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SAQ 1

A 68 year old male is leaving the pub when he is struck by a passing car travelling at low speed. An ambulance is called. He mobilises into the ambulance and walks into your tertiary ED, where he is placed on a bed. An Xray is ordered by the triage nurse (shown).

1. List three features of this x ray. (3 marks)
   • Open book pelvic fracture (LC 3 classification)
   • No femoral fracture evident
   • No pubic rami fracture
2. List your next three management steps. (3 marks)
   • Move patient to resuscitation room
   • Apply pelvic binder
   • Urgent bloods/group and cross match
3. What is the most common source of bleeding in pelvic trauma? (1 mark)
   • Venous bleeding – sacral plexus, iliac vessels etc
4. After the actions taken in (b), the patient has a BP of 85/60, HR 119. He is still complaining of pain. A FAST scan is performed and is negative. There is no evidence of external haemorrhage. What is your next step in management? (1 mark)
   • Angiography and embolization – if available in under 30 mins
5. After taking the action above (d), your patient remains haemodynamically unstable. What is your next step in his management? (1 mark)
   • OT for extraperitoneal packing/laparotomy

_{Ref: trauma.org, management of pelvic fractures – algorithm.}

SAQ 2

A 38 year old male is retrieved by Medstar after being found unconscious in a house fire 4 hours ago. He is now conscious with spontaneous respirations. He has a black, sooty face with blistering and his hair and nasal hair are both singed. There is circumferential blistering of his entire left leg below the groin.

1. List four indications for intubation in burns patients. (4 marks)
   • ARDS Progressive air hunger
   • Supraglottic oedema
   • Decreased GCS/respiratory depression
   • Facial burns – full thickness
   • Circumferential neck burns
2. Calculate his fluid resuscitation requirements based on his burns, assuming he weighs 70kg. Show calculations where appropriate. (4 marks)
   • *Face (4.5%), leg (9+9%) = 22.5%
   • Assume 70kg male
   • Fluids: *4ml/tbsa/wt = 6300ml of *Hartmanns
   • *Give half over 4 hours (four hours has already elapsed), remainder over 16 hours.
3. State three methods of assessing his response to fluid resuscitation. (3 marks)
   • Urine output – aim >1ml/kg/hr
   • BP – invasive art line would be good
   • CVP
   • Lactate clearance
   • No points for cap refill, given burns would be difficult.
4. List three expected complications of his burns, and your solution for each. (3 marks)
   • Compartment syndrome leg – escharatomy if needed
   • Sepsis – ADT, antibiotics to cover pseudomonas
   • Rhabdomyolysis – IVT+++ etc
   • Electrolyte disturbance
   • Airway issues…..any reasonable ones…ARDS
5. List four indications for hyperbaric oxygen in burns patients. (4 marks)
   • Altered mental state
   • ECG changes
   • Pregnant female with symptoms of CO poisoning
   • CoHb >25%
   • Compartment syndrome

SAQ 3

A 30 year old male presents with an amputated right hand at the level of his wrist after a farming accident. His workmate has brought in the amputated hand.

1. List four immediate steps in your management of this patient. (4 marks)
   • Direct pressure on limb
   • Place amputant part in plastic bag, then in ice slurry
   • Analgesia, antibiotics, IVT, NBM
   • Xray both forearm and amputant part
2. List four indicators of a favourable outcome in limb amputation. (4 marks)
   • Early presentation after accident (<6 hours)
   • No comorbidities (esp DM, PVD)
   • No mangling injury to hand
   • Early access to good surgery
   • Patient willingness to comply with hand therapy
3. List four contraindications to re-implantation surgery. (4 marks)
   • Severe crush injury
   • Prolonged warm ischaemia, particularly of muscle (>6 hrs)
   • Severe contamination
   • Medical co-morbidities that can affect anaesthetic, healing, etc
   • Life threatening injuries
   • Refusal to accept blood transfusion/product in cases of major amputation

SAQ 4

An electricity worker sustains a high voltage injury working on a power line. He had 60 seconds loss of consciousness and injuries to his left hand and both feet with loss of tissue. He is BIBA to your rural hospital. His BP is 110/80, HR 70, Sats 96% RA, GCS 13/15.

1. What is the main cause of cardiac arrest in the following electrical injuries? (2 marks)
   
   High-voltage injury: VF arrest
   Lightning strike: Asystole
2. List four possible complications of this injury IN THIS PATIENT. (4 marks)
   • Compartment syndrome
   • Arrhythmias
   • Rhabdomyolysis
   • Burns
   • Possible C spine injury
3. Outline your management of this patient and state his disposition. (5 marks)
   • Early intubation – risk of oedema, GCS low
   • Aggressive fluids
   • Monitor – high voltage with LOC mandates monitoring for arrhythmia
   • C spine precautions if unable to clear radiologically
   • Disposition: burns unit (electrical burn with likely significant internal injuries).
4. Before “disposing” of the patient, you obtain a CXR to exclude pulmonary injury. What is the abnormality on this X ray?
   • Bilateral posterior shoulder dislocations

SAQ 5

An 18 year old soccer player is struck by lightning during a match. He received brief CPR on the scene with ROSC before being transported to hospital by ambulance.

1. List two complications of lightning strike in any patient. (2 marks)
   • Cardiac arrest
   • Respiratory arrest – hypoxic arrest may occur post-strike in pts who survive original rhythm
   • Autonomic dysfunction
   • Keraunoparalysis
2. The soccer player is unable to move his left leg and his right pupil is dilated compared to his left. An imageof his back is shown (image). Briefly explain these findings and your management of each. (6 marks)
   • Keraunoparalysis – transient stunning with paralysis, resolves spontaneously
   • Anisocoria = autonomic dysfunction, resolves by itself. No prognostic value
   • Lichtenberg figures – ferning from electron showers.

SAQ 6

For each of the following X-rays, state the diagnosis and list three early and three late complications. (7 marks each)