ANSWERS MCQ A & E POSTING1. F F T T F2. T F F F T3. F F F F T4. T F T T F5. T T F T F6. T T F T T7. T F T F F8. T F T F T

9. T T T F F10. T T F F F11. T T T T T12. F F F T T13. T F T T T14. T F T F F15. F T T F F16. T T F T F

Question 1 A – False Explanation : Pulsus paradoxus is an abnormally reduced SBP during inspiration due to increased pulmonary intravascular volume during inspiration. A decrease SBP >15mmHg is pathological

Reference : Macleod Clinical Examination

B – FalseExplanation : Shock is a clinical syndrome occurs when there is in adequate tissue perfusion. Symptoms of shock are low BP (< 90mmHg SBP/ cannot be obtained/ 30 mm Hg fall in baseline BP), tachycardia > 100 bpm (weak rapid pulse), tachypnea (respiratory rate > 22 and hyperventilate, cold, clammy and pale skin, change in level of consciousness, increase CRT and reduce urine output

Reference: Shock : Shock and Fluid Resuscitation : Merck Manual Professional http://www.merckmanuals.com/professional/sec06/ch067/ch067b.html

C – TrueExplanation :Neurogenic shock is caused due to impairment of descending sympathetic pathway characterized by hypotension and bradycardia. This type of shock is diagnosed by exclusion

Reference :NMS Emergency Medicine 2nd Edition

D – TrueExplanation : Or can be calculated by DBP + 1/3 pulse pressure

Reference :Page 252, Medical Physiology 2nd Edition by Walter F. Boron & Emile L. Boulpaep

E – FalseExplanation : The formula is HR/SBP

Reference : Page 1Shock Index as a Predictor of Mortality among Severely Injured Hemorrhagic Shock Patients

http://www.ferne.org/Lectures/2008_research_lecture/pubpdf/DCLHb_saem01_shock_index_newformat.pdf

Question 2A – TrueExplanation :Trauma score consists of blood pressure, heart rate and Glasgow Coma Scale

Reference :Page 38, Manual For the Malaysian Trauma Life Support Course

B – FalseExplanation :All hemodynamically unstable and shock patients are to be triaged to the critical zone

Reference :Page 164, Manual For the Malaysian Trauma Life Support Course

C – FalseExplanation :Patients that are brought into red zones are the ones with ruptured Triple A and while unruptured triple A patients are assessed and treated conservatively or elective surgical intervention if more than 5 cm

Reference :Page 170, Guide to the Essentials in Emergency Medicine by Shirley Ooi and Peter Manning

D – FalseExplanation :The primary survey is consists of management the level of consciousness, cervical spine, airway, breathing, circulation, and rapid body survey

Reference :Page 42 – 46, Manual For the Malaysian Trauma Life Support Course

E – TrueExplanation :The first responders (a person who has completed a course and received certification in providing pre-hospital care for medical emergencies) could pronounce death. In some jurisdiction, they must consult a physician first before officially pronouncing patients’ deceased

Reference :http://en.wikipedia.org/wiki/Dead_on_arrival

Question 3A – FalseExplanation :Sebab nk bezakan unstable angina ngan non-STEMI ialah thru cardiac enzymes/biomarkers yg raised in non-STEMI, bukan unstable angina

Reference :Page 86, Cardiovascular System at a Glance

B – FalseExplanation :ST elevations seen in V1-V3 indicates anteroseptal MI. For lateral MI, die ade ST elevations kat V4-V6

Reference :Page 3, CPG Management of acute STEMI 2007 2nd EditionSlides ECG "Language of the heart" by Dr. Effa

C – FalseExplanation :They may appear within a few hours of an acute MI

Reference :Page 82, Oxford Handbook of Clinical Medicine 7th Edition

D – FalseExplanation :Since CK-MB rises early (4-8H) and falls early (paling penting, 48-72H), CK-MB measurements lah yg digunakan tok detect reinfarction, bukan troponin T yg can remain elevated for up to 14 days! Lambat sgt turun, so die sesuai tok detect MI patient yg present late to the hospital

Reference :Page 4, CPG Management of acute STEMI 2007 2nd Edition

E – TrueExplanation :For 2nd/3rd degree AV block

Reference :Page 18, CPG Management of acute STEMI 2007 2nd Edition

Extra Notes :Other contraindications of B-blockers are bradycardia, SBP < 100mmHg, pulmonary congestions with crepts beyond the lung bases, signs of peripheral hypoperfusion, asthma /COPD or severe peripheral vascular disease

Question 4A – TrueExplanation : Primary brain injury refers to the sudden and profound injury to the brain that is considered to be more or less complete at the time of impact. Secondary brain injury refers to the changes that evolve over a period of time (from hours to days) after the primary brain injury. It includes an entire cascade of cellular, chemical, tissue, or blood vessel changes in the brain that contribute to further destruction of brain tissue by causing hypoxia or anoxia

Reference :http://www.outreach-online.org/leaflets/abi/brain_injury.htm http://medicalcenter.osu.edu/patientcare/healthcare_services/physical_rehabilitation/about/brain/Pages/index.aspx

B - False

Explanation :Brain injury may occur in one of two ways:

- Closed brain injury – when there is a non-penetrating injury to the brain with no break in the skull

- Penetrating brain injury – a.k.a open head injuries occur when there is a break in the skull, such as when a bullet pierces the brain

The most common is closed brain injury. Kalau soalan ditukar kepada the most common head injury is closed brain injury - then it is true

Reference :Brain Injury – The Teenage Years PDF Filehttp://www.google.com.my/url?sa=t&source=web&cd=5&ved=0CDgQFjAE&url=http%3A%2F%2Fwww.bianys.org%2F_literature_44390%2FBrain_Injury_The_Teenage_Years&ei=vf65TeXFA5LsvQOAmsm5Cw&usg=AFQjCNElIOGNCMJ7lu7KrbHZk-yzwmjVew

C - TrueExplanation :Cantu Concussion Severity Grades (1991)Grade 2: Loss of Consciousness < 5 Minutes OR Post Traumatic Amnesia of 30 Minutes to 24 Hours

Reference :http://cpancf.com/headinjuryclassification.asp

D – TrueExplanation :An open brain injury always involves some sort of break in the skull. Types of skull fracture include linear, depressed, diastatic and basilar skull fracture

Reference :http://www.new-york-brain-injury-lawyers.com/penetrating-head-injuries.html

E – FalseExplanation :Without prompt treatment, death is often the result of epidural hematoma. Treatment often consists of surgery, as well as drugs designed to reduce and control the amount of swelling in the brain.

Reference :http://www.brainandspinalcord.org/hematoma/epidural-hematoma.html

Question 5A – TrueExplanation :Patient will regain back the normal brain function, but the duration of recovery depends on severity of trauma

Reference :Page 233, Neurology and Neurosurgery Illustrated 4th Edition by Kenneth W.Lindsay and Ian Bone, Churchill Livingstone

B – TrueExplanation :

Even after relatively minor head injury, patients may have persistent symptoms of :- Headache, dizziness and increase irritability- Difficulty in concentration and in coping with work- Fatigue and depression

Reference :Page 233, Neurology and Neurosurgery Illustrated 4th Edition by Kenneth W.Lindsay and Ian Bone, Churchill Livingstone

Extra Notes:If the trauma more severe

- LOC- Period of post-traumatic amnesia- Some neurological damage – delayed information processing (resolve in several weeks)- Vestibular concussion – leads to dizziness and vertigo

C – FalseExplanation :The most common cause of traumatic brain injury is road traffic accident. Most common in young males; maybe involving alcohol.

Reference :Page 216, Neurology and Neurosurgery Illustrated 4th Edition by Kenneth W.Lindsay and Ian Bone, Churchill Livingstone

D – TrueExplanation :Description exactly in the book

Reference :Page 216, Neurology and Neurosurgery Illustrated 4th Edition by Kenneth W.Lindsay and Ian Bone, Churchill Livingstone

E – FalseExplanation :Only grade from I to III. No grade IV

Reference:http://orthopedics.about.com/od/sportsinjuries/a/concussion.htm

Question 6A – TrueExplanation :These are the principles of emergency medicineA – airway and cervical spine B – breathing and ventilationC – Circulation and hemorrhage control D – DisabilityE – Exposure and environment

Reference :Page 1 – 8, Emergency Medicine (lecture notes) 3rd edition, Chris Moulton, David Yates

B – True

Explanation :The primary survey (C= circulation) is conducted to correct any hypoxia and hypovolemia, the main aim is to ensure the oxygen supply to the brain

Reference :Page 206, Emergency Medicine : The Principles of Practice 5th Edition by Gordian W.O. Fulde

C – FalseExplanation :The rapid restoration of circulating volume in blood loss patient will prevent a sudden failure of the compensatory mechanisms and often irreversible fall in cardiac output.

Reference :Page 6, Emergency Medicine (lecture notes) 3rd edition, Chris Moulton, David Yates

D – TrueExplanation :Further neurological assessment (in secondary survey) include 1. Level of consciousness (assess using GCS)2. Focal neurological signs (variation in muscle tone, asymmetrical limb movement)3. Pulse (down), BP (up), pupil size (up), papillary response (down) – late indicator for increase ICP

Reference :Page 35, Emergency Medicine (lecture notes) 3rd edition, Chris Moulton, David Yates

E – TrueExplanation :Patient who is unconscious with head injury or have blunt injury above clavicle, or multiple trauma patient is assume to have cervical spine injury. Hence, cervical collar application.

Reference :Page 11, Manual For the Malaysian Trauma Life Support Course

Question 7A – TrueExplanation :HR is increased as compensatory mechanism to increased BP. The increasing HR will increased the cardiac output (CO) subsequently MAP will also increased as refer to the formula of MAP= CO x TPR

Reference :Page 104 – 105, Robbins Basic Pathology 8th EditionPage 448 – 450, Human Physiology 9th Edition

B – FalseExplanation :Not heart only become hypoxic. Shock will cause multiorgans failure, heart, kidney, brain

Reference :Page 104 – 105, Robbins Basic Pathology 8th Edition

C – TrueExplanation :

Cellular destruction cause multiorgan failure such as heart, brain, renal and pulmonary as well

Reference :http://en.wikipedia.org/wiki/Shock_(circulatory)

D – FalseExplanation :Restoration of BP and fluid volume occur in compensatory mechanism and able restore homeostasis of tissue. However in decompensated state, the compensatory mechanism is useless because cell/ tissue destruction is severe and lead to organ failure

Reference :http://en.wikipedia.org/wiki/Shock_(circulatory)

E – FalseExplanation :Acidosis with hyperkalemia occurs in the initial stage of shock due to anerobic mechanism then produced excessive lactic acid

Reference :Page 456 – 457, Human Physiology 9th Edition

Question 8A – TrueExplanation :Hypovolemia dalam Bailey— is because kurangnya circulating volume. This can be due to hemorrhagic & non-hemorrhagic causes. Example of hemorrhage is exogenous blood loss

Reference :Page 14, Bailey & Love’s Short Practice of Surgery 25th Edition

B – FalseExplanation :Tachycardia ade sebab nak compensate for the reduced stroke volume to maintain the cardiac output & BP. ( cardiac output = stroke volume x heart rate)Tapi sweating x de. Cos dalam compensated shock, body will maintain the cardiovascular state dengan kurangkan perfusion to the skin, muscle & GI tract. Kurang perfusion jadi bila ade vasoconstriction. Vasoconstriction akan cause cool peripheries, makanye memang x akn jadi sweating.

Reference :Page 15, Bailey & Love’s Short Practice of Surgery 25th Edition

C – TrueExplanation :Cardiogenic shock jadi because jantung tu sendiri fail nak pump darah keluar kepada tissues for their metabolic demands. Bila kurangnya darah keluar maka kuranglah cardiac output BP

Reference :Page 57, Emergency Medicine Manual 6th edition, O John Ma

D – False

Explanation :Shock ade 4 types yang kite belajar time seminar & aku cari kat buku2- cardiogenic, distributive, hypovolemic and obstructive. X de lah pulak restrictive

Reference :Page 14, Bailey & Love’s Short Practice of Surgery 25th Edition

E – TrueExplanation :Formula= heart rate/ systolic BP

Reference :Page 50, Emergency Medicine Manual 6th edition, O John Ma Extra Notes :index ni diguna pakai untuk menggambarkan kerja mengepam oleh left ventricle in acute circulatory failure. Normal value is 0.5 - 0.7. Kalo > 1.0 maka ade impaired left ventricular function

Question 9A – TrueExplanation :Complication such as pulmonary aspiration and gastrointestinal obstruction, have been reported in patients treated with multiple doses of activated charcoal. Electrolyte imbalance like hypernatremia and hypermagnesemia also been reported. However, the actual rate of its occurrence is low.

Reference :http://healthoracle.org/downloads/A/Activated%20Charcoal.pdf http://www.drugs.com/sfx/activated-charcoal-side-effects.html

B – TrueExplanation :Barbiturates = Phenobarbitone can be adsorbed by charcoal

Reference :Page 119, Guide to the Essentials in Emergency Medicine by Shirley Ooi and Peter Manning

C – TrueExplanation :In this position the risk of aspiration is reduced

Reference :http://drratin.hpage.us/principle_of_poisoning_management_24937600.html

D – FalseExplanation :Management Airway management equipment must be immediately available, a patient with adequate oxygenation who has impaired gag reflex and who need gastric lavage will require prophylactic orotracheal intubation.

Reference :Page 116, Guide to the Essentials in Emergency Medicine by Shirley Ooi and Peter Manning

E – FalseExplanation :Force emesis is not recommended in both children and adult

Reference :http://www-clinpharm.medschl.cam.ac.uk/pages/teaching/topics/poison/poison2.html

Question 10A – TrueExplanation :In DKA, stress, infection, surgery is the precipitating factors

Reference :http://qjmed.oxfordjournals.org/content/97/12/773.2.full

B – TrueExplanation :As DKA lead to shock if left untreated, so, kaloa de renal disease, lagi la worsen, as u know what will happened in shock, reduced perfusion to vital organs like heart, renal, and brain. If they already had underlying disease like those stated above, lagi la worse kan keadaan, da la shock, jantung lemah, kidney prob plak, ofkos la mortality rate will be high

Reference :http://www.ispub.com/journal/the_internet_journal_of_endocrinology/volume_3_number_2_15/article/clinical_and_laboratory_characteristics_of_diabetic_ketoacidosis_in_adult_diabetic_patients.html

C – FalseExplanation :Increase risk of arterial thrombosis only and as well as MI, stroke sbb mainly it involved artery circulation

Reference :Page 658 – 662, Pocket Essentials of Clinical Medicine 4th Edition (Kumar & Clark)

D – FalseExplanation :Of course EMERGENCY!!! Because both may lead to profound dehydration if left untreated. shock la kan ape lg?

Reference :Page 814 – 816, Oxford Handbook of Clinical Medicine 7th Edition

E – FalseExplanation :In HHS, endogenous insulin is reduced not absent, but still sufficient to inhibit hepatic ketogenesis. While in DKA, there will be absence of insulin.

Reference :Page 658 – 662, Pocket Essentials of Clinical Medicine 4th Edition (Kumar & Clark)

Question 11

A – TrueExplanation :Severe hypoglycemia occurs most often in people with type 1 DM. Hypoglycemia can also be caused by sulfonylureas in people with type 2 diabetes

Reference:http://en.wikipedia.org/wiki/Diabetic_hypoglycemia

B – TrueExplanation :Alcohol akan cause redistribution of blood flow kat pancreas menggalakkan insulin secretion thereby evoking hypoglycemia

Reference :http://care.diabetesjournals.org/content/24/11/1888.full

C – TrueExplanation :It can be taken as food or drink if the person is conscious and able to swallow

Reference :http://en.wikipedia.org/wiki/Diabetic_hypoglycemia

D – TrueExplanation :Severe hypoglycemia can result in cerebral edema

Reference :wvc.omnibooksonline.com/data/papers/2006_V79.pdf

E – TrueExplanation :The two commonly administered hypertonic agents are mannitol and hypertonic saline

Reference :wvc.omnibooksonline.com/data/papers/2006_V79.pdf

Question 12A – FalseExplanation :When acetoacetic acid reacts with nitroprusside, a color change develops, covering the range from beige (negative) to maroon (positive). The test does not react with acetone or B-hydroxybutyrate

Reference :http://www.anytestkits.com/utk-ketones-in-urine.htm

B – FalseExplanation :Serum osmolality of >340mmol/kg is often seen in HONK. Normal value :280-300 mmol/kg

Reference :Page 816, Oxford Handbook of Clinical Medicine 7th Edition

C – FalseExplanation :Plasma glucose is usually >20mmol/L

Reference :Page 815, Oxford Handbook of Clinical Medicine 7th Edition

D – TrueExplanation :If serum Na is normal,use 0.9% NaCl. If serum sodium is elevated (>160mmol/L),use 0.45% NaCl

Reference :http://www.kck.usm.my/husm/pharmacy/formulary/ENDOCRINE%20UNIT_add_31.01.10.pdf

E – TrueExplanation :The choice of replacement fluid largely depends upon the fluid that is being lost. Some debate exists whether colloid or crystalloid solutions should be used, however both randomized controlled trials and meta-analyses have failed to demonstrate outcome benefit of colloid solutions over the cheaper and more readily available crystalloid.

Reference :http://medresidents.stanford.edu/TeachingMaterials/Shock%20and%20Sepsis/Shock%20and%20Sepsis%20Handout.doc

Question 13A – TrueExplanation :These actions are termed links in the “Chain of Survival”

Reference :Page 2, Basic Life Support 2010 Guidelines by Dr Julina Md Noor

B – FalseExplanation :Recognize cardiac arrest by checking the response then activate EMS

Reference :Page 2, Basic Life Support 2010 Guidelines by Dr Julina Md NoorC – TrueExplanation :If a lone rescuer finds an unresponsive adult, check for a response, activate the community emergency response system, immediately begin CPR

Reference :Page 3, Basic Life Support 2010 Guidelines by Dr Julina Md Noor

D – TrueExplanation : A lone rescuer will have to decide whether to start resuscitation or to go for help first. In these circumstances, if the likely cause of unconsciousness is trauma (injury) or drowning or if the victim is

an infant or a child, the rescuer should perform resuscitation for about 1 minute before going for help.

Reference :http://circ.ahajournals.org/cgi/content/full/circulationaha;95/8/2174#SEC7

E – TrueExplanation :The 1992 AHA guidelines2 emphasized that the rescuer should, if no other help is available, leave an adult victim immediately after establishing unresponsiveness in order to call an ambulance or EMS system ("phone first").

Reference :http://circ.ahajournals.org/cgi/content/full/circulationaha;95/8/2174#SEC7

Question 14A – TrueExplanation :3rd degree burn – destruction of all epidermal and dermal layers (Full thickness burn)4th degree burn – involved tissue beneath the skin such as muscle, ligament, tendon and bone(Absent of pain in both – because nerve endings that present in dermis layer already destroyed)

Reference :Page 135, Manual For the Malaysian Trauma Life Support Course

B – FalseExplanation :3rd degree burn involved whole dermis

Reference :Page 135, Manual For the Malaysian Trauma Life Support Course

C – TrueExplanation :Present in superficial partial thickness burn / superficial 2nd degree burn

Reference :Page 135, Manual For the Malaysian Trauma Life Support Course

D – FalseExplanation :Superficial burn = first degree burn – epidermis only while 2nd degree burn extends into outermost part of dermis

Reference :Page 135, Manual For the Malaysian Trauma Life Support Course

E – FalseExplanation :The percentage BSA in children are more accurately estimated using the Lund-Browder chart as children have proportionally larger heads and smaller lower extremities. We also have modified rule of nine for pediatrics.But rule of nine and Lund & Browder chart have different distribution.

Reference :Page 381, Bailey and Love’s Short Practice of Surgery 25th Edition

Question 15A – FalseExplanation :Major burn - DO NOT!!!! It can cause shock

Reference :http://www.nlm.nih.gov/medlineplus/ency/article/000030.htmhttp://www.ygoy.com/index.php/how-to-treat-a-burn/

B – TrueExplanation :Selagi mangsa berasa sakit, kita hendaklah bg analgesic. Tak kiralah minor or major burn.

Reference :Page 138, Manual For the Malaysian Trauma Life Support Course

C – TrueExplanation :Memang kita guna Parkland formula

Reference :Page 384, Bailey and Love’s Short Practice of Surgery 25th Edition

D – FalseExplanation :Start IV line – Lactated Ringer

Reference :Page 384, Bailey and Love’s Short Practice of Surgery 25th Edition

E – FalseExplanation :fluid replacemet finished after giving 24 hours of fluid replacement bukan 24 jam selepas mangsa sampai di hospital. First 24hrs, mangsa memerlukan 4ml/kg body weight/ % of body surface

Reference :Page 384, Bailey and Love’s Short Practice of Surgery 25th Edition

Question 16A – TrueExplanation :Of all deaths caused by fire, 75% are due to inhalation burns

Reference :http://www.mdguidelines.com/inhalation-burns

B – TrueExplanation :

Complications include subglottic stenosis, bronchiectasis, pulmonary edema, pneumonia, atelectasis, asthma, bronchospasm, and extreme difficulty breathing

Reference :http://www.mdguidelines.com/inhalation-burns

C – FalseExplanation :Thermal burn injury to the lower airway is rare

Reference :Page 381, Bailey and Love’s Short Practice of Surgery 25th Edition

D – TrueExplanation :The inhalation of toxic smoke causes the release of thromboxane and other mediators, which increases pulmonary artery pressure and causes secondary damage to the respiratory epithelium and release of chemotactic factors

Reference :http://ccforum.com/content/11/1/R22

E – FalseExplanation :the burned airway creates symptoms of swelling to the airway & block the airway, hence the treatment is to secure the airway and early intubation is the treatment of choice

Reference :Page 380 – 381, Bailey and Love’s Short Practice of Surgery 25th Edition