MedCosmos Surgery
Surgery Lecture Notes, Books, MCQ and Good Articles
Friday, September 5, 2008
Trauma and Burns MCQ
1. Nasotracheal intubation:
A. Is preferred for the unconscious patient without cervical spine
injury.
B. Is preferred for patients with suspected cervical spine injury.
C. Maximizes neck manipulation.
D. Is contraindicated in the patient who is breathing spontaneously.
Answer: B
DISCUSSION: The first principle in the management of any injured
patient is to secure an adequate airway. This can be particularly
difficult in the presence of facial or laryngeal trauma, or in the
unconscious patient with a suspected cervical spine injury. The
mechanical removal of oral debris followed by the “chin lift” or “jaw
thrust” maneuvers to relieve soft tissue obstruction of the pharynx are
the first steps. However, when there is any question regarding the
adequacy of the airway, or in the presence of severe head injury, or
when the patient is in profound shock, more definitive airway control
is required. In most patients this involves oral endotracheal
intubation. However, the insertion of an oral endotracheal tube often
involves hyperextension of the neck with the potential for aggravating
cervical spine ligamentous or bony injury. Nasotracheal intubation is
the preferred option for the patient with suspected cervical spine
ligamentous or bony injury since the head and neck can be
maintained in the neutral position with minimal manipulation. This
technique requires a breathing patient, as the passage of air must be
heard through the nasotracheal tube prior to its insertion through the
larynx into the trachea. Nasotracheal intubation is contraindicated in
the presence of mid-face fractures. In this situation, a surgical airway
(cricothyroidotomy, tracheostomy, or needle cricothyroidotomy) is the
preferred option.
2. Cardiac contusions caused by blunt chest trauma:
A. Are fairly easy to diagnose.
,B. Occur in up to 20% to 40% of patients with major blunt thoracic
trauma.
C. Do not usually cause right ventricular dysfunction.
D. Demonstrate arrhythmia as the most common complication.
Answer: BD
DISCUSSION: Cardiac contusions are often difficult to diagnose, but
have been estimated to occur in 5% of major trauma patients, and up
to 20% to 40% of patients with severe blunt chest injury. The difficulty
in diagnosing cardiac contusions is that they remain a pathologic
diagnosis, confirmed only at autopsy or on direct cardiac examination.
The injury may vary from superficial epicardial petechiae to complete
transmural damage. Although significant myocardial injuries, such as
ventricular rupture, coronary vessel thrombosis, and valvular
disruption, have been reported, the most common clinically significant
result of cardiac contusion is the occurrence of arrhythmias. Hence,
an initial electrocardiogram (ECG) and subsequent continuous cardiac
monitoring for at least 24 hours is generally recommended.
Alternative methods of diagnosing myocardial contusion include
creatine phosphokinase cardiac isoenzymes (CPK-MB),
two-dimensional echocardiography, gated ventricular scintigraphic
angiography (GVA), radioactive thallous chloride ( 201Tl) uptake, and
right ventricular monitoring. Unfortunately, none of these tests is
adequately sensitive or specific in the diagnosis of cardiac contusion,
and their correlation with the presence of arrhythmias or ECG
changes is also imprecise.
3. According to the recommendations of the American College of
Surgeons Committee on Trauma, which of the following patients
should be transported to a trauma center?
A. Fifty-year-old female who fell 8 feet from a step ladder, with
isolated hip fracture and normal vital signs.
B. Fifteen-year-old bicyclist with closed head injury and Glasgow Coma
Scale score of 12.
C. Twenty-three-year-old male assault victim with stab wound to the
back, normal vital signs, and respiratory distress.
D. Three-year-old infant passenger (restrained) in motor vehicle
accident with normal vital signs and no apparent injuries except
abdominal wall contusion.
Answer: BCD
DISCUSSION: The American College of Surgeons Committee on
Trauma has developed a field triage decision scheme to help identify
trauma victims with a significant risk of dying as a result of their
injuries. This classification is based on four factors: (1) abnormal
physiologic signs, (2) anatomic area of injury, (3) mechanism of injury,
,and (4) concurrent or co-morbid disease states. Major physiologic
abnormalities include a Glasgow Coma Scale score of less than 13,
systolic blood pressure less than 90 mm. Hg, respiratory rate less than
10 or greater than 29 per minute, or a Revised Trauma Score of less
than 11 or a Pediatric Trauma Score of less than 9. Significant
anatomic considerations include penetrating injuries to the torso,
head and neck, and proximal extremities, flail chest, combination of
trauma with burns to greater than 10% of body surface area, two or
more proximal long bone fractures, pelvic fractures, paralysis, or
traumatic amputation above the wrist or ankle. Significant
mechanisms of injury include a death in the same passenger
compartment or ejection from the automobile, high-impact (greater
than 5 miles per hour) auto-pedestrian injuries, or a pedestrian
thrown or run over. The co-morbid factors include pediatric or elderly
(<5 or >55) patients or known history of insulin-dependent diabetes or
cardiac, respiratory, or psychotic disorders. These criteria should
serve as guidelines for medical control and the pre-hospital care
providers. Such triage guidelines have been shown to produce the
triage of only a small fraction (5% to 10%) of all injured patients to
Level I or Level II trauma centers.
4. Which of the following statements about head injuries is/are false?
A. The majority of deaths from auto accidents are due to head
injuries.
B. Head injury alone often produces shock.
C. A rapid and complete neurologic examination is part of the initial
evaluation of the trauma patient.
D. Optimizing arterial oxygenation is part of initial therapy.
Answer: B
DISCUSSION: Head injuries cause the majority of deaths following
automobile accidents, with rupture of the thoracic aorta the second
most common cause of fatality. Head injury itself rarely produces
hypotensive shock. It is only in the terminal phases of brain death that
hypotension may be attributable to head injury alone. Therefore,
hypotension in trauma patients must be assumed to be secondary to
volume depletion or ongoing hemorrhage. An occult site of
hemorrhage (chest, abdomen, pelvis, retroperitoneum, or extremities)
must be strongly suspected and dealt with accordingly. A rapid and
complete neurologic assessment is a crucial part of the initial
assessment of all trauma patients. This initial exam gives an excellent
indication of injury severity and prognosis. Since the ultimate
outcome of a brain injury is dependent on adequate cerebral
perfusion and oxygenation, adequate airway control, ventilation,
hemorrhage control, volume restitution, and arterial oxygenation are
crucial factors in the early management of head injuries.
, 5. Which of the following statements about maxillofacial trauma is/are
false?
A. Asphyxia due to upper airway obstruction is the major cause of
death from facial injuries.
B. The mandible is the most common site of facial fracture.
C. The Le Fort II fracture includes a horizontal fracture of the maxilla
along with nasal bone fracture.
D. Loss of upward gaze may indicate either an orbital floor or orbital
roof fracture.
Answer: B
DISCUSSION: Maxillofacial injuries generally do not cause
life-threatening injuries, with the exception of those that occlude the
airway. Therefore, the first priority in assessing and managing the
patient with maxillofacial trauma is to assess and assure the adequacy
of the airway. The face is typically divided into thirds when defining
injuries. Injuries to the upper third of the face are often accompanied
by ocular or central nervous system complications as well as facial
deformities. Fractures of the orbital roof are frequently associated
with frontal sinus and nasal ethmoid fractures, and are accompanied
by a loss of upward gaze due to involvement of the superior rectus
muscle. However, the most common cause of loss of upward gaze is
orbital floor injury and associated entrapment of the globe or injury to
the inferior rectus muscle. Middle third of facial structures include the
maxilla, zygoma, orbits, and nose. The Le Fort classifications of facial
fractures are commonly employed to describe these complex fracture
lines. In a Le Fort II fracture, the superior fracture line is transverse
through the nasal bones or through the articulation of the maxillary
and nasal bones with the frontal bones. This is also known as the
“pyramidal” fracture of the mid-face. The diagnosis is established by
digital manipulation of the anterior maxilla and observation for
mobility of the central triangle (the maxilla and nose). The lower third
of the face contains a single facial bone, the mandible. After the nasal
bones, the mandible is the second most commonly fractured facial
bone.
6. What percentage of patients with thoracic trauma require
thoracotomy?
A. 10%–15%.
B. 20%–25%.
C. 30%–40%.
D. 45%–50%.
Answer: A
Surgery Lecture Notes, Books, MCQ and Good Articles
Friday, September 5, 2008
Trauma and Burns MCQ
1. Nasotracheal intubation:
A. Is preferred for the unconscious patient without cervical spine
injury.
B. Is preferred for patients with suspected cervical spine injury.
C. Maximizes neck manipulation.
D. Is contraindicated in the patient who is breathing spontaneously.
Answer: B
DISCUSSION: The first principle in the management of any injured
patient is to secure an adequate airway. This can be particularly
difficult in the presence of facial or laryngeal trauma, or in the
unconscious patient with a suspected cervical spine injury. The
mechanical removal of oral debris followed by the “chin lift” or “jaw
thrust” maneuvers to relieve soft tissue obstruction of the pharynx are
the first steps. However, when there is any question regarding the
adequacy of the airway, or in the presence of severe head injury, or
when the patient is in profound shock, more definitive airway control
is required. In most patients this involves oral endotracheal
intubation. However, the insertion of an oral endotracheal tube often
involves hyperextension of the neck with the potential for aggravating
cervical spine ligamentous or bony injury. Nasotracheal intubation is
the preferred option for the patient with suspected cervical spine
ligamentous or bony injury since the head and neck can be
maintained in the neutral position with minimal manipulation. This
technique requires a breathing patient, as the passage of air must be
heard through the nasotracheal tube prior to its insertion through the
larynx into the trachea. Nasotracheal intubation is contraindicated in
the presence of mid-face fractures. In this situation, a surgical airway
(cricothyroidotomy, tracheostomy, or needle cricothyroidotomy) is the
preferred option.
2. Cardiac contusions caused by blunt chest trauma:
A. Are fairly easy to diagnose.
,B. Occur in up to 20% to 40% of patients with major blunt thoracic
trauma.
C. Do not usually cause right ventricular dysfunction.
D. Demonstrate arrhythmia as the most common complication.
Answer: BD
DISCUSSION: Cardiac contusions are often difficult to diagnose, but
have been estimated to occur in 5% of major trauma patients, and up
to 20% to 40% of patients with severe blunt chest injury. The difficulty
in diagnosing cardiac contusions is that they remain a pathologic
diagnosis, confirmed only at autopsy or on direct cardiac examination.
The injury may vary from superficial epicardial petechiae to complete
transmural damage. Although significant myocardial injuries, such as
ventricular rupture, coronary vessel thrombosis, and valvular
disruption, have been reported, the most common clinically significant
result of cardiac contusion is the occurrence of arrhythmias. Hence,
an initial electrocardiogram (ECG) and subsequent continuous cardiac
monitoring for at least 24 hours is generally recommended.
Alternative methods of diagnosing myocardial contusion include
creatine phosphokinase cardiac isoenzymes (CPK-MB),
two-dimensional echocardiography, gated ventricular scintigraphic
angiography (GVA), radioactive thallous chloride ( 201Tl) uptake, and
right ventricular monitoring. Unfortunately, none of these tests is
adequately sensitive or specific in the diagnosis of cardiac contusion,
and their correlation with the presence of arrhythmias or ECG
changes is also imprecise.
3. According to the recommendations of the American College of
Surgeons Committee on Trauma, which of the following patients
should be transported to a trauma center?
A. Fifty-year-old female who fell 8 feet from a step ladder, with
isolated hip fracture and normal vital signs.
B. Fifteen-year-old bicyclist with closed head injury and Glasgow Coma
Scale score of 12.
C. Twenty-three-year-old male assault victim with stab wound to the
back, normal vital signs, and respiratory distress.
D. Three-year-old infant passenger (restrained) in motor vehicle
accident with normal vital signs and no apparent injuries except
abdominal wall contusion.
Answer: BCD
DISCUSSION: The American College of Surgeons Committee on
Trauma has developed a field triage decision scheme to help identify
trauma victims with a significant risk of dying as a result of their
injuries. This classification is based on four factors: (1) abnormal
physiologic signs, (2) anatomic area of injury, (3) mechanism of injury,
,and (4) concurrent or co-morbid disease states. Major physiologic
abnormalities include a Glasgow Coma Scale score of less than 13,
systolic blood pressure less than 90 mm. Hg, respiratory rate less than
10 or greater than 29 per minute, or a Revised Trauma Score of less
than 11 or a Pediatric Trauma Score of less than 9. Significant
anatomic considerations include penetrating injuries to the torso,
head and neck, and proximal extremities, flail chest, combination of
trauma with burns to greater than 10% of body surface area, two or
more proximal long bone fractures, pelvic fractures, paralysis, or
traumatic amputation above the wrist or ankle. Significant
mechanisms of injury include a death in the same passenger
compartment or ejection from the automobile, high-impact (greater
than 5 miles per hour) auto-pedestrian injuries, or a pedestrian
thrown or run over. The co-morbid factors include pediatric or elderly
(<5 or >55) patients or known history of insulin-dependent diabetes or
cardiac, respiratory, or psychotic disorders. These criteria should
serve as guidelines for medical control and the pre-hospital care
providers. Such triage guidelines have been shown to produce the
triage of only a small fraction (5% to 10%) of all injured patients to
Level I or Level II trauma centers.
4. Which of the following statements about head injuries is/are false?
A. The majority of deaths from auto accidents are due to head
injuries.
B. Head injury alone often produces shock.
C. A rapid and complete neurologic examination is part of the initial
evaluation of the trauma patient.
D. Optimizing arterial oxygenation is part of initial therapy.
Answer: B
DISCUSSION: Head injuries cause the majority of deaths following
automobile accidents, with rupture of the thoracic aorta the second
most common cause of fatality. Head injury itself rarely produces
hypotensive shock. It is only in the terminal phases of brain death that
hypotension may be attributable to head injury alone. Therefore,
hypotension in trauma patients must be assumed to be secondary to
volume depletion or ongoing hemorrhage. An occult site of
hemorrhage (chest, abdomen, pelvis, retroperitoneum, or extremities)
must be strongly suspected and dealt with accordingly. A rapid and
complete neurologic assessment is a crucial part of the initial
assessment of all trauma patients. This initial exam gives an excellent
indication of injury severity and prognosis. Since the ultimate
outcome of a brain injury is dependent on adequate cerebral
perfusion and oxygenation, adequate airway control, ventilation,
hemorrhage control, volume restitution, and arterial oxygenation are
crucial factors in the early management of head injuries.
, 5. Which of the following statements about maxillofacial trauma is/are
false?
A. Asphyxia due to upper airway obstruction is the major cause of
death from facial injuries.
B. The mandible is the most common site of facial fracture.
C. The Le Fort II fracture includes a horizontal fracture of the maxilla
along with nasal bone fracture.
D. Loss of upward gaze may indicate either an orbital floor or orbital
roof fracture.
Answer: B
DISCUSSION: Maxillofacial injuries generally do not cause
life-threatening injuries, with the exception of those that occlude the
airway. Therefore, the first priority in assessing and managing the
patient with maxillofacial trauma is to assess and assure the adequacy
of the airway. The face is typically divided into thirds when defining
injuries. Injuries to the upper third of the face are often accompanied
by ocular or central nervous system complications as well as facial
deformities. Fractures of the orbital roof are frequently associated
with frontal sinus and nasal ethmoid fractures, and are accompanied
by a loss of upward gaze due to involvement of the superior rectus
muscle. However, the most common cause of loss of upward gaze is
orbital floor injury and associated entrapment of the globe or injury to
the inferior rectus muscle. Middle third of facial structures include the
maxilla, zygoma, orbits, and nose. The Le Fort classifications of facial
fractures are commonly employed to describe these complex fracture
lines. In a Le Fort II fracture, the superior fracture line is transverse
through the nasal bones or through the articulation of the maxillary
and nasal bones with the frontal bones. This is also known as the
“pyramidal” fracture of the mid-face. The diagnosis is established by
digital manipulation of the anterior maxilla and observation for
mobility of the central triangle (the maxilla and nose). The lower third
of the face contains a single facial bone, the mandible. After the nasal
bones, the mandible is the second most commonly fractured facial
bone.
6. What percentage of patients with thoracic trauma require
thoracotomy?
A. 10%–15%.
B. 20%–25%.
C. 30%–40%.
D. 45%–50%.
Answer: A
