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Principles-Of-Surgery-In-General-Emergency-Medicine-Management-Of-Truma
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MyPasTest » MRCS A Online - Jan Exam 201512. Principles of Surgery in General; Emergency Medicine & Management of Trauma (49Qs)
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01. Theme: Priorities in immediate trauma care
A Airway management
B Anteroposterior chest X-ray
C Anteroposterior pelvis X-ray
D Chest drain
E Chest X-ray
F Cross-match and blood transfusion
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G Intravenous access and fluid resuscitation 1033
H Lateral cervical spine X-ray
I Pericardiocentesis
J Pneumatic anti-shock garment
K Rewarming
L Urgent neurological opinion.
The following scenarios describe road traffic accidents where the patient has been brought in by
ambulance with cervical spine immobilisation and 100% oxygen administered by mask. However, no other
active management has been instigated. From the list above please select the most appropriate
resuscitation measure with the highest priority. A measure may be chosen once, more than once, or not at
all.
Scenario 1
An 18-year-old motorcyclist is brought in after being thrown off his bike. He is confused and there is evidence of
blood and vomit around his mouth. Vital signs: blood pressure 130/65 mmHg, pulse rate 110/min, respiratory rate
28 breaths/min.
A - Airway management« CORRECT ANSWER
Regardless of the presentation of the patient, the management of this man follows the Advanced Trauma
Life Support (ATLS) criteria of Airways, Breathing and Circulation. It appears that he has sustained oro-
facial trauma, and possibly aspirated. He needs oropharyngeal suction and insertion of an appropriate
airway. Once his breathing has been managed, intravenous access must be gained to begin fluid
resuscitation. He demonstrates signs of Class II haemorrhagic shock (15–30% blood loss.
Scenario 2
A 35-year-old woman is brought to casualty after being pinned in her car following collision with a lamp post. After
extrication it is apparent that she had not been wearing a seatbelt. On examination, after appropriate airway
management, she demonstrates central cyanosis, distended neck veins but equal air entry with marked bruising
over her anterior chest wall. Vital signs: blood pressure 80/40 mmHg, pulse rate 140/min, respiratory rate 50
breaths/min. Which management step is likely to provide the most relief for this patient?
B - Anteroposterior chest X-ray« YOUR ANSWER
I - Pericardiocentesis« CORRECT ANSWER.
This lady has signs of cardiac tamponade, although a differential diagnosis would have included tension
pneumothorax had she demonstrated unequal air entry. Cardiac tamponade results in the classic Beck’s
triad of raised jugular venous pressure, muffled heart sounds and hypotension. There would also be a
resultant pulsus paradoxus or a large fall in systolic pressure and blood volume on inspiration. Her
hypotension is secondary to a low cardiac output because of ineffectual myocardial contraction. Immediate
pericardiocentesis is necessary, which involves insertion of a broad-bore needle, attached to a three-way
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Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest » MRCS A Online - Jan Exam 2015
12. Principles of Surgery in General; Emergency Medicine & Management of Trauma (49Qs)
----------------------------------------------------------------------------------------------------------------------------------
syringe, into a point 1–2 cm inferior to the left of the xiphochondral junction. The needle should be
advanced slowly, while aspirating, towards the tip of the left scapula, while carefully observing the
electrocardiogram trace for evidence of a ‘current of injury’, eg extreme ST-T waves or widened QRS
complexes. This alerts the operator to the fact that the needle has been inserted into the myocardium.
Scenario 3
A 20-year-old man is brought in after being found under the wheel of a car. He is drowsy, aggressive but keeps
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complaining of abdominal and left leg pain. Vital signs: blood pressure 80/40 mmHg, pulse rate 150/min, respiratory 1034
rate 38 breaths/min. Airway management has been dealt with appropriately.
C - Anteroposterior pelvis X-ray« YOUR ANSWER
G - Intravenous access and fluid resuscitation« CORRECT ANSWER.
This man has clear signs of Class IV haemorrhagic shock. This is seen following blood loss of more than 2
litres (> 40%) and results in drowsiness and, occasionally, aggression. Class IV haemorrhagic shock is
classified as a pulse rate > 140/min, decreased blood pressure and pulse pressure, and a respiratory rate >
35 breaths/min. The likely source of bleeding is from within the abdomen and a possible long-bone fracture
of his lower limb, both of which will also require attention. However, he requires management according to
the A,B,C principles of ATLS, with specific management of his circulation. In the initial stages, in casualty,
this involves crystalloid fluid replacement followed promptly by blood therapy.
02. Theme: Radial nerve injury
A Compression at the level of the elbow
B Fracture at the level of the mid-humerus
C Compression at the level of the axilla
D Laceration at the level of the wrist.
Describe the level of injury for the following patients. Each option may be used once, more than once, or
not at all.
Scenario 1
A 25-year-old man presenting with weakness of wrist and hand with paralysis of the triceps and absent triceps
reflex.
A - Compression at the level of the elbow« YOUR ANSWER
C - Compression at the level of the axilla« CORRECT ANSWER.
Scenario 2
A 19-year-old man presenting with a wrist drop with inability to extend the metacarpophalangeal joints of the hand,
together with altered sensation over the region of the anatomical snuff box. The triceps reflex is present.
B - Fracture at the level of the mid-humerus« CORRECT ANSWER.
Scenario 3
A 30-year-old man presenting with inability to extend the metacarpophalangeal joints of the hand with weakness of
thumb abduction and interphalangeal extension.
C - Compression at the level of the axilla« YOUR ANSWER
A - Compression at the level of the elbow« CORRECT ANSWER.
In low radial nerve lesions, ie those due to fractures or dislocations at the elbow, the posterior interosseus
nerve may be injured and the patient is unable to extend the fingers; there is also weakness of thumb
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest » MRCS A Online - Jan Exam 2015
12. Principles of Surgery in General; Emergency Medicine & Management of Trauma (49Qs)
----------------------------------------------------------------------------------------------------------------------------------
abduction and extension. In high lesions such as in fractures of the humerus or due to prolonged
tourniquet pressure, there is weakness of the radial extensors of the wrist and numbness over the
anatomical snuff box. In very high lesions, the radial nerve may be compressed in the axilla, eg, crutch
palsy, which leads to paralysis of the triceps and absent triceps reflex.
03. A 45-year-old man sustains a displaced intracapsular fracture of his neck of femur following a motor
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bike accident. What is the most likely complication of this injury?
Avascular necrosis « YOUR ANSWER (Correct Answer)
1035
Femoral artery thrombosis
Non-union
Post-traumatic osteoarthritis
Sciatic nerve palsy.
Femoral neck fractures are high energy injuries in young patients. Avascular necrosis (AVN) is the most
common complication after femoral neck fractures due to the disruption of blood supply. The risk of AVN in
a displaced intracapsular neck of femur fracture is approx 30-40%. Risk increases with delayed surgical
fixation and therefore emergent operative treatment is recommended in the young patient to enable fixation
and avoid arthroplasty.
04. Theme: Glasgow Coma Scale
A 14
B 13
C 12
D5
E4
F3
G 0.
For each of the clinical scenarios listed below, select the correct Glasgow Coma Score for the patient. Each
option may be used once, more than once, or not at all.
Scenario 1
A 66-year-old gentleman is brought in by ambulance. He was found collapsed having fallen off a ladder. On arrival
the paramedics are performing cardiopulmonary resuscitation.
A - 14« YOUR ANSWER
F - 3« CORRECT ANSWER.
Eye opening: none – 1, best motor response: none – 1, verbal response: none – 1.
Scenario 2
You see a 16-year-old girl in the emergency department. She seems to be sleeping and smells of alcohol. She
opens her eyes when you ask her to and tries to knock your hand away when you rub on her sternum. When she
opens her eyes you have a brief conversation, which doesn’t quite make sense.
B - 13« YOUR ANSWER
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Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest » MRCS A Online - Jan Exam 2015
12. Principles of Surgery in General; Emergency Medicine & Management of Trauma (49Qs)
----------------------------------------------------------------------------------------------------------------------------------
C - 12« CORRECT ANSWER.
Eye opening: to speech – 3, best motor response: localises pain – 5, verbal response: confused
conversation – 4.
Scenario 3
A 30-year-old woman is brought in by ambulance. She was ejected from her car during a road traffic collision. She
Page
is tolerating an oropharygeal airway, is tachyopnoeic, tachycardic and has a systolic blood pressure of 90/30 1036
mmHg. She is not opening her eyes and abnormally flexes to pain. She was making some sounds when she first
came in but is now silent.
C - 12« YOUR ANSWER
D - 5« CORRECT ANSWER.
Eye opening: none – 1, best motor response: abnormal flexion – 3, verbal response: none – 1.
Scenario 4
A 28-year-old is brought in from a nightclub. He has fallen from a balcony and sustained a head injury. He has been
drinking and taking illicit drugs. He is being aggressive and tried to punch your house officer but missed. He is now
shouting abuse although it doesn’t seem to make sense.
D - 5« YOUR ANSWER
A - 14« CORRECT ANSWER.
Eye opening: spontaneous – 4, best motor response: obeys commands (in this instance you are told he is
able to initiate spontaneous, positive action (aggressive punch) not movement as a result of painful
stimulus – 6, verbal response: confused conversation – 4
05. Theme: Chest and thoracic wall injuries
A Cardiac tamponade
B Diaphragmatic rupture
C Flail chest
D Fracture of the sternum
E Myocardial contusion
F Perforated oesophagus
G Pulmonary contusion
H Ruptured thoracic aorta
I Tension pneumothorax
J Traumatic haemothorax.
For each of the following situations, select the most appropriate cause for the chest condition from the
above list. Each option may be used once, more than once, or not at all.
Scenario 1
A 38-year-old man presents with respiratory distress, tachycardia, distended neck veins and tracheal deviation
following a penetrating injury to the right side of his chest. The patient’s BP is 100/60 mmHg and respiratory rate is
20/min.
A - Cardiac tamponade « YOUR ANSWER
I - Tension pneumothorax« CORRECT ANSWER.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
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