of immediate release paracetamol. If extended‐release paracetamol is ingested, and or the overdose has occurred over a longer period of time, it is no longer validated. In these cases, NAC infusion should be commenced regardless, given the lack of harm. If there was co‐ingestion of opioids or anticholinergics, as they can affect gastric emptying and absorption of paracetamol, NAC should be given.
For patients who present within 2 hours of immediate release paracetamol overdoses or present within 4 hours of immediate release paracetamol ingestions greater than 30 gm, activated charcoal should be given in alert and co‐operative patients.
Only a small percentage of patients develop hepatotoxicity following acute paracetamol overdoses with symptoms that can include nausea, vomiting, abdominal pain, and right‐upper quadrant tenderness. Of these patients, a small number of patients develop fulminant hepatic failure. Most patients recover after standard treatment.
Liver transplant unit should be consulted if patients meet any of the following criteria:
INR >3.0 at 48 hours or >4.5 at any time.
Oliguria or serum creatinine is >200 μmol/L.
Persistent acidosis (pH <7.3) or arterial lactate >3 mmol/L.
Systolic blood pressure <80 mmHg, despite fluid resuscitation.
Hypoglycaemia, severe thrombocytopenia, or encephalopathy.
Any alteration of consciousness (GCS <15) not associated with concomitant sedative overdoses.
Chiew A, Reith D, Pomerleau A, Wong A, Isoardi K, Soderstrom J et al. Updated guidelines for the management of paracetamol poisoning in Australia and New Zealand. Medical Journal of Australia. 2019;212(4):175–183.
