MODULE nine short answer questions.
saq 1.
A 40 year old male attends your emergency department after a fight in a bar 15 minutes previously. He is complaining of left jaw pain and a missing front tooth which the ambulance have transported to you under the patient’s tongue. He did not lose consciousness, has a full memory of the event, and there are no other concerns for a closed head injury.
His vital signs are
HR 89 /min
BP 119/78 mmHg
RR 18 /min
Sats 98% RA
T 36.9
Question 1.
An OPG is shown below. What are the two major abnormalities? (2 marks)
His vital signs are
HR 89 /min
BP 119/78 mmHg
RR 18 /min
Sats 98% RA
T 36.9
Question 1.
An OPG is shown below. What are the two major abnormalities? (2 marks)
Must include:
-undisplaced fracture of the left mandibular condyle
-absent/avulsed front left incisor
Question 2.
Give 8 steps will you take in managing the avulsed tooth? (8 marks)
Answer (mandatory steps in bold (1 mark per step)
1.Handle avulsed tooth by crown only/do not touch root
2.Provide appropriate analgesia and or dental block
3.Rinse root of tooth with normal saline
4.Gently irrigate socket with normal saline
5.Reimplant tooth into socket
6.Stabilise with dental mould
7.Administer ADT if required
8.Refer to a dentist urgently for follow up
-undisplaced fracture of the left mandibular condyle
-absent/avulsed front left incisor
Question 2.
Give 8 steps will you take in managing the avulsed tooth? (8 marks)
Answer (mandatory steps in bold (1 mark per step)
1.Handle avulsed tooth by crown only/do not touch root
2.Provide appropriate analgesia and or dental block
3.Rinse root of tooth with normal saline
4.Gently irrigate socket with normal saline
5.Reimplant tooth into socket
6.Stabilise with dental mould
7.Administer ADT if required
8.Refer to a dentist urgently for follow up
saq 2.
A 45 year old construction worker presents to your department after being hit in the left face with a falling brick. He has no loss of consciousness, and no symptoms of closed head injury. He has a swollen painful left eye.
His vital signs are:
HR 99 /min
BP 123/88 mmHg
RR 16 /min
Sats 99% RA
T 37.1 oC
Question 1.
A CT of the patient’s face is shown below. Give 4 major abnormalities? (4 marks)
His vital signs are:
HR 99 /min
BP 123/88 mmHg
RR 16 /min
Sats 99% RA
T 37.1 oC
Question 1.
A CT of the patient’s face is shown below. Give 4 major abnormalities? (4 marks)
Must include
1.Fracture through frontozygomatic suture
2.Fracture through floor of orbit
3.Fracture through lateral wall maxillary sinus
4. Blood in left maxillary sinus
Question 2. (2 marks)
What other fracture is likely to be present but not seen on the above image? What is the name given to this complex of fractures?
Answer: zygomatic arch fracture, as part of a tripod fracture
Question 3. Using the table below give associated injuries will you examine for? (8 marks)
1.Fracture through frontozygomatic suture
2.Fracture through floor of orbit
3.Fracture through lateral wall maxillary sinus
4. Blood in left maxillary sinus
Question 2. (2 marks)
What other fracture is likely to be present but not seen on the above image? What is the name given to this complex of fractures?
Answer: zygomatic arch fracture, as part of a tripod fracture
Question 3. Using the table below give associated injuries will you examine for? (8 marks)
COMPLICATION
1. Hyphaema 2. Globe rupture 3. Entrapped extraoccular muscle 4. Infraorbital nerve injury |
SIGN
1. Blood in the anterior chamber 2. Irregular shape to globe/pupil or enopthalmos 3. Diplopia or pain with gaze to an extremity 4. Parasthesia to upper lip |
saq 3.
A 24 year old man is brought to the emergency department after a high speed MVA. His primary survey does not reveal any evidence of acute airway compromise or chest injury and an e-FAST ultrasound of the chest reveals no pneumothorax.
His vital signs are:
HR 110 /min
BP 93/67 mmHg
RR 24 /min
Sats 99% 6L
T 36.7 oC
GCS 6 (E1 V1 M4)
Question 1. (6 marks)
Using the table below outline 3 important principles of your intubation of this patient and state how you will apply them to this patient.
His vital signs are:
HR 110 /min
BP 93/67 mmHg
RR 24 /min
Sats 99% 6L
T 36.7 oC
GCS 6 (E1 V1 M4)
Question 1. (6 marks)
Using the table below outline 3 important principles of your intubation of this patient and state how you will apply them to this patient.
PRINCIPLE
1. Prevention of secondary neurologic injury 2. Prevention of secondary c-spine injury 3. Optimized intubation/"1st attempt is the best attempt" |
PRACTICE
1. Prevention of hypoxia/hyptension during intubation 2. Manual in line stabilisation during intubation 3. Use of adjuncts (bougie/stylet), experienced operator |
The patient is successfully intubated and transferred to the CT scanner. A clinical image is produced below.
Question 2. (4 marks)
Give 4 major abnormalities?
Question 2. (4 marks)
Give 4 major abnormalities?
Must include:
1. large extradural haematoma R parietal region, crossing into frontal region
2. significant midline shift
3. compression of R lateral ventricle and distortion of the left
4. loss of normal sulci and gyri indicating raised ICP
Question 3. (3 marks)
After you return to resus from CT the patient’s blood pressure increases to 190/130mmHg and the right pupil dilates to 6mm.
State the 3 next steps in your management that you will undertake.
Must include:
-immediate neurosurgical input for decompression
-administration of either 5ml/kg 3% NaCl or 0.5g/kg IV mannitol
Plus any of (for 1 mark)
-ventilate to low normal PaCO2
-head up 30 degrees
-or other reasonable management strategy in this situation.
1. large extradural haematoma R parietal region, crossing into frontal region
2. significant midline shift
3. compression of R lateral ventricle and distortion of the left
4. loss of normal sulci and gyri indicating raised ICP
Question 3. (3 marks)
After you return to resus from CT the patient’s blood pressure increases to 190/130mmHg and the right pupil dilates to 6mm.
State the 3 next steps in your management that you will undertake.
Must include:
-immediate neurosurgical input for decompression
-administration of either 5ml/kg 3% NaCl or 0.5g/kg IV mannitol
Plus any of (for 1 mark)
-ventilate to low normal PaCO2
-head up 30 degrees
-or other reasonable management strategy in this situation.
saq 4.
A 19 year old female is brought to the emergency department at midnight by the ambulance in a c-collar after falling down a set of stairs in a nightclub.
Question 1.
What 4 factors will make you image her neck? (4 marks)
Must include either NEXUS criteria or Canadian rule.
NEXUS
-focal neurologic deficit
-midline spinal tenderness
-altered level of consciousness OR intoxication
-distracting injury
CANADIAN
-dangerous mechanism (fall down >5 stairs)
-neck pain at scene
-neck pain during palpation
-numbness or tingling in extremities
Question 2.
The patient complains of left arm numbness and pain in her mid to lower c-spine on palpation. Will you perform an xray or CT of her c-spine and why? (2 marks)
Must include (1 mark for CT, 1 mark for reasonable explanation):
-CT of the C spine. This patient has two indications for scanning, and thus should have a test of appropriate sensitivity (ie a CT).
Question 3.
An image of the c-spine is shown below. What give 2 major abnormalities and the diagnosis?
Question 1.
What 4 factors will make you image her neck? (4 marks)
Must include either NEXUS criteria or Canadian rule.
NEXUS
-focal neurologic deficit
-midline spinal tenderness
-altered level of consciousness OR intoxication
-distracting injury
CANADIAN
-dangerous mechanism (fall down >5 stairs)
-neck pain at scene
-neck pain during palpation
-numbness or tingling in extremities
Question 2.
The patient complains of left arm numbness and pain in her mid to lower c-spine on palpation. Will you perform an xray or CT of her c-spine and why? (2 marks)
Must include (1 mark for CT, 1 mark for reasonable explanation):
-CT of the C spine. This patient has two indications for scanning, and thus should have a test of appropriate sensitivity (ie a CT).
Question 3.
An image of the c-spine is shown below. What give 2 major abnormalities and the diagnosis?
Must include (1 mark each):
>50% anterior displacement of C6 on C7
anteriorly displaced fracture of the body of C7
This is a diagnosis of bilateral facet joint dislocation (2 marks)
>50% anterior displacement of C6 on C7
anteriorly displaced fracture of the body of C7
This is a diagnosis of bilateral facet joint dislocation (2 marks)
saq 5. (follows into saq 6)
A 30 year old man is brought to the emergency department with neck pain after a sporting injury. He had been fielding at silly point whilst playing cricket, and has been struck in the anterior neck over the adam’s apple by a cricket bat.
Question 1.
What will you assess for with regards to a laryngeal fracture? (5 marks)
Must include:
- stridor
-voice changes/hoarseness
-pain with laryngeal palpation
-bruising/swelling/loss of laryngeal landmarks
-crepitus/surgical emphysema over larynx
Question 2.
The patient has clinical evidence of a laryngeal fracture and a decision is made to intubate. Describe your procedure for a surgical airway in the event of not being able to intubate or oxygenate the patient.
Must include:
1.Landmark is cricothyroid membrane.
2.Scalpel used to divide skin and puncture membrane
3.Insertion of mosquito forceps or finger into opening
4.Insertion of bougie
5.Size 6.0 ETT placed over bougie into trachea and secured
6.confirmation of ventilation with capnography
Question 1.
What will you assess for with regards to a laryngeal fracture? (5 marks)
Must include:
- stridor
-voice changes/hoarseness
-pain with laryngeal palpation
-bruising/swelling/loss of laryngeal landmarks
-crepitus/surgical emphysema over larynx
Question 2.
The patient has clinical evidence of a laryngeal fracture and a decision is made to intubate. Describe your procedure for a surgical airway in the event of not being able to intubate or oxygenate the patient.
Must include:
1.Landmark is cricothyroid membrane.
2.Scalpel used to divide skin and puncture membrane
3.Insertion of mosquito forceps or finger into opening
4.Insertion of bougie
5.Size 6.0 ETT placed over bougie into trachea and secured
6.confirmation of ventilation with capnography
SAQ 6. (Follows on from saq 5.)
You successfully achieve a surgical airway. Once the tube is placed and confirmed by waveform capnography you notice that there is an abundance of pink frothy sputum accumulating near the filter.
An arterial gas taken immediately is shown below.
FiO2 60%
pH 7.21
pCO2 69 mmHg
pO2 110 mmHg
HCO3- 27 mmol/L
Na+ 140 mmol/L
K+ 4.5 mmol/L
Cl- 110 mmol/L
Question 1. (2 marks)
Give two acid base disturbances present.
1. Respiratory acidosis
2. Metabolic compensation/alkalosis
Question 2. (2 marks)
What is the likely diagnosis? Perform a calculation to support your answer.
This patient likely has negative pressure pulmonary oedema after his obstructed airway above.
His AA gradient is 450 - 1.25x69 - 110 = 450 - 86 - 110 = 254, which confirms a V/Q mismatch.
Question 3.
A chest xray is taken and shown below.
Give 2 major findings on the chest X-ray and relate it to your diagnosis above.
An arterial gas taken immediately is shown below.
FiO2 60%
pH 7.21
pCO2 69 mmHg
pO2 110 mmHg
HCO3- 27 mmol/L
Na+ 140 mmol/L
K+ 4.5 mmol/L
Cl- 110 mmol/L
Question 1. (2 marks)
Give two acid base disturbances present.
1. Respiratory acidosis
2. Metabolic compensation/alkalosis
Question 2. (2 marks)
What is the likely diagnosis? Perform a calculation to support your answer.
This patient likely has negative pressure pulmonary oedema after his obstructed airway above.
His AA gradient is 450 - 1.25x69 - 110 = 450 - 86 - 110 = 254, which confirms a V/Q mismatch.
Question 3.
A chest xray is taken and shown below.
Give 2 major findings on the chest X-ray and relate it to your diagnosis above.
Must include:
These are also consistent with negative pressure pulmonary oedema.
Question 4. (5 marks)
Give 5 strategies will you now institute to address this problem.
Read more about negative pressure APO here.
- tube in trachea
- bilateral fluffy infiltrates extending out from both hila
These are also consistent with negative pressure pulmonary oedema.
Question 4. (5 marks)
Give 5 strategies will you now institute to address this problem.
- Increase FiO2 to keep SpO2 >94%
- Increase PEEP
- Position 30 degrees head up/Trendelenburg
- Aspirate/suction tube
- Consider preload reduction with GTN if adequate BP (e.g. SBP >100mmHg)
Read more about negative pressure APO here.