A&e answers

1. ANSWERS MCQ A & E POSTING F F T T F

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16. T T F T FQuestion 1 A – False Explanation : Pulsus paradoxus is an abnormally reduced SBP during inspiration due to increased pulmonary intravascular volume during inspiration. A decrease SBP >15mmHg is pathological Reference : Macleod Clinical Examination B – False Explanation : Shock is a clinical syndrome occurs when there is in adequate tissue perfusion. Symptoms of shock are low BP (< 90mmHg SBP/ cannot be obtained/ 30 mm Hg fall in baseline BP), tachycardia > 100 bpm (weak rapid pulse), tachypnea (respiratory rate > 22 and hyperventilate, cold, clammy and pale skin, change in level of consciousness, increase CRT and reduce urine output Reference: Shock : Shock and Fluid Resuscitation : Merck Manual Professional http://www.merckmanuals.com/professional/sec06/ch067/ch067b.html C – True Explanation : Neurogenic shock is caused due to impairment of descending sympathetic pathway characterized by hypotension and bradycardia. This type of shock is diagnosed by exclusion Reference : NMS Emergency Medicine 2nd Edition D – True Explanation : Or can be calculated by DBP + 1/3 pulse pressure Reference : Page 252, Medical Physiology 2nd Edition by Walter F. Boron & Emile L. Boulpaep E – False Explanation : The formula is HR/SBP Reference : Page 1 Shock Index as a Predictor of Mortality among Severely Injured Hemorrhagic Shock Patients http://www.ferne.org/Lectures/2008_research_lecture/pubpdf/DCLHb_saem01_shock_index_newformat.pdf Question 2 A – True Explanation : Trauma score consists of blood pressure, heart rate and Glasgow Coma Scale Reference : Page 38, Manual For the Malaysian Trauma Life Support Course B – False Explanation : All hemodynamically unstable and shock patients are to be triaged to the critical zone Reference : Page 164, Manual For the Malaysian Trauma Life Support Course C – False Explanation : Patients that are brought into red zones are the ones with ruptured Triple A and while unruptured triple A patients are assessed and treated conservatively or elective surgical intervention if more than 5 cm Reference : Page 170, Guide to the Essentials in Emergency Medicine by Shirley Ooi and Peter Manning D – False Explanation : The primary survey is consists of management the level of consciousness, cervical spine, airway, breathing, circulation, and rapid body survey Reference : Page 42 – 46, Manual For the Malaysian Trauma Life Support Course E – True Explanation : The first responders (a person who has completed a course and received certification in providing pre-hospital care for medical emergencies) could pronounce death. In some jurisdiction, they must consult a physician first before officially pronouncing patients’ deceased Reference : http://en.wikipedia.org/wiki/Dead_on_arrival Question 3 A – False Explanation : Sebab nk bezakan unstable angina ngan non-STEMI ialah thru cardiac enzymes/biomarkers yg raised in non-STEMI, bukan unstable angina Reference : Page 86, Cardiovascular System at a Glance B – False Explanation : ST elevations seen in V1-V3 indicates anteroseptal MI. For lateral MI, die ade ST elevations kat V4-V6 Reference : Page 3, CPG Management of acute STEMI 2007 2nd Edition Slides ECG \" Language of the heart\" by Dr. Effa C – False Explanation : They may appear within a few hours of an acute MI Reference : Page 82, Oxford Handbook of Clinical Medicine 7th Edition D – False Explanation : Since CK-MB rises early (4-8H) and falls early (paling penting, 48-72H), CK-MB measurements lah yg digunakan tok detect reinfarction, bukan troponin T yg can remain elevated for up to 14 days! Lambat sgt turun, so die sesuai tok detect MI patient yg present late to the hospital Reference : Page 4, CPG Management of acute STEMI 2007 2nd Edition E – True Explanation : For 2nd/3rd degree AV block Reference : Page 18, CPG Management of acute STEMI 2007 2nd Edition Extra Notes : Other contraindications of B-blockers are bradycardia, SBP < 100mmHg, pulmonary congestions with crepts beyond the lung bases, signs of peripheral hypoperfusion, asthma /COPD or severe peripheral vascular disease Question 4 A – True Explanation : Primary brain injury refers to the sudden and profound injury to the brain that is considered to be more or less complete at the time of impact. Secondary brain injury refers to the changes that evolve over a period of time (from hours to days) after the primary brain injury. It includes an entire cascade of cellular, chemical, tissue, or blood vessel changes in the brain that contribute to further destruction of brain tissue by causing hypoxia or anoxia Reference : http://www.outreach-online.org/leaflets/abi/brain_injury.htm http://medicalcenter.osu.edu/patientcare/healthcare_services/physical_rehabilitation/about/brain/Pages/index.aspx B - False Explanation : Brain injury may occur in one of two ways: Closed brain injury – when there is a non-penetrating injury to the brain with no break in the skull

17. Penetrating brain injury – a.k.a open head injuries occur when there is a break in the skull, such as when a bullet pierces the brainThe most common is closed brain injury. Kalau soalan ditukar kepada the most common head injury is closed brain injury - then it is true Reference : Brain Injury – The Teenage Years PDF File http://www.google.com.my/url?sa=t&source=web&cd=5&ved=0CDgQFjAE&url=http%3A%2F%2Fwww.bianys.org%2F_literature_44390%2FBrain_Injury_The_Teenage_Years&ei=vf65TeXFA5LsvQOAmsm5Cw&usg=AFQjCNElIOGNCMJ7lu7KrbHZk-yzwmjVew C - True Explanation : Cantu Concussion Severity Grades (1991) Grade 2: Loss of Consciousness < 5 Minutes OR Post Traumatic Amnesia of 30 Minutes to 24 Hours Reference : http://cpancf.com/headinjuryclassification.asp D – True Explanation : An open brain injury always involves some sort of break in the skull. Types of skull fracture include linear, depressed, diastatic and basilar skull fracture Reference : http://www.new-york-brain-injury-lawyers.com/penetrating-head-injuries.html E – False Explanation : Without prompt treatment, death is often the result of epidural hematoma. Treatment often consists of surgery, as well as drugs designed to reduce and control the amount of swelling in the brain. Reference : http://www.brainandspinalcord.org/hematoma/epidural-hematoma.html Question 5 A – True Explanation : Patient will regain back the normal brain function, but the duration of recovery depends on severity of trauma Reference : Page 233, Neurology and Neurosurgery Illustrated 4th Edition by Kenneth W.Lindsay and Ian Bone, Churchill Livingstone B – True Explanation : Even after relatively minor head injury, patients may have persistent symptoms of : Headache, dizziness and increase irritability

18. Difficulty in concentration and in coping with work

19. Fatigue and depressionReference : Page 233, Neurology and Neurosurgery Illustrated 4th Edition by Kenneth W.Lindsay and Ian Bone, Churchill Livingstone Extra Notes: If the trauma more severe LOC

20. Period of post-traumatic amnesia

21. Some neurological damage – delayed information processing (resolve in several weeks)

22. Vestibular concussion – leads to dizziness and vertigoC – False Explanation : The most common cause of traumatic brain injury is road traffic accident. Most common in young males; maybe involving alcohol. Reference : Page 216, Neurology and Neurosurgery Illustrated 4th Edition by Kenneth W.Lindsay and Ian Bone, Churchill Livingstone D – True Explanation : Description exactly in the book Reference : Page 216, Neurology and Neurosurgery Illustrated 4th Edition by Kenneth W.Lindsay and Ian Bone, Churchill Livingstone E – False Explanation : Only grade from I to III. No grade IV Reference: http://orthopedics.about.com/od/sportsinjuries/a/concussion.htm Question 6 A – True Explanation : These are the principles of emergency medicine A – airway and cervical spineB – breathing and ventilation C – Circulation and hemorrhage controlD – Disability E – Exposure and environment Reference : Page 1 – 8, Emergency Medicine (lecture notes) 3rd edition, Chris Moulton, David YatesB – True Explanation : The primary survey (C= circulation) is conducted to correct any hypoxia and hypovolemia, the main aim is to ensure the oxygen supply to the brain Reference : Page 206, Emergency Medicine : The Principles of Practice 5th Edition by Gordian W.O. Fulde C – False Explanation : The rapid restoration of circulating volume in blood loss patient will prevent a sudden failure of the compensatory mechanisms and often irreversible fall in cardiac output. Reference : Page 6, Emergency Medicine (lecture notes) 3rd edition, Chris Moulton, David Yates D – True Explanation : Further neurological assessment (in secondary survey) include 1. Level of consciousness (assess using GCS) 2. Focal neurological signs (variation in muscle tone, asymmetrical limb movement) 3. Pulse (down), BP (up), pupil size (up), papillary response (down) – late indicator for increase ICP Reference : Page 35, Emergency Medicine (lecture notes) 3rd edition, Chris Moulton, David Yates E – True Explanation : Patient who is unconscious with head injury or have blunt injury above clavicle, or multiple trauma patient is assume to have cervical spine injury. Hence, cervical collar application. Reference : Page 11, Manual For the Malaysian Trauma Life Support Course Question 7 A – True Explanation : HR is increased as compensatory mechanism to increased BP. The increasing HR will increased the cardiac output (CO) subsequently MAP will also increased as refer to the formula of MAP= CO x TPR Reference : Page 104 – 105, Robbins Basic Pathology 8th Edition Page 448 – 450, Human Physiology 9th Edition B – False Explanation : Not heart only become hypoxic. Shock will cause multiorgans failure, heart, kidney, brain Reference : Page 104 – 105, Robbins Basic Pathology 8th Edition C – True Explanation : Cellular destruction cause multiorgan failure such as heart, brain, renal and pulmonary as well Reference : http://en.wikipedia.org/wiki/Shock_(circulatory) D – False Explanation : Restoration of BP and fluid volume occur in compensatory mechanism and able restore homeostasis of tissue. However in decompensated state, the compensatory mechanism is useless because cell/ tissue destruction is severe and lead to organ failure Reference : http://en.wikipedia.org/wiki/Shock_(circulatory) E – False Explanation : Acidosis with hyperkalemia occurs in the initial stage of shock due to anerobic mechanism then produced excessive lactic acid Reference : Page 456 – 457, Human Physiology 9th Edition Question 8 A – True Explanation : Hypovolemia dalam Bailey— is because kurangnya circulating volume. This can be due to hemorrhagic & non-hemorrhagic causes. Example of hemorrhage is exogenous blood loss Reference : Page 14, Bailey & Love’s Short Practice of Surgery 25th Edition B – False Explanation : Tachycardia ade sebab nak compensate for the reduced stroke volume to maintain the cardiac output & BP. ( cardiac output = stroke volume x heart rate) Tapi sweating x de. Cos dalam compensated shock, body will maintain the cardiovascular state dengan kurangkan perfusion to the skin, muscle & GI tract. Kurang perfusion jadi bila ade vasoconstriction. Vasoconstriction akan cause cool peripheries, makanye memang x akn jadi sweating. Reference : Page 15, Bailey & Love’s Short Practice of Surgery 25th Edition C – True Explanation : Cardiogenic shock jadi because jantung tu sendiri fail nak pump darah keluar kepada tissues for their metabolic demands. Bila kurangnya darah keluar maka kuranglah cardiac output BP Reference : Page 57, Emergency Medicine Manual 6th edition, O John Ma D – False Explanation : Shock ade 4 types yang kite belajar time seminar & aku cari kat buku2- cardiogenic, distributive, hypovolemic and obstructive. X de lah pulak restrictive Reference : Page 14, Bailey & Love’s Short Practice of Surgery 25th Edition E – True Explanation : Formula= heart rate/ systolic BP Reference : Page 50, Emergency Medicine Manual 6th edition, O John Ma Extra Notes : index ni diguna pakai untuk menggambarkan kerja mengepam oleh left ventricle in acute circulatory failure. Normal value is 0.5 - 0.7. Kalo > 1.0 maka ade impaired left ventricular function Question 9 A – True Explanation : Complication such as pulmonary aspiration and gastrointestinal obstruction, have been reported in patients treated with multiple doses of activated charcoal. Electrolyte imbalance like hypernatremia and hypermagnesemia also been reported. However, the actual rate of its occurrence is low. Reference : http://healthoracle.org/downloads/A/Activated%20Charcoal.pdf http://www.drugs.com/sfx/activated-charcoal-side-effects.html B – True Explanation : Barbiturates = Phenobarbitone can be adsorbed by charcoal Reference : Page 119, Guide to the Essentials in Emergency Medicine by Shirley Ooi and Peter Manning C – True Explanation : In this position the risk of aspiration is reduced Reference : http://drratin.hpage.us/principle_of_poisoning_management_24937600.html D – False Explanation : Management Airway management equipment must be immediately available, a patient with adequate oxygenation who has impaired gag reflex and who need gastric lavage will require prophylactic orotracheal intubation. Reference : Page 116, Guide to the Essentials in Emergency Medicine by Shirley Ooi and Peter Manning E – False Explanation : Force emesis is not recommended in both children and adult Reference : http://www-clinpharm.medschl.cam.ac.uk/pages/teaching/topics/poison/poison2.html Question 10 A – True Explanation : In DKA, stress, infection, surgery is the precipitating factors Reference : http://qjmed.oxfordjournals.org/content/97/12/773.2.full B – True Explanation : As DKA lead to shock if left untreated, so, kaloa de renal disease, lagi la worsen, as u know what will happened in shock, reduced perfusion to vital organs like heart, renal, and brain. If they already had underlying disease like those stated above, lagi la worse kan keadaan, da la shock, jantung lemah, kidney prob plak, ofkos la mortality rate will be high Reference : http://www.ispub.com/journal/the_internet_journal_of_endocrinology/volume_3_number_2_15/article/clinical_and_laboratory_characteristics_of_diabetic_ketoacidosis_in_adult_diabetic_patients.html C – False Explanation : Increase risk of arterial thrombosis only and as well as MI, stroke sbb mainly it involved artery circulation Reference : Page 658 – 662, Pocket Essentials of Clinical Medicine 4th Edition (Kumar & Clark) D – False Explanation : Of course EMERGENCY!!! Because both may lead to profound dehydration if left untreated. shock la kan ape lg? Reference : Page 814 – 816, Oxford Handbook of Clinical Medicine 7th Edition E – False Explanation : In HHS, endogenous insulin is reduced not absent, but still sufficient to inhibit hepatic ketogenesis. While in DKA, there will be absence of insulin. Reference : Page 658 – 662, Pocket Essentials of Clinical Medicine 4th Edition (Kumar & Clark) Question 11 A – True Explanation : Severe hypoglycemia occurs most often in people with type 1 DM. Hypoglycemia can also be caused by sulfonylureas in people with type 2 diabetes Reference: http://en.wikipedia.org/wiki/Diabetic_hypoglycemia B – True Explanation : Alcohol akan cause redistribution of blood flow kat pancreas menggalakkan insulin secretion thereby evoking hypoglycemia Reference : http://care.diabetesjournals.org/content/24/11/1888.full C – True Explanation : It can be taken as food or drink if the person is conscious and able to swallow Reference : http://en.wikipedia.org/wiki/Diabetic_hypoglycemia D – True Explanation : Severe hypoglycemia can result in cerebral edema Reference : wvc.omnibooksonline.com/data/papers/2006_V79.pdf E – True Explanation : The two commonly administered hypertonic agents are mannitol and hypertonic saline Reference : wvc.omnibooksonline.com/data/papers/2006_V79.pdf Question 12 A – False Explanation : When acetoacetic acid reacts with nitroprusside, a color change develops, covering the range from beige (negative) to maroon (positive). The test does not react with acetone or B-hydroxybutyrate Reference : http://www.anytestkits.com/utk-ketones-in-urine.htm B – False Explanation : Serum osmolality of >340mmol/kg is often seen in HONK. Normal value :280-300 mmol/kg Reference : Page 816, Oxford Handbook of Clinical Medicine 7th Edition C – False Explanation : Plasma glucose is usually >20mmol/L Reference : Page 815, Oxford Handbook of Clinical Medicine 7th Edition D – True Explanation : If serum Na is normal,use 0.9% NaCl. If serum sodium is elevated (>160mmol/L),use 0.45% NaCl Reference : http://www.kck.usm.my/husm/pharmacy/formulary/ENDOCRINE%20UNIT_add_31.01.10.pdf E – True Explanation : The choice of replacement fluid largely depends upon the fluid that is being lost. Some debate exists whether colloid or crystalloid solutions should be used, however both randomized controlled trials and meta-analyses have failed to demonstrate outcome benefit of colloid solutions over the cheaper and more readily available crystalloid. Reference : http://medresidents.stanford.edu/TeachingMaterials/Shock%20and%20Sepsis/Shock%20and%20Sepsis%20Handout.doc Question 13 A – True Explanation : These actions are termed links in the “Chain of Survival” Reference : Page 2, Basic Life Support 2010 Guidelines by Dr Julina Md Noor B – False Explanation : Recognize cardiac arrest by checking the response then activate EMS Reference : Page 2, Basic Life Support 2010 Guidelines by Dr Julina Md Noor C – True Explanation : If a lone rescuer finds an unresponsive adult, check for a response, activate the community emergency response system, immediately begin CPR Reference : Page 3, Basic Life Support 2010 Guidelines by Dr Julina Md Noor D – True Explanation : A lone rescuer will have to decide whether to start resuscitation or to go for help first. In these circumstances, if the likely cause of unconsciousness is trauma (injury) or drowning or if the victim is an infant or a child, the rescuer should perform resuscitation for about 1 minute before going for help. Reference : http://circ.ahajournals.org/cgi/content/full/circulationaha;95/8/2174#SEC7 E – True Explanation : The 1992 AHA guidelines2 emphasized that the rescuer should, if no other help is available, leave an adult victim immediately after establishing unresponsiveness in order to call an ambulance or EMS system (\" phone first\" ). Reference : http://circ.ahajournals.org/cgi/content/full/circulationaha;95/8/2174#SEC7 Question 14 A – True Explanation : 3rd degree burn – destruction of all epidermal and dermal layers (Full thickness burn) 4th degree burn – involved tissue beneath the skin such as muscle, ligament, tendon and bone (Absent of pain in both – because nerve endings that present in dermis layer already destroyed) Reference : Page 135, Manual For the Malaysian Trauma Life Support Course B – False Explanation : 3rd degree burn involved whole dermis Reference : Page 135, Manual For the Malaysian Trauma Life Support Course C – True Explanation : Present in superficial partial thickness burn / superficial 2nd degree burn Reference : Page 135, Manual For the Malaysian Trauma Life Support Course D – False Explanation : Superficial burn = first degree burn – epidermis only while 2nd degree burn extends into outermost part of dermis Reference : Page 135, Manual For the Malaysian Trauma Life Support Course E – False Explanation : The percentage BSA in children are more accurately estimated using the Lund-Browder chart as children have proportionally larger heads and smaller lower extremities. We also have modified rule of nine for pediatrics.But rule of nine and Lund & Browder chart have different distribution. Reference : Page 381, Bailey and Love’s Short Practice of Surgery 25th Edition Question 15 A – False Explanation : Major burn - DO NOT!!!! It can cause shock Reference : http://www.nlm.nih.gov/medlineplus/ency/article/000030.htm http://www.ygoy.com/index.php/how-to-treat-a-burn/ B – True Explanation : Selagi mangsa berasa sakit, kita hendaklah bg analgesic. Tak kiralah minor or major burn. Reference : Page 138, Manual For the Malaysian Trauma Life Support Course C – True Explanation : Memang kita guna Parkland formula Reference : Page 384, Bailey and Love’s Short Practice of Surgery 25th Edition D – False Explanation : Start IV line – Lactated Ringer Reference : Page 384, Bailey and Love’s Short Practice of Surgery 25th Edition E – False Explanation : fluid replacemet finished after giving 24 hours of fluid replacement bukan 24 jam selepas mangsa sampai di hospital. First 24hrs, mangsa memerlukan 4ml/kg body weight/ % of body surface Reference : Page 384, Bailey and Love’s Short Practice of Surgery 25th Edition Question 16 A – True Explanation : Of all deaths caused by fire, 75% are due to inhalation burns Reference : http://www.mdguidelines.com/inhalation-burns B – True Explanation : Complications include subglottic stenosis, bronchiectasis, pulmonary edema, pneumonia, atelectasis, asthma, bronchospasm, and extreme difficulty breathing Reference : http://www.mdguidelines.com/inhalation-burns C – False Explanation : Thermal burn injury to the lower airway is rare Reference : Page 381, Bailey and Love’s Short Practice of Surgery 25th Edition D – True Explanation : The inhalation of toxic smoke causes the release of thromboxane and other mediators, which increases pulmonary artery pressure and causes secondary damage to the respiratory epithelium and release of chemotactic factors Reference : http://ccforum.com/content/11/1/R22 E – False Explanation : the burned airway creates symptoms of swelling to the airway & block the airway, hence the treatment is to secure the airway and early intubation is the treatment of choice Reference : Page 380 – 381, Bailey and Love’s Short Practice of Surgery 25th Edition

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