MODULE ten short answer questions.
saq 1.
A 32 year old male presents with the ambulance service after falling off a dirt bike. His vital signs on arrival are:
HR 112 /min
BP 105/67 mmHg
RR 30 /min
Sats 93% 2L O2
T 36.5 oC
A supine film from the trauma bay is shown below.
Question 1. (4 marks)
Give 2 positive findings and 2 negative findings from the chest X-ray.
HR 112 /min
BP 105/67 mmHg
RR 30 /min
Sats 93% 2L O2
T 36.5 oC
A supine film from the trauma bay is shown below.
Question 1. (4 marks)
Give 2 positive findings and 2 negative findings from the chest X-ray.
Must include:
Positive (1 mark each)
1.Fractures of left 3rd and 6th (must specify both) ribs laterally
2.Large left sided pulmonary contusion
Negatives:
Any 2 from (for 1 mark each)
-no surgical emphysema
-no deep sulcus sign
-no obvious pneumo/haemothorax
-no right sided injuries
-no spinal column injuries
Question 2. (6 marks)
Describe 3 modality options for managing this patient’s pain.
Must include:
1.Parenteral opiates: morphine 0.1mg/kg titrated to pain
2.Patient Controlled analgesia: morphine/fentanyl in consult with anaesthetics or pain management
3.Intercostal nerve block: 5ml 1% lignocaine to the level of the fracture and ribs above and below
or other reasonable options (post these up in the VSG for discussion)
Question 3. (4 marks)
An arterial blood gas is performed on the patient.
i) Give 2 acid base disorders present. (2 marks)
ii) Perform a calculation to describe the patient's respiratory function (2 marks)
FiO2 .40
pH 7.22
pCO2 58 mmHg
PO2 99 mmHg
HCO3- 19 mmol/L
Na+ 140 mmol/L
K+ 5.5 mmol/L
Cl- 104 mmol/L
Must include:
i) primary respiratory acidosis and RAGMA
ii) grossly elevated Aa gradient (300 - 1.25x58 - 99 = 300 - 72 - 99 = 300 - 171 = 129mmHg.) Grossly raised and implies V/Q mismatch from pulmonary contusions
Question 4. (4 marks)
On full work up it appears the chest injuries seen above are the only major ones sustained. What are the implications of the patient’s injuries, and where will you refer the patient?
Must include (themes)
-rib fractures: may impair respiration, predispose towards ventilatory failure
-pulmonary contusion: will progress over next 12 hrs and pt already has an oxygen requirement/VQ mismatch.
Therefore the patient should be referred to a closely monitored environment such as HDU or ICU in case escalation of respiratory support is required.
Positive (1 mark each)
1.Fractures of left 3rd and 6th (must specify both) ribs laterally
2.Large left sided pulmonary contusion
Negatives:
Any 2 from (for 1 mark each)
-no surgical emphysema
-no deep sulcus sign
-no obvious pneumo/haemothorax
-no right sided injuries
-no spinal column injuries
Question 2. (6 marks)
Describe 3 modality options for managing this patient’s pain.
Must include:
1.Parenteral opiates: morphine 0.1mg/kg titrated to pain
2.Patient Controlled analgesia: morphine/fentanyl in consult with anaesthetics or pain management
3.Intercostal nerve block: 5ml 1% lignocaine to the level of the fracture and ribs above and below
or other reasonable options (post these up in the VSG for discussion)
Question 3. (4 marks)
An arterial blood gas is performed on the patient.
i) Give 2 acid base disorders present. (2 marks)
ii) Perform a calculation to describe the patient's respiratory function (2 marks)
FiO2 .40
pH 7.22
pCO2 58 mmHg
PO2 99 mmHg
HCO3- 19 mmol/L
Na+ 140 mmol/L
K+ 5.5 mmol/L
Cl- 104 mmol/L
Must include:
i) primary respiratory acidosis and RAGMA
ii) grossly elevated Aa gradient (300 - 1.25x58 - 99 = 300 - 72 - 99 = 300 - 171 = 129mmHg.) Grossly raised and implies V/Q mismatch from pulmonary contusions
Question 4. (4 marks)
On full work up it appears the chest injuries seen above are the only major ones sustained. What are the implications of the patient’s injuries, and where will you refer the patient?
Must include (themes)
-rib fractures: may impair respiration, predispose towards ventilatory failure
-pulmonary contusion: will progress over next 12 hrs and pt already has an oxygen requirement/VQ mismatch.
Therefore the patient should be referred to a closely monitored environment such as HDU or ICU in case escalation of respiratory support is required.
saq 2.
A 28 year old male presents to your department after being run over by a motorcycle whilst participating in motocross. The motorcycle ran directly over the patient’s abdomen, and he has tyre marks and a large bruise in the left hypochondrium.
The patient’s initial vital signs are:
HR 105 /min
BP 104/68 mmHg
RR 19 /min
Sats 99% RA
T 36.8 oC
Question 1. (3 marks)
The junior surgical registrar who has attended your trauma call asks you to perform a FAST scan “to exclude abdominal injury”. What is the role of FAST scanning in this patient?
Answer must include (1 mark each themes)
-FAST is a specific test, not a sensitive one.
-It is used for compartment triage in haemodynamically unstable patients (ie to prioritize laparotomy without CT scan)
-This patient is stable, and therefore a FAST scan will not alter the need for a CT scan, or give additional information to this.
Question 2.
A CT scan of the patient’s abdomen is shown below. What abnormalities does it show? (3 marks)
The patient’s initial vital signs are:
HR 105 /min
BP 104/68 mmHg
RR 19 /min
Sats 99% RA
T 36.8 oC
Question 1. (3 marks)
The junior surgical registrar who has attended your trauma call asks you to perform a FAST scan “to exclude abdominal injury”. What is the role of FAST scanning in this patient?
Answer must include (1 mark each themes)
-FAST is a specific test, not a sensitive one.
-It is used for compartment triage in haemodynamically unstable patients (ie to prioritize laparotomy without CT scan)
-This patient is stable, and therefore a FAST scan will not alter the need for a CT scan, or give additional information to this.
Question 2.
A CT scan of the patient’s abdomen is shown below. What abnormalities does it show? (3 marks)
Must include:
- avulsion of the spleen at the hilum
- loss of contrast in the distal splenic artery
- perisplenic haematoma
Question 3. (4 marks)
The patient’s blood pressure drops on return from CT to 65/-, and the HR increases to 120/min. The patient has already had 2 units of packed red cells in the CT scanning room. There are no other injuries discovered on the CT scan.
What treatments will you administer to this patient in view of this problem?
Must include:
-Packed red cells FFP and platelets as massive transfusion 1:1:1
-Cyroprecipitate
Adjuncts:
-Tranexamic acid 1g
-Calcium to ensure N ionised serum Ca++
Question 4. (3 marks)
Give 3 haemodynamic endpoints for these treatments.
SBP approx 90
HR ~100/min
cap refill 2 secs
- avulsion of the spleen at the hilum
- loss of contrast in the distal splenic artery
- perisplenic haematoma
Question 3. (4 marks)
The patient’s blood pressure drops on return from CT to 65/-, and the HR increases to 120/min. The patient has already had 2 units of packed red cells in the CT scanning room. There are no other injuries discovered on the CT scan.
What treatments will you administer to this patient in view of this problem?
Must include:
-Packed red cells FFP and platelets as massive transfusion 1:1:1
-Cyroprecipitate
Adjuncts:
-Tranexamic acid 1g
-Calcium to ensure N ionised serum Ca++
Question 4. (3 marks)
Give 3 haemodynamic endpoints for these treatments.
SBP approx 90
HR ~100/min
cap refill 2 secs
saq 3.
A 50 year old woman presents after a domestic altercation. Her partner has stabbed her in the left side of the neck with a kitchen knife.
Question 1. (6 marks)
What are the anatomic boundaries of the zones of the neck?
Must include:
Zone 1: clavicle/suprasternal notch to cricoid cartilage.
Zone 2: Cricoid cartilage to angle of mandible.
Zone 3: Angle of mandible to the base of the skull.
Question 2. (2 marks)
The stab wound is anterior to the left sternocleidomastoid muscle and above the cricoid cartilage. What are the 2 major vascular structures at risk here?
Must include carotid artery and internal jugular vein (this is zone 2 of the neck).
Question 3.
Give 4 features on examination would indicate injury to one of these two structures. (4 marks)
Must include:
-active haemorrhage
Plus any from:
-systemic hypotension
-thrill
-bruit
-pulse deficit
-contralateral hemiparesis
-large haematoma/neck swelling
-tracheal deviation away from side stabbed
Question 4. (4 marks)
What are the underlying principles of the “no zone” approach to neck trauma?
Must include (themes, 1 mark each)
-poor correlation between external site of injury and structures injured
-CT angiography of the neck gives clear delineation of injuries in stable patients
-unstable patients must go to OT irrespective of where the injury is.
-the above therefore make algorithms based on the anatomic zone of the neck irrelevant.
Question 1. (6 marks)
What are the anatomic boundaries of the zones of the neck?
Must include:
Zone 1: clavicle/suprasternal notch to cricoid cartilage.
Zone 2: Cricoid cartilage to angle of mandible.
Zone 3: Angle of mandible to the base of the skull.
Question 2. (2 marks)
The stab wound is anterior to the left sternocleidomastoid muscle and above the cricoid cartilage. What are the 2 major vascular structures at risk here?
Must include carotid artery and internal jugular vein (this is zone 2 of the neck).
Question 3.
Give 4 features on examination would indicate injury to one of these two structures. (4 marks)
Must include:
-active haemorrhage
Plus any from:
-systemic hypotension
-thrill
-bruit
-pulse deficit
-contralateral hemiparesis
-large haematoma/neck swelling
-tracheal deviation away from side stabbed
Question 4. (4 marks)
What are the underlying principles of the “no zone” approach to neck trauma?
Must include (themes, 1 mark each)
-poor correlation between external site of injury and structures injured
-CT angiography of the neck gives clear delineation of injuries in stable patients
-unstable patients must go to OT irrespective of where the injury is.
-the above therefore make algorithms based on the anatomic zone of the neck irrelevant.
saq 4.
A 38 year old male construction worker presents to the emergency department after an industrial accident. He was hit in the abdomen by a large iron girder swinging from a chain on a crane.
His vital signs on arrival are:
HR 114 /min
BP 88/45 mmHg
RR 28 /min
Sats 99% RA
T 34.2 oC
Question 1. (4 Marks)
Your resus team is unable to site a line in the patient’s cubital fossae or other sites in the arms. Where and by what method will you establish your vascular access? Justify your choice.
Must include:
1.Any site above diaphragm so as to feed into SVC circulation. In the event of an IVC distribution injury, any venous return will not reach the right atrium (2 marks).
2.Therefore site a humeral head intraosseous line (2 marks)
Question 2. (2 marks)
The patient receives 2 units of packed cells and the blood pressure improves to 95/55 and the HR decreases to 105/min. Your registrar performs a bedside ultrasound and a picture is shown below. What does it show, and what are the implications?
His vital signs on arrival are:
HR 114 /min
BP 88/45 mmHg
RR 28 /min
Sats 99% RA
T 34.2 oC
Question 1. (4 Marks)
Your resus team is unable to site a line in the patient’s cubital fossae or other sites in the arms. Where and by what method will you establish your vascular access? Justify your choice.
Must include:
1.Any site above diaphragm so as to feed into SVC circulation. In the event of an IVC distribution injury, any venous return will not reach the right atrium (2 marks).
2.Therefore site a humeral head intraosseous line (2 marks)
Question 2. (2 marks)
The patient receives 2 units of packed cells and the blood pressure improves to 95/55 and the HR decreases to 105/min. Your registrar performs a bedside ultrasound and a picture is shown below. What does it show, and what are the implications?
Must include:
-free fluid laterally to the bladder
- implies significant intra-abdominal bleeding
Question 3.
Will you perform a CT scan of the patient? Justify your choice. (2 marks)
Must include:
-yes, this patient is stable post resuscitation
-a CT scan will deliver valuable information to assist in surgical control of the injury
Question 4. (4 marks)
A CT scan of the patient’s abdomen is shown below. Give 2 important positive findings and 2 important negative findings?
-free fluid laterally to the bladder
- implies significant intra-abdominal bleeding
Question 3.
Will you perform a CT scan of the patient? Justify your choice. (2 marks)
Must include:
-yes, this patient is stable post resuscitation
-a CT scan will deliver valuable information to assist in surgical control of the injury
Question 4. (4 marks)
A CT scan of the patient’s abdomen is shown below. Give 2 important positive findings and 2 important negative findings?
Positives
-laceration/rupture of the spleen
-large volume of free fluid in abdomen
Negatives (any two of the following)
-normally enhancing liver
-no intra-abdominal air to suggest perforation
-no fractures seen
-normally enhancing vessels
or other reasonable comment.
-laceration/rupture of the spleen
-large volume of free fluid in abdomen
Negatives (any two of the following)
-normally enhancing liver
-no intra-abdominal air to suggest perforation
-no fractures seen
-normally enhancing vessels
or other reasonable comment.
saq 5.
A 77 year old woman with a prior history of a dense left CVA presents to your department with chest pain after a fall.
Her vital signs are:
HR 105 /min
BP 110/60 mmHg
RR 22 /min
Sats 94% RA
T 36.7 oC
A chest xray is ordered from triage is reproduced below.
Question 1. (5 marks)
Give 5 abnormalities seen on the X-ray.
Her vital signs are:
HR 105 /min
BP 110/60 mmHg
RR 22 /min
Sats 94% RA
T 36.7 oC
A chest xray is ordered from triage is reproduced below.
Question 1. (5 marks)
Give 5 abnormalities seen on the X-ray.
Must include (1st three findings are mandatory to pass Q):
1. Fractures of ribs 5 and 6 posteriorly
2. large pneumothorax on left: discontinuous with diaphragm
3. Fluid level/haemothorax on right
4. Healed fracture of the left neck of humerus
5. Decorticate posture L hand consistent with prior CVA
Question 2. (3 marks)
In the event of this patient becoming unstable give three problems with needle decompression of the left hemithorax.
Must include:
1. Failure to penetrate pleural cavity
2. Kinking of catheter means decompression unreliable
3. Not definitive treatment for this injury
Question 3. (2 marks)
Give 2 indications for surgical management in this patient once a large gauge chest drain is placed?
Must include:
1. >1500mls of blood out chest tube
2. >200mls/hr of blood out tube for 2 hrs
1. Fractures of ribs 5 and 6 posteriorly
2. large pneumothorax on left: discontinuous with diaphragm
3. Fluid level/haemothorax on right
4. Healed fracture of the left neck of humerus
5. Decorticate posture L hand consistent with prior CVA
Question 2. (3 marks)
In the event of this patient becoming unstable give three problems with needle decompression of the left hemithorax.
Must include:
1. Failure to penetrate pleural cavity
2. Kinking of catheter means decompression unreliable
3. Not definitive treatment for this injury
Question 3. (2 marks)
Give 2 indications for surgical management in this patient once a large gauge chest drain is placed?
Must include:
1. >1500mls of blood out chest tube
2. >200mls/hr of blood out tube for 2 hrs