1. A 12 month old infant is brought to your ED after being found submerged and unresponsive in a local home swimming pool. CPR is in progress, and there has been no  return of spontaneous circulation.

(a) Describe the technique you use to establish an intraosseous line.  (70%)
(b) Outline the complications of an intraosseous line                            (30%)

Here is a suggested list of points that should be included \ considered for all procedure \ skill related questions, written and viva, during the examination process. A structured answer always sounds professional and competent, even if you haven’t performed the procedure in question personally.

Patient explanation + reassurance
Appropriate location
Universal precautions
Aftercare \ disposition
Controversies \ Pitfalls


2. You are leading the resuscitation team for a 60 year old man who suffered an out of hospital cardiac arrest. Describe the factors you use to decide the appropriate time to terminate resuscitative efforts.

Key issues

  • Out of hospital arrest survival primarily dependent on time to defibrillation and ROSC unless primary reversible cause
  • Prolonged ( say > 30 – 40 minutes in hospital) resuscitation efforts only indicated if reversible cause eg toxicology, hypothermia
  • Survival to discharge minimal if initial rhythm on arrival ED asystole or agonal

In general I would maintain initial prehospital resus efforts after patient arrival until I had adequate information to make the call to discontinue, taking the following into account.

Factors related to circumstances of arrest:
Premorbid medical state, eg presence of cancer, advanced dementia etc
Advanced directive?
Time of arrest / time until resus commenced / time to first shock / ROSC pre-hospital?
Effective bystander CPR?
Rhythm on ambulance arrival?

Prehospital measures taken and response
Number of shocks?
ROSC?  Rhythm changes?
Any other measures, ACLS drugs?
Time since arrest

In hospital measures and response
Any of the H’s and T’s factors requiring treatment/reversal?
Number of shocks?
Drugs given per resus guidelines
ROSC?  Rhythm changes?
ETCO2 readings > 10 mmHg suggesting circulation present
Bedside echo findings – any cardiac activity?
Any other measures
Time since arrest

I usually discontinue efforts  15 – 20 minutes post arrival if no ROSC / viable cardiac rhythm re-established, and no reversible factors present that would potentially alter outcome


Additional resources / reading