Emergency Medicine And Management Of Trauma Flashcards
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?
Deep vein thrombosis Compartment syndrome Rhabdomyolysis Synergistic spreading infection Nerve injury
Compartment syndrome
Circumferential burns may constrict the limb and cause a compartment syndrome to develop. Eshcarotomy is required, and compartmental decompression.
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?
Use Factor VIII concentrates early Avoid use of "o" negative blood Transfuse packed cells, FFP and platelets in fixed ratios of 1:1:1 Transfuse packed cells and FFP in a fixed ratio of 4:1 Perform goal directed transfusion based on the Hb, PT and TEG studies
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.
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?
Immediate CT scanning with ongoing CPR Echocardiography Thoracotomy Pericardiocentesis Chest ultrasound
Thoracotomy
Penetrating thoracic trauma that is then followed by cardiac arrest in the department is an indication for ER thoracotomy.
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?
Temazepam Lorazepam Naloxone Intralipid 20% Sodium bicarbonate 20%
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.
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?
Gastro-oesophageal reflux Boerhaaves syndrome Oesophageal cancer Achalasia Pulmonary embolus
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.
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?
Tracheobronchial tree injury Traumatic aortic disruption Cardiac laceration Diaphragmatic rupture Rupture of the oesophagus
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.
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?
Disseminated intra vascular coagulation Cushings ulcers Curlings ulcers Dieulafoy lesion Mallory Weiss tear
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
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?
Acute exacerbation asthma Pulmonary embolus Mitral regurgitation Mitral valve stenosis Aortic dissection
Mitral valve stenosis
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?
Undertake an immediate laparotomy and splenectomy Undertake a laparoscopy and laparoscopic splenectomy Admit the child to the high dependency unit for close monitoring Arrange splenic artery embolisation Undertake a laparotomy and splenic repair
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.
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?
Tension pneumothorax Aortic transection Splenic rupture Haemopericardium Tracheobronchial dislocation
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.
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:
Epidural haematoma Sub dural haematoma Intra parenchymal brain haemorrhage Base of skull fracture None of the above
None of the above
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
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?
Le Fort 1 fracture affecting maxilla Le Fort 3 fracture affecting the maxilla Mandibular fracture Unilateral fracture of the zygoma Isolated temporal bone injury
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.
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?
Ventilate the patient in the prone position Escharotomy Extubate the patient Undertake skin grafting Transfer to a burns unit
Escharotomy
He requires an escharotomy as this will be contributing to impaired ventilation. That may need to precede transfer.
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 * 109/l
WBC 14 * 109/l
What is the most likely diagnosis? Septic shock secondary to appendicitis Neutropenic sepsis Phaeochromocytoma Perforated bowel Addisonian crisis
Addisonian
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.
crisis
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?
Deep vein thrombosis Disseminated intra vascular coagulation Rhabdomyolysis Myocardial infarct Glomerulonephritis
Rhabdomyolysis
Electrical high voltage burns are associated with rhabdomyolysis. Acute tubular necrosis may occur. Aggressive IV fluids should be given
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:
Tibial nerve neuropraxia Displaced tibial nail Compartment syndrome Deep vein thrombosis Sciatic nerve injury
Compartment syndrome
Severe pain in a limb should raise suspicions of compartment syndrome especially in tibial fractures following fixation with intra medullary devices
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?
Undertake a repair of the descending colon and place drains Resect the left colon and perform an end to end anastomosis Resect the left colon and construct a left iliac fossa end colostomy Place an omental patch over the defect in the colon and drains adjacent to this Perform a sub total colectomy and end ileostomy
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.
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?
Pneumothorax Myocardial contusion Cardiac tamponade Haemothorax Ventricular septal defect
Cardiac tamponade
The presence of a cardiac tamponade is suggested by Becks Triad:
Hypotension
Muffled heart sounds
Raised JVP
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?
Wernicke's encephalopathy and CVA Extra dural haematoma Decompensated liver failure and CVA Sub dural haematoma Vascular dementia
Extra dural haematoma
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.
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?
Acute phrenic nerve injury Cardiac tamponade Tension pneumothorax Aorta rupture Diaphragmatic rupture
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.
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?
Arrange a departmental abdominal USS scan Arrange an urgent abdominal MRI scan Perform a laparotomy Perform diagnostic peritoneal lavage Arrange an urgent abdominal CT scan
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.
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?
Pulmonary embolism Aortic dissection Mitral valve stenosis Pneumonia Pneumothorax
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.
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?
Discharge with advice to return if symptoms worsen Insertion of chest drain Admission for observation CT scanning of the chest Thoracocentesis
Insertion of chest drain
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.
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?
Functional disorder Malignant hyperthermia Oculogyric crisis Epilepsy Serotonin syndrome
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.
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?
Preservation of hair follicles Formation of vesicles or bullae Damage to sweat glands Healing by re-epithelialisation Pain at the burn site
Damage to sweat glands
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.
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?
Hypoglycaemia Bisoprolol Hypomagnesaemia Dehydration Hyperthyroidism
Hypomagnesaemia
Based on the current guidelines, which option regarding management of head injuries is false?
Opiates should be avoided Consider intubation if the GCS is <8 or = 8 Immediate CT head if there is > 1 episode of vomiting Half hourly GCS assessment until GCS is 15 Contact neurosurgeons if suspected penetrating injury
Opiates should be avoided
Pain should be controlled, with opiates preferably, as this avoids distress and hypertension post injury.
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?
Intra cerebral haematoma Sub dural haematoma Extra dural haematoma Intraventricular haemorrhage Sub arachnoid haemorrhage
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.
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?
Dextran 40 5% Dextrose Fresh frozen plasma Hartmans solution Blood
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
A 23 year old man sustains a severe facial fracture and reconstruction is planned. Which of the following investigations will facilitate pre-operative planning?
Mandibular tomography Magnetic resonance scan of face Skull X-ray Computerised tomography of the head Orthopantomogram
Computerised tomography of the head
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.
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?
Undertake an escharotomy Undertake debridement and skin grafting Transfer to a regional burns unit Intubate and admit to intensive care Discharge home with daily review
Transfer to a regional burns unit
This women has been resuscitated and requires transfer for specialist management.
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?
Pack the liver and close the abdomen Occlude the hepatic inflow with a pringles manoeuvre and suture the defects Occlude vascular inflow and resect the most severely affected area anatomically Perform a portosystemic shunt procedure Suture the defects without vascular occlusion
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.
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?
Pulmonary embolus Perforated peptic ulcer Oesophageal perforation Myocardial infarct Pneumothorax
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.
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?
IV Atropine IV Potassium IV Magnesium sulphate IV Bicarbonate IV Adrenaline
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.
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:
Conventional angiography Immediate exploration and repair Fasciotomy of the anterior compartment Observation for resolution of spasm Local wound exploration
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.
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?
Simple rib fractures Flail chest injury Cardiac tamponade Pneumothorax Aortic rupture
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
