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  • Question 1 - A 52-year-old individual is brought to the emergency room after a car accident....

    Incorrect

    • A 52-year-old individual is brought to the emergency room after a car accident. They present with a fracture in the middle of their left femur and complain of abdominal pain. The patient appears restless. The following are their vital signs:

      Blood pressure: 112/94 mmHg
      Pulse rate: 102 bpm
      Respiration rate: 21 rpm
      SpO2: 97% on room air
      Temperature: 36 ºC

      Considering the possibility of significant blood loss, what grade of hypovolemic shock would you assign to this patient?

      Your Answer: Grade 1

      Correct Answer: Grade 2

      Explanation:

      Grade 2 shock is characterized by a pulse rate of 100 to 120 beats per minute and a respiratory rate of 20 to 30 breaths per minute. These clinical features align with the symptoms of grade 2 hypovolemic shock, as indicated in the below notes.

      Further Reading:

      Shock is a condition characterized by inadequate tissue perfusion due to circulatory insufficiency. It can be caused by fluid loss or redistribution, as well as impaired cardiac output. The main causes of shock include haemorrhage, diarrhoea and vomiting, burns, diuresis, sepsis, neurogenic shock, anaphylaxis, massive pulmonary embolism, tension pneumothorax, cardiac tamponade, myocardial infarction, and myocarditis.

      One common cause of shock is haemorrhage, which is frequently encountered in the emergency department. Haemorrhagic shock can be classified into different types based on the amount of blood loss. Type 1 haemorrhagic shock involves a blood loss of 15% or less, with less than 750 ml of blood loss. Patients with type 1 shock may have normal blood pressure and heart rate, with a respiratory rate of 12 to 20 breaths per minute.

      Type 2 haemorrhagic shock involves a blood loss of 15 to 30%, with 750 to 1500 ml of blood loss. Patients with type 2 shock may have a pulse rate of 100 to 120 beats per minute and a respiratory rate of 20 to 30 breaths per minute. Blood pressure is typically normal in type 2 shock.

      Type 3 haemorrhagic shock involves a blood loss of 30 to 40%, with 1.5 to 2 litres of blood loss. Patients with type 3 shock may have a pulse rate of 120 to 140 beats per minute and a respiratory rate of more than 30 breaths per minute. Urine output is decreased to 5-15 mls per hour.

      Type 4 haemorrhagic shock involves a blood loss of more than 40%, with more than 2 litres of blood loss. Patients with type 4 shock may have a pulse rate of more than 140 beats per minute and a respiratory rate of more than 35 breaths per minute. They may also be drowsy, confused, and possibly experience loss of consciousness. Urine output may be minimal or absent.

      In summary, shock is a condition characterized by inadequate tissue perfusion. Haemorrhage is a common cause of shock, and it can be classified into different types based on the amount of blood loss. Prompt recognition and management of shock are crucial in order to prevent further complications and improve patient outcomes

    • This question is part of the following fields:

      • Trauma
      20.6
      Seconds
  • Question 2 - A 28-year-old woman is brought into the emergency room by an ambulance with...

    Correct

    • A 28-year-old woman is brought into the emergency room by an ambulance with sirens blaring after being involved in a car accident. She was hit by a truck while riding a bicycle and is suspected to have a pelvic injury. Her blood pressure is unstable, and the hospital has activated the massive transfusion protocol. You decide to also give her tranexamic acid.
      What is the appropriate initial dose of tranexamic acid to administer and over what duration of time?

      Your Answer: 1 g IV over 10 minutes

      Explanation:

      ATLS guidelines now suggest administering only 1 liter of crystalloid fluid during the initial assessment. If patients do not respond to the crystalloid, it is recommended to quickly transition to blood products. Studies have shown that infusing more than 1.5 liters of crystalloid fluid is associated with higher mortality rates in trauma cases. Therefore, it is advised to prioritize the early use of blood products and avoid large volumes of crystalloid fluid in trauma patients. In cases where it is necessary, massive transfusion should be considered, defined as the transfusion of more than 10 units of blood in 24 hours or more than 4 units of blood in one hour. For patients with evidence of Class III and IV hemorrhage, early resuscitation with blood and blood products in low ratios is recommended.

      Based on the findings of significant trials, such as the CRASH-2 study, the use of tranexamic acid is now recommended within 3 hours. This involves administering a loading dose of 1 gram intravenously over 10 minutes, followed by an infusion of 1 gram over eight hours. In some regions, tranexamic acid is also being utilized in the prehospital setting.

    • This question is part of the following fields:

      • Trauma
      4.3
      Seconds
  • Question 3 - A 25-year-old arrives at the emergency department after being involved in a car...

    Correct

    • A 25-year-old arrives at the emergency department after being involved in a car accident. A FAST scan is conducted to assess for abdominal injuries caused by blunt trauma. Which of the following is NOT among the four standard views obtained during a FAST scan?

      Your Answer: Umbilical view

      Explanation:

      FAST scans consist of four standard views that are obtained to assess different areas of the body. These views include the right upper quadrant (RUQ), left upper quadrant (LUQ), pericardial sac, and the pelvis.

      In the RUQ view, the focus is on the right flank or peri-hepatic area, which includes Morison’s pouch and the right costophrenic pleural recess.

      The LUQ view examines the left flank or peri-splenic area, which includes the spleen-renal recess and the left costophrenic pleural space.

      The pericardial sac is also assessed to evaluate any abnormalities in this area.

      Lastly, the pelvis is examined in two planes to ensure a comprehensive evaluation.

      In addition to these four standard views, an anterior pleural view is often performed alongside the others. This view used to be part of the extended FAST (eFAST) scan but is now commonly included routinely.

      Further Reading:

      Abdominal trauma can be classified into two categories: blunt trauma and penetrating trauma. Blunt trauma occurs when compressive or deceleration forces are applied to the abdomen, often resulting from road traffic accidents or direct blows during sports. The spleen and liver are the organs most commonly injured in blunt abdominal trauma. On the other hand, penetrating trauma involves injuries that pierce the skin and enter the abdominal cavity, such as stabbings, gunshot wounds, or industrial accidents. The bowel and liver are the organs most commonly affected in penetrating injuries.

      When it comes to imaging in blunt abdominal trauma, there are three main modalities that are commonly used: focused assessment with sonography in trauma (FAST), diagnostic peritoneal lavage (DPL), and computed tomography (CT). FAST is a non-invasive and quick method used to detect free intraperitoneal fluid, aiding in the decision on whether a laparotomy is needed. DPL is also used to detect intraperitoneal blood and can be used in both unstable blunt abdominal trauma and penetrating abdominal trauma. However, it is more invasive and time-consuming compared to FAST and has largely been replaced by it. CT, on the other hand, is the gold standard for diagnosing intra-abdominal pathology and is used in stable abdominal trauma patients. It offers high sensitivity and specificity but requires a stable and cooperative patient. It also involves radiation and may have delays in availability.

      In the case of penetrating trauma, it is important to assess these injuries with the help of a surgical team. Penetrating objects should not be removed in the emergency department as they may be tamponading underlying vessels. Ideally, these injuries should be explored in the operating theater.

      In summary, abdominal trauma can be classified into blunt trauma and penetrating trauma. Blunt trauma is caused by compressive or deceleration forces and commonly affects the spleen and liver. Penetrating trauma involves injuries that pierce the skin and commonly affect the bowel and liver. Imaging modalities such as FAST, DPL, and CT are used to assess and diagnose abdominal trauma, with CT being the gold standard. Penetrating injuries should be assessed by a surgical team and should ideally be explored in the operating theater.

    • This question is part of the following fields:

      • Trauma
      5.1
      Seconds
  • Question 4 - A 15 year old is brought into the emergency department with burns to...

    Correct

    • A 15 year old is brought into the emergency department with burns to the feet which she sustained whilst removing an item from a lit bonfire. The patient's father is worried she has full thickness burns. Which of the following signs is indicative of a full thickness burn?

      Your Answer: Painless

      Explanation:

      Full thickness burns are devoid of pain as they result in the complete destruction of the superficial nerve endings. These burns usually display characteristics such as a lack of sensation, a coloration of the burnt skin in shades of white, brown, or black, a texture that is waxy or leathery, and a dry appearance without any blistering.

      Further Reading:

      Burn injuries can be classified based on their type (degree, partial thickness or full thickness), extent as a percentage of total body surface area (TBSA), and severity (minor, moderate, major/severe). Severe burns are defined as a >10% TBSA in a child and >15% TBSA in an adult.

      When assessing a burn, it is important to consider airway injury, carbon monoxide poisoning, type of burn, extent of burn, special considerations, and fluid status. Special considerations may include head and neck burns, circumferential burns, thorax burns, electrical burns, hand burns, and burns to the genitalia.

      Airway management is a priority in burn injuries. Inhalation of hot particles can cause damage to the respiratory epithelium and lead to airway compromise. Signs of inhalation injury include visible burns or erythema to the face, soot around the nostrils and mouth, burnt/singed nasal hairs, hoarse voice, wheeze or stridor, swollen tissues in the mouth or nostrils, and tachypnea and tachycardia. Supplemental oxygen should be provided, and endotracheal intubation may be necessary if there is airway obstruction or impending obstruction.

      The initial management of a patient with burn injuries involves conserving body heat, covering burns with clean or sterile coverings, establishing IV access, providing pain relief, initiating fluid resuscitation, measuring urinary output with a catheter, maintaining nil by mouth status, closely monitoring vital signs and urine output, monitoring the airway, preparing for surgery if necessary, and administering medications.

      Burns can be classified based on the depth of injury, ranging from simple erythema to full thickness burns that penetrate into subcutaneous tissue. The extent of a burn can be estimated using methods such as the rule of nines or the Lund and Browder chart, which takes into account age-specific body proportions.

      Fluid management is crucial in burn injuries due to significant fluid losses. Evaporative fluid loss from burnt skin and increased permeability of blood vessels can lead to reduced intravascular volume and tissue perfusion. Fluid resuscitation should be aggressive in severe burns, while burns <15% in adults and <10% in children may not require immediate fluid resuscitation. The Parkland formula can be used to calculate the intravenous fluid requirements for someone with a significant burn injury.

    • This question is part of the following fields:

      • Trauma
      11
      Seconds
  • Question 5 - A 35 year old female presents to the emergency department following a motor...

    Correct

    • A 35 year old female presents to the emergency department following a motor vehicle collision. Which system should be utilized to evaluate the potential for cervical spine injury?

      Your Answer: Canadian C-spine rules

      Explanation:

      When a 35-year-old female comes to the emergency department after a motor vehicle collision, it is important to assess the potential for cervical spine injury. To do this, the Canadian C-spine rules should be utilized. These rules provide a systematic approach to determine whether imaging, such as X-rays, is necessary to evaluate the cervical spine. The Canadian C-spine rules take into account various factors such as the patient’s age, mechanism of injury, and presence of certain symptoms or physical findings. By following these rules, healthcare professionals can effectively evaluate the potential for cervical spine injury and determine the appropriate course of action for further assessment and management.

      Further Reading:

      When assessing for cervical spine injury, it is recommended to use the Canadian C-spine rules. These rules help determine the risk level for a potential injury. High-risk factors include being over the age of 65, experiencing a dangerous mechanism of injury (such as a fall from a height or a high-speed motor vehicle collision), or having paraesthesia in the upper or lower limbs. Low-risk factors include being involved in a minor rear-end motor vehicle collision, being comfortable in a sitting position, being ambulatory since the injury, having no midline cervical spine tenderness, or experiencing a delayed onset of neck pain. If a person is unable to actively rotate their neck 45 degrees to the left and right, their risk level is considered low. If they have one of the low-risk factors and can actively rotate their neck, their risk level remains low.

      If a high-risk factor is identified or if a low-risk factor is identified and the person is unable to actively rotate their neck, full in-line spinal immobilization should be maintained and imaging should be requested. Additionally, if a patient has risk factors for thoracic or lumbar spine injury, imaging should be requested. However, if a patient has low-risk factors for cervical spine injury, is pain-free, and can actively rotate their neck, full in-line spinal immobilization and imaging are not necessary.

      NICE recommends CT as the primary imaging modality for cervical spine injury in adults aged 16 and older, while MRI is recommended as the primary imaging modality for children under 16.

      Different mechanisms of spinal trauma can cause injury to the spine in predictable ways. The majority of cervical spine injuries are caused by flexion combined with rotation. Hyperflexion can result in compression of the anterior aspects of the vertebral bodies, stretching and tearing of the posterior ligament complex, chance fractures (also known as seatbelt fractures), flexion teardrop fractures, and odontoid peg fractures. Flexion and rotation can lead to disruption of the posterior ligament complex and posterior column, fractures of facet joints, lamina, transverse processes, and vertebral bodies, and avulsion of spinous processes. Hyperextension can cause injury to the anterior column, anterior fractures of the vertebral body, and potential retropulsion of bony fragments or discs into the spinal canal. Rotation can result in injury to the posterior ligament complex and facet joint dislocation.

    • This question is part of the following fields:

      • Trauma
      3.5
      Seconds
  • Question 6 - A 35-year-old woman is brought in by ambulance following a car accident where...

    Incorrect

    • A 35-year-old woman is brought in by ambulance following a car accident where her car was struck by a truck. She has suffered severe facial injuries and shows signs of airway obstruction. Her neck is immobilized. She has suffered significant midface trauma, and the anesthesiologist decides to secure a definitive airway by intubating the patient. He is unable to pass an endotracheal tube, and he decides to perform a needle cricothyroidotomy.

      Which of the following statements about needle cricothyroidotomy is correct?

      Your Answer: The cricothyroid membrane is located directly below the cricoid cartilage

      Correct Answer: Evidence of local infection is a valid contraindication

      Explanation:

      A needle cricothyroidotomy is a procedure used in emergency situations to provide oxygenation when intubation and oxygenation are not possible. It is typically performed when a patient cannot be intubated or oxygenated. There are certain conditions that make this procedure contraindicated, such as local infection, distorted anatomy, previous failed attempts, and swelling or mass lesions.

      To perform a needle cricothyroidotomy, the necessary equipment should be assembled and prepared. The patient should be positioned supine with their neck in a neutral position. The neck should be cleaned in a sterile manner using antiseptic swabs. If time allows, the area should be anesthetized locally. A 12 or 14 gauge over-the-needle catheter should be assembled to a 10 mL syringe.

      The cricothyroid membrane, located between the thyroid and cricoid cartilage, should be identified anteriorly. The trachea should be stabilized with the thumb and forefinger of one hand. Using the other hand, the skin should be punctured in the midline with the needle over the cricothyroid membrane. The needle should be directed at a 45° angle caudally while negative pressure is applied to the syringe. Needle aspiration should be maintained as the needle is inserted through the lower half of the cricothyroid membrane, with air aspiration indicating entry into the tracheal lumen.

      Once the needle is in place, the syringe and needle should be removed while the catheter is advanced to the hub. The oxygen catheter should be attached and the airway secured. It is important to be aware of possible complications, such as technique failure, cannula obstruction or dislodgement, injury to local structures, and surgical emphysema if high flow oxygen is administered through a malpositioned cannula.

    • This question is part of the following fields:

      • Trauma
      21.8
      Seconds
  • Question 7 - A 32 year old woman is brought into the emergency department with burns...

    Correct

    • A 32 year old woman is brought into the emergency department with burns to her chest and arms. The patient was trying to handle a grease fire but accidentally spilled the burning contents onto herself. Your consultant requests you to evaluate the severity of the burns. What is used to estimate the extent of a burn injury?

      Your Answer: Lund and Browder chart

      Explanation:

      TBSA, or Total Body Surface Area, is a method commonly used to estimate the size of small burns and very large burns by including the area of unburnt skin. However, it is not considered a reliable method for medium-sized burns.

      Further Reading:

      Burn injuries can be classified based on their type (degree, partial thickness or full thickness), extent as a percentage of total body surface area (TBSA), and severity (minor, moderate, major/severe). Severe burns are defined as a >10% TBSA in a child and >15% TBSA in an adult.

      When assessing a burn, it is important to consider airway injury, carbon monoxide poisoning, type of burn, extent of burn, special considerations, and fluid status. Special considerations may include head and neck burns, circumferential burns, thorax burns, electrical burns, hand burns, and burns to the genitalia.

      Airway management is a priority in burn injuries. Inhalation of hot particles can cause damage to the respiratory epithelium and lead to airway compromise. Signs of inhalation injury include visible burns or erythema to the face, soot around the nostrils and mouth, burnt/singed nasal hairs, hoarse voice, wheeze or stridor, swollen tissues in the mouth or nostrils, and tachypnea and tachycardia. Supplemental oxygen should be provided, and endotracheal intubation may be necessary if there is airway obstruction or impending obstruction.

      The initial management of a patient with burn injuries involves conserving body heat, covering burns with clean or sterile coverings, establishing IV access, providing pain relief, initiating fluid resuscitation, measuring urinary output with a catheter, maintaining nil by mouth status, closely monitoring vital signs and urine output, monitoring the airway, preparing for surgery if necessary, and administering medications.

      Burns can be classified based on the depth of injury, ranging from simple erythema to full thickness burns that penetrate into subcutaneous tissue. The extent of a burn can be estimated using methods such as the rule of nines or the Lund and Browder chart, which takes into account age-specific body proportions.

      Fluid management is crucial in burn injuries due to significant fluid losses. Evaporative fluid loss from burnt skin and increased permeability of blood vessels can lead to reduced intravascular volume and tissue perfusion. Fluid resuscitation should be aggressive in severe burns, while burns <15% in adults and <10% in children may not require immediate fluid resuscitation. The Parkland formula can be used to calculate the intravenous fluid requirements for someone with a significant burn injury.

    • This question is part of the following fields:

      • Trauma
      6
      Seconds
  • Question 8 - A 32-year-old construction worker is brought into the emergency department with burns to...

    Correct

    • A 32-year-old construction worker is brought into the emergency department with burns to the right forearm. The patient explains that he was smoking a cigarette while driving back from work when the cigarette accidentally fell onto his arm, igniting his sleeve which might have been soaked in gasoline from work. You observe circumferential burns encompassing the entire right forearm. What would be your primary concern regarding potential complications?

      Your Answer: Compartment syndrome

      Explanation:

      Compartment syndrome can occur when there are circumferential burns on the arms or legs. This typically happens with full thickness burns, where the burnt skin becomes stiff and compresses the compartment, making it difficult for blood to flow out. To treat this condition, escharotomy and possibly fasciotomy may be necessary.

      Further Reading:

      Burn injuries can be classified based on their type (degree, partial thickness or full thickness), extent as a percentage of total body surface area (TBSA), and severity (minor, moderate, major/severe). Severe burns are defined as a >10% TBSA in a child and >15% TBSA in an adult.

      When assessing a burn, it is important to consider airway injury, carbon monoxide poisoning, type of burn, extent of burn, special considerations, and fluid status. Special considerations may include head and neck burns, circumferential burns, thorax burns, electrical burns, hand burns, and burns to the genitalia.

      Airway management is a priority in burn injuries. Inhalation of hot particles can cause damage to the respiratory epithelium and lead to airway compromise. Signs of inhalation injury include visible burns or erythema to the face, soot around the nostrils and mouth, burnt/singed nasal hairs, hoarse voice, wheeze or stridor, swollen tissues in the mouth or nostrils, and tachypnea and tachycardia. Supplemental oxygen should be provided, and endotracheal intubation may be necessary if there is airway obstruction or impending obstruction.

      The initial management of a patient with burn injuries involves conserving body heat, covering burns with clean or sterile coverings, establishing IV access, providing pain relief, initiating fluid resuscitation, measuring urinary output with a catheter, maintaining nil by mouth status, closely monitoring vital signs and urine output, monitoring the airway, preparing for surgery if necessary, and administering medications.

      Burns can be classified based on the depth of injury, ranging from simple erythema to full thickness burns that penetrate into subcutaneous tissue. The extent of a burn can be estimated using methods such as the rule of nines or the Lund and Browder chart, which takes into account age-specific body proportions.

      Fluid management is crucial in burn injuries due to significant fluid losses. Evaporative fluid loss from burnt skin and increased permeability of blood vessels can lead to reduced intravascular volume and tissue perfusion. Fluid resuscitation should be aggressive in severe burns, while burns <15% in adults and <10% in children may not require immediate fluid resuscitation. The Parkland formula can be used to calculate the intravenous fluid requirements for someone with a significant burn injury.

    • This question is part of the following fields:

      • Trauma
      8.7
      Seconds
  • Question 9 - You are summoned to a cardiac arrest in the resuscitation area of your...

    Incorrect

    • You are summoned to a cardiac arrest in the resuscitation area of your Emergency Department. As part of your treatment, a dose of adrenaline is given.
      Which of the following is NOT a beta-adrenergic effect of adrenaline?

      Your Answer: Increased post-cardiac arrest myocardial dysfunction

      Correct Answer: Systemic vasoconstriction

      Explanation:

      The effects of adrenaline on alpha-adrenergic receptors result in the narrowing of blood vessels throughout the body, leading to increased pressure in the coronary and cerebral arteries. On the other hand, the effects of adrenaline on beta-adrenergic receptors enhance the strength of the heart’s contractions and increase the heart rate, which can potentially improve blood flow to the coronary and cerebral arteries. However, it is important to note that these positive effects may be counteracted by the simultaneous increase in oxygen consumption by the heart, the occurrence of abnormal heart rhythms, reduced oxygen levels due to abnormal blood flow patterns, impaired small blood vessel function, and worsened heart function following a cardiac arrest.

    • This question is part of the following fields:

      • Trauma
      24.7
      Seconds
  • Question 10 - A 52 year old male visits the emergency department after crashing into the...

    Correct

    • A 52 year old male visits the emergency department after crashing into the side of a car while riding his bicycle downhill at a fast pace. The handlebars were forcefully pushed into his abdomen, resulting in a noticeable large contusion on the front of his abdominal wall. The patient's vital signs are as follows:

      Blood pressure: 92/60 mmHg
      Pulse rate: 104 bpm
      Temperature: 37.1ºC
      SpO2: 97% on room air

      Which two abdominal organs are most commonly affected in cases of blunt abdominal trauma?

      Your Answer: Liver and spleen

      Explanation:

      Blunt abdominal trauma often results in injury to the liver and spleen, which are the two organs most commonly affected. The liver, being the largest and located in a vulnerable position, is particularly prone to injury in such cases.

      Further Reading:

      Abdominal trauma can be classified into two categories: blunt trauma and penetrating trauma. Blunt trauma occurs when compressive or deceleration forces are applied to the abdomen, often resulting from road traffic accidents or direct blows during sports. The spleen and liver are the organs most commonly injured in blunt abdominal trauma. On the other hand, penetrating trauma involves injuries that pierce the skin and enter the abdominal cavity, such as stabbings, gunshot wounds, or industrial accidents. The bowel and liver are the organs most commonly affected in penetrating injuries.

      When it comes to imaging in blunt abdominal trauma, there are three main modalities that are commonly used: focused assessment with sonography in trauma (FAST), diagnostic peritoneal lavage (DPL), and computed tomography (CT). FAST is a non-invasive and quick method used to detect free intraperitoneal fluid, aiding in the decision on whether a laparotomy is needed. DPL is also used to detect intraperitoneal blood and can be used in both unstable blunt abdominal trauma and penetrating abdominal trauma. However, it is more invasive and time-consuming compared to FAST and has largely been replaced by it. CT, on the other hand, is the gold standard for diagnosing intra-abdominal pathology and is used in stable abdominal trauma patients. It offers high sensitivity and specificity but requires a stable and cooperative patient. It also involves radiation and may have delays in availability.

      In the case of penetrating trauma, it is important to assess these injuries with the help of a surgical team. Penetrating objects should not be removed in the emergency department as they may be tamponading underlying vessels. Ideally, these injuries should be explored in the operating theater.

      In summary, abdominal trauma can be classified into blunt trauma and penetrating trauma. Blunt trauma is caused by compressive or deceleration forces and commonly affects the spleen and liver. Penetrating trauma involves injuries that pierce the skin and commonly affect the bowel and liver. Imaging modalities such as FAST, DPL, and CT are used to assess and diagnose abdominal trauma, with CT being the gold standard. Penetrating injuries should be assessed by a surgical team and should ideally be explored in the operating theater.

    • This question is part of the following fields:

      • Trauma
      5
      Seconds
  • Question 11 - A 32-year-old woman was involved in a car accident where her car collided...

    Incorrect

    • A 32-year-old woman was involved in a car accident where her car collided with a tree at high speed. She was not wearing a seatbelt and was thrown forward onto the steering wheel of her car. She has bruising over her anterior chest wall and is experiencing chest pain. A helical contrast-enhanced CT scan of the chest reveals a traumatic aortic injury. After receiving analgesia, which has effectively controlled her pain, her vital signs are as follows: HR 95, BP 128/88, SaO2 97% on room air, temperature is 37.4ºC.
      Which of the following medications would be most appropriate to administer next?

      Your Answer: Nicardipine

      Correct Answer: Esmolol

      Explanation:

      Traumatic aortic rupture, also known as traumatic aortic disruption or transection, occurs when the aorta is torn or ruptured due to physical trauma. This condition often leads to sudden death because of severe bleeding. Motor vehicle accidents and falls from great heights are the most common causes of this injury.

      The patients with the highest chances of survival are those who have an incomplete tear near the ligamentum arteriosum of the proximal descending aorta, close to where the left subclavian artery branches off. The presence of an intact adventitial layer or contained mediastinal hematoma helps maintain continuity and prevents immediate bleeding and death. If promptly identified and treated, survivors of these injuries can recover. In cases where traumatic aortic rupture leads to sudden death, approximately 50% of patients have damage at the aortic isthmus, while around 15% have damage in either the ascending aorta or the aortic arch.

      Initial chest X-rays may show signs consistent with a traumatic aortic injury. However, false-positive and false-negative results can occur, and sometimes there may be no abnormalities visible on the X-ray. Some of the possible X-ray findings include a widened mediastinum, hazy left lung field, obliteration of the aortic knob, fractures of the 1st and 2nd ribs, deviation of the trachea to the right, presence of a pleural cap, elevation and rightward shift of the right mainstem bronchus, depression of the left mainstem bronchus, obliteration of the space between the pulmonary artery and aorta, and deviation of the esophagus or NG tube to the right.

      A helical contrast-enhanced CT scan of the chest is the preferred initial investigation for suspected blunt aortic injury. It has proven to be highly accurate, with close to 100% sensitivity and specificity. CT scanning should be performed liberally, as chest X-ray findings can be unreliable. However, hemodynamically unstable patients should not be placed in a CT scanner. If the CT results are inconclusive, aortography or trans-oesophageal echo can be performed for further evaluation.

      Immediate surgical intervention is necessary for these injuries. Endovascular repair is the most common method used and has excellent short-term outcomes. Open repair may also be performed depending on the circumstances. It is important to control heart rate and blood pressure during stabilization to reduce the risk of rupture. Pain should be managed with appropriate analgesic

    • This question is part of the following fields:

      • Trauma
      26.2
      Seconds
  • Question 12 - A 28 year old female is brought into the emergency department after a...

    Incorrect

    • A 28 year old female is brought into the emergency department after a jet skiing accident at a local lake. The patient fell off the jet ski but her leg got caught in the handlebars and she was submerged for 2-3 minutes before being freed. The patient's friends started rescue breaths and chest compressions as the patient was unconscious but were stopped after approximately 30 seconds by an off duty lifeguard who assessed the patient and determined she was breathing spontaneously and had a pulse. On examination, the patient is breathing spontaneously with intermittent coughing, oxygen saturation levels are 97% on room air, a few crackling sounds are heard in the lower parts of the lungs, and the patient's Glasgow Coma Scale score is 13 out of 15.

      Which of the following should be included in the initial management of this patient?

      Your Answer: Give 15 litres oxygen by facemask if oxygen saturations drop below 95% on air.

      Correct Answer: Obtain an arterial blood gas sample for evidence of hypoxia

      Explanation:

      It is recommended to obtain an arterial blood gas (ABG) sample from all patients who have experienced submersion (drowning) as even individuals without symptoms may have a surprising level of hypoxia. Draining the lungs is not effective and not recommended. There is no strong evidence to support the routine use of antibiotics as a preventive measure. Steroids have not been proven to be effective in treating drowning. All drowning patients, except those with normal oxygen levels, normal saturations, and normal lung sounds, should receive supplemental oxygen as significant hypoxia can occur without causing difficulty in breathing.

      Further Reading:

      Drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid. It can be classified as cold-water or warm-water drowning. Risk factors for drowning include young age and male sex. Drowning impairs lung function and gas exchange, leading to hypoxemia and acidosis. It also causes cardiovascular instability, which contributes to metabolic acidosis and cell death.

      When someone is submerged or immersed, they will voluntarily hold their breath to prevent aspiration of water. However, continued breath holding causes progressive hypoxia and hypercapnia, leading to acidosis. Eventually, the respiratory center sends signals to the respiratory muscles, forcing the individual to take an involuntary breath and allowing water to be aspirated into the lungs. Water entering the lungs stimulates a reflex laryngospasm that prevents further penetration of water. Aspirated water can cause significant hypoxia and damage to the alveoli, leading to acute respiratory distress syndrome (ARDS).

      Complications of drowning include cardiac ischemia and infarction, infection with waterborne pathogens, hypothermia, neurological damage, rhabdomyolysis, acute tubular necrosis, and disseminated intravascular coagulation (DIC).

      In children, the diving reflex helps reduce hypoxic injury during submersion. It causes apnea, bradycardia, and peripheral vasoconstriction, reducing cardiac output and myocardial oxygen demand while maintaining perfusion of the brain and vital organs.

      Associated injuries with drowning include head and cervical spine injuries in patients rescued from shallow water. Investigations for drowning include arterial blood gases, chest X-ray, ECG and cardiac monitoring, core temperature measurement, and blood and sputum cultures if secondary infection is suspected.

      Management of drowning involves extricating the patient from water in a horizontal position with spinal precautions if possible. Cardiovascular considerations should be taken into account when removing patients from water to prevent hypotension and circulatory collapse. Airway management, supplemental oxygen, and ventilation strategies are important in maintaining oxygenation and preventing further lung injury. Correcting hypotension, electrolyte disturbances, and hypothermia is also necessary. Attempting to drain water from the lungs is ineffective.

      Patients without associated physical injury who are asymptomatic and have no evidence of respiratory compromise after six hours can be safely discharged home. Ventilation strategies aim to maintain oxygenation while minimizing ventilator-associated lung injury.

    • This question is part of the following fields:

      • Trauma
      29.5
      Seconds
  • Question 13 - A 32-year-old man is brought in by ambulance following a car crash. A...

    Correct

    • A 32-year-old man is brought in by ambulance following a car crash. A FAST scan is conducted to evaluate for a haemoperitoneum.
      Which of the subsequent anatomical regions is evaluated as part of a typical 4 view FAST scan?

      Your Answer: Left upper quadrant

      Explanation:

      A Focussed Assessment with Sonography for Trauma (FAST) scan is a point-of-care ultrasound examination conducted when a trauma patient arrives. Its primary purpose is to identify the presence of intra-abdominal free fluid, which is typically assumed to be haemoperitoneum in the context of trauma. This information helps healthcare providers make decisions regarding further management of the patient.

      The sensitivity of FAST scanning for detecting intraperitoneal fluid is approximately 90%, while its specificity is around 95%. However, its sensitivity for detecting solid organ injuries is much lower. As a result, FAST scanning has largely replaced diagnostic peritoneal lavage as the preferred initial method for assessing haemoperitoneum.

      During a standard FAST scan, four regions are assessed. The first is the subxiphoid transverse view, which is used to check for pericardial effusion and left lobe liver injuries. The second is the longitudinal view of the right upper quadrant, which helps identify right liver injuries, right kidney injuries, and fluid in the hepatorenal recess (Morison’s pouch). The third is the longitudinal view of the left upper quadrant, which is used to assess for splenic injury and left kidney injury. Lastly, the transverse and longitudinal views of the suprapubic region are examined to assess the bladder and fluid in the pouch of Douglas.

      In addition to the standard FAST scan, an extended FAST or eFAST may also be performed. This involves examining the left and right thoracic regions to assess for the presence of pneumothorax and haemothorax.

      The hepatorenal recess is the deepest part of the peritoneal cavity when a patient is lying flat. Therefore, it is the most likely area for fluid to accumulate in a supine position.

    • This question is part of the following fields:

      • Trauma
      12.3
      Seconds
  • Question 14 - A 47-year-old man with a past medical history of alcohol-related visits to the...

    Incorrect

    • A 47-year-old man with a past medical history of alcohol-related visits to the emergency department presents to the ED after falling while intoxicated. He has a 6 cm laceration on the occipital region of his scalp. You examine the wound under local anesthesia. As you remove the dressing and clean away a significant blood clot, you notice pulsatile bleeding from the wound. Which arteries provide blood supply to the posterior scalp?

      Your Answer: Vertebral

      Correct Answer: External carotid

      Explanation:

      The scalp is primarily supplied with blood from branches of the external carotid artery. The posterior half of the scalp is specifically supplied by three branches of the external carotid artery. These branches are the superficial temporal artery, which supplies blood to the frontal and temporal regions of the scalp, the posterior auricular artery, which supplies blood to the area above and behind the external ear, and the occipital artery, which supplies blood to the back of the scalp.

      Further Reading:

      The scalp is the area of the head that is bordered by the face in the front and the neck on the sides and back. It consists of several layers, including the skin, connective tissue, aponeurosis, loose connective tissue, and periosteum of the skull. These layers provide protection and support to the underlying structures of the head.

      The blood supply to the scalp primarily comes from branches of the external carotid artery and the ophthalmic artery, which is a branch of the internal carotid artery. These arteries provide oxygen and nutrients to the scalp tissues.

      The scalp also has a complex venous drainage system, which is divided into superficial and deep networks. The superficial veins correspond to the arterial branches and are responsible for draining blood from the scalp. The deep venous network is drained by the pterygoid venous plexus.

      In terms of innervation, the scalp receives sensory input from branches of the trigeminal nerve and the cervical nerves. These nerves transmit sensory information from the scalp to the brain, allowing us to perceive touch, pain, and temperature in this area.

    • This question is part of the following fields:

      • Trauma
      10
      Seconds
  • Question 15 - A man in his early forties who works at a steel mill is...

    Correct

    • A man in his early forties who works at a steel mill is hit in the front of his abdomen by a steel girder. A FAST scan is conducted, revealing the existence of free fluid within the abdominal cavity.

      Which organ is most likely to have sustained an injury in this scenario?

      Your Answer: Spleen

      Explanation:

      Blunt abdominal trauma often leads to injuries in certain organs. According to the latest edition of the ATLS manual, the spleen is the most frequently injured organ, with a prevalence of 40-55%. Following closely behind is the liver, which sustains injuries in about 35-45% of cases. The small bowel, although less commonly affected, still experiences injuries in approximately 5-10% of patients. It is worth noting that patients who undergo laparotomy for blunt trauma have a 15% incidence of retroperitoneal hematoma. These statistics highlight the significant impact of blunt abdominal trauma on organ health.

    • This question is part of the following fields:

      • Trauma
      13
      Seconds
  • Question 16 - You evaluate the airway and breathing of a child who has been brought...

    Incorrect

    • You evaluate the airway and breathing of a child who has been brought into the emergency room by an ambulance after being rescued from a house fire. You suspect that the child may have signs of airway obstruction.
      Which of the following statements about managing the airway and breathing in burned patients is correct?

      Your Answer: 100% oxygen should be continued until carboxyhaemoglobin levels fall to <5%

      Correct Answer:

      Explanation:

      Patients who have suffered burns should receive high-flow oxygen (15 L) through a reservoir bag while their breathing is being evaluated. If intubation is necessary, it is crucial to use an appropriately sized endotracheal tube (ETT). Using a tube that is too small can make it difficult or even impossible to ventilate the patient, clear secretions, or perform bronchoscopy.

      According to the ATLS guidelines, adults should be intubated using an ETT with an internal diameter (ID) of at least 7.5 mm or larger. Children, on the other hand, should have an ETT with an ID of at least 4.5 mm. Once a patient has been intubated, it is important to continue administering 100% oxygen until their carboxyhemoglobin levels drop to less than 5%.

      To protect the lungs, it is recommended to use lung protective ventilation techniques. This involves using low tidal volumes (4-8 mL/kg) and ensuring that peak inspiratory pressures do not exceed 30 cmH2O.

    • This question is part of the following fields:

      • Trauma
      23
      Seconds
  • Question 17 - A 42-year-old woman was involved in a car accident where her vehicle collided...

    Correct

    • A 42-year-old woman was involved in a car accident where her vehicle collided with a wall at a high speed. She was not wearing a seatbelt and was thrown forward onto the steering wheel. She is experiencing severe bruising on her anterior chest wall and is complaining of chest pain. A chest X-ray reveals a significantly widened mediastinum, tracheal deviation to the right, and fractures of the first and second ribs. Her vital signs are as follows: heart rate of 94, blood pressure of 128/73, and oxygen saturation of 99% on high flow oxygen.

      What is the SINGLE most likely diagnosis?

      Your Answer: Traumatic aortic rupture

      Explanation:

      Traumatic aortic rupture is a relatively common cause of sudden death following major trauma, especially high-speed road traffic accidents (RTAs). It is estimated that 15-20% of deaths from RTAs are due to this injury. If the aortic rupture is promptly recognized and treated, patients who survive the initial injury can fully recover.

      Surviving patients often have an incomplete laceration near the ligamentum arteriosum of the aorta. The continuity is maintained by either an intact adventitial layer or a contained mediastinal hematoma, which prevents immediate exsanguination and death.

      Detecting traumatic aortic rupture can be challenging as many patients do not exhibit specific symptoms, and other injuries may also be present, making the diagnosis unclear.

      Chest X-ray findings can aid in the diagnosis and include fractures of the 1st and 2nd ribs, a grossly widened mediastinum, a hazy left lung field, obliteration of the aortic knob, deviation of the trachea to the right, presence of a pleural cap, elevation and rightward shift of the right mainstem bronchus, depression of the left mainstem bronchus, obliteration of the space between the pulmonary artery and aorta, and deviation of the esophagus (or NG tube) to the right.

      Helical contrast-enhanced CT scanning is highly sensitive and specific for detecting aortic rupture, but it should only be performed on hemodynamically stable patients.

      Treatment options include primary repair or resection of the torn segment with replacement using an interposition graft. Endovascular repair is also now considered an acceptable alternative approach.

    • This question is part of the following fields:

      • Trauma
      31.2
      Seconds
  • Question 18 - A 28-year-old individual presents to the emergency department with burns on their hands....

    Correct

    • A 28-year-old individual presents to the emergency department with burns on their hands. After evaluation, it is determined that the patient has superficial partial thickness burns on the entire palmar surfaces of both hands. The burns do not extend beyond the wrist joint due to the patient wearing a thick jacket.

      To document the extent of the burns on a Lund and Browder chart, what percentage of the total body surface area is affected by this burn injury?

      Your Answer: 2-3%

      Explanation:

      Based on the Lund and Browder chart, the total percentage of burns is calculated as 3 since it affects one side of both hands.

      Further Reading:

      Burn injuries can be classified based on their type (degree, partial thickness or full thickness), extent as a percentage of total body surface area (TBSA), and severity (minor, moderate, major/severe). Severe burns are defined as a >10% TBSA in a child and >15% TBSA in an adult.

      When assessing a burn, it is important to consider airway injury, carbon monoxide poisoning, type of burn, extent of burn, special considerations, and fluid status. Special considerations may include head and neck burns, circumferential burns, thorax burns, electrical burns, hand burns, and burns to the genitalia.

      Airway management is a priority in burn injuries. Inhalation of hot particles can cause damage to the respiratory epithelium and lead to airway compromise. Signs of inhalation injury include visible burns or erythema to the face, soot around the nostrils and mouth, burnt/singed nasal hairs, hoarse voice, wheeze or stridor, swollen tissues in the mouth or nostrils, and tachypnea and tachycardia. Supplemental oxygen should be provided, and endotracheal intubation may be necessary if there is airway obstruction or impending obstruction.

      The initial management of a patient with burn injuries involves conserving body heat, covering burns with clean or sterile coverings, establishing IV access, providing pain relief, initiating fluid resuscitation, measuring urinary output with a catheter, maintaining nil by mouth status, closely monitoring vital signs and urine output, monitoring the airway, preparing for surgery if necessary, and administering medications.

      Burns can be classified based on the depth of injury, ranging from simple erythema to full thickness burns that penetrate into subcutaneous tissue. The extent of a burn can be estimated using methods such as the rule of nines or the Lund and Browder chart, which takes into account age-specific body proportions.

      Fluid management is crucial in burn injuries due to significant fluid losses. Evaporative fluid loss from burnt skin and increased permeability of blood vessels can lead to reduced intravascular volume and tissue perfusion. Fluid resuscitation should be aggressive in severe burns, while burns <15% in adults and <10% in children may not require immediate fluid resuscitation. The Parkland formula can be used to calculate the intravenous fluid requirements for someone with a significant burn injury.

    • This question is part of the following fields:

      • Trauma
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  • Question 19 - A 42-year-old man was involved in a car accident where his vehicle collided...

    Correct

    • A 42-year-old man was involved in a car accident where his vehicle collided with a wall. He was rescued at the scene and has been brought to the hospital by ambulance. He is currently wearing a cervical immobilization device. He is experiencing chest pain on the left side and is having difficulty breathing. As the leader of the trauma response team, his vital signs are as follows: heart rate of 110, blood pressure of 102/63, oxygen saturation of 90% on room air. His Glasgow Coma Scale score is 15 out of 15. Upon examination, he has extensive bruising on the left side of his chest and shows reduced chest expansion, dullness to percussion, and decreased breath sounds throughout the entire left hemithorax.

      What is the most likely diagnosis for this patient?

      Your Answer: Massive haemothorax

      Explanation:

      A massive haemothorax occurs when more than 1500 mL of blood, which is about 1/3 of the patient’s blood volume, rapidly accumulates in the chest cavity. The classic signs of a massive haemothorax include decreased chest expansion, decreased breath sounds, and dullness to percussion. Both tension pneumothorax and massive haemothorax can cause decreased breath sounds, but they can be differentiated through percussion. Hyperresonance indicates tension pneumothorax, while dullness suggests a massive haemothorax.

      The first step in managing a massive haemothorax is to simultaneously restore blood volume and decompress the chest cavity by inserting a chest drain. In most cases, the bleeding in a haemothorax has already stopped by the time management begins, and simple drainage is sufficient. It is important to use a chest drain of adequate size (preferably 36F) to ensure effective drainage of the haemothorax without clotting.

    • This question is part of the following fields:

      • Trauma
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  • Question 20 - You are evaluating a 25-year-old male with a puncture wound to the stomach....

    Correct

    • You are evaluating a 25-year-old male with a puncture wound to the stomach. Which of the following is NOT a reason for immediate laparotomy in cases of penetrating abdominal injury?

      Your Answer: Negative diagnostic peritoneal lavage

      Explanation:

      Urgent laparotomy is necessary in cases of penetrating abdominal trauma when certain indications are present. These indications include peritonism, the presence of free air under the diaphragm on an upright chest X-ray, evisceration, hypotension or signs of unstable blood flow, a gunshot wound that has penetrated the peritoneum or retroperitoneum, gastrointestinal bleeding following penetrating trauma, genitourinary bleeding following penetrating trauma, the presence of a penetrating object that is still in place (as removal may result in significant bleeding), and the identification of free fluid on a focused assessment with sonography for trauma (FAST) or a positive diagnostic peritoneal lavage (DPL).

      Further Reading:

      Abdominal trauma can be classified into two categories: blunt trauma and penetrating trauma. Blunt trauma occurs when compressive or deceleration forces are applied to the abdomen, often resulting from road traffic accidents or direct blows during sports. The spleen and liver are the organs most commonly injured in blunt abdominal trauma. On the other hand, penetrating trauma involves injuries that pierce the skin and enter the abdominal cavity, such as stabbings, gunshot wounds, or industrial accidents. The bowel and liver are the organs most commonly affected in penetrating injuries.

      When it comes to imaging in blunt abdominal trauma, there are three main modalities that are commonly used: focused assessment with sonography in trauma (FAST), diagnostic peritoneal lavage (DPL), and computed tomography (CT). FAST is a non-invasive and quick method used to detect free intraperitoneal fluid, aiding in the decision on whether a laparotomy is needed. DPL is also used to detect intraperitoneal blood and can be used in both unstable blunt abdominal trauma and penetrating abdominal trauma. However, it is more invasive and time-consuming compared to FAST and has largely been replaced by it. CT, on the other hand, is the gold standard for diagnosing intra-abdominal pathology and is used in stable abdominal trauma patients. It offers high sensitivity and specificity but requires a stable and cooperative patient. It also involves radiation and may have delays in availability.

      In the case of penetrating trauma, it is important to assess these injuries with the help of a surgical team. Penetrating objects should not be removed in the emergency department as they may be tamponading underlying vessels. Ideally, these injuries should be explored in the operating theater.

      In summary, abdominal trauma can be classified into blunt trauma and penetrating trauma. Blunt trauma is caused by compressive or deceleration forces and commonly affects the spleen and liver. Penetrating trauma involves injuries that pierce the skin and commonly affect the bowel and liver. Imaging modalities such as FAST, DPL, and CT are used to assess and diagnose abdominal trauma, with CT being the gold standard. Penetrating injuries should be assessed by a surgical team and should ideally be explored in the operating theater.

    • This question is part of the following fields:

      • Trauma
      12.9
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  • Question 21 - A 35-year-old woman is brought into the emergency room by an ambulance with...

    Incorrect

    • A 35-year-old woman is brought into the emergency room by an ambulance with flashing lights. She has been in a car accident and has sustained severe burns. You examine her airway and have concerns about potential airway blockage. Your plan is to intubate the patient and begin preparing the required equipment.
      As per the ATLS guidelines, what is the minimum internal diameter of the endotracheal tube that should be utilized?

      Your Answer: 6.5 mm

      Correct Answer: 7.5 mm

      Explanation:

      Patients who have suffered burns should receive high-flow oxygen (15 L) through a reservoir bag while their breathing is being evaluated. If intubation is necessary, it is crucial to use an appropriately sized endotracheal tube (ETT). Using a tube that is too small can make it difficult or even impossible to ventilate the patient, clear secretions, or perform bronchoscopy.

      According to the ATLS guidelines, adults should be intubated using an ETT with an internal diameter (ID) of at least 7.5 mm or larger. Children, on the other hand, should have an ETT with an ID of at least 4.5 mm. Once a patient has been intubated, it is important to continue administering 100% oxygen until their carboxyhemoglobin levels drop to less than 5%.

      To protect the lungs, it is recommended to use lung protective ventilation techniques. This involves using low tidal volumes (4-8 mL/kg) and ensuring that peak inspiratory pressures do not exceed 30 cmH2O.

    • This question is part of the following fields:

      • Trauma
      13.9
      Seconds
  • Question 22 - A 35-year-old man is brought into resus by blue light ambulance. He has...

    Correct

    • A 35-year-old man is brought into resus by blue light ambulance. He has been involved in a car accident and has suffered severe injuries. You assess his airway and are concerned about the potential for airway obstruction.
      What is the primary risk factor for airway obstruction in a patient with severe injuries?

      Your Answer: A carboxyhaemoglobin level of 15%

      Explanation:

      Early assessment of the airway is a critical aspect of managing a patient who has suffered burns. Airway blockage can occur rapidly due to direct injury, such as inhalation injury, or as a result of swelling caused by the burn. If there is a history of trauma, the airway should be evaluated and treated while maintaining control of the cervical spine.

      Signs of airway obstruction may not be immediately apparent, as swelling typically does not occur right away. Children with thermal burns are at a higher risk of airway obstruction compared to adults due to their smaller airway size, so they require careful observation.

      There are several risk factors for airway obstruction in burned patients, including inhalation injury, the presence of soot in the mouth or nostrils, singed nasal hairs, burns to the head, face, or neck, burns inside the mouth, a large burn area with increasing depth, and associated trauma. A carboxyhemoglobin level above 10% is also suggestive of an inhalation injury.

    • This question is part of the following fields:

      • Trauma
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  • Question 23 - A female trauma victim that has experienced substantial blood loss is estimated to...

    Incorrect

    • A female trauma victim that has experienced substantial blood loss is estimated to have experienced a grade III haemorrhage. The patient's weight is approximately 60 kg.
      Which of the following physiological indicators aligns with a diagnosis of grade III haemorrhage?

      Your Answer: Loss of 25% of blood volume

      Correct Answer: Urine output of 10 ml/hr

      Explanation:

      Recognizing the extent of blood loss based on vital sign and mental status abnormalities is a crucial skill. The Advanced Trauma Life Support (ATLS) classification for hemorrhagic shock correlates the amount of blood loss with expected physiological responses in a healthy individual weighing 70 kg. In terms of body weight, the total circulating blood volume accounts for approximately 7%, which is roughly equivalent to five liters in an average 70 kg male patient.

      The ATLS classification for hemorrhagic shock is as follows:

      CLASS I:
      – Blood loss: Up to 750 mL
      – Blood loss (% blood volume): Up to 15%
      – Pulse rate: Less than 100 beats per minute (bpm)
      – Systolic blood pressure: Normal
      – Pulse pressure: Normal (or increased)
      – Respiratory rate: 14-20 breaths per minute
      – Urine output: Greater than 30 mL/hr
      – CNS/mental status: Slightly anxious

      CLASS II:
      – Blood loss: 750-1500 mL
      – Blood loss (% blood volume): 15-30%
      – Pulse rate: 100-120 bpm
      – Systolic blood pressure: Normal
      – Pulse pressure: Decreased
      – Respiratory rate: 20-30 breaths per minute
      – Urine output: 20-30 mL/hr
      – CNS/mental status: Mildly anxious

      CLASS III:
      – Blood loss: 1500-2000 mL
      – Blood loss (% blood volume): 30-40%
      – Pulse rate: 120-140 bpm
      – Systolic blood pressure: Decreased
      – Pulse pressure: Decreased
      – Respiratory rate: 30-40 breaths per minute
      – Urine output: 5-15 mL/hr
      – CNS/mental status: Anxious, confused

      CLASS IV:
      – Blood loss: More than 2000 mL
      – Blood loss (% blood volume): More than 40%
      – Pulse rate: More than 140 bpm
      – Systolic blood pressure: Decreased
      – Pulse pressure: Decreased
      – Respiratory rate: More than 40 breaths per minute
      – Urine output: Negligible
      – CNS/mental status: Confused, lethargic

    • This question is part of the following fields:

      • Trauma
      13
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  • Question 24 - A 15 year old female patient is brought to the emergency department after...

    Incorrect

    • A 15 year old female patient is brought to the emergency department after being kicked by a horse multiple times. The patient had recently started work cleaning stables and was kicked several times whilst behind one of the horses. The patients observations are shown below:

      Parameter Result
      Blood pressure 108/62 mmHg
      Pulse rate 124 bpm
      Respiration rate 30 rpm
      SpO2 95% on air

      On examination there is significant bruising to the right anterolateral aspect of the chest wall, the patient is clammy, there is reduced air entry with dull percussion to the right lung base and the trachea is central. What is the likely diagnosis?

      Your Answer:

      Correct Answer: Massive haemothorax

      Explanation:

      Massive haemothorax is characterized by the presence of more than 1.5 litres of blood in the pleural space. The patient’s history and examination findings are indicative of haemothorax. When blood loss exceeds 1500ml, it is classified as grade 3 hypovolemic shock, which is considered severe. Symptoms such as a pulse rate over 120, respiration rate over 30, and low blood pressure align with grade 3 shock and are consistent with massive haemothorax. In the case of pneumothorax, percussion reveals a resonant or hyper-resonant sound. Chylothorax, on the other hand, is a rare condition that typically occurs due to injury to the thoracic duct.

      Further Reading:

      Haemothorax is the accumulation of blood in the pleural cavity of the chest, usually resulting from chest trauma. It can be difficult to differentiate from other causes of pleural effusion on a chest X-ray. Massive haemothorax refers to a large volume of blood in the pleural space, which can impair physiological function by causing blood loss, reducing lung volume for gas exchange, and compressing thoracic structures such as the heart and IVC.

      The management of haemothorax involves replacing lost blood volume and decompressing the chest. This is done through supplemental oxygen, IV access and cross-matching blood, IV fluid therapy, and the insertion of a chest tube. The chest tube is connected to an underwater seal and helps drain the fluid, pus, air, or blood from the pleural space. In cases where there is prompt drainage of a large amount of blood, ongoing significant blood loss, or the need for blood transfusion, thoracotomy and ligation of bleeding thoracic vessels may be necessary. It is important to have two IV accesses prior to inserting the chest drain to prevent a drop in blood pressure.

      In summary, haemothorax is the accumulation of blood in the pleural cavity due to chest trauma. Managing haemothorax involves replacing lost blood volume and decompressing the chest through various interventions, including the insertion of a chest tube. Prompt intervention may be required in cases of significant blood loss or ongoing need for blood transfusion.

    • This question is part of the following fields:

      • Trauma
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  • Question 25 - A 35-year-old woman is brought in by ambulance following a car accident where...

    Incorrect

    • A 35-year-old woman is brought in by ambulance following a car accident where her vehicle was hit by a truck. She has sustained severe facial injuries and shows signs of airway blockage. Her cervical spine is immobilized in three places.

      Which two fundamental airway techniques are recommended by ATLS guidelines to clear the airway in trauma patients?

      Your Answer:

      Correct Answer: Chin-lift and jaw-thrust manoeuvres

      Explanation:

      The most recent ATLS guidelines recommend using either the jaw-thrust or chin-lift techniques as the initial approach to open the airway in trauma patients. It is important to avoid moving the head and neck in patients with suspected cervical spine injuries. However, if the patient is unconscious and does not have a gag reflex, temporarily placing an oropharyngeal airway can be beneficial.

      To perform the chin-lift technique, gently place your fingers under the mandible and lift it upwards to bring the chin forward. Use your thumb to slightly depress the lower lip and open the mouth. Alternatively, you can place your thumb behind the lower incisors while gently lifting the chin. It is crucial not to hyperextend the neck during the chin-lift technique.

      For the jaw thrust technique, place one hand on each side of the mandible and push it forward. This can be done in conjunction with a bag-mask device to achieve a good seal and provide adequate ventilation. Just like with the chin-lift technique, be cautious not to extend the patient’s neck.

    • This question is part of the following fields:

      • Trauma
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  • Question 26 - A 4-year-old girl is brought in by an emergency ambulance after being involved...

    Incorrect

    • A 4-year-old girl is brought in by an emergency ambulance after being involved in a car accident. A trauma alert is activated, and you are tasked with obtaining intravenous access and administering a fluid bolus. However, you are unable to successfully establish intravenous access and decide to prepare for intraosseous access instead.

      Which of the following anatomical sites would be the most appropriate for insertion?

      Your Answer:

      Correct Answer: Proximal humerus

      Explanation:

      Intraosseous access is recommended in trauma, burns, or resuscitation situations when other attempts at venous access fail or would take longer than one minute. It is particularly recommended for circulatory access in pediatric cardiac arrest cases. This technique can also be used when urgent blood sampling or intravenous access is needed and traditional cannulation is difficult and time-consuming. It serves as a temporary measure to stabilize the patient and facilitate long-term intravenous access.

      Potential complications of intraosseous access include compartment syndrome, infection, and fracture. Therefore, it is contraindicated to use this method on the side of definitively fractured bones or limbs with possible proximal fractures. It should also not be used at sites of previous attempts or in patients with conditions such as osteogenesis imperfecta or osteopetrosis.

      There are several possible sites for intraosseous access insertion. These include the proximal humerus, approximately 1 cm above the surgical neck; the proximal tibia, on the anterior surface, 2-3 cm below the tibial tuberosity; the distal tibia, 3 cm proximal to the most prominent aspect of the medial malleolus; the femoral region, on the anterolateral surface, 3 cm above the lateral condyle; the iliac crest; and the sternum.

    • This question is part of the following fields:

      • Trauma
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  • Question 27 - A 42 year old man is brought into the emergency department after a...

    Incorrect

    • A 42 year old man is brought into the emergency department after a car accident. He has significant bruising on the right side of his chest. You suspect he may have a hemothorax. When would thoracotomy be considered as a treatment option?

      Your Answer:

      Correct Answer: Prompt drainage of ≥1500 ml of blood following chest drain insertion

      Explanation:

      Thoracotomy is recommended when there is a need for prompt drainage of at least 1500 ml of blood following the insertion of a chest drain. Additionally, it is indicated when there is a continuous blood loss of more than 200 ml per hour for a period of 2-4 hours or when there is a persistent requirement for blood transfusion.

      Further Reading:

      Haemothorax is the accumulation of blood in the pleural cavity of the chest, usually resulting from chest trauma. It can be difficult to differentiate from other causes of pleural effusion on a chest X-ray. Massive haemothorax refers to a large volume of blood in the pleural space, which can impair physiological function by causing blood loss, reducing lung volume for gas exchange, and compressing thoracic structures such as the heart and IVC.

      The management of haemothorax involves replacing lost blood volume and decompressing the chest. This is done through supplemental oxygen, IV access and cross-matching blood, IV fluid therapy, and the insertion of a chest tube. The chest tube is connected to an underwater seal and helps drain the fluid, pus, air, or blood from the pleural space. In cases where there is prompt drainage of a large amount of blood, ongoing significant blood loss, or the need for blood transfusion, thoracotomy and ligation of bleeding thoracic vessels may be necessary. It is important to have two IV accesses prior to inserting the chest drain to prevent a drop in blood pressure.

      In summary, haemothorax is the accumulation of blood in the pleural cavity due to chest trauma. Managing haemothorax involves replacing lost blood volume and decompressing the chest through various interventions, including the insertion of a chest tube. Prompt intervention may be required in cases of significant blood loss or ongoing need for blood transfusion.

    • This question is part of the following fields:

      • Trauma
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  • Question 28 - You are treating a patient who fell from a rooftop and has sustained...

    Incorrect

    • You are treating a patient who fell from a rooftop and has sustained a fracture to the left calcaneus. Which of the following injuries is frequently associated with calcaneal fractures?

      Your Answer:

      Correct Answer: Vertebral fracture

      Explanation:

      When patients have calcaneal fractures, it is important to evaluate them for any additional injuries that may be present. These can include vertebral fractures, fractures in the opposite calcaneus, and injuries to the cuboid bone.

      Further Reading:

      Calcaneus fractures are a common type of lower limb and joint injury. The calcaneus, or heel bone, is the most frequently fractured tarsal bone. These fractures are often intra-articular, meaning they involve the joint. The most common cause of calcaneus fractures is a fall or jump from a height.

      When assessing calcaneus fractures, X-rays are used to visualize the fracture lines. Two angles are commonly assessed to determine the severity of the fracture. Böhler’s angle, which measures the angle between two tangent lines drawn across the anterior and posterior borders of the calcaneus, should be between 20-40 degrees. If it is less than 20 degrees, it indicates a calcaneal fracture with flattening. The angle of Gissane, which measures the depression of the posterior facet of the subtalar joint, should be between 120-145 degrees. An increased angle of Gissane suggests a calcaneal fracture.

      In the emergency department, the management of a fractured calcaneus involves identifying the injury and any associated injuries, providing pain relief, elevating the affected limb(s), and referring the patient to an orthopedic specialist. It is important to be aware that calcaneus fractures are often accompanied by other injuries, such as bilateral fractures of vertebral fractures.

      The definitive management of a fractured calcaneus can be done conservatively or through surgery, specifically open reduction internal fixation (ORIF). The orthopedic team will typically order a CT or MRI scan to classify the fracture and determine the most appropriate treatment. However, a recent UK heel fracture trial suggests that in most cases, ORIF does not improve fracture outcomes.

    • This question is part of the following fields:

      • Trauma
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  • Question 29 - A 35 year old female is brought into the emergency department with chest...

    Incorrect

    • A 35 year old female is brought into the emergency department with chest injuries after a canister was thrown into a fire and the explosive projectile struck the patient's chest wall. On examination, there is asymmetry of the chest. You observe that the chest wall moves inward during inhalation and outward during expiration.

      What is the term for this clinical sign?

      Your Answer:

      Correct Answer: Paradoxical breathing

      Explanation:

      The patient in this scenario is exhibiting a clinical sign known as paradoxical breathing. This is characterized by an abnormal movement of the chest wall during respiration. Normally, the chest expands during inhalation and contracts during exhalation. However, in paradoxical breathing, the opposite occurs. The chest wall moves inward during inhalation and outward during exhalation. This can be seen in cases of chest trauma or injury, where there is a disruption in the normal mechanics of breathing.

      Further Reading:

      Flail chest is a serious condition that occurs when multiple ribs are fractured in two or more places, causing a segment of the ribcage to no longer expand properly. This condition is typically caused by high-impact thoracic blunt trauma and is often accompanied by other significant injuries to the chest.

      The main symptom of flail chest is a chest deformity, where the affected area moves in a paradoxical manner compared to the rest of the ribcage. This can cause chest pain and difficulty breathing, known as dyspnea. X-rays may also show evidence of lung contusion, indicating further damage to the chest.

      In terms of management, conservative treatment is usually the first approach. This involves providing adequate pain relief and respiratory support to the patient. However, if there are associated injuries such as a pneumothorax or hemothorax, specific interventions like thoracostomy or surgery may be necessary.

      Positive pressure ventilation can be used to provide internal splinting of the airways, helping to prevent atelectasis, a condition where the lungs collapse. Overall, prompt and appropriate management is crucial in order to prevent further complications and improve the patient’s outcome.

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  • Question 30 - A 45-year-old presents to the emergency department following a seemingly minor rear-end car...

    Incorrect

    • A 45-year-old presents to the emergency department following a seemingly minor rear-end car accident. There are no reported sensory deficits. What clinical finding would indicate the need for radiological evaluation of the cervical spine in this scenario?

      Your Answer:

      Correct Answer: Patient unable to actively rotate their neck 45 degrees to the left and right

      Explanation:

      The ability to rotate the neck actively by 45 degrees to the left and right is a crucial distinction between the ‘no risk’ and ‘low risk’ categories when applying the Canadian C-spine rules. In this case, the patient does not exhibit any high-risk factors for cervical spine injury according to the Canadian C-spine rule. However, they do have a low-risk factor due to their involvement in a minor rear-end motor collision. If a patient with a low-risk factor is unable to actively rotate their neck by 45 degrees in either direction, they should undergo imaging. It is important to note that while the patient’s use of anticoagulation medication may affect the need for brain imaging, it typically does not impact the decision to perform a CT scan of the cervical spine.

      Further Reading:

      When assessing for cervical spine injury, it is recommended to use the Canadian C-spine rules. These rules help determine the risk level for a potential injury. High-risk factors include being over the age of 65, experiencing a dangerous mechanism of injury (such as a fall from a height or a high-speed motor vehicle collision), or having paraesthesia in the upper or lower limbs. Low-risk factors include being involved in a minor rear-end motor vehicle collision, being comfortable in a sitting position, being ambulatory since the injury, having no midline cervical spine tenderness, or experiencing a delayed onset of neck pain. If a person is unable to actively rotate their neck 45 degrees to the left and right, their risk level is considered low. If they have one of the low-risk factors and can actively rotate their neck, their risk level remains low.

      If a high-risk factor is identified or if a low-risk factor is identified and the person is unable to actively rotate their neck, full in-line spinal immobilization should be maintained and imaging should be requested. Additionally, if a patient has risk factors for thoracic or lumbar spine injury, imaging should be requested. However, if a patient has low-risk factors for cervical spine injury, is pain-free, and can actively rotate their neck, full in-line spinal immobilization and imaging are not necessary.

      NICE recommends CT as the primary imaging modality for cervical spine injury in adults aged 16 and older, while MRI is recommended as the primary imaging modality for children under 16.

      Different mechanisms of spinal trauma can cause injury to the spine in predictable ways. The majority of cervical spine injuries are caused by flexion combined with rotation. Hyperflexion can result in compression of the anterior aspects of the vertebral bodies, stretching and tearing of the posterior ligament complex, chance fractures (also known as seatbelt fractures), flexion teardrop fractures, and odontoid peg fractures. Flexion and rotation can lead to disruption of the posterior ligament complex and posterior column, fractures of facet joints, lamina, transverse processes, and vertebral bodies, and avulsion of spinous processes. Hyperextension can cause injury to the anterior column, anterior fractures of the vertebral body, and potential retropulsion of bony fragments or discs into the spinal canal. Rotation can result in injury to the posterior ligament complex and facet joint dislocation.

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  • Question 31 - A 62 year old male is brought into the emergency department after being...

    Incorrect

    • A 62 year old male is brought into the emergency department after being hit by a car while crossing the street. The patient is breathing rapidly and clinical examination shows a flail segment. What is the most suitable initial intervention to relieve respiratory distress?

      Your Answer:

      Correct Answer: Positive pressure ventilation

      Explanation:

      To relieve the patient’s respiratory distress, the most suitable initial intervention would be positive pressure ventilation. This involves providing mechanical assistance to the patient’s breathing by delivering air or oxygen under pressure through a mask or endotracheal tube. This helps to improve oxygenation and ventilation, ensuring that the patient’s lungs are adequately supplied with oxygen and carbon dioxide is effectively removed. Positive pressure ventilation can help stabilize the patient’s breathing and alleviate the respiratory distress caused by the flail segment.

      Further Reading:

      Flail chest is a serious condition that occurs when multiple ribs are fractured in two or more places, causing a segment of the ribcage to no longer expand properly. This condition is typically caused by high-impact thoracic blunt trauma and is often accompanied by other significant injuries to the chest.

      The main symptom of flail chest is a chest deformity, where the affected area moves in a paradoxical manner compared to the rest of the ribcage. This can cause chest pain and difficulty breathing, known as dyspnea. X-rays may also show evidence of lung contusion, indicating further damage to the chest.

      In terms of management, conservative treatment is usually the first approach. This involves providing adequate pain relief and respiratory support to the patient. However, if there are associated injuries such as a pneumothorax or hemothorax, specific interventions like thoracostomy or surgery may be necessary.

      Positive pressure ventilation can be used to provide internal splinting of the airways, helping to prevent atelectasis, a condition where the lungs collapse. Overall, prompt and appropriate management is crucial in order to prevent further complications and improve the patient’s outcome.

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  • Question 32 - A 45-year-old woman is brought into the emergency room by an ambulance with...

    Incorrect

    • A 45-year-old woman is brought into the emergency room by an ambulance with sirens blaring after being involved in a car accident. She was hit by a truck while crossing the street and is suspected to have a pelvic injury. Her condition is unstable, and the hospital has activated the massive transfusion protocol. You decide to also administer tranexamic acid and give an initial dose of 1 g intravenously over a period of 10 minutes.
      What should be the subsequent dose of tranexamic acid and how long should it be administered for?

      Your Answer:

      Correct Answer: 1 g IV over 8 hours

      Explanation:

      ATLS guidelines now suggest administering only 1 liter of crystalloid fluid during the initial assessment. If patients do not respond to the crystalloid, it is recommended to quickly transition to blood products. Studies have shown that infusing more than 1.5 liters of crystalloid fluid is associated with higher mortality rates in trauma cases. Therefore, it is advised to prioritize the early use of blood products and avoid large volumes of crystalloid fluid in trauma patients. In cases where it is necessary, massive transfusion should be considered, defined as the transfusion of more than 10 units of blood in 24 hours or more than 4 units of blood in one hour. For patients with evidence of Class III and IV hemorrhage, early resuscitation with blood and blood products in low ratios is recommended.

      Based on the findings of significant trials, such as the CRASH-2 study, the use of tranexamic acid is now recommended within 3 hours. This involves administering a loading dose of 1 gram intravenously over 10 minutes, followed by an infusion of 1 gram over eight hours. In some regions, tranexamic acid is also being utilized in the prehospital setting.

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  • Question 33 - A 35-year-old woman is brought in by ambulance following a car accident where...

    Incorrect

    • A 35-year-old woman is brought in by ambulance following a car accident where her car was hit by a truck. She has sustained severe facial injuries and shows signs of airway obstruction. Her cervical spine is immobilized. The anesthesiologist has attempted to intubate her but is unsuccessful and decides to perform a surgical cricothyroidotomy.

      Which of the following statements regarding surgical cricothyroidotomy is FALSE?

      Your Answer:

      Correct Answer: It is the surgical airway of choice in patients under the age of 12

      Explanation:

      A surgical cricothyroidotomy is a procedure performed in emergency situations to secure the airway by making an incision in the cricothyroid membrane. It is also known as an emergency surgical airway (ESA) and is typically done when intubation and oxygenation are not possible.

      There are certain conditions in which a surgical cricothyroidotomy should not be performed. These include patients who are under 12 years old, those with laryngeal fractures or pre-existing or acute laryngeal pathology, individuals with tracheal transection and retraction of the trachea into the mediastinum, and cases where the anatomical landmarks are obscured due to trauma.

      The procedure is carried out in the following steps:
      1. Gathering and preparing the necessary equipment.
      2. Positioning the patient on their back with the neck in a neutral position.
      3. Sterilizing the patient’s neck using antiseptic swabs.
      4. Administering local anesthesia, if time permits.
      5. Locating the cricothyroid membrane, which is situated between the thyroid and cricoid cartilage.
      6. Stabilizing the trachea with the left hand until it can be intubated.
      7. Making a transverse incision through the cricothyroid membrane.
      8. Inserting the scalpel handle into the incision and rotating it 90°. Alternatively, a haemostat can be used to open the airway.
      9. Placing a properly-sized, cuffed endotracheal tube (usually a size 5 or 6) into the incision, directing it into the trachea.
      10. Inflating the cuff and providing ventilation.
      11. Monitoring for chest rise and auscultating the chest to ensure adequate ventilation.
      12. Securing the airway to prevent displacement.

      Potential complications of a surgical cricothyroidotomy include aspiration of blood, creation of a false passage into the tissues, subglottic stenosis or edema, laryngeal stenosis, hemorrhage or hematoma formation, laceration of the esophagus or trachea, mediastinal emphysema, and vocal cord paralysis or hoarseness.

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  • Question 34 - A 32 year old male is brought into the emergency department following a...

    Incorrect

    • A 32 year old male is brought into the emergency department following a car accident. You evaluate the patient's risk of cervical spine injury using the Canadian C-spine rule. What is included in the assessment for the Canadian C-spine rule?

      Your Answer:

      Correct Answer: Ask patient to rotate their neck 45 degrees to the left and right

      Explanation:

      The Canadian C-spine assessment includes evaluating for tenderness along the midline of the spine, checking for any abnormal sensations in the limbs, and assessing the ability to rotate the neck 45 degrees to the left and right. While a significant portion of the assessment relies on gathering information from the patient’s history, there are also physical examination components involved. These include testing for tenderness along the midline of the cervical spine, asking the patient to perform neck rotations, ensuring they are comfortable in a sitting position, and assessing for any sensory deficits in the limbs. It is important to note that any reported paraesthesia in the upper or lower limbs can also be taken into consideration during the assessment.

      Further Reading:

      When assessing for cervical spine injury, it is recommended to use the Canadian C-spine rules. These rules help determine the risk level for a potential injury. High-risk factors include being over the age of 65, experiencing a dangerous mechanism of injury (such as a fall from a height or a high-speed motor vehicle collision), or having paraesthesia in the upper or lower limbs. Low-risk factors include being involved in a minor rear-end motor vehicle collision, being comfortable in a sitting position, being ambulatory since the injury, having no midline cervical spine tenderness, or experiencing a delayed onset of neck pain. If a person is unable to actively rotate their neck 45 degrees to the left and right, their risk level is considered low. If they have one of the low-risk factors and can actively rotate their neck, their risk level remains low.

      If a high-risk factor is identified or if a low-risk factor is identified and the person is unable to actively rotate their neck, full in-line spinal immobilization should be maintained and imaging should be requested. Additionally, if a patient has risk factors for thoracic or lumbar spine injury, imaging should be requested. However, if a patient has low-risk factors for cervical spine injury, is pain-free, and can actively rotate their neck, full in-line spinal immobilization and imaging are not necessary.

      NICE recommends CT as the primary imaging modality for cervical spine injury in adults aged 16 and older, while MRI is recommended as the primary imaging modality for children under 16.

      Different mechanisms of spinal trauma can cause injury to the spine in predictable ways. The majority of cervical spine injuries are caused by flexion combined with rotation. Hyperflexion can result in compression of the anterior aspects of the vertebral bodies, stretching and tearing of the posterior ligament complex, chance fractures (also known as seatbelt fractures), flexion teardrop fractures, and odontoid peg fractures. Flexion and rotation can lead to disruption of the posterior ligament complex and posterior column, fractures of facet joints, lamina, transverse processes, and vertebral bodies, and avulsion of spinous processes. Hyperextension can cause injury to the anterior column, anterior fractures of the vertebral body, and potential retropulsion of bony fragments or discs into the spinal canal. Rotation can result in injury to the posterior ligament complex and facet joint dislocation.

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  • Question 35 - The FY1 doctor seeks your guidance concerning an elderly patient they are managing...

    Incorrect

    • The FY1 doctor seeks your guidance concerning an elderly patient they are managing who has experienced a head injury. They are uncertain whether to request a CT head scan for their patient. What clinical criteria would necessitate an immediate CT head scan in an elderly individual?

      Your Answer:

      Correct Answer: Haemotympanum

      Explanation:

      Patients with head injuries who show any signs of basal skull fracture, such as haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, or Battle’s sign, should undergo urgent CT imaging. Additionally, the following indications also warrant a CT scan: a Glasgow Coma Scale (GCS) score of less than 13 on initial assessment in the emergency department (ED), a GCS score of less than 15 at 2 hours after the injury on assessment in the ED, suspected open or depressed skull fracture, post-traumatic seizure, new focal neurological deficit, greater than 1 episode of vomiting, or the patient being on anticoagulation. If any of these signs are present, a CT scan should be performed within 1 hour, except for patients on anticoagulation who should have a CT scan within 8 hours if they do not have any other signs. However, if patients on anticoagulation do have any of the other signs, the CT scan should be performed within 1 hour.

      Further Reading:

      Indications for CT Scanning in Head Injuries (Adults):
      – CT head scan should be performed within 1 hour if any of the following features are present:
      – GCS < 13 on initial assessment in the ED
      – GCS < 15 at 2 hours after the injury on assessment in the ED
      – Suspected open or depressed skull fracture
      – Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
      – Post-traumatic seizure
      – New focal neurological deficit
      – > 1 episode of vomiting

      Indications for CT Scanning in Head Injuries (Children):
      – CT head scan should be performed within 1 hour if any of the features in List 1 are present:
      – Suspicion of non-accidental injury
      – Post-traumatic seizure but no history of epilepsy
      – GCS < 14 on initial assessment in the ED for children more than 1 year of age
      – Paediatric GCS < 15 on initial assessment in the ED for children under 1 year of age
      – At 2 hours after the injury, GCS < 15
      – Suspected open or depressed skull fracture or tense fontanelle
      – Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
      – New focal neurological deficit
      – For children under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head

      – CT head scan should be performed within 1 hour if none of the above features are present but two or more of the features in List 2 are present:
      – Loss of consciousness lasting more than 5 minutes (witnessed)
      – Abnormal drowsiness
      – Three or more discrete episodes of vomiting
      – Dangerous mechanism of injury (high-speed road traffic accident, fall from a height.

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  • Question 36 - A 42-year-old woman was involved in a car accident where her car collided...

    Incorrect

    • A 42-year-old woman was involved in a car accident where her car collided with a tree at high speed. She was not wearing a seatbelt and was thrown forward onto the steering wheel of her car. She has severe bruising over her anterior chest wall and is experiencing chest pain. A chest X-ray reveals a significantly widened mediastinum, deviation of the trachea to the left, and fractures of the third and fourth ribs. Her vital signs are HR 88, BP 130/78, SaO2 98% on high flow oxygen.

      At which anatomical site is an injury MOST likely to have occurred in this case?

      Your Answer:

      Correct Answer: Near the ligamentum arteriosum

      Explanation:

      Traumatic aortic rupture is a relatively common cause of sudden death following major trauma, especially high-speed road traffic accidents (RTAs). It is estimated that 15-20% of deaths from RTAs are due to this injury. If the aortic rupture is promptly recognized and treated, patients who survive the initial injury can fully recover.

      Surviving patients often have an incomplete laceration near the ligamentum arteriosum of the aorta. The continuity is maintained by either an intact adventitial layer or a contained mediastinal hematoma, which prevents immediate exsanguination and death.

      Detecting traumatic aortic rupture can be challenging as many patients do not exhibit specific symptoms, and other injuries may also be present, making the diagnosis unclear.

      Chest X-ray findings can aid in the diagnosis and include fractures of the 1st and 2nd ribs, a grossly widened mediastinum, a hazy left lung field, obliteration of the aortic knob, deviation of the trachea to the right, presence of a pleural cap, elevation and rightward shift of the right mainstem bronchus, depression of the left mainstem bronchus, obliteration of the space between the pulmonary artery and aorta, and deviation of the esophagus (or NG tube) to the right.

      Helical contrast-enhanced CT scanning is highly sensitive and specific for detecting aortic rupture, but it should only be performed on hemodynamically stable patients.

      Treatment options include primary repair or resection of the torn segment with replacement using an interposition graft. Endovascular repair is also now considered an acceptable alternative approach.

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  • Question 37 - A 7-year-old girl is brought into the resus room after a car accident....

    Incorrect

    • A 7-year-old girl is brought into the resus room after a car accident. She is struggling to breathe, and you cannot hear any breath sounds on the right side. Her trachea is shifted to the left, and her neck veins are swollen. Based on your clinical assessment, you diagnose her with a tension pneumothorax and decide to perform a needle thoracocentesis.
      Where should you perform the needle thoracocentesis?

      Your Answer:

      Correct Answer: 2nd intercostal space midclavicular line

      Explanation:

      A tension pneumothorax occurs when there is an air leak from the lung or chest wall that acts like a one-way valve. This causes air to build up in the pleural space without any way to escape. As a result, pressure in the pleural space increases and pushes the mediastinum into the opposite hemithorax. If left untreated, this can lead to cardiovascular instability, shock, and cardiac arrest.

      The clinical features of tension pneumothorax include respiratory distress and cardiovascular instability. Tracheal deviation away from the side of the injury, unilateral absence of breath sounds on the affected side, and a hyper-resonant percussion note are also characteristic. Other signs include distended neck veins and cyanosis, which is a late sign. It’s important to note that both tension pneumothorax and massive haemothorax can cause decreased breath sounds on auscultation. However, percussion can help differentiate between the two conditions. Hyper-resonance suggests tension pneumothorax, while dullness suggests a massive haemothorax.

      Tension pneumothorax is a clinical diagnosis and should not be delayed for radiological confirmation. Requesting a chest X-ray in this situation can delay treatment and put the patient at risk. Immediate decompression through needle thoracocentesis is the recommended treatment. Traditionally, a large-bore needle or cannula is inserted into the 2nd intercostal space in the midclavicular line of the affected hemithorax. However, studies on cadavers have shown better success in reaching the thoracic cavity when the 4th or 5th intercostal space in the midaxillary line is used in adult patients. ATLS now recommends this location for needle decompression in adults. The site for needle thoracocentesis in children remains the same, using the 2nd intercostal space in the midclavicular line. It’s important to remember that needle thoracocentesis is a temporary measure, and the insertion of a chest drain is the definitive treatment.

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  • Question 38 - You are evaluating a 25-year-old patient who has arrived at the emergency department...

    Incorrect

    • You are evaluating a 25-year-old patient who has arrived at the emergency department by ambulance following a fall from a second-floor balcony. The patient reports experiencing upper abdominal discomfort, which raises concerns about potential hepatic and splenic injuries. In the trauma setting, which imaging modality would be considered the gold standard for assessing these organs?

      Your Answer:

      Correct Answer: Computerised tomography

      Explanation:

      CT scan is considered the most reliable imaging technique for diagnosing intra-abdominal conditions. It is also considered the gold standard for evaluating organ damage. However, it is crucial to carefully consider the specific circumstances before using CT scan, as it may not be suitable for unstable patients or those who clearly require immediate surgical intervention. In such cases, other methods like FAST can be used to detect fluid in the abdominal cavity, although it is not as accurate in assessing injuries to solid organs or hollow structures within the abdomen.

      Further Reading:

      Abdominal trauma can be classified into two categories: blunt trauma and penetrating trauma. Blunt trauma occurs when compressive or deceleration forces are applied to the abdomen, often resulting from road traffic accidents or direct blows during sports. The spleen and liver are the organs most commonly injured in blunt abdominal trauma. On the other hand, penetrating trauma involves injuries that pierce the skin and enter the abdominal cavity, such as stabbings, gunshot wounds, or industrial accidents. The bowel and liver are the organs most commonly affected in penetrating injuries.

      When it comes to imaging in blunt abdominal trauma, there are three main modalities that are commonly used: focused assessment with sonography in trauma (FAST), diagnostic peritoneal lavage (DPL), and computed tomography (CT). FAST is a non-invasive and quick method used to detect free intraperitoneal fluid, aiding in the decision on whether a laparotomy is needed. DPL is also used to detect intraperitoneal blood and can be used in both unstable blunt abdominal trauma and penetrating abdominal trauma. However, it is more invasive and time-consuming compared to FAST and has largely been replaced by it. CT, on the other hand, is the gold standard for diagnosing intra-abdominal pathology and is used in stable abdominal trauma patients. It offers high sensitivity and specificity but requires a stable and cooperative patient. It also involves radiation and may have delays in availability.

      In the case of penetrating trauma, it is important to assess these injuries with the help of a surgical team. Penetrating objects should not be removed in the emergency department as they may be tamponading underlying vessels. Ideally, these injuries should be explored in the operating theater.

      In summary, abdominal trauma can be classified into blunt trauma and penetrating trauma. Blunt trauma is caused by compressive or deceleration forces and commonly affects the spleen and liver. Penetrating trauma involves injuries that pierce the skin and commonly affect the bowel and liver. Imaging modalities such as FAST, DPL, and CT are used to assess and diagnose abdominal trauma, with CT being the gold standard. Penetrating injuries should be assessed by a surgical team and should ideally be explored in the operating theater.

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  • Question 39 - A 30-year-old woman suffers a gunshot wound to the chest in a domestic...

    Incorrect

    • A 30-year-old woman suffers a gunshot wound to the chest in a domestic dispute. A FAST scan is performed, which shows the presence of intra-thoracic free fluid.

      Which of the following organs is most likely to be injured in this case?

      Your Answer:

      Correct Answer: Small bowel

      Explanation:

      Low-velocity gunshot wounds to the abdomen result in tissue damage through laceration and cutting. On the other hand, high-velocity gunshot wounds transfer a greater amount of kinetic energy to the abdominal viscera. These types of wounds can cause more extensive damage in the surrounding area of the missile’s path due to temporary cavitation.

      When patients experience penetrating abdominal trauma as a result of gunshot wounds, certain organs are more commonly injured. The small bowel is affected in approximately 50% of cases, followed by the colon in 40% of cases. The liver is injured in around 30% of cases, while abdominal vascular structures are affected in about 25% of cases.

      Please note that these statistics have been obtained from the most recent edition of the ATLS manual.

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  • Question 40 - A 35-year-old woman is involved in a car accident. Her observations are taken...

    Incorrect

    • A 35-year-old woman is involved in a car accident. Her observations are taken one hour after arriving in the Emergency Department. Her pulse rate is 145 bpm, BP is 72/38 mmHg, respiratory rate 45 breaths/minute, and her urine output over the past hour has been negligible. She is drowsy, lethargic, and confused. The patient weighs approximately 70 kg.
      How would you classify her hemorrhage according to the ATLS hemorrhagic shock classification?

      Your Answer:

      Correct Answer: Class IV

      Explanation:

      This patient is showing significant signs of distress, including a highly elevated heart rate and respiratory rate, as well as very little urine output. Additionally, they are experiencing drowsiness, lethargy, and confusion. These symptoms indicate that the patient has suffered a class IV haemorrhage at this stage.

      Recognizing the extent of blood loss based on vital signs and mental status abnormalities is a crucial skill. The Advanced Trauma Life Support (ATLS) classification for haemorrhagic shock correlates the amount of blood loss with expected physiological responses in a healthy 70 kg patient. In a 70 kg male patient, the total circulating blood volume is approximately five litres, accounting for around 7% of their total body weight.

      The ATLS haemorrhagic shock classification is summarized as follows:

      CLASS I
      Blood loss (mL): Up to 750
      Blood loss (% blood volume): Up to 15%
      Pulse rate (bpm): <100
      Systolic BP: Normal
      Pulse pressure: Normal (or increased)
      Respiratory rate: 14-20
      Urine output (ml/hr): >30
      CNS/mental status: Slightly anxious

      CLASS II
      Blood loss (mL): 750-1500
      Blood loss (% blood volume): 15-30%
      Pulse rate (bpm): 100-120
      Systolic BP: Normal
      Pulse pressure: Decreased
      Respiratory rate: 20-30
      Urine output (ml/hr): 20-30
      CNS/mental status: Mildly anxious

      CLASS III
      Blood loss (mL): 1500-2000
      Blood loss (% blood volume): 30-40%
      Pulse rate (bpm): 120-140
      Systolic BP: Decreased
      Pulse pressure: Decreased
      Respiratory rate: 30-40
      Urine output (ml/hr): 5-15
      CNS/mental status: Anxious, confused

      CLASS IV
      Blood loss (mL): >2000
      Blood loss (% blood volume): >40%
      Pulse rate (bpm): >140
      Systolic BP: Decreased
      Pulse pressure: Decreased
      Respiratory rate: >40
      Urine output (ml/hr): Negligible
      CNS/mental status: Confused, lethargic

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  • Question 41 - A 5-year-old child is brought into the emergency room by an ambulance with...

    Incorrect

    • A 5-year-old child is brought into the emergency room by an ambulance with sirens blaring. The child has been in a house fire and has sustained severe burns. The anesthesiologist examines the child's airway and is worried about the potential for airway blockage. Intubation is scheduled for the patient, and the necessary equipment is being prepared.
      As per the ATLS recommendations, what is the smallest internal diameter endotracheal tube that should be utilized?

      Your Answer:

      Correct Answer: 4.5 mm

      Explanation:

      Patients who have suffered burns should receive high-flow oxygen (15 L) through a reservoir bag while their breathing is being evaluated. If intubation is necessary, it is crucial to use an appropriately sized endotracheal tube (ETT). Using a tube that is too small can make it difficult or even impossible to ventilate the patient, clear secretions, or perform bronchoscopy.

      According to the ATLS guidelines, adults should be intubated using an ETT with an internal diameter (ID) of at least 7.5 mm or larger. Children, on the other hand, should have an ETT with an ID of at least 4.5 mm. Once a patient has been intubated, it is important to continue administering 100% oxygen until their carboxyhemoglobin levels drop to less than 5%.

      To protect the lungs, it is recommended to use lung protective ventilation techniques. This involves using low tidal volumes (4-8 mL/kg) and ensuring that peak inspiratory pressures do not exceed 30 cmH2O.

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  • Question 42 - A 28-year-old man is brought in by ambulance following a car crash. A...

    Incorrect

    • A 28-year-old man is brought in by ambulance following a car crash. A FAST scan is conducted to evaluate for a haemoperitoneum.
      Which of the following anatomical regions is NOT examined as part of a typical 4 view FAST scan?

      Your Answer:

      Correct Answer: Parasternal

      Explanation:

      A Focussed Assessment with Sonography for Trauma (FAST) scan is a point-of-care ultrasound examination conducted when a trauma patient arrives. Its primary purpose is to identify the presence of intra-abdominal free fluid, which is typically assumed to be haemoperitoneum in the context of trauma. This information helps healthcare providers make decisions regarding further management of the patient.

      The sensitivity of FAST scanning for detecting intraperitoneal fluid is approximately 90%, while its specificity is around 95%. However, its sensitivity for detecting solid organ injuries is much lower. As a result, FAST scanning has largely replaced diagnostic peritoneal lavage as the preferred initial method for assessing haemoperitoneum.

      During a standard FAST scan, four regions are assessed. The first is the subxiphoid transverse view, which is used to check for pericardial effusion and left lobe liver injuries. The second is the longitudinal view of the right upper quadrant, which helps identify right liver injuries, right kidney injuries, and fluid in the hepatorenal recess (Morison’s pouch). The third is the longitudinal view of the left upper quadrant, which is used to assess for splenic injury and left kidney injury. Lastly, the transverse and longitudinal views of the suprapubic region are examined to assess the bladder and fluid in the pouch of Douglas.

      In addition to the standard FAST scan, an extended FAST or eFAST may also be performed. This involves examining the left and right thoracic regions to assess for the presence of pneumothorax and haemothorax.

      The hepatorenal recess is the deepest part of the peritoneal cavity when a patient is lying flat. Therefore, it is the most likely area for fluid to accumulate in a supine position.

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  • Question 43 - You are overseeing the care of a trauma patient in the resuscitation bay....

    Incorrect

    • You are overseeing the care of a trauma patient in the resuscitation bay. A chest tube has been inserted through thoracostomy to drain the hemothorax. The initial amount of blood drained is documented, and there are plans to monitor the additional blood volume drained every hour. What would be an indication for thoracotomy in this patient?

      Your Answer:

      Correct Answer: 250 ml blood drained from pleural cavity (in addition to previous volumes) between hours 2 and 3 post insertion

      Explanation:

      The main indications for thoracotomy in patients with haemothorax are prompt drainage of at least 1500 ml of blood, ongoing blood loss of more than 200 ml per hour for 2-4 hours, and the need for continued blood transfusion. Option 3 in the given choices meets these criteria as the blood loss remains above 200 ml per hour for more than 2 hours after the drain is inserted. Option 1 does not meet the criteria as the blood volume is below 1500 ml. Option 2 does not meet the criteria as the blood loss has not been ongoing for at least 2 hours. Option 4 does not meet the criteria as there is no information indicating the need for ongoing blood transfusion.

      Further Reading:

      Haemothorax is the accumulation of blood in the pleural cavity of the chest, usually resulting from chest trauma. It can be difficult to differentiate from other causes of pleural effusion on a chest X-ray. Massive haemothorax refers to a large volume of blood in the pleural space, which can impair physiological function by causing blood loss, reducing lung volume for gas exchange, and compressing thoracic structures such as the heart and IVC.

      The management of haemothorax involves replacing lost blood volume and decompressing the chest. This is done through supplemental oxygen, IV access and cross-matching blood, IV fluid therapy, and the insertion of a chest tube. The chest tube is connected to an underwater seal and helps drain the fluid, pus, air, or blood from the pleural space. In cases where there is prompt drainage of a large amount of blood, ongoing significant blood loss, or the need for blood transfusion, thoracotomy and ligation of bleeding thoracic vessels may be necessary. It is important to have two IV accesses prior to inserting the chest drain to prevent a drop in blood pressure.

      In summary, haemothorax is the accumulation of blood in the pleural cavity due to chest trauma. Managing haemothorax involves replacing lost blood volume and decompressing the chest through various interventions, including the insertion of a chest tube. Prompt intervention may be required in cases of significant blood loss or ongoing need for blood transfusion.

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  • Question 44 - You evaluate the airway and breathing of a patient who has been brought...

    Incorrect

    • You evaluate the airway and breathing of a patient who has been brought into the emergency department by an ambulance after being rescued from a house fire. You suspect that the patient may have an obstructed airway.
      Which of the following statements about managing the airway and breathing in burn patients is NOT true?

      Your Answer:

      Correct Answer: High tidal volumes should be used in intubated patients

      Explanation:

      Patients who have suffered burns should receive high-flow oxygen (15 L) through a reservoir bag while their breathing is being evaluated. If intubation is necessary, it is crucial to use an appropriately sized endotracheal tube (ETT). Using a tube that is too small can make it difficult or even impossible to ventilate the patient, clear secretions, or perform bronchoscopy.

      According to the ATLS guidelines, adults should be intubated using an ETT with an internal diameter (ID) of at least 7.5 mm or larger. Children, on the other hand, should have an ETT with an ID of at least 4.5 mm. Once a patient has been intubated, it is important to continue administering 100% oxygen until their carboxyhemoglobin levels drop to less than 5%.

      To protect the lungs, it is recommended to use lung protective ventilation techniques. This involves using low tidal volumes (4-8 mL/kg) and ensuring that peak inspiratory pressures do not exceed 30 cmH2O.

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  • Question 45 - A 25 year old male is brought to the emergency department by the...

    Incorrect

    • A 25 year old male is brought to the emergency department by the police. The man tried to evade capture by leaping from a ground floor window. The patient reports that both of his feet are hurting, but the left foot is significantly more painful than the right. The patient exhibits tenderness in the left heel, leading you to suspect a calcaneus fracture. Which of the following statements about calcaneus fractures is accurate?

      Your Answer:

      Correct Answer: Contralateral calcaneus fractures are present in 10% of patients

      Explanation:

      Fractures that extend into the calcaneocuboid joint are commonly intra-articular. It is recommended to refer patients to orthopaedics for further evaluation and treatment. Conservative management usually involves keeping the patient non-weight bearing for a period of 6-12 weeks.

      Further Reading:

      Calcaneus fractures are a common type of lower limb and joint injury. The calcaneus, or heel bone, is the most frequently fractured tarsal bone. These fractures are often intra-articular, meaning they involve the joint. The most common cause of calcaneus fractures is a fall or jump from a height.

      When assessing calcaneus fractures, X-rays are used to visualize the fracture lines. Two angles are commonly assessed to determine the severity of the fracture. Böhler’s angle, which measures the angle between two tangent lines drawn across the anterior and posterior borders of the calcaneus, should be between 20-40 degrees. If it is less than 20 degrees, it indicates a calcaneal fracture with flattening. The angle of Gissane, which measures the depression of the posterior facet of the subtalar joint, should be between 120-145 degrees. An increased angle of Gissane suggests a calcaneal fracture.

      In the emergency department, the management of a fractured calcaneus involves identifying the injury and any associated injuries, providing pain relief, elevating the affected limb(s), and referring the patient to an orthopedic specialist. It is important to be aware that calcaneus fractures are often accompanied by other injuries, such as bilateral fractures of vertebral fractures.

      The definitive management of a fractured calcaneus can be done conservatively or through surgery, specifically open reduction internal fixation (ORIF). The orthopedic team will typically order a CT or MRI scan to classify the fracture and determine the most appropriate treatment. However, a recent UK heel fracture trial suggests that in most cases, ORIF does not improve fracture outcomes.

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  • Question 46 - A 35-year-old woman is brought in by ambulance following a car accident where...

    Incorrect

    • A 35-year-old woman is brought in by ambulance following a car accident where her car was hit by a truck. She has sustained severe facial injuries and shows signs of airway obstruction. Her cervical spine is immobilized. The anesthesiologist has tried to intubate her but is unsuccessful and decides to perform a surgical cricothyroidotomy.

      Which of the following statements about surgical cricothyroidotomy is correct?

      Your Answer:

      Correct Answer: It is contraindicated in the presence of a laryngeal fracture

      Explanation:

      A surgical cricothyroidotomy is a procedure performed in emergency situations to secure the airway by making an incision in the cricothyroid membrane. It is also known as an emergency surgical airway (ESA) and is typically done when intubation and oxygenation are not possible.

      There are certain conditions in which a surgical cricothyroidotomy should not be performed. These include patients who are under 12 years old, those with laryngeal fractures or pre-existing or acute laryngeal pathology, individuals with tracheal transection and retraction of the trachea into the mediastinum, and cases where the anatomical landmarks are obscured due to trauma.

      The procedure is carried out in the following steps:
      1. Gathering and preparing the necessary equipment.
      2. Positioning the patient on their back with the neck in a neutral position.
      3. Sterilizing the patient’s neck using antiseptic swabs.
      4. Administering local anesthesia, if time permits.
      5. Locating the cricothyroid membrane, which is situated between the thyroid and cricoid cartilage.
      6. Stabilizing the trachea with the left hand until it can be intubated.
      7. Making a transverse incision through the cricothyroid membrane.
      8. Inserting the scalpel handle into the incision and rotating it 90°. Alternatively, a haemostat can be used to open the airway.
      9. Placing a properly-sized, cuffed endotracheal tube (usually a size 5 or 6) into the incision, directing it into the trachea.
      10. Inflating the cuff and providing ventilation.
      11. Monitoring for chest rise and auscultating the chest to ensure adequate ventilation.
      12. Securing the airway to prevent displacement.

      Potential complications of a surgical cricothyroidotomy include aspiration of blood, creation of a false passage into the tissues, subglottic stenosis or edema, laryngeal stenosis, hemorrhage or hematoma formation, laceration of the esophagus or trachea, mediastinal emphysema, and vocal cord paralysis or hoarseness.

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  • Question 47 - A 35-year-old man is brought into the emergency room by an ambulance with...

    Incorrect

    • A 35-year-old man is brought into the emergency room by an ambulance with flashing lights. He has been in a building fire and has sustained severe burns. You examine his airway and have concerns about the potential for airway blockage.
      Which of the following is NOT a notable factor that increases the risk of airway obstruction in a patient with significant burns?

      Your Answer:

      Correct Answer: A carboxyhaemoglobin level of 8%

      Explanation:

      Early assessment of the airway is a critical aspect of managing a patient who has suffered burns. Airway blockage can occur rapidly due to direct injury, such as inhalation injury, or as a result of swelling caused by the burn. If there is a history of trauma, the airway should be evaluated and treated while maintaining control of the cervical spine.

      Signs of airway obstruction may not be immediately apparent, as swelling typically does not occur right away. Children with thermal burns are at a higher risk of airway obstruction compared to adults due to their smaller airway size, so they require careful observation.

      There are several risk factors for airway obstruction in burned patients, including inhalation injury, the presence of soot in the mouth or nostrils, singed nasal hairs, burns to the head, face, or neck, burns inside the mouth, a large burn area with increasing depth, and associated trauma. A carboxyhemoglobin level above 10% is also suggestive of an inhalation injury.

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  • Question 48 - You assess a patient with airway obstruction in the resuscitation area of the...

    Incorrect

    • You assess a patient with airway obstruction in the resuscitation area of the Emergency Department at your hospital.
      Which of the following is the LEAST probable cause?

      Your Answer:

      Correct Answer: GCS score of 9

      Explanation:

      The airway is deemed at risk when the Glasgow Coma Scale (GCS) falls below 8. There are various factors that can lead to airway obstruction, including the presence of blood or vomit in the airway, a foreign object such as a tooth or food blocking the passage, direct injury to the face or throat, inflammation of the epiglottis (epiglottitis), involuntary closure of the larynx (laryngospasm), constriction of the bronchial tubes (bronchospasm), swelling in the pharynx due to infection or fluid accumulation (oedema), excessive bronchial secretions, and blockage of a tracheostomy tube.

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  • Question 49 - A 45-year-old woman was involved in a car accident where her car collided...

    Incorrect

    • A 45-year-old woman was involved in a car accident where her car collided with a tree at high speed. She was not wearing a seatbelt and was thrown forward onto the steering wheel of her car. She has bruising over her anterior chest wall and is experiencing chest pain. Her chest X-ray in the emergency room reveals evidence of a traumatic aortic injury.
      Which of the following fractures are most indicative of this injury?

      Your Answer:

      Correct Answer: 1st and 2nd ribs

      Explanation:

      Traumatic aortic rupture, also known as traumatic aortic disruption or transection, occurs when the aorta is torn or ruptured due to physical trauma. This condition often leads to sudden death because of severe bleeding. Motor vehicle accidents and falls from great heights are the most common causes of this injury.

      The patients with the highest chances of survival are those who have an incomplete tear near the ligamentum arteriosum of the proximal descending aorta, close to where the left subclavian artery branches off. The presence of an intact adventitial layer or contained mediastinal hematoma helps maintain continuity and prevents immediate bleeding and death. If promptly identified and treated, survivors of these injuries can recover. In cases where traumatic aortic rupture leads to sudden death, approximately 50% of patients have damage at the aortic isthmus, while around 15% have damage in either the ascending aorta or the aortic arch.

      Initial chest X-rays may show signs consistent with a traumatic aortic injury. However, false-positive and false-negative results can occur, and sometimes there may be no abnormalities visible on the X-ray. Some of the possible X-ray findings include a widened mediastinum, hazy left lung field, obliteration of the aortic knob, fractures of the 1st and 2nd ribs, deviation of the trachea to the right, presence of a pleural cap, elevation and rightward shift of the right mainstem bronchus, depression of the left mainstem bronchus, obliteration of the space between the pulmonary artery and aorta, and deviation of the esophagus or NG tube to the right.

      A helical contrast-enhanced CT scan of the chest is the preferred initial investigation for suspected blunt aortic injury. It has proven to be highly accurate, with close to 100% sensitivity and specificity. CT scanning should be performed liberally, as chest X-ray findings can be unreliable. However, hemodynamically unstable patients should not be placed in a CT scanner. If the CT results are inconclusive, aortography or trans-oesophageal echo can be performed for further evaluation.

      Immediate surgical intervention is necessary for these injuries. Endovascular repair is the most common method used and has excellent short-term outcomes. Open repair may also be performed depending on the circumstances. It is important to control heart rate and blood pressure during stabilization to reduce the risk of rupture. Pain should be managed with appropriate analgesic

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  • Question 50 - A 22 year old male patient is brought into the emergency department with...

    Incorrect

    • A 22 year old male patient is brought into the emergency department with a stab wound to the left side of the chest. During assessment, you observe a 2 cm wide entry wound overlying the 4th intercostal space anterior axillary line, and you can hear a bubbling sound when the patient exhales. Upon examination, the trachea is central, there is reduced air entry on the left side, and percussion reveals a resonant left hemithorax.

      What is the probable diagnosis?

      Your Answer:

      Correct Answer: Open pneumothorax

      Explanation:

      An open pneumothorax, also known as a sucking chest wound, occurs when air enters the pleural space due to an open chest wound or physical defect. This can lead to ineffective ventilation, causing hypoxia and hypercarbia. Air can enter the pleural cavity passively or be sucked in during inspiration, leading to lung collapse on that side. Sucking wounds can be heard audibly as air passes through the chest defect, and entry wounds are usually visible.

      To manage an open pneumothorax, respiratory compromise can be alleviated by covering the wound with a dressing or using a chest seal device. It is important to ensure that one side of the dressing is not occluded, allowing the dressing to function as a flutter valve and prevent significant air ingress during inspiration while allowing air to escape the pleural cavity. If tension pneumothorax is suspected after applying a dressing, the dressing may need to be temporarily removed for decompression.

      Intubation and intermittent positive pressure ventilation (IPPV) can be used to ventilate the patient and alleviate respiratory distress. Definitive management involves either inserting a chest drain or surgically repairing the defect. Surgical repair is typically preferred, especially for large wounds.

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SESSION STATS - PERFORMANCE PER SPECIALTY

Trauma (14/23) 61%
Passmed