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  • Question 1 - A 9 year old girl is admitted to the A&E department after having...

    Incorrect

    • A 9 year old girl is admitted to the A&E department after having a fall. Her blood pressure is 101/56 mmHg, pulse is 91 and her abdomen is soft but tender on the left side. Imaging shows that there is a grade III splenic laceration. What is the best course of action?

      Your Answer: Undertake an immediate laparotomy and splenectomy

      Correct Answer: Admit the child to the high dependency unit for close monitoring

      Explanation:

      Answer: Admit the child to the high dependency unit for close monitoring.

      Grade 3: This mid-stage rupture is a tear more than 3 cm deep. It can also involve the splenic artery or a hematoma that covers over half of the surface area. A grade 3 rupture can also mean that a hematoma is present in the organ tissue that is greater than 5 cm or expanding.
      The trend in management of splenic injury continues to favour nonoperative or conservative management.
      Most haemodynamically stable injuries can be managed non-operatively (especially Grades I to III).

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      2
      Seconds
  • Question 2 - 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
      7
      Seconds
  • Question 3 - 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
      0
      Seconds
  • Question 4 - A 27-year-old professional tennis player presents to the A&E department with a swollen,...

    Incorrect

    • A 27-year-old professional tennis player presents to the A&E department with a swollen, painful right arm. On examination, his fingers are dusky.

      Out of the following, which is the most appropriate investigation?

      Your Answer:

      Correct Answer: Venous duplex scan

      Explanation:

      This patient has an axillary vein thrombosis. It classically presents with pain and swelling of the affected limb. Venous duplex scan is needed to exclude a thrombus.

      Primary proximal upper-extremity deep vein thrombosis (UEDVT) is less common than its secondary forms. The most common primary form is effort-related thrombosis, also called Paget-Schroetter syndrome. It usually occurs in, otherwise, healthy young men who report, before the onset of thrombosis, vigorous arm exercise such as lifting weights, playing badminton/tennis, pitching a baseball, or performing repetitive overhead activities, such as painting or car repair. Most patients with effort-related UEDVT have an underlying venous thoracic outlet syndrome (VTOS). Secondary causes of UEDVT include central line insertion, malignancy, or pacemakers.

      Patients with UEDVT typically present with heaviness, discomfort, pain, paraesthesia, and swelling of the affected arm. Physical examination may reveal pitting oedema, redness, or cyanosis of the involved extremity; visible collateral veins at the shoulder or upper arm; and fever.

      Diagnosis is made by:
      1. FBC: platelet function
      2. Coagulation profile
      3. Liver function tests
      4. Venous duplex scan: investigation of choice, provides information relating to flow and characteristics of the vessels.
      5. D-dimer testing
      6. CT scan: for VTOS

      Treatment options for primary UEDVT are as follows:
      1. Anticoagulation therapy should be undertaken with a once-daily regimen of LMWH or fondaparinux for at least five days, followed by vitamin K antagonists for at least three months. Unfractionated heparin instead of LMWH is recommended for patients with renal failure or for those treated with CDT.

      2. Early thrombus removal and restoration of venous patency aim should be done immediately after starting the patient on heparin. Catheter-based therapy is recommended for patients with proximal UEDVT of recent onset and severe symptoms, low risk for bleeding complications, and good functional status.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Vascular
      0
      Seconds
  • Question 5 - A 31-year-old woman who is 30 weeks pregnant presents with sudden onset of...

    Incorrect

    • A 31-year-old woman who is 30 weeks pregnant presents with sudden onset of chest pain associated with loss of consciousness. On examination, she is afebrile and her heart rate is 120 bpm, blood pressure is 170/90 mmHg, and saturation is 93% on 15L oxygen. Furthermore, an early diastolic murmur and occasional bibasilar crepitations are auscultated and mild pedal oedema is observed. Her ECG shows ST-segment elevation in leads II, III, and aVF.

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Aortic dissection

      Explanation:

      The most likely diagnosis is aortic dissection.

      Aortic dissection occurs following a tear in the aortic intima with subsequent separation of the tissue within the weakened media by the propagation of blood. There are four different classifications of aortic dissection and the commonest one used is the Stanford classification dividing them into type A and type B. A type A dissection involves the ascending aorta and/or the arch whilst type B dissection involves only the descending aorta and occurs distal to the origin of the left subclavian artery.

      Aortic dissection in pregnancy occurs most commonly in the third trimester due to the hyperdynamic state and hormonal effect on vasculature. Other common predisposing factors for aortic dissection include Marfans syndrome, Ehlers-Danlos syndrome, and bicuspid aortic valve. Aortic dissection often presents with sudden severe, tearing chest pain, vomiting, and syncope, most often from acute pericardial tamponade. The patient may be hypertensive, clinically. The right coronary artery may become involved in the dissection, causing myocardial infarct in up to 2% of the cases (hence ST-segment elevation in the inferior leads). An aortic regurgitant murmur may be auscultated.

      The management options during pregnancy include:
      1. <28 weeks of gestation: aortic repair with the foetus kept in utero
      2. 28–32 weeks of gestation: dependent on foetal condition
      3. >32 weeks of gestation: caesarean section followed by aortic repair in the same operation

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      0
      Seconds
  • Question 6 - A 26-year-old right-handed tennis player presents to the A&E department with a painful,...

    Incorrect

    • A 26-year-old right-handed tennis player presents to the A&E department with a painful, swollen right arm. On examination, his upper limb pulses are present, but he has dusky fingers. A diagnosis of axillary vein thrombosis is made and confirmed. He is immediately started on low-molecular-weight heparin (LMWH).

      What should be the next best step of management to achieve venous patency?

      Your Answer:

      Correct Answer: Catheter-directed tPA

      Explanation:

      Catheter-directed thrombolysis (CDT) is recommended as the next step of management for patients with proximal upper-extremity deep vein thrombosis (UEDVT) of recent onset or severe symptoms.

      Primary UEDVT is less common than secondary forms. The most common primary form is effort-related thrombosis, also called Paget-Schroetter syndrome. It usually occurs in otherwise healthy young men who report, before the onset of thrombosis, vigorous arm exercise such as lifting weights, playing badminton, pitching a baseball, or performing repetitive overhead activities, such as painting or car repair. Most patients with effort-related UEDVT have an underlying venous thoracic outlet syndrome (VTOS). Secondary causes of UEDVT include central line insertion, malignancy, or pacemakers.

      Patients with UEDVT typically present with heaviness, discomfort, pain, paraesthesia, and swelling of the affected arm. Physical examination may reveal pitting oedema, redness, or cyanosis of the involved extremity; visible collateral veins at the shoulder or upper arm; and fever.

      Diagnosis is made by:
      1. FBC: platelet function
      2. Coagulation profile
      3. Liver function tests
      4. Duplex scan: investigation of choice
      5. D-dimer testing
      6. CT scan: for VTOS

      Treatment options for primary UEDVT are as follows:
      1. Anticoagulation therapy should be undertaken with a once-daily regimen of LMWH or fondaparinux for at least five days, followed by vitamin K antagonists for at least three months. Unfractionated heparin instead of LMWH is recommended for patients with renal failure or for those treated with CDT.

      2. Early thrombus removal and restoration of venous patency should be done immediately after starting the patient on heparin. Catheter-based therapy is recommended for patients with proximal UEDVT of recent onset and severe symptoms, low risk for bleeding complications, and good functional status.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Vascular
      0
      Seconds
  • Question 7 - A 30 year old waiter is stabbed in the right upper quadrant during...

    Incorrect

    • A 30 year old waiter is stabbed in the right upper quadrant during a fight at the restaurant and is haemodynamically unstable. He is rushed to the hospital where a laparotomy is performed and the liver has some extensive superficial lacerations and is bleeding profusely. He becomes progressively more haemodynamically unstable. What is the best management option?

      Your Answer:

      Correct Answer: Pack the liver and close the abdomen

      Explanation:

      Perihepatic packing is a surgical procedure used in connection with surgery to the liver. In this procedure the liver is packed to stop non arterial bleeding, most often caused by liver injury.

      During this surgery laparotomy pads are placed around the site of the bleeding. The main purpose of hepatic packing is to prevent the person from succumbing to the trauma triad of death. Under- or over-packing of the liver can cause adverse outcomes, and if the bleeding cannot be controlled through this surgical method, the Pringle manoeuvre is an alternate technique that can be utilized.

      Rebleeding, constant decline of haemoglobin and increased transfusion requirement, as well as the failure of angioembolization of actively bleeding vessels are a few factors which indicate the need for laparotomy.

      The operative approach has also evolved over the last two decades. Direct suture ligation of the parenchymal bleeding vessel, perihepatic packing, repair of venous injury under total vascular isolation and damage control surgery with utilization of preoperative and/or postoperative angioembolization are the preferred methods, compared to anatomical resection of the liver and use of the atriocaval shunt.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      0
      Seconds
  • Question 8 - A 48-year-old female with haematemesis is admitted to accident and emergency in hypovolaemic...

    Incorrect

    • A 48-year-old female with haematemesis is admitted to accident and emergency in hypovolaemic shock. She undergoes resuscitation including administration of packed red cells. The blood transfusion centre will not release certain blood products unless a ‘massive bleeding’ protocol is initiated. Which of the following is not a definition of massive bleeding?

      Your Answer:

      Correct Answer: Ongoing blood loss of 100 mL/min

      Explanation:

      Various definitions of massive blood transfusion (MBT) have been published in the medical literature such as:

      – Replacement of one entire blood volume within 24 h

      – Transfusion of >10 units of packed red blood cells (PRBCs) in 24 h

      – Transfusion of >20 units of PRBCs in 24 h

      – Transfusion of >4 units of PRBCs in 1 h when on-going need is foreseeable

      – Replacement of 50% of total blood volume (TBV) within 3 h.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      0
      Seconds
  • Question 9 - A 42-year-old man is brought to the emergency department following a road traffic...

    Incorrect

    • A 42-year-old man is brought to the emergency department following a road traffic accident. He has sustained a flail chest injury and is hypotensive on arrival at the hospital. Examination shows an elevated jugular venous pressure and auscultation of the heart reveals muffled heart sounds.

      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Cardiac tamponade

      Explanation:

      This patient has presented with a classical picture of cardiac tamponade, suggested by Beck’s triad: hypotension, raised jugular venous pressure (JVP), and muffled heart sounds.

      Cardiac tamponade is a clinical syndrome caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent haemodynamic compromise. This condition is a medical emergency, the complications of which include pulmonary oedema, shock, and death.

      Patients with cardiac tamponade have a collection of three medical signs known as Beck’s triad. These are low arterial blood pressure, distended neck veins, and distant, muffled heart sounds. The diagnosis may be further supported by specific ECG changes, chest X-ray, or an ultrasound of the heart. If fluid increases slowly, the pericardial sac can expand to contain more than 2 L; however, if the increase is rapid, as little as 200 mL can result in tamponade.

      Management options may include pericardiocentesis, surgery to create a pericardial window, or a pericardiectomy.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      0
      Seconds
  • Question 10 - A 30-year-old man sustains a severe facial fracture, and reconstruction is planned. Which...

    Incorrect

    • A 30-year-old man sustains a severe facial fracture, and reconstruction is planned. Which of the following investigations will facilitate preoperative planning?

      Your Answer:

      Correct Answer: Computerised tomography of the head

      Explanation:

      Significant facial fractures may have an intracranial effect. Computerised tomography (CT) scan of the head allows delineation of the injury extent, and a 3D reconstruction of images can be done. An Orthopantomogram (OPT) provides good images of mandible and surrounding bony structures but cannot give intracranial details. X-ray of the skull lacks the details important in modern practice.

      Craniomaxillofacial (CMF) injuries in the UK are due to:
      1. Interpersonal violence (52%)
      2. Motor vehicle accidents (16%)
      3. Sporting injuries (19%)
      4. Falls (11%)

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      0
      Seconds
  • Question 11 - A 40-year-old male pedestrian is brought to the A&E department after being hit...

    Incorrect

    • A 40-year-old male pedestrian is brought to the A&E department after being hit by a car. On examination, he is found to be dyspnoeic and hypoxic despite administration of high flow oxygen therapy. Moreover, his pulse is 115bpm and blood pressure is 110/70 mmHg. The right side of his chest is hyper-resonant on percussion and has decreased breath sounds. His trachea is deviated to the left.

      What is the most likely underlying diagnosis?

      Your Answer:

      Correct Answer: Tension pneumothorax

      Explanation:

      This patient has developed a tension pneumothorax following a blunt trauma.

      Tension pneumothorax is a life-threatening condition that develops when air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary function. Blunt or penetrating chest trauma that creates a flap-type defect on the surface of the lung can result in this life-threatening condition.

      Signs and symptoms of tension pneumothorax include:
      1. Chest pain that usually has a sudden onset, is sharp, and may lead to feeling of tightness in the chest
      2. Dyspnoea and progressive hypoxia
      3. Tachycardia
      4. Hyperventilation
      5. Cough
      6. Fatigue

      On examination, hyper-resonant percussion note and tracheal deviation are typically found. Treatment is immediate without waiting for the CXR result and includes needle decompression and chest tube insertion.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      0
      Seconds
  • Question 12 - A 28-year-old electrician is brought to the A&E department after a high-voltage full-thickness...

    Incorrect

    • A 28-year-old electrician is brought to the A&E department after a high-voltage full-thickness burn to his left leg. His urinalysis shows haematuria 1+ and his blood reports show mild hyperkalaemia and serum CK level of 3000 U/L.

      What is the most likely explanation?

      Your Answer:

      Correct Answer: Rhabdomyolysis

      Explanation:

      High-voltage electrical burns are associated with rhabdomyolysis. Acute tubular necrosis may also occur.

      Electrical burns occur following exposure to electrical current. Full-thickness burns are third-degree burns. With these types of burns, the epidermal and dermal layers of skin are destroyed, and the damage may even penetrate the layer of fat beneath the skin.

      Following the burn, there is a local response with progressive tissue loss and release of inflammatory cytokines. Systemically, there are cardiovascular effects resulting from fluid loss and sequestration of fluid into the third space. There is a marked catabolic response as well. Immunosuppression is common with large burns, and bacterial translocation from the gut lumen is a recognised event. Sepsis is a common cause of death following major burns.

      After the initial management and depth assessment of the burn, the patient is transferred to burn centre if:
      1. Needs burn shock resuscitation
      2. Face/hands/genitals affected
      3. Deep partial-thickness or full-thickness burns
      4. Significant electrical/chemical burns

      Management options include:
      1. The initial aim is to stop the burning process and resuscitate the patient. Adults with burns greater than 15% of total body surface area require burn fluid resuscitation. Fluids administration is calculated using the Parkland formula. Half of the fluid is administered in the first eight hours. A urinary catheter should be inserted and analgesics should be started.

      2. Conservative management is appropriate for superficial burns and mixed superficial burns that will heal in two weeks. More complex burns may require excision and skin grafting. Excision and primary closure is not generally practised as there is a high risk of infection.

      3. Circumferential full-thickness burns affecting a limb or severe torso burns impeding respiration may require escharotomy to divide the burnt tissue.

      4. There is no evidence to support the use of antimicrobial prophylaxis or topical antibiotics in burn patients.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      0
      Seconds
  • Question 13 - A 20 year old man is involved in a car accident where he...

    Incorrect

    • A 20 year old man is involved in a car accident where he is thrown out of the car. He is seen with distended neck veins and a weak pulse on admission. The trachea is central. Which of the following is the most likely cause?

      Your Answer:

      Correct Answer: Hemopericardium

      Explanation:

      Answer: Hemopericardium

      Hemopericardium refers to the presence of blood within the pericardial cavity, i.e. a sanguineous pericardial effusion. If enough blood enters the pericardial cavity, then a potentially fatal cardiac tamponade can occur. There is a very long list of causes but some of the more common are:
      -ruptured myocardial infarction
      -ruptured left ventricular aneurysm
      -aortic dissection
      -pericarditis
      -trauma
      -blunt/penetrating/deceleration
      -iatrogenic, e.g. pacemaker wire insertion
      -cardiac malignancies
      -ruptured coronary artery aneurysm
      -post-thrombolysis

      Cardiac tamponade is a clinical syndrome caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise. The condition is a medical emergency, the complications of which include pulmonary oedema, shock, and death.
      Symptoms vary with the acuteness and underlying cause of the tamponade. Patients with acute tamponade may present with dyspnoea, tachycardia, and tachypnoea. Cold and clammy extremities from hypoperfusion are also observed in some patients. Other symptoms and signs may include the following:
      Elevated jugular venous pressure

      Pulsus paradoxus

      Chest pressure

      Decreased urine output

      Confusion

      Dysphoria

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      0
      Seconds
  • Question 14 - A 40-year-old woman is in the surgical intensive care unit. She suffered a...

    Incorrect

    • A 40-year-old woman is in the surgical intensive care unit. She suffered a flail chest injury several hours ago and was, subsequently, intubated and ventilated. However, for the past few minutes, she has become increasingly hypoxic and now requires increased ventilation pressures.

      What is the most likely cause of such deterioration?

      Your Answer:

      Correct Answer: Tension pneumothorax

      Explanation:

      A flail chest segment may lacerate the underlying lung and create a flap valve. Tension pneumothorax can, therefore, occur by intubation and ventilation in this situation.

      Tension pneumothorax is a life-threatening condition that develops when air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary function. The development of a tension pneumothorax can be life-threatening during mechanical ventilation, since with each breath, the pressure within the pneumothorax becomes greater, compromising both ventilatory and cardiovascular function.

      Signs and symptoms of tension pneumothorax include:
      1. Chest pain that usually has a sudden onset, is sharp, and may lead to feeling of tightness in the chest
      2. Dyspnoea and progressive hypoxia
      3. Tachycardia
      4. Hyperventilation
      5. Cough
      6. Fatigue

      On examination, hyper-resonant percussion note and tracheal deviation are typically found.

      CXR shows:
      1. Lung collapse towards the hilum
      2. Contralateral mediastinal deviation
      3. Diaphragmatic depression and increased rib separation
      4. Increased thoracic volume
      5. Ipsilateral flattening of the heart border

      Management options for tension pneumothorax include
      immediate needle decompression followed by definitive wide-bore chest drain insertion (without waiting for CXR results).

    • 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 15 - A 48-year-old male is admitted after his clothing caught fire. He suffers a...

    Incorrect

    • A 48-year-old male is admitted after his clothing caught fire. He suffers a full-thickness circumferential burn to his lower thigh. He complains of increasing pain in the lower leg and on examination, there is paraesthesia and severe pain in the lower leg. Foot pulses are normal. What is the most likely explanation?

      Your Answer:

      Correct Answer: Compartment syndrome

      Explanation:

      Full-thickness circumferential and near-circumferential skin burns result in the formation of a tough, inelastic mass of burnt tissue (eschar). The eschar, by virtue of this inelasticity, results in the burn-induced compartment syndrome. This is caused by the accumulation of extracellular and extravascular fluid within confined anatomic spaces of the extremities or digits. The excessive fluid causes the intracompartmental pressures to increase, resulting in the collapse of the contained vascular and lymphatic structures and, hence, loss of tissue viability.
      Most compartment syndromes associated with a burn injury do not present in the immediate postburn period unless there is associated with traumatic injury or the patient presents in a delayed fashion. As such, compartment syndromes after burns are not commonly observed in the emergency department. Instead, they develop during the first 6–12 h of the initial volume resuscitation period as the administered intravascular volume goes into the interstitial and intracellular spaces resulting in tissue oedema in or under the burned tissue.

      Patients with compartment syndrome typically present with pain whose severity appears out of proportion to the injury. The pain is often described as burning. The pain is also deep and aching in nature and is worsened by passive stretching of the involved muscles. The patient may describe a tense feeling in the extremity. Pain, however, should not be a sine qua non of the diagnosis. In severe trauma, such as an open fracture, it is difficult to differentiate between pain from the fracture and pain resulting from increased compartment pressure.
      Paraesthesia or numbness is an unreliable early complaint; however, decreased 2-point discrimination is a more reliable early test and can be helpful to make the diagnosis.
      The traditional 5 P’s of acute ischemia in a limb (i.e., pain, paraesthesia, pallor, pulselessness, poikilothermia) are not clinically reliable; they may manifest only in the late stages of compartment syndrome, by which time extensive and irreversible soft tissue damage may have taken place.

      Escharotomy is the surgical division of the nonviable eschar, which allows the cutaneous envelope to become more compliant. Hence, the underlying tissues have an increased available volume to expand into, preventing further tissue injury or functional compromise

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      0
      Seconds
  • Question 16 - A young lady is rushed to the A&E department after being stabbed on...

    Incorrect

    • A young lady is rushed to the A&E department after being stabbed on her way home. She coughs up blood and a drain is placed into the left chest which removes 750ml of frank blood. She fails to improve and has been given 4 units of blood. Her CVP is now 13. What is the best course of action?

      Your Answer:

      Correct Answer: Thoracotomy in theatre

      Explanation:

      Answer: Thoracotomy in theatre

      A high CVP of 13 indicates cardiac tamponade. Cardiac tamponade is a clinical syndrome caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise. The condition is a medical emergency, the complications of which include pulmonary oedema, shock, and death.
      A pericardiotomy via a thoracotomy is mandatory for lifesaving cardiac decompression in acute traumatic cardiac tamponade in cases of ineffective drainage due to clot formation within the pericardial space. Wherever possible a patient needing surgery for penetrating chest trauma should be moved to an operating theatre where optimal surgical expertise and facilities are available.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      0
      Seconds
  • Question 17 - A 21 year old intravenous drug abuser is recovering following surgical drainage of...

    Incorrect

    • A 21 year old intravenous drug abuser is recovering following surgical drainage of a psoas abscess. She is found collapsed and unresponsive in the bathroom with pinpoint pupils. Which of the following is the best step in immediate management?

      Your Answer:

      Correct Answer: Intravenous naloxone

      Explanation:

      Answer: Intravenous naloxone

      Naloxone is a medication approved by the Food and Drug Administration (FDA) to prevent overdose by opioids such as heroin, morphine, and oxycodone. It blocks opioid receptor sites, reversing the toxic effects of the overdose. Naloxone is administered when a patient is showing signs of opioid overdose. The medication can be given by intranasal spray, intramuscular (into the muscle), subcutaneous (under the skin), or intravenous injection.

      Several conditions and drugs can cause pinpoint pupils, including:
      Prescription opioids or narcotics
      Some medications have opioids or narcotics in them. Opioids, including morphine, are drugs commonly used for pain relief. Opioids can affect a person psychologically and are highly addictive.

      People often take prescription opioids in pill form to treat severe post-surgical pain, such as from dental surgery, or for long-term pain, as with some cancers.

      Prescription opioids that may cause pinpoint pupils include:

      oxycodone
      morphine
      hydrocodone
      codeine
      methadone

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      0
      Seconds
  • Question 18 - 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
      Seconds
  • Question 19 - A 14 year old boy is suspected of having CSF rhinorrhoea after sustaining...

    Incorrect

    • A 14 year old boy is suspected of having CSF rhinorrhoea after sustaining a basal skull fracture. Which laboratory test would be able to accurately detect the presence of CSF?

      Your Answer:

      Correct Answer: Beta 2 transferrin assay

      Explanation:

      Answer: Beta 2 transferrin assay

      Beta-2-transferrin is a protein found only in CSF and perilymph. Since 1979, beta-2-transferrin has been used extensively by otolaryngologists in the diagnosis of CSF rhinorrhoea and skull-base cerebrospinal fluid fistulas. With sensitivity of 94% – 100%, and specificity of 98% – 100%, this assay has become the gold standard in detection of CSF leakage. CSF rhinorrhoea is characterized by clear or xanthochromic watery rhinorrhoea that may not become apparent until nasal packing is removed.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      0
      Seconds
  • Question 20 - A 65 year old man is scheduled to undergo an elective femoral-popliteal bypass....

    Incorrect

    • A 65 year old man is scheduled to undergo an elective femoral-popliteal bypass. He presents to the physician with sudden onset of central crushing chest pain that radiates to his left arm. ECG is significant for some ischemic changes. The nursing staff initiates high flow oxygen and gives a spray of glyceryl trinitrate. However, this has resulted in no relief of his symptoms. Which of the following drugs should be administered next to this patient?

      Your Answer:

      Correct Answer: Aspirin 300mg

      Explanation:

      Unstable angina is a common cardiovascular condition associated with major adverse clinical events. Over the last 15 years, therapeutic advances have dramatically reduced the complication and mortality rates of this serious condition. The standard of therapy in patients with unstable angina now incorporates the combined use of a potent antithrombotic (aspirin, clopidogrel, heparin and glycoprotein IIb/IIIa receptor antagonists) and anti-anginal (β-blockade and intravenous nitrates) regimens complemented by the selective and judicious application of coronary revascularisation strategies.
      Increasingly, these invasive and non-invasive therapeutic interventions are being guided not only by the clinical risk profile but also by the determination of serum cardiac and inflammatory markers.
      Moreover, rapid and intensive management of associated risk factors, such as hypercholesterolaemia, would appear to have potentially substantial benefits even within the acute in-hospital phase of unstable angina. 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.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
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  • Question 21 - A 64 year old diabetic man presents with a deep laceration of his...

    Incorrect

    • A 64 year old diabetic man presents with a deep laceration of his lateral thigh which measures 3cm in depth by 7cm in length, that penetrates to the bone. There are no signs of fracture. His diabetes is diet controlled and is on low dose prednisolone therapy for polymyalgia rheumatica. Which of the following options should be employed most safely for the wound management of this patient?

      Your Answer:

      Correct Answer: Delayed primary closure

      Explanation:

      Delayed primary closure is often intentionally applied to lacerations that are not considered clean enough for immediate primary closure. The wound is left open for 5-10 days; then, it is sutured closed to decrease the risk of wound infection. Improved blood flow at the wound edges, which develops increasingly over the first few days, is another benefit of this style of wound healing and can be associated with progressive increases in resistance to infections. 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.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
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  • Question 22 - A 31 year old woman presents to the clinic for assessment of varicose...

    Incorrect

    • A 31 year old woman presents to the clinic for assessment of varicose veins that she developed several years ago. Examination reveals marked truncal varicosities with a long tortuous saphenous vein. Which of the following would be the next most appropriate step in her management?

      Your Answer:

      Correct Answer: Arrange a venous duplex scan

      Explanation:

      Deep vein thrombosis (DVT) is the formation of a blood clot in a deep vein of the legs, thigh, or pelvis. Thrombosis is most often seen in individuals with a history of immobilization, obesity, malignancy, or hereditary thrombophilia. Vascular endothelial damage, venous stasis, and hypercoagulability, collectively referred to as the Virchow triad, are the main factors contributing to the development of DVT.
      Symptoms usually occur unilaterally and include swelling, tenderness, and redness or discoloration. Pulmonary embolism (PE), a severe complication of DVT, should be suspected in patients with dizziness, dyspnoea, and fever. The diagnostic test of choice for DVT is compression ultrasound. In most cases, a negative D-dimer test allows thrombosis or PE to be ruled out, but a positive test is nonspecific.
      Initial acute treatment of DVT consists of anticoagulation with heparin and, if the thrombus is large or unresponsive to anticoagulation, may also include thrombolysis or thrombectomy. Secondary prophylaxis is achieved with oral warfarin or direct factor Xa inhibitors and supportive measures such as regular exercise and compression stockings.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Vascular
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  • Question 23 - A young lady is taken to the A&E department after she falls from...

    Incorrect

    • A young lady is taken to the A&E department after she falls from the 3rd floor balcony. A chest x-ray shows depression of the left main bronchus and deviation of the trachea to the right. What is the most likely injury that she sustained?

      Your Answer:

      Correct Answer: Aortic rupture

      Explanation:

      Answer: Aortic rupture

      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.
      Features on plain chest radiography that suggest aortic injury and can help guide the further use of angiography include; an abnormal aortic arch contour, left apical cap, loss of the aorticopulmonary window, rightward deviation of the trachea, depression of the left main stem bronchus, and a wide left paravertebral pleural stripe. Also, widening of the mediastinum (greater than 8 cm) has a reported sensitivity of 81% to 100% and a specificity of 60%.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
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  • Question 24 - A 27-year-old woman who is 32 weeks pregnant is struck by a car....

    Incorrect

    • A 27-year-old woman who is 32 weeks pregnant is struck by a car. On arrival in the emergency department, she has a systolic blood pressure of 105 mmHg and a pulse rate of 126 bpm. Abdominal examination demonstrates diffuse tender abdomen and some bruising of the left flank. The FAST scan is normal.

      What should be the most appropriate course of action?

      Your Answer:

      Correct Answer: Arrange an urgent abdominal CT scan

      Explanation:

      The patient’s history and examination point towards a significant visceral injury. FAST scan is associated with a false-negative result in pregnancy which makes the normal result, in this scenario, less reassuring. CT scan of the abdomen remains the gold standard for diagnosis.

      Sonography and FAST scanning are established in pregnancy and provide the advantage of avoiding ionising radiations. However, the sensitivity of the FAST scan is reduced in pregnancy especially with advanced gestational age. CT scan remains the first-line investigation in major trauma where significant visceral injury is suspected. The maximum permitted safe dose of radiation in pregnancy is 5 mSv.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
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  • Question 25 - A 38-year-old man presents to the A&E department after sustaining a single gunshot...

    Incorrect

    • A 38-year-old man presents to the A&E department after sustaining a single gunshot wound to his left thigh. He complains of paraesthesia in his left foot. On examination, he is noted to have a large haematoma on the medial aspect of his left thigh. There are weak palpable pulses distal to the injury, and the patient is unable to move his foot.

      What should be the most appropriate initial management of this patient?

      Your Answer:

      Correct Answer: Immediate exploration and repair

      Explanation:

      The classic presentation of arterial injury include the five Ps: pallor, pain, paraesthesia, paralysis, and pulselessness. In the extremities, the tissues most sensitive to anoxia are the peripheral nerves and striated muscles. Early development of paraesthesia and paralysis indicates that there is significant ischaemia present, and therefore, immediate exploration and repair are warranted. Presence of a palpable pulse does not exclude an arterial injury because this may represent a transmitted pulsation through a blood clot.

      When severe ischaemia is present, the repair must be completed within six to eight hours to prevent irreversible muscle ischaemia and loss of limb function. Delay to obtain a conventional angiogram or to observe for change needlessly prolongs the ischaemic time. Fasciotomy may be required but should be done in conjunction with and after re-establishment of arterial flow. Local wound exploration is not recommended because brisk haemorrhage may be encountered without prior securing of vascular control.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
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  • Question 26 - A 42 year old lawyer is rushed to the emergency room after she...

    Incorrect

    • A 42 year old lawyer is rushed to the emergency room after she was found lying unconscious on her left arm with an empty bottle of Diazepam beside her. Her left arm has red and purple marks and is swollen. Her hand is stiff and insensate. Which of the following substances would be expected to be present in her urine in increased quantities?

      Your Answer:

      Correct Answer: Myoglobin

      Explanation:

      Answer: Myoglobin

      When muscle is damaged, a protein called myoglobin is released into the bloodstream. It is then filtered out of the body by the kidneys. Myoglobin breaks down into substances that can damage kidney cells.
      Compartment syndrome is a painful condition that occurs when pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells.

      Compartment syndrome can be either acute or chronic.

      Acute compartment syndrome is a medical emergency. It is usually caused by a severe injury. Without treatment, it can lead to permanent muscle damage.

      Chronic compartment syndrome, also known as exertional compartment syndrome, is usually not a medical emergency. It is most often caused by athletic exertion. Compartments are groupings of muscles, nerves, and blood vessels in your arms and legs. Covering these tissues is a tough membrane called a fascia. The role of the fascia is to keep the tissues in place, and, therefore, the fascia does not stretch or expand easily.
      Compartment syndrome develops when swelling or bleeding occurs within a compartment. Because the fascia does not stretch, this can cause increased pressure on the capillaries, nerves, and muscles in the compartment. Blood flow to muscle and nerve cells is disrupted. Without a steady supply of oxygen and nutrients, nerve and muscle cells can be damaged.

      In acute compartment syndrome, unless the pressure is relieved quickly, permanent disability and tissue death may result. This does not usually happen in chronic (exertional) compartment syndrome.

      Compartment syndrome most often occurs in the anterior (front) compartment of the lower leg (calf). It can also occur in other compartments in the leg, as well as in the arms, hands, feet, and buttocks.

      Acute compartment syndrome usually develops after a severe injury, such as a car accident or a broken bone. Rarely, it develops after a relatively minor injury.

      Conditions that may bring on acute compartment syndrome include:

      A fracture.
      A badly bruised muscle. This type of injury can occur when a motorcycle falls on the leg of the rider, or a football player is hit in the leg with another player’s helmet.
      Re-established blood flow after blocked circulation. This may occur after a surgeon repairs a damaged blood vessel that has been blocked for several hours. A blood vessel can also be blocked during sleep. Lying for too long in a position that blocks a blood vessel, then moving or waking up can cause this condition. Most healthy people will naturally move when blood flow to a limb is blocked during sleep. The development of compartment syndrome in this manner usually occurs in people who are neurologically compromised. This can happen after severe intoxication with alcohol or other drugs.
      Crush injuries.
      Anabolic steroid use. Taking steroids is a possible factor in compartment syndrome.
      Constricting bandages. Casts and tight bandages may lead to compartment syndrome. If symptoms of compartment syndrome develop, remove or loosen any constricting bandages.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
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  • Question 27 - A 25 year old man is taken to the A&E department after being...

    Incorrect

    • A 25 year old man is taken to the A&E department after being hit in the head with a batton. He opens his eyes to pain and groans or grunts. He extends his hands at the elbow on application of painful stimulus. What is his Glasgow coma score?

      Your Answer:

      Correct Answer: 6

      Explanation:

      Answer: 6

      Eye Opening Response
      Spontaneous–open with blinking at baseline – 4 points
      Opens to verbal command, speech, or shout – 3 points
      Opens to pain, not applied to face – 2 point
      None – 1 point

      Verbal Response
      Oriented – 5 points
      Confused conversation, but able to answer questions – 4 points
      Inappropriate responses, words discernible – 3 points
      Incomprehensible speech – 2 points
      None – 1 point

      Motor Response
      Obeys commands for movement – 6 points
      Purposeful movement to painful stimulus – 5 points
      Withdraws from pain – 4 points
      Abnormal (spastic) flexion, decorticate posture – 3 points
      Extensor (rigid) response, decerebrate posture – 2 points
      None – 1 point

      He opens his eyes to pain and groans or grunts. He extends his hands at the elbow on application of painful stimulus. This gives him a Glasgow score of 6: eye opening response of 2, verbal response 2 and motor response 2.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
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  • Question 28 - A 29-year-old man with gunshot to the abdomen is transferred to the operating...

    Incorrect

    • A 29-year-old man with gunshot to the abdomen is transferred to the operating theatre, following his arrival in the A&E department. He is unstable and his FAST scan is positive. During the operation, extensive laceration to the right lobe of the liver and involvement of the IVC are found, along with massive haemorrhage.

      What should be the most appropriate approach to blood component therapy?

      Your Answer:

      Correct Answer:

      Explanation:

      There is strong evidence to support haemostatic resuscitation in the setting of massive haemorrhage due to trauma. This advocates the use of 1:1:1 ratio.

      Uncontrolled haemorrhage accounts for up to 39% of all trauma-related deaths. In the UK, approximately 2% of all trauma patients need massive transfusion. Massive transfusion is defined as the replacement of a patient’s total blood volume in less than 24 hours or the acute administration of more than half the patient’s estimated blood volume per hour. During acute bleeding, the practice of haemostatic resuscitation has been shown to reduce mortality rates. It is based on the principle of transfusion of blood components in fixed ratios. For example, packed red cells, FFP, and platelets are administered in a ratio of 1:1:1.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
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  • Question 29 - A 26-year-old woman who is 18 weeks pregnant presents with sudden chest pain....

    Incorrect

    • A 26-year-old woman who is 18 weeks pregnant presents with sudden chest pain. On examination, her heart rate is 130 bpm, blood pressure is 150/70 mmHg, and saturation is 92% on 15L oxygen. Signs of thrombophlebitis are seen in the left leg. Moreover, auscultation of the heart reveals no murmurs and her chest is clear.

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Pulmonary embolism

      Explanation:

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

      PE is one of the leading causes of mortality in pregnancy. Evaluation with low-dose perfusion scintigraphy may be preferable to computed tomographic pulmonary angiography (CTPA).
      PE is treated with LMWH throughout pregnancy and for 4–6 weeks after childbirth. Warfarin is contraindicated in pregnancy (though may be continued in women with mechanical heart valves due to a significant risk of thromboembolism).

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
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  • Question 30 - A 62 year old man presents with sudden onset of palpitations. ECG shows...

    Incorrect

    • A 62 year old man presents with sudden onset of palpitations. ECG shows broad complex tachycardia at a rate of 150 beats per minute. The blood pressure is 120/82 mmHg and there is no evidence of heart failure. The doctor wants to prescribe a rate controlling medication. Which of the following should be avoided in this case?

      Your Answer:

      Correct Answer: Verapamil

      Explanation:

      The use of intravenous diltiazem or verapamil is contraindicated in patients with ventricular tachycardia. The IV administration of a calcium channel blocker can precipitate cardiac arrest in such patients.
      Marked hemodynamic deterioration and ventricular fibrillation have occurred in patients with wide-complex ventricular tachycardia (QRS >= 0.12 seconds) treated with IV verapamil.

    • 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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