17- Trouma & ER MSQs Only

Question 1

1 of 93

A 45 year old man complains of sharp chest pain. He is due to have elective surgery to replace his left hip. He has been bed bound for 3 months. He suddenly collapses; his blood pressue is 70/40mmHg, heart rate 120 bpm and his saturations are 74% on air. He is deteriorating in front of you. What is the next best management plan?

Answer 1

Thrombolysis with Alteplase

This man is peri arrest with the diagnosis of pulmonary embolism (chest pain,bedbound, collapse, low saturations). He needs urgent thrombolysis with alteplase (he may not survive if you wait for the medical Spr/ITU to arrive!).

Question 2

2 of 93

A 28 year old woman, who is 30 weeks pregnant, presents with sudden onset chest pain associated with loss of consciousness. Her blood pressure is 170/90 mmHg, saturations on 15L oxygen 93%, heart rate 120 bpm and she is apyrexial. On examination, there is an early diastolic murmur, occasional bibasal creptitations and mild pedal oedema. An ECG shows ST elevation in leads II, III and aVF. What is the most likely diagnosis?

Answer 2

Aortic dissection

Aortic dissection is associated with the 3rd trimester of pregnancy, connective tissue disorders (Marfan’s, Ehlers- Danlos) and bicuspid valve. Patients may complain of a tearing chest pain or syncope. Clinically they may be hypertensive.
The right coronary artery may become involved in the dissection, causing myocardial infarct in up to 2% cases (hence ST elevation in the inferior leads). An aortic regurgitant murmur may be auscultated.

Question 3

4 of 93

A 31 year old lady is struck by a car and is 32 weeks pregnant. On arrival in the emergency department she has a systolic blood pressure of 105mmHg and a pulse rate of 126 beats per minute. Abdominal examination demonstrates a diffusely tender abdomen and some left sided flank bruising. A FAST scan is normal. What is the most appropriate course of action?

Answer 3

Arrange an urgent abdominal CT scan

The patient’s mechanism of injury makes a solid organ injury likely. FAST scanning is associated with a false negative rate in pregnancy which makes the negative result less reassuring. CT scanning remains the gold standard.

Question 4

3 of 93

A 28 year old man falls and sustains a simple rib fracture. On examination, there is a small pneumothorax. What is the most appropriate course of action?

Answer 4

Insertion of chest drain
…………………………………………….
Do not confuse the management of pneumothorax due to trauma with the management of spontaneous uncomplicated pneumothorax.

For a rib fracture to cause a pneumothorax, there must also be laceration to the underlying lung parenchyma. This has the risk of developing into a tension pneumothorax and for this reason a chest drain should be inserted and the patient admitted.

Question 5

5 of 93

A 60 year old alcoholic presents with worsening confusion over 2 weeks. He has weakness of the left side of the body. What is the least likely explanation?

Answer 5

Wernicke’s encephalopathy and CVA
Extra dural haematoma(Right)
Decompensated liver failure and CVA
Sub dural haematoma
Vascular dementia
……………………………………………………
If you answered the question incorrectly, check you have read it properly as it asks for the least likely cause.

Note the question asks for the least likely cause. There are many reasons why an alcoholic may develop neurology. However, an extra dural bleed would not typically present such a long latent period.

Question 6

6 of 93

A 20 year old man is trapped in a warehouse fire. He has sustained 60% burns to his torso and limbs. The limb burns are partial thickness but the torso burns are full thickness. He was intubated by paramedics at the scene and is receiving intravenous fluids. His ventilation pressure requirements are rising. What is the best course of action?

Answer 6

Escharotomy

He requires an escharotomy as this will be contributing to impaired ventilation.
That may need to precede transfer.

Question 7

7 of 93

A patient is brought to the emergency department following a motor vehicle accident. He is unconscious and has a deep scalp laceration. His heart rate is 120/min, blood pressure is 80/40 mmHg, and respiratory rate is 35/min. Despite rapid administration of 2 litres of Hartmans solution, the patient’s vital signs do not change significantly. The injury likely to explain this patient’s hypotension is:

Answer 7

Epidural haematoma
Sub dural haematoma
Intra parenchymal brain haemorrhage
Base of skull fracture
None of the above(Right)
……………………………………………..
Raised intracranial pressure (Cushing response)
Hypertension
Bradycardia
Respiratory depression

In the patient described, hypotension and tachycardia should not be uncritically attributed to the head injury, since these findings in the setting of blunt trauma are suggestive of serious thoracic, abdominal, or pelvic hemorrhage. When cardiovascular collapse occurs as a result of rising intracranial pressure, it is generally accompanied by hypertension, bradycardia, and respiratory depression.

Question 8

8 of 93

A 28 year old Indian woman, who is 18 weeks pregnant, presents with increasing shortness of breath, chest pain and coughing clear sputum. She is apyrexial, blood pressure is 140/80 mmHg, heart rate 130 bpm and saturations 94% on 15L oxygen. On examination, there is a mid diastolic murmur, there are bibasal crepitations and mild pedal oedema. She suddenly deteriorates and has a respiratory arrest. Her chest x-ray shows a whiteout of both of her lungs. What is the most likely explanation?

Answer 8

Mitral valve stenosis

Mitral stenosis is the commonest cause of cardiac abnormality occurring in pregnant women. Mitral stenosis is becoming less common in the UK population, however should be considered in women from countries where there is a higher incidence of rheumatic heart disease. Mitral stenosis causes a mid diastolic murmur which may be difficult to auscultate unless the patient is placed into the left lateral position. These patients are at risk of atrial fibrillation (up to 40%), which can also contribute to rapid decompensation such as pulmonary oedema (hence cxr ‘whiteout’ of lungs). Physiological changes in pregnancy may cause an otherwise asymptomatic patient to suddenly deteriorate. Balloon valvuloplasty is the treatment of choice.

Question 9

9 of 93

A 27 year old man is involved in a road traffic accident. He is seen in the emergency department with chest pain. Clinical examination is essentially unremarkable and he is discharged. He subsequently is found dead at home. What is the most likely underlying injury?

Answer 9

Traumatic aortic disruption

Aortic injuries that do not die at the scene may have a contained haematoma.
Clinical signs are subtle and the diagnosis may not be apparent on clinical examination. Without prompt treatment the haematoma usually bursts and the patient dies.

Question 10

10 of 93

A 22 year old man is admitted with severe retrosternal chest pain and recurrent episodes of dysphagia. These occur sporadically and often resolve spontaneously. On examination, there are no physical abnormalities and the patient seems well. What is the most likely explanation?

Answer 10

Achalasia

Achalasia may produce severe chest pain and many older patients may undergo cardiac investigations prior to endoscopy.
Endoscopic injection with botulinum toxin is a popular treatment (although the benefit is not long lasting). Cardiomyotomy together with an antireflux procedure is a more durable alternative.

Question 11

11 of 93

A 76 year old woman with a body weight of 50 kg is undergoing an excision of a lipoma from her forehead. It is the first time the senior house officer has performed the procedure. He administers 30ml of 2% lignocaine to the area. The procedure is complicated by bleeding and the patient experiences discomfort, a further 10ml of the same anaesthetic formulation is then administered. Over the following 5 minutes the patient complains of tinnitus and becomes drowsy. Which of the drugs listed below should be administered?

Answer 11

Intralipid 20%
………………………………..
Local anaesthetic toxicity treatment = Intralipid

Intralipid is indicated for the treatment of local anaesthetic toxicity. In this case the safe dose of local anaesthetic has been exceeded and is thus this lady’s symptoms are likely to represent toxicity.

Question 12

12 of 93

A 20 year old man falls over and bangs his head whilst intoxicated. On arrival in the emergency department he opens his eyes in response to speech, and is able to speak, although he is disorientated. He obeys motor commands. What is his Glasgow coma score?

Answer 12

13

E=3, V=4, M=6.

Question 13

13 of 93

A 56-year-old female is admitted to ITU with a severe pancreatitis. Thyroid function tests show:
TSH = 0.5 Low
Thyroxine = 1.0 Low
T3 = 0.5 Low
What is the most likely cause?

Answer 13

Sick euthyroid syndrome

This patient has sick euthyroid syndrome as all thyroid parameters are reduced.
Graves disease and levothyroxine will cause hyperthyroidism (low TSH and elevated thyroxine/T3). Hashimotos thyroiditis is associated with hypothyroidism (high TSH and low thyroxine/T3).

Question 14

14 of 93

A 42 year old motorcyclist is involved in a road traffic accident. A FAST scan in the emergency department shows free intrabdominal fluid and a laparotomy is performed. At operation there is evidence of small liver laceration that has stopped bleeding and a tear to the inferior pole of the spleen. What is the best course of action?

Answer 14

Attempt measures to conserve the spleen

Mobilising the spleen will result in removal. Splenic injuries like this are amenable to conservation.

Question 15

15 of 93

A 52 year old male type 2 diabetic is admitted to the vascular ward for a femoral popliteal bypass. He suddenly develops expressive dysphasia and marked right sided weakness. The Senior house officer arranges a CT head scan which shows a 60% left middle cerebral artery territory infarct. There are no beds on the stroke unit. Overnight the patient becomes unresponsive and a CT head confirms no bleed. What is the next best management option?

Answer 15

Hemicranieotomy
……………………………………..
The likely cause for the reduced consciousness is raised intracranial pressure due to increasing cerebral oedema related to the infarct. In this situation, urgent neurosurgical review is needed for possible decompressive hemicranieotomy to relieve the pressure. Ideally no further antiplatelet or anticoagulation therapy should be given until a plan for surgery is confirmed.

Indications for hemicranieotomy include:
Age under 60 years
Clinical deficit in middle cerebral artery territory
Decreased consciousness
>50% territory infarct

Question 16

16 of 93

A 17 year old male is involved in a motorcycle accident in which he is thrown from his motorcycle. On admission he has distended neck veins and a weak pulse. The trachea is central. What is the most likely cause?

Answer 16

Haemopericardium

This is most likely a cardiac tamponade produced by haemopericardium. As little as 100ml of blood may result in tamponade as the pericardial sac is not distensible. Diagnosis is suggested by muffled heart sounds, paradoxical pulse and jugular vein distension. A tension pneumothorax is made less likely in this case by the central trachea.

Question 17

17 of 93

A 52 year old male presents with central chest pain. On examination, he has an mitral regurgitation murmur. An ECG shows ST elevation in leads V1 to V6. There is no ST elevation in leads II, III and aVF. What is the diagnosis?

Answer 17

Anterior myocardial infarct

The most likely diagnosis is an anterior MI. As there are no ST changes in the inferior leads, aortic dissection is less likely.

Question 18

18 of 93

A Medical F1 phones you as he is concerned his patient has had a major internal bleed. The patient is 42 years old and is known to have sickle cell anaemia. His blood results are:
Hb 3.7 g /dl
Reticulocyte count 0.4%
His Hb is normally 7g/dl. What is the diagnosis?

Answer 18

Parvovirus

A sudden anemia and a LOW reticulocyte count indicates parvovirus. Acute sequestration and haemolysis causes a high reticulocyte count. There is no clinical indication to suspect a bleed, therefore you can advise the F1 not to panic and to speak to the haematologists!

Question 19

19 of 93

A 63 year old man undergoes a salvage abdominoperineal excision of the anus and rectum for recurrent anal cancer. He has previously been treated with radical chemoradiotherapy. At the conclusion of the procedure, there is a 10cm x 10cm perineal skin defect. What is the most appropriate option for providing closure?

Answer 19

Pedicled myocutaneous flap

The use of previous radiotherapy means that the wound will not heal well. A myocutaneous flap will mean that non irradiated tissue is interposed into the wound bed. Rotational skin flaps will comprise irradiated tissue and won’t heal.

Question 20

20 of 93

A 28 year old man presents with a burn injury secondary to a house fire. He has sustained 25% mixed full and partial thickness burns to his torso and limbs. Which of the following resuscitation protocols would be most appropriate in this case?

Answer 20

1. Administration of 2 ml of Hartmanns x weight in kg x 25 to maintain a urine output of 30ml/ hour

Lower infusion volumes are now administered to burn patients to minimize the potential harm caused by excessive fluid administration

Question 21

21 of 93

What is the least likely examination finding in patients with Le Fort II fractures?

Answer 21

Excessive mobility of the palate
Paraesthesia in the region supplied by the inferior alveolar nerve(Right)
Malocclusion of the teeth
Enopthalmos
Parasthesia in the region supplied by the infraorbital nerve
………………………………………………………….
Le Fort II fractures have a pyramidal shape. The fracture line involves the orbit and extends to involve the bridge of the nose and the ethmoids. In continues to involve the infraorbital rim and usually through the infraorbital foramen. As a result infraorbital parasthesia, palatal mobility and malocclusion are common findings.
Severe fractures may result in enopthalmos. However, the fracture does not, by definition, involve the inferior alveolar nerve.

Question 22

22 of 93

Which of the features below, following a head injury, is not an indication for an immediate CT head scan in children?

Answer 22

Drowsiness
A single, discrete episode of vomiting(Right)
A 9 month old child with a 6cm haematoma on the head
Numb left arm
Suspicion of a non accidental head injury
………………………………………….
Whilst not an indication for immediate CT there should be a low threshold for admission and observation.

Question 23

23 of 93

A 10 year old boy is playing with a firework which explodes and he sustains a full thickness burn to his left arm. Which of the following statements is not characteristic of this situation?

Answer 23

They have a leathery appearance
The burn area is extremely painful until skin grafted(Right)
They always heal with scarring
Blanching does not occur under pressure
Absence of,or few, blisters
……………………………………………………….
Full thickness burns involve complete injury to the dermis and sub dermal appendages. They have a leathery, often white appearance. They are initially insensate although pain often occurs during healing following skin grafting. They do not blanch under pressure.

Question 24

25 of 93

A 22 year old man has a full thickness burn of his leg after being trapped in a burning car. There are no fractures of the limb. There burn is circumferential. After 2 hours he complains of tingling of his leg and it appears dusky. What is the best management for this?

Answer 24

Escharotomy

The full thickness burn has oedema which is affecting the peripheral circulation.
Therefore the burn needs to be divided (not the fascia) to allow normal circulation to return.

Question 24

24 of 93

A 28 year old man is in the surgical intensive care unit. He has suffered a flail chest injury several hours earlier and he was intubated and ventilated. Over the past few minutes he has become increasingly hypoxic and is now needing increased ventilation pressures. What is the most common cause?

Answer 24

Tension pneumothorax

A flail chest segment may lacerate the underlying lung and create a flap valve. A tension pneumothorax can be created by intubation and ventilation in this situation. Sudden hypoxia and increased ventilation pressure are clues.

Question 25

26 of 93

A 45-year-old man is seen in the Emergency Department with nausea, pallor and lethargy. He has no past medical history of note. A cannula is inserted and serum urea and electrolytes show the following
Na+ 140 mmol/l
K+ 6.7 mmol/l
Bicarbonate 14 mmol/l
Urea 18.2 mmol/l
Creatinine 230 micro mol/l
An ECG shows peaked T waves.
What is the most appropriate initial management?

Answer 25

Intravenous calcium gluconate

The first priority in this patient is to stabilise the myocardium with intravenous calcium gluconate.

Question 26

27 of 93

A 62 year old male attends the hernia clinic. He suddenly develops speech problems, left facial weakness and left sided arm and leg weakness lasting longer than 5 minutes. A CT head shows no intracerebral bleed. What is the next line of management?

Answer 26

Urgent referral for thrombolysis

This patient is within 3h of symptom onset of a stroke. Therefore he should be urgently referred to the medical team for thrombolysis, before Aspirin is given.
There are concerns that high dose aspirin would increase the risk of intracerebral haemorrhage if thrombolysis is undertaken.
This is an example of the type of medical problem you should be aware of as a surgeon, as ultimately you can make a difference by referring QUICKLY to the correct specialty for management.

Question 27

28 of 93

A 60-year-old man develops palpitations while on the acute surgical unit. An ECG shows a broad complex tachycardia at a rate of 150 bpm. His blood pressure is 124/82 mmHg and there is no evidence of heart failure. The surgical consultant wants to give rate control (the medical team are not answering their bleeps). Which one of the following is least appropriate to give?

Answer 27

Procainamide
Lidocaine
Amiodarone
Adenosine
Verapamil( Right)
………………………………………………..
Ventricular tachycardia - verapamil is contraindicated

Verapamil should never be given to a patient with a broad complex tachycardia as it may precipitate ventricular fibrillation in patients with ventricular tachycardia.
Adenosine is sometimes given in this situation as a ‘trial’ if there is a strong suspicion the underlying rhythm is a supraventricular tachycardia with aberrant conduction

Question 28

29 of 93

An 18 year old male is shot in the left chest. He was unstable but his blood pressure has improved with 1 litre of crystalloid. His chest x-ray shows a left sided pneumothorax with no lung visible. What is the best course of action?

Answer 28

Insertion of 36 Fr chest drain

The issue in this question is that its a traumatic pneumothorax. As a result, there is a risk of bleeding and indeed, of underlying parenchymal lung injury (these can develop into recurrent pneumothoraces quickly). Blood of even small volumes can quickly block narrow lumen drains and these can then allow a tension pneumothorax to develop. A large bore drain is less likely to develop such a complication and is preferred in the setting of trauma.

Question 29

30 of 93

Which of the following is not a feature found on a CXR in traumatic aortic disruption?

Answer 29

Widened mediastinum
Trachea deviated to the left(Right)
Depression of the left main stem bronchus
Obliteration of the aortic knob
Widened paraspinal interfaces
………………………………………………..
The trachea is normally deviated to the right.

Question 30

31 of 93

A 43 year old man who has a long term history of alcohol misuse is admitted with a history of an attack of vomiting after an episode of binge drinking. After vomiting he developed sudden onset left sided chest pain, which is pleuritic in nature. On examination, he is profoundly septic and drowsy with severe epigastric tenderness and left sided chest pain. What is the most likely cause?

Answer 30

Boerhaaves syndrome

In patients with Boerhaaves the rupture is often on the left side. The story here is typical. All patients should have a contrast study to confirm the diagnosis and the affected site prior to thoracotomy.

Question 31

32 of 93

A 28 year old male is involved in a road traffic accident he is thrown from his motorbike onto the pavement and sustains a haemopneumothorax and flail segment of the right chest. What is the most appropriate course of action?

Answer 31

Insertion of intercostal tube drain

He requires a chest drain and analgesia. In general all haemopneumothoraces should be managed by intercostal chest drain insertion as they have a risk of becoming a tension pneumothorax until the lung laceration has sealed. This is due to the laceration of the underlying lung parenchyma having a flap effect.

Question 32

33 of 93

The following features are typical of superficial partial dermal burns except:

Answer 32

Erythema
Absence of blisters(Right)
Spontaneous healing in most cases
No extension beyond proximal dermal papillae
Good capillary refill at the burn site
……………………………………………………….
Superficial dermal burns are typically erythematous, do not extend beyond the upper part of the dermal papillae, capillary return and blisters are both usually present.

Question 33

34 of 93

Which of the following statements relating to large volume blood loss in trauma is incorrect?

Answer 33

Tranexamic acid reduces the incidence of rebleeding following surgery
Hypocalcaemia may complicate resuscitation
Colloids are preferred initially as they reduce the incidence of coagulopathy(Right)
When patients receive over 5 units of whole blood mortality increases when blood products greater than 3 weeks old are utilised
In the battlefield setting a ratio of 1:1:1 for blood, plasma and platelets is used
………………………………………………………..
Fresh blood is the fluid of choice when large volume blood loss complicates trauma. Mortality is doubled when blood >3 weeks old is used.

Question 34

35 of 93

Which of the following is not typically associated with a degloving injury?

Answer 34

Overlying pallor of the skin
Abnormal motility of the overlying skin
History of friction type injury
Improved results when the degloved segment is left in situ as a temporary closure(Right)
Poor results when primary compression treatment is used in preference to skin grafting
……………………………………………………
Degloving injuries typically involve extremities and are usually friction injuries e.g. arm being run over. There is abnormal motility of the overlying skin, pallor, loss of sensation. Early treatment is key and should involve skin grafting which may use the degloved segment. This however, should be formally prepared for the role and simple compression bandaging gives poor results.

Question 35

36 of 93

A 55 year old motorcyclist is involved in a road traffic accident and sustained a Gustilo and Anderson IIIc type fracture to the distal tibia. He was trapped in the wreckage for 7 hours during which time he bled profusely from the fracture site. He has an established distal neurovascular deficit. What is the most appropriate course of action?

Answer 35

Amputation

This man is unstable, and at 7 hours after extraction, the limb is not viable. The safest option is primary amputation.

Question 36

37 of 93

A 19 year old student falls from a 2nd floor window. He is hypotensive, though this improves with a small volume of crystalloid. A CXR shows depression of the left main bronchus and deviation of the trachea to the right. What is the most likely injury?

Answer 36

Aortic rupture

He has a deceleration injury, with persistent hypotension (contained haematoma).
This should indicate aorta rupture. Widened mediastinum may not always be present on a CXR. A CT angiogram will provide clearer evidence of the extent of injury. Its unusual for hypotension to persist following resuscitation and free intra thoracic bleeding is usually fatal quickly.

Question 37

40 of 93

A 19 year intravenous drug abuser is recovering following a surgical drainage of a psoas abscess. He is found collapsed in the ward toilet unresponsive and with pinpoint pupils. What is the most appropriate immediate management?

Answer 37

Intravenous naloxone

Intravenous nalaxone is needed to treat the patient who has had an overdose of opiate. Naloxone has the quickest onset of action, however it is important to be aware of its short acting duration and the need for further administration. There is also the risk of rebound pain once naloxone is given.

Question 37

38 of 93

A 63 year old male is gardening when he trips and lands on a scythe. He sustains a deep laceration of his lateral thigh, it measures 3cm depth by 7cm length, it penetrates down to the bone, but no fracture is evident on imaging or examination. His co- morbidities include type II diabetes mellitus (diet controlled) and polymyalgia rheumatica (takes regular low dose prednisolone). Which of the options below is the safest way of managing the wound?

Answer 37

Delayed primary closure

Wounds which are contaminated or have the potential to become so are unsafe for immediate primary closure. The combination of diabetes and steroids makes wound complications more likely. Despite his high risk a primary skin graft or flap is unlikely to be a safer option. Either may be used at a later date in the event that delayed primary closure is unsuccessful.

Question 37

41 of 93

A 28 year old woman, who is 18 weeks pregnant, presents with sudden chest pain. Her blood pressure is 150/70 mmHg, saturations are 92% on 15L oxygen and her heart rate is 130 bpm. There are no murmurs and her chest is clear. There are signs of thrombophlebitis in the left leg. What is the most likely problem?

Answer 37

Pulmonary embolism

Chest pain, hypoxia and clear chest on auscultation in pregnancy should lead to a high suspicion of pulmonary embolism.

Question 37

39 of 93

A 68 year old male is admitted to the surgical ward for assessment of severe epigastric pain. His abdomen is soft and non tender. However the Nurse forces you to look at the ECG. It looks abnormal. Which of the following features is an indication for urgent coronary thrombolysis or percutaneous intervention?

Answer 37

ST elevation of greater than 1mm in leads II, III and aVF
………………………………………………..
ECG changes for thrombolysis or percutaneous intervention: ST elevation of > 2mm (2 small squares) in 2 or more consecutive anterior leads (V1-V6) OR
ST elevation of greater than 1mm (1 small square) in greater than 2 consecutive inferior leads (II, III, avF, avL) OR
New Left bundle branch block

ST elevation of 1mm in leads II, III and aVF reflects significant cardiac ischaemia due to the right coronary artery occlusion. The medical registrar should be contacted to urgently assess the patient. Note right coronary artery occlusions puts the patient at risk of cardiac arrhythmias (due to blood supply to the sino atrial node).

Question 37

42 of 93

A 7 year old boy falls off a wall the distance is 7 feet. He lands on his left side and there is left flank bruising. There is no haematuria. He is otherwise stable and haemoglobin is within normal limits. What is the most appropriate course of action?

Answer 37

Undertake an abdominal USS

This will demonstrate any overt splenic injury. A CT scan carries a significant dose of radiation. In the absence of haemodynamic instability or other major associated injuries the use of USS to exclude intraabdominal free fluid (blood) would seem safe when coupled with active observation. An USS will also show splenic haematomas.

Question 38

43 of 93

A 22 year old man is brought to the emergency department. He was found lying unconscious on his right arm and it is evident that he has taken a temazepam overdose. His right arm is mottled in colour and swollen, his hand is insensate and stiff. What substance is most likely to be present in the urine in increased quantities?

Answer 38

Myoglobin

This man is likely to have muscle death secondary to compartment syndrome. This will result in muscle breakdown and release of myoglobin. This may accumulate in the kidney and result in renal failure.

Question 39

44 of 93

A 66 year old male is admitted to the vascular ward for an amputation. He reports episodes of vertigo and dysarthria to the house officer. He suddenly collapses with a Glasgow Coma Score of 3. What is the most likely diagnosis?

Answer 39

Basilar artery occlusion

Vertigo and dysarthria suggest a posterior circulation event. In the scenario of a patient complaining of posterior symptoms and a sudden deterioration in consciousness, the main differential diagnosis is of a basilar artery occlusion.

Question 40

45 of 93

An 18 year old man accidentally pours boiling water onto his left arm. The area is erythematous and has a blister measuring 5cm. The wound is extremely painful. What is the best course of action?

Answer 40

Deroof the blister and review in outpatients

Deroofing is preferred for larger areas (with thinner skin) and careful dressing as retention of the blister can result in infection.

Question 41

46 of 93

A 16 year old man sustains a basal skull fracture and is suspected of having CSF rhinorrhoea. Which of the following laboratory tests would most accurately identify whether CSF is present or not?

Answer 41

Beta 2 transferrin assay

Beta 2 transferrin is a carbohydrate free form of transferrin that is almost exclusively found in the CSF. Although lab stix testing for glucose is traditional it is associated with false positive results secondary to contamination with other glucose containing bodily secretions.

Question 42

47 of 93

A 20 year old man is hit over the head with a mallet. On arrival in the accident and emergency department he opens his eyes to pain and groans or grunts. On application of a painful stimulus to his hands, he extends his arm at the elbow. What is his Glasgow coma score

Answer 42

6

E=2, V= 2, M=2.

Question 43

48 of 93

A 22 year old man has a large full thickness burn on his chest. It is well circumscribed. In A&E his saturations are reduced to 92% on 15L Oxygen, Blood pressure 102/66 mmHg and HR 105bpm. What is the best management?

Answer 43

Escharotomy

The chest burn and its associated oedema is limiting respiration. Therefore an escharotomy of the chest is indicated, this will remove the constriction on the chest wall and improve ventilation.

Question 44

49 of 93

A 21 year old man is undergoing an inguinal hernia repair and receives a dose of intravenous co-amoxiclav. He is reported to have a penicillin allergy. Over the next few minutes his vital signs are: Pulse - 130bpm, blood pressure- 60/40mmHg. What is the first line treatment?

Answer 44

Adrenaline 1:1000 IM

The first line treatment of anaphylactic shock is intra muscular adrenaline.

Question 45

50 of 93

A 42 year old woman is admitted to surgery with acute cholecystitis. She is known to have hypertension, rheumatoid arthritis and polymyalgia rheumatica. Her medical therapy includes:
Paracetamol 1g qds
Codeine phosphate 30mg qds
Bendrofluazide 2.5 mg od
Ramipril 10mg od
Methotrexate 7.5mg once a week
Prednisolone 5mg od
You are called by the CT1 to assess this lady as she has become delirious and hypotensive 2 hours after surgery. Her blood results reveal:
Na 132 mmol/l
K 5.3 mmol/l
Urea 7 mmol/l
Creatinine 108 μmol/l

Hb 12.4 g/dl
Platelets 178 * 10 /l
WBC 15.4 * 10 /l

What management is needed immediately?

Answer 45

Hydrocortisone 100mg IV

This patient has acute adrenal insufficiency and urgently needs steroid replacement.

Question 46

51 of 93

A 21 year old man falls down a ravine whilst skiing and is trapped for several hours. He is finally brought to the emergency department profoundly hypothermic with a core temperature of 29 C. Which method is most effective at raising the core temperature?

Answer 46

Instillation of warmed intra peritoneal fluid

Visceral cavity re-warming be it lung or abdomen (or both) provides rapid rewarming. Only extracorporeal circulatory devices provide faster rates of re- warming.

Question 47

54 of 93

A 44 year old man is involved in a road traffic accident. He suffers significant injuries to his thorax, he has bilateral haemopneumothoraces and a suspected haemopericardium. He is to undergo surgery, what is the best method of accessing these injuries?

Answer 47

Clam shell thoracotomy

Patients with significant mediastinal and lung injuries are best operated on using a Clam shell thoracotomy. All modes of access involve a degree of compromise. A sternotomy would give good access to the heart. However, it takes longer to perform and does not provide good access to the lungs. Trauma should not be managed using laparoscopy.

Question 47

52 of 93

Which of the following is not a change found on an ECG in acute pulmonary embolism?

Answer 47

No changes
J waves (Right)
P pulmonale
Right ventricular strain
T wave inversion in the inferior leads
………………………………………..
S1, Q3, T3

J waves are pathognomonic of hypothermia.

Question 47

53 of 93

A 63 year old male is admitted to the surgical ward for an elective femoral popliteal bypass. He suddenly starts complaining of central, crushing chest pain which is radiating to the left arm. An ECG shows some ischaemic changes. The Nursing staff start high flow oxygen and give a spray of glyceryl trinitrate spray. Unfortunately there is no relief of symptoms. What is the next agent to be administered?

Answer 47

Aspirin 300mg

Aspirin 300mg should be given as soon as possible. If the patient has a moderate to high risk of myocardial infarction, then Clopidogrel should be given with a low molecular weight heparin. Thromboloysis or urgent percutaneous intervention should be given if there are significant ECG changes.

Question 48

57 of 93

Which option is not recommended during the management of compartment syndrome?

Answer 48

Anticoagulation(Right)
Keep limb level with the body
Intravenous fluids
Pain control
Fasciotomy
……………………………………..
Anticoagulation will worsen compartment syndrome.

Question 48

55 of 93

A 23 year old man who plays rugby for a hobby presents with recurrent anterior dislocation of the shoulder. Which of the following abnormalities is most likely to be present to account for this?

Answer 48

Bankart lesion
………………………………………….
A Bankart lesion is an injury of the anterior (inferior) glenoid labrum of the shoulder due to anterior shoulder dislocation. When this happens, a pocket at the front of the glenoid forms that allows the humeral head to dislocate into it.

Anterior dislocations are the most common. When recurrent, a Bankart lesion is the most common underlying abnormality. This is usually visualised by CT and MRI scanning and often repaired arthroscopically.

Question 48

59 of 93

An 18 year old man is involved in a road traffic accident. He arrives haemodynamically unstable. A CT scan shows disruption of the splenic hilum and a moderate sized perisplenic haematoma. What is the best course of action?

Answer 48

Splenectomy

Hilar injuries usually mandate splenectomy. The main risk with conservative management here is that he will rebleed and with hilar injuries this can be dramatic.

Question 49

56 of 93

A 22 year old man is hit over the head with an iron bar. On arrival in the emergency department he opens his eyes in response to pain, his only verbal responses are in the form of groans and grunts. On application of a painful stimulus to his hands, he flexes his forearms away from the painful stimuli. What is his Glasgow coma score?

Answer 49

8

E=2, V=2, M=4.
Appropriate flexion to pain carries a higher score than decorticate posturing or inappropriate flexion.

Question 49

58 of 93

A 49-year-old male sustained a severe blunt injury just below the bridge of the nose with industrial machinery. Imaging demonstrates a fracture involving the superior orbital fissure. On examination an ipsilateral pupillary defect is present and loss of the corneal reflexes. In addition to these examination findings, which of the following will not be present?

Answer 49

Altered cutaneous sensation from the forehead to the vertex
Ptosis
Complete opthalmoplegia
Nystagmus(Right)
Enopthalmos
…………………………………………
Orbital apex syndrome
This is an extension of superior orbital fissure syndrome and includes compression of the optic nerve passing through the optic foramen. It is indicated by features of superior orbital fissure syndrome and ipsilateral afferent pupillary defect.

This type of injury will result in the orbital apex syndrome (See above). As such opthalmoplegia will be present and nystagmus cannot occur.

Question 50

60 of 93

A 20 year old male is stabbed outside a nightclub, he has a brisk haemoptysis and in the ED has a drain inserted into the left chest. This drained 750ml frank blood. He fails to improve with this intervention. He has received 4 units of blood. His CVP is now 13. What is the best definitive course of action?

Answer 50

Thoracotomy in theatre

This man has cardiac tamponade. The raised CVP in the setting of haemodynamic compromise is the pointer to this. The definitive management of this, would be an emergency thoracotomy. Since he still has a cardiac output, this should occur in theatre and a clam shell approach will give the best access. If there is a significant delay if operating some may consider a pericardiocentesis. However, this is not a widely practiced option.

Question 51

61 of 93

A 28 year old African man is admitted with acute severe abdominal pain. He has just flown into the UK long haul and the pain developed whilst in flight. On examination he is tender in the left upper quadrant. His blood tests are as shown.
Hb 6 g/dl
Reticulocyte count 15%.
Ultrasound shows a spleen with a heterogeous texture and a few small gallstones but is otherwise normal.
What is the most likely diagnosis?

Answer 51

Sickle cell anaemia

A combination of a high reticulocyte count and severe anaemia indicates sickle cell anaemia, however another differential can be of a transient aplastic crisis due to parvovirus. This is less likely as this causes a reticulocytopenia rather than a reticulocytosis.
Parvovirus B19 infects erythroid progenitor cells in the bone marrow and causes temporary cessation of red blood cell production, patients who have underlying hematologic abnormalities are at risk of cessation of red blood cell production if they become infected. This can result in a transient aplastic crisis. Thus, patients with sickle cell anaemia are at risk. Typically, these patients have a viral prodrome followed by anaemia, often with haemoglobin concentrations falling below 5.0 g/dL and reticulocytopenia.

Question 52

62 of 93

An obese 53 year old man presents with symptoms of recurrent retrosternal discomfort and dyspepsia. This is typically worse at night after eating a large meal. On examination, there is no physical abnormality to find. What is the most likely cause of his symptoms?

Answer 52

Reflux disease

Patients with GORD often have symptoms that are worse at night. In this age group an Upper GI endoscopy should probably be performed.

Question 53

64 of 93

A 25 year old male pedestrian is hit by a van on a busy road. He is brought to the Emergency Department by ambulance. On examination he is dyspneoic, and hypoxic despite administration of high flow 100% oxygen. His blood pressure is 110/70 and pulse rate is 115 bpm. The right side of his chest is hyper-resonant on percussion and has decreased breath sounds. The trachea is deviated to the left. What is the most likely underlying diagnosis?

Answer 53

Tension pneumothorax

Blunt or penetrating chest trauma that creates a flap type defect on the surface of the lung can result in a tension pneumothorax. Typical features include dyspnoea, progressive hypoxia, hyperresonance and tracheal deviation. Treatment is with needle decompression and chest tube insertion.

Question 53

63 of 93

A 19 year old student is involved in a head on car collision. He complains of severe chest pain. A Chest x-ray performed as part of a trauma series shows widening of the mediastinum. Which is the most likely injury in this scenario?

Answer 53

Rupture of the aorta distal to the left subclavian artery

The aorta may be injured in deceleration accidents. In the setting of deceleration injury, chest pain and mediastinal widening the most likely problem is aortic rupture. This will typically occur distal to the left subclavian artery. Rupture of the proximal aorta may occur. However, survival is unlikely. It is important to note that the question uses the term Most likely injury as this is the component that distinguishes an ascending rupture from a descending rupture.

Question 54

66 of 93

A 32 year old man is involved in a road traffic accident and sustains a significant laceration to the lateral aspect of the nose which is associated with tissue loss. What is the best management option?

Answer 54

Rotational skin flap

Nasal injuries can be challenging to manage and where there is tissue loss, it can be difficult to primarily close them and still obtain a satisfactory aesthetic result. Debridement together with a rotational flap would obtain the best results here.

Question 54

65 of 93

A 54-year-old man is brought to the Emergency Department after being found collapsed in the street. He is known to have a history of alcoholic liver disease. Blood tests reveal the following:
Calcium 1.62 mmol/l
Albumin 33 g/l
Which one of the following is the most appropriate management of the calcium result?

Answer 54

10ml of 10% calcium gluconate over 10 minutes

Even after correction for the low albumin level this patient has significant hypocalcaemia which should be corrected. Both calcium chloride and gluconate can be used. Currently, gluconate is the favored agent.

Question 55

67 of 93

A 32 year old male is receiving a blood transfusion after being involved in a road traffic accident. A few minutes after the transfusion he complains of loin pain. His observations show temperature 39 C, HR 130bpm and blood pressure is 95/40mmHg. What is the best test to confirm his diagnosis?

Answer 55

Direct Coomb’s test
…………………………………………………………
Mnemonic for transfusion reactions:
Got a bad unit
G raft vs. Host disease
O verload
T hrombocytopaenia
A lloimmunization
B lood pressure unstable
A cute haemolytic reaction
D elayed haemolytic reaction
U rticaria
N eutrophilia
I nfection
T ransfusion associated lung injury

The diagnosis is of an acute haemolytic transfusion reaction, normally due to ABO incompatibility. Haemolysis of the transfused cells occurs causing the combination of shock, haemoglobinaemia and loin pain. This may subsequently lead to disseminated intravascular coagulation. A Coomb’s test should confirm haemolysis. Other tests for haemolysis include: unconjugated bilirubin, haptoglobin, serum and urine free haemoglobin. Note that delayed haemolytic reactions are normally associated with antibodies to the Rh system and occur 5-10 days after transfusion.

Question 55

68 of 93

A 19 year old motorcyclist is involved in a road traffic accident. His chest movements are irregular. He is found to have multiple rib fractures, with 2 fractures in the 3rd rib and 3 fractures in the 4th rib. What is the underlying diagnosis?

Answer 55

Flail chest injury

Multiple rib fractures with > or = 2 rib fractures in more than 2 ribs is diagnosed as a flail chest. This is associated with pulmonary contusion.

Question 56

69 of 93

A 36 year old man is admitted following a major electrical injury. He is assessed as having a second degree burn which affects 30% of the total body surface area and full thickness burn which affects 5% of the total body surface area. He is catheterized and the catheter drains 50ml of dark coloured urine. Which of the resuscitation protocols below is most appropriate in this case?

Answer 56

1. Administration of 4ml/kg/%total body surface area of Hartmanns solution to achieve a urine output of 100ml per hour

Electrical burn infusion protocols are different to those for flame or scald burns as higher volumes of fluid are given with increased targets for urine output to minimize the effects of rhabdomyolysis.

Question 57

70 of 93

A 27 year old man sustains a single gunshot wound to the left thigh. In the emergency department, he is noted to have a large haematoma of his medial thigh. He complains of parasthesia in his foot. On examination, there are weak pulses palpable distal to the injury and the patient is unable to move his foot. The appropriate initial management of this patient is:

Answer 57

Immediate exploration and repair

The five P’s of arterial injury include pain, parasthesias, pallor, pulselessness and paralysis. In the extremities, the tissues most sensitive to anoxia are the peripheral nerves and striated muscle. The early developments of paresthesias and paralysis are signals that there is significant ischemia present, and immediate exploration and repair are warranted. The presence of palpable pulse does not exclude an arterial injury because this presence may represent a transmitted pulsation through a blood clot. When severe ischemia is present, the repair must be completed within 6 to 8 h to prevent irreversible muscle ischemia and loss of limb function. Delay to obtain a conventional angiogram or to observe for change needlessly prolongs the ischemic time. A CT angiogram may be a reasonable alternative. Fasciotomy may be required but should be done in conjunction with and after re-establishment of arterial flow. Local wound exploration is not recommended because brisk hemorrhage may be encountered without the securing of prior vascular control.

Question 58

72 of 93

A 52 year old male presents with central chest pain and vomiting. He has drunk a bottle of vodka. On examination, there is some mild crepitus in the epigastric region. What is the likely diagnosis?

Answer 58

Oesophageal perforation

The Mackler triad for Boerhaave syndrome: vomiting, thoracic pain, subcutaneous emphysema. It typically presents in middle aged men with a background of alcohol abuse.

Question 58

71 of 93

A 62 year old woman presents with acute bowel obstruction. She has been vomiting up to 15 times a day and is taking erythromycin. She suddenly complains of dizziness. Her ECG shows torsades de pointes. What is the management of choice?

Answer 58

IV Magnesium sulphate
…………………………………………….
Torsades de pointes: Treatment IV magnesium sulphate

This woman is likely to have hypokalaemia and hypomagnasaemia as a result of vomiting. In addition to this, the erythromycin will predispose her to torsades de pointes. The patient needs Magnesium 2g over 10 minutes. Knowledge of the management of this peri arrest diagnosis is hence important in surgical practice.

Question 59

73 of 93

A 23 year old man is stabbed in the right upper quadrant and is haemodynamically unstable. A laparotomy is performed and the liver has some extensive superficial lacerations and is bleeding profusely. The patient becomes progressively more haemodynamically unstable. What is the best management option?

Answer 59

Pack the liver and close the abdomen

Packing of the liver is the safest option and resection or repair considered later when the physiology is normalised. Often when the packs are removed all the bleeding has ceased and the abdomen can be closed without further action.
Definitive attempts at suturing or resection at the primary laparotomy are often complicated by severe bleeding.

Question 60

75 of 93

A 23 year old man sustains a severe facial fracture and reconstruction is planned. Which of the following investigations will facilitate pre-operative planning?

Answer 60

Computerised tomography of the facial bones

Significant facial fractures may have intracranial communication. CT scanning will allow delineation of injury extent and 3D reconstruction images can be created. An Orthopantomogram (OPT) will provide good images of mandible and surrounding bony structures but will not give intracranial detail. A skull x-ray lacks the detail for modern practice.

Question 60

74 of 93

A 34 year old women trips over and falls into a bonfire whilst intoxicated at a party. She suffers burns to her arms, torso and face. These are calculated to be 25% body surface area. She is otherwise stable. The burns to the torso are superficial, her left forearm has a full thickness burn and the burns to her face are superficial. There is no airway compromise. She has received 1000ml of intravenous Hartman’s solution, with a further 1000ml prescribed to run over 4 hours. What should be the next course of action?

Answer 60

Transfer to a regional burns unit

This women has been resuscitated and requires transfer for specialist management.

Question 61

76 of 93

A 30 year old male is hit on the side of the head with a bat. He now presents to Emergency Department with odd behaviour and complaining of a headache. Whilst waiting for a CT scan he becomes drowsy and unresponsive. What is the most likely underlying injury?

Answer 61

Extra dural haematoma

The middle meningeal artery is prone to damage when the temporal side of the head is hit. Note that there may NOT be any initial LOC or lucid interval.

Question 62

78 of 93

A 6 year old boy pulls over a kettle and suffers superficial partial thickness burns to his legs. Which of the following will not occur?

Answer 62

Preservation of hair follicles
Formation of vesicles or bullae
Damage to sweat glands(Right)
Healing by re-epithelialisation
Pain at the burn site
…………………………………………..
Partial thickness burns are divided into superficial and deep burns, however, this is often not possible on initial assessment and it may be a week or more before the distinction is clear cut. Dermal appendages are, by definition, intact. Superficial partial thickness burns will typically heal by re-epithelialisation, deeper burns will heal with scarring.

Question 63

77 of 93

You are called to the acute surgical unit. A patient who has short gut syndrome has developed a broad complex tachycardia. You suspect a diagnosis of ventricular tachycardia. What is the most likely precipitant?

Answer 63

Hypomagnesaemia

Question 64

79 of 93

A 14-year-old boy is admitted to the acute surgical unit with appendicitis. He is normally fit and well. Apart from metoclopramide, the patient has had no other medications. The nursing staff contact you as the patient is acting strange. On examination he is agitated, has a clenched jaw and his eyes are deviated upwards. What is the most likely diagnosis?

Answer 64

Oculogyric crisis

This is a classic description of an oculogyric crisis, a form of extrapyramidal disorder. An oculogyric crisis is an acute dystonic reaction. This is precipitated by antipsychotics (haloperidol) and metoclopramide in susceptible individuals with a genetic predisposition to this. Treatment is with procyclidine IM.

Question 65

80 of 93

An 18 year old student is involved in a car crash, with another car crashing into the side of the car. A CXR shows an indistinct left hemidiaphragm. What is the most likely diagnosis?

Answer 65

Diaphragmatic rupture
……………………………………………..
CXR findings in diaphragmatic rupture:
Hemidiaphragm is not visible
Bowel loops in the lower half of the hemi-thorax
Mediastinum is displaced

A lateral blunt injury during a road traffic accident is a common cause of diaphragmatic rupture. Diagnosis is usually evident on chest x-ray. CXR changes include non visible diaphragm, bowel loops in the hemithorax and displacement of the mediastinum. In most cases direct surgical repair is the best option.

Question 66

81 of 93

A 22 year old man suffers 20% partial and full thickness burns in a house fire. There is an associated inhalational injury. It is decided to administer intravenous fluids to replace fluid losses. Which of the intravenous fluids listed below should be used for initial resuscitation?

Answer 66

Hartmans solution

In most units a crystalloid such as Hartmans (Ringers lactate) is administered initially. Controversy does remain and some units do prefer colloid. Should this leak in the interstitial tissues this may increase the risk of oedema.

Question 66

82 of 93

A 28 year old man is involved in a road traffic accident and sustains a flail chest injury. On arrival in the emergency department he is hypotensive. On examination; he has an elevated jugular venous pulse and auscultation of the heart reveals quiet heard sounds. What is the most likely diagnosis?

Answer 66

Cardiac tamponade

The presence of a cardiac tamponade is suggested by Becks Triad:
Hypotension
Muffled heart sounds
Raised JVP

Question 66

83 of 93

A 55 year old man is involved in a stabbing and receives an injury to the left iliac fossa. After transfer to hospital he is taken immediately to theatre because of haemodynamic instability. At laparotomy, an injury to the colonic mesentery is found to be the cause of blood loss, there is an associated injury to the left colon with local perforation and contamination. What is the most appropriate course of action?

Answer 66

Resect the left colon and construct a left iliac fossa end colostomy

Colonic injuries in the face of significant instability and contamination are probably safest resected, particularly since the scenario alludes to the presence of colonic mesenteric vascular injury which might compromise attempt to heal a repair.

Question 66

84 of 93

A 32 year old man is involved in a motorcycle accident and sustains a closed unstable spiral tibial fracture. This is managed with an intramedullary nail. On return to the ward he is noted to have increasing pain in the limb and on examination the limb is swollen and tender with pain on passive stretching of the toes. The most likely diagnosis is:

Answer 66

Compartment syndrome

Severe pain in a limb should raise suspicions of compartment syndrome especially in tibial fractures following fixation with intra medullary devices.

Question 67

86 of 93

A 42 year old man is admitted to surgery with acute appendicitis. He is known to have hypertension, psoriatic arthropathy and polymyalgia rheumatica. His medical therapy includes:
Paracetamol 1g qds
Codeine phosphate 30mg qds
Bendrofluazide 2.5 mg od
Ramipril 10mg od
Methotrexate 7.5mg once a week
Prednisolone 5mg od
You are called by the core surgical trainee to assess this man as he has become delirious and hypotensive 2 hours after surgery. His blood results reveal:

Na 132 mmol/l
K 5.2 mmol/l
Urea 10 mmol/l
Creatinine 111 μmol/l
Glucose 3.5
CRP 158

Hb 10.2 g/dl
Platelets 156 * 10 /l
WBC 14 * 10 /l

What is the most likely diagnosis?

Answer 67

Addisonian crisis
…………………………………………..
Features of an addisonian crisis:
Hyponatraemia
Hyperkalaemia
Hypoglycaemia

This man is on steroids for polymyalgia rheumatica. Surgery can precipitate acute adrenal deficiency. The diagnosis is further confirmed by the blood results of hyponatraemia, hyperkalaemia and hypoglycaemia. This patient urgently needs hydrocortisone.

Question 67

85 of 93

A 26 year old electrician suffers a full thickness high voltage burn to his leg. On routine urine analysis he has + blood. His U+E’s show mild hyperkalaemia and a CK of 3000. What is the most likely explanation?

Answer 67

Rhabdomyolysis

Electrical high voltage burns are associated with rhabdomyolysis. Acute tubular necrosis may occur. Aggressive IV fluids should be given.

Question 68

87 of 93

A 32 year old female hits her head on the steering wheel during a collision with another car. She has periorbital swelling and a flattened appearance of the face. What is the most likely injury?

Answer 68

Le Fort 3 fracture affecting the maxilla

The flattened appearance of the face is a classical description of the dish/pan face associated with Le fort fracture 2 or 3 of the maxilla.

Question 69

89 of 93

A 10 year old child is admitted to the emergency department after a fall. On examination, the blood pressure is 100/55mmHg, pulse rate 90, abdomen soft but tender on the left. Abdominal imaging demonstrates a grade III splenic laceration. What is the most appropriate course of action?

Answer 69

Admit the child to the high dependency unit for close monitoring

Splenic trauma is nearly always managed conservatively. Hilar injuries (grade IV) are less amenable to this and will tend to come to surgery.

Question 69

88 of 93

A 24 year old motorist is involved in a road traffic accident in which he collides with the wall of a tunnel in a head on car crash, speed 85mph. He is wearing a seatbelt and the airbags have deployed. When rescuers arrive he is lucid and conscious and then dies suddenly. What is the most likely underlying injury?

Answer 69

Aortic transection
………………………………………………….
Persisting hypotensive episodes in patients with aortic transections are often due to extra thoracic injury. Most patients with aortic transections who survive to reach hospital have a contained haematoma. If this fails or is disrupted, death occurs within a few minutes if not quickly treated.

Aortic transections typically occur distal to the ligamentum arteriosum. A temporary haematoma may prevent the immediate death that usually occurs. This is a deceleration injury. A widened mediastinum may be seen on x-ray.

Question 69

90 of 93

A 10 year old child is admitted with severe 30% burns following a house fire. After wound cleaning and dressings he is admitted to critical care. 1 day following skin grafts he becomes tachycardic and hypotensive. He vomits twice and this shows evidence of haematemesis. What is the most likely explanation?

Answer 69

Curlings ulcers

Stress ulcers may occur in the duodenum of burns patients and are more common in children. Cushings ulcers occur as a result of raised ICP.

Question 70

91 of 93

A 19 year old man is stabbed in the chest at a nightclub. He develops a cardiac arrest in casualty following an attempted transfer to the CT scanning room. What is the most appropriate course of action?

Answer 70

Thoracotomy
………………………………………..
Massive hemothorax results from the rapid accumulation of more than 1500 mL of blood or one third or more of the patients blood volume in the chest cavity. It is most commonly caused by a penetrating wound that disrupts the systemic or hilar vessels, although massive hemothorax can also result from blunt trauma. In massive haemothorax the neck veins are typically collapsed and the chest wall remains mobile. These features can help distinguish it from pneumothorax where the neck veins are distended.

Penetrating thoracic trauma that is then followed by cardiac arrest in the department is an indication for ER thoracotomy.

Question 70

92 of 93

A 25 year old man is shot in the abdomen and is transferred to the operating theatre following arrival in the emergency department, as he is unstable and a FAST scan is positive. At operation there is an extensive laceration to the right lobe of the liver and involvement of the IVC. There is massive haemorrhage. What is the most appropriate approach to blood component therapy?

Answer 70

Transfuse packed cells, FFP and platelets in fixed ratios of 1:1:1

There is strong evidence to support the use of haemostatic transfusion in the setting of major haemorrhage due to trauma. This advocates the use of 1:1:1 ratios.

Question 71

93 of 93

A 45 year old man is admitted after his clothing caught fire. He suffers a full thickness circumferential burn to his lower thigh. He complains of increasing pain in lower leg and on examination there is parasthesia and severe pain in the lower leg. Foot pulses are normal. What is the most likely explanation?

Answer 71

Compartment syndrome

Circumferential burns may constrict the limb and cause a compartment syndrome to develop. Eshcarotomy is required, and compartmental decompression.