Surgery, Trauma & Emergency Medicine

A 25-year-old motorcyclist is brought in after a crash with a deformed, painful thigh. His pulse is 130 and blood pressure 88/50. What is the most likely cause of his shock?

• ANeurogenic shock from a spinal cord injury sustained when he was thrown from the motorcycle
• BAnaphylaxis to the intravenous morphine given by the paramedics at the roadside before transfer
• CCardiogenic shock from a bruised heart after the handlebars struck his chest in the crash
• DHaemorrhage into the femoral fracture, requiring fluid resuscitation and splinting✓

Answer: A femoral shaft fracture can bleed over a litre into the thigh, and hypovolaemic shock is the commonest cause of shock in trauma. Splinting reduces bleeding and pain; neurogenic shock causes bradycardia rather than tachycardia.

A 60-year-old man has sudden severe colicky pain radiating from loin to groin, with blood in his urine. What is the most likely diagnosis?

• AUreteric colic from a kidney stone✓
• BAcute appendicitis
• CTesticular torsion
• DRuptured abdominal aortic aneurysm

Answer: Loin-to-groin colicky pain with haematuria is the classic presentation of ureteric colic; a non-contrast CT of the kidneys, ureters and bladder confirms it. A ruptured aneurysm causes collapse with back or abdominal pain and hypotension.

A 74-year-old man collapses with severe abdominal and back pain. He is pale and hypotensive with a pulsatile abdominal mass. What is the immediate management?

• ACall the vascular surgeons and arrange emergency repair, with permissive hypotension and cross-matched blood✓
• BGive 2 litres of intravenous crystalloid rapidly to normalise the blood pressure before any surgical referral or imaging is arranged
• CArrange an outpatient ultrasound to measure the aneurysm
• DGive morphine and observe on the ward overnight

Answer: A ruptured abdominal aortic aneurysm is a surgical emergency; survival depends on immediate transfer for repair, with blood products and a restrained approach to fluids so that clot is not disrupted. Aggressive crystalloid worsens bleeding.

A 40-year-old woman has right upper quadrant pain, fever and jaundice. What is the diagnosis and the key concern?

• AHepatitis A — supportive treatment only, with a stool sample to confirm the diagnosis
• BAscending cholangitis — a biliary infection needing urgent antibiotics and drainage of the obstructed duct✓
• CBiliary colic — an outpatient laparoscopic cholecystectomy can be arranged once the pain has settled
• DPancreatitis — nil by mouth, intravenous fluids and analgesia until the amylase falls

Answer: Fever, jaundice and right upper quadrant pain (Charcot's triad) indicate ascending cholangitis, which can progress rapidly to sepsis; treatment is intravenous antibiotics and relief of the obstruction, usually by ERCP.

A 22-year-old has a head injury after a fall and vomited twice. He was briefly knocked out. According to NICE, what should happen?

• ADischarge with written head-injury advice, since he is now fully alert and orientated with no focal signs
• BA CT head within one hour, given more than one episode of vomiting✓
• CObservation on the ward for 24 hours with hourly neurological observations and no imaging
• DAn X-ray of the skull to look for a fracture, with a CT only if the X-ray shows one

Answer: NICE lists more than one episode of vomiting among the criteria for a CT head within one hour of the risk factor being identified. Skull X-rays have no role in modern head-injury assessment.

A 50-year-old woman has a burn to her forearm from hot water. What is the correct first aid?

• ACool the burn under cool running water for at least 20 minutes and cover it loosely with cling film✓
• BWrap the burn tightly in a dry towel to keep it warm and prevent shock
• CBurst any blisters with a clean needle and apply butter or a greasy cream to keep the air off the burn
• DApply ice directly to the burn for ten minutes, since ice cools the skin faster than water

Answer: Cooling with running water for 20 minutes reduces tissue damage even if started some time after the injury; cling film provides a clean, non-adherent cover. Ice causes further injury, blisters are left intact, and butter has no place.

A 68-year-old woman with a hip fracture after a fall is medically stable. According to NICE, when should surgery take place?

• AWithin one hour of arrival
• BOn the day of, or the day after, admission✓
• CAfter a week of traction and rehabilitation
• DOnly if she was able to walk unaided before the fall

Answer: NICE recommends operating on the day of admission or the day after, because delay increases complications and mortality. Traction is obsolete, and surgery is offered regardless of pre-fracture mobility, to allow pain relief and nursing care.

A 30-year-old man has a suspected tension pneumothorax after a stab wound: he is breathless, hypotensive, with a deviated trachea and absent breath sounds on one side. What is the immediate action?

• AIntubation and positive-pressure ventilation first
• BImmediate needle decompression followed by a chest drain, without waiting for a chest X-ray✓
• CAn urgent chest X-ray to confirm the diagnosis before any intervention
• DHigh-flow oxygen and observation on the resuscitation trolley

Answer: Tension pneumothorax is a clinical diagnosis and an immediate threat to life; decompression comes before imaging. Positive-pressure ventilation without decompression makes the tension worse.