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  • Question 1 - A 20 year old lady is involved in a motor vehicle accident in...

    Incorrect

    • A 20 year old lady is involved in a motor vehicle accident in which her car crashes head on into a truck. She complains of severe chest pain and a chest x-ray performed as part of a trauma series shows widening of the mediastinum. Which of the following is the most likely injury that she has sustained?

      Your Answer: Rupture of the aorta proximal to the left subclavian artery

      Correct Answer: Rupture of the aorta distal to the left subclavian artery

      Explanation:

      Answer: Rupture of the aorta distal to the left subclavian artery

      Aortic rupture is typically the result of a blunt aortic injury in the context of rapid deceleration. After traumatic brain injury, blunt aortic rupture is the second leading cause of death following blunt trauma. Thus, this condition is commonly fatal as blood in the aorta is under great pressure and can quickly escape the vessel through a tear, resulting in rapid haemorrhagic shock, exsanguination, and death.
      Traumatic aortic transection or rupture is associated with a sudden and rapid deceleration of the heart and the aorta within the thoracic cavity. Anatomically, the heart and great vessels (superior vena cava, inferior vena cava, pulmonary arteries, pulmonary veins, and aorta) are mobile within the thoracic cavity and not fixed to the chest wall, unlike the descending abdominal aorta. Injury to the aorta during a sudden deceleration commonly originates near the terminal section of the aortic arch, also known as the isthmus. This portion lies just distal to the take-off of the left subclavian artery at the intersection of the mobile and fixed portions of the aorta.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
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  • Question 2 - A middle aged man who is reported to have a penicillin allergy is...

    Incorrect

    • A middle aged man who is reported to have a penicillin allergy is given a dose of intravenous co-amoxiclav before undergoing an inguinal hernia repair. His vital signs a few minutes after are: pulse 131bpm and blood pressure 61/42mmHg. Which of the following is the first line treatment?

      Your Answer:

      Correct Answer: Adrenaline 1:1000 IM

      Explanation:

      Answer: Adrenaline 1:1000 IM

      Early treatment with intramuscular adrenaline is the treatment of choice for patients having an anaphylactic reaction. IM Injection:

      Adults: The usual dose is 500 micrograms (0.5ml of adrenaline 1/1000). If necessary, this dose may be repeated several times at 5-minute intervals according to blood pressure, pulse and respiratory function.

      Additional measures

      Beta2-agonists for bronchospasm: administer salbutamol or terbutaline by aerosol or nebuliser.

      Antihistamines: administer both H1and H2receptor blockers slowly intravenously:
      promethazine 0.5-1 mg/kg
      and
      ranitidine 1 mg/kg or famotidine 0.4 mg/kg or cimetidine 4 mg/kg
      Corticosteroids: administer intravenously: hydrocortisone 2-6 mg/kg or dexamethasone 0.1-0.4 mg/kg
      Nebulised adrenaline (5 mL of 1:1000) may be tried in laryngeal oedema and often will ease upper airways obstruction. However, do not delay intubation if upper airways obstruction is progressive.

      Anaphylaxis is an acute, potentially fatal, multiorgan system reaction caused by the release of chemical mediators from mast cells and basophils. The classic form involves prior sensitization to an allergen with later reexposure, producing symptoms via an immunologic mechanism.

      Anaphylaxis most commonly affects the cutaneous, respiratory, cardiovascular, and gastrointestinal systems. The skin or mucous membranes are involved in 80-90% of cases. A majority of adult patients have some combination of urticaria, erythema, pruritus, or angioedema. However, for poorly understood reasons, children may present more commonly with respiratory symptoms followed by cutaneous symptoms. It is also important to note that some of the most severe cases of anaphylaxis present in the absence of skin findings.

      Initially, patients often experience pruritus and flushing. Other symptoms can evolve rapidly, such as the following:

      Dermatologic/ocular: Flushing, urticaria, angioedema, cutaneous and/or conjunctival injection or pruritus, warmth, and swelling

      Respiratory: Nasal congestion, coryza, rhinorrhoea, sneezing, throat tightness, wheezing, shortness of breath, cough, hoarseness, dyspnoea

      Cardiovascular: Dizziness, weakness, syncope, chest pain, palpitations

      Gastrointestinal: Dysphagia, nausea, vomiting, diarrhoea, bloating, cramps

      Neurologic: Headache, dizziness, blurred vision, and seizure (very rare and often associated with hypotension)

      Other: Metallic taste, feeling of impending doom

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
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  • Question 3 - A 52 year old man presents to the emergency department with a stab...

    Incorrect

    • A 52 year old man presents to the emergency department with a stab wound to his left iliac fossa. He is hemodynamically unstable and is taken immediately to the OT for emergency laparotomy. During surgery, colonic mesentery is found to be injured that has resulted in the blood loss. The left colon is also injured with signs of local perforation and contamination. Which of the following is the most important aspect of management?

      Your Answer:

      Correct Answer: Resect the left colon and construct a left iliac fossa end colostomy

      Explanation:

      Colonic injuries that are managed with resection are associated with a high complication rate regardless of whether an anastomosis or colostomy is performed. Colonic resection and anastomosis can be performed safely in the majority of patients with severe colonic injury, including injuries to the left colon. For injuries of the right colon, an ileocolostomy has a lower incidence of leakage than a colocolonic anastomosis. For injuries to the left colon, there remains a role for colostomy specifically in the subgroups of patients with a high ATI or hypotension, because these patients are at greater risk for an anastomotic leak. The role of resection and primary anastomosis versus colostomy in colonic trauma requires further investigation.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
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  • Question 4 - A 64 year old man registered at the hernia clinic, suddenly presents with...

    Incorrect

    • A 64 year old man registered at the hernia clinic, suddenly presents with speech problems and left sided weakness which has lasted longer than 5 minutes. The head CT shows no signs of intracerebral bleed. Which of the following would be the next most appropriate step of management?

      Your Answer:

      Correct Answer: Urgent referral for thrombolysis

      Explanation:

      Patients treated with moderate-dose intravenous thrombolysis within 3 hours after the onset of stroke symptoms benefit substantially from therapy, despite a modest increase in the rate of symptomatic haemorrhage. 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. According to the current guidelines, in order to limit the
      risk of an intracranial haemorrhagic complication, no antiplatelet treatment should be administered in the 24 hours that follow treatment of an ischemic stroke by intravenous thrombolysis.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
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  • Question 5 - A 46-year-old male complains of sharp chest pain. He is due to have...

    Incorrect

    • A 46-year-old male 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 pressure 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?

      Your Answer:

      Correct Answer: Thrombolysis with Alteplase

      Explanation:

      The patient has Pulmonary embolism (PE).
      PE is when a thrombus becomes lodged in an artery in the lung and blocks blood flow to the lung. Pulmonary embolism usually arises from a thrombus that originates in the deep venous system of the lower extremities; however, it rarely also originates in the pelvis, renal, upper extremity veins, or the right heart chambers. After travelling to the lung, large thrombi can lodge at the bifurcation of the main pulmonary artery or the lobar branches and cause hemodynamic compromise.
      The classic presentation of PE is the abrupt onset of pleuritic chest pain, shortness of breath, and hypoxia. However, most patients with pulmonary embolism have no obvious symptoms at presentation. Rather, symptoms may vary from sudden catastrophic hemodynamic collapse to gradually progressive dyspnoea.
      Physical signs of pulmonary embolism include the following:
      Tachypnoea (respiratory rate >16/min): 96%
      Rales: 58%
      Accentuated second heart sound: 53%
      Tachycardia (heart rate >100/min): 44%
      Fever (temperature >37.8°C [100.04°F]): 43%
      Diaphoresis: 36%
      S3 or S4 gallop: 34%
      Clinical signs and symptoms suggesting thrombophlebitis: 32%
      Lower extremity oedema: 24%
      Cardiac murmur: 23%
      Cyanosis: 19%
      Management
      Anticoagulation and thrombolysis
      Immediate full anticoagulation is mandatory for all patients suspected of having DVT or PE. Diagnostic investigations should not delay empirical anticoagulant therapy.
      Thrombolytic therapy should be used in patients with acute pulmonary embolism who have hypotension (systolic blood pressure< 90 mm Hg) who do not have a high bleeding risk and in selected patients with acute pulmonary embolism not associated with hypotension who have a low bleeding risk and whose initial clinical presentation or clinical course suggests a high risk of developing hypotension.
      Long-term anticoagulation is critical to the prevention of recurrence of DVT or pulmonary embolism because even in patients who are fully anticoagulated, DVT and pulmonary embolism can and often do recur.
      Thrombolytic agents used in managing pulmonary embolism include the following:
      – Alteplase
      – Reteplase

      Heparin should be given to patients with intermediate or high clinical probability before imaging.
      Unfractionated heparin (UFH) should be considered (a) as a first dose bolus, (b) in massive PE, or (c) where rapid reversal of effect may be needed.
      Otherwise, low molecular weight heparin (LMWH) should be considered as preferable to UFH, having equal efficacy and safety and being easier to use.
      Oral anticoagulation should only be commenced once venous thromboembolism (VTE) has been reliably confirmed.
      The target INR should be 2.0–3.0; when this is achieved, heparin can be discontinued.
      The standard duration of oral anticoagulation is: 4–6 weeks for temporary risk factors, 3 months for first idiopathic, and at least 6 months for other; the risk of bleeding should be balanced with that of further VTE.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
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  • Question 6 - A 13 year old boy is admitted to the surgical ward with appendicitis....

    Incorrect

    • A 13 year old boy is admitted to the surgical ward with appendicitis. Medical history shows that he has been taking Metoclopramide. He is normally fit and well. However, he is reported to be acting strange and on examination, he is agitated with a clenched jaw and eyes are deviated upwards. What is his diagnosis?

      Your Answer:

      Correct Answer: Oculogyric crisis

      Explanation:

      Answer: Oculogyric crisis

      Oculogyric crisis is an acute dystonic reaction of the ocular muscles characterized by bilateral dystonic elevation of visual gaze lasting from seconds to hours. This reaction is most commonly explained as an adverse reaction to drugs such as antiemetics, antipsychotics, antidepressants, antiepileptics, and antimalarials. Metoclopramide is a benzamide selective dopamine D2 receptor antagonist that is used as an antiemetic, with side effects that are seen frequently in children.1 The most common and most important side effects of metoclopramide are acute extrapyramidal symptoms, which require immediate treatment. Acute dystonic reactions occur as contractions of the muscles, opisthotonos, torticollis, dysarthria, trismus, and oculogyric crisis.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
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  • Question 7 - A 27-year-old man presents to the A&E department with a headache and odd...

    Incorrect

    • A 27-year-old man presents to the A&E department with a headache and odd behaviour after being hit on the side of his head by a bat. Whilst waiting for a CT scan, he becomes drowsy and unresponsive.

      What is the most likely underlying injury?

      Your Answer:

      Correct Answer: Extradural haematoma

      Explanation:

      Extradural haematoma is the most likely cause of this patient’s symptomology. The middle meningeal artery is prone to damage when the temporal side of the head is hit.

      Patients who suffer head injuries should be managed according to ATLS principles and extracranial injuries should be managed alongside cranial trauma. Inadequate cardiac output compromises the CNS perfusion, irrespective of the nature of cranial injury.

      An extradural haematoma is a collection of blood in the space between the skull and the dura mater. It often results from acceleration-deceleration trauma or a blow to the side of the head. The majority of extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. There is often loss of consciousness following a head injury, a brief regaining of consciousness, and then loss of consciousness again—lucid interval. Other symptoms may include headache, confusion, vomiting, and an inability to move parts of the body. Diagnosis is typically by a CT scan or MRI, and treatment is generally by urgent surgery in the form of a craniotomy or burr hole.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      0
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  • Question 8 - A 24-year-old woman sustains a simple rib fracture resulting from a fall. On...

    Incorrect

    • A 24-year-old woman sustains a simple rib fracture resulting from a fall. On examination, a small pneumothorax is found.

      What should be the most appropriate course of action?

      Your Answer:

      Correct Answer: Insertion of chest drain

      Explanation:

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

      Pneumothorax is a collection of free air in the chest cavity that causes the lung to collapse. The most common cause of pneumothorax is lung laceration with air leakage. In some instances, the lung continues to leak air into the chest cavity and results in compression of the chest structures, including vessels that return blood to the heart. This is known as a tension pneumothorax and can be fatal if not treated immediately. Blunt or penetrating chest trauma that creates a flap-type defect on the surface of the lung can result in this life-threatening condition.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
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  • Question 9 - A 29-year-old woman is brought to the A&E department with chest pain after...

    Incorrect

    • A 29-year-old woman is brought to the A&E department with chest pain after being involved in a road traffic accident. Clinical examination is essentially unremarkable and she is discharged. However, she is subsequently found dead at home.

      What could have been the most likely underlying injury?

      Your Answer:

      Correct Answer: Traumatic aortic disruption

      Explanation:

      Aortic injuries not resulting in immediate death may be due to a contained haematoma. Clinical signs are subtle, and diagnosis may not be apparent on clinical examination. Without prompt treatment, the haematoma usually bursts and the patient dies.

      Traumatic aortic disruption, or aortic transection, is typically the result of a blunt aortic injury in the context of rapid deceleration. This condition is commonly fatal as blood in the aorta is under great pressure and can quickly escape the vessel through a tear, resulting in rapid haemorrhagic shock and death. A temporary haematoma may prevent the immediate death. Injury to the aorta during a sudden deceleration commonly originates near the terminal section of the aortic arch, also known as the isthmus. This portion lies just distal to the take-off of the left subclavian artery at the intersection of the mobile and fixed portions of the aorta. As many as 80% of the patients with aortic transection die at the scene before reaching a trauma centre for treatment.

      A widened mediastinum may be seen on the X-ray of a person with aortic rupture. Other findings on CXR may include:
      1. Deviation of trachea/oesophagus to the right
      2. Depression of left main stem bronchus
      3. Widened paratracheal stripe/paraspinal interfaces
      4. Obliteration of space between aorta and pulmonary artery
      5. Rib fracture/left haemothorax

      Diagnosis can be made by angiography, usually CT aortogram.

      Treatment options include repair or replacement. The patient should, ideally, undergo endovascular repair.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
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  • Question 10 - A 36 year old female who is admitted in the intensive care unit...

    Incorrect

    • A 36 year old female who is admitted in the intensive care unit after being involved in a motor vehicle accident is being considered as an organ donor following discussion with her family. What is not a precondition for the diagnosis of brainstem death?

      Your Answer:

      Correct Answer: A PaCO2 of > 7 kPa has been documented

      Explanation:

      In adults 50% of the cases of brain death follow severe head injury, 30% are due to subarachnoid haemorrhage and 20% are due to a severe hypoxic-ischaemic event. Thus supra-tentorial catastrophes lead to pressure effect which cause the irretrievable death of the brain-stem.

      The Criteria for Diagnosis of Brain-Stem Death

      All the pre-conditions must be satisfied and
      there should be demonstrably no pharmacological or
      metabolic reason for the coma before formally testing the
      integrity of the brain-stem reflexes.

      Pre Conditions
      1. The patient is comatose and mechanically ventilated
      for apnoea.
      2. The diagnosis of structural brain damage has been
      established or the immediate cause of coma is known.
      3. A period of observation is essential.

      Exclusions
      1. Drugs are not the cause of coma e.g. barbiturates.
      Neuromuscular blockade has been demonstrably reversed.
      2. Hypothermia does not exist.
      3. There is no endocrine or metabolic disturbance.

      Testing for Brain-Stem Death
      Reflexes involving brain-stem function.
      1. No pupillary response to light.
      2. No corneal reflex.
      3. No vestibulo ocular reflex (Caloric test).
      4. Doll’s eye reflex
      5. No motor response to pain – in the Vth nerve distribution.
      6. No gag reflex in response to suction through endotracheal tube or tracheostomy.
      7. Apnoea persists despite a rise in PaCO2 to greater than 50 mmHg (6.6kPa) against a background of a normal PaO2.

      Diagnosis is to be made by two doctors who have been registered for more than five years and are competent in the procedure. At least one should be a consultant. Testing should be undertaken by the doctors together and must always be performed completely and successfully on two occasions in total.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
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SESSION STATS - PERFORMANCE PER SPECIALTY

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