# 2024.1 Day 1 VIVA 8

A 26-year-old male presents to the Emergency Department with a closed fracture of the left tibia and fibula with deformity, after a fall from a ladder.&#x20;

He is a smoker, with occasional recreational drug use. He is 80kg and 180cm tall.&#x20;

The patient has had a FULL trauma assessment showing some minor grazes but NO other injuries. He is complaining of severe pain at the fracture site.

<details>

<summary>What will you do to treat his pain?</summary>

**Initial assessment**:

* Confirm isolated injury through primary and secondary survey
* Evaluate neurovascular status distal to fracture site
* Assess pain characteristics: location, intensity (NRS), quality, movement-related
* Rule out compartment syndrome: disproportionate pain, pallor, paresthesia, paralysis, pressure
* Review relevant medical history: allergies, comorbidities, medication use

**Immediate interventions**:

* **Mechanical stabilization**:&#x20;
  * Apply padded splint in anatomical position&#x20;
  * Elevate limb to reduce edema and pain&#x20;
  * Apply ice in 20-minute cycles (avoid direct skin contact)
* **Pharmacological approach (stepwise)**:&#x20;
  * **Initial analgesia**:
    * IV morphine 0.1mg/kg (titrated to effect) or fentanyl 1-1.5μg/kg
    * IV paracetamol 1g
    * IV ketorolac 30mg (if no contraindications)
  * **Regional analgesia**:
    * Ultrasound-guided fascia iliaca block (primary choice in rural setting)
    * Alternative: femoral nerve block
    * Local anesthetic choice: 20-30ml of 0.5% ropivacaine (≤3mg/kg)

**Ongoing management**:

* Reassess pain score every 15 minutes until controlled (target NRS ≤4)
* Monitor for opioid side effects: sedation score, respiratory rate, SpO₂
* Maintain regular multimodal analgesia schedule
* Plan for definitive management (surgical vs conservative)
* Document all interventions and their effectiveness

</details>

<details>

<summary>On further history, he reveals occasional heroin use, last used 48 hours ago. How does this affect your management?</summary>

**Modified assessment**:

* Screen for opioid withdrawal symptoms (COWS score)
* Assess for tolerance: prior opioid requirements, pattern of use
* Check for signs of injection drug use (vascular access implications)
* Consider underlying infectious complications (endocarditis, abscess)

**Analgesic modifications**:

* **Opioid approach**:&#x20;
  * Anticipate increased requirements (1.5-2× standard dose)&#x20;
  * Use shorter-acting agents (fentanyl) for better titratability&#x20;
  * More frequent reassessment intervals (every 5-10 minutes)&#x20;
  * Consider patient-controlled analgesia earlier
* **Regional anesthesia becomes higher priority**:&#x20;
  * Maximize local anesthetic dose safely (calculate based on weight) &#x20;
  * Consider adding adjuncts: clonidine 50-100μg to prolong block

**Special considerations**:

* Engagement approach: non-judgmental, focus on acute pain management
* Addiction service consultation if available via telehealth
* Early discussion of discharge planning and follow-up

</details>

<details>

<summary>The patient develops respiratory depression (RR 6, SpO₂ 88%) after your initial opioid dose. Your immediate management?</summary>

**ABC approach**:

* Position patient for optimal airway patency
* Apply supplemental oxygen (15L via non-rebreather mask)
* Consider basic airway maneuvers if reduced consciousness
* Prepare bag-mask ventilation equipment

**Opioid reversal strategy**:

* **Titrated naloxone approach**:&#x20;
  * Dilute 400μg naloxone to 10ml (40μg/ml)&#x20;
  * Administer 40-80μg IV increments q1-2min&#x20;
  * Target: respiratory rate >12 while maintaining analgesia&#x20;
  * Avoid complete reversal (precipitates withdrawal and pain crisis)
* **Post-reversal monitoring**:&#x20;
  * Continuous SpO₂ monitoring&#x20;
  * Consider naloxone infusion if using long-acting opioids&#x20;
  * Rural hospital limitation: may need 1:1 nursing observation

- **Alternative analgesia**:
  * **Pivot to regional technique immediately**
  * Reduce subsequent opioid dosing by 25-50%
  * Consider ketamine as opioid-sparing agent (0.1-0.3mg/kg IV PRN)

</details>

<details>

<summary>Your ultrasound machine has malfunctioned. How would you proceed with regional analgesia in this scenario?</summary>

**Landmark-based regional techniques**:

* **Fascia iliaca compartment block**:&#x20;
  * Identify ASIS and pubic tubercle&#x20;
  * Insert needle 1cm below lateral third of inguinal ligament&#x20;
  * Feel two "pops" (fascia lata and iliaca)&#x20;
  * Reduced efficacy vs. ultrasound-guided (65-75% vs 85-95%)&#x20;
  * Use larger volume (30-40ml) to compensate for placement uncertainty
* **Femoral nerve block (landmark)**:&#x20;
  * Identify femoral artery pulse below inguinal ligament&#x20;
  * Insert needle 1-1.5cm lateral to pulse&#x20;
  * Paresthesia technique not recommended (nerve injury risk)

**Alternative approaches**:

* **Hematoma block** at fracture site:&#x20;
  * Direct infiltration with 10-15ml of 1% lidocaine&#x20;
  * Limited duration but immediate relief&#x20;
  * Useful adjunct while arranging definitive analgesia
* **Intravenous regional analgesia**:&#x20;
  * Consider Bier block if appropriate expertise available&#x20;
  * Requires dedicated monitoring and equipment

- **Systemic analgesia optimisation**:
  * Low-dose ketamine (0.1-0.2mg/kg IV)
  * Consider IV clonidine 1-2μg/kg if stable hemodynamics
  * Scheduled rather than PRN multimodal analgesia

</details>

<details>

<summary>How would you differentiate between pain from the fracture and early compartment syndrome in this rural setting?</summary>

**Clinical assessment** (critical in resource-limited settings):

* **Cardinal signs** comparison:&#x20;
  * Fracture pain: improves with immobilisation, responds to analgesia&#x20;
  * Compartment syndrome: disproportionate, unrelenting, worsens with passive stretch
* **Specific examination findings**:
  * Tenseness of compartment (firm, "wooden" feel)&#x20;
  * Pain out of proportion to stimulus&#x20;
  * Progressive sensory deficit in nerve distribution&#x20;
  * Diminished pulses (late finding, often preserved initially)&#x20;
  * Paralysis (late, irreversible sign)

- **Objective measurements**:
  * **Improvised pressure monitoring**:&#x20;
    * Arterial line transducer (if available)&#x20;
    * Normal saline-filled syringe technique&#x20;
    * Threshold: compartment pressure within 30mmHg of diastolic pressure
- **Management implications**:
  * **Rural challenges**:&#x20;
    * Limited surgical backup requires lower threshold for intervention&#x20;
    * Consider early transfer to higher-level facility&#x20;
    * Avoid regional blocks that could mask compartment syndrome if high suspicion&#x20;
    * Document serial examinations at 1-2 hour intervals

</details>

<details>

<summary>The patient requires ORIF of his tibial fracture. Outline your anesthetic approach focusing on perioperative pain management.</summary>

**Preoperative preparation**:

* Continue multimodal analgesia up to theater
* Consider preoperative gabapentinoid (pregabalin 75-150mg)
* Discuss regional options and consent
* Assess suitability for neuraxial technique
* Review contraindications to NSAIDs and adjuncts

**Anesthetic technique selection**:

* **Primary option**:&#x20;
  * Spinal anesthesia + peripheral nerve blocks&#x20;
  * Spinal: hyperbaric bupivacaine 10-15mg + fentanyl 10-25μg&#x20;
  * Advantages: excellent intraoperative analgesia, reduced PONV&#x20;
  * Rural consideration: simplified postoperative monitoring
* **Alternative**: General anesthesia + regional blocks&#x20;
  * Indicated if: patient preference, contraindications to neuraxial&#x20;
  * Technique: TIVA preferred if available (reduced PONV)&#x20;
  * Airway: LMA suitable if non-beach chair position

**Regional analgesia components**:

* **Combined approach for comprehensive coverage**:&#x20;
  * Proximal sciatic nerve block (subgluteal preferred)&#x20;
  * Femoral nerve block or adductor canal block &#x20;
  * Local anesthetic choice: ropivacaine 0.5% (longer duration)&#x20;
  * Consider catheter placement if expected prolonged pain

**Intraoperative adjuncts**:

* Low-dose ketamine (0.5mg/kg bolus + 0.1-0.2mg/kg/hr if prolonged)
* Dexamethasone 8mg IV (prolongs block duration, anti-emetic)
* Magnesium sulfate 30-50mg/kg (NMDA antagonist, opioid-sparing)
* Local infiltration by surgeon at wound closure

**Postoperative plan**:

* **Multimodal regimen**:&#x20;
  * Regular paracetamol 1g QID&#x20;
  * NSAIDs if not contraindicated (ibuprofen 400mg TDS)&#x20;
  * PRN oral opioids (oxycodone 5-10mg Q4-6H)
* **Rural-specific considerations**:
  * Simplified regimens preferred (limited monitoring)&#x20;
  * Family education for non-pharmacological techniques&#x20;
  * Clear parameters for escalation to medical staff

</details>

<details>

<summary>During the procedure, the patient develops sudden tachycardia (HR 130) and hypotension (BP 80/40). What is your differential diagnosis and management?</summary>

**Immediate actions**:

* Call for assistance (resource limitation: may be limited staff)
* Increase FiO₂ to 100%
* Initiate fluid bolus (500ml crystalloid)
* Reduce anesthetic depth temporarily
* Verify ECG for rhythm identification

- **Differential diagnosis**:
  * **Anesthetic-related**:&#x20;
    * Spinal-induced sympathectomy (high/total spinal)&#x20;
    * Light anesthesia/pain response&#x20;
    * Anaphylaxis (to antibiotics, muscle relaxants)
  * **Surgical/patient-related**:&#x20;
    * Hemorrhage (arterial injury, tourniquet release)&#x20;
    * Pulmonary embolism (fat embolism syndrome)&#x20;
    * Cardiac event (arrhythmia, MI)&#x20;
    * Drug effect (ketamine-induced tachycardia)
- **Specific management approach**:
  * **For SVT with hypotension**:&#x20;
    * Establish etiology (12-lead ECG if stable enough)&#x20;
    * Vagal maneuvers (if SVT confirmed, patient stable)&#x20;
    * Adenosine 6mg rapid IV push (only if hemodynamically improving)&#x20;
    * Cardioversion (50-100J synchronized) if deteriorating
  * **Rural hospital limitations**:&#x20;
    * Limited blood products availability&#x20;
    * Point-of-care testing availability&#x20;
    * Consider early activation of retrieval service

</details>

<details>

<summary>The patient is now in PACU with pain score 8/10 despite your regional blocks. What is your approach?</summary>

**Systematic assessment**:

* Evaluate block success (sensory and motor testing)
* Determine pain location relative to expected block coverage
* Rule out surgical complications (compartment syndrome, hematoma)
* Assess for breakthrough or incident pain patterns

**Block troubleshooting**:

* **Block failure patterns**:&#x20;
  * Partial block: supplement with targeted injection&#x20;
  * Patchy block: consider different approach&#x20;
  * Failed block: assess for technical or anatomical reasons&#x20;
  * Block wearing off: timing since placement

**Rescue analgesia options**:

* **Immediate relief strategies**:&#x20;
  * Fentanyl 25-50μg IV titrated (avoid morphine boluses)&#x20;
  * Ketamine 10-20mg IV as adjunct&#x20;
  * Regional rescue: supplemental block or catheter bolus
* **Avoid "opioid stacking"**:&#x20;
  * Wait 5-10 minutes between assessments&#x20;
  * Document cumulative opioid dose&#x20;
  * Consider PCA setup if available

**Multi-modal optimisation**:

* Ensure scheduled non-opioids initiated
* Consider clonidine 75-150μg PO as adjunct
* Non-pharmacological: reposition, elevate, ice application
* Rural limitation: negotiate protocols for nursing-initiated interventions

</details>

<details>

<summary>How would your pain management differ if the patient had a crushed, contaminated compound fracture instead of a closed fracture?</summary>

**Acute trauma considerations**:

* **Antimicrobial coverage**:&#x20;
  * Administer antibiotics before regional techniques&#x20;
  * Consider infection risk with catheter placement
* **Hemodynamic stability prioritisation**:&#x20;
  * Volume resuscitation before neuraxial techniques&#x20;
  * Consider vasopressor support if needed&#x20;
  * Lower threshold for arterial and central access

**Regional modifications**:

* **Block placement timing**:&#x20;
  * Consider blocks in ED before wound debridement&#x20;
  * May need repeat blocks for multiple theater visits&#x20;
  * Avoid areas of cellulitis or infection for injection sites
* **Technique selection**:&#x20;
  * Prefer single-shot over catheters if contaminated&#x20;
  * Consider more proximal approaches (e.g., popliteal vs ankle)&#x20;
  * Higher vigilance for compartment syndrome

**Systemic analgesia emphasis**:

* Earlier ketamine utilization
* Consider scheduled gabapentinoids earlier
* Increased opioid requirements anticipated
* Multimodal approach even more critical

**Rural-specific challenges**:

* Limited specialist support for complex wounds
* Transportation delays for definitive care
* Need for prolonged analgesia during transfer
* Balance infection risk with analgesia requirements

</details>

<details>

<summary>The patient requires transfer to a tertiary center 4 hours away. How would you manage pain during transfer?</summary>

**Pre-transfer optimization**:

* Ensure adequate analgesia before departure
* Fresh regional block with long-acting local anesthetic
* Consider single-dose adjuvants (dexamethasone 8mg IV)
* Backup plan for breakthrough pain

**Transfer analgesia options**:

* **IV PCA if available in transport**:&#x20;
  * Fentanyl preferred (hemodynamic stability)&#x20;
  * Simple protocol for limited monitoring (1.5μg/kg/hr background + 15μg bolus)
* **Alternative if PCA unavailable**:&#x20;
  * Nurse-administered fentanyl boluses PRN&#x20;
  * Oral opioids if tolerating (oxycodone 10-20mg)&#x20;
  * Low-dose ketamine boluses (10-20mg PRN)

**Non-pharmacological considerations**:

* Splint reinforcement before transfer
* Positioning for comfort in confined space
* Distraction techniques for ambulance journey

**Transfer team communication**:

* Clear handover of analgesic strategy
* Documentation of administered medications
* Parameters for additional medication administration
* Emergency protocols for respiratory depression

</details>

<details>

<summary>What factors might predispose this patient to developing chronic post-surgical pain, and how would you mitigate these risks within your rural hospital setting?</summary>

**Risk factor assessment**:

* **Patient-specific factors**:&#x20;
  * Demographics: young male (less risk than middle-aged)&#x20;
  * Pre-existing pain conditions (assess history)&#x20;
  * Psychological factors: catastrophizing, anxiety, depression&#x20;
  * Substance use: heroin use increases chronic pain risk&#x20;
  * Genetic predisposition (difficult to assess clinically)
* **Injury-specific factors**:&#x20;
  * Nerve involvement (peroneal nerve proximity)&#x20;
  * High-energy trauma mechanism&#x20;
  * Potential for long-term inflammatory response&#x20;
  * Surgical approach and possible nerve handling

**Preventive strategies – acute phase**:

* **Aggressive early analgesia**:&#x20;
  * Optimal pain control within first 48 hours&#x20;
  * Regular rather than PRN medication scheduling&#x20;
  * Regional anesthesia continuation when possible
* **Anti-hyperalgesic approaches**:&#x20;
  * Ketamine 0.1-0.2mg/kg/hr for 24-48 hours&#x20;
  * Gabapentinoids early (pregabalin 75mg BD)&#x20;
  * Dexamethasone 8mg daily × 3 days (inflammation control)

**Intermediate interventions**:

* **Rural rehabilitation optimisation**:&#x20;
  * Early mobilization protocols (even with limited PT)&#x20;
  * Patient education on home exercises&#x20;
  * Telehealth PT consults if available&#x20;
  * Family training for assisted exercises
* **Psychological support**:&#x20;
  * Brief pain coping strategies education&#x20;
  * Sleep hygiene optimisation
  * Realistic expectation setting&#x20;
  * Telehealth psychology referral if available

**Long-term planning**:

* **Discharge planning**:&#x20;
  * Limited duration opioid prescription (3-5 days maximum)&#x20;
  * Clear weaning protocol for all medications&#x20;
  * Red flag signs requiring reassessment&#x20;
  * Follow-up arrangements before discharge
* **Rural-specific approaches**:&#x20;
  * GP engagement for continuity of care&#x20;
  * Community support services identification&#x20;
  * Return-to-work planning appropriate to rural setting

</details>

<details>

<summary>Three months post-surgery, the patient reports burning pain and hypersensitivity in the distribution of the superficial peroneal nerve. How would you approach this?</summary>

**Diagnostic assessment**:

* **Neuropathic pain evaluation**:&#x20;
  * Validated screening tool (DN4, LANSS)&#x20;
  * Sensory mapping (allodynia, hyperalgesia patterns)&#x20;
  * Functional impact assessment&#x20;
  * Rule out surgical complications (hardware issues, infection)
* **Rural limitations consideration**:&#x20;
  * Limited access to neurophysiological testing&#x20;
  * Reduced specialist access&#x20;
  * Delays in advanced imaging

**First-line management**:

* **Pharmacological approach**:&#x20;
  * Pregabalin initiation (75mg BD, titrate weekly)&#x20;
  * TCAs alternative (amitriptyline 10-25mg nocte)&#x20;
  * Avoid opioids as primary management&#x20;
  * Topical options: lidocaine patch, capsaicin 0.075%
* **Non-pharmacological**:&#x20;
  * Desensitisation exercises (teachable remotely)&#x20;
  * TENS if available (can prescribe home unit)&#x20;
  * Mirror therapy for complex regional pain&#x20;
  * Graded motor imagery program

**Rural-adapted follow-up**:

* **Monitoring strategy**:&#x20;
  * Brief pain inventory tracking&#x20;
  * Telehealth review schedule&#x20;
  * HADS scale for psychological comorbidity&#x20;
  * Functional improvement metrics
* **Escalation pathway**:&#x20;
  * Clear telehealth referral criteria to pain service&#x20;
  * Patient-initiated contact protocols&#x20;
  * pharmacy consultation for medication adjustments

</details>

<details>

<summary>The patient requests ongoing opioid prescription at discharge. How would you respond?</summary>

**Risk assessment**:

* **Stratify risk based on**:&#x20;
  * Pre-existing substance use history&#x20;
  * DIRE score or similar opioid risk tool&#x20;
  * Expected trajectory of acute surgical pain&#x20;
  * Alternative treatment options available
* **Structured approach**:&#x20;
  * Clear documentation of decision-making process&#x20;
  * Discussion with surgical team about expected course&#x20;
  * Consider addiction medicine telehealth consultation

**Opioid stewardship principles**:

* **Limited prescription**:&#x20;
  * Maximum 3-5 days supply
  * Low effective dose (40-60 OME/day)&#x20;
  * Fixed tapering schedule provided&#x20;
  * No automatic refills
* **Patient agreement**:&#x20;
  * Single prescriber and pharmacy arrangement&#x20;
  * Realistic goal setting (function vs elimination)&#x20;
  * Urine drug screening if available&#x20;
  * Regular reassessment schedule

**Non-opioid optimisation**:

* Ensure maximal multimodal non-opioid analgesia
* Physical therapy engagement
* Psychological strategies emphasis
* Sleep hygiene optimization

**Rural-specific challenges**:

* **Limited resources navigation**:
  * Pharmacy availability (limited hours)&#x20;
  * Transportation challenges for follow-up&#x20;
  * Primary care coordination essential&#x20;
  * Consider remote monitoring options

</details>

<details>

<summary>Due to staffing limitations in your rural hospital, what simplified pain protocol would you implement for nursing staff to follow?</summary>

**Protocol design principles**:

* **Clear decision algorithms**:&#x20;
  * Flow-chart format for easy reference&#x20;
  * Minimal calculation requirements&#x20;
  * Standard order sets for common scenarios&#x20;
  * Regular nursing education sessions
* **Safety parameters**:&#x20;
  * Standardised monitoring requirements&#x20;
  * Clear escalation criteria&#x20;
  * Regular pain reassessment intervals&#x20;
  * Documentation requirements

**Practical implementation**:

* **Standing orders approach**:&#x20;
  * Pre-approved PRN medication protocols&#x20;
  * Tiered analgesia based on pain scores&#x20;
  * Non-pharmacological interventions list&#x20;
  * Standardised drug administration times
* **Communication tools**:&#x20;
  * Structured handover format&#x20;
  * Regular pain rounds (even if via telephone)&#x20;
  * Daily goals for pain management&#x20;
  * Patient information sheets

**Quality improvement**:

* **Outcome monitoring**:&#x20;
  * Weekly review of pain scores&#x20;
  * Critical incident reporting&#x20;
  * Quarterly protocol revision&#x20;
  * Patient satisfaction measurement

**Resource optimisation**:

* **Staff efficiency strategies**:&#x20;
  * Batched medication administration times&#x20;
  * Patient/family education to support care&#x20;
  * Peer support among nursing staff&#x20;
  * Telehealth access to specialist advice

</details>

<details>

<summary>What would be your approach if the patient develops signs of opioid use disorder after discharge?</summary>

**Recognition of signs**:

* **Clinical indicators**:&#x20;
  * Multiple early refill requests&#x20;
  * Doctor shopping behavior&#x20;
  * Reported lost prescriptions&#x20;
  * Dose escalation requests&#x20;
  * Functional decline despite treatment&#x20;
  * Opioid withdrawal symptoms
* **Rural detection challenges**:&#x20;
  * Limited prescription monitoring programs&#x20;
  * Pharmacy communication barriers&#x20;
  * Reduced surveillance capacity

**Initial management**:

* **Supportive approach**:&#x20;
  * Non-judgmental discussion&#x20;
  * Emphasie medical model of addiction&#x20;
  * Screen for other substance use disorders&#x20;
  * Mental health assessment
* **Structure implementation**:&#x20;
  * Weekly dispensing arrangements&#x20;
  * Supervised medication in pharmacy if needed&#x20;
  * Formal treatment agreement&#x20;
  * Urine drug screening program

**Treatment options**:

* **Evidence-based interventions**:&#x20;
  * Medication-assisted treatment (buprenorphine/naloxone)&#x20;
  * Rural challenges: provider licensure, pharmacy availability&#x20;
  * Telehealth addiction medicine consultation&#x20;
  * Gradual taper schedule if appropriate
* **Support services**:&#x20;
  * Virtual support groups&#x20;
  * Remote counseling options&#x20;
  * Family involvement with consent&#x20;
  * Primary care physician partnership

**Harm reduction approach**:

* Naloxone prescription and education
* Safe storage and disposal guidance
* Overdose prevention information
* Regular monitoring and follow-up

</details>

### **Key ANZCA Phrases to Include:**

* "Evidence-based multimodal analgesia reduces opioid requirements and improves outcomes"
* "Regional anesthesia techniques are particularly valuable in resource-limited settings"
* "Early aggressive pain management reduces chronic post-surgical pain development"
* "Structured opioid stewardship is essential in patients with substance use history"
* "Neuropathic pain requires targeted pharmacotherapy different from nociceptive pain"
