get through Trauma Examinations gET THROUgH Trauma Examinations

James Wigley MBBS BSc MRCS AFHEA University Hospital Southampton, Southampton, UK

Saran Shantikumar MRCS BHF Research Fellow, Bristol Heart Institute, Bristol, UK

Andrew Paul Monk DPhil MRCS Academic Clinical Lecturer in Orthopaedics University of Oxford, Oxford, UK

Editorial Advisor Stuart Blagg BSc FRCS FRCS (Tr & Orth) Consultant Trauma and Orthopaedic Surgeon, Stoke Mandeville Hospital, Buckinghamshire, UK

Boca Raton London New York

CRC Press is an imprint of the Taylor & Francis Group, an informa business gET THROUgH Trauma Examinations

James Wigley MBBS BSc MRCS AFHEA University Hospital Southampton, Southampton, UK

Saran Shantikumar MRCS BHF Research Fellow, Bristol Heart Institute, Bristol, UK

Andrew Paul Monk DPhil MRCS Academic Clinical Lecturer in Orthopaedics University of Oxford, Oxford, UK

Editorial Advisor Stuart Blagg BSc FRCS FRCS (Tr & Orth) Consultant Trauma and Orthopaedic Surgeon, Stoke Mandeville Hospital, Buckinghamshire, UK

Boca Raton London New York

CRC Press is an imprint of the Taylor & Francis Group, an informa business CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742

© 2014 by James Wigley, Saran Shantikumar, and Andrew Paul Monk CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works Version Date: 20140124

International Standard Book Number-13: 978-1-4441-7663-6 (eBook - PDF)

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Preface vii

1 Paper 1: Questions 1

2 Paper 1: Answers 17

3 Paper 2: Questions 33

4 Paper 2: Answers 49

5 Paper 3: Questions 63

6 Paper 3: Answers 77

v

PREFACE

Welcome to Get Through: Trauma Examinations. Ahead lie 150 SBA (single best answer) questions arranged as three practice papers. Each paper comprises a breadth of trauma topics but you will see that we have included more questions on particular topics, to emphasize where most exams centre their focus. I hope this book fulfills its aim in being a useful, informative revision aid. If you have any feedback or suggestions, please let me know ([email protected]). Finally, I would like to dedicate this book to my parents, and thank them for their endless support and inspiration over the years.

James Wigley

vii

PAPER 1 1 QUESTIONS Question 1

An oropharyngeal airway should be sized according to which one of the following descriptions? A. The measurement between the canines and the angle of the jaw B. The measurement between the labial commissure and the external auditory meatus C. The approximate diameter of the patient’s little finger D. By a combination of the patient’s sex and approximate size (big or small) E. The measurement between the hyoid and the chin Question 2

Before intubating a 28-year-old man, you aim to assess him for ease of intubation. Which of the following features would be suggestive of a difficult intubation? A. Long neck B. Distance of four fingers between the incisors with the mouth opened C. Mallampati class I D. An inability to rule out cervical spine fracture E. Distance of two fingers between the thyroid notch and floor of the mouth Question 3

A 41-year-old man has been attacked and has multiple stab to the abdomen. He is pale and sweaty, and you see pools of blood collecting on the floor. His pulse is 140/min. His systolic blood pressure is 85 mmHg. On arrival into the emergency department what is your first priority? A. Insert large bore peripheral cannula to each antecubital fossa B. Check his airway C. Elevate his legs in order to increase venous return D. Apply pressure to the laceration that you see is contributing to the blood loss E. Quickly turn the patient over to see if there are further wounds

1 Right bundle branch block Sinus tachycardia All the of above Atrial fibrillation Multiple ventricular ectopics Tracheobronchial tree Aortic disruption Diaphragmatic injury Haemothorax Perform a pericardiocentesis Insert a chest drain into the fifthintercostal side space left-hand Insert a wide cannula bore into the second intercostal spaceside left-hand Request an urgent chest X-ray Request an urgent ECG

B. B. B. E. E. E. C. D. contusion? A. Question 6 Which the of following ECG changes are commonly following found a myocardial D. A. C. hyperresonance percussion to and evidence subcutaneous of emphysema. No penetrating is apparent. Which the of following is the most likely underlying cause symptoms? her of Question 5 woman is admittedA 21-year-old following a road trafficcollision. She is dyspnoeic and has haemoptysis. On examination there is reduced air entry the on left with

A. C. D. reduced air entry the on leftside and the trachea is deviatedto the right. Which the of following is the course most appropriate action? of A 32-year-old man isA 32-year-old into the brought emergency department following a high- speed collision with a truck. is complaining He chest severe left-sided of pain. is he breathless, note tachycardicYou and hypotensive. On examination there is Question 4

Paper 1 QUESTIONS 2 Paper 1 QUESTIONS 3 Realignment without splintage Realignment and splintage Immobilization in the most comfortable position Splinting in the position they are found Applying dressings compression Complete transectionComplete the of cervical spinal cord informationMore is required make to a diagnosis Central syndrome cord Anterior syndrome cord Brown-Séquard syndrome A normal intracranial pressure is mmHg equal approximately to 10–15 Secondary brain injury is preventable Cerebral perfusion pressure is equal mean to arterial blood pressure minus intracranial pressure Mean arterial blood pressure is equal diastolic to blood pressure 1/3 plus (systolic blood pressure–diastolic blood pressure) A reduction in intracerebral pressure can be caused raising by the partial pressure of carbon dioxide Thepupils are not reactive no There spontaneousis respiratory effort The gag The reflex is absent The GCS is 3 temperature The core is 34°C

B. B. B. B. E. E. E. E. C. D. The The immediate managementof displaced fracturesrequires whichof following? the A. Question 10 C. D. What is the most likely diagnosis? A. A heavy goods vehicle ploughs into the rear a car. Inside of the car is a 72-year-old female following who, the crash, these develops clinical signs: in power the upper inlimbs power limbs the lower 2/5, 4/5. Question 9 C. D.

Which the of following statements with is FALSE regard cerebral to blood flow? A. Question 8 C. D. Which the of documented features a diagnosis preclude brain of death being given? A. A 67-year-old man is beingA 67-year-old evaluated brain for death.following The features are noted: the gag reflex is absent, the GCS 3, is temperature the core is 34°C, the pupils are reactive not and there is spontaneousno ventilatory effort. Question 7 Arrange angiography prompt Fluid challenge with dextrose 1 litre 5% of Arrange a CT and abdomen of pelvis Reassure the nurses that the full blood count is a consequence dilution of from fluid Repeat the blood test again as is it likely be to an erroneous result C3 Cervico-thoracic junction Occipito-cervical junction C1 C2 Consider the use vasopressors of remains a tilt at degrees 15 of in the position supine Obtain a CTG ensure to the health the of foetus Elevate the legs theTransfer the patient to theatre immediately Log roll the the patient to left and insertwedge on a the side so she right-hand

B. B. B. E. E. E. C. D. A. reported as normal. Of the following options, what is the next step most appropriate in the management thisof patient? admission was measured at 11.9 g/dl. Two hours later you are hours later you calledadmission g/dl. was Two review to measured 11.9 at him the by nursing staff, lookshe as pale Repeat bloods and sweaty. reveal a haemoglobin 6.4 scan of g/dl. Of note, a FAST was performed admission on and Question 13 manA 70-year-old has been involved in a cyclist versus car collision. has He sustained a fracture his to second lumbar vertebrae. His haemoglobin on D. A. C. Question 12 The hangman’s fracture whichof involves following the vertebral areas?

C. D. What should be the next step in management? her A. A pregnant weeks woman 35 of has been assaulted. has She been stabbed in the left anterolateral abdominal wall. stepsbeenappropriate The have made withregard to managing airway her and breathing. remains She hypotensive. Question 11

Paper 1 QUESTIONS 4 Paper 1 QUESTIONS 5 >10% in any age group >10% Any in years patients under 10 Facial burns Full-thickness burns >5% Inhalation Clear the C-spine Remove largeRemove foreign bodies from skin wounds openObtain ankle of X-rays fracture Insert an indwelling catheter Obtain haemodynamic stability Lund & Browder chartsLund & Browder body surface palmUsing the 1% to patient’s area) (equates ‘rule nines’ of Wallace’s Measure the area with a tape measure Parkland The formula

B. B. B. E. E. E.

A. C. D. typically require transfer a burn to centre. Which the of following is such a criterion? NOT Question 16 The AmericanBurn Association hasidentified several types ofthermal injury that C. D. A. has been are and completed that problems noted some require intervention. Which the of following necessary interventions should be addressed to prior transfer? Question 15 A patient was who recently admitted your to emergency department following a road trafficcollision requires transfer a to tertiary of centre care. A primary survey D. A. C. Which is the most accurate calculate to way the body surface area burns of in children? Question 14 Emergency thoracotomy Immediate intubation Pericardiocentesis Oxygen, analgesia and respiratory support Chest drain insertion Sitting upright Trendelenburg Left lateral position Right lateral position Supine rapidly and simultaneously Continue replenish to fluids with crystalloidsreducedat a speed and the save’ ‘Group patient Consider blood products and rapidly assess the a source bleeding patient for of Insert a urethral catheter so an hourly urine can output be determined Obtain further intravenous access so two bags crystalloid of can be infused

B. B. B. E. E. E. C. D. the likely diagnosis? A. she isshe short breath of and complains chest left-sided pain. of On examination there is an area paradoxical of the of chest wall. movement Which the of following would be the management most appropriate option given Question 19 woman isA 59-year-old involved in collision. a motor On arrival the at hospital D. A. C. A 24-year-old man presents after a fightand is suspectedhaving of bilateral mandible fractures. begins He respiratory develop to distress. What resuscitation ongoing position for should be considered in this patient? Question 18 D. A. C. saline in the emergency department.awake The patient is describesand how you to the accident happened. theBefore patient is rolled, log which the of following should next? be done A motorcyclist has been involvedin a collision with a car high at speed. While the to en route hospital has he received 1 litre crystalloid. of His systolicblood pressure is 80 mmHg and increases mmHg 85 to with a further litre normal of Question 17

Paper 1 QUESTIONS 6 Paper 1 QUESTIONS 7 0 1 Perform a cricothyroidotomy Attempt laryngeal mask airway insertion Perform a tracheostomy Re-attempt orotracheal intubation after 5 minutes nasotrachealAttempt intubation 5 7 despite displaying features no peritonism of The diaphragm marks of superiorthe border the abdominal cavity A fracture the of fifthrib can give rise to penetratingintra-abdominal injury aponeurotic The sheathsof the abdominalanterior wall relative weakare points compared with the musculature that surrounds the lateral and posterior abdomen Diagnostic peritoneal lavage is effectiveat detecting bloodloss within the retroperitoneum Patients can lose a significant bloodof amount within the abdominal cavity 3

B. B. E. E.

C. D. insertion is unsuccessful. Which the of following would be the next step in his airway management? A. A 42-year-old man is the to brought emergency department following a road trafficcollision. On arrival,note you he isthat immobilized in a collar, hard has facial fractures and is in acute respiratory distress. An attempt orotracheal at tube Question 22 B. C. D. E. What is his Glasgow Coma Score? A. A 45-year-old man is the to brought emergency after room a fall a balcony. from On arrival makes he sound, no does open his not eyes pain to and makes motor no response stimuli. to Question 21 D. C. Which the of following statements is FALSE? A. Question 20 Positive pressurePositive ventilation in patients with visceral pleural injury Spontaneous rupture an of bulla emphysematous Subclavian vein catheterization Markedly displaced thoracic spine fractures Penetrating chest trauma 9 10 11 7 8 25% 50% 75% 5% 10% 17 17 mmHg 22 mmHg 1 mmHg 5 mmHg 9 mmHg

B. B. B. B. E. E. E. E. C. D. Which the of following is the most common cause ? a tension of A. Question 26 C. D. What is his Glasgow Coma Score? A. his eyes as fragments glass of from are his removed scalp. is groaning He as he tries your stop to rubbing his sternum raising by his right arm and moving it towards you. Question 25 manA 23-year-old has been smashed the over head with a beer bottle. opens He C. D. A. Question 24 In a patient with a C-spine fracture identifiedfollowing primary a survey, what is the likelihood a second, of non-contiguous fracture? D. A. C. Which the of following is considered a normal intracranial pressure in the resting state? Question 23

Paper 1 QUESTIONS 8 Paper 1 QUESTIONS 9 The The cerebral perfusionpressure is calculatedby mean the arterialpressure minus the intracranial pressure Brain injury result may in an acute drop in cerebral blood flow Cerebralhypotension, reducedby is blood flow hypoxia hypocapnia and During childhood, cerebral blood flow canreach brain90 g ml/minute/100 tissue normal The cerebralblood flow in healthyadults is 20 g brain ml/minute/100 tissue to theto tissue, the duration energy of transfer and the amount tissue of involved The damage caused a by shotgun diminishes considerably if fired a from distance 3 metres of more or Fiftyof percent gunshotwounds to the abdomen small involve the bowel Exit wounds from a gunshot will be located in a line made from the pistol and the entry wound Handguns a medium represent energy penetrating injury The of amount damage causedbulletby a upon is dependent the transferof energy 200 ml/hr 250 ml/hr 50 ml/hr 100 ml/hr 150 ml/hr

B. B. B. E. E. E.

A. C. D. Question 29 Which the of followingFALSE? statements cerebral about is blood flow C. D. A. An inner city shopkeeper in is shot the abdomen. Which the of following statements is FALSE? Question 28 C. D. What rate infusion of should be prescribed? A. You are prescribing crystalloidYou intravenous fluidresuscitation a for 40-year-old man has who sustained second-degree burn decide a 15% give to his to chest. You 2 ml/kg.weighs The patient 80 kg. Question 27 Lumbar Lumbar–sacral junction Cervical Thoracic junction Thoracolumbar 4 5 1 2 3 25% 55% 1% 2% 5% Chest drain insertion Oxygen supplementation Sterile occlusive dressing the over wound Surgical airway Analgesia

B. B. B. B. E. E. E. E. D. A. C. Question 33 most The region spinalfor common injuriesto occur is: D. A. C. Question 32 The highest achievableopening eye on score Glasgowthe Coma Scale is: D. A. C. What is the likelihood a patient with of a having an injury? spinal associated Question 31 C. D. Which the of following an is management not appropriate option? A. A 21-year-old man is the to brought emergency departmentA 21-year-old after being stabbed in the chest. is visibly He tachypnoeic and examination on has a large sucking wound theto of leftside the chest. Question 30

Paper 1 QUESTIONS 10 Paper 1 QUESTIONS 11 Every 30 minutes Every 45 minutes Every 1 hour Every 2 hours Every 4 hours Diagnostic investigations All the of above Patient demographicPatient details AMPLE history Status and previous management Lap seatbelt: Chance fracture lumbar of spine Rear shunt: end hyperextension the of cervical spine with multiple laminar, pedicle and spinous process fractures Pedestrian versus cyclist: deceleration injury Air bag: corneal abrasionand cardiac rupture Shoulder harness: pulmonary contusion and intimal tear thrombosis or of subclavian artery Primary survey Secondary survey Choice of adjunct History All the of above

B. B. B. B. E. E. E. E. D. A. C. In patients with spinal immobilization in often place, rollshouldlog a how be performed minimize to the risk pressure of sores? Question 37 C. D. Helpful information the for receiving institution a patient transfer of includes which the of following? A. Question 36 D. C. Which the of following consistent is with not the mechanism injury? of A. Question 35 C. D. Anassessment the of musculoskeletal system formspart which of the of following? A. Question 34 Time patient last drank or ate Involvement of police of Involvement Time day of Post-crash location the of patient patient Height of Injuries through growth result plates may in subsequent growth abnormalities Internal organ damage is often seen overlying without bony fracture children of Around 10% sustain who severe multisystem trauma residual have personality changes 1 year at Hypothermia quickly tends more develop to Injuries in a child can result in personality and emotional disturbances in uninjured siblings 45% 27% 30% 36% 18% 4 litres thanGreater 5 litres 1 litre 2 litres 3 litres

B. B. B. B. E. E. E. E.

A. C. D. Pertinent questions from the history regarding musculoskeletal trauma include which the of following? Question 41 C. D. A. Regarding the unique characteristics paediatric of patients, which the of following statements is FALSE? Question 40 C. D. Estimate the percentage burn has he sustained. A. Question 39 manAn is involved in 18-year-old a firework.He at has full-thicknessburns over both his arms and partial thickness burns the the of over whole torso. front D. A. C. A typical fracture closed bone long results in what approximate blood of volume loss? Question 38

Paper 1 QUESTIONS 12 Paper 1 QUESTIONS 13 Full range less but than motion of normal strength Non-testable Total Total paralysis Full range with motion of gravity eliminated Full range against motion of gravity Isolated head injuries Isolated fracture bone) (non-long Thoracictrauma All the of above Partial thickness Full thickness First degree Superficial Second degree No changeNo in the quality the of voice Distended neck veins Inability palpate to the fracture Tachycardia

B. B. B. B. E. E. E. E. C. D. During the assessment muscle strength, of what does 4 represent? a score of A. Question 45 C. D. A secondary survey is required in which the of following scenarios? A. Question 44 C. D. How is theHow depth the of burn best described? A. left hand. On examination in notice emergency the you room, a dry, dark of area skin the over dorsum the of hand, which appears leathery. There a is demonstrable absence pain of from this area. Question 43 A 42-year-old woman hasaccidentally spilled oil hot from a frying pan her over C. D. A. A 42-year-old woman is in brought afterroad a traffic You notice she that collision. is hypoxic and struggling ventilate. to Palpation the of neck is abnormal. Which the of following most specifically suggests a laryngeal fracture? Question 42 Fracture Pelvic organ damage All the of above Arterial damage Venous damage other instructs the helmet remove to the himself how patient on Three providesone person people: in-line stabilizationof head the neck, and the feet, the removes holds helmetone one patient’s in the position supine One person:One rotate sliding the before side neckone to the helmet off person people: provides one in-line stabilizationTwo the of head and neck, the other the removes helmet in the supine position person people: provides one in-line stabilizationTwo the of head and neck, the One person:One gently slide the helmet from the head in the supine position Minor Moderate Severe Life-threatening Very Very minor

B. B. B. E. E. E. C. D. Severe injury following pelvic major disruption can which to be due the of following? A. Question 48

C. D. How should theHow helmet be removed? A. You come across come an injured motorcyclistYou following a road trafficcollision. He is wearing are this keen remove to a helmet. in perform to order You an airway maintenance manoeuvre. Question 47 C. D. How would hisHow brain injury be classified? A. A 29-year-old manA 29-year-old is admitted the to emergency departmentafter a fall from his bike, which resulted in a . On examination his eyes open spontaneously, is obey to he able commands and his verbal response is orientated. Question 46

Paper 1 QUESTIONS 14 Paper 1 QUESTIONS 15 Acetabular fracture: superior and inferior gluteal nerve Supracondylar fractures in children: median and anterior interosseous nerve Knee dislocation: posterior tibial nerve Fibular neck fracture: superficial peronealnerve Anterior shoulder dislocation: ulnar nerve A cherry-red skin discolouration is common Inhalation even small of quantities usually results in headaches Intubation is mandatory cannotIt result in coma withTreatment oxygen 100% increases the rate dissociation of of carboxyhaemoglobin

B. B. E. E. D. A. C. Question 50 Which the of following nerve palsies associated is not with thepreceding injuries?

C. D. Regarding carbon inhalation,monoxide which the of following statements is TRUE? A. Question 49