Q1:
A
12-year-old driver who was not wearing a seatbelt was involved in a high-speed
head-on collision. He has suffered extensive trauma to the chest. In the
emergency department, he is alert but tachypneic, with markedly diminished
breath sounds on the right. Chest radiography reveals several anterior rib
fractures on the right and fluid in the right pleural space.
Of
the following, the MOST appropriate next step in the management of this boy is:
A. administration
of intravenous furosemide
B. chest
tube placement
C. elevation
of the head of the bed
D. emergent
thoracotomy
E. endotracheal
intubation
Answer
B
Answer
B
The
patient described in the vignette has a right hemothorax, a collection of blood
in the pleural space due to trauma. Physical findings of an acute hemothorax
include respiratory distress, shock due to blood loss, and diminished breath
sounds with dullness to percussion on the affected side. A thoracostomy tube
should be inserted to evacuate the hematoma in any patient who has a
radiologically significant hemothorax. Evacuation of the blood both reduces the
risk for a clotted hemothorax and eventual restrictive lung disease and
provides a method for evaluation of continuing blood loss. If the patient is in
respiratory or circulatory distress and other physical findings suggest a
hemothorax, tube thoracostomy should be performed before a chest radiograph is
obtained.
Continued
bleeding at greater than 1 to 2 mL/kg per hour after chest tube placement is an
indication for emergent operative thoracotomy, as is retained blood within the
pleural cavity or an inability to re-expand the lung. There is no indication in
the patient in the vignette for a diuretic such as furosemide. Endotracheal
intubation should be considered for those in severe respiratory distress
despite chest decompression with a chest tube. Elevation of the head of the bed
is not advisable in a patient who has suffered significant acute blood loss.
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Q 2
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Q 2
A
12-year-old child has been struck in the right eye by a baseball traveling at a
high rate of speed. On physical examination, there is marked bruising and
swelling of the periorbital region. The anterior chamber is clear, and
pupillary reflexes are intact. Extraocular movement testing reveals
dysconjugate gaze when looking to the left.
Of
the following, the MOST likely diagnosis is:
A. blow-out
fracture of the orbit
B. hyphema
C. lens
disruption
D. retinal
detachment
E. ruptured
globe
Question 3
A
6-year-old girl is brought to the emergency department because of confusion
followed by sleepiness. During the physical examination, she begins to exhibit
increased extensor tone in her lower extremities and increased flexor tone in
the upper extremities. There is no papilledema, and her pupils are small. She
is intubated and stabilized.
Of
the following, the most appropriate INITIAL diagnostic study to perform is:
A. computed
tomography of the head
B. electroencephalography
C. lumbar
puncture
D. toxicology
screen
E. ultrasonography
of the head
Answer
A
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Q 4:
Answer
A
-------------------
Q 4:
A
12-year-old boy is brought to the emergency department after being kicked in
the leg by another player during a soccer match. He is in marked distress due
to pain. On physical examination, you note a bruise and severe swelling of the
right lower leg, but no obvious deformity. His right foot is pale, and there is
decreased sensation to light touch and pinprick, but pulses are present. No
fracture is evident on radiography.
Of
the following, the MOST appropriate management is to:
A. administer
intravenous heparin
B. apply
ice to the injured area and recommend early ambulation
C. firmly
apply a wrap to the injured area and give the patient crutches
D. immediately
obtain compartment pressures
E. schedule
an orthopedic follow-up for the next day
Answer
D
Answer
D
Compartment
syndrome represents a constellation of signs and symptoms that result from
elevated pressures within a closed fascial space. Vascular insufficiency, ischemia,
and tissue necrosis can result from untreated compartment syndrome. Clinical
signs are classically described by the “Five Ps”: Pain, Paresthesia, Pallor,
Paralysis, and Pulselessness, although paralysis and pulselessness are late
signs. Most patients who have compartment syndrome have palpable distal pulses,
as described for the boy in the vignette. The most common sites of the syndrome
are the lower leg, the forearm, and the supracondylar region of the arm.
Compartment syndrome may be caused by fractures, crush injuries, snake bites,
or any severe soft-tissue trauma that causes significant swelling.
Compartment
syndrome should be suspected when pain seems out of proportion to the injury or
when pain increases significantly with time after the injury. Because
irreversible damage occurs within 6 to 8 hours in the absence of treatment,
emergency orthopedic evaluation also should be sought. All circumferential
bandages, dressings, or splints should be removed from the involved area.
Intracompartmental pressures should be measured by the orthopedic consultant.
Pressures that persist above 35 to 45 mm Hg will compromise capillary blood
flow and perfusion and are an indication for immediate fasciotomy to release
the pressure. In the presence of hypotension, compartment syndrome can result
from intracompartmental pressures of less than 35 mm Hg.
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