Trauma

Question 1

A 25-year-old man is blue-lighted into the emergency department following an
accident at work. A pan of hot cooking oil had spilled over half of his back, and
over both his legs and he has sustained extensive burns in this distribution. He
weighs 70 kg. Calculate the additional volume of fluid this patient will require in
the first 4 hours (from the time of his burn) of his treatment using the Mount
Vernon Formula and the Wallace Rule of Nines:
A. 250mL
B. 1575 mL
C. 2370 mL
D. 3580 mL
E. None, only patients with a percentage burn more than 15 per cent
require admission

Answer 1

C. 2370 mL

The mount vernon formula is used to calculate the required volume of fluid resuscitation: (Weight (kg) x % Burn)/2 = Volume X (mL of colloid)

The percentage burn can be calculated using the Wallace rule of nines:

• Head = 9 per cent
• Arm = 9 per cent
• Leg = 18 per cent
• Trunk front = 18 per cent
• Back = 18 per cent

With half the back (9%) and both legs (2x18%) this patient has a 45% burn

Substituting into the mount venon formula gives (70x45)/2 = 1575ml, answer (B)

This anount is given over 4hrs and ten repeted over two more 4 hour periods, then over 2 six hour periods, and then over 12 hours. Meaning that the patient recieves 6 regimes of 1575ml of fluid.

Question 2

A patient is admitted following a motorcycle accident. He has fractured his left
femur, tibia, fibula and pelvis. His blood pressure is 70/35 mmHg, pulse is 140
beats/min, respiratory rate is 35 breaths/min and the Glasgow Coma Scale score is 9/15. You wish to resuscitate the patient. Which one of the following procedures may be contraindicated in such a patient?

A. Motorcycle helmet removal
B. Urinary catheterization
C. Neck line insertion
D. Nasogastric tube insertion
E. Intubation

Answer 2

B. Urinary catheterization

This patient appears to be suffering from class III shock, he needs circulatory support which should include a central line.

His low GCS makes intubation a possibility, to do which his helmet needs to be removed in a controlled fashion in the ED with full C-spine support.

Gastric distention is common in traumatised patients which puts them at a risk of aspiration, as such NG insertion is warrented.

Urinary catheterization is desirable in cases of shock to monitor urine output, however a fractured pelvis is a scenario which makes urethral disruption more likely so it may be contraindicated. The following are scenarios where urethral disruption should be suspected;

• blood at the penile meatus
• perineal bruising
• blood in the scrotum
• high-riding prostate
• pelvic fracture.

The integrity of the urethra needs to be established with a retrograde urethrogram before any attempt to catheterize. Any damage to the urethra indicates the need for supra-pubic catheterization.

Question 3

Initial primary survey of the chest commonly identifies the following causes of
cardiorespiratory compromise, except:

A. Flail chest
B. Cardiac tamponade
C. Tension pneumothorax
D. Haemothorax
E. Pulmonary contusion

Answer 3

E. Pulmonary contusion

The life threatening chest pathologies that a primary survey is desinged to detect include:

Airway obstruction

Tension pneumothorax,

Open pneumothorax,

Massive haemothorax

Flail chest,

Cardiac tamponade

Remember the mnenomic ATOM FC

Pulmonary contusion is not an immediate life threatening condition and so is not going to be picked up on a primary survey. It may go on to complicate recovery as the injured lung tissue can impair gas exchange and become fluid overloaded.

Question 4

A patient is admitted following an assault. On assessment, he has a stab wound to his chest. Clinically, he has a massive haemothorax and his Glasgow Coma Scale score is 4/15. Without further management this patient will succumb to which cause of death first:

A. Haemorrhagic shock
B. Respiratory failure
C. Airway compromise
D. Intracranial haemorrhage
E. Multiorgan failure

Answer 4

C. Airway compromise

As with all things ATLS its alphabetical prioritisation, A comes first. THis patient is GCS4 so can’t maintain his own airway so that will be the first factor in his demise if untreated.

Question 5

As well as measuring oxygen saturation, a pulse oximeter also gives useful
information regarding what other factor, used in initial assessment of the
traumatized patient?

A. Blood pressure
B. Partial pressure of oxygen
C. Partial pressure of carbon dioxide
D. Peripheral perfusion
E. Acid–base balance

Answer 5

D. Peripheral perfusion

There are several factors that affect the accuracy of pulse oximetry, such as methaemogloinaemia, nair varnish, and a BP cuff on the same arm. Poor peripheral perfusion is another factor which will reduce the reading gained on pulse oximetry. If the there is a low pulse oximetry compared to arterial blood gas sampling then you have an indication that this patient is shut down.

The other answers to this question are not possible to obtain from a pulse oximeter.

Question 6

Which of the following techniques does not provide a definitive airway?

A. Cricothyroidotomy
B. Tracheostomy
C. Nasotracheal tube
D. Laryngeal mask airway
E. Endotracheal tube

Answer 6

D. Laryngeal mask airway

A definitive airway is defined as one which places a cuffed tube within the trachea, and so protects against aspiration.

These are either nasotracheal, orotracheal or a surgical approach

Conversely a LMA (D0 doesn’t actually enter the trachea and so doesn’t provide any protection from aspiration, it is not a definite airway.

Question 7

A patient is admitted following a road traffic accident. He has sustained significant blunt injury to his head, chest and abdomen and has a Glasgow Coma Scale score of 8/15. His saturations are poor at 89 per cent on 15 L of oxygen via a rebreathing mask. You note bruising around both eyes and blood-stained fluid issuing from his left ear, which forms concentric circles when dripped on a white sheet. You wish to support his airway to improve oxygenation. The best choice of airway adjunct would be:

A. Oropharyngeal airway
B. Nasopharyngeal tube
C. Laryngeal mask
D. Intubation
E. Positive pressure ventilation (continuous positive airway pressure)

Answer 7

D. Intubation

This patient has suffered a significant head injury, he has signs of a basal skull fracture with periorbital ecchymosis (panda eyes), and CSF leakage from the ear. The CSF is confirmed by forming rings when dropped, unlike pure blood which would not.

Other possible indication of a basal skull fracture would be Battle’s sign (retroauricular ecchymosis) and Cranial nerve VII/VIII dysfunction.

With the prescence of a likely basal skull fracture you should not be putting anything up the nose, so no nasopharyngeal tube or NG tube.

THis leaves the first airway adjunct as a oropharengeal (Guedel), but intubation would follow. As such it’s hard to say what the question wants for the ‘best choice’, OP is definietly the immediate management but intubation is definitive.

Question 8

A 35-year-old man is admitted after severing his arm on industrial machinery. His
airway is patent and there is no identifiable hindrance to breathing. His pulse is
110 beats/min, blood pressure is 130/105 mmHg, and respiratory rate is 25
breaths/min. In which stage of shock therefore is this patient?
A. Class I
B. Class II
C. Class III
D. Class IV
E. Impossible to say from given information

Answer 8

B. Class II

ATLS divides shock into 4 classes based on vital signs and each class has an associated estimated blood loss. The attached image shows the table but the salient points for remembering;

The %blood loss is like a tennis score; <15, <30, <40, ‘game’ (>40)

The heart rate is the easiest parameter to remember; <100, >100, >120, >140

In class I shock the only deranged parementer may be the respiratory rate, or in a youg person there may be no abnormalities to be found.

Question 9

A 35-year-old butcher is admitted after stabbing himself with a knife
inadvertently. His airway is patent and there are no identifiable hindrances to
breathing. His pulse is 110 beats/min, BP 130/105 mmHg, and respiratory rate is
25 breaths/min. Assuming a body mass of 70 kg, what is the best estimated volume of blood lost?
A. 400 mL
B. 1000 mL
C. 1800 mL
D. 2500 mL
E. Impossible to say from given information

Answer 9

B. 1000 mL

Circulating volume acounts for around 7% of body mass, so a our ‘average’ 70kg adult has a circulating volume of around 5L. This is less reliable in children whos circulating volume accounts for 8-9% and the obese who you should use the ideal body weight.

Once again we have to use the ATLS guide to shock (attached picture) which given this set of observations the patient is in Class II shock. That gives an estimate of 15-30% blood loss, or 750-1500ml in this patient. Therefore answer (B)

Question 10

A patient is admitted in haemorrhagic shock following a road traffic accident. A
final year medical student places an intravenous cannula; they have inserted a
pink (20 G) cannula in the antecubital fossa. What volume flow into the patient
will this allow?
A. 250 mL/min
B. 170 mL/min
C. 55 mL/min
D. 25 mL/min
E. 10 mL/min

Answer 10

C. 55 mL/min

Poiseuille’s law tells us that flow through a lumen is a function of the length of the tube, the diameter of the tube and the viscosity of the liquid. Flow is actually a drop in pressure along a tube, so increasing the starting pressure will also increase the amount of volume delivered.

As such the most efficient delivery of fluid is through a short fat lumen, like an intraosseus device, or a large bore cannula. The different gauge of cannula can deliver these amounts;

• Brown/orange (14 G) cannula – may deliver 250 mL/min
• Grey (16 G) cannula – 170 mL/min
• Green (18 G) cannula – 90 mL/min
• Pink (20 G) cannula – 55 mL/min
• Blue (22 G) cannula – 25 mL/min.

Question 11

A patient is admitted to the emergency department following an assault. You note a penetrating wound on the anterior chest wall. On examination, his blood
pressure is 80/65 mmHg, pulse is thready and respiratory rate is 38 breaths/min. His jugular venous pulse is unrecognizable as the neck veins are grossly distended. Breath sounds are equal bilaterally. During your evaluation the patient’s output becomes undetectable. The next course of action should be:
A. Thoracocentesis
B. Plain chest radiograph
C. Pericardiocentesis
D. Resuscitative thoracotomy
E. Echocardiogram

Answer 11

C. Pericardiocentesis

Beck’s triad consists of elevated venous pressure (as seen in the JVP), Reduced arterial blood pressure, and muffled heart sounds. This is the triad of cardiac tamponade, and must be delt with urgently. Unfortunately if a patient presents in cardiac arrest due to tamponade these signs are no longer present!

Other signs of tamponade include pulsus paradoxus (a fall in arterial BP of >10mmHg on inspiration) and Kussmaul’s sign (Rising venous pressure on inspiration).

Having established the likely diagnosis of a cardiac tamponade there are two diagnostic options here the Echo (E) and pericardiocentesis (C), given how unwell this patient is and the prescence of trauma the best option is pericardiocentisis. Thoracotomy (D) may be indicated but it is a procedure that requires more preperation and is ususally reserved for when pericardiocentisis fails, either way the pericardiocentisis will buy time for this very unwell patient.

Question 12

A 42-year-old construction worker is admitted following a crush injury. The
patient is in great distress and complaining of chest pain. Arterial blood gases
show hypoxia with pO2 7.5 and pCO2 8.2. A chest radiograph shows multiple rib
fractures. The life-saving intervention is:
A. High-flow oxygen
B. Cricothyroidotomy
C. Endotracheal tube insertion
D. Aggressive fluid resuscitation
E. Adequate analgesia to allow effective respiration

Answer 12

C. Endotracheal tube insertion

This patient has a flail chest, defined as two or more fractures across two or more ribs.In this stuation there is a section of rib cage that is not continous with the chest and so it moves paradoxically. This causes damage to the lung parenchyma and issues with gas exchange, the pain also limits breathing.

Analgesia (E) will help the breathing effort but it isn’t the pain that will kill the patient. Fluid resuscitation is tricky as too much resuscitation will fluid overload the lung (D). High flow oxygen (A) is a temporary fix, and will not help the rising CO2.

This patient needs mechanical ventilation and so needs intubating (C), the cricothyroidotomy (B) is reserved for when you can’t intubate and can’t ventilate.

Question 13

A male patient is admitted following a fall from height. On arrival his Glasgow
Coma Scale score is 5/15 and he is therefore intubated. During primary
resuscitation a chest film is taken which shows a widened mediastinum and rightsided deviation of the trachea. The diagnosis is:
A. Tension pneumothorax
B. Ruptured oesophagus
C. Cardiac tamponade
D. Right lobe collapse
E. Aortic rupture

Answer 13

E. Aortic rupture

Aortic rupture is a common cause of sudden death following an acceleration-deceleration injury such as a fall from height or RTC. The rapid movement of the mediastnum causes damage to the aorta at it’s point of anchoring, the ligamentum arteriosum, leading to rupture or dissection.

This is a condition with a high likelihood of death, features on the radiograph include;

• widening of the mediastinum
• loss of the aortic knuckle
• deviation of the trachea to the right
• obliteration of the space between the aorta and pulmonary artery
(the AP window)
• depression of the left main bronchus
• left-sided haemothorax.

In 1-2% of cases there are no signs on a plain radiograph

Question 14

A 27-year-old man was resuscitated in the emergency department and required the insertion of a chest drain. The drain was removed 2 days later before he was discharged. He re-presents 10 days later complaining of chest pain associated with high fever and sweats. An empyema is suspected and a chest radiograph confirms a collection. The most appropriate next course of action is:
A. Intravenous antibiotics for 6 weeks
B. Needle tap and aspiration
C. Chest drain reinsertion
D. Computed tomography scan of the thorax
E. Ultrasound scan

Answer 14

E. Ultrasound scan

An Empyema typically occurs 10 days after a chest drain insertion , it is common and potentially fatal. There is little reason to advocate a conservative approach and the collection needs to be surgically drained, a needle aspiration will not be effective at dislodging the thick loculated collection.

Definitive management is by the insertion of another chest drain but this needs to be guided by imaging, ultrasound being preferable to CT due to speed and saftey.

Question 15

Which one of the following statements regarding diagnostic peritoneal lavage is not true?
A. A positive test would follow injury to spleen, liver, pancreas or intestine
B. It is more sensitive than computed tomography and focused assessment
with sonography for trauma (FAST) scanning
C. It is the technique of choice when attempting to confirm hollow viscus
injury
D. Urinary catheterization and nasogastric tube insertion is required prior
to diagnostic peritoneal lavage
E. Diagnostic peritoneal lavage is contraindicated in the presence of an
indication for explorative laparotomy

Answer 15

D. Urinary catheterization and nasogastric tube insertion is required prior
to diagnostic peritoneal lavage

Diagnostic peritoneal lavage (DPL) is a very sensitive, 98%, diagnostic technique for hollow organ rupture. It is more sensitive than CT and FAST.

DPL involves a catheter into the peritoneum and irrigating with a litre of Hartmann’s solution and then draining and the fluid examined for blood, food fibre, and gram stained.

Due to the insertion of a catheter into the peritoneum the bladder and stomach should be deflated with a catheter and NG tube.

A DPL, however, is unable to diagnose injury to retroperitoneal structures, such as the pancreas (A)

Question 16

Which of the following is not an independent indication for laparotomy following
trauma?
A. Evisceration of healthy bowel
B. Evisceration of omentum
C. Stab wound to anterior abdomen
D. Gunshot to abdomen
E. Blunt abdominal trauma with free intraperitoneal air on erect chest
radiograph

Answer 16

C. Stab wound to anterior abdomen

Studies show that 33% of anterior abdominal stab wounds penetrate the peritoneum, and only 30% cause damage to the viscera.

ATLS doesn’t advocate exploratory laporotomy in all such cases. If the patient is haemodynamically stable with no peritonism may be managed conservatively with regular observations and serial examinations. If there is doubt exploration of the wound under anaestesia or a DPL or diagnostic laparoscopy.

Any eviseration of bowel or omentum is an automatic indication for laporotomy, as is a gunshot due to the much higher energy, and any evidence of perforation.

Question 17

A 35-year-old man was involved in a motor vehicle collision, where he was
thrown against the steering column. He sustained a blunt traumatic injury to his
left upper abdomen. On arrival at the emergency department he complains of
abdominal pain but is haemodynamically stable. Computed tomography (CT)
scanning shows a splenic tear and retained intra-abdominal haematoma. The tear extends through the splenic capsule but not to the hilum. Which one of the
following treatment options is not indicated in this case?
A. Cross-match, group and save
B. Pneumovax
C. Explorative laparotomy
D. Serial CT scanning
E. 24-hour monitoring in the high-dependency/intensive care setting

Answer 17

C. Explorative laparotomy

In this patient we are aiming for a conservative approach to this splenic injury (we can see that here with the correct answers all being conservative measures).

It is important to know that the spleen is the most common organ injured as a result of blunt abdominal trauma. If there is a requirement for splenectomy there are significant compliations such as; sepsis, pneumonia and meningitis. As such any injury for the spleen is in an indication for vaccines againsy pnumococcus (B) and meningitis.

It therefore stands to reason that in modern surgical care every effort is made to save the spleen, haemodynamically stable patients will be investigated with ultrasound and CT. Splenic injury, as a result of imaging, is then graded 1-4 depnding on the extent of the tear in relation to the hilum. Only grade 4 injuries (the tear extends all the way to the hilum) should be considered for an explorative laparotomy.

In the other patients every effort should be made to prepare for the worst case scenario (A) and they should be closely monitored (E) and they should be regularly imaged (D).

It should be noted that in 5% of presumed single solid organ there is a coexisting hollow organ injury. Any signs of peritonism or deterioration in this patient will warrant an exploratory laparotomy (C), but that is not the case here.

Question 18

The following factors detract from the diagnostic sensitivity of FAST scanning,
except:
A. Surgical empysema
B. Patient with high body mass index
C. Operator inexperience
D. Previous surgery
E. Large-volume intraperitoneal blood loss

Answer 18

E. Large-volume intraperitoneal blood loss

FAST is non-invasive and quick, as such is preffered to diagnostic peritoneal lavage, despite it’s lesser sensitivity except in the most skilled hands.

It looks at 4 views:

• the pericardium
• hepatorenal fossa
• splenorenal fossa
• pouch of Douglas.

Air defeats ultrasound, so any subcutaneous free air (A) makes it impossible

The greater depth of penetration required in an obese patient (B) makes it more difficult to get the views

All ultrasound scans are operator dependent (C)

and previous surgery (D) distorts the normal anatomy, and adhesions may prevent free fluid appearing where expected.

FAST is a screening test for free fluid in the abdomen, so option (E) would be more obvious on a FAST scan.

Question 19

A patient is admitted to the emergency department with a reduced level of
consciousness, smelling of alcohol. A boggy haematoma is noted on the posterior aspect of his skull. The patient’s eyes open to voice but he makes no attempt to vocalize. A sternal rub causes the patient to open his eyes, moan and extend his arms and legs. His Glasgow Coma Scale score is:
A. 4/15
B. 5/15
C. 6/15
D. 7/15
E. 8/15

Answer 19

D. 7/15

This is made up of the individual scores of:

Eyes: ‘Open to verbal command’ = 3

Verbal: ‘Incomprehensible sounds’ = 2

Motor: ‘Abnormal extension’ = 2

Question 20

A patient is admitted into the emergency department following a head injury at
work. He is resuscitated and stabilized but a computed tomography scan shows significant brain contusion. He is intubated and cared for on the intensive care unit. You attempt to evaluate his Glasgow Coma Scale score; there is no response to voice but pressing a pen into his finger nail causes the patient to open his eyes and attempt to withdraw his hand from you. His Glasgow Coma Scale score is therefore:
A. 5/10
B. 6/10
C. 5/15
D. 6/15
E. 7/15

Answer 20

B. 6/10

It’s important to appreciate that an intubated patient cannot be assessed for the verbal component of the GCS, as such they are scored out of 10.

This score is made of:

Eyes: ‘Open to pain’ = 2

Motor: ‘Flexor witdrawal’ = 4

Question 21

A 31-year-old man is admitted following an assault outside a nightclub. During the fight he was hit by a blunt object across the side of the head. On admission his Glasgow Coma Scale score is initially 12/15 but falls to 8/15 during his evaluation. The decision is taken to perform a computed tomography head scan, which identifies a lens-shaped space-occupying lesion within the cranial vault. The diagnosis is:
A. Extradural haematoma
B. Subdural haematoma
C. Subarachnoid haemorrhage
D. Cerebral contusion
E. Intracerebral haemorrhage

Answer 21

A. Extradural haematoma

Heamorrhage within the cranium is classified as to the layer of the meninges in which it occurs.

The dura is tough and fibrous and attached firmly to the cranium, within the dura runs the venous sinuses. Bleeding in this layer arises commonly from the meningeal arteriesand is termed an extradural haemorrhage and fill form a classic lens shape on CT as it has to peel the dura off the skull.

Beneth the dura are the meningeal arteries, which penetrate the dura to suply the cebrebral parenchyma.

The arachnoid is beneath the dura and is not attached to it, so leaving a potential space, the subdural space.

Beneath the arachnoid is the pia mater, and the space between is the subarachnoid space. The pia mater is the only layer that can experience pain, as such any bleed in that layer causes symptoms of meningism. The potential occlusion of the arachnoid granulations can prevent CSF drainage and lead to hydocephalus.

In this case there is a classic presentation of an extradural haemorrhage, the bleeding is most commonly from a meningeal artery. The middle meningeal artery is the most vulnerable as it underlies the relatively weak temporal bone. The bleeding is restricted by the tough dura and that gives the typical lens shape.

Question 22

Of the following options, which is not a risk factor for subdural haematoma?
A. Pregnancy
B. Alcoholism
C. Dementia
D. Old age
E. Schizophrenia

Answer 22

A. Pregnancy

because the dura is attached to the skull and the arachnoid is related to the cerebellum anything that reduces the volume of the cerebral parenchyma creates distance between these two layers.

This expansion stretches the vessels traversing this space, the veins are particularly vulnerable to shearing leading to bleeding.

Therefore any factor that leads to cerebral atrophy will increase the space between the dura and the arachnoid leading to increased risk of a subdural haematoma. These include: alcohol, dementia, and schizophrenia. There is no cerebral atrophy associated with pregnancy.

Subdural haematoma are the most common cause of intracranial haemorrhage.

Question 23

The following are the treatment options available for the management of the
patient with severe head injury. Which of the following does not have an effect on reducing intracranial pressure?

A. Corticosteroids
B. Mannitol
C. Barbiturates
D. Hyperventilation
E. Furosemide

Answer 23

A. Corticosteroids

Head injury is classified as primary or secondary, with primary injury occuring at the time and secondary which arises as a result of swelling and, potentially, mismanagement.

The primary aim of head injury management is to minimise any secondary injury by maintaining cerebral perfusion.

Patients need ventilation on ITU/HDU and kept normotensive with normal blood gas.

With a raised ICP steps must be taken to improve this, mechanical hyperventilation is used as the hypocapnia leads to cerebral vasoconstriction and therefore reduced CSF and vascular volume within the cranial vault. However this has the side effect of potential hypoxia and so should not be used for a prolonged period.

In a normotensive patient mannitol +/- frusomide may be used to reduce ICP.

As these diuretics can cause hypotension they should be used wth caution.

When raised ICP is refractory barbituates can be used, but these also have a high propensity to cause hypotension.

Studies have shown that steroids have no effect on ICP and no short or long term benefits. This is very much an old treatment modality.

Question 24

A female patient is admitted following a domestic assault during which she
sustained an isolated head injury. On admission she had a Glasgow Coma Scale score of 13/15 but remained confused. She was therefore admitted overnight for observations. You are called to see her by the high-dependency unit nurses who have noticed a drop in her Glasgow Coma Scale score to 8/15. On examination you note her left pupil is now fixed and dilated. The most likely cause of this is:

A. Transient ischaemic attack/cerebrovascular accident
B. Basal skull fracture
C. Isolated III nerve palsy
D. Uncal herniation
E. Previously undocumented eye trauma

Answer 24

D. Uncal herniation

This patient has presented with a moderate brain injury, up to 20% of these patients would be expected to deteriorate.

This may be as a result of an expanding intra-cranial haemorrhage, leading to a rising ICP. Kowledge of the Munro-Kellie doctrine explains this, there is around 150ml of expansion that can be compensated by loss of ventricular and sinus space, after that there is no more room for expansion and ICP rises exponetially. This huge increase in pressure compromises the arterial flow and puts pressure on the brain leading to herniation.

Uncal herniation is the most common result, the uncus is the medial part of the temporal lobe and it becomes compressed against the tentorial notch, where the third cranial nerve lies. The parasympathetic fibres run on the outside of the nerve leading to the dilated pupil, before further pressue leads to complete oculomotor palsy, a ‘down and out’ eye.

Given this clinical picture this patient needs to be referred for emergency neurosurgery

Question 25

A patient is admitted following a fall from 4 m. He has sustained an injury to the
posterior aspect of his head and has a Glasgow Coma Scale score of 12/15. On
primary and secondary survey you identify a fracture of the left tibia but no focal neurology. You wish to remove the cervical spine collar and spinal board and so you review the cervical spine films; they show no abnormalities but the lateral and swimmer’s view films do not show the C7–T1 junction. Which one of the following is the most appropriate next step?

A. Clear the cervical spine clinically, asking whether neck pain is felt and
assessing for neurology
B. Flexion and extension views
C. Continue management on a spinal board and collar until clinical
assessment is possible
D. Ask senior clinician/radiologist to review films
E. Clear the cervical spine using computed tomography

Answer 25

E. Clear the cervical spine using computed tomography

Question 26

Which of the following is not a recognized complication of severe burn injury?

A. Renal failure
B. Pancreatitis
C. Liver failure
D. Gastric ulceration
E. Carbon monoxide poisoning

Answer 26

B. Pancreatitis

A sever burn has systemic effects, the fluid loss can cause hypovolaemic shock, which can lead to hepatorenal syndrome (A)(C). The kidneys get a double hit as there are also all of the myoglobin released from tissue damage, which is nephrotoxic.

The systemic effects of a severe burn are an acute stressor and can lead to gastric and duodenal ulcers (D), these are termed Curling’s ulcers.

Carbon monoxide poisoning is an obvious complication (E)

Pancreatitis is not caused by burns (B), there’s no ‘B’ in GET SMASHED!

Question 27

A patient is admitted following a house fire. He has extensive partial and full
thickness burns over his arms, upper torso and neck. You note black carbon
deposits around his nostrils and oropharynx. Which of the following is the
immediate priority?

A. Adequate analgesia
B. Sterile water irrigation
C. Intubation
D. Fluid resuscitation
E. Immediate transfer to a specialist burns centre

Answer 27

C. Intubation

The prescence of black deposits around the mouth and nostrils of a burns victim should make you immediately think of an airway burn. Although the trachea is protected by the epiglotis the upper airway is vulnerable and the laryngeal oedema that follows will make airway management more difficult. As such intubation is the first priority (C) in a patient with an airway burn, the drugs used in intubation will also act as analgesia.

Other signs that should make you think of an airway burn include; singed nasal hair, facial burns, hoarse voice, carbonaceous sputum, and a history of being confined in a burning enviroment.

All of the other answers here will be part of the management, but the airway is, as usual, the priority.

Question 28

A 32-year-old woman is admitted following a house fire. She has no obvious
injuries save for some partial thickness burning to her back and legs. On initial
assessment she appears confused, Glasgow Coma Scale score 14/15, and complains of nausea and headache. Her blood pressure is 165/110 mmHg, pulse rate is 105 beats/min and her respiratory rate is 23 breaths/min. Oxygen saturation is 98 per cent on room air. Arterial blood gases reveal respiratory alkalosis with no other abnormalities. The next stage of management is:

A. High-flow oxygen via non-rebreathable mask
B. Intubate and ventilate
C. Computed tomography head scan
D. Focused assessment with sonography for trauma (FAST) scan of the
abdomen
E. 100 per cent oxygen via rebreathing bag

Answer 28

A. High-flow oxygen via non-rebreathable mask

Confusion, nausea and headache in a burns patient should make you think of carbon monoxide poisioning. This is supported with the examination findings of tachycardia and tachyopnea. In these cases pulse oximetry is totally unreliable as the machine cannot tell the difference between oxygen bound and carbon monoxide bound haemoglobin. normal Arterial blood gas measurements are normally found in CO poisioning also.

The treatment for carbon monoxide poisioning is high flow oxygen (A) as this will more rapidly dislodge the bound CO. On room air it takes around 4 hours to remove the CO versus 40 minutes on high flow oxygen.

If confusion persists then another cause should be sought and a CT would be advisable (C)

Intubation (B) is rarely needed, unless there is an airway burn.

There isn’t a reason to suspect abdominal trauma so FAST (D) isn’t indicated.

Question 29

A 48-year-old man is admitted with a burn over his arm and anterior chest. The
involved tissue includes the entire circumference of his upper arm. Following
initial resuscitation he is admitted for observation. You are called to assess him as he is beginning to complain of increasing pain and tightness in his forearm. On examination you note weak peripheral pulses, paraesthesia and pain on active movement of the fingers, hand and wrist. The next stage in management is:

A. Angiography
B. Fasciotomy
C. Fluid resuscitation
D. Electrolyte assay and replenishment
E. Escharotomy

Answer 29

E. Escharotomy

This patient has a circumfrential burn, which puts them at risk of the burnt tissue comprising the underlying structures as the necrotic tissue lacks elasticity. In this case the arm is circumfrentially burnt so the patient has developed a muscle compartment compromise (not a true compartment syndrome as that results from pressure inside the compartment) and needs an emergency escharotomy (E). If this scenario had involved the chest there would be severe compromise to breathing.

If the patient isn’t managed quickly there can be tissue damage due to ischaemia and this can lead to a true compartment syndrome, which would require a fasciotomy (B)

There is no reason to expect that the patient’s situation is due to vascular pathology so an angio (A) isn’t needed.

Electrolyte disturbances may be an issue (D) but it isn’t the most likely cause of the symptoms.

The patient has already been resucitated as per the question stem, so doesn’t need more (C)

Question 30

A homeless man is admitted unresponsive after being found by police on a park bench. He has no external signs of injury. An oesophageal temperature probe records his core body temperature to be 34 °C. Which of the following management options is not routinely indicated in this case?

A. Cardiac monitoring
B. Warmed peritoneal lavage
C. Warmed intravenous fluids
D. Intravenous dextrose
E. Blood alcohol and toxin screen

Answer 30

B. Warmed peritoneal lavage

Hypothermia is classified as mild (35-32c), moderate (32-30c), and severe (<30c).

Hypothermia manifests as a decreased level of consciousness, decresed resps, and decresed HR, CO also falls and a severly hypothermic patient can appear dead, hence the old addage that ‘you’re not dead until you’re warm and dead’.

The concern with hypothermia is cardiac arrythmias as the myocardium destabilises below 33c, so monitoring is essential (A)

All hypothermic patient’s should be rewarmed with ‘passive external warming techniques’ I.E. blankets, external heating, and warmed I.V. fluids (C).

Other causes of confusion should be excluded (E)

Hypoglycaemia is another cause of reduced consciousness and should be monitored and dextrose given (D).

‘Active core rewarming methods’ are used in severe hypothermia, or in high risk patients (multiple injuries), and so are not indicated in this patient. These techniques include warmed peritoneal lavage (B), warmed plural lavage,warmed bladder irrigation, arterio-venous rewarming, and cardiopulmonary bypass (e.g. ECMO)