fmcfacem.files.wordpress.com · web viewa 4 week-old boy is brought in by his concerned parents....

EMQ 1

Select ONE agent (in toxic overdose or exposure) that best fits each scenario. For each scenario, assume that the patient is an otherwise healthy 30 year-old man who takes no usual medications, and is not concurrently poisoned by another agent. Clinical information pertains to untreated acute, severe toxicity. An agent may be selected more than once.

A. Isoniazid

F. Verapamil

B. Digoxin

G. Iron

C. Amphetamine

H. Salicylate

D. Amitriptyline

I. Strychnine

E. Colchicine

J. Cyanide

1. Symptoms: Nausea, agitation, painful muscle spasms.

Signs:

· Temp385deg C

· GCS 15 (distressed)

· Pulse 100 bpm SR

· BP 130/90mmHg

· RR28/ min

Muscle spasm and opisthotonus are marked.

Answer: I

Murray p. 293

2. Symptoms: Anxiety, agitation, dysphoria.

Signs:

· Temp38deg C

· GCS 14 (confused)

· Pulse 120 bpm SR

· BP 150/95mmHg

· RR20/ min

Mydriasis, sweating, myoclonus, features of paranoid delusions.

Answer: C

Murray p. 131

3. Symptoms: Nausea, vomiting, diarrhoea.

Signs:

· Temp365deg C

· GCS 15

· Pulse 90 bpm SR

· BP 110/80mmHg

· RR16/ min

Features of mild dehydration. Bone marrow suppression and rhabdomyolysis 2 days post ingestion.

Answer: E

Murray p. 182

4. Symptoms: Headache, dyspnoea. Deteriorating mental state after inhalation of toxic gas.

Signs:

· Temp37deg C

· GCS 9 (obtunded)

· Pulse 110 bpm SR

· BP 140/90mmHg

· RR28/ min

Profound lactic acidosis on arterial blood gases.

Answer: J

Murray p. 187

5. Symptoms: Initial abdominal pain and diarrhoea, resolving spontaneously within hours.

Signs:

· Temp37deg C

· GCS 15

· Pulse 100 bpm SR

· BP 120/80mmHg

· RR24/ min

Vasodilatation, hepatorenal failure and metabolic acidosis 14 hours after exposure.

Answer: G

Murray p. 213

6. Symptoms: Drowsiness, before generalized seizure.

Signs:

· Temp375deg C

· GCS 13before generalized seizure

· Pulse 120 bpm SR

· BP 90/50mmHg

· RR24/ min

Before seizure: Mydriasis, dry mouth, flushed skin that’s hot to touch and dry.

Answer: D

Murray p. 298

7. Symptoms: Nausea, abdominal pain, xanthopsia.

Signs:

· Temp365deg C

· GCS 13 (confused)

· Pulse 200 bpm, supraventricular tachycardia with AV block

· BP 80/40mmHg

· RR20/ min

Answer: B

Murray p. 190

8. Symptoms: Nausea, vomiting, tinnitus, vertigo.

Signs:

· Temp39deg C

· GCS 13 (delirious)

· Pulse 100 bpm SR

· BP 110/70mmHg

· RR30/ min

Dehydrated. Arterial blood gases show hyperglycaemia, primary metabolic acidosis and primary respiratory alkalosis.

Answer: H

Murray p. 287

9. Symptoms: Dizziness and weakness.

Signs:

· Temp365deg C

· GCS 15

· Pulse 40 bpm, SR with first degree block

· BP 80/40mmHg

· RR16/ min

Answer: F (B accepted too)

Murray p. 158

10. Symptoms: Blurred vision, photophobia, nausea, before generalized seizure.

Signs:

· Temp37deg C

· GCS 15 before generalized seizure

· Pulse 110 bpm SR

· BP 130/85mmHg

· RR18/ min

Before seizure: Lactic acidosis on arterial blood gases. Mydriasis, ataxia, hyper-reflexia, skin cool and dry.

Answer: A

Murray p. 217

EMQ 2

Select ONE antidote that is best indicated for each setting. Assume that in each setting, there is no other clinical problem (including concurrent toxicity from other agents), and that the antidote is not contra-indicated for other reasons. An antidote may be selected more than once.

A. Atropine

F. Dicobalt Edetate

B. Cyproheptadine

G. Methylene Blue

C. Ethanol

H. Pralidoxime

D. Calcium

I. Pyridoxine

E. Folinic Acid

J. Succimer (2,3 dimercaptosuccinic acid)

11. A 40 year-old man presents with exposure to a toxin from his workplace. Assessment reveals heavy metal poisoning.

Answer: J

Murray p. 369

12. A 65 year-old lady develops bone marrow suppression and acute renal failure from supratherapeutic doses of an agent used to treat her psoriasis. This agent is administered once per week.

Answer: E

Murray p. 336

13. A 70 year-old woman develops dyspnoea and headache soon after undergoing intravenous regional anaesthesia, which utilized intravenous prilocaine. The patient is unwell and cyanosed. Arterial blood taken for analysis is chocolate-brown coloured; it shows marked metabolic acidosis.

Answer: G

Murray p. 346

14. A 45 year-old man is rescued from a factory fire. The patient was trapped in the burning building, and suffers a toxic inhalation. Despite normal and stable haemodynamic parameters, he has mental obtundation, and severe lactic acidosis from tissue hypoxia.

Answer: F

Murray p. 326

15. A 35 year-old man is poisoned by deliberate ingestion of insecticides. The patient’s haemodynamic parameters have already been appropriately treated with another antidote. The intention now is to reverse the pathophysiological processes at the neuromuscular endplates.

Answer: H

Murray p. 358

16. A 50 year-old woman presents after overdose of her slow-release antihypertensive agent. She is drowsy, with profound bradycardia and hypotension. The chosen antidote should help normalise cardiac output AND peripheral vascular resistance.

Answer: D

Murray p. 298

17. A 65 year-old man overdoses on an antibiotic used to treat pulmonary tuberculosis. He develops a generalized seizure.

Answer: I

Murray p. 360

18. A 20 year-old man develops acute confusion, tachycardia and hypertension. He had been taking excessive amounts of his prescribed fluoxetine.

Answer: B

Murray p. 323

19. A healthy 30 year-old woman underwent an uneventful general anaesthetic for an elective surgical procedure. Neostigmine is administered to reverse the muscle relaxant, but a concurrent agent is needed to counter neostigmine’s unwanted effects on her heart rate.

Answer: A

Murray p. 319

20. After deliberately ingesting motor vehicle engine coolant, a 25 year-old man develops acute renal failure.

Answer: C

Murray p. 332

EMQ 3

Select ONE condition that best matches each scenario. Assume that in each scenario, there is no other clinical problem. A condition may be selected more than once.

A. Croup

F. Anaphylaxis

B. Acute Asthma

G. Whooping Cough

C. Bronchiolitis

H. Apparent Life-Threatening Event

D. Acute Epiglottitis

I. Peritonsillar abscess

E. Inhaled Foreign Body

J. Retropharyngeal abscess

21. An 11 month-old boy is referred to the ED with 3 days of persistent cough, preceded by 1 week of rhinorrhoea, conjunctivitis and low-grade fever. He is usually healthy, but is unvaccinated.

On examination:

· Not unwell

· No stridor

· Temp375deg C

· O2 sats 98 % on RA

Frequent bouts of severe coughing, followed by gagging. Chest clear on auscultation.

Answer: GPaed Cameron, p. 134

22. An 18 month-old girl presents at noon with acute respiratory distress and stridor. She was perfectly well just before this episode, playing with her 4 year-old brother in the toy room.

On examination:

· Distressed

· Marked stridor

· Temp37deg C


Chest exam: no abnormalities other than transmitted upper airway sounds. No rash.

Answer: EPaed Cameron, p. 126

23. A 6 month-old boy is brought to ED by his parents one evening. They report poor feeding and apparent breathing difficulties. He had coryza and fever in the preceding 2 days.

On examination:

· Moderately unwell

· Temp38deg C


Bilateral chest hyperinflation, subcostal recession and scattered expiratory wheezes.

Answer: CPaed Cameron, p. 139

24. A 14 month-old boy is brought in by his parents at 0100hrs, with fever and cough. The child had coryza, irritability and malaise in the preceding 3 days.

On examination:

· Well looking, happy child

· Stridor evident when crying

· Temp375deg C


Barking cough. Clear chest with good bilateral breath sounds.

Answer: APaed Cameron, p. 142

25. A 20 month-old boy is brought in by ambulance one afternoon. He suffered acute respiratory distress while having lunch at a nearby restaurant. His parents state he was perfectly well before that.

On examination:

· In distress, vomiting

· Stridor evident at rest

· Temp375deg C


Diffuse erythematous, blanching rash. Lip swelling. Reduced bilateral breath sounds, some wheezes also heard.

Answer: FPaed Cameron, p. 468

26. A 24 month-old boy is brought in by ambulance one evening, with respiratory distress. The child is unvaccinated. He was completely well only 4 hours before. On examination:

· Unwell, toxic looking. Sitting forward, drooling.


· Temp395deg C


Marked work of breathing, with subcostal recession. Reduced breath sounds bilaterally, with transmitted stridor.

Answer: DTintinalli, p. 789

27. A 4 week-old boy is brought in by his concerned parents. The child appeared to suffer a sudden choking or gagging episode, followed by a brief period of apnoea and cyanosis. The whole event lasted less than 1 minute. He was completely well before the episode, and seems to be well now. The child was prematurely born at 34 weeks gestation, but had been developing normally since.

· Well looking infant

· No stridor, wheeze or other signs of respiratory compromise

· Temp37deg C


Child is small for age, but within expected range, based on past history.

Answer: H Tinitinalli, p. 746

28. An 18 month-old girl is brought in by her parents at 0400hrs, with cough and breathing difficulty. The child is usually healthy, except for eczema. She has no usual medications or known allergies. Her mother reports episodic coughing at night and early morning over the last few months, especially when she suffers a viral respiratory tract infection. There is a strong family history of atopy.

· Not unwell

· Mild subcostal recession

· Temp375deg C


Good breath sounds bilaterally, with scattered expiratory wheezes.

Answer: BPaed Cameron, p. 128

29. A 3 year-old boy presents with sore throat and fever. The child is usually healthy, but had an upper respiratory tract infection 3 days prior. Since then, his sore throat has progressed insidiously. He cannot swallow liquids or food, owing to throat pain. There is no cough.

· Unwell, with muffled voice. Drooling.

· Inspiratory stridor when crying

· Temp39deg C


Neck stiffness present.

Answer: J(I also accepted, but reluctantly!)Tintinalli, p. 789

30. A 13 year-old girl presents with sore throat (worse on the right) and fever. She had milder symptoms over the preceding 3 days, but currently complains of the “worst sore throat ever”, in a muffled voice. She complains of pain when swallowing even cool water.

· Miserable.

· No stridor or respiratory distress.

· Temp39deg C


Tender cervical lymphadenopathy, worse on the right. Trismus present.

Answer: ITintinalli, p. 789 and 795

EMQ 3


A. Croup

F. Anaphylaxis

B. Acute Asthma

G. Whooping Cough

C. Bronchiolitis







On examination:

· Not unwell

· No stridor

· Temp375deg C





On examination:

· Distressed

· Marked stridor

· Temp37deg C





On examination:


· Temp38deg C





On examination:



· Temp375deg C





On examination:



· Temp375deg C







· Temp395deg C







· Temp37deg C





· Not unwell


· Temp375deg C







· Temp39deg C





· Miserable.


· Temp39deg C




EMQ 3


A. Croup

F. Anaphylaxis

B. Acute Asthma

G. Whooping Cough

C. Bronchiolitis







On examination:

· Not unwell

· No stridor

· Temp375deg C





On examination:

· Distressed

· Marked stridor

· Temp37deg C





On examination:


· Temp38deg C





On examination:



· Temp375deg C





On examination:



· Temp375deg C







· Temp395deg C







· Temp37deg C





· Not unwell


· Temp375deg C







· Temp39deg C





· Miserable.


· Temp39deg C




EMQ 6

You respond to a “Code Blue” activation in a ward of a rural hospital. The patient was found to have an acute critical condition. For each scenario, select ONE option that is the most appropriate initial / immediate intervention for the condition. Assume that in each scenario, all Basic Life Support measures, including effective cardiac compressions and artificial ventilation if indicated, are being provided. However, no agents other than oxygen have been administered. The patient also has a functioning peripheral intravenous cannula in situ. All electrical therapy uses a biphasic waveform. An intervention may be selected more than once.

A. Defibrillation – 200J as single shock

F. Intravenous adrenaline – 100mcg

B. Defibrillation – 100J as single shock

G. Intramuscular adrenaline – 300mcg

C. Synchronized cardioversion – 100J or more

H. Intramuscular adrenaline – 100mcg

D. Synchronized cardioversion – 10 to 20J

I. Application of ice to the face

E. Intravenous adrenaline – 1.0mg

J. Defibrillation – 200J as 3 stacked shocks

51. 65 year-old man admitted for investigation of chest pain. Witnessed collapse 3 minutes ago, with ventricular fibrillation (VF) captured on cardiac monitor. Remains in VF.

Answer: A

http://resus.org.au/download/section_11/guideline-11-4dec10.pdf Accessed Jan 5th 2014

52. 2 month-old girl. Weight 6 kg. Recent poor feeding and failure to thrive. Pulse rate noted to be 210 bpm. Regular narrow complex tachycardia on monitor, with rate as above. Normal BP, normal oxygen saturations.

Answer: I


53. 12 month-old girl. Weight 10 kg. Known peanut allergy. Developed a rash soon after inadvertent exposure to peanuts. Stridor, angio-oedema evident. GCS 15. Tachycardic for age, but normal BP. Widespread itchy rash.

Answer: H

http://resus.org.au/download/section_11/guideline-11-10-nov2011.pdf Accessed Jan 5th 2014

54. 70 year-old woman post elective bowel surgery. Found collapsed 4 minutes ago, with ventricular tachycardia (VT) captured on cardiac monitor. Normal serum potassium. GCS 3. Remains in VT.

Answer: A


55. 65 year-old man with history of hypertension, admitted for pneumonia. Developed palpitations, with chest pain and dizziness.

· GCS11

· Pulse180bpm, atrial fibrillation

· BP 80/40mmHg

Answer: Chttp://resus.org.au/download/section_11/guideline-11-9nov09.pdf Accessed 5th Jan 2014

56. 12 month-old boy. Weight 10 kg. Admitted for septic workup. Found unresponsive and pulseless. Blood glucose is normal; intravenous fluid bolus given. Sinus tachycardia on cardiac monitor. Remains pulseless, with GCS of 3.

Answer: F


57. 8 year-old boy. Weight 25 kg. Admitted for respiratory infection. Known congenital heart disease. Sudden, witnessed collapse, with VF on monitor. Serum potassium and glucose normal.

Answer: B


58. 30 year-old woman who developed a severe allergic reaction to intravenous penicillin. She has a known allergy to this antibiotic. Ward staff administered nebulized adrenaline. She has acute airway obstruction, and anaphylactic shock. She became pulseless and unresponsive. Sinus tachycardia on cardiac monitor.

Answer: E


59. 60 year-old woman admitted with acute pericarditis. Since admission, she developed dyspnoea and dizziness before collapsing in the ward. She is now unresponsive and pulseless.

· GCS3

· Heart rate on monitor180bpm, sinus rhythm

· BP 80/40mmHg

Distended neck veins. Inaudible heart sounds. A bedside echocardiogram is being performed.

Answer: E


60. 12 month-old boy. Weight 10 kg. Admitted with possible sepsis for investigation. Ward staff noted he was pale and lethargic.

· GCS8

· BP not recordable, but faint femoral pulse present

· Afebrile

Child is pale and sweaty. Cardiac rhythm strip is shown:

Answer: D


EMQ 7

Select ONE condition that best matches each scenario. Assume that in each scenario, there is no other clinical problem. That is, all clinical features result from an acute, isolated episode of that condition. A condition may be selected more than once.

A. Bacterial conjunctivitis

F. Acute angle closure glaucoma

B. Viral conjunctivitis

G. Central retinal artery occlusion

C. Retinal detachment

H. Central retinal vein occlusion

D. Chalazion

I. Anterior ischaemic optic neuropathy

E. Subconjunctival haemorrhage

J. Optic neuritis

61. 75 year-old man with history of rheumatoid arthritis. Headache and left sided jaw pain in preceding days. Progressive painless loss of vision in left eye over hours.

On examination: Markedly reduced visual acuity in left eye, with relative afferent pupillary defect (RAPD). No abnormality in right eye. Tender in left temporal area.

Answer: ITintinalli, p. 1545

62. 35 year-old woman with a few hours of painful right eye, worse with eye movement. Rapid loss of vision in same eye. She has no history of myopia.

On examination: Moderate reduction in visual acuity in right eye, with very poor colour vision; normal on left. Swollen, oedematous right optic disc on fundoscopy.

Answer: JTintinalli, p. 1544

63. 75 year-old woman with history of hypertension, diabetes and peripheral vascular disease. Gradual, painless loss of vision in left eye over days.

On examination: Marked reduction in visual acuity in left eye; normal on right. Fundoscopy: Swollen, oedematous left optic disc; diffuse retinal haemorhages in all quandrants.

Answer: HTintinalli, p. 1545

64. 30 year-old woman with 2 days of progressive pain in left eyelid, associated with redness and swelling. No vision disturbance.

On examination: Not unwell. Focal, slightly tender, inflammed nodule on left upper eyelid. Normal visual acuity; no ocular abnormality.


65. 35 year-old man with 4 days of bilateral red eyes. It commenced in the right eye, and spread to involve the left eye after 2 days. No pain, but persistent eye irritation. Suffered a respiratory tract infection one week prior.

On examination: Bilateral conjunctival injection and periauricular lymphadenopathy. Small follicles on inferior palpebral conjunctiva with slit lamp examination.

Answer: BTintinalli, p. 1531

66. 60 year-old man with very sudden, profound, painless loss of vision in right eye. Past history of hypertension. He reports several episodes of transient visual loss in the same eye, but each was very short lived.

On examination: Right sided monocular blindness with RAPD. Fundoscopy: pale retina with cherry red macula.

Answer: GTintinalli, p. 1544

67. 50 year-old man with longstanding myopia. Complains of flashing lights in right eye, associated with multiple “floaters” across his field of vision. Upon arrival to ED, he reports “a shade coming over my right eye”. No pain. No symptoms when right eye covered.

On examination: Bilateral myopia. Visual field deficit affecting right eye only, in supero-temporal quadrant. No abnormality seen with standard fundoscopy.

Answer: CTintinalli, p. 1545

68. 60 year-old woman with history of hypermetropia. Presents with sudden left eye / periorbital pain, blurred vision, nausea and vomiting.

On examination of left eye: Unilateral mid-dilated, ovoid pupil. Marked conjunctival injection. Cloudy cornea. Reduced visual acuity. No abnormality in right eye.

Answer: FTintinalli, p. 1543

69. 25 year-old man with 2-day history of right eye redness, discomfort and purulent discharge. He reports waking on last 2 mornings with sticky right eyelids that are adherent. He has no history of myopia.

On examination: Unilateral right sided red eye, with marked conjunctival injection and mucopurulent discharge. Reduced visual acuity in same eye, but improved with pinhole correction. No abnormality in left eye.

Answer: ATintinalli, p. 1530

70. 50 year-old woman discovered a terrifying appearance of her left eye, when she gazed into her mirror that morning. She sneezed a few times earlier that day, owing to hay fever. She reports no pain, no visual loss, or any other symptoms. Examination reveals the image below (darker shades around the left eye are actually red). There is no deficit of visual acuity or visual fields.

Answer: ETintinalli, p. 1535

EMQ 8

Select ONE option of antimicrobial agent(s) that is most appropriate as empiric treatment for each scenario. Assume that in each scenario, there is no other clinical problem. That is, all clinical features result from an acute, isolated episode of that condition. Assume also that the patient has known allergy / adverse reaction to the selected agent(s). An option may be selected more than once.

A. Azithromycin and ceftriaxone

F. Vancomycin

B. Flucloxacillin

G. Fluconazole

C. Valacyclovir or famciclovir

H. Cefotaxime and amoxicillin

D. Penicillin

I. Metronidazole

E. Permethrin

J. No empiric antibiotic is currently indicated

71. A usually healthy 5 year-old boy presents with 24 hours of sore throat and fever, with no prodromal symptoms. Examination reveals a febrile, unwell looking boy with tender cervical lymphadenopathy, exudative tonsillophrayngitis and strawberry tongue. The child is fully vaccinated.

Answer: DPaed Cameron, p. 125

72. A 3 week-old girl is brought in by her parents with 24 hours of fever and poor feeding. Examination reveals a febrile, lethargic looking infant without an obvious focus of infection. Cardiovascular examination is unremarkable; serum glucose is normal.

Answer: HPaed Cameron, p. 231

73. A 24 year-old woman presents with vaginal discharge, dyspareunia and dysuria. Examination reveals cervical excitation and cervicitis on speculum inspection, with mucopurulent discharge. A swab is taken of the discharge.


74. A 30 year-old woman complains of vulval irritation, dysuria, dyspareunia and offensive vaginal discharge.

Examination reveals mucosal inflammation of the vulva and vagina. Punctate cervical haemorrhages are noted, without discharge. Initial microscopy of vaginal swabs reveals motile parasites.

Answer: ITintinalli, p. 992

75. A GP refers a 40 year-old man with 3 days of progressive right leg pain, swelling and redness. The patient is usually healthy. Examination reveals a febrile, though not unwell man. He has circumferential swelling and marked erythema of his right leg above the ankle. The area is tender. There is regional lymphadenopathy.


76. A 7 year-old girl is brought in by her parents with 24 hours widespread rash, in the background of 2 days of low-grade fever and malaise. The child is usually healthy, and is up to date with vaccinations. Examination reveals a well-looking, afebrile child. Several erythematous macules are present on her face, torso and all limbs. Some lesions are small blisters. There is no tenderness, and no cellulitis. The child is able to eat and drink without problems.

Answer: JPaed Cameron, p. 282

77. A 60 year-old woman presents with right-sided hemifacial pain for 3 days. She reports paroxysms of sharp pain in her right forehead and ear. Examination reveals an afebrile, well-looking patient. A crop of erythematous, maculo-papular skin lesions is noted lateral to her right eye. That region is sensitive to touch. The patient states she only noticed the rash this same day.


78. A 40 year-old man presents 2 days of intense itching of his hands, feet and groins, which are worse at night. He resides in shared, supported accommodation. Examination reveals a well-looking man with no fever. Small, longitudinal erythematous papules are noted in the affected areas, especially in the inter-digital spaces of his hands and feet. There are no lesions on his head and neck.


79. A 19 year-old woman is referred by her GP with 4 days of sore throat. She is usually healthy, and resides at a university residential college. Soon after commencing amoxicillin, she developed a slightly itchy widespread rash. Examination reveals a not unwell, afebrile patient, with widespread exanthem without cellulitis. She has exudative tonsillopharyngitis with tender cervical lymphadenopathy. Hepatosplenomegaly is present. Laboratory investigations reveal derangement of liver enzymes and lymphocytosis.


80. A 65 year-old homeless man develops generalized muscle spasms 2 days after sustaining an open wound on his right leg. The man’s history is unknown. Examination reveals a critically unwell patient with risus sardonicus, lockjaw, trismus and generalized muscle rigidity. The wound on his right leg is heavily contaminated with soil.

Answer: I or D

Tintinalli, p. 1048 states that penicillin is contra-indicated because it may exacerbate tetanospasm

The WHO (http://www.who.int/diseasecontrol_emergencies/who_hse_gar_dce_2010_en.pdf Accessed 7th Jan 2015) declares penicillin as acceptable.

Best stick to metronidazole! But of course, the mainstay of Rx is immunotherapy with TIG.

EMQ 9

Select ONE option that is the most appropriate specific, initial treatment for the condition described in each scenario. Assume that in each scenario, there is no other clinical injury. That is, all clinical features result from that acute, isolated injury. All necessary advanced life support, fluid resuscitation and analgesia (if required) are already provided, in a tertiary trauma hospital. An option may be selected more than once.

A. Large bore tube thoracostomy

F. Heart rate and BP optimisation; urgent cardiothoracic referral

B. Needle thoracostomy

G. Emergent laparotomy

C. Ultrasound-guided needle pericardiocentesis

H. Emergent thoracotomy

D. 3-sided dressing over injury

I. Urgent embolization of bleeding vessel(s)

E. Positive pressure ventilation

J. No specific treatment intervention currently indicated

81. A 55 year-old woman was involved in a high speed, rollover motor vehicle accident. She complains of abdominal pain.

Examination:

· GCS13

· Heart rate120 bpm

· BP80/50mmHg

Rigid, silent abdomen. Haemodynamics unresponsive to 3L of rapid intravenous fluid infusion.

Answer: GTintinalli, p. 1769

82. A 25 year-old man was involved in a high speed, motorcycle accident.

Examination:

· GCS15


· BP100/60mmHg

Chest x-ray reveals a fractured left 1st rib, widened mediastinum, left upper lobe pulmonary contusion and a small left haemothorax.

Answer: FTintinalli, p. 1765

83. A 74 year-old woman who is on rivaroxaban sustained high-force blunt trauma to her sternum. She complains of chest pain, dyspnoea and dizziness.

· GCS13


· BP80/60mmHg; pulsus paradoxus present

Extensive bruising over sternum. Distended neck veins, muffled heart sounds. Widened mediastinum on chest x-ray, without other abnormality. Small voltage ECG complexes, with electrical alternans.


84. A 19 year-old man was allegedly stabbed in the chest at a bar brawl.

Examination:

· GCS14


· BP90/50mmHg

A deep penetrating wound in left chest wall is present, with blood oozing from wound. Soon after arrival, the patient suffers a cardiopulmonary arrest, with pulse electrical activity.


85. A 35 year-old builder fell 3m from a scaffold, sustaining blunt trauma to his right chest wall.

Examination:

· GCS14


· BP90/50mmHg

No chest movement on right, with stony dull percussion of entire hemithorax. Absent right sided breath sounds.


86. A 27 year-man suffers a gunshot wound to the right chest.

Examination:

· GCS15


· BP130/90mmHg

Sucking chest wound on right, approximately 5cm in diameter. Small ipsilateral haemo-pneumothorax. Stable haemodynamic parameters.

Answer: DPaed Cameron, p. 282

87. A 20 year-old man was tackled heavily in a football match, sustaining blunt trauma to his left side. He complains of left upper quadrant pain, worse with movement.

Examination:

· GCS15

· Heart rate90 bpm

· BP120/80mmHg

CT of the abdomen reveals a splenic laceration, with subcapsular, non-expanding parenchymal haematoma.


88. A 30 year-old woman has just been transferred from rural hospital. She sustained a closed head injury from a motor vehicle accident, and was intubated / ventilated for the transfer via fixed wing transport. She had no other injury, so received no intervention other than neuro-protection. She was clinically stable during the flight. Soon after her arrival in your ED, the ventilator alarms are triggered.

Examination:

· GCS3 (sedated and paralysed)


· BP80/50mmHg

Distended neck veins. Trachea deviated to left. Reduced breath sounds on right, with ipsilateral hyper-resonance.


89. A frail 85 year-old man fell off a chair at his home, hitting his left chest wall against a table edge. He complains of left sided chest pain, markedly worse with any movement, including inspiration.

Examination:

· GCS14 (agitated from pain and hypoxia)


· BP160/90mmHg

· Oximetry90% on high flow oxygen

Bony crepitus, tenderness and bruising on left chest wall, consistent with multiple fractured ribs. Paradoxical segmental chest wall movement in same area. No haemo- or pneumothorax on chest X-ray.


90. A 40 year-old man sustained a right-sided haemo-pneumothorax from blunt trauma. A large bore intercostal catheter was inserted 1 hour ago, which initially drained 600ml of blood. He has received 3 litres of intravenous crystalloids. Initially stable, the patient deteriorated.

Examination:

· Pale and sweaty

· GCS13 (agitated from hypoxia)


· BP90/60mmHg

· Oximetry91% on high flow oxygen

Another 500ml of blood drained via the intercostal tube in the last 15 minutes.


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