1. The following are indicators of a severe attack acute pancreatitis:

A. Plasma calcium 2.6 mmol/lB. Arterial pO2 8 kPaC. Amylase three times upper limit of laboratory normD. Blood glucose 8 mmol/lE. White cell count (WCC) 15 109/l

1. A. false B. true C. false D. false E. trueGlasgow (& Ranson’s) criteria are used for indication of a severeattack of pancreatitis. The defined criteria are: Age 55 years White cell count (WCC) 15 109/l Urea 16 mmol/l Glucose 10 mmol/l Calcium 2 mmol/l Albumin 32 g/l Arterial pO2 8kPa Lactate dehydrogenase (LDH) 600 iu/l

The following are factors which increase risk of rebleeding following a gastrointestinal haemorrhage:

A. MalignancyB. Acute rather than chronic ulcerC. Shock on admissionD. Age 60 yearsE. Gastric ulcer

2. A. true B. false C. true D. false E. trueThe following are factors influencing rebleeding: Age 60 Shock on admission Chronic rather than acute ulcer Gastric ulcer Underlying medical problem Bleeding source unknown 5 unit transfusion Bleeding from varices or malignancy

3. Concerning severe pancreatitis:

A. Hypocalcaemia is the most common metabolic problemB. Coagulopathy is usually the first organ system failure tomanifest itselfC. Failure of two organ systems is associated with 90% mortalityD. Solid, infected pancreatic necrosis will often respond tointravenous antibioticsE. Positive end expiratory pressure (PEEP) may be useful inmanaging respiratory failure

A. false B. false C. false D. false E. trueOrgan failure in severe pancreatitis is usually respiratory,cardiovascular, renal then disseminated intravascular coagulation(DIC). Two organ system failure has a mortality of about 55%whereas three or more is associated with a mortality of 90%. Hypercalcaemia and hypomagnesaemia are the most commonmetabolic disturbances and solid infected necrosis requiressurgical debridement. Positive end expiratory pressure (PEEP)may prevent the development of adult respiratory distresssyndrome (ARDS).

5. Concerning thoracic trauma:

A. Chest trauma is responsible for approximately 25% of trauma deathsB. Most patients with chest injuries ultimately requirethoracotomyC. Penetrating chest wounds often require formal surgeryutilising cardiopulmonary bypassD. Massive haemothorax is defined as 750 ml blood in thechest cavityE. Continuing blood loss of 50 ml/h is an indication forthoracotomy

5. A. true B. false C. true D. false E. falseMost chest injuries can be managed by intercostal tube drainage,analgesia and appropriate fluid management. Massivehaemothorax is 1500 ml blood and blood loss of 200 ml is anindication for thoracotomy

6. Characteristic injuries of blunt thoracic trauma include:

A. Fractured sternumB. Transected aortaC. Pulmonary contusionD. Ruptured spleenE. Bilateral rib fractures

6. A. true B. true C. true D. true E. trueTransected aorta is a typical high velocity deceleration injury.Bilateral rib fractures occur in major crush injuries.

11. Concerning smoke inhalation injuries:

A. The half life of carboxyhaemoglobin (COHb) breathing 100%oxygen is less than 1hB. High flow oxygen should be given until the COHb level is lessthan 5%C. Smoke inhalation causes thermal damage to the wholerespiratory tractD. Soot in the mouth is an indication for fibre-opticlaryngoscopyE. Intubation should be avoided

11. A. true B. false C. false D. true E. falseHigh flow oxygen therapy is necessary until carboxyhaemoglobin(COHb) levels are less than 10%. Smoke only causes damage tothe larynx and pharynx. Early intubation should be performed ifthere are any doubts as to the airway.

15. Concerning clinical evaluation of pelvic injuries:A. Rectal examination is often unnecessaryB. The patient should have a urethral catheter inserted in allcases to monitor urine outputC. Antero-posterior (AP) compression injuries are usually moresevere than lateral compression injuriesD. Pelvic stabilisation is the first priorityE. Unstable pelvic ring fractures are associated with a highmortality

15. A. false B. false C. true D. false E. trueRectal examination in patients with pelvic injury/fracture ismandatory to exclude open fractures or high riding prostate.Catheterisation should occur after urethral injury has beenexcluded. Airway, Breathing and Circulation (ABC) remains thepriority.

17. Anastamotic leakage:

A. Is uncommonB. Has a higher incidence in shocked patientsC. When suspected merits an early 2nd look procedureD. There is no role for CT scanningE. Early nutritional support is advisable

17. A. false B. true C. true D. false E. trueLeaks occur in 10–15% of colonic anastamoses. Dehydrated andshocked patients have a higher incidence of leaks. PercutaneousCT (or ultrasound) guided drainage may be useful.

20. The following are indications for laparotomy inabdominal trauma:

A. PeritonitisB. Persistent shockC. EviscerationD. Uncontrolled haemorrhageE. Gunshot wounds

20. A. true B. true C. true D. true E. truePeritonitis, evisceration and abdominal gunshot wounds are allindications for laparotomy as are uncontrolled haemorrhage,persistent shock and a clinical deterioration.

22. Concerning mortality after liver injury:

A. The overall mortality is approximately 25%B. Penetrating injury carries a mortality of 15–20%C. Blunt injury has a lower mortality than penetrating injuryD. Mortality of blunt hepatic injury is approximately 10% ifonly the liver is injuredE. Bleeding causes the majority of deaths

22. A. false B. false C. false D. true E. trueMortality after hepatic injury Overall 10–15% Penetrating (civilian) 1% Blunt 20% Blunt (liver only) 10% Blunt (3 major organs injured) 70%Bleeding causes 50% of deaths.

23. Blunt trauma to the pancreas:

A. May be clinically occultB. Abdominal radiographs may show retroperitoneal airC. Endoscopic retrograde cholangio-pancreatogram (ERCP) isthe best investigationD. Serum amylase is a good investigationE. Duct damage may be missed at laparotomy

23. A. true B. true C. false D. false E. trueA high index of suspicion is necessary to recognise pancreatictrauma. Abdominal X-ray (AXR) may show retroperitoneal air ordiaphragmatic rupture. Serum amylase is a poor indicator andcan be normal in patients with severe pancreatic damage.Contrast enhanced CT is the best investigation and demonstratespancreatic oedema or swelling and collections. ERCP should beused to assess the ducts.

24. The following complications are associated withpancreatic trauma:

A. PseudocystB. Pancreatic fistulaC. AscitesD. Pancreatic abscessE. Acute pancreatitis

24. A. true B. true C. true D. true E. truePancreatic trauma can lead to pseudocyst, fistulae, ascitesintra-abdominal abscess, wound infection, pancreatic abscess andacute and chronic pancreatitis.

The following endocrine responses occur after major trauma:

A. Increased prolactinB. Decreased anti-diuretic hormone (ADH)C. Increased thyroxineD. Increased catecholaminesE. Increased cortisol

30. A. true B. false C. false D. true E. trueMajor trauma results in increased prolactin, anti-diuretichormone (ADH), catecholamine and cortisol and decreasedthyroxine (T3 and T4).

The following are radiological signs of major thoracic trauma:

A. Mediastinal wideningB. Fractured 2nd ribC. Fractured sternumD. Mediastinal emphysemaE. Loss of aortic definition

33. A. true B. true C. true D. true E. true

41. The following are indications for surgery in acutepancreatitis:A. Positive fine needle aspirateB. SepsisC. PeritonitisD. Failure to respond to ICU therapyE. Respiratory insufficiency

41. A. false B. true C. true D. true E. trueRespiratory insufficiency forms part of a failure to respondto ICU therapy

Burns:

A. Mortality associated with a concomitant inhalation injury is30% greater than that without inhalate injuryB. Inhalation injury commonly results in hypoxaemia associatedwith bronchospasm and bronchorrhoeaC. Burn wound sepsis is the leading cause of deathD. The hypermetabolic response to burn injury peaksat 48hE. Burns patients suffer a marked protein catabolism

40. A. true B. true C. false D. false E. truePulmonary sepsis is the leading cause of death.The hypermetabolic response peaks at 7–10 days.pp

The following would be indications to transfer a patient to a burns centre:

A. Chemical burnsB. 15% 2nd degree burns in a patient aged 60C. 10% burns in an 8 year old boyD. An electrical burn with an entry wound on the finger and thepatient unable to flex the fingerE. 10% 3rd degree burns to the chest in a 25 year old

50. A. true B. true C. true D. true E. trueTable 3.1 Criteria for transfer to a burns centreSecond- and third-degree burns 10% TBSA in patients 10 or50 years of ageSecond- and third-degree burns to 20% TBSA in all other agesThird-degree burns 5% TBSA in patients of any ageAll second- and third-degree burns with the threat of functional orcosmetic impairment to the face, hands, feet, genitalia, perineum ormajor joints

All electrical burns, including lightning injuriesChemical burnsBurns involving inhalation injuryCircumferential burns of the extremities and/or chestBurns involving concomitant trauma among which the burn injuryposes the greatest risk of morbidity or mortality.Burns in patients with pre-existing medical conditions that maycomplicate management and/or prolong recovery, such as coronaryartery disease, lung disease or diabetes.

Disseminated intravascular coagulation (DIC) ischaracterised by:

A. Increased fibrinogen concentrationB. Increased fibrinogen degradation productsC. Prolonged activated partial thromboplastin time (APTT)D. ThrombocythaemiaE. Fragmented red cells on blood film

52. A. false B. true C. true D. false E. trueDIC is characterised by activation of the clotting cascades withgeneration of fibrin, consumption of clotting factors andplatelets, and secondary activation of fibrinolysis leading toproduction of fibrinogen degradation products (FDPs). DIC maybe asymptomatic manifest only on blood investigations, or mayresult in bleeding, or tissue ischaemia due to vessel occlusion byfibrin and platelets.

The prothrombin time (or international normalised ratio (INR)),activated partial thromboplastin time (APTT), and thrombin timeare usually prolonged. The fibrinogen level and platelet countare low. High levels of FDPs are present. There may befragmented red cells on the blood film due to red cell damageduring passage through fibrin webs in the circulation. Treatmentis aimed at correcting the underlying cause. Blood productsupport (platelets, fresh frozen plasma (FFP), cryoprecipitate,packed red cells) is given under haematology advice.

DIC may be caused by:

A. Gram-negative septicaemiaB. Myocardial infarctionC. BurnsD. Pulmonary embolismE. Haemolytic blood transfusion reactions

53. A. true B. false C. true D. false E. trueDIC may be caused by gram-negative, meningococcal andstaphylococcal septicaemia, tissue damage after trauma, burns orsurgery, malignancy, haemolytic blood transfusion reactions,falciparum malaria, snake bites, and obstetric conditions such asplacental abruption and amniotic fluid embolism.

Fluid balance:

A. A 70 kg man has approximately 28 l fluid in the interstitialcompartmentB. Approximately 95% potassium is extracellularC. The daily requirement of sodium is 1–2 mmol/kg/dayD. Hartmann’s solution is preferred to normal saline in patientswith renal failureE. The stress response to surgery leads to sodium retention

43. A. true B. false C. true D. false E. true95% of potassium is intracellular. Hartmann’s solution should beavoided in renal failure as it contains potassium and can lead tohyperkalaemia. The stress response to surgery also results inwater retention.