HOW TO ANSWER MANAGEMENT QUESTIONS ON THE FEX SAQ
Dominic Lang (edits by Viet Tran)
Management questions seem easy because it's just what we do on the floor but we all found them difficult to answer.
You definitely need to practice them. I highly recommend doing it for each VBG / ECG / clinical scenario you come across.
Look at the number of marks and give that many answers. Make sure you give the answers that best show your understanding of the specific scenario. So focus on what is most important for this patient and give appropriate details. For example avoid answering generic things like CXR, NGT, lines for an ICU level patient, unless you can't think of anything better. Answering investigations for management may or may not be appropriate depending on how the question is asked.Your answer to earlier questions should have given you a list of problems so use that to focus your management.
I also had generic answer templates to give a bit of structure and prompt me if I couldn't think of enough answers:
- consultantoid: talk with family, manage rest of department, debrief staff, incident reports, coroner, etc
- A: airway support, intubation
- B: oxygen, ventilation
- C: cardiac monitoring, fluids, inotropes
- D: analgesia, antiemetics, sedation, BSLs
- E: keep warm
- other: IDC, NGT
Here's an example of what I mean:
Question: A 35 year old male is brought in by ambulance following an out of hospital cardiac arrest. He was thrombolysed as part of his arrest management. A blood gas is performed - here.
a) Please interpret the blood gas (answer below the gas in the link above)
b) How will you manage this patient?
For this patient, the problems from the stem and ABG are:
- post cardiac arrest with potential hypoxic brain injury
- presumed massive PE
- inadequate ventilation
- overly oxygenated
- lactic acidosis
- potential aspiration
Possible management answers:
- RSI & intubate - obviously don't put this if it's clearly been done
- Vt 6-8 mL/kg, resp rate for pCO2 40 - critical for this patient given acidaemia, risk brain injury, risk ARDS
- reduce oxygen SpO2 90-94% (or pO2 80-100) - important given risk brain injury
- appropriate fluids then inotropes for MAP 65, fluid balance, catheter
- sedate eg propofol & fentanyl, head up 30 deg, aim normoglycaemia
- heparin infusion post thrombolysis
- consideration clot retrieval or embolectomy
- IV potassium, recheck <1 hour
- prophylactic IV ceftriaxone & azithromycin
- ICU with ECMO capability, depending on setting may need transfer
- talk with family, high chance will die or have brain injury, unclear for days