USMLE STEP 3 SURGERY

Question 1

First step in the management of trauma and change in mental status.

Answer 1

Establish airway

Question 2

Best step in securing an airway when trauma patient has cervical spine injury?

Answer 2

Use flexible bronchoscope and orotracheal intubation with manual cervical immobilization.

Question 3

2 ways to secure and airway when trauma patient has extensive facial trauma or bleeding into their airway/gurgling sounds.

Answer 3

cricothyroidotomy and percutaneous tracheostomy

Question 4

First thing to do when oxygen saturation drops < 90

Answer 4

Obtain ABG

Try to find likely cause of hypoxia based on history

Question 5

Normal PC02?

Answer 5

40

Question 6

Normal Bicarb

Answer 6

24

Question 7

First step in management of a patient in hypotensive shock?

Answer 7

Find and control the source of bleeding

Question 8

Best way to identify hypovolemic shock

Answer 8

R atrial pressure, Pulmonary capillary wedge pressure, cardiac index and mixed venous saturation are all decreased. The only thing increased is systemic vascular resistance.

Question 9

2 chest trauma conditions that manifest as distended neck veins and high CVP?

Answer 9

Pericardial tamponade and tension pneumothorax.

Question 10

Dx & Next step in management:

enlarged heart on CXR, electrical alternans on EKG, pulsus paradoxus on vs,

Answer 10

Pericardial tamponade

Do pericardiocentesis and pericardial window if unsuccessful.

Question 11

Dx and next step in management:

respiratory distress, tracheal deviation, absent breath sounds and hyperresonance to percussion.

Answer 11

Large bore needle or IV catheter into pleural space followed by a chest tube.

Question 12

Where to insert an IV catheter or large bore needle when tension pneumothorax is the problem?

Answer 12

Second intercostal space

Question 13

What should you never wait for in order to diagnose a tension pneumothorax?

Answer 13

CXR

Question 14

The next step in management in a patient with abdominal trauma who is bleeding and hypotensive.

Answer 14

2 large bore IVs
give fluids and blood
type and screen
foley cath
IV abx
prepare for immediate exploratory lap

Question 15

First step in management in a patient in vasomotor shock (hypotension and tachycardia, warm and flushed). Bee sting or medication allergy etc

Answer 15

Vasoconstrictor and fluids

Question 16

Never do this in a patient who presents with a penetrating wound with damage to internal organs.

Answer 16

Never remove the embedded object in the ER, Head to the OR

Question 17

Next step in management: Asymptomatic robbery victim with a closed skull fracture and an overlying wound?

Answer 17

Clean and stitch laceration

Question 18

Next step in management: Asymptomatic robbery victim with a comminuted or depressed skull fracture.

Answer 18

OR immediately

Question 19

next step in management: a head trauma patient lost consciousness but has remained asymptomatic along with a no neurologic signs.

Answer 19

Not going home yet! CT head & neck without contrast, serial neuro exams

Question 20

Next step in management: Trauma patient with racoon eyes, clear fluid leaking from nose and ear.

Answer 20

CT head and neck to see basal skull fracture.

Expect possible facial palsy 2-3 days later due to neuropraxia.

Question 21

Dx and next step in management: Natasha Richardson falls in a colorado skii resort and suddenly looses consciousness but recovers and is lucid. CT head shows lens shaped/biconvex hematoma without a midline shift.

Answer 21

OR for emergency craniotomy
This is an arterial bleed from the middle meningeal artery, third branch of the maxillary artery which is from the external carotid artery.

Question 22

Dx and next step in management: An elderly woman on coumadin falls, hits her head and is having gradual headaches, memory loss, personality changes, deme ntia, confusion and drowsiness. Her consciousness is fluctuating. CT head shows semilunar, crescent shaped hematoma with midline shift.

Answer 22

Subdural hematoma

To OR now for emergency craniotomy

Question 23

Why order CT head without contrast to rule out head bleeds?

Answer 23

Blood and contrast look the same on CTs - so false positive