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This is a 15 MCQ quiz on some of the recent updates to the manual. We suggest reviewing the recent updates before taking this quiz.
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Question 1 of 15
1. Question
Warfarin is usually preferred over NOACs in all of the following situations except
Correct
Warfarin is the preferred therapy in patients: with AFib associated with valvular heart disease; with a prosthetic heart valve; who have a significant bleeding risk; who require dual anti-platelet therapy; who have liver disease with ALT > 3 times normal; who have had fibrinolytic treatment within the previous 10 days; who have a creatinine clearance < 30ml/min or who are lactating.
New anti-coagulants may be preferred in patients: in remote locations where monitoring may be difficult; with difficult IV access; requiring treatment with drugs likely to make warfarin control difficult such as Azoles, thyroxine or anticonvulsants. (link)
Incorrect
Warfarin is the preferred therapy in patients: with AFib associated with valvular heart disease; with a prosthetic heart valve; who have a significant bleeding risk; who require dual anti-platelet therapy; who have liver disease with ALT > 3 times normal; who have had fibrinolytic treatment within the previous 10 days; who have a creatinine clearance < 30ml/min or who are lactating.
New anti-coagulants may be preferred in patients: in remote locations where monitoring may be difficult; with difficult IV access; requiring treatment with drugs likely to make warfarin control difficult such as Azoles, thyroxine or anticonvulsants. (link)
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Question 2 of 15
2. Question
NOACS are usually preferred to warfarin for anti-coagulation in the following situation
Correct
Warfarin is the preferred therapy in patients: with AFib associated with valvular heart disease; with a prosthetic heart valve; who have a significant bleeding risk; who require dual anti-platelet therapy; who have liver disease with ALT > 3 times normal; who have had fibrinolytic treatment within the previous 10 days; who have a creatinine clearance < 30ml/min or who are lactating.
New anti-coagulants may be preferred in patients: in remote locations where monitoring may be difficult; with difficult IV access; requiring treatment with drugs likely to make warfarin control difficult such as Azoles, thyroxine or anticonvulsants. (link)
Incorrect
Warfarin is the preferred therapy in patients: with AFib associated with valvular heart disease; with a prosthetic heart valve; who have a significant bleeding risk; who require dual anti-platelet therapy; who have liver disease with ALT > 3 times normal; who have had fibrinolytic treatment within the previous 10 days; who have a creatinine clearance < 30ml/min or who are lactating.
New anti-coagulants may be preferred in patients: in remote locations where monitoring may be difficult; with difficult IV access; requiring treatment with drugs likely to make warfarin control difficult such as Azoles, thyroxine or anticonvulsants. (link)
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Question 3 of 15
3. Question
All of the following statements regarding age adjusted D dimer levels are correct except
Correct
The age adjusted cut off level for D dimer is 500ng/mL for patients aged 50 years or less then (age in years X 10). In non high risk patients (Modified Wells score or Simplified Geneva score of 4 or less) values below these levels do not require further investigation for DVT or PE. The use of age related cut off levels increases the number of patients with low-intermediate risk for VTE who can be safely excluded by about 10% (30% in patients > 75 years of age) and misses only about 0.3% of patients with PE (95% chance of < 1.5%). Age adjusted cut off values have not been validated in pregnancy, life expectancy of < 3 months or in patients already taking anti-coagulants, or with D dimer levels from bedside analysers. (link)
Incorrect
The age adjusted cut off level for D dimer is 500ng/mL for patients aged 50 years or less then (age in years X 10). In non high risk patients (Modified Wells score or Simplified Geneva score of 4 or less) values below these levels do not require further investigation for DVT or PE. The use of age related cut off levels increases the number of patients with low-intermediate risk for VTE who can be safely excluded by about 10% (30% in patients > 75 years of age) and misses only about 0.3% of patients with PE (95% chance of < 1.5%). Age adjusted cut off values have not been validated in pregnancy, life expectancy of < 3 months or in patients already taking anti-coagulants, or with D dimer levels from bedside analysers. (link)
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Question 4 of 15
4. Question
Which one of the following statements regarding validation of age adjusted D dimer levels for the evaluation of VTE (as of September 2014) is not correct
Correct
The age adjusted cut off level for D dimer is 500ng/mL for patients aged 50 years or less then (age in years X 10). In non high risk patients (Modified Wells score or Simplified Geneva score of 4 or less) values below these levels do not require further investigation for DVT or PE. The use of age related cut off levels increases the number of patients with low-intermediate risk for VTE who can be safely excluded by about 10% (30% in patients > 75 years of age) and misses only about 0.3% of patients with PE (95% chance of < 1.5%). Age adjusted cut off values have not been validated in pregnancy, life expectancy of < 3 months or in patients already taking anti-coagulants, or with D dimer levels from bedside analysers. (link)
Incorrect
The age adjusted cut off level for D dimer is 500ng/mL for patients aged 50 years or less then (age in years X 10). In non high risk patients (Modified Wells score or Simplified Geneva score of 4 or less) values below these levels do not require further investigation for DVT or PE. The use of age related cut off levels increases the number of patients with low-intermediate risk for VTE who can be safely excluded by about 10% (30% in patients > 75 years of age) and misses only about 0.3% of patients with PE (95% chance of < 1.5%). Age adjusted cut off values have not been validated in pregnancy, life expectancy of < 3 months or in patients already taking anti-coagulants, or with D dimer levels from bedside analysers. (link)
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Question 5 of 15
5. Question
At a disaster site with multiple casualties, what disaster triage code should be allocated to a patient with a RR of 8, a sBP of 60mmHg and a GCS of 6.
Correct
A patient with these observations scores 6 points on the triage sort scale, so is categorised as potentially salvageable and allocated a priority 1 (P1) disaster triage code. (link)
Incorrect
A patient with these observations scores 6 points on the triage sort scale, so is categorised as potentially salvageable and allocated a priority 1 (P1) disaster triage code. (link)
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Question 6 of 15
6. Question
In a mass casualty situation, which one of the following situations would not increase the triage priority of an ambulant patient from category P3 to a higher urgency category
Correct
In a mass casualty situation, patients who are ambulant at the scene are usually allocated as P3. Exceptions to this include: >20% TBSA burns; inhalational injury; respiratory distress; confusion; or other obvious findings of concern. A minor open fracture of an upper limb would not be considered a finding of concern. (link)
Incorrect
In a mass casualty situation, patients who are ambulant at the scene are usually allocated as P3. Exceptions to this include: >20% TBSA burns; inhalational injury; respiratory distress; confusion; or other obvious findings of concern. A minor open fracture of an upper limb would not be considered a finding of concern. (link)
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Question 7 of 15
7. Question
Lisfranc’s injuries to the foot must involve
Correct
All Lisfranc’s injuries involve disruption of the ligament between the medial cunieform and the 2nd metatarsal base (Lisfranc’s ligament). As the metatarsals are bound by ligaments into a unit, disruption of the base of the second metatarsal causes the first metatarsal to separate from the metatarsal unit. Other features are variable, including: dorsal dislocation at the tarsometatarsal joint; fracture of the 2nd metatarsal base (in 75% of cases); fracture of the medial cuneiform; fracture of the cuboid. (link)
Incorrect
All Lisfranc’s injuries involve disruption of the ligament between the medial cunieform and the 2nd metatarsal base (Lisfranc’s ligament). As the metatarsals are bound by ligaments into a unit, disruption of the base of the second metatarsal causes the first metatarsal to separate from the metatarsal unit. Other features are variable, including: dorsal dislocation at the tarsometatarsal joint; fracture of the 2nd metatarsal base (in 75% of cases); fracture of the medial cuneiform; fracture of the cuboid. (link)
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Question 8 of 15
8. Question
Which one of the following statements regarding Gissane’s angle of the calcaneum is correct
Correct
Gissane’s angle is also known as the ‘critical angle’ and is formed by the downward and upward slopes of the calcaneal superior surface on a lateral radiograph. It is normally between 120-135 degrees so angles > 135 degrees suggest a calcaneal fracture. The angle between the posterior junction of two lines drawn between the highest point of the posterior tuberosity to the highest midpoint and the highest midpoint to the highest point of the anterior process is Bohler’s angle. (link)
Incorrect
Gissane’s angle is also known as the ‘critical angle’ and is formed by the downward and upward slopes of the calcaneal superior surface on a lateral radiograph. It is normally between 120-135 degrees so angles > 135 degrees suggest a calcaneal fracture. The angle between the posterior junction of two lines drawn between the highest point of the posterior tuberosity to the highest midpoint and the highest midpoint to the highest point of the anterior process is Bohler’s angle. (link)
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Question 9 of 15
9. Question
A Pilon fracture of the leg is
Correct
Pilon / Tibial plafond fracture is an axial loading injury resulting in a distal tibial intra-articular metaphyseal fracture which is commonly comminuted and has a longitudinal component to the tibial fracture. It may also have a fracture of the medial malleolus, a fracture of the anterior margin of the tibia or a fibula fracture in 20%. A LeFort – Wagstaffe fracture is an avulsion fracture of the anterior margin of the distal fibula at the insertion of the anterior tibio-fibular ligament. A Tillaux – Chaput fracture is an avulsion fracture of the anterior tibial margin by the anterior tibio-fibular ligament. (link)
Incorrect
Pilon / Tibial plafond fracture is an axial loading injury resulting in a distal tibial intra-articular metaphyseal fracture which is commonly comminuted and has a longitudinal component to the tibial fracture. It may also have a fracture of the medial malleolus, a fracture of the anterior margin of the tibia or a fibula fracture in 20%. A LeFort – Wagstaffe fracture is an avulsion fracture of the anterior margin of the distal fibula at the insertion of the anterior tibio-fibular ligament. A Tillaux – Chaput fracture is an avulsion fracture of the anterior tibial margin by the anterior tibio-fibular ligament. (link)
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Question 10 of 15
10. Question
In which one of the following situations is embolisation most likely to be required for a pelvic fracture.
Correct
A positive blush on helical CT > 1.5cm diameter is 98% specific of the for need for embolization. Bleeding may be from venous, rather than arterial, sources therefore a blush may not be present if an arterial phase scan is used. Bleeding in the prevescical region or anterior to the sacrum is usually venous and less likely to benefit from embolisation. Bleeding near the actetabular column is more likely to be arterial, and benefit from embolisation. Bleeding is more likely to be ongoing with vertical shear and open book injuries. (link)
Incorrect
A positive blush on helical CT > 1.5cm diameter is 98% specific of the for need for embolization. Bleeding may be from venous, rather than arterial, sources therefore a blush may not be present if an arterial phase scan is used. Bleeding in the prevescical region or anterior to the sacrum is usually venous and less likely to benefit from embolisation. Bleeding near the actetabular column is more likely to be arterial, and benefit from embolisation. Bleeding is more likely to be ongoing with vertical shear and open book injuries. (link)
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Question 11 of 15
11. Question
Which one of the following is not a damage control orthopaedic technique
Correct
In the severely injured patient without vascular compromise to a limb, definitive treatment should be delayed until patient stable and only damage control orthopaedic techniques should be used. These include: stopping any major sources of bleeding; irrigating contaminated wounds; relieving compartment syndrome(s); application of external bridging fixation. Internal fixation is not considered a damage control technique. (link)
Incorrect
In the severely injured patient without vascular compromise to a limb, definitive treatment should be delayed until patient stable and only damage control orthopaedic techniques should be used. These include: stopping any major sources of bleeding; irrigating contaminated wounds; relieving compartment syndrome(s); application of external bridging fixation. Internal fixation is not considered a damage control technique. (link)
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Question 12 of 15
12. Question
Following trauma, the number of rib fractures that doubles the mortality risk is
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Question 13 of 15
13. Question
The strongest indication for chest wall stabilisation surgery of the following is
Correct
The strongest indication is for flail chest with 3 or more ribs fractured in 2 or more places, especially if the fractures are displaced 2mm or more as this reduces hospital and ICU length of stay and duration of ventilation. Other possible indications include; chest wall deformity; open rib fractures; post emergency thoracotomy for treatment of traumatic thoracic injuries; isolated fractures with severe pain unable to be controlled by standard analgesic therapy. To be of most use, chest wall stabilisation surgery is usually performed within 3 days of injury in patients who are already ventilated due to their injuries.(link)
Incorrect
The strongest indication is for flail chest with 3 or more ribs fractured in 2 or more places, especially if the fractures are displaced 2mm or more as this reduces hospital and ICU length of stay and duration of ventilation. Other possible indications include; chest wall deformity; open rib fractures; post emergency thoracotomy for treatment of traumatic thoracic injuries; isolated fractures with severe pain unable to be controlled by standard analgesic therapy. To be of most use, chest wall stabilisation surgery is usually performed within 3 days of injury in patients who are already ventilated due to their injuries.(link)
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Question 14 of 15
14. Question
Factors that reduce the urgency for operative intervention in open fractures include all of the following except
Correct
Factors that reduce the urgency for operative intervention in open fractures include: wounds without gross contamination; major wounds when they are able to be effectively irrigated and upper limb fractures. High dose penicillin is indicated in heavily soil contaminated wounds, but does not reduce the urgency of operative management of these wounds. (link)
Incorrect
Factors that reduce the urgency for operative intervention in open fractures include: wounds without gross contamination; major wounds when they are able to be effectively irrigated and upper limb fractures. High dose penicillin is indicated in heavily soil contaminated wounds, but does not reduce the urgency of operative management of these wounds. (link)
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Question 15 of 15
15. Question
Inadequate fibrinogen levels at the time of patient arrival in hospital following major trauma occurs
Correct
Inadequate fibrinogen levels thought to be a significant contributor in 2-7% of major trauma patients at the time of hospital arrival. In patients with an ISS > 25, the mean fibrinogen level is < 2g/L. In patients with an ISS > 40, the mean fibrinogen level is < 1.5g/L. Tranexamic acid, if anything, would be expected to increase fibrinogen levels, due to inhibition of fibrinolysis. (link)
Incorrect
Inadequate fibrinogen levels thought to be a significant contributor in 2-7% of major trauma patients at the time of hospital arrival. In patients with an ISS > 25, the mean fibrinogen level is < 2g/L. In patients with an ISS > 40, the mean fibrinogen level is < 1.5g/L. Tranexamic acid, if anything, would be expected to increase fibrinogen levels, due to inhibition of fibrinolysis. (link)