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
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 oC, HR 130bpm and blood pressure is 95/40mmHg. What is the best test to confirm his diagnosis?
USS abdomen Direct Coomb's test Blood cultures Blood film Sickle cell test
Direct Coomb’s test
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.
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?
Aspirin Thrombolysis with Alteplase Unfractionated heparin Thrombolysis with streptokinase Clopidogrel
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!).
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?
Split thickness skin graft Rotational skin flap Delayed primary closure Simple primary closure Use of vacuum closure system
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.
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?
10ml of 10% calcium chloride over 10 minutes 20% albumin infusion 10ml of 10% calcium gluconate over 10 minutes No action 10ml of 10% calcium chloride over 4 hours
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.
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?
Fat embolism Tension pneumothorax Rupture of the right main bronchus Rupture of the diaphragm Pulmonary contusion
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.
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?
Rupture of the distal oesophagus Rupture of the left main bronchus Rupture of the aorta proximal to the left subclavian artery Rupture of the aorta distal to the left subclavian artery Rupture of the inferior vena cava
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 occu
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?
Oesophageal cancer Achalasia Reflux disease Oesophageal candidiasis Pulmonary embolus
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.
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?
Pancreatitis Parvovirus infection Sickle cell anaemia Pulmonary embolism Beta Thalassaemia minor
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.
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?
Thoracotomy in theatre Thoracotomy in ED CT angiogram Bronchoscopy MRI aortic arch
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
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?
Manage conservatively Arrange USS Transfer to centre for interventional radiology Discharge Splenectomy
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
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?
Altered cutaneous sensation from the forehead to the vertex Ptosis Complete opthalmoplegia Nystagmus Enopthalmos
Nystagmus
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. As such opthalmoplegia will be present and nystagmus cannot occur.
Which option is not recommended during the management of compartment syndrome?
Anticoagulation Keep limb level with the body Intravenous fluids Pain control Fasciotomy
Anticoagulation
Anticoagulation will worsen compartment syndrome.
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?
8 6 10 5 12
8
E=2, V=2, M=4.
Appropriate flexion to pain carries a higher score than decorticate posturing or inappropriate flexion.
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?
Rotator cuff tear Biceps tendon rupture Bankart lesion Axillary nerve injury Infraspinatus tendinitis
Bankart lesion
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.
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.
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?
Bilateral thoracoscopy and mediastinoscopy Midline sternotomy Bilateral posterolateral thoracotomy Clam shell thoracotomy None of the above
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.
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?
Aspirin 75mg Clopidogrel 75mg Aspirin 300mg Clopidogrel 300mg Direct admission to angiography suite
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. Thrombolysis or urgent percutaneous intervention should be given if there are significant ECG changes.
Which of the following is not a change found on an ECG in acute pulmonary embolism?
No changes J waves P pulmonale Right ventricular strain T wave inversion in the inferior leads
J waves
J waves are pathognomonic of hypothermia.
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 29oC. Which method is most effective at raising the core temperature?
Re-warming with electric blankets Increasing the room temperature Instillation of warm intravesical fluid Instillation of warmed rectal fluid Instillation of warmed intra peritoneal fluid
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.
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 * 109/l
WBC 15.4 * 109/l
What management is needed immediately?
Ceftriaxone IV Hydrocortisone 50mg IV CT scan abdomen Urgent exploratory laparotomy Hydrocortisone 100mg IV
Hydrocortisone 100mg IV
This patient has acute adrenal insufficiency and urgently needs steroid replacement.
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?
Hydrocortisone 100mg IV Adrenaline 1:1000 IV Chlorpheniramine 10mg IV Adrenaline 1:1000 IM Adrenaline 1:10000 IV
Adrenaline 1:1000 IM
The first line treatment of anaphylactic shock is intra muscular adrenaline.
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?
Haemodialysis Escharotomy Fasciotomy Cardiac bypass Non invasive ventilation
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.
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
10 6 3 7 4
6
E=2, V= 2, M=2.
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?
Microscopy to identify red blood cells Lab stix testing for glucose Lab stix testing for protein Beta 2 transferrin assay Microscopy, gram stain and culture
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.
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?
Deroof the blister and review in outpatients Intravenous fluids calculated according to extent of burned area Broad spectrum intravenous antibiotics Debridement and skin grafting Burn excision
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.
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?
Cerebral haemorrhage in left temporal parietal area Opiate overdose Cerebral haemorrhage in right temporal parietal area Diazepam overdose Basilar artery occlusion
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.
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?
Protein Haemoglobin Myoglobin Erythrocytes Lymphocytes
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.
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?
Undertake a CT scan of the abdomen Undertake an abdominal USS Undertake diagnostic peritoneal lavage Undertake a splenectomy Arrange an angiogram and possibly proceed to embolisation
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
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?
Pulmonary embolism Aortic dissection Mitral valve regurgitation Myocardial infarct Myocarditis
Pulmonary embolism
Chest pain, hypoxia and clear chest on auscultation in pregnancy should lead to a high suspicion of pulmonary embolism.
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?
Intravenous flumazenil Intravenous naloxone Intravenous benxhexol No further management Intravenous glycopyrolate
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.
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?
Right bundle branch block ST elevation of 1mm in leads V1 to V6 Ventricular tachycardia Q waves in leads V1 to V6 ST elevation of greater than 1mm in leads II, III and aVF
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
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?
Primary closure using deep tension sutures Primary closure in layers Delayed primary closure Full thickness skin graft Split thickness skin graft
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.
A 19 year old student falls from a 2nd floor window. He is persistently hypotensive. A CXR shows depression of the left main bronchus and deviation of the trachea to the right. What is the most likely injury?
Tension pneumothorax Parenchymal lung injury Aortic rupture Cardiac tamponade Flail chest
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. The presence of persistent hypotension, from a early stage is more consistent with haematoma than a tension pneumothorax in which it occurs as a final periarrest phenomena.
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?
Amputation Skeletal traction Application of external fixator and arterial reconstruction Insertion of intramedullary nail and arterial reconstruction Application of plate to tibia and arterial reconstruction
Amputation
This man is unstable, and at 7 hours after extraction, the limb is not viable. The safest option is primary amputation.
Which of the following is not typically associated with a degloving injury?
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 Poor results when primary compression treatment is used in preference to skin grafting
Improved results when the degloved segment is left in situ as a temporary closure
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.
Which of the following statements relating to large volume blood loss in trauma is incorrect?
Tranexamic acid reduces the incidence of rebleeding following surgery Hypocalcaemia may complicate resuscitation Colloids are preferred initially as they reduce the incidence of coagulopathy 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
Colloids are preferred initially as they reduce the incidence of coagulopathy
Fresh blood is the fluid of choice when large volume blood loss complicates trauma. Mortality is doubled when blood >3 weeks old is used.
The following features are typical of superficial partial dermal burns except:
Erythema Absence of blisters Spontaneous healing in most cases No extension beyond proximal dermal papillae Good capillary refill at the burn site
Absence of blisters
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.
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?
CT scanning of the thorax Insertion of intercostal tube drain Video assisted thoracoscopy Thoracotomy CT angiogram of the thorax
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.
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?
Chest infection Boerhaaves syndrome Oesophageal cancer Pulmonary embolus Myocardial infarct
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.
Which of the following is not a feature found on a CXR in traumatic aortic disruption?
Widened mediastinum Trachea deviated to the left Depression of the left main stem bronchus Obliteration of the aortic knob Widened paraspinal interfaces
Trachea deviated to the left
The trachea is normally deviated to the right.
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?
Insertion of 14Fr chest drain Thoracotomy in ED Insertion of 36 Fr chest drain Thoracotomy in theatre Thoracoscopy
Insertion of 36 Fr chest drain
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?
Procainamide Lidocaine Amiodarone Adenosine Verapamil
Verapamil
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
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?
Aspirin 300mg Aspirin 75 mg Clopidogrel 300mg Urgent referral for thrombolysis Carotid endarterectomy
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.
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?
Nebulised salbutamol Intravenous bicarbonate Haemodialysis Insulin/dextrose infusion Intravenous calcium gluconate
Intravenous calcium gluconate
The first priority in this patient is to stabilise the myocardium with intravenous calcium gluconate.
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?
Fasciotomy Escharotomy Angioplasty Pain control Anticoagulation
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.
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?
Pulmonary embolism Cardiac tamponade Fat embolism Tension pneumothorax Adult respiratory distress syndrome
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.
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?
They have a leathery appearance The burn area is extremely painful until skin grafted They always heal with scarring Blanching does not occur under pressure Absence of,or few, blisters
The burn area is extremely painful until skin grafted
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
Which of the features below, following a head injury, is not an indication for an immediate CT head scan in children?
Drowsiness A single, discrete episode of vomiting A 9 month old child with a 6cm haematoma on the head Numb left arm Suspicion of a non accidental head injury
A single, discrete episode of vomiting
Whilst not an indication for immediate CT there should be a low threshold for admission and observation.
What is the least likely examination finding in patients with Le Fort II fractures?
Excessive mobility of the palate Paraesthesia in the region supplied by the inferior alveolar nerve Malocclusion of the teeth Enopthalmos Parasthesia in the region supplied by the infraorbital nerve
Paraesthesia in the region supplied by the inferior alveolar 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.
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?
Use of a VAC wound management system Rotational skin flap Deep tension sutures and primary closure Pedicled myocutaneous flap Delayed primary closure
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.
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?
Psoas haemorrhage Acute sequestration Parvovirus Splenic haemorrhage Acute haemolysis
Parvovirus
A sudden anemia and a LOW reticulocute 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!
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?
Pulmonary embolism Boerhaaves syndrome Inferior myocardial infarct Prinzmetal angina Anterior myocardial infarct
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.
A 17 year old boy 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?
Aortic transection Haemopericardium Simple pneumothorax Tension pneumothorax Tracheobronchial dislocation
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.
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?
IV heparin Clopidogrel Burr hole surgery Aspirin Hemicranieotomy
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
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?
Proceed to splenectomy Attempt measures to conserve the spleen Resection of the inferior pole of the spleen Ligate the splenic vein alone Fully mobilise the spleen to inspect it
Attempt measures to conserve the spleen
Mobilising the spleen will result in removal. Splenic injuries like this are amenable to conservation.
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?
Sick euthyroid syndrome Graves disease Hashimotos thyroiditis Levothyroxine None of the above
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).
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?
10 8 15 13 11
13
E=3, V=4, M=6.
