MH SAQ practice Surgery

A patient presents to the emergency department after sustaining multiple lacerations to the sole of the foot from oyster shells after walking on the beach. You wish to perform a regional block to the plantar aspect of the foot.

1. Name the 3 nerves involved and their cutaneous distribution (3 marks)

  • posterior tibial – most of the sole and heel
  • sural – posterolateral sole
  • saphenous – small area, medially over arch

2. Where would you insert LA to anaesthetise these regions (3 marks)

  • posterior tibial – upper border of medial malleolus, between posterior tibial artery and Achilles tendon
  • sural – fanlike distribution, superficial, lateral to Achilles tendon
  • saphenous – superficially, between medial malleolus and tibialis anterior tendon

4. What other issues must be addressed in the treatment of this injury prior at discharge (4 marks)

  • infection prophylaxis – skin commensals, vibrioegdoxyclycline if not pregnant
  • tetanus update
  • aftercare and follow up advice
  • documentation, certificates for work etc

A 2 year old boy is brought into the ED by his mother after swallowing his older sister’s earring. He is drooling.

1. What in the history would alert you to the presence of a foreign body? (3 marks)

  • choking episode, difficulty in breathing
  • drooling,
  • coughing

2. You review the Xray. Do you think the FB is in the trachea or oesophagus and why? (1 mark)

  • Oesophagus as it is at the level of C6 cricopharyngeus where a foreignbodyoften sticks

3. Where in the oesophagus might a foreign body become lodged? (3 marks)

• T4 Aortic arch,

• T8 where the aorta crosses the oesophagus

• T10 GOJ

4. Describe 3 instances where this FB would need to removed urgently (3 marks)

  • If foreign body suspected button batteries
  • complete impaction
  • abdominal pain or obstruction

A 32 year-old alcoholic diabetic male presents with a painful facial swelling from a tooth abscess which has been getting worse over 2 days. He is of no fixed address and has been unable to get to a dentist. His vital signs show a HR: 110bpm, BP 120/75; RR 24 with saturation of 94% and aural temp of 38.5 degrees C. His neck and throat are tender to palpation and are swollen . He has difficulty opening his mouth and is unable to protrude his tongue. His tongue appears displaced superiorly and anteriorly.

1. What is the likely diagnosis? (1 mark)

  • Submandibular space infection (Ludwig's angina)

2. What are the 2 serious complications of this diagnosis? (2 marks)

  • can lead rapidly to a threatened airway
  • can lead rapidly to septic shock

3. List your top 3 treatment priorities (3 marks)

  • Secure the airway early. Prepare for difficult intubation/surgical airway. Consider Options for airway management include which include awake fibreoptic intubation, creating a surgical airway (tracheostomy or cricothyroidotomy), inhalational induction , and awake blind nasal intubation
  • Give antibiotics early
  • Surgical drainage of any collection of pus

4. List the antibiotics that may be useful and state the rational for your choice. (4 marks)

  • Need to cover gram pos, gram negative and anaerobes
  • metronidazole 500mg IV every 12 hours AND benzylpenicillin 1.2g IV every 6 hours
  • For patients with non-immediate hypersensitivity to penicillin: cephazolin 2g IV every 8 hours
  • For patients with immediate hypersensitivity to penicillin: clindamycin 450 mg IV every 8 hours OR lincomycin 600 mg IV every 8 hours

A 24 year old male had been assaulted. He has swelling around his LEFT eye and a cut on his RIGHT cheek. Your SHO has requested facial views.

a. Give 3 abnormalities on the x-ray. (3 marks)

left, ? orbital floor fracture. ? fluid level in left antrum.

b. List six aspects of assessment of the orbit and its contents. (4 marks)

Visual acuity. pupil response, anterior chamber/lens and fundus. eye movements, infraorbital nerve function. proptosis and enophthalmos, subcut emphysema.

c. List 3 further steps in this patient’s management. (3 marks)

discus with max fax,

advice re nose blowing.

return immediately if decreased vision or pain on eye movements

Analgesia- eg 800 mg ibuprofen TDS

advice to avoid flying/pressurined areas

commence on ABX

A 25 year old man sustains facial injuries in a high speed motor vehicle crash in which he was the unrestrained driver.


His observations are:

GCS15

HR100/min

BP130/75mmHg supine

O2 sat97% room air

a. Describe 3 abnormalities shown in this photograph. (3 marks)

  • Periorbital bruising bilaterally
  • Facial swelling especially over the right zygoma
  • Haemoserous nasal discharge
  • Possible swollen tongue
  • Chipped right upper incisor

What 3 underlying injuries could there be? (3 marks)

  • Facial bone fractures
  • Mandibular fracture
  • Base of skull fractures
  • Intracranial haemorrhage

b. List 5 factors that provide a risk to his airway? (5 marks)

  • Swollen tongue – haematoma
  • Direct trauma to airway
  • ICH causing depressed GCS
  • Blood loss into airway from facial fractures
  • Mandibular fracture
  • Small mouth
  • Bull neck

This 32 year old male lost control of a high pressure injector and comes in with a wound on his left lower leg.

a. List three complications that are likely to occur within the next 48 hours. (3 marks)

  1. Compartment syndrome
  2. Tissue necrosis from local trauma
  3. Wound infection

b. List the management priorities for this injury. (5 marks)

  1. Analgesia
  2. Elevation
  3. Tetanus
  4. Plain film to rule out other injury
  5. Surgical or orthopaedic admission +/- exploration in OT

c. What factors contribute to damage? (3 marks)

  1. Type of liquid injected
  2. Location of injury
  3. Amount injected
  4. Proximity of nozzle

A 14 month old girl presents via ambulance to your tertiary ED. She was eating a sausage when she appeared to choke and turn blue. Parental back blows were given.

On arrival the child is drooling, has mild respiratory distress, is upset and has Sats of 96% on 6L 02, a RR of 34 /min and a mild stridor.

A neck x-ray has been done and is shown below.

a. What is the major abnormality on the neck x-ray? (2 marks)

Large radio opaque FB (Snag) in allecular and partially occluding upper airway

b. List and justify 3 options to managing her airway issue. (6 marks)

1. Straight to OT with ENT/paedsanaes: has airway now, prob safest, could go bad on way up to OT, may not be possible if in small place

2. ED RSI : if loses airway needs first aid (back blows) then direct laryngoscopy with magills for FB removal; should be achievable in all EDs (backup Cric)

3. Delayed RSI/sedation in ED after getting help down to ED (eganes/ENT etc). Good approach if remains stable, issues with OT etcetc

c. What are 2 ways an unwitnessed bronchial foreign body aspiration may present in children. (2 marks)

present with persistent or recurrent cough, wheezing, persistent or recurrent pneumonia, lung abscess, focal bronchiectasis, or hemoptysis

A 58 year old woman presents to the ED complaining of a five day history of sore throat and progressive difficulty swallowing. Examination reveals she is febrile with stridor at rest. Oropharyngeal examination does not reveal an overt diagnosis.

a. What is your differential diagnosis? (2 marks)

Retropharyngeal abscess – most likely

Prevertebral abscess – rare

Epiglottitis – rare

Peritonsillar abscess – expect local signs

Submandibular cellulitis – expect local signs

b. What are the key features in your immediate management? (8 marks)

ABC approach in Resus and keep sitting in comfortable position

Have difficult airway kit ready if needed

Keep NBM

Analgesia e.g. morphine/fentanyl

IV fluids if clinically dehydrated

Nebulised Adrenaline 5mg - mandatory

Dexamethasone 5mg IV - mandatory

IV Ceftriaxone 2g and Flucloxacillin 1g and metronidazole 500mg (or other appropriate as per local guidelines) - mandatory

Urgent ENT review – mandatory

Anaesthesia and ICU

Disposition HDU/ICU

A 74 year old female presents to ED with 2 hrs of left sided epistaxis. HR is 80 /min, all other vitals are within normal limits. She has been pinching the anterior nares tight for 20 minutes.

a. List 4 risk factors for epistaxis in this patient population. (2 marks)

Hypertension

Anticoagulants/antiplatelet

Atherosclerosis

Tumours

General: trauma, infection, nose picking, allergies, travel, low humidity

b. You examine the nose and the nostril is full of clotted blood, there is still active bleeding around this and the patient reports blood trickling down the back of their throat. Outline your approach. (6 marks)

Sit up in room with ENT equipment and good lighting

Ensure BP monitoring

IV access and check Hb and G+H

Personal PPE - mandatory

Nasal speculum to allow visualisation

Suction clots

Local anaesthesia spray with constrictor e.g. lignocaine and phenylephrine spray, or co-phenelcaine

Can try adrenaline soaked pledget with pressure if bleeding spot seen

Cautery (ring if active bleeding spot)

Disposition is discharge if treated ENT if packing or unable to obtain haemostasis

c. You are now able to examine the nose and there is still active bleeding but you are unable to see a bleeding point.

The patient’s vitals are HR 115 /min, BP 105/60 mmHg, Sa02 96% RA.

What methods are available to specifically treat this scenario? (2 marks)

Posterior packing: e.g rapid rhino or other device

Foley catheter if above unavailable/not working

Arterial ligation/embolisation if still bleeding and unstable

A 75 year old man has been brought to the ED with abdominal pain. He has come from a nursing

home. His background history includes dementia and ischaemic heart disease.

An Xray has been performed:

1. Give your diagnosis/diagnoses with supportive Xray findings. (4 marks)

______

______

______

______

2. List 3 specific treatment options for this patient’s problem. (3 marks)

______

______

______

3. List 2 features of your supportive treatment. Include doses and end-points.

(4 marks)

______

______

______

______

4. List 3 important considerations in determining your ceiling of care. (3 marks)

______

______

1.

Sigmoid volvulus – massively dilated loop of sigmoid colon with axis pointing to LIF (CRITICAL)

LBO – dilated large bowel proximal to volvulus with no gas distal (ie rectum)

1 mark for each diagnosis, 1 mark for explanation

Pass 2of 4

2.

Per rectal tube decompression

Laparotomy

Conservative (ie no management)

Percutaneous drainage initially

Pass 2 of 3

3.

Analgesia – IV opiate morphine 1-2mg aliquots, fentanyl 10-20mcg aliquots

IV fluid – N/S 20ml/kg boluses to correct shock then maintenance fluid titrated tom UO

Communication – explanation to pt/ substitute decision maker

1 for each concept 1 for explanation

Pass 2 of 4

4.

Pt competence to make decisions

Presence of advanced health directive

NOK wishes if pt not competent

Baseline level of function

Pass 2 of 3

Total pass 8/14 corrects to5.5/10

A 2 year old child who has inserted a plastic bead into his right nostril is brought to the emergencydepartment by his mother.The child is not distressed. Part of the bead is visualised high up in the nostril.

a) Describe the 'parental kiss' method for removing the bead, as you would to a parent.

______

______

b) List two (2) other methods for removing the bead.

______

c) You decide you will need sedation to remove the bead. Give three (3) options for sedation, including dosing and an adverse effect.

Drug / Dose / Adverse effects