An 18-year-old man presents to the emergency department after an automobile accident. His vitals have significantly dropped since admission. Upon examination, his abdomen is slightly distended, the ribs on the right side are tender and appear broken, and breath sounds are diminished at the base of the right lung. An abdominal ultrasound and chest X-ray are ordered. Ultrasound shows fluid in the abdominal cavity and trauma to the liver. X-ray confirmed broken ribs and pleural effusion on the right. Based on these findings, the surgeons recommend immediate surgery. Upon entering the abdomen, an exsanguinating hemorrhage is observed. The Pringle maneuver is used to reduce bleeding. What was clamped during this maneuver?
Q152
A 33-year-old man is brought to the emergency department 20 minutes after losing control over his bicycle and colliding with a parked car. The handlebar of the bicycle hit his lower abdomen. On arrival, he is alert and oriented. His pulse is 90/min, respirations are 17/min and blood pressure is 110/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. The pupils are equal and reactive to light. There are multiple bruises over his chest and lower extremities. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. There is no pelvic instability. Rectal examination is unremarkable. A complete blood count, prothrombin time, and serum concentrations of glucose, creatinine, and electrolytes are within the reference range. Urine dipstick is mildly positive for blood. Microscopic examination of the urine shows 20 RBCs/hpf. Which of the following is the most appropriate next step in management?
Q153
A 22-year-old man comes to the emergency department for pain and swelling of his left knee one day after injuring it while playing soccer. While sprinting on the field, he slipped as he attempted to kick the ball and landed on the anterior aspect of his knee. He underwent an appendectomy at the age of 16 years. His vitals signs are within normal limits. Examination shows a swollen and tender left knee; range of motion is limited by pain. The tibial tuberosity shows tenderness to palpation. The left tibia is displaced posteriorly when force is applied to the proximal tibia after flexing the knee. The remainder of the examination shows no abnormalities. An x-ray of the left knee joint shows an avulsion fracture of the tibial condyle. Which of the following is the most likely diagnosis?
Q154
A 65-year-old man comes to the emergency department because of sudden, worsening pain in his right calf and foot that started 30 minutes ago. He also has a tingling sensation and weakness in his right leg. He has had no similar episodes, recent trauma, or claudication. He has type 2 diabetes mellitus and was diagnosed with hypertension 20 years ago. His sister has systemic sclerosis. He works as an office administrator and sits at his desk most of the day. He has smoked one and a half packs of cigarettes daily for 30 years. Current medications include metformin and lisinopril. His pulse is 110/min, respirations are 16/min, and blood pressure is 140/90 mm Hg. His right leg is pale and cool to touch. Muscle strength in his right leg is mildly reduced. Pedal pulses are absent on the right. Which of the following is the most likely underlying cause of this patient's symptoms?
Q155
Three hours later, the patient is reassessed. Her right arm is put in an elevated position and physical examination of the extremity is performed. The examination reveals reduced capillary return and peripheral pallor. Pulse oximetry of her right index finger on room air shows an oxygen saturation of 84%. Which of the following is the most appropriate next step in management?
Q156
A 67-year-old man comes to the emergency department because of decreased vision and black spots in front of his left eye for the past 24 hours. He states that it feels as if 'a curtain is hanging over his eye.' He sees flashes of light intermittently. He has no pain or diplopia. He underwent cataract surgery on the left eye 2 weeks ago. He has hypertension and type 2 diabetes mellitus. His sister has open-angle glaucoma. Current medications include metformin, linagliptin, ramipril, and hydrochlorothiazide. Vital signs are within normal limits. Examination shows a visual acuity in the right eye of 20/25 and the ability to count fingers at 3 feet in the left eye. The pupils are equal and reactive. The corneal reflex is present. The anterior chamber shows no abnormalities. The confrontation test is normal on the right side and shows nasal and inferior defects on the left side. Cardiopulmonary examination shows no abnormalities. The patient is awaiting dilation for fundus examination. Which of the following is the most likely diagnosis?
Q157
A 25-year-old male wrestler presents to his primary care physician for knee pain. He was in a wrestling match yesterday when he was abruptly taken down. Since then, he has had pain in his left knee. The patient states that at times it feels as if his knee locks as he moves it. The patient has a past medical history of anabolic steroid abuse; however, he claims to no longer be using them. His current medications include NSAIDs as needed for minor injuries from participating in sports. On physical exam, you note medial joint tenderness of the patient’s left knee, as well as some erythema and bruising. The patient has an antalgic gait as you observe him walking. Passive range of motion reveals a subtle clicking of the joint. There is absent anterior displacement of the tibia relative to the femur on an anterior drawer test. The rest of the physical exam, including examination of the contralateral knee is within normal limits. Which of the following structures is most likely damaged in this patient?
Q158
A 27-year-old man is brought to the emergency department after a motor vehicle accident. He complains of tingling of his legs, and he is unable to move them. His temperature is 36.5°C (97.7°F), the blood pressure is 110/75 mm Hg, and the pulse is 88/min. On physical examination, pinprick sensation is absent below the umbilicus and there is no rectal tone. Muscle strength in the lower extremities is 1/5 bilaterally. He has 5/5 strength in his bilateral upper extremities. Plain films and computerized tomography (CT) show the displacement of the thoracolumbar vertebrae. Which of the following is the best next step in the management of this patient?
Q159
A 55-year-old woman who works as a chef is brought to the hospital for evaluation of burns sustained in a kitchen accident. Physical examination reveals 3rd-degree burns over the anterior surface of the right thigh and the lower limbs, which involve approx. 11% of the total body surface area (TBSA). The skin in the burned areas is thick and painless to touch, and the dorsalis pedis pulses are palpable but weak. Initial fluid resuscitation has been started and the patient is hemodynamically stable. Which of the following is the most appropriate next step in management?
Q160
A 59-year-old patient comes to the emergency department accompanied by his wife because of severe right leg pain and numbness. His condition suddenly started an hour ago. His wife says that he has a heart rhythm problem for which he takes a blood thinner, but he is not compliant with his medications. He has smoked 10–15 cigarettes daily for the past 15 years. His temperature is 36.9°C (98.42°F), blood pressure is 140/90 mm Hg, and pulse is 85/min and irregular. On physical examination, the patient is anxious and his right leg is cool and pale. Palpation of the popliteal fossa shows a weaker popliteal pulse on the right side compared to the left side. Which of the following is the best initial step in the management of this patient's condition?
Trauma/Emergencies US Medical PG Practice Questions and MCQs
Question 151: An 18-year-old man presents to the emergency department after an automobile accident. His vitals have significantly dropped since admission. Upon examination, his abdomen is slightly distended, the ribs on the right side are tender and appear broken, and breath sounds are diminished at the base of the right lung. An abdominal ultrasound and chest X-ray are ordered. Ultrasound shows fluid in the abdominal cavity and trauma to the liver. X-ray confirmed broken ribs and pleural effusion on the right. Based on these findings, the surgeons recommend immediate surgery. Upon entering the abdomen, an exsanguinating hemorrhage is observed. The Pringle maneuver is used to reduce bleeding. What was clamped during this maneuver?
A. Aorta above celiac axis
B. Splenic artery only
C. Hepatic artery only
D. Hepatic vein only
E. Hepatoduodenal ligament (Correct Answer)
Explanation: ***Hepatoduodenal ligament***
- The **Pringle maneuver** involves clamping the **hepatoduodenal ligament** to control bleeding from the liver. This ligament contains the **hepatic artery**, **portal vein**, and **bile duct**.
- Clamping the hepatoduodenal ligament effectively stops blood flow into the liver, allowing for temporary control of hemorrhage during hepatic trauma repair.
*Aorta above celiac axis*
- Clamping the **aorta above the celiac axis** would severely compromise blood flow to multiple vital organs, including the stomach, spleen, and most of the intestines, leading to widespread ischemia.
- This is a much more extensive and dangerous clamping maneuver typically reserved for massive intra-abdominal hemorrhage not controllable by other means, rather than liver-specific bleeding.
*Splenic artery only*
- Clamping the **splenic artery** would only stop blood flow to the spleen and would not significantly impact bleeding from the liver.
- The described trauma is to the liver, so addressing the splenic artery would not be the primary intervention for a liver hemorrhage.
*Hepatic artery only*
- While clamping the **hepatic artery** would reduce arterial blood flow to the liver, the liver also receives a significant blood supply from the portal vein.
- Therefore, clamping only the hepatic artery would not completely stop the blood flow into the liver, making it less effective than the Pringle maneuver (which includes the portal vein).
*Hepatic vein only*
- Clamping the **hepatic vein** would obstruct blood outflow from the liver, leading to **hepatic venous congestion**, but it would not stop the inflow of blood from the hepatic artery and portal vein.
- This would worsen rather than control an exsanguinating hemorrhage from a liver injury.
Question 152: A 33-year-old man is brought to the emergency department 20 minutes after losing control over his bicycle and colliding with a parked car. The handlebar of the bicycle hit his lower abdomen. On arrival, he is alert and oriented. His pulse is 90/min, respirations are 17/min and blood pressure is 110/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. The pupils are equal and reactive to light. There are multiple bruises over his chest and lower extremities. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. There is no pelvic instability. Rectal examination is unremarkable. A complete blood count, prothrombin time, and serum concentrations of glucose, creatinine, and electrolytes are within the reference range. Urine dipstick is mildly positive for blood. Microscopic examination of the urine shows 20 RBCs/hpf. Which of the following is the most appropriate next step in management?
A. Intravenous pyelography
B. Laparotomy
C. Observation and follow-up
D. Suprapubic catheterization
E. CT scan of the abdomen and pelvis (Correct Answer)
Explanation: ***CT scan of the abdomen and pelvis***
- This patient has suffered significant trauma to the lower abdomen, as indicated by colliding with a parked car and handlebar impact, along with **hematuria** (urine dipstick positive for blood, 20 RBCs/hpf).
- A CT scan of the abdomen and pelvis is crucial to assess for potential **intra-abdominal organ injury**, particularly to the kidneys, bladder, or bowel, given the mechanism of injury and the presence of hematuria.
*Intravenous pyelography*
- While IVP can visualize the urinary tract, it is generally **less sensitive and specific** than CT scanning for detecting trauma-related urinary tract injuries and concurrent injuries to other abdominal organs.
- Furthermore, modern trauma care primarily utilizes **CT scanning** due to its superior anatomical detail and ability to assess multiple organ systems simultaneously.
*Laparotomy*
- **Exploratory laparotomy** is a surgical procedure indicated for patients with signs of **hemodynamic instability**, peritonitis, or clear evidence of severe intra-abdominal injury, none of which are present in this hemodynamically stable patient.
- Performing a laparotomy without further diagnostic imaging in a stable patient is premature and carries unnecessary risks.
*Observation and follow-up*
- While the patient is currently hemodynamically stable and the abdomen is soft and non-tender, the **mechanism of injury** (handlebar impact to the lower abdomen) combined with **hematuria** suggests a high likelihood of significant internal injury that requires further evaluation.
- **Observation alone** without imaging could lead to delayed diagnosis and treatment of a potentially serious injury to the urinary tract or other abdominal organs.
*Suprapubic catheterization*
- **Suprapubic catheterization** is used to drain the bladder when urethral catheterization is not possible or contraindicated, for example in cases of suspected urethral injury.
- There is no indication of urethral injury here (**unremarkable rectal exam**, no gross blood at the meatus), and the primary concern is evaluation of the organs, not bladder drainage.
Question 153: A 22-year-old man comes to the emergency department for pain and swelling of his left knee one day after injuring it while playing soccer. While sprinting on the field, he slipped as he attempted to kick the ball and landed on the anterior aspect of his knee. He underwent an appendectomy at the age of 16 years. His vitals signs are within normal limits. Examination shows a swollen and tender left knee; range of motion is limited by pain. The tibial tuberosity shows tenderness to palpation. The left tibia is displaced posteriorly when force is applied to the proximal tibia after flexing the knee. The remainder of the examination shows no abnormalities. An x-ray of the left knee joint shows an avulsion fracture of the tibial condyle. Which of the following is the most likely diagnosis?
A. Anterior cruciate ligament injury
B. Posterior cruciate ligament injury (Correct Answer)
C. Lateral meniscus injury
D. Medial meniscus injury
E. Medial collateral ligament injury
Explanation: ***Posterior cruciate ligament injury***
- The patient's mechanism of injury, **falling on the anterior aspect of the knee** (dashboard injury), is highly suggestive of a **PCL injury**.
- The finding of the **tibia displacing posteriorly** when force is applied to the proximal tibia after flexing the knee (positive **posterior drawer sign**) is a classic sign of PCL rupture.
*Anterior cruciate ligament injury*
- An **ACL injury** typically results from a twisting injury, hyperextension, or direct blow to the lateral aspect of the knee, not direct anterior impact.
- The **anterior drawer sign** (tibia displacing anteriorly) or **Lachman test** (increased anterior translation at 30 degrees of flexion) would be positive, not the posterior drawer sign.
*Lateral meniscus injury*
- **Meniscal injuries** often involve twisting or direct trauma, but the primary indicator would be clicking, locking, or catching of the knee, along with joint line tenderness.
- While an avulsion fracture is present, the posterior displacement of the tibia points more specifically to a ligamentous injury.
*Medial meniscus injury*
- Similar to a lateral meniscus injury, a **medial meniscus tear** would typically present with symptoms like clicking, locking, and pain along the medial joint line.
- The specific physical exam finding of posterior tibial displacement is not characteristic of a meniscus injury.
*Medial collateral ligament injury*
- An **MCL injury** usually occurs due to a **valgus stress** (force applied to the lateral side of the knee), causing pain on the medial side.
- The primary physical exam finding would be **instability with valgus stress**, not posterior tibial displacement.
Question 154: A 65-year-old man comes to the emergency department because of sudden, worsening pain in his right calf and foot that started 30 minutes ago. He also has a tingling sensation and weakness in his right leg. He has had no similar episodes, recent trauma, or claudication. He has type 2 diabetes mellitus and was diagnosed with hypertension 20 years ago. His sister has systemic sclerosis. He works as an office administrator and sits at his desk most of the day. He has smoked one and a half packs of cigarettes daily for 30 years. Current medications include metformin and lisinopril. His pulse is 110/min, respirations are 16/min, and blood pressure is 140/90 mm Hg. His right leg is pale and cool to touch. Muscle strength in his right leg is mildly reduced. Pedal pulses are absent on the right. Which of the following is the most likely underlying cause of this patient's symptoms?
A. Popliteal artery aneurysm
B. Atherosclerotic narrowing of the artery
C. Arterial vasospasm
D. Atheroembolism
E. Arterial embolism (Correct Answer)
Explanation: ***Arterial embolism***
- The sudden onset of severe unilateral limb pain, pallor, coolness, and absent pulses in a patient with risk factors for **atherosclerosis** and possible **arrhythmias** (given the history of hypertension and diabetes) strongly suggests acute limb ischemia due to an arterial embolism.
- The patient's presentation aligns with the "6 P's" of acute limb ischemia: **pain, pallor, pulselessness, paresthesias, poikilothermia (coolness), and paralysis** (weakness).
*Popliteal artery aneurysm*
- While a popliteal artery aneurysm can cause acute limb ischemia due to thrombosis or embolism within the aneurysm, it is more commonly associated with chronic limb ischemia or rupture, and a **palpable pulsatile mass** is typically present, which is not mentioned.
- The suddenness and severity of symptoms are more indicative of an embolic event rather than a thrombotic event within an aneurysm, which often presents less acutely.
*Atherosclerotic narrowing of the artery*
- **Atherosclerotic narrowing** typically causes chronic limb ischemia with symptoms like **claudication**, which is pain that worsens with exercise and improves with rest. The patient explicitly denies claudication.
- Acute worsening of atherosclerotic narrowing, often due to **plaque rupture and thrombosis**, would usually affect a limb with pre-existing claudication, and the onset might be less abrupt than described.
*Arterial vasospasm*
- **Arterial vasospasm** (e.g., Raynaud's phenomenon) primarily affects the small arteries and arterioles, typically in the digits, and is often triggered by cold or stress.
- It would not typically cause acute, severe, and widespread limb ischemia with absent pedal pulses in a large artery, and the patient's symptoms are not consistent with known vasospastic disorders affecting large vessels.
*Atheroembolism*
- **Atheroembolism** (e.g., "blue toe syndrome") typically involves multiple, small cholesterol emboli showering downstream, causing patchy ischemia, livedo reticularis, and renal or gastrointestinal involvement.
- While the patient has significant atherosclerotic risk factors, the sudden, complete obliteration of flow to the entire right leg, indicated by absent pedal pulses and diffuse symptoms, points more towards a **single, larger embolic occlusion** rather than diffuse microemboli.
Question 155: Three hours later, the patient is reassessed. Her right arm is put in an elevated position and physical examination of the extremity is performed. The examination reveals reduced capillary return and peripheral pallor. Pulse oximetry of her right index finger on room air shows an oxygen saturation of 84%. Which of the following is the most appropriate next step in management?
A. Perform fasciotomy
B. Obtain split-thickness skin graft
C. Decrease rate of IV fluids
D. Perform right upper extremity amputation
E. Perform escharotomy (Correct Answer)
Explanation: ***Perform escharotomy***
- The patient's symptoms of **reduced capillary return**, **peripheral pallor**, and **low oxygen saturation** in the setting of an elevated arm indicate **compartment syndrome** due to circumferential burn-related edema.
- **Escharotomy** is the appropriate immediate intervention to relieve pressure and restore circulation in deep circumferential burns.
*Perform fasciotomy*
- **Fasciotomy** is indicated for compartment syndrome due to **non-burn-related trauma** or other causes, where the tight fascia is the primary constricting factor.
- In burns, the **tough, inelastic eschar** itself is usually the constricting element, requiring escharotomy.
*Obtain split-thickness skin graft*
- A **split-thickness skin graft** is a reconstructive procedure performed after the burn wound has been adequately debrided and the patient is stable.
- It is not an emergent intervention to address acute limb ischemia from compartment syndrome.
*Decrease rate of IV fluids*
- While excessive fluid resuscitation can contribute to edema, the immediate and critical issue is the **compromised circulation** due to the constricting eschar, not solely fluid overload.
- Reducing IV fluids would not rapidly reverse the existing limb ischemia and could potentially lead to **hypoperfusion** if the patient is already under-resuscitated.
*Perform right upper extremity amputation*
- **Amputation** is a last resort, considered only after all attempts to salvage the limb, including escharotomy, have failed and there is irreversible tissue necrosis.
- It is not the appropriate first-line response to acute compartment syndrome from burns.
Question 156: A 67-year-old man comes to the emergency department because of decreased vision and black spots in front of his left eye for the past 24 hours. He states that it feels as if 'a curtain is hanging over his eye.' He sees flashes of light intermittently. He has no pain or diplopia. He underwent cataract surgery on the left eye 2 weeks ago. He has hypertension and type 2 diabetes mellitus. His sister has open-angle glaucoma. Current medications include metformin, linagliptin, ramipril, and hydrochlorothiazide. Vital signs are within normal limits. Examination shows a visual acuity in the right eye of 20/25 and the ability to count fingers at 3 feet in the left eye. The pupils are equal and reactive. The corneal reflex is present. The anterior chamber shows no abnormalities. The confrontation test is normal on the right side and shows nasal and inferior defects on the left side. Cardiopulmonary examination shows no abnormalities. The patient is awaiting dilation for fundus examination. Which of the following is the most likely diagnosis?
A. Endophthalmitis
B. Degenerative retinoschisis
C. Hemorrhagic choroidal detachment
D. Acute angle-closure glaucoma
E. Retinal detachment (Correct Answer)
Explanation: ***Retinal detachment***
- The patient's symptoms of **decreased vision**, **black spots** (floaters), **flashes of light** (photopsia), and the sensation of a "**curtain hanging over the eye**" are classic signs of **retinal detachment**.
- Recent **cataract surgery** is a significant risk factor for retinal detachment, and the visual field defects (nasal and inferior) noted in the confrontation test are consistent with the detached retina.
*Degenerative retinoschisis*
- While retinoschisis can cause visual field defects, it typically presents with **asymptomatic peripheral vision loss** and **does not usually cause photopsia or floaters**.
- It is a **splitting of the retina**, often stable and less likely to cause a sudden, symptomatic curtain-like vision loss.
*Endophthalmitis*
- Endophthalmitis is a severe intraocular infection characterized by **pain**, **redness**, and significant **vision loss**, often with **hypopyon** (pus in the anterior chamber).
- The patient has no pain or redness, and the anterior chamber is unremarkable, making endophthalmitis unlikely.
*Hemorrhagic choroidal detachment*
- This condition is often associated with **severe pain**, a **deepening of the anterior chamber**, and can occur post-operatively after intraocular surgery.
- While vision loss can be profound, the absence of pain and a normal anterior chamber make this diagnosis less likely.
*Acute angle-closure glaucoma*
- This condition presents with **sudden, severe eye pain**, **redness**, **halos around lights**, and often **nausea and vomiting**.
- The patient denies pain and redness, and the symptoms described are more consistent with retinal pathology than acute angle-closure glaucoma.
Question 157: A 25-year-old male wrestler presents to his primary care physician for knee pain. He was in a wrestling match yesterday when he was abruptly taken down. Since then, he has had pain in his left knee. The patient states that at times it feels as if his knee locks as he moves it. The patient has a past medical history of anabolic steroid abuse; however, he claims to no longer be using them. His current medications include NSAIDs as needed for minor injuries from participating in sports. On physical exam, you note medial joint tenderness of the patient’s left knee, as well as some erythema and bruising. The patient has an antalgic gait as you observe him walking. Passive range of motion reveals a subtle clicking of the joint. There is absent anterior displacement of the tibia relative to the femur on an anterior drawer test. The rest of the physical exam, including examination of the contralateral knee is within normal limits. Which of the following structures is most likely damaged in this patient?
A. Lateral meniscus
B. Lateral collateral ligament
C. Anterior cruciate ligament
D. Medial collateral ligament
E. Medial meniscus (Correct Answer)
Explanation: ***Medial meniscus***
- The patient's history of knee trauma during a wrestling match, followed by **locking** and **clicking** sensations, is highly indicative of a meniscal tear.
- **Medial joint line tenderness** specifically points towards involvement of the medial meniscus, which is more commonly injured than the lateral meniscus.
*Lateral meniscus*
- While a meniscal tear is likely, the presence of **medial joint tenderness** makes a lateral meniscus tear less probable.
- A lateral meniscus tear would typically present with pain localized to the **lateral aspect** of the knee.
*Lateral collateral ligament*
- Injury to the LCL typically results from a **varus stress** to the knee, often causing pain on the lateral side and instability, which are not primary complaints here.
- The physical exam did not describe any instability on **varus stress testing**, making an isolated LCL injury less likely.
*Anterior cruciate ligament*
- ACL injuries usually involve a distinct "pop" sensation and **knee instability**, particularly during activities requiring pivoting or cutting.
- The **absent anterior displacement** on the anterior drawer test effectively rules out an acute ACL tear.
*Medial collateral ligament*
- MCL injuries result from a **valgus stress** to the knee, causing pain and tenderness along the medial aspect of the knee and often **instability** during valgus stress testing.
- While there is medial tenderness, the presence of **locking and clicking** strongly points towards a meniscal injury rather than an isolated ligamentous injury, and significant instability is not described.
Question 158: A 27-year-old man is brought to the emergency department after a motor vehicle accident. He complains of tingling of his legs, and he is unable to move them. His temperature is 36.5°C (97.7°F), the blood pressure is 110/75 mm Hg, and the pulse is 88/min. On physical examination, pinprick sensation is absent below the umbilicus and there is no rectal tone. Muscle strength in the lower extremities is 1/5 bilaterally. He has 5/5 strength in his bilateral upper extremities. Plain films and computerized tomography (CT) show the displacement of the thoracolumbar vertebrae. Which of the following is the best next step in the management of this patient?
A. Immediate surgical decompression and stabilization (Correct Answer)
B. Spinal immobilization and transfer to trauma center
C. High-dose intravenous methylprednisolone
D. MRI of the spine
E. Conservative management with bed rest
Explanation: ***Immediate surgical decompression and stabilization***
- The patient presents with clear signs of **spinal cord compression** (paralysis, absent pinprick sensation below the umbilicus, absent rectal tone) and **vertebral displacement** after trauma.
- **Prompt surgical decompression** is crucial in cases of acute spinal cord injury with ongoing compression to prevent further neurological damage and improve functional outcomes.
*Spinal immobilization and transfer to trauma center*
- **Spinal immobilization** is an initial crucial step at the scene and during transport to prevent further injury, but it is not the definitive next step once in the emergency department with confirmed compression.
- While transfer to a trauma center is important, **surgical intervention** takes precedence once the diagnosis of vertebral displacement with neurological deficit is established and resources are available.
*High-dose intravenous methylprednisolone*
- The use of **high-dose corticosteroids** for acute spinal cord injury is controversial and no longer routinely recommended due to a lack of clear benefit and potential side effects.
- Its administration would delay definitive treatment and has not been shown to significantly improve neurological outcomes.
*MRI of the spine*
- While **MRI provides more detailed imaging** of soft tissues and spinal cord, CT and plain films have already confirmed vertebral displacement and ongoing spinal cord compression.
- Delaying surgical intervention to obtain an MRI is not advisable when there is clear evidence of **neurological deficit due to mechanical compression**.
*Conservative management with bed rest*
- Given the patient's **severe neurological deficits** and confirmed vertebral displacement, conservative management with bed rest is entirely inappropriate and will likely lead to permanent neurological damage.
- This approach is reserved for stable spinal injuries without significant neurological compromise.
Question 159: A 55-year-old woman who works as a chef is brought to the hospital for evaluation of burns sustained in a kitchen accident. Physical examination reveals 3rd-degree burns over the anterior surface of the right thigh and the lower limbs, which involve approx. 11% of the total body surface area (TBSA). The skin in the burned areas is thick and painless to touch, and the dorsalis pedis pulses are palpable but weak. Initial fluid resuscitation has been started and the patient is hemodynamically stable. Which of the following is the most appropriate next step in management?
A. Delayed excision and skin grafting
B. Fluid resuscitation with Ringer’s lactate solution per the Parkland formula
C. Early excision and split-thickness skin grafting (Correct Answer)
D. Topical antibiotic application of mafenide acetate
E. Early excision and full-thickness skin grafting
Explanation: **Early excision and split-thickness skin grafting**
- **Early excision and split-thickness skin grafting** is the most appropriate next step for **deep 3rd-degree burns** of this size to prevent infection, reduce inflammation, and promote wound healing.
- The burns cover 11% TBSA, which is a significant area where **skin grafting** would be beneficial to minimize scarring and improve functional outcomes.
*Delayed excision and skin grafting*
- **Delayed excision and grafting** increases the risk of **infection, sepsis, and prolonged hospitalization**.
- Early intervention is crucial for **optimal outcomes** in large, deep burns.
*Fluid resuscitation with Ringer’s lactate solution per the Parkland formula*
- While **fluid resuscitation** is critical in burn management, it is typically initiated **immediately upon presentation** and often pre-hospital or in the emergency department.
- The question asks for the "most appropriate next step in management" after initial evaluation and stabilization, implying that urgent surgical intervention is being considered for the **definitive wound closure**.
*Topical antibiotic application of mafenide acetate*
- **Topical antibiotics** like mafenide acetate are used to prevent **wound infection** but are primarily adjuncts to surgical treatment for deep burns.
- They do not address the need for **wound closure and definitive healing** in deep burns covering a significant TBSA.
*Early excision and full-thickness skin grafting*
- **Full-thickness skin grafts** are typically reserved for smaller, deeper defects in areas where cosmesis and durability are paramount, such as the face or hands.
- For **large-area 3rd-degree burns** like those on the thigh and lower limbs, **split-thickness skin grafts** are preferred due to their greater availability and ability to cover larger areas.
Question 160: A 59-year-old patient comes to the emergency department accompanied by his wife because of severe right leg pain and numbness. His condition suddenly started an hour ago. His wife says that he has a heart rhythm problem for which he takes a blood thinner, but he is not compliant with his medications. He has smoked 10–15 cigarettes daily for the past 15 years. His temperature is 36.9°C (98.42°F), blood pressure is 140/90 mm Hg, and pulse is 85/min and irregular. On physical examination, the patient is anxious and his right leg is cool and pale. Palpation of the popliteal fossa shows a weaker popliteal pulse on the right side compared to the left side. Which of the following is the best initial step in the management of this patient's condition?
A. Urgent assessment for amputation or revascularization (Correct Answer)
B. Decompressive laminectomy
C. Oral acetaminophen and topical capsaicin
D. Arthroscopic synovectomy
E. Cilostazol
Explanation: ***Urgent assessment for amputation or revascularization***
- The patient presents with classic signs of **acute limb ischemia** (severe pain, numbness, coolness, pallor, and diminished pulse) in the setting of chronic atrial fibrillation and medication non-compliance, indicating an **embolic event**.
- **Immediate surgical consultation** for revascularization and limb salvage is critical to prevent irreversible tissue damage and potential amputation.
*Decompressive laminectomy*
- This procedure is indicated for conditions like **spinal stenosis** or **herniated disc** causing nerve root compression, typically presenting with radicular pain, weakness, or sensory deficits.
- The patient's acute onset of symptoms, limb ischemia signs, and irregular pulse are not consistent with a spinal compressive neuropathy.
*Oral acetaminophen and topical capsaicin*
- These are **palliative treatments** for pain that is typically chronic and less severe, such as osteoarthritis or neuropathic pain.
- They are entirely inadequate for the management of **acute limb ischemia**, which requires urgent intervention to restore blood flow.
*Arthroscopic synovectomy*
- This is a surgical procedure to remove inflamed synovial tissue from a joint, typically performed for conditions like **rheumatoid arthritis** or other inflammatory arthropathies that have not responded to medical management.
- It is irrelevant to the management of acute vascular compromise of a limb.
*Cilostazol*
- **Cilostazol** is a phosphodiesterase inhibitor used in the long-term management of **intermittent claudication** due to peripheral artery disease to improve walking distance and reduce symptoms.
- It has no role in the acute treatment of **severe limb ischemia**, which is an emergency requiring immediate revascularization, not a medication for chronic symptoms.
