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  • Question 1 - 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: Suprapubic

      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.

    • This question is part of the following fields:

      • Trauma
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  • Question 2 - A 37 year old male is brought into the emergency department with severe...

    Incorrect

    • A 37 year old male is brought into the emergency department with severe chest injuries following a car accident. FAST scanning shows the presence of around 100 ml of fluid in the pericardium. The patient's blood pressure is 118/78 mmHg and pulse rate is 92. What is the recommended course of action for managing this patient?

      Your Answer: Perform immediate pericardiocentesis

      Correct Answer: Transfer to theatre for thoracotomy

      Explanation:

      For individuals with traumatic cardiac tamponade, thoracotomy is the recommended treatment. In the case of a trauma patient with a significant buildup of fluid around the heart and the potential for tamponade, it is advised to transfer stable patients to the operating room for thoracotomy instead of performing pericardiocentesis. Pericardiocentesis, when done correctly, is likely to be unsuccessful due to the presence of clotted blood in the pericardium. Additionally, performing pericardiocentesis would cause a delay in the thoracotomy procedure. If access to the operating room is not possible, pericardiocentesis may be considered as a temporary solution.

      Further Reading:

      Cardiac tamponade, also known as pericardial tamponade, occurs when fluid accumulates in the pericardial sac and compresses the heart, leading to compromised blood flow. Classic clinical signs of cardiac tamponade include distended neck veins, hypotension, muffled heart sounds, and pulseless electrical activity (PEA). Diagnosis is typically done through a FAST scan or an echocardiogram.

      Management of cardiac tamponade involves assessing for other injuries, administering IV fluids to reduce preload, performing pericardiocentesis (inserting a needle into the pericardial cavity to drain fluid), and potentially performing a thoracotomy. It is important to note that untreated expanding cardiac tamponade can progress to PEA cardiac arrest.

      Pericardiocentesis can be done using the subxiphoid approach or by inserting a needle between the 5th and 6th intercostal spaces at the left sternal border. Echo guidance is the gold standard for pericardiocentesis, but it may not be available in a resuscitation situation. Complications of pericardiocentesis include ST elevation or ventricular ectopics, myocardial perforation, bleeding, pneumothorax, arrhythmia, acute pulmonary edema, and acute ventricular dilatation.

      It is important to note that pericardiocentesis is typically used as a temporary measure until a thoracotomy can be performed. Recent articles published on the RCEM learning platform suggest that pericardiocentesis has a low success rate and may delay thoracotomy, so it is advised against unless there are no other options available.

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      • Trauma
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  • Question 3 - 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 125 bpm, BP is 92/46 mmHg, respiratory rate 35 breaths/minute, and her urine output over the past hour has been 10 ml. She is anxious and slightly 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 III

      Explanation:

      This patient is experiencing an increased heart rate and respiratory rate, as well as a decrease in urine output. Additionally, they are feeling anxious and confused. These symptoms indicate that the patient has suffered a class III haemorrhage at this point in time.

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

      The ATLS haemorrhagic shock classification is summarized as follows:

      CLASS I:
      – Blood loss: Up to 750 mL
      – Blood loss (% blood volume): Up to 15%
      – Pulse rate: Less than 100 bpm
      – Systolic BP: 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 BP: 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 BP: 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 BP: Decreased
      – Pulse pressure: Decreased
      – Respiratory rate: More than 40 breaths per minute
      – Urine output: Negligible
      – CNS/mental status: Confused, leth

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      • Trauma
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  • Question 4 - 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 5 - 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:

      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.

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      • Trauma
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  • Question 6 - A 45-year-old woman is brought into the emergency department after a car accident....

    Incorrect

    • A 45-year-old woman is brought into the emergency department after a car accident. She has significant bruising on the right side of her chest. You suspect she may have a hemothorax. What clinical signs would you anticipate observing in a patient with a hemothorax?

      Your Answer:

      Correct Answer: Decreased fremitus on affected side

      Explanation:

      Haemothorax often leads to reduced or absent air entry, a dull percussion sound, and decreased fremitus on the affected side. Commonly observed symptoms in patients with haemothorax include decreased or absent air entry, a dull percussion note when the affected side is tapped, reduced fremitus on the affected side, and in cases of massive haemothorax, tracheal deviation away from the affected side. Other signs that may be present include a rapid heart rate (tachycardia), rapid breathing (tachypnoea), low blood pressure (hypotension), and signs of shock.

      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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      • Trauma
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  • Question 7 - A 45-year-old individual is brought into the emergency department following a head injury...

    Incorrect

    • A 45-year-old individual is brought into the emergency department following a head injury from a ladder fall. The patient's condition worsens. You proceed to re-evaluate the patient's GCS. At what GCS range is intubation recommended?

      Your Answer:

      Correct Answer: 8 or less

      Explanation:

      Intubation is necessary for patients with a compromised airway. In comatose patients, a Glasgow Coma Scale (GCS) score of 8 or less indicates the need for intubation. According to NICE guidelines, immediate intubation and ventilation are advised in cases of coma where the patient is not responsive to commands, not speaking, and not opening their eyes. Other indications for intubation include the loss of protective laryngeal reflexes, ventilatory insufficiency as indicated by abnormal blood gases, spontaneous hyperventilation, irregular respirations, significantly deteriorating conscious level, unstable fractures of the facial skeleton, copious bleeding into the mouth, and seizures. In certain cases, intubation and ventilation should be performed before the patient begins their journey.

      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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      • Trauma
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  • Question 8 - 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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      • Trauma
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  • Question 9 - A child presents with a thermal burn affecting her left hand that occurred...

    Incorrect

    • A child presents with a thermal burn affecting her left hand that occurred in the kitchen while baking. You evaluate the burn and observe that it is a deep partial-thickness burn.
      Which of the following statements about deep partial-thickness burns is accurate?

      Your Answer:

      Correct Answer: They do not blanch with pressure

      Explanation:

      Assessing the depth of a burn is crucial for determining the severity of the injury and planning appropriate wound care. Burns are typically classified as first-, second-, or third-degree, depending on how deeply they penetrate the skin’s surface.

      First-degree burns, also known as superficial burns, only affect the outer layer of skin called the epidermis. These burns are characterized by redness and pain, with dry skin and no blistering. An example of a first-degree burn is mild sunburn. They usually do not require intravenous fluid replacement and are not included in the assessment of the burn’s extent. Long-term tissue damage is rare with these burns.

      Second-degree burns, also called partial-thickness burns, involve both the epidermis and part of the dermis layer of skin. They can be further categorized as superficial partial-thickness or deep partial-thickness burns. Superficial partial-thickness burns are moist, hypersensitive, potentially blistered, uniformly pink, and blanch when touched. Deep partial-thickness burns are drier, less painful, potentially blistered, red or mottled in appearance, and do not blanch when touched.

      Third-degree burns, also known as full-thickness burns, destroy both the epidermis and dermis layers of skin and extend into the subcutaneous tissue. These burns may also damage underlying bones, muscles, and tendons. The burn site appears translucent or waxy white, or it can be charred. Once the epidermis is removed, the underlying dermis may initially appear red but does not blanch under pressure. This dermis is typically dry and does not produce any fluid. Since the nerve endings are destroyed, there is no sensation in the affected area.

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      • Trauma
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  • Question 10 - 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:

      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.

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      • Trauma
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  • Question 11 - A 48-year-old male presents to the emergency department following a workplace injury. He...

    Incorrect

    • A 48-year-old male presents to the emergency department following a workplace injury. He sustained a large contusion to the anterior abdominal wall after a pneumatic tool discharged into his abdomen. The patient's vital signs are as follows:

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

      Which imaging modality would be most appropriate for evaluating this patient with blunt abdominal trauma?

      Your Answer:

      Correct Answer: FAST scan

      Explanation:

      The preferred imaging method for unstable patients with blunt abdominal trauma is FAST scanning (Focused Assessment with Sonography in Trauma). It has replaced DPL as the imaging modality of choice. It is important to note that the primary purpose of a FAST scan is to detect intraperitoneal fluid, assumed to be blood, and guide the decision on whether a laparotomy is necessary. In this case, a CT scan is not recommended as the patient is unstable with tachycardia and hypotension. While CT is the most diagnostically accurate imaging technique, it requires a stable and cooperative patient.

      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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      • Trauma
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  • Question 12 - A young patient who has been in a car accident experiences a traumatic...

    Incorrect

    • A young patient who has been in a car accident experiences a traumatic cardiac arrest. You decide to perform an anterolateral thoracotomy.
      During this procedure, which structures will need to be divided?

      Your Answer:

      Correct Answer: Latissimus dorsi

      Explanation:

      An anterolateral thoracotomy is a surgical procedure performed on the front part of the chest wall. It is commonly used in Emergency Department thoracotomy, with a preference for a left-sided approach in patients experiencing traumatic arrest or left-sided chest injuries. However, in cases where patients have not arrested but present with severe low blood pressure and right-sided chest injuries, a right-sided approach is recommended.

      The procedure is conducted as follows: an incision is made along the 4th or 5th intercostal space, starting from the sternum at the front and extending to the posterior axillary line. The incision should be deep enough to partially cut through the latissimus dorsi muscle. Subsequently, the skin, subcutaneous fat, and superficial portions of the pectoralis and serratus muscles are divided. The parietal pleura is then divided, allowing access to the pleural cavity. The intercostal muscles are completely cut, and a rib spreader is inserted and opened to provide visualization of the thoracic cavity.

      The anterolateral approach enables access to crucial anatomical structures during resuscitation, including the pulmonary hilum, heart, and aorta. In cases where a right-sided heart injury is suspected, an additional incision can be made on the right side, extending across the entire chest. This procedure is known as a bilateral anterolateral thoracotomy or a clamshell thoracotomy.

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  • Question 13 - 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 14 - 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 15 - 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 16 - 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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  • Question 17 - 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 18 - 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:

      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.

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  • Question 19 - A 25-year-old arrives at the emergency department after being involved in a car...

    Incorrect

    • 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:

      Correct 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.

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  • Question 20 - You are managing an elderly trauma patient in the resuscitation bay. The patient...

    Incorrect

    • You are managing an elderly trauma patient in the resuscitation bay. The patient has sustained severe chest contusions and you have concerns regarding the presence of cardiac tamponade. What is considered a classic clinical sign of cardiac tamponade?

      Your Answer:

      Correct Answer: Neck vein distension

      Explanation:

      Cardiac tamponade is characterized by several classic clinical signs. These include distended neck veins, hypotension, and muffled heart sounds. These three signs are collectively known as Beck’s triad. Additionally, patients with cardiac tamponade may also experience pulseless electrical activity (PEA). It is important to recognize these signs as they can indicate the presence of cardiac tamponade.

      Further Reading:

      Cardiac tamponade, also known as pericardial tamponade, occurs when fluid accumulates in the pericardial sac and compresses the heart, leading to compromised blood flow. Classic clinical signs of cardiac tamponade include distended neck veins, hypotension, muffled heart sounds, and pulseless electrical activity (PEA). Diagnosis is typically done through a FAST scan or an echocardiogram.

      Management of cardiac tamponade involves assessing for other injuries, administering IV fluids to reduce preload, performing pericardiocentesis (inserting a needle into the pericardial cavity to drain fluid), and potentially performing a thoracotomy. It is important to note that untreated expanding cardiac tamponade can progress to PEA cardiac arrest.

      Pericardiocentesis can be done using the subxiphoid approach or by inserting a needle between the 5th and 6th intercostal spaces at the left sternal border. Echo guidance is the gold standard for pericardiocentesis, but it may not be available in a resuscitation situation. Complications of pericardiocentesis include ST elevation or ventricular ectopics, myocardial perforation, bleeding, pneumothorax, arrhythmia, acute pulmonary edema, and acute ventricular dilatation.

      It is important to note that pericardiocentesis is typically used as a temporary measure until a thoracotomy can be performed. Recent articles published on the RCEM learning platform suggest that pericardiocentesis has a low success rate and may delay thoracotomy, so it is advised against unless there are no other options available.

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  • Question 21 - You evaluate a 38-year-old woman who was hit on the side of her...

    Incorrect

    • You evaluate a 38-year-old woman who was hit on the side of her leg by a soccer player while spectating the match from the sidelines. You suspect a tibial plateau fracture and order an X-ray of the affected knee. Besides the fracture line, what other radiographic indication is frequently observed in individuals with acute tibial plateau fractures?

      Your Answer:

      Correct Answer: Lipohaemathrosis evident in suprapatellar pouch

      Explanation:

      Lipohaemathrosis is commonly seen in the suprapatellar pouch in individuals who have tibial plateau fractures. Notable X-ray characteristics of tibial plateau fractures include a visible fracture of the tibial plateau and the presence of lipohaemathrosis in the suprapatellar pouch.

      Further Reading:

      Tibial plateau fractures are a type of traumatic lower limb and joint injury that can involve the medial or lateral tibial plateau, or both. These fractures are classified using the Schatzker classification, with higher grades indicating a worse prognosis. X-ray imaging can show visible fractures of the tibial plateau and the presence of lipohaemathrosis in the suprapatellar pouch. However, X-rays often underestimate the severity of these fractures, so CT scans are typically used for a more accurate assessment.

      Tibial spine fractures, on the other hand, are separate from tibial plateau fractures. They occur when the tibial spine is avulsed by the anterior cruciate ligament (ACL). This can happen due to forced knee hyperextension or a direct blow to the femur when the knee is flexed. These fractures are most common in children aged 8-14.

      Tibial tuberosity avulsion fractures primarily affect adolescent boys and are often caused by jumping or landing from a jump. These fractures can be associated with Osgood-Schlatter disease. The treatment for these fractures depends on their grading. Low-grade fractures may be managed with immobilization for 4-6 weeks, while more significant avulsions are best treated with surgical fixation.

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  • Question 22 - A 45 year old male is brought into the emergency department following a...

    Incorrect

    • A 45 year old male is brought into the emergency department following a car crash. There is significant bruising on the right side of the chest. You suspect the patient has a haemothorax. What are the two main objectives in managing this condition?

      Your Answer:

      Correct Answer: Replace lost circulating blood volume and decompression of the pleural space

      Explanation:

      The main objectives in managing haemothorax are to restore the lost blood volume and relieve pressure in the pleural space. These actions are crucial for improving the patient’s oxygen levels.

      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 23 - A 42-year-old male is brought into the ED by ambulance following a car...

    Incorrect

    • A 42-year-old male is brought into the ED by ambulance following a car accident with suspected internal abdominal injury. Upon arrival in the ED, his blood pressure was recorded as 102/68 mmHg and his pulse rate was 114 bpm. Initial resuscitation measures have been initiated, and a fluid bolus of 500 ml of 0.9% saline has been administered. The patient's vital signs are reassessed after the bolus and are as follows:

      Blood pressure: 92/66 mmHg
      Pulse rate: 124 bpm
      Respiration rate: 29 bpm
      SpO2: 98% on 15 liters of oxygen
      Temperature: 36.1 ºC

      What percentage of the patient's circulating blood volume would you estimate has been lost?

      Your Answer:

      Correct Answer: 30-40%

      Explanation:

      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

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  • Question 24 - You are evaluating a 25-year-old male with a puncture wound to the stomach....

    Incorrect

    • 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:

      Correct 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.

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  • Question 25 - 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:

      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

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  • Question 26 - A 35-year-old woman that has been involved in a car accident is estimated...

    Incorrect

    • A 35-year-old woman that has been involved in a car accident is estimated to have suffered a class II haemorrhage according to the Advanced Trauma Life Support (ATLS) haemorrhagic shock classification. The patient weighs approximately 60 kg.
      Which of the following physiological parameters is consistent with a diagnosis of class II haemorrhage?

      Your Answer:

      Correct Answer: Heart rate of 110 bpm

      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

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  • Question 27 - 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 28 - A 52 year old male visits the emergency department after crashing into the...

    Incorrect

    • 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:

      Correct 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.

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  • Question 29 - 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 110 bpm, BP is 120/80 mmHg, respiratory rate 20 breaths/minute, and her urine output over the past hour has been 30 ml. She is currently mildly anxious. The patient weighs approximately 65 kg.
      How would you classify her haemorrhage according to the ATLS haemorrhagic shock classification?

      Your Answer:

      Correct Answer: Class II

      Explanation:

      This patient is showing a slightly elevated heart rate and respiratory rate, as well as a slightly reduced urine output. These signs indicate that the patient has experienced a class II haemorrhage at this point. It is important to be able to recognize the degree of blood loss based on vital sign and mental status abnormalities. The Advanced Trauma Life Support (ATLS) haemorrhagic shock classification provides a way to link the amount of blood loss to expected physiological responses in a healthy 70 kg patient. In a 70 kg male patient, the total circulating blood volume is approximately five liters, which accounts for about 7% of their total body weight.

      The ATLS haemorrhagic shock classification is summarized as follows:

      CLASS I:
      – Blood loss: Up to 750 mL
      – Blood loss (% blood volume): Up to 15%
      – Pulse rate: Less than 100 bpm
      – Systolic BP: 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 BP: 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 BP: 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 BP: Decreased
      – Pulse pressure: Decreased
      – Respiratory rate: More than 40 breaths per minute
      – Urine output: Negligible
      – CNS/mental status: Confused, lethargic

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  • Question 30 - 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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      • Trauma
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