Burns assessment and management — MCQs

10 questions

A 27-year-old male presents to the emergency department after being brought in from a house fire. The patient has extensive burns covering his body and is conscious but in severe pain. The patient has a past medical history notable for marijuana use. He is not currently on any medications. Physical exam is notable for extensive burns covering the patient's back, chest, thighs, and legs. The patient's oropharynx reveals no signs of damage or extensive smoke inhalation. The patient is breathing on his own and has normal breath sounds bilaterally. His temperature is 99.5°F (37.5°C), pulse is 145/min, blood pressure is 100/70 mmHg, respirations are 27/min, and oxygen saturation is 93% on room air. Which of the following interventions is most likely to reduce mortality in this patient?

A 55-year-old man with a history of IV drug abuse presents to the emergency department with an altered mental status. He was found unconscious in the park by police. His temperature is 100.0°F (37.8°C), blood pressure is 87/48 mmHg, pulse is 150/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for multiple scars and abscesses in the antecubital fossa. His laboratory studies are ordered as seen below. Serum: Na+: 139 mEq/L Cl-: 105 mEq/L K+: 4.3 mEq/L HCO3-: 19 mEq/L BUN: 20 mg/dL Glucose: 95 mg/dL Creatinine: 1.5 mg/dL Ca2+: 10.2 mg/dL Which of the following is the most appropriate treatment for this patient’s blood pressure and acid-base status?

A 44-year-old man is brought to the emergency department after sustaining high-voltage electrical burns over his left upper limb. On examination, the tip of his left middle finger is charred, and there are 2nd-degree burns involving the whole of the left upper limb. Radial and ulnar pulses are strong, and there are no signs of compartment syndrome. An exit wound is present over the sole of his right foot. His temperature is 37.7°C (99.8°F), the blood pressure is 110/70 mm Hg, the pulse is 105/min, and the respiratory rate is 26/min. His urine is reddish-brown, and urine output is 0.3 mL/kg/h. Laboratory studies show: Hemoglobin 13.9 g/dL Hematocrit 33% Leukocyte count 11,111/mm3 Serum Creatinine 4.6 mg/dL Creatine phosphokinase 15,230 U/L K+ 7.7 mEq/L Na+ 143 mEq/L What is the most likely mechanism for this patient's renal failure?

A 28-year-old soldier is brought back to a military treatment facility 45 minutes after sustaining injuries in a building fire from a mortar attack. He was trapped inside the building for around 20 minutes. On arrival, he is confused and appears uncomfortable. He has a Glasgow Coma Score of 13. His pulse is 113/min, respirations are 18/min, and blood pressure is 108/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows multiple second-degree burns over the chest and bilateral upper extremities and third-degree burns over the face. There are black sediments seen within the nose and mouth. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in management?

A 35-year-old man is pulled out of a burning building. He is unconscious and severely injured. He is transported to the nearest emergency department. Upon arrival, he is stabilized and evaluated for burns and trauma. Approximately 40% of his body is covered in burns. The burned areas appear blackened and charred but the skin is mostly intact. It is noted that the patient has loss of pain sensation in the burnt areas with minimal blanching on palpation. The affected area is leathery when palpated. What category of burn did the patient most likely to suffer from?

A 35-year-old woman is brought to the emergency department 45 minutes after being rescued from a house fire. On arrival, she appears confused and has shortness of breath. The patient is 165 cm (5 ft 5 in) tall and weighs 55 kg (121 lb); BMI is 20 kg/m2. Her pulse is 125/min, respirations are 29/min, and blood pressure is 105/65 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Examination shows second and third-degree burns over the anterior surfaces of the chest and abdomen, and the anterior surface of the upper extremities. There is black debris in the mouth and nose. There are coarse breath sounds over the lung bases. Cardiac examination shows no murmurs, rubs, or gallop. Femoral and pedal pulses are palpable bilaterally. Which of the following is the most appropriate fluid regimen for this patient according to the Parkland formula?

A 33-year-old man is brought to the emergency department because of trauma from a motor vehicle accident. His pulse is 122/min and rapid and thready, the blood pressure is 78/37 mm Hg, the respirations are 26/min, and the oxygen saturation is 90% on room air. On physical examination, the patient is drowsy, with cold and clammy skin. Abdominal examination shows ecchymoses in the right flank. The external genitalia are normal. No obvious external wounds are noted, and the rest of the systemic examination values are within normal limits. Blood is sent for laboratory testing and urinalysis shows 6 RBC/HPF. Hematocrit is 22% and serum creatinine is 1.1 mg/dL. Oxygen supplementation and IV fluid resuscitation are started immediately, but the hypotension persists. The focused assessment with sonography in trauma (FAST) examination shows a retroperitoneal fluid collection. What is the most appropriate next step in management?

A 67-year-old man comes to the physician for a follow-up examination. He has had lower back pain for several months. The pain radiates down the right leg to the foot. He has no history of any serious illness and takes no medications. His pain increases after activity. The straight leg test is positive on the right. The results of the laboratory studies show: Laboratory test Hemoglobin 14 g/d Leukocyte count 5,500/mm3 with a normal differential Platelet count 350,000/mm3 Serum Calcium 9.0 mg/dL Albumin 3.8 g/dL Urea nitrogen 14 mg/dL Creatinine 0.9 mg/dL Serum immunoelectrophoresis shows an immunoglobulin G (IgG) type monoclonal component of 40 g/L. Bone marrow plasma cells return at 20%. Skeletal survey shows no bone lesions. Magnetic resonance imaging (MRI) shows a herniated disc at the L5. Which of the following is the most appropriate next step?

A 35-year-old man is brought to the emergency department from a kitchen fire. The patient was cooking when boiling oil splashed on his exposed skin. His temperature is 99.7°F (37.6°C), blood pressure is 127/82 mmHg, pulse is 120/min, respirations are 12/min, and oxygen saturation is 98% on room air. He has dry, nontender, and circumferential burns over his arms bilaterally, burns over the anterior portion of his chest and abdomen, and tender spot burns with blisters on his shins. A 1L bolus of normal saline is administered and the patient is given morphine and his pulse is subsequently 80/min. A Foley catheter is placed which drains 10 mL of urine. What is the best next step in management?

Q10

A patient presents to the emergency department with arm pain. The patient recently experienced an open fracture of his radius when he fell from a ladder while cleaning his house. Surgical reduction took place and the patient's forearm was put in a cast. Since then, the patient has experienced worsening pain in his arm. The patient has a past medical history of hypertension and asthma. His current medications include albuterol, fluticasone, loratadine, and lisinopril. His temperature is 99.5°F (37.5°C), blood pressure is 150/95 mmHg, pulse is 90/min, respirations are 19/min, and oxygen saturation is 99% on room air. The patient's cast is removed. On physical exam, the patient's left arm is tender to palpation. Passive motion of the patient's wrist and fingers elicits severe pain. The patient's left radial and ulnar pulse are both palpable and regular. The forearm is soft and does not demonstrate any bruising but is tender to palpation. Which of the following is the next best step in management?

Burns assessment and management US Medical PG Practice Questions and MCQs

Question 1: A 27-year-old male presents to the emergency department after being brought in from a house fire. The patient has extensive burns covering his body and is conscious but in severe pain. The patient has a past medical history notable for marijuana use. He is not currently on any medications. Physical exam is notable for extensive burns covering the patient's back, chest, thighs, and legs. The patient's oropharynx reveals no signs of damage or extensive smoke inhalation. The patient is breathing on his own and has normal breath sounds bilaterally. His temperature is 99.5°F (37.5°C), pulse is 145/min, blood pressure is 100/70 mmHg, respirations are 27/min, and oxygen saturation is 93% on room air. Which of the following interventions is most likely to reduce mortality in this patient?

A. Topical antibiotics
B. IV fluids (Correct Answer)
C. Oxygen administration
D. Oral antibiotics
E. Normal saline soaked dressings

Explanation: ***IV fluids*** - Due to **extensive burns**, patients experience significant fluid shifts and loss, leading to a risk of **hypovolemic shock**. IV fluid resuscitation is crucial to maintain **circulatory volume** and prevent organ hypoperfusion. - The patient's **tachycardia** (pulse 145/min) and **hypotension** (BP 100/70 mmHg) with extensive burns indicate significant fluid deficits, making immediate and aggressive IV fluid resuscitation the most critical intervention to reduce mortality. *Topical antibiotics* - While important for preventing **burn wound infection**, topical antibiotics are a secondary concern after initial resuscitation, especially in the context of acute hemodynamic instability. - They do not address the immediate systemic compromise from **fluid loss** and **shock**. *Oxygen administration* - The patient's oxygen saturation is 93% on room air, and there are **no signs of smoke inhalation** or airway damage, making immediate oxygen administration less critical than fluid resuscitation for mortality reduction. - While supportive, it does not address the primary threat of **hypovolemic shock** from massive fluid shifts. *Oral antibiotics* - Similar to topical antibiotics, oral antibiotics are used to prevent or treat **burn wound infections** but are not an immediate life-saving intervention for acute burn shock. - They are typically reserved for bacterial prophylaxis or treatment if an infection is suspected later. *Normal saline soaked dressings* - These dressings can help with initial burn care by cooling the burn and providing some pain relief, but they do **not address the systemic fluid loss** and hemodynamic instability. - They are part of local wound management but are not the primary intervention to prevent **mortality in severe burns**.

Question 2: A 55-year-old man with a history of IV drug abuse presents to the emergency department with an altered mental status. He was found unconscious in the park by police. His temperature is 100.0°F (37.8°C), blood pressure is 87/48 mmHg, pulse is 150/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for multiple scars and abscesses in the antecubital fossa. His laboratory studies are ordered as seen below. Serum: Na+: 139 mEq/L Cl-: 105 mEq/L K+: 4.3 mEq/L HCO3-: 19 mEq/L BUN: 20 mg/dL Glucose: 95 mg/dL Creatinine: 1.5 mg/dL Ca2+: 10.2 mg/dL Which of the following is the most appropriate treatment for this patient’s blood pressure and acid-base status?

A. Ringer lactate (Correct Answer)
B. Dextrose 5% normal saline
C. Sodium bicarbonate
D. Hypertonic saline
E. Normal saline

Explanation: ***Ringer lactate*** - This patient presents with **hypotension** (BP 87/48 mmHg) and **metabolic acidosis** (HCO3- 19 mEq/L, with an elevated anion gap if calculated). Ringer lactate is a **balanced crystalloid solution** that contains lactate, which is metabolized to bicarbonate in the liver, helping to correct metabolic acidosis while providing fluid resuscitation. - The patient's history of **IV drug abuse**, fever, and altered mental status suggests a possible underlying infection (e.g., sepsis), which often presents with hypotension and metabolic acidosis requiring aggressive fluid resuscitation with a balanced solution. *Dextrose 5% normal saline* - While it provides fluids and some sodium, Dextrose 5% normal saline contains **free water**, which is not ideal for a patient with hypotension and may exacerbate cerebral edema if present. - It does not contain bicarbonate precursors and therefore would not directly address the patient's **metabolic acidosis**. *Sodium bicarbonate* - Administering sodium bicarbonate directly might be considered for severe metabolic acidosis, but **fluid resuscitation with a balanced solution** like Ringer lactate is usually the initial step to address both hypotension and acidosis. - Excessive or rapid administration of sodium bicarbonate can lead to **alkalosis**, worsening intracellular acidosis, and fluid overload. *Hypertonic saline* - **Hypertonic saline** is primarily used to treat severe **hyponatremia** or to reduce intracranial pressure. - It would not be appropriate for a patient with normal sodium levels and hypotension, as it could lead to further dehydration or worsen hypernatremia. *Normal saline* - **Normal saline (0.9% NaCl)** is an isotonic crystalloid often used for fluid resuscitation, but it has a high chloride content. - Large volumes of normal saline can worsen or induce **hyperchloremic metabolic acidosis**, which would be detrimental to a patient who already has metabolic acidosis.

Question 3: A 44-year-old man is brought to the emergency department after sustaining high-voltage electrical burns over his left upper limb. On examination, the tip of his left middle finger is charred, and there are 2nd-degree burns involving the whole of the left upper limb. Radial and ulnar pulses are strong, and there are no signs of compartment syndrome. An exit wound is present over the sole of his right foot. His temperature is 37.7°C (99.8°F), the blood pressure is 110/70 mm Hg, the pulse is 105/min, and the respiratory rate is 26/min. His urine is reddish-brown, and urine output is 0.3 mL/kg/h. Laboratory studies show: Hemoglobin 13.9 g/dL Hematocrit 33% Leukocyte count 11,111/mm3 Serum Creatinine 4.6 mg/dL Creatine phosphokinase 15,230 U/L K+ 7.7 mEq/L Na+ 143 mEq/L What is the most likely mechanism for this patient's renal failure?

A. Septicemia leading to acute pyelonephritis
B. Rhabdomyolysis, myoglobinuria, and renal injury (Correct Answer)
C. Direct visceral electrical injury to the kidneys
D. Fluid and electrolyte loss and hypovolemia
E. Volume overload because of excessive intravenous fluid resuscitation

Explanation: ***Rhabdomyolysis, myoglobinuria, and renal injury*** - The high **creatine phosphokinase (CPK)** level of 15,230 U/L indicates significant **muscle damage** (**rhabdomyolysis**) from the high-voltage electrical burn. - **Myoglobin** released from damaged muscle is **nephrotoxic** and precipitates in the renal tubules, leading to **acute kidney injury**, evidenced by **reddish-brown urine** and elevated **creatinine (4.6 mg/dL)**. *Septicemia leading to acute pyelonephritis* - While burns can lead to infection, there are no specific signs of **septicemia** or **pyelonephritis** (e.g., fever, flank pain) in the provided information. - The patient's **hyperkalemia** and elevated **CPK** are not typical findings for pyelonephritis. *Direct visceral electrical injury to the kidneys* - **Direct electrical injury** to internal organs such as the kidneys is **rare** unless the electrical current traverses the abdomen. - The entry and exit wounds (left upper limb and right foot) suggest a current path that is **less likely** to directly involve the kidneys. *Fluid and electrolyte loss and hypovolemia* - Although **burn injuries** can cause significant fluid loss, this patient's **blood pressure (110/70 mm Hg)** and **heart rate (105/min)** do not strongly suggest severe **hypovolemic shock**. - The **hemoglobin (19.9 g/dL)** and **hematocrit (33%)** also do not directly point to severe acute fluid loss as the primary cause of renal failure in the context of other findings. *Volume overload because of excessive intravenous fluid resuscitation* - The patient's **low urine output (0.3 mL/kg/h)** suggests **renal failure**, not fluid overload. - There is no mention of **fluid resuscitation** being administered, making this an unlikely cause of the current presentation.

Question 4: A 28-year-old soldier is brought back to a military treatment facility 45 minutes after sustaining injuries in a building fire from a mortar attack. He was trapped inside the building for around 20 minutes. On arrival, he is confused and appears uncomfortable. He has a Glasgow Coma Score of 13. His pulse is 113/min, respirations are 18/min, and blood pressure is 108/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows multiple second-degree burns over the chest and bilateral upper extremities and third-degree burns over the face. There are black sediments seen within the nose and mouth. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in management?

A. Insertion of nasogastric tube and enteral nutrition
B. Intravenous antibiotic therapy
C. Intubation and mechanical ventilation (Correct Answer)
D. Immediate bronchoscopy
E. Intravenous corticosteroid therapy

Explanation: ***Intubation and mechanical ventilation*** - The patient exhibits several signs of impending **airway compromise** due to **inhalation injury**, including perioral burns, black sediments in the nose and mouth, and being trapped in a fire. - While current oxygen saturation is 96%, **airway edema** can rapidly worsen, leading to respiratory failure. **Early intubation** is crucial to secure the airway before it becomes obstructed. *Insertion of nasogastric tube and enteral nutrition* - A nasogastric tube is often placed in burn patients to decompress the stomach and provide nutritional support, but it is **not the immediate priority** when there is a risk of airway obstruction. - **Enteral nutrition** is important but should be initiated only after airway control is established and the patient is stable for feeding. *Intravenous antibiotic therapy* - **Prophylactic antibiotics** are generally **not recommended** in the immediate management of burn patients unless there is clear evidence of infection, which is not present here. - Unnecessary antibiotic use can lead to **antibiotic resistance** and fungal infections. *Immediate bronchoscopy* - While **bronchoscopy** can confirm the extent of inhalation injury, it is not the primary immediate step. **Securing the airway** through intubation takes precedence over diagnostic procedures when airway compromise is imminent. - Bronchoscopy can be considered *after* intubation to assess the lower airway for damage and guide further management. *Intravenous corticosteroid therapy* - **Corticosteroids** are typically **contraindicated** in the management of inhalation injury because they can **impair immune function** and increase the risk of infection in burn patients. - Evidence does not support the routine use of corticosteroids to reduce inflammation in inhalation injury, and they may worsen outcomes.

Question 5: A 35-year-old man is pulled out of a burning building. He is unconscious and severely injured. He is transported to the nearest emergency department. Upon arrival, he is stabilized and evaluated for burns and trauma. Approximately 40% of his body is covered in burns. The burned areas appear blackened and charred but the skin is mostly intact. It is noted that the patient has loss of pain sensation in the burnt areas with minimal blanching on palpation. The affected area is leathery when palpated. What category of burn did the patient most likely to suffer from?

A. Superficial (1st degree)
B. Full-thickness (3rd degree) (Correct Answer)
C. Superficial-partial thickness (2nd degree)
D. Deep-partial thickness (deep 2nd degree)
E. Full-thickness with extension to underlying structures (4th degree)

Explanation: ***Full-thickness (3rd degree)*** - The description of **blackened, charred appearance**, **loss of pain sensation**, **minimal blanching**, and **leathery texture** are classic signs of a **full-thickness (3rd-degree) burn**. - **Full-thickness burns** destroy the entire dermis, including nerve endings, leading to a painless area. - The leathery texture results from protein coagulation in the destroyed dermis. *Superficial (1st degree)* - This type of burn affects only the **epidermis**, causing redness, pain, and no blistering. - The patient's presentation of charred skin and insensitivity to pain is inconsistent with a **superficial burn**. *Superficial-partial thickness (2nd degree)* - **Superficial partial-thickness burns** involve the epidermis and superficial dermis, characterized by painful blisters and redness. - The absence of pain and presence of charred skin rule out this type of burn. *Deep-partial thickness (deep 2nd degree)* - **Deep partial-thickness burns** extend into the deep dermis and may have **decreased pain sensation** due to nerve damage. - However, these burns typically appear **mottled red or white** rather than blackened and charred, and usually have some blanching response. - The completely charred, blackened appearance with absent pain indicates full-thickness injury. *Full-thickness with extension to underlying structures (4th degree)* - A **4th-degree burn** extends beyond the skin into **muscle, bone, or tendons**, often with visible destruction of these structures. - The affected area would typically be **very firm or hard** with exposed deeper tissues. - While the burn is severe, the description focuses on skin characteristics without obvious involvement of deeper anatomical structures like muscle or bone.

Question 6: A 35-year-old woman is brought to the emergency department 45 minutes after being rescued from a house fire. On arrival, she appears confused and has shortness of breath. The patient is 165 cm (5 ft 5 in) tall and weighs 55 kg (121 lb); BMI is 20 kg/m2. Her pulse is 125/min, respirations are 29/min, and blood pressure is 105/65 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Examination shows second and third-degree burns over the anterior surfaces of the chest and abdomen, and the anterior surface of the upper extremities. There is black debris in the mouth and nose. There are coarse breath sounds over the lung bases. Cardiac examination shows no murmurs, rubs, or gallop. Femoral and pedal pulses are palpable bilaterally. Which of the following is the most appropriate fluid regimen for this patient according to the Parkland formula?

A. Administer 4 liters of intravenous colloids over the next 8 hours
B. Administer 5 liters of intravenous colloids over the next 6 hours
C. Administer 5 liters of intravenous crystalloids over the next 6 hours
D. Administer 8 liters of intravenous colloids over the next 12 hours
E. Administer 6 liters of intravenous crystalloids over the next 24 hours (Correct Answer)

Explanation: ***Administer 6 liters of intravenous crystalloids over the next 24 hours*** - The **Parkland formula** is 4 mL × weight (kg) × %TBSA burn. The patient's weight is 55 kg. The burns cover the anterior chest (9%), anterior abdomen (9%), and anterior surfaces of both upper extremities (4.5% + 4.5% = 9%), totaling **27% TBSA**. - Calculation: 4 mL × 55 kg × 27% = **5,940 mL ≈ 6 liters**. Half is given in the first 8 hours (approximately 3 L), and the remaining half over the next 16 hours (approximately 3 L). Total fluid in 24 hours is approximately **6 liters of crystalloids**. *Administer 4 liters of intravenous colloids over the next 8 hours* - The Parkland formula primarily uses **crystalloids** (lactated Ringer's solution) for initial fluid resuscitation in burn patients, not colloids. - Administering only 4 liters would be insufficient given the patient's 27% TBSA burn, and colloids are not first-line. *Administer 5 liters of intravenous colloids over the next 6 hours* - **Colloids** are not the first-line fluid for initial burn resuscitation under the Parkland formula; crystalloids are used. - The timing of 6 hours does not align with the Parkland formula's 24-hour resuscitation period (half in first 8 hours, half in next 16 hours). *Administer 5 liters of intravenous crystalloids over the next 6 hours* - While **crystalloids** are appropriate, 5 liters over 6 hours represents an inappropriately rapid infusion rate that does not follow the Parkland formula timing. - The first 8 hours should receive approximately 3 liters, not 5 liters over 6 hours, which could lead to complications such as **pulmonary edema or compartment syndrome**. *Administer 8 liters of intravenous colloids over the next 12 hours* - This option incorrectly specifies **colloids** instead of crystalloids as the primary fluid for burn resuscitation according to the Parkland formula. - The volume of 8 liters exceeds the calculated requirement of 6 liters for this patient's 27% TBSA burn.

Question 7: A 33-year-old man is brought to the emergency department because of trauma from a motor vehicle accident. His pulse is 122/min and rapid and thready, the blood pressure is 78/37 mm Hg, the respirations are 26/min, and the oxygen saturation is 90% on room air. On physical examination, the patient is drowsy, with cold and clammy skin. Abdominal examination shows ecchymoses in the right flank. The external genitalia are normal. No obvious external wounds are noted, and the rest of the systemic examination values are within normal limits. Blood is sent for laboratory testing and urinalysis shows 6 RBC/HPF. Hematocrit is 22% and serum creatinine is 1.1 mg/dL. Oxygen supplementation and IV fluid resuscitation are started immediately, but the hypotension persists. The focused assessment with sonography in trauma (FAST) examination shows a retroperitoneal fluid collection. What is the most appropriate next step in management?

A. Perform an MRI scan of the abdomen and pelvis
B. CT of the abdomen and pelvis with contrast
C. Obtain a retrograde urethrogram
D. Take the patient to the OR for an exploratory laparotomy (Correct Answer)
E. Perform a diagnostic peritoneal lavage

Explanation: ***Take the patient to the OR for an exploratory laparotomy*** - The patient is **hemodynamically unstable** (BP 78/37 mm Hg, pulse 122/min) with signs of hemorrhagic shock (cold and clammy skin, drowsy, tachycardia) and **hypotension persists despite IV fluid resuscitation**. - FAST examination shows **retroperitoneal fluid collection** (presumed blood), flank ecchymoses (Grey Turner sign), and hematocrit of 22% indicating **significant blood loss**. - According to **ATLS (Advanced Trauma Life Support) protocols**, hemodynamically **unstable patients with positive FAST exams require immediate surgical intervention** and should not be delayed for further imaging. - **Exploratory laparotomy** allows for immediate identification and control of bleeding sources, which is life-saving in this persistently hypotensive patient. The retroperitoneal hematoma can be explored and bleeding vessels ligated or repaired. *CT of the abdomen and pelvis with contrast* - CT scan is the **appropriate next step for hemodynamically STABLE trauma patients** or those who **respond to initial resuscitation** to characterize injuries and guide management. - This patient has **persistent hypotension despite resuscitation**, making him too unstable to safely transport to the CT scanner. Delaying surgery for imaging in an unstable patient increases mortality risk. - The principle is: **"Blood pressure is better than pictures"** - unstable patients need operative hemorrhage control, not diagnostic imaging. *Perform an MRI scan of the abdomen and pelvis* - **MRI has no role in acute trauma evaluation** due to long acquisition time (30-60 minutes), limited availability, and inability to adequately monitor critically ill patients in the MRI suite. - This would be an inappropriate and potentially fatal delay in a patient with ongoing hemorrhage and hemodynamic instability. *Perform a diagnostic peritoneal lavage* - **Diagnostic peritoneal lavage (DPL)** has been largely replaced by FAST examination for detecting intraperitoneal hemorrhage in the modern trauma algorithm. - While DPL can detect intra-abdominal blood, the **FAST has already identified retroperitoneal fluid**, and the patient's persistent instability mandates immediate surgical intervention rather than additional diagnostic procedures. - DPL also does not evaluate the retroperitoneum well and would not change management in this unstable patient. *Obtain a retrograde urethrogram* - **Retrograde urethrogram (RUG)** is indicated when urethral injury is suspected (blood at meatus, high-riding prostate, perineal hematoma, inability to void). - This patient has **normal external genitalia** and only microscopic hematuria (6 RBC/HPF), which is nonspecific in blunt trauma. - The immediate life-threatening issue is **hemorrhagic shock from retroperitoneal bleeding**, not potential urethral injury. RUG would be an inappropriate delay in management and can be performed later if clinically indicated.

Question 8: A 67-year-old man comes to the physician for a follow-up examination. He has had lower back pain for several months. The pain radiates down the right leg to the foot. He has no history of any serious illness and takes no medications. His pain increases after activity. The straight leg test is positive on the right. The results of the laboratory studies show: Laboratory test Hemoglobin 14 g/d Leukocyte count 5,500/mm3 with a normal differential Platelet count 350,000/mm3 Serum Calcium 9.0 mg/dL Albumin 3.8 g/dL Urea nitrogen 14 mg/dL Creatinine 0.9 mg/dL Serum immunoelectrophoresis shows an immunoglobulin G (IgG) type monoclonal component of 40 g/L. Bone marrow plasma cells return at 20%. Skeletal survey shows no bone lesions. Magnetic resonance imaging (MRI) shows a herniated disc at the L5. Which of the following is the most appropriate next step?

A. Dexamethasone
B. Thalidomide
C. Physical therapy (Correct Answer)
D. Autologous stem cell transplantation
E. Plasmapheresis

Explanation: ***Physical therapy*** - The patient's symptoms of radiated lower back pain, positive straight leg test, and MRI findings of a **herniated disc at L5** are classic for **radiculopathy** caused by disc herniation. - **Conservative management**, including physical therapy, is the most appropriate initial step for symptomatic lumbar disc herniation, aiming to reduce pain and improve function. *Dexamethasone* - While corticosteroids like dexamethasone can reduce inflammation and pain, they are typically considered for **short-term relief** in severe cases or as an adjunct, not as the primary or sole treatment for herniated disc. - In the context of the elevated IgG monoclonal component and plasma cells, dexamethasone is part of treatment regimens for **multiple myeloma**, but the primary issue presented is disc herniation. *Thalidomide* - Thalidomide is an **immunomodulatory drug** used in the treatment of multiple myeloma, particularly in combination with dexamethasone. - It has no role in the management of **lumbar disc herniation** or radiculopathy. *Autologous stem cell transplantation* - This is a treatment option for **multiple myeloma** once a patient achieves remission, especially in younger, fitter patients. - It is an aggressive procedure and **not indicated** for the treatment of a herniated disc, nor as an initial step for myeloma given the current presentation. *Plasmapheresis* - Plasmapheresis is used to remove **excess proteins** or antibodies from the blood, often in conditions like hyperviscosity syndrome or specific autoimmune diseases. - It is **not a treatment** for herniated disc and would only be considered for multiple myeloma in cases of severe hyperviscosity, which is not indicated by the current lab values.

Question 9: A 35-year-old man is brought to the emergency department from a kitchen fire. The patient was cooking when boiling oil splashed on his exposed skin. His temperature is 99.7°F (37.6°C), blood pressure is 127/82 mmHg, pulse is 120/min, respirations are 12/min, and oxygen saturation is 98% on room air. He has dry, nontender, and circumferential burns over his arms bilaterally, burns over the anterior portion of his chest and abdomen, and tender spot burns with blisters on his shins. A 1L bolus of normal saline is administered and the patient is given morphine and his pulse is subsequently 80/min. A Foley catheter is placed which drains 10 mL of urine. What is the best next step in management?

A. Additional fluids and escharotomy (Correct Answer)
B. Escharotomy
C. Continuous observation
D. Moist dressings and discharge
E. Additional fluids and admission to the ICU

Explanation: ***Additional fluids and escharotomy*** - The patient has **circumferential full-thickness burns** on both arms (dry, nontender), which require **escharotomy** to prevent compartment syndrome and vascular compromise to the limbs. - The **oliguria** (10 mL urine output) despite a 1L fluid bolus indicates **inadequate fluid resuscitation** from burn shock. With approximately 40% TBSA burns, the patient requires aggressive fluid resuscitation per the Parkland formula (4 mL/kg/% TBSA), which would be approximately 11 liters in the first 24 hours. Adequate resuscitation targets urine output of 0.5-1 mL/kg/hr (35-70 mL/hr for this patient). - Both interventions are immediately necessary: fluids for burn shock and escharotomy for circumferential burns. *Escharotomy* - While **escharotomy** is essential for the circumferential full-thickness burns to prevent compartment syndrome, it alone will not address the **severe fluid deficit** causing oliguria and hypoperfusion. - The low urine output reflects systemic hypovolemia from burn shock, not just local compartment issues, requiring aggressive fluid resuscitation. *Continuous observation* - **Continuous observation** is inappropriate given the patient's critical findings: circumferential full-thickness burns requiring urgent escharotomy and oliguria indicating inadequate resuscitation. - Delaying escharotomy can lead to irreversible ischemic damage to the limbs, and inadequate fluid resuscitation can progress to multiorgan failure. *Moist dressings and discharge* - This option is completely inappropriate for a patient with **extensive deep burns** (approximately 40% TBSA) including full-thickness injuries requiring hospitalization and specialized burn care. - Discharge would lead to severe complications including infection, inadequate fluid resuscitation, compartment syndrome, and potential limb loss. *Additional fluids and admission to the ICU* - While ICU admission and additional fluids are necessary components of care, this option is **incomplete** because it omits **escharotomy**, which is urgently needed for the circumferential full-thickness burns. - Escharotomy is a time-sensitive procedure that must be performed promptly to prevent ischemic injury to the limbs from vascular compromise.

Question 10: A patient presents to the emergency department with arm pain. The patient recently experienced an open fracture of his radius when he fell from a ladder while cleaning his house. Surgical reduction took place and the patient's forearm was put in a cast. Since then, the patient has experienced worsening pain in his arm. The patient has a past medical history of hypertension and asthma. His current medications include albuterol, fluticasone, loratadine, and lisinopril. His temperature is 99.5°F (37.5°C), blood pressure is 150/95 mmHg, pulse is 90/min, respirations are 19/min, and oxygen saturation is 99% on room air. The patient's cast is removed. On physical exam, the patient's left arm is tender to palpation. Passive motion of the patient's wrist and fingers elicits severe pain. The patient's left radial and ulnar pulse are both palpable and regular. The forearm is soft and does not demonstrate any bruising but is tender to palpation. Which of the following is the next best step in management?

A. Replace the cast with a sling
B. Measurement of compartment pressure (Correct Answer)
C. Ibuprofen and reassurance
D. Emergency fasciotomy
E. Radiography

Explanation: ***Measurement of compartment pressure*** - The patient exhibits classic signs of **compartment syndrome**, including severe pain out of proportion to injury, pain with passive stretching, and a history of trauma followed by casting. Measuring compartment pressure is crucial for diagnosis despite palpable pulses. - Early measurement of compartment pressures can confirm the diagnosis and guide the decision for an **emergency fasciotomy** to prevent irreversible tissue damage. *Replace the cast with a sling* - This action would likely worsen the patient's condition by delaying the diagnosis and treatment of potential **compartment syndrome**. - A sling does not address the underlying issue of increased pressure within the muscle compartments. *Ibuprofen and reassurance* - Administering **Ibuprofen (NSAID)** might mask the pain but will not resolve the increased pressure within the compartment, which is a surgical emergency. - Reassurance without proper assessment of compartment syndrome could lead to irreversible muscle and nerve damage. *Emergency fasciotomy* - While a fasciotomy is the definitive treatment for confirmed compartment syndrome, it should only be performed **after compartment pressures have been measured** and the diagnosis confirmed, unless the clinical suspicion is extremely high and pressures cannot be obtained. - Performing a fasciotomy without objective confirmation is generally not the immediate next step, as it is an invasive procedure with its own risks. *Radiography* - **Radiography** would be useful to assess the healing of the fracture or rule out new fractures, but it will not provide information about the soft tissue pressure changes characteristic of compartment syndrome. - The patient's symptoms are more indicative of a circulatory or soft tissue issue rather than a new bony problem.

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