Get Trou Trauma Examination

8/20/2019 Get Trou Trauma Examination

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Trauma

Examinations

GETTHROUGH

© 2014 by James Wigley, Saran Shantikumar, and Andrew Paul Monk


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TraumaExaminations

James Wigley MBBS BSc MRCS AFHEAUniversity Hospital Southampton, Southampton, UK

Saran Shantikumar MRCSBHF Research Fellow, Bristol Heart Institute, Bristol, UK

Andrew Paul Monk DPhil MRCSAcademic 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

GETTHROUGH

CRC Press is an imprint of theTaylor & Francis Group, an informa business

Boca Raton London New York



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CRC PressTaylor & Francis Group6000 Broken Sound Parkway NW, Suite 300Boca Raton, FL 33487-2742

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

No claim to original U.S. Government worksVersion Date: 20140124

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

This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have beenmade to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility orliability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressedin this book by individual editors, authors or contributors are personal to them and do not necessari ly reflect the views/opinionsof the publishers. The information or guidance contained in this book is intended for use by medical, scientific or health-careprofessionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledgeof the patient’s medical history, relevant manufacturer’s instruct ions and the appropriate best practice guidelines. Because ofthe rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently

verified. The reader is strongly urged to consult the drug companies’ printed instructions, and their websites, before adminis-tering any of the drugs recommended in this book. This book does not indicate whether a particular treatment is appropriateor suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her ownprofessional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to tracethe copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publishin this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we mayrectify in any future reprint.

Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in anyform by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming,and recording, or in any information storage or retrieval system, without writ ten permission from the publishers.

For permission to photocopy or use material electronically f rom this work, please access www.copyright.com (http://www.copy-

right.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400.CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that havebeen granted a photocopy license by the CCC, a separate system of payment has been arranged.

Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identifica-tion and explanation without intent to infringe.

Visit the Taylor & Francis Web site athttp://www.taylorandfrancis.com

and the CRC Press Web site athttp://www.crcpress.com



5/97

CRC PressTaylor & Francis Group6000 Broken Sound Parkway NW, Suite 300Boca Raton, FL 33487-2742

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

No claim to original U.S. Government works

Printed on acid-free paperVersion Date: 20140124

International Standard Book Number-13: 978-1-4441-7662-9 (Paperback)

This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have beenmade to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility orliability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressedin this book by individual editors, authors or contributors are personal to them and do not necessari ly reflect the views/opinionsof the publishers. The information or guidance contained in this book is intended for use by medical, scientific or health-careprofessionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledgeof the patient’s medical history, relevant manufacturer’s instruct ions and the appropriate best practice guidelines. Because ofthe rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the drug companies’ printed instructions, and their websites, before adminis-tering any of the drugs recommended in this book. This book does not indicate whether a particular treatment is appropriateor suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her ownprofessional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to tracethe copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publishin this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we mayrectify in any future reprint.

Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in anyform by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming,and recording, or in any information storage or retrieval system, without writ ten permission from the publishers.

For permission to photocopy or use material electronically f rom this work, please access www.copyright.com (http://www.copy-right.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400.CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that havebeen granted a photocopy license by the CCC, a separate system of payment has been arranged.

Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identifica-tion and explanation without intent to infringe.

Library of Congress Cataloging-in-Publication Data

Wigley, James.Get through trauma examinations / James Wigley, Saran Shantikumar, Andrew Paul Monk.

pages cm“A CRC title.”Includes bibliographical references and index.ISBN 978-1-4441-7662-9 (hardcover : alk. paper)1. Traumatology--Examinations, questions, etc. 2. Wounds and injuries--Examinations, questions, etc.

3. Orthopedics--Examinations, questions, etc. I. Shantikumar, Saran. II. Monk, Andrew Paul. III. Title.

RD93.W545 2014617.10076--dc23 2013048179

Visit the Taylor & Francis Web site athttp://www.taylorandfrancis.com

and the CRC Press Web site athttp://www.crcpress.com



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v

CONTENTS

Preface vii

1 Paper 1: Questions 1

2 Paper 1: Answers 17







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vii

PREFACE

Welcome to Get Trough: rauma Examinations. Ahead lie 150 SBA (single bestanswer) questions arranged as three practice papers. Each paper comprises abreadth of trauma topics but you will see that we have included more questions onparticular topics, to emphasize where most exams centre their focus.

I hope this book fullls 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 fortheir endless support and inspiration over the years.

James Wigley



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1Question 1An oropharyngeal airway should be sized according to which one o the ollowingdescriptions?

A. Te measurement between the canines and the angle o the jaw B. Te measurement between the labial commissure and the external auditory

meatus C. Te approximate diameter o the patient’s little nger D. By a combination o the patient’s sex and approximate size (big or small) E. Te measurement between the hyoid and the chin

Question 2Be ore intubating a 28-year-old man, you aim to assess him or ease o intubation.Which o the ollowing eatures would be suggestive o a difficult intubation?

A. Long neck B. Distance o our ngers between the incisors with the mouth opened C. Mallampati class I D. An inability to rule out cervical spine racture E. Distance o two ngers between the thyroid notch and oor o the mouth

Question 3A 41-year-old man has been attacked and has multiple stab wounds to theabdomen. He is pale and sweaty, and you see pools o blood collecting on the oor.His pulse is 140/min. His systolic blood pressure is 85 mmHg.On arrival into the emergency department what is your rst priority?

A. Insert large bore peripheral cannula to each antecubital ossa 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 i there are urther wounds

PAPER 1QUESTIONS



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Question 4A 32-year-old man is brought into the emergency department ollowing a high-speed collision with a truck. He is complaining o severe lef-sided chest pain.You note he is breathless, tachycardic and hypotensive. On examination there is

reduced air entry on the lef side and the trachea is deviated to the right.Which o the ollowing is the most appropriate course o action?

A. Insert a chest drain into the fh intercostal space lef-hand side B. Insert a wide bore cannula into the second intercostal space lef-hand side C. Request an urgent chest X-ray D. Request an urgent ECG E. Per orm a pericardiocentesis

Question 5A 21-year-old woman is admitted ollowing a road traffic collision. She is dyspnoeicand has haemoptysis. On examination there is reduced air entry on the lef withhyperresonance to percussion and evidence o subcutaneous emphysema. Nopenetrating wound is apparent.Which o the ollowing is the most likely underlying cause o her symptoms?

A. Aortic disruption B. Diaphragmatic injury

C. Haemothorax D. racheobronchial tree injury E. Pulmonary contusion

Question 6Which o the ollowing ECG changes are commonly ound ollowing a myocardialcontusion?

A. Atrial brillation B. Multiple ventricular ectopics C. Right bundle branch block D. Sinus tachycardia E. All o the above



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Question 7A 67-year-old man is being evaluated or brain death. Te ollowing eatures arenoted: the gag reex is absent, the GCS is 3, the core temperature is 34°C, thepupils are not reactive and there is no spontaneous ventilatory effort.

Which o the documented eatures preclude a diagnosis o brain death being given? A. Te gag reex is absent B. Te GCS is 3 C. Te core temperature is 34°C D. Te pupils are not reactive E. Tere is no spontaneous respiratory effort

Question 8Which o the ollowing statements is FALSE with regard to cerebral blood ow?

A. Cerebral per usion pressure is equal to mean arterial blood pressure minusintracranial pressure

B. Mean arterial blood pressure is equal to diastolic blood pressure plus 1/3(systolic blood pressure–diastolic blood pressure)

C. A reduction in intracerebral pressure can be caused by raising the partialpressure o carbon dioxide

D. A normal intracranial pressure is equal to approximately 10–15 mmHg

E. Secondary brain injury is preventable

Question 9A heavy goods vehicle ploughs into the rear o a car. Inside the car is a 72-year-old

emale who, ollowing the crash, develops these clinical signs: power in the upperlimbs 2/5, power in the lower limbs 4/5.What is the most likely diagnosis?

A. Central cord syndrome B. Anterior cord syndrome C. Brown-Séquard syndrome D. Complete transection o the cervical spinal cord E. More in ormation is required to make a diagnosis

Question 10Te immediate management o displaced ractures requires which o the ollowing?

A. Realignment without splintage B. Realignment and splintage C. Immobilization in the most com ortable position D. Splinting in the position they are ound E. Applying compression dressings



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Question 11A pregnant woman o 35 weeks has been assaulted. She has been stabbed in the lefanterolateral abdominal wall. Te appropriate steps have been made with regard tomanaging her airway and breathing. She remains hypotensive.

What should be the next step in her management? A. Log roll the patient to the lef and insert a wedge on the right-hand side so she

remains at a tilt o 15 degrees in the supine position B. Obtain a C G to ensure the health o the oetus C. Elevate the legs D. rans er the patient to the theatre immediately E. Consider the use o vasopressors

Question 12Te hangman’s racture involves which o the ollowing vertebral areas?

A. Occipito-cervical junction B. C1 C. C2 D. C3 E. Cervico-thoracic junction

Question 13A 70-year-old man has been involved in a cyclist versus car collision. He hassustained a racture to his second lumbar vertebrae. His haemoglobin onadmission was measured at 11.9 g/dl. wo hours later you are called to reviewhim by the nursing staff, as he looks pale and sweaty. Repeat bloods reveal ahaemoglobin o 6.4 g/dl. O note, a FAS scan was per ormed on admission andreported as normal.O the ollowing options, what is the next most appropriate step in the management

o this patient? A. Reassure the nurses that the ull blood count is a consequence o dilution rom

uid resuscitation B. Repeat the blood test again as it is likely to be an erroneous result C. Arrange prompt angiography D. Fluid challenge with 1 litre o 5% dextrose E. Arrange a C o abdomen and pelvis



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Question 14Which is the most accurate way to calculate the body sur ace area o burns inchildren?

A. Lund & Browder charts B. Using the patient’s palm (equates to 1% body sur ace area) C. Wallace’s ‘rule o nines’ D. Measure the area with a tape measure E. Te Parkland ormula

Question 15A patient who was recently admitted to your emergency department ollowing aroad traffic collision requires trans er to a tertiary centre o care. A primary surveyhas been completed and some problems are noted that require intervention.Which o the ollowing necessary interventions should be addressed prior totrans er?

A. Remove large oreign bodies rom skin wounds B. Obtain X-rays o open ankle racture C. Insert an indwelling catheter D. Obtain haemodynamic stability E. Clear the C-spine

Question 16Te American Burn Association has identied several types o thermal injury thattypically require trans er to a burn centre.Which o the ollowing is NO such a criterion?

A. >10% burns in any age group B. Any burn in patients under 10 years C. Facial burns D. Full-thickness burns >5% E. Inhalation injuries



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Question 17A motorcyclist has been involved in a collision with a car at high speed. Whileen route to the hospital he has received 1 litre o crystalloid. His systolic bloodpressure is 80 mmHg and increases to 85 mmHg with a urther litre o normal

saline in the emergency department. Te patient is awake and describes to you howthe accident happened.Be ore the patient is log rolled, which o the ollowing should be done next?

A. Consider blood products and rapidly assess the patient or a source o bleeding B. Insert a urethral catheter so an hourly urine output can be determined C. Obtain urther intravenous access so two bags o crystalloid can be in used

rapidly and simultaneously D. Continue to replenish uids with crystalloids at a reduced speed E. ‘Group and save’ the patient

Question 18A 24-year-old man presents afer a ght and is suspected o having bilateralmandible ractures. He begins to develop respiratory distress.What position or ongoing resuscitation should be considered in this patient?

A. Lef lateral position B. Right lateral position

C. Supine D. Sitting upright E. rendelenburg

Question 19A 59-year-old woman is involved in a motor collision. On arrival at the hospitalshe is short o breath and complains o lef-sided chest pain. On examination thereis an area o paradoxical movement o the chest wall.

Which o the ollowing would be the most appropriate management option giventhe likely diagnosis?

A. Oxygen, analgesia and respiratory support B. Chest drain insertion C. Emergency thoracotomy D. Immediate intubation E. Pericardiocentesis



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Question 20Which o the ollowing statements is FALSE?

A. A racture o the fh rib can give rise to penetrating intra-abdominal injury B. Te aponeurotic sheaths o the anterior abdominal wall are relative weak points

compared with the musculature that surrounds the lateral and posterior abdomen C. Diagnostic peritoneal lavage is effective at detecting blood loss within the

retroperitoneum D. Patients can lose a signicant amount o blood within the abdominal cavity

despite displaying no eatures o peritonism E. Te diaphragm marks the superior border o the abdominal cavity

Question 21A 45-year-old man is brought to the emergency room afer a all rom a balcony.On arrival he makes no sound, does not open his eyes to pain and makes no motorresponse to stimuli.What is his Glasgow Coma Score?

A. 0B. 1C. 3D. 5

E. 7

Question 22A 42-year-old man is brought to the emergency department ollowing a roadtraffic collision. On arrival, you note that he is immobilized in a hard collar, has

acial ractures and is in acute respiratory distress. An attempt at orotracheal tubeinsertion is unsuccess ul.Which o the ollowing would be the next step in his airway management?

A. Re-attempt orotracheal intubation afer 5 minutes B. Attempt nasotracheal intubation C. Per orm a cricothyroidotomy D. Attempt laryngeal mask airway insertion E. Per orm a tracheostomy



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Question 23Which o the ollowing is considered a normal intracranial pressure in the restingstate?

A. 1 mmHg B. 5 mmHg C. 9 mmHg D. 17 mmHg E. 22 mmHg

Question 24In a patient with a C-spine racture identied ollowing a primary survey, what isthe likelihood o a second, non-contiguous racture?

A. 5% B. 10% C. 25% D. 50% E. 75%

Question 25

A 23-year-old man has been smashed over the head with a beer bottle. He openshis eyes as ragments o glass are removed rom his scalp. He is groaning as hetries to stop your rubbing his sternum by raising his right arm and moving ittowards you.What is his Glasgow Coma Score?

A. 7 B. 8 C. 9 D. 10 E. 11

Question 26Which o the ollowing is the most common cause o a tension pneumothorax?

A. Markedly displaced thoracic spine ractures B. Penetrating chest trauma C. Positive pressure ventilation in patients with visceral pleural injury

D. Spontaneous rupture o an emphysematous bulla E. Subclavian vein catheterization



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Question 27You are prescribing crystalloid intravenous uid resuscitation or a 40-year-oldman who has sustained a 15% second-degree burn to his chest. You decide to give2 ml/kg. Te patient weighs 80 kg.

What rate o in usion should be prescribed? A. 50 ml/hr B. 100 ml/hr C. 150 ml/hr D. 200 ml/hr E. 250 ml/hr

Question 28An inner city shopkeeper is shot in the abdomen.Which o the ollowing statements is FALSE?

A. Fify percent o gunshot wounds to the abdomen involve the small bowel B. Exit wounds rom a gunshot will be located in a line made rom the pistol and

the entry wound C. Handguns represent a medium energy penetrating injury D. Te amount o damage caused by a bullet is dependent upon the trans er o energy

to the tissue, the duration o energy trans er and the amount o tissue involved

E. Te damage caused by a shotgun diminishes considerably i red rom adistance o 3 metres or more

Question 29Which o the ollowing statements about cerebral blood ow is FALSE?

A. Brain injury may result in an acute drop in cerebral blood ow B. Cerebral blood ow is reduced by hypotension, hypoxia and hypocapnia C. During childhood, cerebral blood ow can reach 90 ml/minute/100 g brain tissue D. Te normal cerebral blood ow in healthy adults is 20 ml/minute/100 g brain

tissue E. Te cerebral per usion pressure is calculated by the mean arterial pressure

minus the intracranial pressure



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Question 30A 21-year-old man is brought to the emergency department afer being stabbed inthe chest. He is visibly tachypnoeic and on examination has a large sucking woundto the lef side o the chest.

Which o the ollowing is not an appropriate management option? A. Analgesia B. Chest drain insertion C. Oxygen supplementation D. Sterile occlusive dressing over the wound E. Surgical airway

Question 31What is the likelihood o a patient with a traumatic brain injury having anassociated spinal injury?

A. 1% B. 2% C. 5% D. 25% E. 55%

Question 32Te highest achievable eye opening score on the Glasgow Coma Scale is:

A. 1 B. 2 C. 3 D. 4 E. 5

Question 33Te most common region or spinal injuries to occur is:

A. Cervical B. Toracic C. Toracolumbar junction D. Lumbar E. Lumbar–sacral junction



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Question 34An assessment o the musculoskeletal system orms part o which o the ollowing?

A. Primary survey B. Secondary survey C. Choice o adjunct D. History E. All o the above

Question 35Which o the ollowing is not consistent with the mechanism o injury?

A. Air bag: corneal abrasion and cardiac rupture

B. Shoulder harness: pulmonary contusion and intimal tear or thrombosis osubclavian artery

C. Lap seatbelt: Chance racture o lumbar spine D. Rear end shunt: hyperextension o the cervical spine with multiple laminar,

pedicle and spinous process ractures E. Pedestrian versus cyclist: deceleration injury

Question 36

Help ul in ormation or the receiving institution o a patient trans er includeswhich o the ollowing?

A. Patient demographic details B. AMPLE history C. Status and previous management D. Diagnostic investigations E. All o the above

Question 37In patients with spinal immobilization in place, how ofen should a log roll beper ormed to minimize the risk o pressure sores?

A. Every 30 minutes B. Every 45 minutes C. Every 1 hour D. Every 2 hours E. Every 4 hours



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Question 38A typical closed long bone racture results in what approximate volume o bloodloss?

A. 1 litre B. 2 litres C. 3 litres D. 4 litres E. Greater than 5 litres

Question 39An 18-year-old man is involved in a re at work. He has ull-thickness burns overboth his arms and partial thickness burns over the whole o the ront torso.Estimate the percentage burn he has sustained.

A. 18% B. 27% C. 30% D. 36% E. 45%

Question 40Regarding the unique characteristics o paediatric patients, which o the ollowingstatements is FALSE?

A. Hypothermia tends to develop more quickly B. Injuries in a child can result in personality and emotional disturbances in

uninjured siblings C. Injuries through growth plates may result in subsequent growth abnormalities D. Internal organ damage is ofen seen without overlying bony racture E. Around 10% o children who sustain severe multisystem trauma have residual

personality changes at 1 year

Question 41Pertinent questions rom the history regarding musculoskeletal trauma includewhich o the ollowing?

A. Involvement o police B. ime o day

C. Post-crash location o the patient D. Height o patient E. ime patient last ate or drank



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Question 42A 42-year-old woman is brought in afer a road traffic collision. You notice that sheis hypoxic and struggling to ventilate. Palpation o the neck is abnormal.Which o the ollowing most specically suggests a laryngeal racture?

A. Subcutaneous emphysema B. Distended neck veins C. Inability to palpate the racture D. achycardia E. No change in the quality o the voice

Question 43A 42-year-old woman has accidentally spilled hot oil rom a rying pan over herlef hand. On examination in the emergency room, you notice a dry, dark area oskin over the dorsum o the hand, which appears leathery. Tere is a demonstrableabsence o pain rom this area.How is the depth o the burn best described?

A. First degree B. Supercial C. Second degree D. Partial thickness

E. Full thickness

Question 44A secondary survey is required in which o the ollowing scenarios?

A. Isolated head injuries B. Isolated racture (non-long bone) C. Toracic trauma D. Abdominal trauma E. All o the above

Question 45During the assessment o muscle strength, what does a score o 4 represent?

A. otal paralysis B. Full range o motion with gravity eliminated C. Full range o motion against gravity

D. Full range o motion but less than normal strength E. Non-testable



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Question 46A 29-year-old man is admitted to the emergency department afer a all rom hisbike, which resulted in a head injury. On examination his eyes open spontaneously,he is able to obey commands and his verbal response is orientated.

How would his brain injury be classied? A. Very minor B. Minor C. Moderate D. Severe E. Li e-threatening

Question 47You come across an injured motorcyclist ollowing a road traffic collision. Heis wearing a helmet. You are keen to remove this in order to per orm an airwaymaintenance manoeuvre.How should the helmet be removed?

A. One person: gently slide the helmet rom the head in the supine position B. One person: rotate the neck to one side be ore sliding the helmet off C. wo people: one person provides in-line stabilization o the head and neck, the

other removes the helmet in the supine position

D. wo people: one person provides in-line stabilization o the head and neck, theother instructs the patient on how to remove the helmet himsel E. Tree people: one person provides in-line stabilization o the head and neck,

one holds the patient’s eet, one removes the helmet in the supine position

Question 48Severe injury ollowing major pelvic disruption can be due to which o the ollowing?

A. Arterial damage B. Venous damage C. Fracture D. Pelvic organ damage E. All o the above



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Question 49Regarding carbon monoxide inhalation, which o the ollowing statements is RUE?

A. A cherry-red skin discolouration is common B. Inhalation o even small quantities usually results in headaches C. Intubation is mandatory D. It cannot result in coma E. reatment with 100% oxygen increases the rate o dissociation o

carboxyhaemoglobin

Question 50Which o the ollowing nerve palsies is not associated with the preceding injuries?

A. Fibular neck racture: supercial peroneal nerve B. Anterior shoulder dislocation: ulnar nerve C. Acetabular racture: superior and in erior gluteal nerve D. Supracondylar ractures in children: median and anterior interosseous nerve E. Knee dislocation: posterior tibial nerve



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Answer 1: B. The measurement of the labialcommissure to the external auditory meatus

Oropharyngeal (or Guedel) tubes are a type o airway adjunct. Te correct sizeis selected by measuring the airway against the patient’s head, either betweenthe corner o the mouth (labial commissure) and the external auditory meatus,or rom the angle o the jaw to the incisors. A nasopharyngeal tube is sized byapproximating the diameter o the patient’s little nger. Laryngeal mask airways(LMAs) are sized according to the approximate patient size and sex, as ollows:

• LMA size 3: small women • LMA size 4: large women or small man • LMA size 5: large man

Te measurement between the hyoid and the chin is part o the 3-3-2 rule in theassessment o a difficult intubation (see answer 2).

Arthur Ernest Guedel, American anaesthetist (1883–1956)

Answer 2: D. An inability to rule outcervical spine fractureTe LEMON assessment can be used to predict difficult intubation, as ollows.L = look externally or characteristics that are known to cause difficult intubationor ventilation, such as a short, muscular neck, a receding chin or an overbite.E = evaluate the 3-3-2 rule as ollows: the distance between the incisors shouldbe 3 nger breadths; the distance between the hyoid bone and chin should be atleast 3 nger breadths; and the distance between the thyroid notch and oor othe mouth should be at least 2 nger breadths. M = Mallampati score, as ollows:class 1 – sof palate, uvula, auces and pillars visible; class 2 – sof palate, uvula,

auces (but not pillars) visible; class 3 – sof palate and base o uvula visible; class4 – hard palate only visible. O = obstruction: any cause that can cause airwayobstruction, and thus make laryngoscopy and ventilation difficult (e.g. trauma,peritonsillar abscess). N = neck mobility: reduced neck mobility makes intubationdifficult and immobilized patients in a hard collar (such as trauma patients in

PAPER 1ANSWERS2



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whom a cervical spine racture has not yet been ruled out) will clearly have noneck movement.

Te Mallampati score, published in 1985 by theCanadian Anaesthetists’ Society Journal , was named afer Seshagiri Mallampati, an American anaesthetist.

Answer 3: B. Check his airwayTis patient’s presentation carries the risk o airway or breathing problems. Always

ollow a logical progression o ABCDE. Tis reduces the chance o importantinjuries being missed and allows all involved to manage the most imminent threatto li e rst. All the answers here with the exception o option B address circulationand exposure.

Answer 4: B. Insert a wide bore cannula intothe second intercostal space left-hand sideTis patient has a tension pneumothorax. Air entering the pleural cavity duringinspiration cannot escape during expiration due to the pleura acting as a one-way valve. ension pneumothorax is an emergency, as the build-up o air compressesthe lung, preventing expansion. Tis puts pressure on the mediastinum,reducing cardiac output, which can be potentially atal i not relieved. Symptomsinclude breathlessness and chest pain, and on examination there is tachypnoea,hypotension, reduced expansion and air entry on the affected side o the chest,hyperresonance to percussion on the affected side and deviation o the tracheaand apex beat to the opposite side. I not decompressed urgently, cardiorespiratorycollapse and death can ensue within minutes. Decompression is by insertion oa large bore cannula into the second intercostal space in the mid-clavicular lineo the affected side (needle thoracocentesis). A gush o air will be heard as thepressure is released. A ormal chest drain can then be inserted (fh intercostalspace o the mid-axillary line). Do not waste time obtaining a chest X-ray or ECG

i the diagnosis is suspected. reatment should be based on clinical ndings.

Answer 5: D. Tracheobronchial tree injuryTis patient has an injury to the tracheobronchial tree. None o the othergiven options would result in the clinical ndings described. Injuries to thetracheobronchial tree are unusual and associated with a high early mortality.Clinical eatures include haemoptysis and subcutaneous emphysema, as well asthose associated with a tension pneumothorax. Afer chest drain insertion, alarge persistent air leak is common and more than one tube may be required toovercome a large leak. emporary intubation o the contralateral main bronchusmay be possible, but operative intervention is a priority.



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Answer 6: E. All of the aboveBlunt injury to the chest can result in a myocardial contusion. Dysrhythmiasare typical. Te most common ECG ndings are multiple ventricular ectopics,sinus tachycardia, atrial brillation, S -segment changes and bundle branch

block (usually on the right). Affected patients should be closely monitoredor li e-threatening dysrhythmias or 24 hours. Afer this interval, the risk o

dysrhythmias decreases substantially.

Answer 7: C. The core temperature is 34°CTe diagnosis o brain death requires the ollowing criteria to be satised: GCSo 3, pupils are non-reactive, there should be no spontaneous ventilatory effort,and the brainstem reexes must be absent (e.g. oculocephalic, corneal, doll’s

eyes and gag reexes). Ancillary studies that may be used to conrm brain deathinclude: EEG (no activity at high gain), cerebral blood ow (none), intracranialpressure (should exceed mean arterial pressure or an hour) and cerebralangiography. Hypothermia and barbiturate intoxication can mimic brain deathand hence must be excluded. As this patient’s temperature is 34°C, he should bewarmed and a diagnosis o brain death provided only i the criteria are ullledat normothermia.

Answer 8: C. A reduction in intracerebralpressure can be caused by raisingthe partial pressure of carbon dioxideTis question deals with the Monroe-Kelly doctrine, which describes the brain locatedinside a solid box (the skull). It explains how the pressure inside this box (intracerebralpressure) will rise once the compensatory mechanisms have been overcome.Secondary brain injury can be prevented by ensuring adequate oxygenation othe brain, and that carbon dioxide levels do not rise above normal limits.

A raised PaCO 2 causes intracranial vasodilatation and a urther increase inintracranial pressure.

Alexander Monroe, Scottish surgeon (1733–1817)George Kelly, Scottish anatomist (18th century)

Answer 9: A. Central cord syndromeTis vignette describes a classic central cord syndrome resulting rom a rear endshunt and hyperexion injury. Te pathogenesis describes a vascular insufficiency

rom the anterior spinal artery. Te artery supplies the central part o the cord. Tearrangement o the motor bres o the cervical cord causes the upper limbs to bemost severely affected.



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Brown-Séquard syndrome describes the eatures o unilateral transection(hemisection) o the spinal cord. Affected patients suffer ipsilateral loss omotor unction with impaired joint position and vibration sense (dorsal columndys unction). Tere is also a contralateral sensory loss or pain and temperature.Brown-Séquard syndrome has the best prognosis o all spinal cord lesions.

Charles-Édouard Brown-Séquard, British neurologist (1817–1894)

Answer 10: B. Realignment and splintageTe initial management o displaced ractures should be per ormed ollowingmanipulation into the anatomical position. Realignment is achieved using in-linetraction. Te main role o the splint is to prevent any urther damage to the softissue structures including nerves, arteries and veins. I closed reduction o adislocated joint is unsuccess ul it is per ectly reasonable to only splint the de ormity.

Answer 11: A. Log roll the patient to theleft and insert a wedge on the right-handside so she remains at a tilt of 15 degreesin the supine positionTis woman is heavily pregnant. A large uterus can compress the in erior venacava and result in impaired venous return. As Starling’s law predicts, reduced pre-load results in a reduction in contractility, cardiac output and a subsequent dropin blood pressure. Te best way to ensure the health o the oetus is to optimizethe health o the mother. Vasopressors have a detrimental effect on the oetus byreducing uterine blood ow.

Answer 12: C. C2A hangman’s racture involves the posterior elements o C2 at the parsinterarticularis.

Answer 13: C. Arrange prompt angiographyElderly patients admitted with trauma should be closely monitored. Lack ophysiological reserve and co-morbidities makes or a more guarded prognosis thanyounger individuals.

Te low haemoglobin result should be viewed with respect to the clinicalpicture. Sympathetic overdrive caused by inadequate resuscitation will lead toperipheral vasoconstriction o the skin and perspiration.

Retroperitoneal bleeding is a common unrecognized source o bleeding. AFAS scan will not detect retroperitoneal haemorrhage. In this circumstance the



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patient should undergo immediate angiography with attempted transcatheterembolization.

I a all in haemoglobin is caused by dilution, urea and packed cell volume willalso be decreased.

Answer 14: A. Lund & Browder chartsLund & Browder charts are widely used in clinical practice and offer an accurate wayo assessing the percentage body sur ace area o burns. Areas o skin with erythemaand no blistering should not be included in the calculation. Wallace’s ‘rule o nines’is easier to remember and use, but less accurate. Knowing that the sur ace area o thepatient’s palm equates to 1% o the total body sur ace area can also be use ul.

Once the percentage body sur ace area o burn is known, an accurate calculationcan be made o the volume o uid that should be used or resuscitation. TeParkland ormula can be used or this.

Answer 15: D. Obtain haemodynamic stabilityTe principle o immediate trauma management is to per orm the primary surveyand, where required, address issues prior to immediate trans er. Remember, ‘li ebe ore limb’.

Answers A, B, C and E would be per ormed either during the secondary surveyor later. During the primary survey, the C-spine would be protected using collarand blocks, but not necessarily denitively cleared.

Answer 16: B. Any burn in patientsunder 10 years

rans erring all patients under the age o 10 with minor burns would be aninappropriate use o resources.

Te American Burn Association gives the ollowing list o types o burn injury

that require trans er to a burn centre: 1. Partial-thickness and ull-thickness burns on greater than 10% o the body

sur ace area in any patient 2. Partial-thickness and ull-thickness burns involving the ace, eyes, ears, hands,

eet, genitalia, and perineum, as well as those that involve skin overlying major joints

3. Full-thickness burns o any size in any age group 4. Signicant electrical burns, including lightning injury (signicant volumes o

tissue beneath the sur ace can be injured and result in acute renal ailure and

other complications) 5. Signicant chemical burns 6. Inhalation injury 7. Burn injury in patients with pre-existing illness that could complicate

treatment, prolong recovery, or affect mortality



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8. Any patient with a burn injury who has concomitant trauma poses anincreased risk o morbidity or mortality, and may be treated initially in atrauma centre until stable be ore being trans erred to a burn centre

9. Children with burn injuries who are seen in hospitals without qualiedpersonnel or equipment to manage their care should be trans erred to a burn

centre with these capabilities 10. Burn injury in patients will require specialized social and emotional or

long-term rehabilitative support, including cases involving suspected childmaltreatment and neglect

Answer 17: A. Consider blood productsand rapidly assess the patientfor a source of bleedingTe patient is almost certainly haemorrhaging rom somewhere but is per using his vital organs adequately at this stage as evidenced by his appropriate narrative o whathappened. Be aware though that young and t patients may per use their brain witha loss o up to 50% o their circulating volume, and then crash. Tis question aims toaddress the valid risk o over-trans using with crystalloid in hypovolaemic shock.

Answer 18: D. Sitting upright

Bilateral mandibular ractures can cause a loss o normal airway support. Forthis reason, airway obstruction can result i the patient is in a supine position.Remember that the patient who re uses to lie at may be having difficultymaintaining their airway, and those with bilateral mandible ractures wouldbe best nursed sitting upright. Obviously, this can only be done afer ruling outcervical spine injury, and a denitive airway may be necessary.

Te rendelenburg position describes the patient lying supine with the eet elevatedabove the head. It would there ore exacerbate the problem here. Te lef lateral positionis use ul in pregnant patients, as this relieves the pressure o the gravid uterus rom

the in erior vena cava, thus improving venous return. Tere is no specic advantageo the right (as opposed to lef) lateral decubitus position in the trauma setting.

Answer 19: A. Oxygen, analgesiaand respiratory supportTe examination ndings suggest a ail chest. A ail chest is a li e-threatening injurycaused by high-impact trauma resulting in two or more consecutive ribs being brokenin two or more places. Tat segment o the chest wall then moves independently,moving in on inspiration and out on expiration – so-called paradoxical motion. Flailchests may be associated with an underlying pulmonary contusion and there is a risko pneumothorax rom rupture o the pleura by bone ends. Tis injury is associatedwith a high mortality. Te most important part o management is the administration



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o oxygen but, by improving patient com ort by providing adequate analgesia (suchas intercostal nerve blocks), respiratory effort can also be improved. Depending onthe degree o hypoxia, positive pressure ventilation may be required and its use haslargely superseded rib racture xation. Te mortality associated with a ail chestis largely dependent on the degree o the underlying pulmonary contusion.

Answer 20: C. Diagnostic peritoneallavage is effective at detecting bloodloss within the retroperitoneumTe identication o retroperitoneal bleeding can be clinically difficult, and DPL(diagnostic peritoneal lavage) would be inappropriate i such a suspicion wasraised. I an injury to a retroperitoneal organ is suspected, a FAS scan (Focused

Assessment with Sonography or rauma) or C imaging would be indicated.Retroperitoneal organs include the pancreas, duodenum, ureters, kidneys andposterior aspects o ascending and descending colons.

Answer 21: C. 3Based on the Glasgow Coma Scale (below), this patient’s score is E1 V1 M1. TeGlasgow Coma Scale (GCS) is a subjective scale used or the initial and continuingassessment o levels o consciousness in patients presenting ollowing brain injury.

Te components are as ollows:Eye opening (E)

4 Eyes open spontaneously 3 Eyes open to speech2 Eyes open to pain1 No eye opening

Best motor response (M)6 Obeys commands

5 Localizes to pain4 Withdraws rom pain (normal exion)3 Abnormal exion in response to pain (decorticate response)2 Abnormal extension in response to pain (decerebrate response)1 No motor response

Verbal response (V)5 Coherent speech4 Con used/disorientated speech3 Inappropriate words without conversational exchange2 Incomprehensible sounds1 No verbal response

Te maximum score is thus 15 (E4 M6 V5), and the minimum is 3 (E1 M1 V1).Hence a score o 0 or 1 is impossible.



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Answer 22: D. Attempt laryngealmask airway insertionTe ollowing airway decision scheme is or use in immobilized patients (i.e. suspectedC-spine racture) with apnoea or acute respiratory distress. I an attempt atorotracheal intubation is unsuccess ul, it is best to proceed swifly rather thanwait and re-attempt it later. Given the patient’s acial injuries, a nasotracheal tubeshould not be inserted. In this case a laryngeal mask airway (or other extraglotticdevice) should be inserted as a temporary bridge to a denitive airway. I this ails,a cricothyroidotomy should be per ormed.

Answer 23: C. 9 mmHgTe normal intracranial pressure (ICP) in the resting state is approximately10 mmHg (7 to 15 mmHg). Many pathological processes that affect the brainmay result in a raised ICP. A raised ICP in turn may reduce cerebral per usionand cause or exacerbate cerebral ischaemia. A sustained ICP over 20 mmHg isassociated with poorer outcomes.

Answer 24: B. 10%Approximately 10% o patients with C-spine ractures have a second non-contiguous

vertebral column racture.

Answer 25: C. 9Tis man is able to localize pain, open his eyes to noxious stimuli and is makingincomprehensible sounds. Tis gives him a Glasgow Coma Score o 9 (Eyes 2,Verbal 2, Motor 5). Patients intoxicated with alcohol represent a challenge to theattending physician. NICE guidelines stipulate that i any o the ollowing listbe present, urgent C imaging should be arranged. Note the act that alcohol

intoxication should have no bearing on the decision to image the brain.Te ollowing is a list o indications or urgent neuroimaging:

• GCS


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• Post-traumatic seizure • Focal neurological decit • >1 episode o vomiting • Amnesia or events more than 30 minutes be ore the injury

William Henry Battle, English surgeon (1855–1936)

Te Glasgow Coma Score was rst published in 1974 by Grahameasdale and Bryan Jennett, both pro essors o neurosurgery at the

University o Glasgow. Note there is a modied version o the scale:a 14-point scale that omits ‘abnormal exion’. Te modied scale

is also in use, including at the ounding unit in Glasgow.

Answer 26: C. Positive pressure ventilationin patients with visceral pleural injuryTe most common cause o a tension pneumothorax is mechanical ventilation,specically with positive pressure ventilation in patients with visceral pleuralinjury. In these cases it may be difficult to spot as the patient is typically sedated. Itcan also occur as a complication o a simple pneumothorax ollowing penetratingor blunt chest injuries where the parenchymal lung injury ails to seal. Othercauses include attempted subclavian/internal jugular venous catheter insertion,

poor occlusive dressings in open chest wounds that create a ap-valve andmarkedly displaced thoracic spine ractures.

Answer 27: C. 150 ml/hr In accordance with A LS guidelines, patients with signicant burns require 2 to4 ml/kg o intravenous uid resuscitation per percentage o second-/third-degreeburn in the rst 24 hours. Hal o this is given in the rst 8 hours, and the secondhal is given over the subsequent 16 hours. In this case, at 2 ml/kg, or an 80 kgman and 15% burn, we require 2 × 80 × 15 = 2400 ml in 24 hours. As hal is givenin the rst 8 hours, a prescription should be made or 150 ml/hr, which equates to1200 ml over 8 hours. Please note this calculation does not include maintenanceuid, which will be in addition to this.

Answer 28: B. Exit wounds from a gunshot will be located in a line made fromthe pistol and the entry woundBullets do not always ollow a single trajectory but ollow the line o leastresistance. It is important to establish the path with which the bullet has taken toascertain which anatomic structures are likely to have been involved.



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Answer 29: D. The normal cerebralblood ow in healthy adults is20 ml/minute/100 g brain tissue

In healthy adults, cerebral blood ow is 50 ml/minute/100 g brain tissue. While theow rate is similar in in ants, it gradually increases to a peak o 90 ml/minute/100 gbrain tissue at the age o 5. Brain injury can reduce cerebral blood ow or therst ew hours, but this tends to normalize in the subsequent days. Te cerebralper usion pressure is calculated by the mean arterial pressure minus the intracranialpressure. A cerebral per usion pressure between 50 and 150 mmHg is requiredto maintain a constant cerebral blood ow. Cerebral blood ow is reduced byhypotension, hypoxia and hypocapnia.

Answer 30: E. Surgical airwayA sucking wound is characteristic o an open pneumothorax, caused by largede ects in the chest wall that remain open. An opening in the chest o more thantwo-thirds o the diameter o the trachea allows air to pass pre erentially throughthe chest wound. Tis impairs ventilation, resulting in hypoxia, hypercarbia andrespiratory acidosis. Management is initially by closing the de ect with a sterileocclusive dressing that overlaps the wound and is taped on three sides. Tis createsa utter valve, allowing air to escape on expiration, but avoiding air entry during

inspiration. Denitive treatment is by insertion o a chest drain remote to the siteo the wound.

Answer 31: C. 5%Approximately 5% o patients with brain injury have an associated spinal injury.Conversely, 25% o spinal injury patients have an associated brain injury.

Answer 32: D. 4Te eye opening component o the GCS is as ollows:

1 No response 2 Eyes open to pain 3 Eyes open to voice 4 Eyes open spontaneously

Answer 33: A. CervicalApproximately 55% o all spinal injuries occur in the cervical region, 15% occur inthe thoracic region, 15% in the thoracolumbar, and 15% in the lumbar-sacral area.



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Answer 34: E. All of the aboveDuring the primary survey, control o external haemorrhage (e.g. rom racturesprior to reduction) orms part o the assessment o the circulation. Te mainassessment o the musculoskeletal system occurs during the secondary survey and

baseline X-rays are obtained as a orm o adjunct to the secondary survey.

Answer 35: E. Pedestrian versus cyclist:deceleration injuryDeceleration injuries tend to occur with high-energy accidents. Tey result whenthere is differential movement between a mobile body part and a xed body part.Examples include the mobile aortic arch against the xed descending aorta and themobile lobes o the liver against the xed ligamentum teres.

Answer 36: E. All of the aboveAll the listed in ormation is o use to the receiving hospital. However, this canbe communicated by telephone, ax or electronically. Documentation should notdelay trans er under any circumstances.

Answer 37: D. Every 2 hoursIdeally the spinally immobilized patient should be removed rom a rigidspine board and log rolled every 2 hours, to minimize the risk o developingpressure sores.

Answer 38: B. Two litresDisplaced emoral ractures can result in up to 2 litres o blood loss into thethigh, which, in the multiple injuries patient, may mani est itsel as Class 3 shock.Reduction and splinting signicantly decreases subsequent haemorrhage.

Answer 39: D. 36%Assessing the extent o burns is done quickly using Wallace’s ‘rule o nines’. Tebody is ractioned into units divisible by nine, as ollows:

Head and neck 9%Upper limb 9% eachAnterior torso 18%

Posterior torso 18%Lower limb 18% eachPerineum 1%

otal 100%

In this case: both arms = 9% + 9% and ront torso = 18%, giving a total o 36%.



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All depths o burn except rst grade are included in assessing the burned area.An alternate way o assessing the extent o the burn is to use the patient’s palmto represent an area o 1%. Although the ‘rule o nines’ is use ul in adults, it isinaccurate or children due to the relative disproportionate size o certain bodyparts (e.g. the head is relatively larger). Most burn units have charts (e.g. the Lund

& Browder chart) that can more accurately predict body sur ace areas with respectto age.

Answer 40: E. Around 10% of children whosustain severe multisystem trauma haveresidual personality changes at 1 year As the child’s skeleton is incompletely calcied, it is more pliable. Hence, internal

organ damage is ofen seen without an overlying bony racture. Indeed, theidentication o ractures in children suggests the trans er o a massive amount oenergy, and underlying organ injuries should be suspected. Te body sur ace areato body volume ratio is higher in children (but diminishes with age), and thermalenergy loss is thus a greater risk, and hypothermia can develop more quickly.As many as 60% o children suffering severe multisystem trauma have residualpersonality changes at 1 year afer discharge, and up to 50% have either a cognitive orphysical disability. Childhood injuries can have an impact on the wider amily, withemotional or personality disturbances ound in two-thirds o uninjured siblings.

Injuries through growth plates can result in long-term growth abnormalities, suchas leg-length discrepancy ( emur) or scoliosis (thoracic vertebra).

Answer 41: C. Post-crash locationof the patientTe pre- and post-crash location o the patient gives an idea as to whether thepatient was ejected and the distance the patient was thrown. Damage to the vehicleprovides a directional indication o orces applied across a racture site. Te useo a sa ety restraint may indicate potential spinal, intra-abdominal and C-spineinjuries. I the patient ell it is important to orm a mental picture o how thepatient landed. I the patient was hit by a vehicle, what was the orientation o thelimb during the collision? An AMPLE history is always required. Tis includesany allergies, the mechanism o ingestion o pharmacological or recreationaldrugs, psychiatric complaints and previous musculoskeletal injuries. Additionalpre-hospital in ormation includes the position in which the patient was ound, theextent o bleeding at the scene (as a rule o thumb the number o units o blood thathave been lost are ‘blood on the oor and our more’), exposed bone ends, openwounds and any obvious de ormity. In the acute trauma situation, considerationo last meal or uid input is largely academic. I the airway is compromised, then arapid sequence induction o anaesthesia will usually be per ormed.



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Answer 42: A. Subcutaneous emphysemaFracture o the larynx is rare and can present with airway obstruction. Te typical triado symptoms in laryngeal racture is (1) hoarseness, (2) subcutaneous emphysema,and (3) a palpable racture. Severe respiratory distress or complete airway obstruction

warrants intubation (or a surgical airway i this ails). Tese injuries may be associatedwith trauma to the oesophagus, carotid artery or jugular vein. C imaging can helpconrm the diagnosis (although airway management should not be delayed!).

Distended neck veins in the trauma setting can be due to pneumothorax orpericardial effusion.

Answer 43: E. Full thicknessA rst-degree burn is erythematous and pain ul without evidence o blistering.

It is conned to the epidermis. A second-degree burn (also known as a partialthickness burn) is characteristically red and mottled with evidence o swelling andblistering. Injury extends into the dermis. A third-degree burn ( ull thickness)appears leathery, dry, and can be dark or waxy white. It can (but not always) bepainless representing injury to the nerve endings within the subcutaneous layer.

Answer 44: B. Isolated fracture(non-long bone)By denition the multiple-injured trauma patient has the potential or distractinginjuries. Assessment o the extremities has three goals: identication o li e-threatening injury, identication o limb-threatening injury and a systematic reviewo all musculoskeletal areas to look or any other injuries. It involves a history andrigorous examination o the bones and joints to highlight any tenderness, swelling,de ormity, laxity and an assessment o the range o movement o the joints. Tis isthen ollowed by assessment o the neurovascular status o all limbs. Te nal part othe musculoskeletal examination is baseline radiography o suspected injured areas.

Answer 45: D. Full range of motionbut less than normal strengthTe MRC scale or assessing muscle power is a reliable and validated scale, rstpublished by the Medical Research Council in 1975. Each muscle group can begraded as ollows:

0 otal paralysis 1 Palpable or visible contraction 2 Full range o motion with gravity eliminated 3 Full range o motion against gravity 4 Full range o motion but less than normal strength 5 Normal strength N Non-testable



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Answer 46: B. Minor Tis patient’s GCS is 15. He opens his eyes spontaneously (E4), can obeycommands (M6) and has orientated speech (V5). Tis classies the brain injuryas ‘minor’. Te classication o brain injury is as ollows: minor (GCS 13 to 15);

moderate (GCS 9 to 12); and severe (GCS 3 to 8). Te terms ‘very minor’ and‘li e-threatening’ do not exist in this context. A GCS o 8 or less has become anaccepted denition o coma, and urgent anaesthetic input is required or airwayassessment and consideration o intubation.

Answer 47: C. Two people: one personprovides in-line stabilization of the headand neck, the other removes the helmetin the supine position

rauma patients with a helmet who require airway management need the headand neck immobilized in a neutral position be ore helmet removal. One personthere ore immobilizes the head and neck in-line rom below. A second personexpands the helmet laterally be ore gently removing it, taking care to clear the noseand occiput. Once the helmet is removed, the second person takes over in-lineimmobilization rom above. Where possible, a cast cutter may be used to removethe helmet under immobilization, thus reducing unnecessary movement o thecervical spine. A third person is not required. Clearly, the other methods describedare unsa e in the setting o a potential cervical injury.

Answer 48: E. All of the abovePelvic disruption is associated with tears to the pelvic venous plexus and, in severeanterio-posterior compression injuries, internal iliac vessel rupture. Commonlyassociated injuries include genito-urinary complications.

Answer 49: E. Treatment with 100% oxygenincreases the rate of dissociationof carboxyhaemoglobinInhalation o carbon monoxide (CO) can result in nausea and headaches,con usion, coma and death, but low-level inhalation is ofen asymptomatic.CO bonds to haemoglobin around 240 times as well as oxygen (to ormcarboxyhaemoglobin). Furthermore, dissociation is slow, with a hal -li e o 4 hours

in room air. reatment with 100% oxygen reduces the dissociation hal -li e ocarboxyhaemoglobin to approximately 40 minutes. Oxygen is delivered by anon-rebreathe mask. Intubation is not routinely required. Te cherry-red skindiscolouration is a rare eature. Indeed, this is more commonly seen in thedeceased, as the discolouration masks the usual bluish pallor.



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Answer 50: B. Anterior shoulder dislocation:ulnar nerveAlthough a ull neurological assessment o an injured limb should be carried out, itis worthwhile considering which nerve or nerves are most likely to be affected.

Fibular neck ractures are associated with supercial peroneal nerve damagecausing impairment o ankle eversion, and a sensory decit o the lateral aspect othe dorsum o the oot.

Te unction o the axillary nerve and musculocutaneous nerve should be notedin anterior shoulder dislocations. From a medicolegal standpoint, this should alsobe documented in the notes prior to reduction on the joint. Assessing shoulderabduction and the sensation over the military badge area tests axillary nerve

unction. Te musculocutaneous nerve can be tested by assessing elbow exionand the sensation o the lateral aspect o the orearm.

Acetabular ractures can damage both superior and in erior gluteal nerves,which are predominantly motor nerves. Hip abduction and extension shouldbe evaluated, respectively. Childhood supracondylar ractures can result in anabsence o exion o the middle nger distal interphalangeal joint. Dislocationso the knee can result in posterior tibial nerve palsy, leading to an absence o toeexion and paraesthesia in the sole o the oot.



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3Question 1You attend a trauma call or a 32-year-old cyclist and suspect he has airwayobstruction.Which o the ollowing is not an objective sign o possible airway obstruction?

A. Agitation B. Obtundation C. Cyanosis D. Accessory muscle use E. Subcutaneous emphysema

Question 2A patient is brought in by ambulance ollowing a motor vehicle collision andis ound to have both vasodilation and relative hypovolaemia. Tere is no clearevidence o haemorrhage.What type o shock are they most likely to have?

A. Cardiogenic shock B. Neurogenic shock C. Hypovolaemic shock D. Addisonian shock E. Not enough in ormation to say

Question 3Which o the ollowing is not consistent with a massive haemothorax?

A. Accumulation o more than a third o the patient’s blood volume in the chestcavity

B. Accumulation o over 1500 ml o blood in the chest cavity

C. Distension o the neck veins D. Ipsilateral hyperresonance to percussion E. Large accumulation o blood in a hemithorax resulting in respiratory

compromise

PAPER 2QUESTIONS



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Question 4A patient, who is opening his eyes to a voice command, is con used and localizingto pain ul stimuli.What is his Glasgow Coma Score (GCS)?

A. 3 B. 6 C. 7 D. 12 E. 15

Question 5Which o the ollowing describes the eatures o central cord syndrome?

A. Lef-sided neurological signs worse than the right B. Right-sided neurological signs worse than the lef C. Upper limb neurological signs worse than the lower limbs D. Lower limb neurological signs worse than the upper limbs E. Ipsilateral loss o power below the lesion and contralateral loss o pain and

temperature

Question 6A 20-year-old man is brought to the emergency department with a head injury ounknown cause. On examination there is clear uid arising rom the ear and nose,and evidence o bruising behind the lef ear. Te patient vomits twice during theconsultation.Which o the ollowing eatures does not specically suggest an underlying basilarskull racture?

A. Bruising behind the lef ear B. Clear uid rom the ear C. Clear uid rom the nose D. Vomiting E. All o the above point specically to a basal skull racture



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Question 7A patient is admitted having been assaulted. As part o the surgical team youexamine his abdomen. You detect percussion tenderness in the lef ank.Which o the ollowing options is not appropriate?

A. Care ully assess or rebound tenderness B. Auscultate the abdomen to determine whether an ileus is present C. Once your examination is complete, ensure the patient is covered knowing that

hypothermia contributes to impaired coagulation D. Examine the pelvis or stability, care ully documenting your ndings E. Inspect the gluteal region or associated injuries

Question 8You are about to per orm a rapid sequence intubation.Which o the ollowing is not part o the sequence?

A. Pre-oxygenate with 100% oxygen B. Apply pressure over the thyroid cartilage C. Administer an induction drug D. Administer a muscle relaxant E. Intubation

Question 9A 42-year-old man is admitted ollowing a road traffic collision. Althoughthere is no evidence o penetrating trauma, the patient is hypoxic, tachycardicand hypotensive, with decreased air entry and dullness to percussion over theright hemithorax. A haemothorax is suspected and a subsequent chest drainconrms the diagnosis.Which o the ollowing is a poor indication or thoracotomy?

A. A persistent drain loss o over 200 ml/hour B. Immediate drain output o over 1500 ml C. Inability to stabilize the patient D. Persistent need or blood trans usion E. Te presence o bright blood in the tube suggestive o an arterial source



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Question 10A 49-year-old engineer is orced to stop his car on the hard shoulder o themotorway due to a mechanical ailure. As he steps out o the vehicle a passing lorrysideswipes him. He sustained multiple injuries o which the most serious is a crush

amputation to the thigh.As the rst responder on scene, what is the best way to control the bleeding romhis mangled limb at the roadside?

A. Elevate what is remaining o the crushed limb B. Apply direct pressure to the thigh C. Establish intravenous access D. Apply a tourniquet E. Wrap the thigh with bandages

Question 11A 21-year-old man has just undergone a C brain scan ollowing a head injury.Which o the ollowing eatures would suggest a subdural haematoma?

A. A biconvex lesion o an intensity suggestive o blood B. A crescentic lesion o an intensity suggestive o blood C. Diffuse swelling o the brain with loss o normal grey–white distinction D. Lesions within the cerebrum o an intensity suggestive o blood

E. Petechial haemorrhages

Question 12Central cord syndrome is classically seen in which o the ollowing mechanisms oinjury?

A. Axial compression type injuries B. Lateral exion type injuries C. Hyperexion injuries D. Hyperextension injuries E. Lap belt injuries



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Question 13As part o a trauma call, you are asked to see a 59-year-old gentleman who has sel -harmed. He has taken a kni e to his orearm and made multiple deep incisions. Tisis not the rst time that he has sel -harmed in this way. As part o your assessment,

you see that the lacerations extend deep to the investing ascia. You are unable topalpate an ulnar pulse and there is demonstrable motor and sensory decit in anulnar nerve distribution. Te capillary rell time distally is 2 seconds. His pulse is120/min and blood pressure is 80/55 mmHg.What is your next course o action?

A. Ascertain whether an ulnar pulse is detectable with a handheld Doppler probe B. Check his old notes to see i his neurovascular decit is pre-existing C. Commence an intravenous uid in usion D. Explore the wounds under local anaesthesia to ascertain whether the ulna

artery has been lacerated E. Re er to your local plastic surgery team in light o the neurovascular decit

Question 14You are the rst responder to a 17-year-old girl who has been stabbed in theanterior chest wall on the lef-hand side. On examination she is in extremis. Yound there is tracheal deviation to the right and there is hyperresonance and quietbreath sounds throughout the lef side.What should you do?

A. ube thoracostomy at fh intercostal space, anterior to the mid-axillary line,lef-hand side

B. ube thoracostomy at fh intercostal space, anterior to the mid-axillary line,right-hand side

C. Needle decompression at second intercostal space mid-axillary line, lef-handside

D. Needle decompression at second intercostal space mid-clavicular line, right-

hand side E. Needle decompression at second intercostal space mid-clavicular line, lef-handside

Question 15Which o the ollowing is not a eature consistent with cardiac tamponade?

A. A rise in jugular venous pressure on inspiration B. Clearly dened gallop rhythm on auscultation C. Hypotension D. Pulseless electrical activity E. Raised jugular venous pressure



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Question 16A 34-year-old woman is admitted to the hospital within hal an hour o ahead injury.Which o the ollowing is an indication or a C brain scan?

A. A deep skull laceration B. A single reported episode o vomiting since the injury C. Age o 34 D. Amnesia o an hour prior to the injury E. GCS o 14 on admission

Question 17Which o the ollowing statements regarding anterior cord syndrome is RUE?

A. Tere is loss o posterior column unction B. Classically affects the upper limbs more than the lower limbs C. Has the best prognosis o incomplete injuries D. Is characterized by paraplegia and loss o pain and temperature sensation E. Is usually caused by a hyperextension injury

Question 18

Te radial nerve in the upper limb provides innervation to all except which o theollowing?

A. riceps brachii B. Flexor pollicis brevis C. Extensor digitorum communis D. Sensation in the rst dorsal web space E. Extensor carpi radialis

Question 19An 18-month-old boy is brought into the emergency department by his parents. Hewas lowered into a bath o water that was too hot and sustained burns to the ulllength o both his legs on the posterior aspect and also his buttocks.Estimate the percentage burn he has sustained.

A. 9% B. 14% C. 19%

D. 32% E. 40%



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Question 20You are asked to per orm an airway maintenance manoeuvre during a trauma callwhile awaiting the arrival o an anaesthetist.Which o the ollowing statements about these manoeuvres is FALSE?

A. Te chin should be lifed anteriorly in the chin lif B. Te neck needs to be hyperextended in the chin lif and the jaw thrust C. It is appropriate to rest the hands on the maxilla during the jaw thrust D. I simple airway-opening manoeuvres ail, an oropharyngeal or nasopharyngeal

airway may be o benet E. Immobilization o the cervical spine is essential during these procedures

Question 21Te emoral nerve is involved in which one o the ollowing?

A. Knee extension B. Knee exion C. Sensation to the outer aspect o the thigh D. Great toe dorsiexion E. Sensation to the sole o the oot

Question 22Which o the ollowing terms is used to describe a burst racture o the rstcervical vertebra?

A. Jefferson racture B. Hangman’s racture C. Greater compression racture D. Chance racture E. Wedge compression racture

Question 23A 28-year-old man is admitted to the emergency department ollowing a stabbing.On examination he is tachycardic and hypotensive, with distended neck veins andan obvious wound to the lef side o his chest. Air entry is normal and the chest isresonant to percussion.Which o the ollowing is the denitive management or the likely underlyingcondition?

A. Chest drain insertion B. Intubation and positive pressure ventilation C. Needle thoracocentesis D. Pericardiocentesis E. Pericardiotomy



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Question 24Which o the ollowing is RUE regarding hypovolaemic shock?

A. Class 1 shock is associated with a urine output greater than 30 ml/hour, arespiratory rate o 14–20 breaths per minute and a decreased pulse pressure

B. Class 2 shock is associated with 750–1500 ml o blood loss, a raised respiratoryrate o 20–30 breaths per minute and a urine output o 20–30 ml/hour

C. Class 4 haemorrhage represents the smallest volume o blood loss that isconsistently associated with a drop in systolic blood pressure

D. Class 3 shock is associated with a lowered urine output o 5–15 ml/hour and apulse o 100–120/min

E. Class 4 shock is associated with >2000 ml o blood loss and an increase in pulsepressure

Question 25In which o the ollowing positions is it sa est to immobilize the hand and wrist?

A. Full exion B. Edinburgh position C. Dublin position D. Full extension E. Straight

Question 26Which o the ollowing statements regarding chemical burns is NO true?

A. Alkali burns are more serious than acid ones B. Antibiotics are not indicated C. I dry powder is present, this should be brushed away be ore washing is

commenced D. Neutralizing agents should be used E. Te affected area should be washed with water

Question 27Regarding the surgical management o head injuries, which o the ollowingstatements is NO true?

A. Depressed skull ractures need operative elevation i the degree o depression ishal the thickness o the adjacent skull

B. Intracranial mass lesions should be treated by a neurosurgeon C. Penetrating injuries require monitoring o the intracranial pressure D. Prophylactic antibiotics are given or penetrating injuries E. Scalp wounds without underlying ractures can be closed sa ely



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Question 28In which o the ollowing scenarios would diagnostic peritoneal lavage NO beindicated?

A. A patient with a penetrating abdominal injury who is haemodynamicallyunstable

B. A patient who ell rom a roo , who is now tachycardic and complaining oaltered sensation

C. A patient who is haemodynamically normal but no FAS scan or abdominal Cis available

D. A pedestrian who has collided with a our-wheel-drive vehicle ishaemodynamically unstable and has ractured his pelvis

E. A ront seat passenger in a car is involved in a high-speed impact; he is con usedand disorientated but complaining o abdominal pain

Question 29A patient who was recently admitted to an emergency department requires urgenttrans er to a tertiary centre.Which o the ollowing investigations must be completed prior to trans er?

A. C-spine X-rays B. Haemoglobin

C. ECG D. Oxygen saturations E. None o the above

Question 30A 31-year-old man has sustained an injury to the chest and is brought into theemergency room. He is being assessed or signs o li e in the presence o a qualiedcardiac surgeon.

Which o the ollowing eatures suggests he is a candidate or resuscitativethoracotomy?

A. Blunt injury with a eeble pulse and no signs o li e B. Blunt injury with pulseless electrical activity and signs o li e C. Penetrating injury with a eeble pulse and signs o li e D. Penetrating injury with pulseless electrical activity and no signs o li e E. Penetrating injury with pulseless electrical activity and signs o li e



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Question 31You are called to assess the airway o a multiple-injured patient.Which one o the ollowing Glasgow Coma Scores would suggest the need orprompt intubation?

A. 15 B. 13 C. 11 D. 9 E. 7

Question 32With regard to the anatomy o the brain and skull, which o the ollowingstatements is FALSE?

A. Te meningeal arteries are located between the dura and the skull B. Epidural haematomas ofen lead to a rapid increase in intracranial pressure C. Te pterion is an anatomical weak spot o the skull under which the anterior

branch o the middle meningeal artery lies D. Te subdural space exists because the arachnoid membrane is not adhered to

the dura E. Te pia mater is attached to the arachnoid membrane

Question 33Te inability to ex the elbow indicates injury to which o the ollowing nerve roots?

A. C5 and C6 B. C6 and C7 C. C7 D. C8 E. 1



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Question 34A 45-year-old Jehovah’s Witness has allen rom a horse. She has an open-book

racture o her pelvis and a GCS o 13. She is tachycardic and hypotensive despiteintravenous uids. Her partner insists that she has a strongly held belie that she

should not have any blood trans usion. She has re used blood trans usions inthe past.What should you do?

A. Proceed with a blood trans usion despite her partner’s concerns B. Consider other blood products such as resh rozen plasma (FFP) C. Continue with a urther crystalloid in usion D. Apply a pelvic binder and consider urgent embolization E. ell the partner that, as the patient has an altered conscious level, this decision

is to be made by the doctors looking afer her

Question 35Regarding the airway management in paediatric trauma, which o the ollowingstatements is RUE?

A. An in ant’s trachea is approximately 8 cm long B. An oropharyngeal airway should be inserted backwards and rotated 180 degrees

into position

C. Intubation should be per ormed with cuffed tubes in younger children D. Te optimum position or airway opening is with the ace parallel to the planeo the bed

E. Pre-oxygenation is not required be ore intubation

Question 36A 45-year-old emale is admitted 30 minutes afer having had a high-speed roadtraffic accident. On examination o her abdomen, you see a prominent lap belt sign.

You suspect a small bowel injury.What would be the most effective imaging modality to conrm this suspicion?

A. C abdomen B. Diagnostic peritoneal lavage C. Ultrasound scan D. Abdominal radiograph E. MRI abdomen



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Question 37A sensory level at the umbilicus indicates spinal involvement to the level o whicho the ollowing?

A. 1 B. 4 C. 6 D. 8 E. 10

Question 38Which o the ollowing is most accurate at predicting mortality in geriatrictrauma?

A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory alkalosis D. Respiratory acidosis E. PaCO2

Question 39

Tere are numerous changes that occur during pregnancy. Having an appreciationo these changes is imperative in treating trauma in emales.Which o the ollowing statements best describes the growth o the oetus?

A. Te uterus expands in size, emerging rom the pelvic brim by week 10 B. Te mother’s abdominal viscera are pushed posteriorly to make room or the

oetus C. Te uterus is thicker-walled in trimester 3 in comparison to trimester 2 D. Foetal skull ractures late in pregnancy can result rom a mother’s pelvic

racture E. Te placenta is highly elastic

Question 40You are preparing a tray o drugs in readiness or a rapid sequence intubation.Which one o the ollowing statements about relevant drugs is correct?

A. Etomidate has a marked effect on both blood pressure and intracranial pressure B. Succinylcholine has a rapid onset and is long-acting

C. Flumazenil may be used to reverse the effects o benzodiazepines D. Succinylcholine administrations carry a risk o hypokalaemia E. Sedative drugs should be avoided in rapid sequence intubation



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Question 41Assessment o sensation provided by the radial nerve is per ormed by touchingwhich o the ollowing?

A. Fifh nger B. First web space C. Fingertips D. Regimental patch area E. Armpit

Question 42Which o the ollowing statements is RUE regarding trauma in elderly patients?

A. Patients on long-term diuretics are likely to have a chronically contractedintravascular volume

B. BP >120 mmHg suggests a normal circulating volume C. Once corrected or their smaller lean body mass, the uid requirements o

elderly patients are less than that o younger patients D. Patients on long-term diuretics are likely to have a metabolic acidosis E. Fluid resuscitation o the elderly patient should be more aggressive, due to likely

increases in systemic vascular resistance and cardiac aferload

Question 43What is the likelihood o a patient with a traumatic brain injury having anassociated spinal injury?

A. 1% B. 2% C. 5% D. 25% E. 55%

Question 44An inappropriate response to questions scores how many points on the GCS?

A. 1 B. 2 C. 3 D. 4

E. 5



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Question 45At which level does the spinal cord terminate?

A. 11 B. 12 C. L1 D. L2 E. L3

Question 46A 28-year-old homeless man presents to the emergency department duringa particularly cold winter evening. He complains o pain in his lef oot. Onexamination there is hyperaemia and oedema o the grea

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