Single best answer
1
A 24-year-old presents to the emergency department following a stab injury in the right side of the lower chest . His BP is 65/20 mmHg, HR 110 bpm and a GCS 13. He has two large bore IV access and is getting fluid and blood resuscitated but continues to deteriorate. He then suffers a cardiac arrest. Which of the following is true regarding the management of this patient?
- A.
A needle decompression is attempted immediately on arrival
- B.
Intercostal catheter insertion is quickly done through the stab wound
- C.
An urgent chest CT angiography is recommended in a patient with hemodynamic instability
- D.
An emergency department thoracotomy is indicated if suitably skilled staff are present
- E.
Closed chest compression has similar success to internal cardiac compressions in this setting
2
A 65-year-old fit and well individual presents to the emergency department with burns involving face, neck and arms. The total body surface area is about 15%. There is mild stridor and nasendoscopy reveals a swollen epiglottis. SpO 2 is 96 on room air. GCS is 15. Which of the following is true regarding the management of this patient?
- A.
This patient will need emergency intubation with a skilled anaesthetist
- B.
This patient may benefit from referral to the nearest burns centre
- C.
Suxamethonium is contraindicated if planning for intubation
- D.
Inhalation protocol with nebulized acetylcysteine has shown to improve the outcomes
- E.
It is advisable to administer prophylactic antibiotics
Multiple choice questions
3
The metabolic and endocrine response to trauma
Which of the following are true regarding the evidence based management of trauma?
- A.
Evidence now suggests a link between increased volume of fluid resuscitation and mortality
- B.
Targeting a lower blood pressure has a mortality benefit in blunt trauma
- C.
Administration of tranexamic acid within 3 hours of injury has been shown to decrease morbidity and mortality
- D.
The use of steroids in traumatic head injury have been shown to decrease mortality
- E.
Addition of micronutrients as well as glutamine in the nutrition regimes demonstrate a clear benefit in trauma patients
4
Drowning and immersion injury
Which of the following are true about the presentation and management of drowning?
- A.
The submersion time is the strongest predictor of outcome
- B.
Active re-warming should be implemented until core body temperature reaches 36 o C
- C.
The risk of cervical spine injury is very high and cervical spine immobilization is recommended in all those who suffer drowning
- D.
An initial ‘shockable’ rhythm (ventricular fibrillation or ventricular tachycardia) is present in only about 5% of cases
- E.
Both fresh and saltwater can cause surfactant washout leading to atelectasis and alveolar damage
5
Pharmacology and clinical use of plasma expanders
Which of the following are true regarding the use of Human Albumin Solution (HAS) in intensive care ?
- A.
HAS when used for fluid resuscitation reduces the need for renal replacement therapy in septic shock
- B.
HAS infusion may decrease mortality in traumatic brain injury by decreasing intracranial pressure
- C.
In advanced liver disease a lack of response to volume expansion with HAS is part of the diagnostic criteria of hepatorenal syndrome
- D.
HAS is considered the replacement fluid of choice for therapeutic plasma exchange
- E.
There is compelling data of benefit to justify the routine use of albumin over crystalloid in septic patients
6
Spinal cord injury
Which of the following are true about the implications of spinal cord injury on respiratory mechanics?
- A.
Lesions above T8 start to impede ventilation
- B.
Lower cervical lesions can cause a paradoxical indrawing of the chest during inspiration
- C.
Evidence suggests that higher tidal volumes of between 10 and 20 ml/kg of ideal bodyweight are beneficial for patients with high cervical lesions
- D.
Functional residual capacity (FRC) is increased in cervical cord injury
- E.
Patients dependent on diaphragmatic breathing wean optimally in the sitting up position
Answers
1. Correct Answer: D. The treatment of a tension pneumothorax is effective pleural decompression. Traditionally this was via needle decompression followed by ICC insertion. Many now advocate finger or tube thoracostomy rather than needle decompression due to higher failure rates of needle thoracostomy and the risk of iatrogenic pneumothorax. The cannula may also get obstructed by blood, tissue or kinking and thus fail to decompress the pneumothorax. In the case of cardiac arrest, bilateral tube or finger thoracostomy is indicated rather than needle thoracostomy.
Open pneumothorax can be encountered in penetrating thoracic trauma and involves an open wound communicating with the pleural space, leading eventually to death by tension pneumothorax. Signs are the same as simple or tension pneumothorax but include a ‘sucking’ wound allowing air to enter the thorax during inspiration. Treatment consists of application of an occlusive dressing, sealed on three out of four sides allowing air to escape from the pleural space, preventing entry of air through the wound and then insertion of an ICC.
A massive haemothorax is defined as >1500 ml in the pleural space. In blunt trauma it is often due to torn intercostal arteries as a result of rib fractures or lacerated lung. In penetrating trauma great vessel injury (aortic and pulmonary) needs to be considered. Signs that distinguish haemothorax from pneumothorax are a dull percussion note rather than hyper-resonance. Treatment is immediate insertion of a large-bore ICC and fluid resuscitation with crystalloids, necessary blood and coagulation products allowing for permissive hypotension (systolic blood pressure >90 mmHg). Surgical thoracotomy should be considered and is indicated if large rates, typically more than 200 ml/hour, of bleeding continue.
Emergency department thoracotomy is indicated in blunt and penetrating thoracic trauma, where arrest is witnessed or within 10 minutes of arrest if suitably skilled staff are present. This allows for internal cardiac compressions. Closed chest compression is rarely successful in the trauma setting.
2. Correct Answer: B. Patients with inhalational injury affecting the upper airway are at risk of airway compromise due to supraglottic oedema. Repeated assessment of the airway using clinical features and flexible nasendoscopy (FNE) is essential. Patients with no signs of significant airway oedema who are clinically stable do not necessarily require emergent intubation. However, within this stable group, it may be reasonable to intubate semi-electively if inter-hospital transfer is necessary. Serial clinical and FNE assessments can aid decision making. If features of airway injury are present accompanied by non-reassuring FNE assessment, intubation should be undertaken promptly by a senior clinician with advanced airway skills.
The use of suxamethonium should be limited to within the first 24 hours since injury due to the risk of hyperkalaemia caused by the increase in extra-junctional nicotinic acetylcholine receptors. Increased receptor numbers can also promote a resistance to non-depolarising agents, therefore requiring higher doses.
Intubated patients with smoke inhalation injury should undergo early bronchoscopy, clearance of particulate matter and washout as this is associated with improved outcomes. Inhalation protocols administering nebulized beta-2 agonists, acetylcysteine and heparin are used in some centres; however, evidence for this is limited.
There is no role for prophylactic antibiotics despite the increased risk of infection.
Assessment and management of any trauma patient should follow the principles of Advanced Trauma Life Support (ATLS) teaching. The approach to a burns patient should be no different. Basic initial measures include high-flow oxygen, basic monitoring and intravenous access. Following stabilization, transfer to a regional burns unit can be considered based upon agreed criteria. (See British Burns Association referral criteria for patients with burn injuries.)
3. Correct answers: A, C
4. Corrects answers: A, D, E
5. Correct answers: C, D
6. Correct answers: A, B, C
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