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D. Intralipid 20%: A. Temazepam B. Lorazepam C. Naloxone
D. Intralipid 20%: A. Temazepam B. Lorazepam C. Naloxone
lipoma from her forehead. It is the first time the senior house officer has performed
the procedure. He administers 30ml of 2% lignocaine to the area. The procedure is
complicated by bleeding and the patient experiences discomfort, a further 10ml of the
same anaesthetic formulation is then administered. Over the following 5 minutes the
patient complains of tinnitus and becomes drowsy. Which of the drugs listed below
should be administered?
A. Temazepam
B. Lorazepam
C. Naloxone
D. Intralipid 20%
Intralipid is indicated for the treatment of local anaesthetic toxicity. In this case the
safe dose of local anaesthetic has been exceeded and is thus this lady's symptoms are
likely to represent toxicity.
Management of toxicity
Safe doses
10ml of lignocaine 1% contains 100mg of drug, this would constitute 70% of the
maximum safe dose in a 50 kg patient. Up to 7mg / kg can be administered if
adrenaline is added to the solution.
1
Doses of local anaesthetics
Agent Dose plain Dose with adrenaline
Lignocaine 3mg/Kg 7mg/Kg
Bupivicane 2mg/Kg 3mg/Kg
Prilocaine 6mg/Kg 9mg/Kg
These are a guide only as actual doses depend on site of administration, tissue
vascularity and co-morbidities.
A. Epidural haematoma
Head injury
2
Features
Subdural Bleeding into the outermost meningeal layer. Most commonly occur
haematoma around the frontal and parietal lobes. May be either acute or
chronic.
Pathophysiology
Management
Where there is life threatening rising ICP such as in extra dural haematoma
and whilst theatre is prepared or transfer arranged use of IV mannitol/
frusemide may be required.
Diffuse cerebral oedema may require decompressive craniotomy
Exploratory Burr Holes have little management in modern practice except
where scanning may be unavailable and to thus facilitate creation of formal
craniotomy flap
Depressed skull fractures that are open require formal surgical reduction and
debridement, closed injuries may be managed non operatively if there is
minimal displacement.
ICP monitoring is appropriate in those who have GCS 3-8 and normal CT
scan.
ICP monitoring is mandatory in those who have GCS 3-8 and Abnormal CT
scan.
3
Hyponatraemia is most likely to be due to syndrome of inappropriate ADH
secretion.
Minimum of cerebral perfusion pressure of 70mmHg in adults.
Minimum cerebral perfusion pressure of between 40 and 70 mmHg in
children.
Hb 10.2 g/dl
Platelets 156 * 109/l
WBC 14 * 109/l
4
What is the most likely diagnosis?
B. Neutropenic sepsis
C. Phaeochromocytoma
D. Perforated bowel
E. Addisonian crisis
Features of an addisonian
crisis:
Hyponatraemia
Hyperkalaemia
Hypoglycaemia
This man is on steroids for polymyalgia rheumatica. Surgery can precipitate acute
adrenal deficiency. The diagnosis is further confirmed by the blood results of
hyponatraemia, hyperkalaemia and hypoglycaemia. This patient urgently needs
Hydrocortisone.
Addisonian crisis
Causes
Management
Hydrocortisone 100 mg im or iv
1 litre normal saline infused over 30-60 mins or with dextrose if
hypoglycaemic
Continue hydrocortisone 6 hourly until the patient is stable. No
fludrocortisone is required because high cortisol exerts weak
mineralocorticoid action
Oral replacement may begin after 24 hours and be reduced to maintenance
over 3-4 days
5
A 32 year old man is involved in a motorcycle accident and sustains a closed unstable
spiral tibial fracture. This is managed with an intramedullary nail. On return to the
ward he is noted to have increasing pain in the limb and on examination the limb is
swollen and tender with pain on passive stretching of the toes. The most likely
diagnosis is:
C. Compartment syndrome
Compartment syndrome
Diagnosis
6
Treatment
A 28 year old man is involved in a road traffic accident and sustains a flail chest
injury. On arrival in the emergency department he is hypotensive. On examination he
has an elevated jugular venous pulse and auscultation of the heart reveals quiet heard
sounds. What is the most likely diagnosis?
A. Pneumothorax
B. Myocardial contusion
C. Cardiac tamponade
D. Haemothorax
Hypotension
Muffled heart sounds
Raised JVP
Thoracic trauma
7
Flail chest Chest wall disconnects from thoracic cage
Multiple rib fractures (at least two fractures per rib in at
least two ribs)
Associated with pulmonary contusion
Abnormal chest motion
Avoid over hydration and fluid overload
8
Mediastinal haematoma or pleural cap suggests great
vessel injury
Mortality is 20%
A 52 year old male type 2 diabetic is admitted to the vascular ward for a femoral
popliteal bypass. He suddenly develops expressive dysphasia and marked right sided
weakness. The Senior house officer arranges a CT head scan which shows a 60% left
middle cerebral artery territory infarct. There are no beds on the stroke unit.
Overnight the patient becomes unresponsive and a CT head confirms no bleed. What
is the next best management option?
A. IV heparin
B. Clopidogrel
D. Aspirin
E. Hemicraniectomy
The likely cause for the reduced consciousness is raised intracranial pressure due to
increasing cerebral oedema related to the infarct. In this situation, urgent
neurosurgical review is needed for possible decompressive hemicraniectomy to
relieve the pressure. Ideally no further antiplatelet or anticoagulation therapy should
be given until a plan for surgery is confirmed.
Stroke: types
9
infarcts (PACI, c. 25%) e.g. upper or lower division of middle cerebral
artery
Higher cognitive dysfunction or two of the three
TACI features
--------------------------------------
Lacunar
10
Present with either isolated hemiparesis, hemisensory loss or hemiparesis with
limb ataxia
Horner's
Pontine
Theme: Trauma
A. Tension pneumothorax
B. Haemopericardium
C. Haemothorax
D. Aortic transection
E. Ruptured spleen
F. Duodeno-jejunal flexure disruption
G. Aorto iliac disruption
H. Ileo-colic junction disruption
For each scenario please select the most likely injury. Each option may be used once,
more than once or not at all.
Aortic transection
11
8. A 30 year old women is involved in a road traffic accident she is a passenger in
a car involved in a head on collision with another vehicle. Her car is travelling
at 60mph. She has been haemodynamically stable throughout with only minimal
tachycardia. On examination she has marked abdominal tenderness and a large
amount of intra abdominal fluid on CT scan
This is another site of sudden deceleration injury. Given the large amount of
free fluid, if it were blood, then a greater degree of haemodynamic instability
would be expected.
Haemopericardium
Thoracic trauma
12
Avoid over hydration and fluid overload
13
A 14-year-old boy is admitted to the acute surgical unit with appendicitis. He is
normally fit and well. Apart from metoclopramide, the patient has had no other
medications. The nursing staff contact you as the patient is acting strange. On
examination he is agitated, has a clenched jaw and his eyes are deviated upwards.
What is the most likely diagnosis?
A. Functional disorder
B. Malignant hyperthermia
C. Oculogyric crisis
D. Epilepsy
E. Serotonin syndrome
Oculogyric crisis
Features
Restlessness, agitation
Involuntary upward deviation of the eyes
Causes
Phenothiazines
Haloperidol
Metoclopramide
Postencephalitic Parkinson's disease
Management
Procyclidine
A 6 year old boy pulls over a kettle and suffers superficial partial thickness burns to
his legs. Which of the following will not occur?
14
B. Formation of vesicles or bullae
D. Healing by re-epithelialisation
Partial thickness burns are divided into superficial and deep burns, however, this is
often not possible on initial assessment and it may be a week or more before the
distinction is clear cut. Dermal appendages are, by definition, intact. Superficial
partial thickness burns will typically heal by re-epithelialisation, deeper burns will
heal with scarring.
Burns
Types of burn
>15% body surface area burns in adults needs urgent burn fluid resuscitation
15
Need burn shock resuscitation
Face/hands/genitals affected
Deep partial thickness or full thickness burns
Significant electrical/chemical burns
Escharotomies
References
www.euroburn.org/e107files/downloads/guidelinesburncare.pdf
A. Hypoglycaemia
B. Bisoprolol
C. Hypomagnesaemia
D. Dehydration
E. Hyperthyroidism
Ventricular tachcardia
16
Causes of a prolonged QT interval
Based on the current guidelines, which option regarding management of head injuries
is false?
Pain should be controlled, with opiates preferably, as this avoids distress and
hypertension post injury.
Summary of guidelines
- GCS < 15
- neck pain/tenderness
- paraesthesia extremities
- focal neurological deficit
- suspected c-spine injury
17
If a c-spine injury is suspected a 3 view c-spine x-ray is indicated. CT c-spine is
preferred if:
- Intubated
- GCS <13
- Normal x-ray but continued concerns regarding c-spine injury
Observations
Reference
http://guidance.nice.org.uk/CG56/QuickRefGuide/pdf/English
22 year old man suffers 20% partial and full thickness burns in a house fire. There is
an associated inhalational injury. It is decided to administer intravenous fluids to
replace fluid losses. Which of the following intravenous fluids should be used for
initial resuscitation?
A. Dextran 40
B. 5% Dextrose
18
D. Hartmans solution
E. Blood
After 24 hours
19
High tension electrical injuries and inhalation injuries require more fluid
Monitor: packed cell volume, plasma sodium, base excess, and lactate
A 23 year old man sustains a severe facial fracture and reconstruction is planned.
Which of the following investigations will facilitate pre-operative planning?
A. Mandibular tomography
C. Skull X-ray
E. Orthopantomogram
Craniomaxillofacial injuries
Le Fort Fractures
Grade Feature
Le Fort The fracture extends from the nasal septum to the lateral pyriform rims, travels
1 horizontally above the teeth apices, crosses below the zygomaticomaxillary
junction, and traverses the pterygomaxillary junction to interrupt the pterygoid
plates.
Le Fort These fractures have a pyramidal shape and extend from the nasal bridge at or
2 below the nasofrontal suture through the frontal process of the maxilla,
inferolaterally through the lacrimal bones and inferior orbital floor and rim
through or near the inferior orbital foramen, and inferiorly through the anterior
wall of the maxillary sinus; it then travels under the zygoma, across the
pterygomaxillary fissure, and through the pterygoid plates.
Le Fort These fractures start at the nasofrontal and frontomaxillary sutures and extend
3 posteriorly along the medial wall of the orbit through the nasolacrimal groove
20
and ethmoid bones. The thicker sphenoid bone posteriorly usually prevents
continuation of the fracture into the optic canal. Instead, the fracture continues
along the floor of the orbit along the inferior orbital fissure and continues
superolaterally through the lateral orbital wall, through the zygomaticofrontal
junction and the zygomatic arch. Intranasally, a branch of the fracture extends
through the base of the perpendicular plate of the ethmoid, through the vomer,
and through the interface of the pterygoid plates to the base of the sphenoid.
This type of fracture predisposes the patient to CSF rhinorrhea more
commonly than the other types.
Ocular injuries
Superior orbital fissure syndrome
Severe force to the lateral wall of the orbit resulting in compression of neurovascular
structures. Results in :
Nasal Fractures
Common injury
Ensure new and not old deformity
Control epistaxis
CSF rhinorrhoea implies that the cribriform plate has been breached and
antibiotics will be required.
Usually best to allow bruising and swelling to settle and then review patient
clinically. Major persistent deformity requires fracture manipulation, best
performed within 10 days of injury.
Retrobulbar haemorrhage
Rare but important ocular emergency. Presents with:
21
Proptosis
Pupil reactions are lost
Paralysis (eye movements lost)
Visual acuity is lost (colour vision is lost first)
Management:
Consider
Papaverine 40mg smooth muscle relaxant
Dextran 40 500mls IV improves perfusion
Theme: Treatment of burns
For the burns patients described below please determine the correct volume and type
of intravenous fluid (if required) for the first 8 hours of care. Each option may be used
once, more than once or not at all.
1. A 25 year old male is admitted having been involved in a house fire. His weight
on admission is 75 kg and he has suffered 22% full thickness burns to his torso
and limbs.
22
Remember half the total is administered in the first 8 hours.
Hartmans is the preferred agent.
2. A 25 year old male is admitted having been involved in a house fire. His weight
on admission is 85 kg and he has suffered 19% full thickness burns to his torso
and limbs.
3. A 25 year old male is admitted having been involved in a house fire. His weight
on admission is 65 kg and he has suffered 25% full thickness burns to his torso
and limbs.
23
50% given in first 8 hours
50% given in next 16 hours
After 24 hours
A 23 year old man is stabbed in the right upper quadrant and is haemodynamically
unstable. A laparotomy is performed and the liver has some extensive superficial
lacerations and is bleeding profusely. The patient becomes progressively more
haemodynamically unstable. Which of the following is the best management option?
B. Occlude the hepatic inflow with a pringles manoeuvre and suture the
defects
C. Occlude vascular inflow and resect the most severely affected area
anatomically
Packing of the liver is the safest option and resection or repair considered later when
the physiology is normalised. Often when the packs are removed all the bleeding has
ceased and the abdomen can be closed without further action. Definitive attempts at
suturing or resection at the primary laparotomy are often complicated by severe
bleeding.
Trauma management
24
The cornerstone of trauma management is embodied in the principles of ATLS.
ABCDE approach.
Tension pneumothoraces will deteriorate with vigorous ventilation attempts.
External haemorrhage is managed as part of the primary survey. As a rule
tourniquets should not be used. Blind application of clamps will tend to
damage surrounding structures and packing is the preferred method of
haemorrhage control.
Urinary catheters and naso gastric tubes may need inserting. Be wary of basal
skull fractures and urethral injuries.
Patients with head and neck trauma should be assumed to have a cervical
spine injury until proven otherwise.
Thoracic injuries
Simple pneumothorax
Mediastinal traversing wounds
Tracheobronchial tree injury
Haemothorax
Blunt cardiac injury
Diaphragmatic injury
Aortic disruption
Pulmonary contusion
25
Tracheobronchial tree injury Unusual injuries. In blunt trauma most injuries
occur within 4cm of the carina. Features suggesting this injury include
haemoptysis and surgical emphysema. These injuries have a very large air leak
and may have tension pneumothorax.
Haemothorax Usually caused by laceration of lung vessel or internal
mammary artery by rib fracture. Patients should all have a wide bore 36F chest
drain. Indications for thoracotomy include loss of more than 1.5L blood
initially or ongoing losses of >200ml per hour for >2 hours.
Cardiac contusions Usually cardiac arrhythmias, often overlying sternal
fracture. Perform echocardiography to exclude pericardial effusions and
tamponade. Risk of arrhythmias falls after 24 hours.
Diaphragmatic injury Usually left sided. Direct surgical repair is performed.
Traumatic aortic disruption Commonest cause of death after RTA or falls.
Usually incomplete laceration near ligamentum arteriosum. All survivors will
have contained haematoma. Only 1-2% of patients with this injury will have a
normal chest x-ray.
Pulmonary contusion Common and lethal. Insidious onset. Early intubation
and ventilation.
Abdominal trauma
26
Amylase may be normal following pancreatic trauma
Urethrography if suspected urethral injury
A 62 year old woman presents with acute bowel obstruction. She has been vomiting
up to 15 times a day and is taking erythromycin. She suddenly collapses. Her ECG
shows torsades de pointes. What is the management of choice?
A. IV Atropine
B. IV Potassium
C. IV Magnesium sulphate
D. IV Bicarbonate
E. IV Adrenaline
Torsades de pointes: Treatment IV
magnesium sulphate
Torsades de pointes
Management
27
IV magnesium sulphate
A 27-yrs-old man sustains a single gunshot wound to the left thigh. In the emergency
department, he is noted to have a large haematoma of his medial thigh. He complains
of parasthesia in his foot. On examination, there are weak pulses palpable distal to the
injury and the patient is unable to move his foot. The appropriate initial management
of this patient is:
A. Angiography
The five P's of arterial injury include pain, parasthesias, pallor, pulselessness and
paralysis. In the extremities, the tissues most sensitive to anoxia are the peripheral
nerves and striated muscle. The early developments of paresthesias and paralysis are
signals that there is significant ischemia present, and immediate exploration and repair
are warranted. The presence of palpable pulse does not exclude an arterial injury
because this presence may represent a transmitted pulsation through a blood clot.
When severe ischemia is present, the repair must be completed within 6 to 8 h to
prevent irreversible muscle ischemia and loss of limb function. Delay to obtain an
angiogram or to observe for change needlessly prolongs the ischemic time.
Fasciotomy may be required but should be done in conjunction with and after
reestablishment of arterial flow. Local wound exploration is not recommended
because brisk hemorrhage may be encountered without the securing of prior vascular
control.
Vascular trauma
Assessment
Management
28
Almost always operative.
Obtaining proximal and distal control of affected vessels is crucial.
Simple lacerations of arteries may be directly closed, or a vein patch applied if
there is a risk of subsequent stenosis.
Transection of the vessel should be treated by either end to end anastomosis
(often not possible) or an interposition vein graft.
Use of PTFE in traumatic open injuries will invariably result in infection.
A. Manage conservatively
B. Immediate emergency theatre
C. Treat in emergency department
D. Treat in emergency department under sedation
E. Operate on next emergency list
Please select the most appropriate intervention for the scenario given. Each option
may be used once, more than once or not at all.
7. A 3 year old child inserts a crayon into their external auditory meatus. Attempts
to remove it have not been successful.
9. A 10 year old boy is shot in the head with an airgun pellet. He is concerned that
29
he will get into trouble and the injury remains concealed for 10 days. Imaging
using CT scanning shows it to be lodged in the frontal lobe.
Manage conservatively
The pellet is small and no serious injury has occurred at this stage. This should
therefore be managed conservatively.
Children will often insert objects into orifices such as the nose and external
auditory meatus
Assessment includes assessment of airway and haemodynamic status
Where the airways is not immediately threatened decisions can be made as to
whether to manage in the emergency department or transfer to theatre
In general children do not tolerate procedures well and it is usually safer to
remove objects in theatre and under general anaesthesia with a secure airway
A chest x-ray is required to ensure that no object is present in the chest, not all
objects are radiolucent. However, signs such as focal consolidation may
indicate small airway obstruction
In the case of small bore missile injuries the decision relating to surgery
depends on the size of the missile and its location. Airgun pellets are a
common culprit, if there is a long time interval between the incident and
presentation and the object has not caused any significant problems then it
may be best left alone
Airgun pellets lodged in the soft tissues (and glass) are usually notoriously
difficult to localise and extract, no matter how superficial. Removal in theatre
is usually the best option. If the object is radiolucent then an image intensifier
should be used
A 32 year old male is receiving a blood transfusion after being involved in a
road traffic accident. A few minutes after the transfusion he complains of loin
pain. His observations show temperature 39 oC, HR 130bpm and blood
pressure is 95/40mmHg. What is the best test to confirm his diagnosis?
A. USS abdomen
C. Blood cultures
D. Blood film
30
Mnemonic for transfusion
reactions:
A lloimmunization
U rticaria
N eutrophilia
I nfection
T ransfusion associated lung
injury
The diagnosis is of an acute haemolytic transfusion reaction, normally due to
ABO incompatibility. Haemolysis of the transfused cells occurs causing the
combination of shock, haemoglobinaemia and loin pain. This may
subsequently lead to disseminated intravascular coagulation. A Coomb's test
should confirm haemolysis. Other tests for haemolysis include: unconjugated
bilirubin, haptoglobin, serum and urine free haemoglobin.
31
A 32 year old male is receiving a blood transfusion after being involved in a
road traffic accident. A few minutes after the transfusion he complains of loin
pain. His observations show temperature 39 oC, HR 130bpm and blood
pressure is 95/40mmHg. What is the best test to confirm his diagnosis?
A. USS abdomen
C. Blood cultures
D. Blood film
A lloimmunization
U rticaria
N eutrophilia
I nfection
T ransfusion associated lung
injury
The diagnosis is of an acute haemolytic transfusion reaction, normally due to
ABO incompatibility. Haemolysis of the transfused cells occurs causing the
combination of shock, haemoglobinaemia and loin pain. This may
subsequently lead to disseminated intravascular coagulation. A Coomb's test
should confirm haemolysis. Other tests for haemolysis include: unconjugated
bilirubin, haptoglobin, serum and urine free haemoglobin.
32
Alloimmunization CCF
Thrombocytopaenia Infections
Transfusion associated lung injury Hyperkalaemia
Graft vs Host disease
Urticaria
Acute or delayed haemolysis
ABO incompatibility
Rhesus incompatibility
Notes:
GVHD: lymphocyte proliferation causing organ failure
Transfusion associated lung injury: neutrophil mediated allergic pulmonary
oedema
ABO and Rhesus incompatibility: causes acute haemolytic transfusion
reaction leading to agglutination and haemolysis
A 45 year old man complains of sharp chest pain. He is due to have elective surgery
to replace his left hip. He has been bed bound for 3 months. He suddenly collapses;
his blood pressue is 70/40mmHg, heart rate 120 bpm and his saturations are 74% on
air. He is deteriorating in front of you. What is the next best management plan?
A. Aspirin
C. Unfractionated heparin
E. Clopidogrel
This man is peri arrest with the diagnosis of pulmonary embolism (chest
pain,bedbound, collapse, low saturations). He needs urgent thrombolysis with
alteplase (he may not survive if you wait for the medical Spr/ITU to arrive!).
33
The target INR should be 2.0-3.0; when this is achieved, heparin can be
discontinued.
The standard duration of oral anticoagulation is: 46 weeks for temporary risk
factors, 3 months for first idiopathic, and at least 6 months for other; the risk
of bleeding should be balanced with that of further VTE.
Massive PE
A 30 year old woman, who is 30 weeks pregnant, attends the varicose vein clinic. She
suddenly complains of shortness of breath and chest pain. She has no underlying lung
condition. Her saturations are 92 % air, blood pressure 150/80 mmHg and her chest
sounds clear. What is the main investigation of choice to confirm her diagnosis?
A. Lung spirometry
C. CTPA
D. CXR
Reference:
Aortic dissection
34
Predisposing factors in pregnancy are hypertension, congenital heart disease
and Marfan's syndrome
Mainly Stanford type A dissections
Sudden tearing chest pain, transient syncope
Patient may be cold and clammy, hypertensive and have an aortic
regurgitation murmur
Involvement of the right coronary artery may cause inferior myocardial
infarction
Surgical management
Gestational Management
timeframe
< 28/40 Aortic repair with the fetus kept in utero
28-32/40 Dependent on fetal condition
> 32/40 Primary Cesarean section followed by aortic repair at the same
operation
Mitral stenosis
Pulmonary embolism
References
1. Bates S.M. and Ginsberg J.S. How we manage venous thromboembolism during
pregnancy. Blood 2002 (100): 3470-3478.
3. Morley C. A. and Lim B. A. Lesson of the Week: The risks of delay in diagnosis of
breathlessness in pregnancy. BMJ 1995 (311) : 1083.
A 30 year old woman, who is 30 weeks pregnant, attends the varicose vein clinic. She
suddenly complains of shortness of breath and chest pain. She has no underlying lung
35
condition. Her saturations are 92 % air, blood pressure 150/80 mmHg and her chest
sounds clear. What is the main investigation of choice to confirm her diagnosis?
A. Lung spirometry
C. CTPA
D. CXR
Reference:
Aortic dissection
Surgical management
Gestational Management
timeframe
< 28/40 Aortic repair with the fetus kept in utero
28-32/40 Dependent on fetal condition
> 32/40 Primary Cesarean section followed by aortic repair at the same
operation
Mitral stenosis
36
Most cases associated with rheumatic heart disease
Becoming less common in British women; suspect in Immigrant women
Commonest cardiac condition in pregnancy
Commonly associated with mortality
Valve surgery; balloon valvuloplasty preferable
Pulmonary embolism
References
1. Bates S.M. and Ginsberg J.S. How we manage venous thromboembolism during
pregnancy. Blood 2002 (100): 3470-3478.
3. Morley C. A. and Lim B. A. Lesson of the Week: The risks of delay in diagnosis of
breathlessness in pregnancy. BMJ 1995 (311) : 1083.
A. Vitamin K deficiency
B. von Willebrand's disease
C. Acquired haemophilia
D. Haemophilia B
E. Protein C deficiency
F. Disseminated intravascular coagulation
G. Factor V Leiden
H. Excess heparin
I. Warfarin overdose
What is the most likely diagnosis for the scenario given? Each option may be used
once, more than once or not at all.
13. A 33 year old female is admitted for varicose vein surgery. She is fit and well.
After the procedure she is persistently bleeding. She is known to have
menorrhagia. Investigations show a prolonged bleeding time and increased
APTT. She has a normal PT and platelet count.
37
von Willebrand's disease
14. A 70 year old coal miner presents with 3 weeks of haematuria and bruising. He
is normally fit and well. He is on no medications. His results reveal:
Hb 9.0
WCC 11
Pl 255
PT 16 (normal)
APTT 58 (increased)
Thrombin time 20 (normal).
15. A 33 year old female is attends the day unit for elective varicose vein surgery.
She has previously had recurrent pulmonary embolic events. After the
procedure she is persistently bleeding. Her APTT is 52 (increased).
Abnormal coagulation
38
Heparin Prevents activation factors 2,9,10,11
Warfarin Affects synthesis of factors 2,7,9,10
DIC Factors 1,2,5,8,11
Liver disease Factors 1,2,5,7,9,10
Which one of the following is the most appropriate management of the calcium
result?
D. No action
Even after correction for the low albumin level this patient has significant
hypocalcaemia which should be corrected.
The clinical history combined with parathyroid hormone levels will reveal the cause
of hypocalcaemia in the majority of cases
Causes
39
Management
A 25 year old male pedestrian is hit by a van on a busy road. He is brought to the
Emergency Department by ambulance. On examination he is dyspneoic, and hypoxic
despite administration of high flow 100% oxygen. His blood pressure is 110/70 and
pulse rate is 115 bpm. The right side of his chest is hyper-resonant on percussion and
has decreased breath sounds. The trachea is deviated to the left. What is the most
likely underlying diagnosis?
A. Fat embolism
B. Tension pneumothorax
E. Pulmonary contusion
Blunt or penetrating chest trauma that creates a flap type defect on the surface of the
lung can result in a tension pneumothorax. Typical features include dyspnoea,
progressive hypoxia, hyperresonance and tracheal deviation. Treatment is with needle
decompression and chest tube insertion.
Thoracic trauma
40
least two ribs)
Associated with pulmonary contusion
Abnormal chest motion
Avoid over hydration and fluid overload
41
Mortality is 20%
References
ATLS Manual 8th Edition
Theme: Management of skin injuries
For the injuries described please select the most appropriate management. Each option
may be used once, more than once or not at all.
18. A 25 year old man is playing with a Pit Bull terrier which bites off a
substantial portion of his nose.
19. A 7 year old boy falls over and sustains a 6cm laceration to his head. On
inspection his wound contains some dirt in it.
By debriding the wound, the area can then be primarily closed. Prophylactic
antibiotics should be administered.
42
20. A 45 year old man is gardening is puts a fork into his foot. On examination
there are cutaneous defects and the surrounding skin looks dusky.
The skin changes described here should be debrided. Closure would not be
safe with the skin changes documented and the wound should be left open.
Method of Indication
closure
Primary closure Clean wound, usually surgically created or following minor
trauma
Standard suturing methods will usually suffice
Wound heals by primary intention
43
breakdown as they require vascular anastomosis
Mechanism of injury: Decelerating force i.e. RTA, fall from a great height
Most people die at scene
Survivors may have an incomplete laceration at the ligamentum arteriosum of
the aorta.
Clinical features
CXR changes
Widened mediastinum
Trachea/Oesophagus to right
Depression of left main stem bronchus
Widened paratracheal stripe/paraspinal interfaces
Space between aorta and pulmonary artery obliterated
Rib fracture/left haemothorax
44
Diagnosis
Angiography, usually CT aortogram.
Treatment
Repair or replacement. Ideally they should undergo endovascular repair.
A 19 year old student is involved in a head on car collision. He complains of severe
chest pain. A Chest x-ray performed as part of a trauma series shows widening of the
mediastinum. Which is the most likely injury in this scenario?
Mechanism of injury: Decelerating force i.e. RTA, fall from a great height
Most people die at scene
Survivors may have an incomplete laceration at the ligamentum arteriosum of
the aorta.
Clinical features
CXR changes
Widened mediastinum
Trachea/Oesophagus to right
Depression of left main stem bronchus
Widened paratracheal stripe/paraspinal interfaces
45
Space between aorta and pulmonary artery obliterated
Rib fracture/left haemothorax
Diagnosis
Angiography, usually CT aortogram.
Treatment
Repair or replacement. Ideally they should undergo endovascular repair.
Theme: Management of head and neck trauma
A. Observation
B. CT head within 1h
C. CT head within 8h
D. Urgent neurosurgical review (even before CT head performed)
E. 3 view c-spine xray
F. 2 view c-spine xray
G. CT c-spine
What is the best initial management plan for the injuries described? Each option may
be used once, more than once or not at all.
22. A 22 year old mechanic is involved in a fight. He is hit on the head with a
hammer. On examination he had clinical evidence of an open depressed skull
fracture and a GCS of 6/15.
23. A 67 year old retired lawyer falls down the stairs. His GCS is 15/15 and he has
some bruising over the mastoid.
This patient has a basal skull fracture, which is indicated by a positive Battle's
sign. He should have a CT head within 1h.
24. A 52 year old secretary falls down the stairs. She complains of neck pain. She
has a GCS of 15/15 and no neurology. She is unable to rotate her c-spine 45
degrees to the left and right.
46
You answered 2 view c-spine xray
She should have her c-spine immobilised and a 3 view c-spine xray.
Summary of guidelines
- GCS < 15
- neck pain/tenderness
- paraesthesia extremities
- focal neurological deficit
- suspected c-spine injury
47
Persistent GCS < 8 or = 8
Unexplained confusion > 4h
Reduced GCS after admission
Progressive neurological signs
Incomplete recovery post seizure
Penetrating injury
Cerebrospinal leak
Observations
Reference
http://guidance.nice.org.uk/CG56/QuickRefGuide/pdf/English
A 28 year old African man is admitted with acute severe abdominal pain. He has just
flown into the UK long haul and the pain developed whilst in flight. On examination
he is tender in the left upper quadrant. His blood tests are as shown.
Hb 6 g/dl
Reticulocyte count 15%.
Ultrasound shows a spleen with a heterogeous texture and a few small gallstones but
is otherwise normal.
What is the most likely diagnosis?
A. Pancreatitis
B. Parvovirus infection
D. Pulmonary embolism
A combination of a high reticulocyte count and severe anaemia indicates sickle cell
anaemia, however another differential can be of a transient aplastic crisis due to
parvovirus. This is less likely as this causes a reticulocytopenia rather than a
reticulocytosis.
Parvovirus B19 infects erythroid progenitor cells in the bone marrow and causes
temporary cessation of red blood cell production, patients who have underlying
hematologic abnormalities are at risk of cessation of red blood cell production if they
become infected. This can result in a transient aplastic crisis. Thus, patients with
sickle cell anaemia are at risk. Typically, these patients have a viral prodrome
followed by anaemia, often with haemoglobin concentrations falling below 5.0 g/dL
and reticulocytosis.
48
Sickle cell anaemia
Autosomal recessive
Single base mutation
Deoxygenated cells become sickle in shape
Causes: short red cell survival, obstruction of microvessels and infarction
Sickling is precipitated by: dehydration, infection, hypoxia
Manifest at 6 months age
Africans, Middle East, Indian
Diagnosis: Hb electrophoresis
Sickle crises
Bone pain
Pleuritic chest pain: acute sickle chest syndrome commonest cause of death
CVA, seizures
Papillary necrosis
Splenic infarcts
Priapism
Hepatic pain
Aplasia: parvovirus
Acute sequestration
Haemolysis
Long-term complications
Surgical complications
Bowel ischaemia
Cholecystitis
Avascular necrosis
49
Management
Supportive
Hydroxyurea
Repeated transfusions pre operatively
Exchange transfusion in emergencies
Heterozygous state
Asymptomatic
Symptoms associated with extreme situations ie anaesthesia complications
Protective against Plasmodium falciparum
Theme: Blood transfusion reactions
2. A 22 year old man is having a blood transfusion after losing blood from
haemorrhoids. He is normally fit and well. After 4h, during the transfusion, he
complains of sudden onset shortness of breath and chest pain. On examination
his temperature is 37.2, saturations are 88% on air, blood pressure 100/55
mmHg and HR 110 bpm. He has crepitations bilaterally up to the midzones. He
is given IV frusemide, but deteriorates and is admitted to ITU. A pulmonary
catheter is inserted and the PCWP is 10 mmHg.
The pulmonary catheter reading indicates that this is not a case of fluid overload
(the PCWP should be high, normal values PCWP systolic 7mmHg, diastolic
10mmHg). Transfusion associated lung injury is a rare reaction causing
neutrophilic mediated allergic pulmonary oedema. Patient's have antibodies to
donor leukocytes. It is important to consider this as a diagnosis when patients
don't respond to treatment for pulmonary oedema. Patients normally respond to
50
supportive therapy including fluids and oxygen.
3. A 32 year male with leukaemia attends the day unit for a blood transfusion. Five
days after the transfusion he attends A&E with a temperature of 38.5,
erythroderma and desquamation.
4. A 22 year old man is having a blood transfusion after losing blood from
haemorrhoids. He is normally fit and well. 3h during the transfusion he
complains of sudden onset abdominal pain and nausea. His temperature is 39
degrees, Blood pressure 98/42 mmHg, HR 105 bpm and saturations 94% air.
His urine appears dark.
Rapid intravascular haemolysis leading to shock, DIC and death can occur with
this reaction.
Blood transfusion reactions
51
ABO and Rhesus incompatibility: causes acute haemolytic transfusion
reaction leading to agglutination and haemolysis
A 49-year-old male sustained a severe blunt injury just below the bridge of the nose
with industrial machinery. Imaging demonstrates a fracture involving the superior
orbital fissure. On examination an ipsilateral pupillary defect is present and loss of the
corneal reflexes. In addition to these examination findings, which of the following
will not be present?
B. Ptosis
C. Complete opthalmoplegia
D. Nystagmus
E. Enopthalmos
Orbital apex syndrome
This is an extension of superior orbital fissure syndrome and includes compression of
the optic nerve passing through the optic foramen. It is indicated by features of
superior orbital fissure syndrome and ipsilateral afferent pupillary defect.
This type of injury will result in the orbital apex syndrome (See above). As such
opthalmoplegia will be present and nystagmus cannot occur.
Craniomaxillofacial injuries
Le Fort Fractures
Grade Feature
Le Fort The fracture extends from the nasal septum to the lateral pyriform rims, travels
1 horizontally above the teeth apices, crosses below the zygomaticomaxillary
junction, and traverses the pterygomaxillary junction to interrupt the pterygoid
plates.
Le Fort These fractures have a pyramidal shape and extend from the nasal bridge at or
2 below the nasofrontal suture through the frontal process of the maxilla,
inferolaterally through the lacrimal bones and inferior orbital floor and rim
through or near the inferior orbital foramen, and inferiorly through the anterior
wall of the maxillary sinus; it then travels under the zygoma, across the
pterygomaxillary fissure, and through the pterygoid plates.
Le Fort These fractures start at the nasofrontal and frontomaxillary sutures and extend
52
3 posteriorly along the medial wall of the orbit through the nasolacrimal groove
and ethmoid bones. The thicker sphenoid bone posteriorly usually prevents
continuation of the fracture into the optic canal. Instead, the fracture continues
along the floor of the orbit along the inferior orbital fissure and continues
superolaterally through the lateral orbital wall, through the zygomaticofrontal
junction and the zygomatic arch. Intranasally, a branch of the fracture extends
through the base of the perpendicular plate of the ethmoid, through the vomer,
and through the interface of the pterygoid plates to the base of the sphenoid.
This type of fracture predisposes the patient to CSF rhinorrhea more
commonly than the other types.
Ocular injuries
Superior orbital fissure syndrome
Severe force to the lateral wall of the orbit resulting in compression of neurovascular
structures. Results in :
Nasal Fractures
Common injury
Ensure new and not old deformity
Control epistaxis
CSF rhinorrhoea implies that the cribriform plate has been breached and
antibiotics will be required.
Usually best to allow bruising and swelling to settle and then review patient
clinically. Major persistent deformity requires fracture manipulation, best
performed within 10 days of injury.
Retrobulbar haemorrhage
Rare but important ocular emergency. Presents with:
53
Pain (usually sharp and within the globe)
Proptosis
Pupil reactions are lost
Paralysis (eye movements lost)
Visual acuity is lost (colour vision is lost first)
Management:
Consider
Papaverine 40mg smooth muscle relaxant
Dextran 40 500mls IV improves perfusion
A. Anticoagulation
C. Intravenous fluids
D. Pain control
E. Fasciotomy
Compartment syndrome
54
Symptoms and signs
Diagnosis
Treatment
For each clinical scenario please select the most likely complication to have occurred.
Each option may be used once, more than once or not at all.
7. A 10 year old child is admitted with severe 30% burns following a house fire.
After wound cleaning and dressings he is admitted to critical care. 1 day
following skin grafts he becomes tachycardic and hypotensive. He vomits twice
55
and this shows evidence of haematemesis
Curlings Ulcer
Stress ulcers may occur in the duodenum of burns patients and are more
common in children.
8. A 26 year old electrician suffers a full thickness high voltage burn to his leg. On
routine urine analysis he has + blood. His U+E's show mild hyperkalaemia and
a CK of 3000
Rhabdomyolysis
Electrical high voltage burns are associated with rhabdomyolysis. Acute tubular
necrosis may occur. Aggressive IV fluids should be given
9. A 45 year old man is admitted after his clothing caught fire. He suffers a full
thickness circumferential burn to his lower thigh. He complains of increasing
pain in lower leg and on examination there is parasthesia and severe pain in the
lower leg. Foot pulses are normal
Compartment syndrome
Burns
Types of burn
56
and subcutaneous hard wound
tissue affected
>15% body surface area burns in adults needs urgent burn fluid resuscitation
Escharotomies
References
www.euroburn.org/e107files/downloads/guidelinesburncare.pdf
C. Bankart lesion
57
D. Axillary nerve injury
E. Infraspinatus tendinitis
Anterior dislocations are the most common. When recurrent a Bankart lesion is the
most common underlying abnormality. This is usually visualised by CT and MRI
scanning and often repaired arthroscopically.
Shoulder disorders
58
Assocociated with Trough sign
Treatment
Prompt reduction is the mainstay of treatment and is usually performed in the
emergency department. Neurovascular status must be checked pre and post reduction
and x-rays should be performed again post reduction to ensure no fracture has
occurred. In recurrent anterior dislocation there is usually a Bankart lesion and this
may be repaired surgically. Recurrent posterior dislocations may be repaired in a
similar manner to anterior lesions but using a posterior (or arthroscopic) approach.
A 44 year old man is involved in a road traffic accident. He suffers significant injuries
to his thorax, he has bilateral haemopneumothoraces and a suspected
haemopericardium. He is to undergo surgery, what is the best method of accessing
these injuries?
B. Midline sternotomy
Patients with significant mediastinal and lung injuries are best operated on using a
Clam shell thoracotomy. All modes of access involve a degree of compromise. A
sternotomy would give good access to the heart. However, it takes longer to perform
and does not provide good access to the lungs. Trauma should not be managed using
laparoscopy.
Trauma management
59
ABCDE approach.
Tension pneumothoraces will deteriorate with vigorous ventilation attempts.
External haemorrhage is managed as part of the primary survey. As a rule
tourniquets should not be used. Blind application of clamps will tend to
damage surrounding structures and packing is the preferred method of
haemorrhage control.
Urinary catheters and naso gastric tubes may need inserting. Be wary of basal
skull fractures and urethral injuries.
Patients with head and neck trauma should be assumed to have a cervical
spine injury until proven otherwise.
Thoracic injuries
Simple pneumothorax
Mediastinal traversing wounds
Tracheobronchial tree injury
Haemothorax
Blunt cardiac injury
Diaphragmatic injury
Aortic disruption
Pulmonary contusion
60
have contained haematoma. Only 1-2% of patients with this injury will have a
normal chest x-ray.
Pulmonary contusion Common and lethal. Insidious onset. Early intubation
and ventilation.
Abdominal trauma
A 44 year old man is involved in a road traffic accident. He suffers significant injuries
to his thorax, he has bilateral haemopneumothoraces and a suspected
haemopericardium. He is to undergo surgery, what is the best method of accessing
these injuries?
B. Midline sternotomy
61
C. Bilateral posterolateral thoracotomy
Patients with significant mediastinal and lung injuries are best operated on using a
Clam shell thoracotomy. All modes of access involve a degree of compromise. A
sternotomy would give good access to the heart. However, it takes longer to perform
and does not provide good access to the lungs. Trauma should not be managed using
laparoscopy.
Trauma management
ABCDE approach.
Tension pneumothoraces will deteriorate with vigorous ventilation attempts.
External haemorrhage is managed as part of the primary survey. As a rule
tourniquets should not be used. Blind application of clamps will tend to
damage surrounding structures and packing is the preferred method of
haemorrhage control.
Urinary catheters and naso gastric tubes may need inserting. Be wary of basal
skull fractures and urethral injuries.
Patients with head and neck trauma should be assumed to have a cervical
spine injury until proven otherwise.
Thoracic injuries
Simple pneumothorax
Mediastinal traversing wounds
Tracheobronchial tree injury
Haemothorax
Blunt cardiac injury
Diaphragmatic injury
Aortic disruption
62
Pulmonary contusion
Abdominal trauma
63
Diagnostic Abdominal CT scan USS
Peritoneal Lavage
Indication Document bleeding if Document organ injury Document fluid if
hypotensive if normotensive hypotensive
Advantages Early diagnosis and Most specific for Early diagnosis, non
sensitive; 98% localising injury; 92 to invasive and
accurate 98% accurate repeatable; 86 to 95%
accurate
Disadvantages Invasive and may Location of scanner Operator dependent
miss retroperitoneal away from facilities, and may miss
and diaphragmatic time taken for reporting, retroperitoneal injury
injury need for contrast
A. Aspirin 75mg
B. Clopidogrel 75mg
C. Aspirin 300mg
D. Clopidogrel 300mg
64
Whilst it is common that non-hypoxic patients receive oxygen therapy there is
little evidence to support this approach. The 2008 British Thoracic Society
oxygen therapy guidelines advise not giving oxygen unless the patient is
hypoxic.
A. No changes
B. J waves
C. P pulmonale
S1, Q3, T3
No changes
S1, Q3, T3
Tall R waves: V1
65
P pulmonale (peaked P waves): inferior leads
Right axis deviation, Right bundle branch block
Atrial arrhythmias
T wave inversion: V1, V2, V3
Right ventricular strain: if identified is associated with adverse short-term
outcome and adds prognostic value to echocardiographic evidence of right
ventricular dysfunction in patients with acute pulmonary embolism and
normal blood pressure.
References
Vanni S et al. Prognostic value of ECG among patients with acute pulmonary
embolism and normal blood pressure. Am J Med. 2009 Mar;122(3):257-64.
A 42 year old woman is admitted to surgery with acute cholecystitis. She is known to
have hypertension, rheumatoid arthritis and polymyalgia rheumatica. Her medical
therapy includes:
Paracetamol 1g qds
Codeine phosphate 30mg qds
Bendrofluazide 2.5 mg od
Ramipril 10mg od
Methotrexate 7.5mg once a week
Prednisolone 5mg od
You are called by the Senior House Officer to assess this lady as she has become
delirious and hypotensive 2h after surgery. Her blood results reveal:
Hb 12.4 g/dl
Platelets 178 * 109/l
WBC 15.4 * 109/l
A. Ceftriaxone IV
B. Hydrocortisone 50mg IV
C. CT scan abdomen
E. Hydrocortisone 100mg IV
66
This patient has acute adrenal insufficiency and urgently needs steroid replacement.
Addisonian crisis
Causes
Management
Hydrocortisone 100 mg im or iv
1 litre normal saline infused over 30-60 mins or with dextrose if
hypoglycaemic
Continue hydrocortisone 6 hourly until the patient is stable. No
fludrocortisone is required because high cortisol exerts weak
mineralocorticoid action
Oral replacement may begin after 24 hours and be reduced to maintenance
over 3-4 days
A. Thoracotomy
B. Manage conservatively
C. Intercostal tube drain insertion
D. CT scanning
E. Bronchoscopy
F. Negative pressure intercostal tube drainage
G. Video assisted thoracoscopy and pleurectomy
For each of the following scenarios please select the most appropriate management
option from the list. Each option may be used once, more than once or not at all.
15. A 28 year old male is involved in a road traffic accident he is thrown from his
motorbike onto the pavement and sustains a haemopneumothorax and flail
segment of the right chest
67
should be managed by intercostal chest drain insertion as they have a risk of
becoming a tension pneumothorax until the lung laceration has sealed.
16. A 19 year old man is stabbed in the chest at a nightclub. He develops a cardiac
arrest in casualty following an attempted transfer to the CT scanning room
Thoracotomy
This is one indication for an 'emergency room' thoracotomy, there are not
many others! Typical injuries include ventricular penetration, great vessel
disruption and hilar lung injuries.
17. A 32 year old male falls over and sustains a small pneumothorax following a
simple rib fracture. He has no physiological compromise
Thoracic trauma
68
Avoid over hydration and fluid overload
69
References
ATLS Manual 8th Edition
A 21 year old man is undergoing an inguinal hernia repair and receives a does of
intravenous co-amoxyclav. He is reported to have a penicillin allergy. Over the next
few minutes his vital signs are: Pulse - 130bpm, blood pressure- 60/40mmHg. What is
the first line treatment?
A. Hydrocortisone 100mg IV
B. Adrenaline 1:1000 IV
C. Chlorpheniramine 10mg IV
D. Adrenaline 1:1000 IM
E. Adrenaline 1:10000 IV
Anaphylactic shock
Management
- Remove allergen
- ABCD
- Drugs:
Reference
Emergency treatment of anaphylactic reactions. Guidelines for healthcare providers.
Working Group of the Resuscitation Council (UK).2008
heme: Types of stroke
70
F. Lateral medullary syndrome
G. Pontine infarct
H. Horner's syndrome
I. Cerebellar infarct
Please select the most likely cause for the symptoms given. Each option may be used
once, more than once or not at all.
19. A 53 year old teacher is admitted to the vascular ward for a carotid
endarterectomy. Your houseman does a preoperative assessment and notes that
there is a right homonymous hemianopia. There is no other neurology.
This patient has had a left occipital infarct, as there is only a homonymous
hemianopia. If this patient had a temporal or parietal lobe infarct, there would
be associated hemiparesis and higher cortical dysfunction. This is important to
differentiate, as the carotid endarterectomy is inappropriate in this patient as
the lesion is in the posterior cerebral artery.
20. A 52 year man is admitted to the vascular ward for an amputation. The patient
complains of unsteadiness. On further examination you detect right facial
numbness and right sided nystagmus. There is sensory loss of the left side.
21. A 48 year old type 2 diabetic complains of numbness in his left arm and leg.
Otherwise there is no other neurological signs.
Lacunar infarct
Stroke: types
71
10%) consciousness
--------------------------------------
72
Posterior cerebral artery
Lacunar
Horner's
Pontine
A 22 year old man has a full thickness burn on his chest. It is well circumscribed. In
A&E his saturations are reduced to 92% on 15L Oxygen, Blood pressure 102/66
mmHg and HR 105bpm. What is the best management?
A. Haemodialysis
B. Escharotomy
C. Fasciotomy
D. Cardiac bypass
The chest burn and its associated oedema is limiting respiration. Therefore an
escharotomy of the chest is indicated, allowing the breast plate to mobilise causing
ventilation.
73
Burns
Types of burn
>15% body surface area burns in adults needs urgent burn fluid resuscitation
Escharotomies
74
References
www.euroburn.org/e107files/downloads/guidelinesburncare.pdf
Summary of guidelines
- GCS < 15
- neck pain/tenderness
- paraesthesia extremities
- focal neurological deficit
- suspected c-spine injury
75
Immediate CT head (within 1h) if:
Observations
Reference
http://guidance.nice.org.uk/CG56/QuickRefGuide/pdf/English
A 66 year old male is admitted to the vascular ward for an amputation. He reports
episodes of vertigo and dysarthria to the house officer. He sudden;y collapses with a
glasgow coma score of 3. What is the most likely diagnosis?
B. Opiate overdose
D. Diazepam overdose
76
patient complaining of posterior symptoms and a sudden deterioration in
consciousness, the main differential diagnosis is of a basilar artery occlusion.
Stroke: types
--------------------------------------
77
Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral hemianopia
Aphasia (Wernicke's)
Gaze abnormalities
Lacunar
Horner's
Pontine
A. Intravenous flumazenil
B. Intravenous nalaxone
C. Intravenous benxhexol
D. No further management
78
E. Intravenous glycopyrolate
Intravenous nalaxone is needed to treat the patient who has had an overdose of opiate.
Naloxone has the quickest onset of action, however it is important to be aware of its
short acting duration and the need for further administration. There is also the risk of
rebound pain once naloxone is given.
Opioid misuse
Opioids are substances which bind to opioid receptors. This includes both naturally
occurring opiates such as morphine and synthetic opioids such as buprenorphine and
methadone.
Rhinorrhoea
Needle track marks
Pinpoint pupils
Drowsiness
A 68 year old male is admitted to the surgical ward for assessment of severe
epigastric pain. His abdomen is soft and non tender. However the Nurse forces you to
look at the ECG. It looks abnormal. Which of the following features is an indication
for urgent coronary thrombolysis or percutaneous intervention?
C. Ventricular tachycardia
79
D. Q waves in leads V1 to V6
ST elevation of 1mm in leads II, III and aVF reflects significant cardiac ischaemia
due to the right coronary artery occlusion. The medical registrar should be contacted
to urgently assess the patient. Note right coronary artery occlusions puts the patient at
risk of cardiac arrhythmias (due to blood supply to the sino atrial node).
Examples
alteplase
tenecteplase
streptokinase
Contraindications to thrombolysis
Side-effects
haemorrhage
hypotension - more common with streptokinase
80
allergic reactions may occur with streptokinase
Degloving injuries typically involve extremities and are usually friction injuries eg
arm being run over. There is abnormal motility of the overlying skin, pallor, loss of
sensation. Early treatment is key and should involve skin grafting which may use the
degloved segment. This however, should be formally prepared for the role and simple
compression bandaging gives poor results.
Wound healing
Surgical wounds are either incisional or excisional and either clean, clean
contaminated or dirty. Although the stages of wound healing are broadly similar their
contributions will vary according to the wound type.
Haemostasis
Inflammation
Regeneration
81
Fibroblasts produce a collagen network.
Angiogenesis occurs and wound resembles granulation tissue.
Remodeling
Longest phase of the healing process and may last up to one year (or longer).
During this phase fibroblasts become differentiated (myofibroblasts) and these
facilitate wound contraction.
Collagen fibres are remodeled.
Microvessels regress leaving a pale scar.
Conditions such as jaundice will impair fibroblast synthetic function and overall
immunity with a detrimental effect in most parts of healing.
Hypertrophic scars
Excessive amounts of collagen within a scar. Nodules may be present histologically
containing randomly arranged fibrils within and parallel fibres on the surface. The
tissue itself is confined to the extent of the wound itself and is usually the result of a
full thickness dermal injury. They may go on to develop contractures.
Image of hypertrophic scarring. Note that it remains confined to the boundaries of the
original wound:
82
Image sourced from Wikipedia
Keloid scars
Excessive amounts of collagen within a scar. Typically a keloid scar will pass beyond
the boundaries of the original injury. They do not contain nodules and may occur
following even trivial injury. They do not regress over time and may recur following
removal.
Image of a keloid scar. Note the extension beyond the boundaries of the original
incision:
83
Immunosupressive agents
Anti neoplastic drugs
Closure
Delayed primary closure is the anatomically precise closure that is delayed for a few
days but before granulation tissue becomes macroscopically evident.
Fresh blood is the fluid of choice when large volume blood loss complicates trauma.
Mortality is doubled when blood >3 weeks old is used.
Trauma management
ABCDE approach.
Tension pneumothoraces will deteriorate with vigorous ventilation attempts.
External haemorrhage is managed as part of the primary survey. As a rule
tourniquets should not be used. Blind application of clamps will tend to
84
damage surrounding structures and packing is the preferred method of
haemorrhage control.
Urinary catheters and naso gastric tubes may need inserting. Be wary of basal
skull fractures and urethral injuries.
Patients with head and neck trauma should be assumed to have a cervical
spine injury until proven otherwise.
Thoracic injuries
Simple pneumothorax
Mediastinal traversing wounds
Tracheobronchial tree injury
Haemothorax
Blunt cardiac injury
Diaphragmatic injury
Aortic disruption
Pulmonary contusion
85
Abdominal trauma
86
Superficial dermal burns are typically erythematous, do not extend beyond the upper
part of the dermal papillae, capillary return and blisters are both usually present.
Burns
Types of burn
87
Percentage burn estimation
Lund Browder chart: most accurate even in children
Wallace rule of nines
Palmar surface: surface area palm = 0.8% burn
>15% body surface area burns in adults needs urgent burn fluid resuscitation
Escharotomies
References
www.euroburn.org/e107files/downloads/guidelinesburncare.pdf
A. Widened mediastinum
Mechanism of injury: Decelerating force i.e. RTA, fall from a great height
88
Most people die at scene
Survivors may have an incomplete laceration at the ligamentum arteriosum of
the aorta.
Clinical features
CXR changes
Widened mediastinum
Trachea/Oesophagus to right
Depression of left main stem bronchus
Widened paratracheal stripe/paraspinal interfaces
Space between aorta and pulmonary artery obliterated
Rib fracture/left haemothorax
Diagnosis
Angiography, usually CT aortogram.
Treatment
Repair or replacement. Ideally they should undergo endovascular repair.
Theme: Head injury management
A. Observation
B. CT head within 1h
C. CT head within 8h
D. Urgent neurosurgical review (even before CT head performed)
E. 3 view c-spine xray
F. 2 view c-spine xray
G. CT c-spine
H. MRI c-spine
What is the best initial management plan for the scenario given? Each option may be
used once, more than once or not at all.
31. A 22 year old male falls of a ladder. He complains of neck pain and cannot feel
his legs. His GCS suddenly deteriorates and a CT head confirms an extradural
haematoma. What is the best imaging for his neck?
89
The correct answer is CT c-spine
This man needs a CT scan of his c-spine. A CT scan will give the best
resolution of any bony injury.
32. A 25 year old teacher falls down the stairs. She complains of a headache and
has vomited 3 times. She has a GCS of 15/15.
CT head within 1h
This lady has a head injury and vomiting > 1, therefore an urgent CT head is
indicated.
Summary of guidelines
- GCS < 15
- neck pain/tenderness
- paraesthesia extremities
- focal neurological deficit
- suspected c-spine injury
90
- Normal x-ray but continued concerns regarding c-spine injury
Observations
Reference
http://guidance.nice.org.uk/CG56/QuickRefGuide/pdf/English
Theme: Head injury management
A. Observation
B. CT head within 1h
C. CT head within 8h
D. Urgent neurosurgical review (even before CT head performed)
E. 3 view c-spine xray
F. 2 view c-spine xray
G. CT c-spine
H. MRI c-spine
What is the best initial management plan for the scenario given? Each option may be
used once, more than once or not at all.
91
31. A 22 year old male falls of a ladder. He complains of neck pain and cannot feel
his legs. His GCS suddenly deteriorates and a CT head confirms an extradural
haematoma. What is the best imaging for his neck?
This man needs a CT scan of his c-spine. A CT scan will give the best
resolution of any bony injury.
32. A 25 year old teacher falls down the stairs. She complains of a headache and
has vomited 3 times. She has a GCS of 15/15.
CT head within 1h
This lady has a head injury and vomiting > 1, therefore an urgent CT head is
indicated.
Summary of guidelines
- GCS < 15
- neck pain/tenderness
- paraesthesia extremities
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- focal neurological deficit
- suspected c-spine injury
Observations
Reference
http://guidance.nice.org.uk/CG56/QuickRefGuide/pdf/English
A 60-year-old man develops palpitations while on the acute surgical unit. An ECG
shows a broad complex tachycardia at a rate of 150 bpm. His blood pressure is 124/82
mmHg and there is no evidence of heart failure. The surgical consultant wants to give
rate control (the medical team are not answering their bleeps). Which one of the
following is it least appropriate to give?
A. Procainamide
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B. Lidocaine
C. Synchronised DC shock
D. Adenosine
E. Verapamil
Ventricular tachycardia -
verapamil is contraindicated
Whilst a broad complex tachycardia may result from a supraventricular rhythm with
aberrant conduction, the European Resuscitation Council advise that in a peri-arrest
situation it is assumed to be ventricular in origin
If the patient has adverse signs (systolic BP < 90 mmHg, chest pain, heart failure or
rate > 150 beats/min) then immediate cardioversion is indicated. In the absence of
such signs antiarrhythmics may be used. If these fail, then electrical cardioversion
may be needed with synchronised DC shocks
Drug therapy
A 24 year old man is admitted to A&E with 35% full thickness burns after being
involved in a house fire. Which fluid is normally avoided during resuscitation in the
first 8-12h?
A. Plasmalyte
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B. Hartmann's
C. Albumin solution
D. Dextrose saline
E. Dextran 40
Albumin causes increased fluid into the interstitial space, therefore is avoided in the
first 8-24h (variable between different departments).
After 24 hours
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Colloids used include albumin and FFP
Antioxidants, such as vitamin C, can be used to minimize oxidant-mediated
contributions to the inflammatory cascade in burns
High tension electrical injuries and inhalation injuries require more fluid
Monitor: packed cell volume, plasma sodium, base excess, and lactate
A 62 year old male attends the hernia clinic. He suddenly develops speech problems,
left facial weakness and left sided arm and leg weakness lasting longer than 5
minutes. What is the next line of management?
A. Aspirin 300mg
B. Aspirin 75 mg
C. Clopidogrel 300mg
E. Carotid endarterectomy
Stroke: types
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hemisensory loss or hemiparesis with limb ataxia
--------------------------------------
Lacunar
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Ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy
e.g.
Horner's
Pontine
A 45-year-old man is seen in the Emergency Department with nausea, pallor and
lethargy. He has no past medical history of note. A cannula is inserted and serum urea
and electrolytes show the following
A. Nebulised salbutamol
B. Intravenous bicarbonate
C. Haemodialysis
D. Insulin/dextrose infusion
The first priority in this patient is to stabilise the myocardium with intravenous
calcium gluconate.
Management of hyperkalaemia
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Intravenous calcium gluconate
A. Ruptured spleen
B. Ileum injury
C. Duodenal injury
D. Urethral injury
E. Rectal injury
F. Oesophageal injury
G. Liver laceration
Please select the most likely injury for the scenario given. Each option may be used
once, more than once or not at all.
Urethral injury
This is classical for urethral injury. Features of a urethral injury include; pelvic
fracture, high riding prostate on digital rectal examination and blood at the
urethral meatus. Where this is the suspected diagnosis a suprapubic catheter
and urethral contrast studies performed.
39. A cyclist loses control and falls off the side of a road landing on the bicycle
handlebars. CT scanning shows a large amount of retroperitoneal air.
Duodenal injury
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retroperitoneal. A handlebar type injury is the commonest cause and the
pancreas should be carefully inspected as it too may be injured. It would be
unusual for the ileum to be injured in this type of scenario as it is mobile.
40. A 23 year old man is shot in the abdomen. He is haemodynamically stable but
on ultrasound he has a large about of intra abdominal free fluid.
Ileum injury
Small bowel injury is the most common type of injury in this scenario. The
enteric contents will tend to result in a large amount of intra abdominal fluid.
Trauma management
ABCDE approach.
Tension pneumothoraces will deteriorate with vigorous ventilation attempts.
External haemorrhage is managed as part of the primary survey. As a rule
tourniquets should not be used. Blind application of clamps will tend to
damage surrounding structures and packing is the preferred method of
haemorrhage control.
Urinary catheters and naso gastric tubes may need inserting. Be wary of basal
skull fractures and urethral injuries.
Patients with head and neck trauma should be assumed to have a cervical
spine injury until proven otherwise.
Thoracic injuries
Simple pneumothorax
Mediastinal traversing wounds
Tracheobronchial tree injury
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Haemothorax
Blunt cardiac injury
Diaphragmatic injury
Aortic disruption
Pulmonary contusion
Abdominal trauma
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Mechanical testing for pelvic stability should only be performed once
A 22 year old man has a full thickness burn of his leg after being trapped in a burning
car. There are no fractures of the limb. There burn is well circumscribed. After 2
hours he complains of tingling of his leg and it appears dusky. What is the best
management for this?
A. Fasciotomy
B. Escharotomy
C. Angioplasty
D. Pain control
E. Anticoagulation
The full thickness burn has oedema which is affecting the peripheral circulation.
Therefore the burn needs to be divided (not the fascia) to allow normal circulation to
return.
Burns
Types of burn
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thickness part of papillary with no
dermis affected intervention
Deep partial thickness Epidermis, whole Mottled red No Needs surgical
papillary dermis colour intervention
affected (depending on
site)
Full thickness Whole skin layer Dry, leathery No Burns centre
and subcutaneous hard wound
tissue affected
>15% body surface area burns in adults needs urgent burn fluid resuscitation
Escharotomies
References
www.euroburn.org/e107files/downloads/guidelinesburncare.pdf
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minutes he has become increasingly hypoxic and is now needing increased ventilation
pressures. What is the most common cause?
A. Pulmonary embolism
B. Cardiac tamponade
C. Fat embolism
D. Tension pneumothorax
A flail chest segment may lacerate the underlying lung and create a flap valve. A
tension pneumothorax can be created by intubation and ventilation in this situation.
Sudden hypoxia and increased ventilation pressure are clues.
Tension Pneumothorax
May occur following thoracic trauma when a lung parenchymal flap is created.
This acts as a one way valve and allows pressure to rise.
The trachea shifts and hyper-resonance is apparent on the affected side.
Treatment is with needle cricothyroidotomy and chest tube insertion.
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Image sourced from Wikipedia
A 10 year old boy is playing with a firework which explodes and he sustains a full
thickness burn to his left arm. Which of the following statements is not characteristic
of this situation?
Full thickness burns involve complete injury to the dermis and sub dermal
appendages. They have a leathery, often white appearance. They are initially insensate
although pain often occurs during healing following skin grafting. They do not blanch
under pressure.
Burns
Types of burn
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Wallace rule of nines
Palmar surface: surface area palm = 0.8% burn
>15% body surface area burns in adults needs urgent burn fluid resuscitation
Escharotomies
References
www.euroburn.org/e107files/downloads/guidelinesburncare.pdf
A. Pneumothorax
B. Tension pneumothorax
C. Flail chest
D. Cardiac tamponade
E. Aorta rupture
F. Cardiac contusion
G. Diaphragmatic rupture
H. Acute phrenic nerve injury
For each of the scenarios given, please select the most likely underlying injury. Each
option may be used once, more than once or not at all.
44. An 18 year old student is involved in a car crash, with another car crashing
into the side of the car.
A CXR shows an indistinct left hemidiaphragm.
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The correct answer is Diaphragmatic rupture
45. A 19 year old motorcyclist is involved in a road traffic accident. His chest
movements are irregular. He is found to have multiple rib fractures, with 2
fractures in the 3rd rib and 3 fractures in the 4th rib.
Flail chest
Multiple rib fractures with > or = 2 rib fractures in more than 2 ribs is
diagnosed as a flail chest. This is associated with pulmonary contusion.
46. A 19 year old student falls from a 2nd floor window. He is persistently
hypotensive. A CXR shows depression of the left main bronchus and deviation
of the trachea to the right.
Aorta rupture
Thoracic trauma
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Most common cause is mechanical ventilation in patient
with pleural injury
Symptoms overlap with cardiac tamponade, hyper-
resonant percussion note is more likely in tension
pnemothorax
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More common on left side
Insert gastric tube, which will pass into the thoracic
cavity
References
ATLS Manual 8th Edition
A 22 year old man is involved in a motorcycle accident. He suffers from bilateral
tibial and fibula fractures. He is taken to theatre and intramedullary nails are inserted.
6h after surgery he complains of severe pain in his limb, which increases on passive
plantar flexion. What is the best management plan?
A. Anticoagulation
B. Fasciotomy
E. Pregabalin
Do not forget to decompress the deep
muscle layer during a fasciotomy.
Compartment syndrome
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Pallor may be present
Arterial pulsation may still be felt as the necrosis occurs as a result of
microvascular compromise
Paralysis of the muscle group may occur
Diagnosis
Treatment
A. Drowsiness
A. Lautenbach regime
B. Below knee amputation
C. Hindquater amputation
D. Above knee amputation
E. Removal of metalwork and implantation of local antibiotics
F. Removal of metalwork and bone grafting
G. Intravenous antibiotics
Which option is the best management plan? Each option may be used once, more than
once or not at all
3. A 65 year old type 2 diabetic with poor glycaemic control is admitted with
forefoot cellulitis. X-ray of the foot shows some evidence of osteomyelitis of
the 2nd ray but overlying skin is healthy.
Intravenous antibiotics
It is worth attempting to try and resolve this situation with antibiotics at first
presentation. A primary amputation will not heal well and may result in
progressive surgery.
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5. A 70 year old man undergoes a revision total hip replacement. 10 days post
operatively the hip dislocates and pus is discharging from the wound. He is
systemically unwell with a temperature of 38.5 and WCC 19.
Osteomyelitis
Causes
Clinical features
Erythema
Pain
Fever
Investigation
Treatment
Prolonged antibiotics
Sequestra may need surgical removal
What is the least likely examination finding in patients with Le Fort II fractures?
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C. Malocclusion of the teeth
D. Endopthalmos
Le Fort II fractures have a pyramidal shape. The fracture line involves the orbit and
extends to involve the bridge of the nose and the ethmoids. In continues to involve the
infraorbital rim and usually through the infraorbital foramen. As a result infraorbital
parasthesia, palatal mobility and malocclusion are common findings. Severe fractures
may result in endopthalmos. However, the fracture does not, by definition, involve the
inferior alveolar nerve.
Craniomaxillofacial injuries
Le Fort Fractures
Grade Feature
Le Fort The fracture extends from the nasal septum to the lateral pyriform rims, travels
1 horizontally above the teeth apices, crosses below the zygomaticomaxillary
junction, and traverses the pterygomaxillary junction to interrupt the pterygoid
plates.
Le Fort These fractures have a pyramidal shape and extend from the nasal bridge at or
2 below the nasofrontal suture through the frontal process of the maxilla,
inferolaterally through the lacrimal bones and inferior orbital floor and rim
through or near the inferior orbital foramen, and inferiorly through the anterior
wall of the maxillary sinus; it then travels under the zygoma, across the
pterygomaxillary fissure, and through the pterygoid plates.
Le Fort These fractures start at the nasofrontal and frontomaxillary sutures and extend
3 posteriorly along the medial wall of the orbit through the nasolacrimal groove
and ethmoid bones. The thicker sphenoid bone posteriorly usually prevents
continuation of the fracture into the optic canal. Instead, the fracture continues
along the floor of the orbit along the inferior orbital fissure and continues
superolaterally through the lateral orbital wall, through the zygomaticofrontal
junction and the zygomatic arch. Intranasally, a branch of the fracture extends
through the base of the perpendicular plate of the ethmoid, through the vomer,
and through the interface of the pterygoid plates to the base of the sphenoid.
This type of fracture predisposes the patient to CSF rhinorrhea more
commonly than the other types.
Ocular injuries
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Superior orbital fissure syndrome
Severe force to the lateral wall of the orbit resulting in compression of neurovascular
structures. Results in :
Nasal Fractures
Common injury
Ensure new and not old deformity
Control epistaxis
CSF rhinorrhoea implies that the cribriform plate has been breached and
antibiotics will be required.
Usually best to allow bruising and swelling to settle and then review patient
clinically. Major persistent deformity requires fracture manipulation, best
performed within 10 days of injury.
Retrobulbar haemorrhage
Rare but important ocular emergency. Presents with:
Management:
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Acetazolamide 500mg IV, (Monitor FBC/U+E) Reduces aqueous pressure by
inhibition of carbonic anhydrase (used in glaucoma)
Dexamethasone 8mg orally or intravenously
In a traumatic setting an urgent catholysis may be needed prior to definitive
surgery.
Consider
Papaverine 40mg smooth muscle relaxant
Dextran 40 500mls IV improves perfusion
A Medical F1 phones you as he is concerned his patient has had a major internal
bleed. The patient is 42 years old and is known to have sickle cell anaemia. His blood
results are:
Hb 3.7 g /dl
Reticulocyte count 0.4%
A. Psoas haemorrhage
B. Acute sequestration
C. Parvovirus
D. Splenic haemorrhage
E. Acute haemolysis
Autosomal recessive
Single base mutation
Deoxygenated cells become sickle in shape
Causes: short red cell survival, obstruction of microvessels and infarction
Sickling is precipitated by: dehydration, infection, hypoxia
Manifest at 6 months age
Africans, Middle East, Indian
Diagnosis: Hb electrophoresis
Sickle crises
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Bone pain
Pleuritic chest pain: acute sickle chest syndrome commonest cause of death
CVA, seizures
Papillary necrosis
Splenic infarcts
Priapism
Hepatic pain
Aplasia: parvovirus
Acute sequestration
Haemolysis
Long-term complications
Surgical complications
Bowel ischaemia
Cholecystitis
Avascular necrosis
Management
Supportive
Hydroxyurea
Repeated transfusions pre operatively
Exchange transfusion in emergencies
Heterozygous state
Asymptomatic
Symptoms associated with extreme situations ie anaesthesia complications
Protective against Plasmodium falciparum
116
Theme: Management of chest trauma
For each of the following scenarios please select the most appropriate next stage of
management. Each option may be used once, more than once or not at all.
This man has cardiac tamponade. The raised CVP in the setting of
haemodynamic compromise is the pointer to this. Whilst he will almost
cetainly require surgery, he requires ungent deompresion of his heart first.
9. A 26 year old male falls from a cliff. He suffers from multiple fractures and
has a right sided pneumothorax that has collapsed a 1/3 of his lung. He has no
respiratory compromise.
10. An 18 year old male is shot in the left chest he was unstable but his blood
pressure has improved with 1 litre of colloid. His chest x-ray shows a left sided
pneumothorax with no lung visible.
117
This man requires wide bore intercostal tube drainage. Smaller intercostal
chest drains can become occluded with blood clot and fail to function
adaquetly.
Thoracic trauma
118
Early intubation within an hour if significant hypoxia
References
ATLS Manual 8th Edition
Theme: Management of burns
A. Escharotomy
B. Endotracheal intubation
C. Broad spectrum intravenous antibiotics
D. Intravenous fluids calculated according to extent of burned area
E. Discharge with review in outpatients
F. Transfer to regional burn centre once stabilised
G. Split thickness skin graft
H. Full thickness skin graft
What is the best management for the scenario given? Each option may be used once,
more than once or not at all.
11. A 34 year old women trips over and falls into a bonfire whilst intoxicated at a
party. She suffers burns to her arms, torso and face. These are calculated to be
25% body surface area. She is otherwise stable. The burns to the torso are
superficial, her left forearm has a full thickness burn and the burns to her face
are superficial. There is no airway compromise. She has received 1000ml of
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intravenous Hartman's solution, with a further 1000ml prescribed to run over 4
hours.
This women has been resuscitated and requires transfer for specialist
management
12. A 20 year old man is trapped in a warehouse fire. He has sustained 60% burns
to his torso and limbs. The limb burns are partial thickness but the torso burns
are full thickness. He was intubated by paramedics at the scene and is
receiving intravenous fluids. His ventilation pressure requirements are rising.
Escharotomy
13. An 18 year old man accidentally pours boiling water onto his left arm. The
area is erythematous and has a blister measuring 5cm. The wound is extremely
painful.
This is a superficial burn and should recover with no further input than simple
dressings, an alternative would be deroofing the blister and applying dressings
prior to outpatient review
Burns
Types of burn
120
and subcutaneous hard wound
tissue affected
>15% body surface area burns in adults needs urgent burn fluid resuscitation
Escharotomies
References
www.euroburn.org/e107files/downloads/guidelinesburncare.pdf
121
A. Sick euthyroid syndrome
B. Graves disease
C. Hashimotos thyroiditis
D. Levothyroxine
This patient has sick euthyroid syndrome as all thyroid parameters are reduced.
Graves disease and levothyroxine will cause hyperthyroidism (low TSH and elevated
thyroxine/T3). Hashimotos thyroiditis is associated with hypothyroidism (high TSH
and low thyroxine/T3).
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