1

A 64-year-old female smoker presents to hospital having been treated for a

‘chest infection’ several months previously. She defaulted from follow-up and
sought alternative therapies but now returns with night sweats and weight loss.
Computated tomography of the chest suggests a multi-loculated basal advanced
empyema with pleural peel.
What is the best treatment?
Single best answer - select one answer only

Chest drain insertion

Intravenous steroids
Open thoracotomy decortication « CORRECT ANSWER
Oral antibiotic therapy alone
VATS debridement

 The Answer
 Comment on this Question
VATS decortication may be performed in early-stage multi-loculated empyema,
however if thick pleural peel is evident, thorascopic management will be
technically difficult and require decortication. Though there is debate on open
surgery versus VATS in the management of empyema, currently open surgery is
preferred for complex multi-loculated empyema. Image-guided percutaneous
drainage tubes may be an option in selected patients without multiple-
loculations. Decortication describes the removal of a restrictive layer of fibrous
tissue overlying the lung, chest wall, and diaphragm to allow the lung to re-
expand. When the peel is removed, compliance in the chest wall returns.

A 19-year-old homeless man falls and suffers a single penetrating injury to the
right thorax. This is through the 5th right intercostal space laterally. Chest x-ray
shows a small pneumothorax, the hemi-diaphragms and costo-phrenic angles
are well defined. He is hypotensive despite adequate resuscitation with
worsening abdominal pain in his abdomen. Ultrasound imaging reveals fluid
around his liver.
 What is the likely cause of his symptoms?
Single best answer - select one answer only

Diaphragmatic injury « CORRECT ANSWER

Empyema
Haemothorax
Pleural effusion
Surgical emphysema

 The Answer
 Comment on this Question
The diaphragm attaches to the sternum, the inner cartilages of the lower six ribs
and to the two crura; the right attaches to the first three lumbar vertebrae and
the left the first two. An incisional injury through the 5th intercostal space
resulting in a liver laceration and peri-hepatic blood must involve penetration of
the diaphragm. Effusion or haemothorax would obscure the hemi-diaphragm and
blunt the costo-phrenic angle.

Theme: Airway management

A Needle cricothyroidotomy
B Tracheostomy
C Mini-tracheostomy
D Endotracheal tube

For each of the following situations select the most useful airway. Each option
may be used once, more than once, or not at all.

Scenario 1
A 55-year-old male 10 days post-cardiac surgery, who developed acute respiratory
distress syndrome following a 6 unit blood transfusion. He is now unable to wean from
the ventilator and likely to require prolonged weaning.

B - Tracheostomy « CORRECT ANSWER

This patient is making a slow recovery from an acute insult to the lungs. He may
remain ventilator dependent for some time.
 A tracheostomy is more comfortable than an endotracheal tube,
 will enable sedative medication to be ceased,
 reduces ventilatory dead space
 and permits tracheobronchial toilet.
All of these factors aid the weaning process.

Scenario 2
A 24-year-old female motorcyclist who sustained multiple thoracic and facial injuries
presents with stridor and arterial oxygen saturation of 68% despite maximal oxygen
administration with a reservoir bag. Repeated attempts of intubations have failed.

A - Needle cricothyroidotomy « CORRECT ANSWER

This patient is struggling to oxygenate adequately. The facial injuries may make
endotracheal intubation impossible, but rapid intervention is required. A needle
cricothyroidotomy would allow oxygenation and provide time to consider the
options to obtain a definitive airway. This would be quicker to achieve under
emergency circumstances than a formal tracheostomy.

Scenario 3
A 63-year-old female 15 days post-left upper lobectomy for adenocarcinoma of the
bronchus. She has undergone multiple flexible bronchoscopies to clear retained
secretions, but remains hypoxic with sputum retention.

C - Mini-tracheostomy « CORRECT ANSWER

This patient has made a slow recovery from lung surgery. The main issue seems
to be retention of secretions. A percutaneously placed mini-tracheostomy is
ideal for mid- to long-term tracheobronchial toilet in those patients not requiring
invasive ventilatory support.

Theme: Aortic bypass grafting

 A Aorto-bifemoral bypass
B Axillo-bifemoral bypass
C Left iliac angioplasty
D Left iliac angioplasty and femoral cross-over
E Femoral to femoral cross-over

For each of the patients described below, select the most likely diagnosis from
the list of options above. Each option may be used once, more than once or not
at all. You may believe that more than one diagnosis is possible but you should
choose the ONE most likely diagnosis.

Scenario 1
A 55-year-old farmer presents to the vascular outpatient clinic with pain in his legs
whilst walking. He claudicates at 50 m but has no rest pain. Angiogram reveals
complete occlusion of lower aorta, with patent femoral vessels.
A - Aorto-bifemoral bypass « CORRECT ANSWER

Scenario 2
A 79-year-old male presents to the vascular outpatient clinic with inability to walk long
distances. He also complains of occasional rest pain. He has emphysema for which he
is on home oxygen. Angiogram reveals complete occlusion of the aorta with patent
femoral vessels.
B - Axillo-bifemoral bypass « CORRECT ANSWER

Scenario 3
A 43-year-old postman presents to the emergency department with acute onset
claudication in both feet. He is fit and well, and is a non-smoker. He is determined to
go back to work. He has an aortic bifurcation block with good femoral run off on both
sides.
A - Aorto-bifemoral bypass « CORRECT ANSWER

 The Answer
 Comment on this Question
It is always best to perform an aorto bifemoral bypass graft if possible. This has the
highest patency rate of any bypass procedures to the femoral vessels. An axillo-
bifemoral bypass graft should only be considered in the very poor, high-risk surgical
patient who has critical ischaemia. It is contraindicated in those patients with
claudication. Axillo-bifemoral bypass is suitable in high-risk patients because it is an
extra-abdominal procedure unlike an aorto-femoral bypass which involves laparaotomy
and quite extensive surgery of the aorta. Obviously this is a major procedure and
hence not suitable in elderly high risk patients. In contrast, axillo-bifemoral bypass is a
low risk procedure (a straight forward graft from the axillary to the femoral artery) and
hence suitable in medically unfit/compromised patients who have/or who are in risk of
developing critical ischaemia.

Theme: Thoracic trauma

A Pulmonary embolus
B Cardiac tamponade
C Tension pneumothorax
D Haemothorax

For each of the following situations, select the most likely diagnosis from the
above list. Each option may be used once, more than once, or not at all.

Scenario 1
A 29-year-old motorcyclist admitted following a road traffic accident. The patient
sustained thoracic and pelvic injuries. A left intercostal drain has been inserted for
pneumothorax. On transfer to the ward, the patient becomes acutely short of breath.
He is hypotensive with engorged neck veins. The trachea is deviated to the right,
reduced breath sounds and hyper-resonance to percussion over the left lung.

C - Tension pneumothorax « CORRECT ANSWER

The clinical signs in this patient clearly suggest a left tension pneumothorax
despite the presence of a left intercostal drain. Chest drains may easily become
blocked, kinked or clamped in error, with a resulting tension pneumothorax if
there is an ongoing airleak.

Scenario 2
A 70-year-old man fell 15 ft from a ladder and landed on his back. The following day on
the ward he becomes short of breath, tachycardic and hypotensive. The trachea is
deviated to the right, and examination of the left chest reveals dullness to percussion
and reduced breath sounds. A loud clicking prosthetic heart sound is heard.
D - Haemothorax « CORRECT ANSWER
This patient has a mechanical prosthetic aortic valve (loud clicking second heart
sound) and will thus be on warfarin. A fall has precipitated a left haemothorax,
with reduced breath sounds and percussion dullness on the left and a degree of
mediastinal shift away from the affected side.

Scenario 3
A 35-year-old woman collapses on the ward 4 days after a thoracotomy and
evacuation of haematoma following a stabbing to the right chest. She is tachypnoeic,
tachycardic and severely hypotensive with engorged neck veins. The trachea is
central, the heart sounds are normal. The post-operative intercostal drains are
swinging with no air leak and minimal drainage.

A - Pulmonary embolus « CORRECT ANSWER

This patient becomes suddenly unwell 4 days after a major surgical procedure.
The observations of the intercostal drains do not suggest a right pneumothorax .
The other clinical features suggest acute right ventricular decompensation, most
likely caused by a large pulmonary embolus. Tamponade is less likely with the
site of injury and normal heart sounds.

An 86-year-old man is diagnosed with a 2cm lung squamous cell carcinoma

confined to the anterior bronchopulmonary segment of the right upper lobe, its
staging is T1N0M0 suggesting curative surgery is an option. He is a life-long
smoker.
Which of the following is the most desirable therapeutic option?
Single best answer - select one answer only

Chemotherapy
Pnuemonectomy
Radiotherapy
Sleeve lobectomy
Wedge resection « CORRECT ANSWER
 The Answer
 Comment on this Question
Sleeve lobectomy describes the resection of a lobe and a portion of the main
stem bronchus with re-implantation of the distal bronchus. It is often performed
for centrally located lesions and especially favourable for patients with limited
cardiopulmonary reserve. Wedge resections can be performed with video-
assisted thorascopic surgery (VATS). Studies comparing lobectomy with wedge
resection in non-small cell lung cancer (NSCLC) have shown that 5-year survival
rate with wedge resection to be lower than with lobectomy however in older
patients with poor lung function this may be a better option. Chemotherapy is
used in the neoadjuvant or adjuvant setting in curable lung cancer. Radiotherapy
may be used in the treatment of small cell lung cancer (SCLC).

A 25-year-old lady is intoxicated with alcohol, she gets into a dispute and is
stabbed in the left 5th intercostal space in the mid-clavicular line. On
examination, she is hypotensive, tachycardic and tachypnoeic. Her jugular
venous pressure is raised and her heart sounds are muffled on auscultation.
Which of the following is the most likely injury?
Single best answer - select one answer only

Cardiac tamponade « CORRECT ANSWER

Diaphragmatic injury
Haemothorax
Surgical emphysema
Tension pneumothorax
 The Answer
 Comment on this Question
Classical symptoms of cardiac tamponade include three signs (Beck's triad):
hypotension occurs because of decreased stroke volume, jugular-venous
distension (Kussmauls’s sign) due to impaired venous return to the heart, and
muffled heart sounds due to fluid inside the pericardium.

8
Theme: Lung cancer: complications
A Bony metastasis
B Cerebellar ataxia
C Clubbing
D Ectopic adrenocorticotropic hormone secretion
E Ectopic antidiuretic hormone secretion
F Ectopic parathyroid hormone secretion
G Intestinal pseudo-obstruction
H Isaac’s syndrome
I Horner’s syndrome
J Hypertrophic pulmonary osteoarthropathy
K Lambert–Eaton myasthenic syndrome
L Pancoast’s syndrome
M Peripheral neuropathy
N Superior vena caval obstruction

The following patients all have lung cancer. Please select the most appropriate
cause for the clinical findings in each case from the above list. The items may be
used once, more than once, or not at all.

Scenario 1
A 47-year-old smoker with a chronic cough attends his general practitioner with a
history of severe pain in his left shoulder and radiating down his left arm. There is
some weakness in the intrinsic muscles of the left hand. Sputum cytology reveals
malignant keratinised cells.

L - Pancoast’s syndrome « CORRECT ANSWER

L – Pancoast’s syndrome
This is a complication of an apically placed squamous cell carcinoma that
invades directly into anatomical structures situated in this area including ribs,
thoracic vertebrae and nerve roots. In addition to local symptoms, there are two
resultant syndromes related to neuronal involvement. In this case, invasion of
the brachial plexus roots leads to Pancoast’s syndrome. The other well-
recognised syndrome is Horner’s syndrome, caused by involvement of
sympathetic fibres as they exit the cord at T1 to ascend to the superior cervical
ganglion (miosis, ptosis, enophthalmosis).
NB Rather confusingly, a Pancoast tumour can lead to both Pancoast’s and
Horner’s syndromes.

Scenario 2
A 75-year-old lady is brought in by ambulance after being found collapsed by
neighbours. On examination she is drowsy and becomes agitated when attempts are
made to rouse her. Routine observations show that her blood pressure is 170/95
mmHg and heart rate is 72 bpm. Her biochemistry results come back as urea &
electrolytes: Na+ 116 mmol/litre, K+ 3.0 mmol/litre, urea 6.5 mmol/litre, creatinine 92
µmol/litre; plasma osmolality: 251 mosmol/kg.

E - Ectopic antidiuretic hormone secretion « CORRECT ANSWER

E – Ectopic antidiuretic hormone secretion (SIADH)
There are many causes for SIADH of which the paraneoplastic, ie nonmetastatic,
syndrome associated with small cell carcinoma of the lung is one. Inappropriate
levels of the hormone lead to hypervolaemic hyponatraemia with inability of the
body to diurese in response to falling plasma osmolality. Severe hyponatraemia
with Na+ < 110 mmol/litre can lead to generalised fits and coma.

Scenario 3
A 67-year-old man with lung cancer is seen by the palliative-care team after
complaining of severe fatigue and weakness. He is now unable to stand from sitting,
has problems chewing and gets occasional double vision. Examination shows normal
power in the hands and feet, but weakness of the girdle muscles and an oculomotor
nerve palsy on the right with ptosis. The doctor is surprised that the weakness
improves after repeated demonstrations to colleagues.

K - Lambert–Eaton myasthenic syndrome « CORRECT ANSWER

K – Lambert–Eaton myasthenic syndrome (LEMS)
This is a rare, paraneoplastic syndrome associated with small cell carcinoma of
the lung. There is impaired release of acetylcholine at the neuromuscular
junction caused by autoantibodies directed to native calcium channels. The
picture is therefore very similar to myasthenia gravis, typically with proximal
weakness and often ocular or bulbar palsies. Unlike myasthenia gravis the
weakness often improves with repeated muscle contraction. Other neural
autoantibodies associated with small cell carcinoma include those to potassium
 channels leading to neuromyotonia (Isaac’s syndrome) and those leading to
cerebellar ataxia and other peripheral neuropathies.

A 47-year-old woman with myasthenia gravis undergoes an open thymectomy

for a suspected large thymoma displacing the heart. Immediately post-
operatively the chest radiograph is abnormal. Compared to the original
radiograph the right lower zone is opacified and the right hemidiaphragm is
significantly elevated above the left.
What is the most likely cause?
Single best answer - select one answer only

Effusion
Haemothorax
Lung consolidation
Phrenic nerve injury « CORRECT ANSWER
Vagus nerve injury

 The Answer
 Comment on this Question
Both an effusion and haemothorax should be considered immediately post-
operatively but in both cases the diaphragm will be obscured. If the diaphragm is
visible it suggests air filled lung tissue is still adjacent to the diaphragm thus
making the diaphragm visible. Lung consolidation may occur with collapse of
lung tissue and injection, however this would occur later post-operatively. The
phrenic nerve (C3,C4,C5) descends obliquely with the internal jugular vein
across the anterior scalene. The right phrenic crosses anterior to the 2nd part of
the subclavian artery and, in the mediastinum, passes over the brachiocephalic
artery, posterior to the subclavian vein, and then crosses the root of the right
lung anteriorly. The right phrenic nerve passes over the right atrium and then
leaves the thorax by passing through the vena cava hiatus opening in the
diaphragm at the level of T8.
10

Theme: Mediastinal masses

A Anterior mediastinum
B Middle mediastinum
C Posterior mediastinum
D Superior mediastinum

For each of the pathologies listed below, select the correct part of the
mediastinum in which they are most likely to be found from the above list. Each
option may be used once, more than once, or not at all.

Scenario 1
Thymic lesions

A - Anterior mediastinum « CORRECT ANSWER

A – Anterior mediastinum

Scenario 2
Neural tumours
C - Posterior mediastinum « CORRECT ANSWER
C – Posterior mediastinum

Scenario 3
Thyroid mass

D - Superior mediastinum « CORRECT ANSWER

D – Superior mediastinum

Scenario 4
Lymphoma

A - Anterior mediastinum « CORRECT ANSWER

A – Anterior mediastinum
 Scenario 5
Bronchogenic cyst

B - Middle mediastinum « CORRECT ANSWER

B – Middle mediastinum
The locations of mediastinal masses include:
Anterior mediastinum: thymic lesions, lymphoma, germ-cell tumours, pleuropericardial
cysts, lymph node enlargement. (Note that lymphoma is more likely to manifest in the
anterior mediastinum than middle mediastinum).
Middle mediastinum: lymph node enlargement, bronchogenic cysts, enterogenic cysts
Posterior mediastinum: neural tumours, thoracic meningocele, oesophageal tumours,
aortic aneurysms, paragangliomas
Superior mediastinum: thyroid masses, lymph node enlargement, oesophageal
tumours, aortic aneurysms, parathyroid lesions

11

A 27-year-old female is involved in a road traffic accident after riding her

motorcycle into an oncoming tractor. A haemothorax is suspected and a surgical
chest drain inserted.
Which of the following is an indication for a thoracotomy?
Single best answer - select one answer only
Chest pain
Continued bleeding of over 250mls/hour for the next 2 hours « CORRECT
ANSWER
Greater than 500ml in initial drain
Greater than 750ml in initial drain
Pneumothorax

 The Answer
 Comment on this Question
In cases of trauma, patient assessment should be performed using the advanced
trauma life support (ATLS) protocol before chest drain for haemothorax. The
chest drain is directed toward the costophrenic angle. For maximum drainage,
placement for haemothorax should ideally be in the sixth or seventh intercostal
space at the posterior axillary line. Massive haemothorax is suggested by
greater than 1 litre of blood initially drained, continued bleeding from the chest,
defined as 150-200 mL/hr for 2-4 hours, or repeated blood transfusion, is
required to maintain haemodynamic stability.

12

Theme: Thoracic emergencies

A Oesophageal perforation
B Aortic dissection
C Tracheobronchial injury
D Flail chest

For each of the following situations select the most likely diagnosis. Each option
may be used once, more than once, or not at all.

Scenario 1
A 26-year-old male found acutely short of breath following a high-velocity side-impact
motor vehicle accident. He complains of right-sided chest and back pain. On
examination he is tachypnoeic, with a large haematoma over the lateral aspect of the
right hemithorax. The chest wall seems to move paradoxically with respiration. A chest
radiograph reveals multiple right-sided rib fractures.

D - Flail chest « CORRECT ANSWER

The mechanism of injury and the clinical finding of a chest wall haematoma with
paradoxical movement (inward movement on inspiration, outward movement on
expiration) suggest a flail segment of chest wall in the first patient.

Scenario 2
A 42-year-old female presents with acute shortness of breath, haemoptysis and
surgical emphysema after a high-velocity motor vehicle accident. On examination she
is tachycardic, tachypnoeic and has considerable surgical emphysema. The chest
radiograph reveals a fractured right first rib, surgical emphysema and a right
pneumothorax.
C - Tracheobronchial injury « CORRECT ANSWER
 The symptoms of haemoptysis and shortness of breath following a major motor
vehicle accident in the second patient should immediately alert the clinician to
an airway disruption. Features on examination such as (rare) surgical
emphysema, in conjunction with the radiological findings are further evidence
favouring the diagnosis of tracheobronchial injury.

Scenario 3
A 79-year-old female is admitted to hospital with a day’s history of nausea and
vomiting preceding severe chest pain radiating through to the back. On examination
she is peripherally cool, tachycardic and hypotensive. The chest radiograph reveals
pneumomediastinum.

A - Oesophageal perforation « CORRECT ANSWER

The history of vomiting followed by severe chest and back pain in the elderly
third patient should lead to the suspicion of Boerhaave’s syndrome
(oesophageal rupture caused by forceful vomiting). The radiological findings of
pneumomediastinum should make oesophageal perforation the most likely
diagnosis.

13

A 64-year-old steel worker undergoes coronary artery bypass surgery for three-
vessel disease. Post-operatively he develops complete heart block. Ischaemia of
the artio-ventricular node is suspected.
Which branch is most likely to be the culprit vessel?
Single best answer - select one answer only

Left anterior descending artery

Left circumflex artery
Posterior descending artery « CORRECT ANSWER
Posterior lateral artery
Right marginal artery

 The Answer
 Comment on this Question
Coronary artery dominance is defined by the artery that supplies the posterior
descending artery (PDA). The PDA can arise from the right coronary artery itself,
or from the left circumflex. The PDA supplies the atrio-ventricular node via the
atrio-ventricular nodal artery and approximately 70% of the population are right
dominant, 20% are co-dominant and 10% are left dominant (the absolute figures
may vary slightly depending on the reference source).
The right marginal artery arises from the right coronary artery and passes along
the inferior margin of the heart to the apex.

14

Theme: Chest trauma management

A Arteriography
B Bilateral thoracostomy
C Computed tomography of thorax
D Emergency thoracotomy
E Immediate needle decompression
F Insertion of chest drain
G Intravenous access fluid resuscitation
H Intubation and ventilation
I Pericardiocentesis
J Resuscitation (emergency room) thoracotomy
K Transoesophageal echocardiography

The following patients have all had thoracic injuries. Please select the most
appropriate management option from the above list. The items may be used
once, more than once, or not at all.

Scenario 1
A 27-year-old man is brought to The Emergency Department following a stab wound to
the left side of the chest. On examination his respiratory rate is 24 breaths/min, pulse
rate is 115/min, and blood pressure is 90/50 mmHg. There is a dull percussion note
and decreased air entry on the affected side.
F - Insertion of chest drain « CORRECT ANSWER
F – Insertion of chest drain
This patient probably has a haemothorax. The primary cause is either lung
laceration or laceration of the intercostal/internal thoracic vessels. It is first
treated with a large calibre chest drain [then intravenous access etc, following
the ABC (Airways, Breathing, Circulation) protocol]. This not only evacuates the
blood and reduces the risk of a clotted haemothorax, but also allows continuous
monitoring of blood loss. Bleeding is usually selflimiting; however, in cases of
massive haemorrhage (e.g. >1.5 litres of blood immediately drained from a chest
tube), an emergency thoracotomy may be required.
Other indications for emergency thoracotomy may be found on
http://www.trauma.org/index.php/main/article/361/

Scenario 2
An 18-year-old woman is brought to The Emergency Department after being hit by a
car travelling at approximately 50 miles/h. She has a suspected fractured pelvis and a
Glasgow Coma Score of 13/15. On arrival, she has a respiratory rate of 36
breaths/min; pulse rate of 120/min and blood pressure is 90/60 mmHg. Examination
reveals engorged neck veins, and a hyper-resonant percussion note on the left side of
the chest. The background noise in the department renders auscultation of either
breath or heart sounds difficult to assess.

E - Immediate needle decompression « CORRECT ANSWER

E – Immediate needle decompression
This lady has a tension pneumothorax, which develops when a ‘one-way valve’
air leak occurs either from the lung or through the chest wall. Air is forced into
the thoracic cavity without means of escape, collapsing the affected lung. It is a
clinical diagnosis and life-saving treatment, large-bore needle decompression
into the second intercostal space in the midclavicular line of the affected
hemithorax, should not be delayed by waiting for radiological confirmation.
Clinical signs of tachypnoea, tachycardia, hypotension and neck vein distension
may initially confuse diagnosis with cardiac tamponade. However, differentiation
may be made by a hyperresonant percussion note and/or the absence of breath
sounds over the affected hemithorax.

Scenario 3
A 65-year-old man is the driver in a high-speed road traffic accident. He is brought to
The Emergency Department complaining of severe chest pain and difficulty breathing.
Examination reveals a shallow respiratory rate of 34 breaths/min and a Sa02 of 92% on
60% oxygen. He has contusions to both sides of the chest and there is reduced air
entry bilaterally. Palpation of the chest wall reveals crepitus and asymmetrical
movement of the right chest wall.

H - Intubation and ventilation « CORRECT ANSWER

H – Intubation and ventilation
This gentleman has a flail chest, which occurs when a segment of the chest wall
loses bony continuity with the rest of the thoracic cage. It usually results from
blunt trauma associated with multiple rib fractures. It is the underlying
significant pulmonary contusion that is problematic. The definitive treatment is
to re-expand the lung and ensure adequate oxygenation; in a hypoxic patient a
short period of intubation and ventilation may be necessary until the diagnosis
of the entire injury pattern is complete.

Scenario 4
A 52-year-old window cleaner falls five storeys. He is brought to The Emergency
Department with suspected bilateral hip dislocation and calcaneal fractures. He seems
stable from a cardiorespiratory perspective. A chest X-ray taken as part of the routine
trauma series reveals a widened mediastinum.

A - Arteriography « CORRECT ANSWER

A – Arteriography
This gentleman has suffered traumatic aortic rupture. It is a common cause of
death after a road traffic accident or after a fall from a great height. For
immediate survivors, salvage is frequently possible if aortic rupture is identified
and treated early. Patients with aortic rupture, who are potentially salvageable,
tend to have a laceration near the ligamentum arteriosum. An intact adventitial
layer or contained mediastinal haematoma prevents immediate death. Specific
signs and symptoms are frequently absent. Its presence may be suggested by a
characteristic widened mediastinum on chest X-ray. If aortic rupture is
suspected, the patient should be evaluated by the most appropriate diagnostic
tool determined by the doctors at the hospital at which the repair will be made.
Angiography is considered the gold standard, although contrast computed
tomography is often performed first.

Scenario 5
 A 20-year-old is brought to The Emergency Department by paramedics having been
stabbed to the left of the chest. He is intubated and ventilated and has been
persistently hypotensive since scene. On transfer to the resuscitation bay he has a
cardiac arrest.

J - Resuscitation (emergency room) thoracotomy « CORRECT ANSWER

J – Resuscitation (emergency room) thoracotomy
This is one of the two indications for this procedure (the other being massive
tracheobronchial bleeding). In even relatively inexperienced hands, good results
can be obtained if the cause is simple to address, eg myocardial puncture with
tamponade. All other indications can probably wait until theatre where suitably
trained staff are available (it is still termed an emergency thoracotomy, however).
The method used to open the chest is a source of contention (the Editor prefers
the clamshell approach).

15

A 53-year-old man undergoes coronary artery bypass grafting for left main stem
atherosclerosis. During weaning from bypass he is noted to have a poor mean
arterial pressure and requires cardiovascular support.
Which of the following will act mainly to increase the coronary artery perfusion and
increase systolic blood pressure?
Single best answer - select one answer only
Intra-aortic balloon pump « CORRECT ANSWER
Noradrenaline
Pulmonary artery (Swan-Ganz) catheter
Dopamine
Glyceryltrinitriate

 The Answer
 Comment on this Question
Catecholamines (including adrenaline, noradrenaline and dopamine) are
secreted from the adrenal medulla. Peripheral vasoconstriction is largely
mediated by alpha-1-receptors, and maximally stimulated by noradrenaline
rather than adrenaline, thus increasing systolic blood pressure. Glycerine
trinitrate is a potent vasodilator and would reduce systemic vascular resistance
and systolic blood pressure.
Aortic balloon pumps inflate during diastole, reducing afterload and increasing
coronary artery perfusion which only occurs in diastole, in addition it deflates in
systole increasing forward blood flow by reducing afterload through a vacuum
effect. A SwanGanz catheter can be used to measure right atrial, pulmonary
artery, and pulmonary capillary wedge pressures and to determine cardiac
output and oxygen saturations in the right heart chambers.

16

THEME: THE DENERVATED HEART

A Reduced parasympathetic stimulation after transplant

B Release of catecholamines
C Increased venous return
D Transplant rejection
E Hypersensitivity of Sino Atrial node to catecholamines
F Decreased baroreceptor activity

For each of the clinical presentations described below, select the single most
likely responsible physiological process from those listed above. Each option
may be used once, more than once, or not at all.

Scenario 1
Resting tachycardia.
A - Reduced parasympathetic stimulation after transplant « CORRECT ANSWER

Scenario 2
Tachycardia in response to exercise.
B - Release of catecholamines « CORRECT ANSWER

Scenario 3
Ventricular fibrillation.
D - Transplant rejection « CORRECT ANSWER
 The Answer
 Comment on this Question
The transplanted or denervated heart has no vagal/parasympathetic innervation
and thus has a higher basal heart rate. The transplanted heart relies on
circulating catecholamines to produce inotropic and chronotropic effects.

17

A 47-year-old man presents to the hospital with a two-month history of night

sweats and weight loss. Blood culture grows a haemophilus species from two
different peripheral venous samples. On examination a pan-systolic murmur is
present. Increasingly there are signs of left heart strain.
What procedure may this patient require if his condition deteriorates?
Single best answer - select one answer only
Trans-catheter aortic valve implantation
Mitral valvuloplasty
Mechanical aortic valve replacement
Biological aortic valve replacement
Mechanical mitral valve replacement « CORRECT ANSWER
 The Answer
 Comment on this Question
Pan-systolic (holo-systolic) murmurs are usually due to regurgitation, such as
 mitral regurgitation,
 tricuspid regurgitation,
 or ventricular septal defect (VSD).
This patient has a clinical history consistent with bacterial endocarditis with a
HACEK organism and mitral valve damage causing regurgitation. The National
Institute of Clinical Excellence (NICE) recommends Trans-catheter aortic valve
implantation (TAVI) for patients with aortic stenosis who are considered to be
unsuitable for surgical aortic valve replacement (NICE interventional procedures
guidance [IPG421]). Percutaneous mitral balloon valvuloplasty (PMBV) has
become the treatment of choice for mitral stenosis in some patients who are
unfit for mitral valve replacement. There are a variety of biological valves, most
are made from cow or pig tissue, and their advantage is the reduced risk of
 thromboembolism. Mechanical valves offer the greatest life span and are the
treatment of choice for younger patients.

18

A 59-year-old long term smoker is referred with haemoptysis and weight loss. A
CT thorax confirms a 7.2cm tumour within the lung parenchyma with no
evidence of localised invasion.
Which of the following terms best describes the stage of this tumour using the
TNM classification for lung cancer?
Select one answer only
T1
T2
T3 « CORRECT ANSWER
T4
T5

 The Answer
 Comment on this Question
The latest TNM staging system for lung cancer (7th edition, 2010) defines a T3
lesion as one that is more than 7 cm or that directly invades parietal pleura,
chest wall, diaphragm, phrenic nerve, mediastinal pleura or parietal pericardium;
with various other minor criteria. Please see the following reference for further
information:
https://cancerstaging.org/references-
tools/quickreferences/Documents/LungMedium.pdf

19

Theme: Chest pain

A Acute aortic dissection

B Unstable angina
C Rupture of the oesophagus
D Pneumothorax
E Pulmonary embolus
F Mallory-Weiss syndrome

Match the most likely diagnosis from the list above to each clinical situation
described below. Each option may be used once only, more than once or not at
all.

Scenario 1
A 50-year-old man with tight chest pain for the last hour, pale, sweaty, and clammy still
in pain. Pain radiates to his jaw.

B - Unstable angina « CORRECT ANSWER

Unstable angina
The cardiac causes of chest pain should always be eliminated with the history,
examination and investigations.

Scenario 2
A man with pain in the central chest radiating to the back that started an hour ago.
Widened mediastinum was noticed on his chest X-ray and his blood pressure was
180/110 mmHg in the right arm and 110/70 mmHg in the left arm.

A - Acute aortic dissection « CORRECT ANSWER

Acute aortic dissection
A difference in blood pressures in both arms, coupled with central chest pain
radiating to the back and a widened mediastinum on CXR in a hypertensive
patient, should alert you to the possibility of aortic dissection (i.e. necessitating
an urgent CT aortogram).

Scenario 3
A young man with chest pain that started Sunday morning, he has been vomiting the
night before. On examination subcutaneous crepitations were found over the chest and
shoulder.

C - Rupture of the oesophagus « CORRECT ANSWER

Rupture of the oesophagus
Boerhaave’s syndrome describes the spontaneous rupture of the oesophagus
following vomiting, and can be associated with surgical emphysema.
 Scenario 4
A 70-year-old lady 10 days after a total hip replacement.

E - Pulmonary embolus « CORRECT ANSWER

Pulmonary embolus
In any post-operative patient, always consider a pulmonary embolus, as well as a
myocardial infarction depending on history.

Scenario 5
A 23-year-old basketball player with sudden-onset chest pain associated with
shortness of breath.

D - Pneumothorax « CORRECT ANSWER

Pneumothorax
Spontaneous pneumothoraces usually occur in tall, young, athletic people and if
small can be treated with simple needle aspiration and follow-up chest X-ray.

20

A 64-year-old dialysis patient has a large pleural effusion compromising her

breathing.
Which of the following is the most appropriate landmark for the safe area of chest drain
insertion?
Single best answer - select one answer only

In the axilla
Inferior to the nipple line
Mid-axillary line « CORRECT ANSWER
Through pectoralis major
7th intercostal space
 The Answer
 Comment on this Question
The landmarks for the safe triangle are:

Anterior to border of latissimus dorsi

Lateral to pectoralis major
Superior to a horizontal line at the nipple
A usual siting place is the 5th intercostal space, in the mid-axillary line and
below the axilla. See BTS Pleural Disease Guideline 2010 'A Quick Reference
Guide', for further guidance on chest drain insertion.

21

Theme: Thoracic incisions

A Median sternotomy
B Posterolateral thoracotomy
C Clamshell thoracotomy
D Anterior thoracotomy

For each of the following situations select the most useful surgical incision.
Each option may be used once, more than once, or not at all.

Scenario 1
Aortic transection at the junction of the aortic arch with descending thoracic aorta

B - Posterolateral thoracotomy « CORRECT ANSWER

The junction of the aortic arch with the descending thoracic aorta is the
commonest site of aortic transection, often after a deceleration injury. The aorta
is found in the posterior mediastinum and is best approached via a left
posterolateral thoracotomy.

Scenario 2
Stab wound to the right ventricle

A - Median sternotomy « CORRECT ANSWER

The right ventricle is the most anterior chamber of the heart and is thus most
easily accessed via a median sternotomy.

Scenario 3
Bilateral penetrating chest injuries with lung parenchymal lacerations
C - Clamshell thoracotomy « CORRECT ANSWER
Bilateral penetrating lung injuries will often need wide exposure to be
appropriately repaired. Access to both lungs is feasible via a median
sternotomy, but a clamshell thoracotomy gives the best access to both
hemithoraces.

22

Theme: Thoracic trauma

A Aortic disruption
B Cardiac tamponade
C Diaphragmatic rupture
D Flail chest
E Haemothorax
F Massive haemothorax
G Myocardial contusion
H Oesophageal rupture
I Open pneumothorax
J Pulmonary contusion
K Simple pneumothorax
L Tension pneumothorax
M Tracheobronchial disruption
N Traumatic asphyxia

The following patients have all had thoracic injuries. Please select the most
appropriate diagnosis from the above list. The items may be used once, more
than once, or not at all.

Scenario 1
A 26-year-old soldier is hit by shrapnel, resulting in a large defect to the left side of his
chest. He is brought to Casualty, the paramedics having securely occluded the defect
on all sides with a sterile dressing. On examination he is severely dyspnoeic,
tachycardic and hypotensive. His trachea is displaced to the right. Percussion reveals
the left side of the chest to be hyper-resonant, with decreased air entry on auscultation.

L - Tension pneumothorax « CORRECT ANSWER

L – Tension pneumothorax
Initially the patient suffers an open pneumothorax (‘sucking chest wound’),
whereby the equilibrium between intrathoracic pressure and atmospheric
pressure is immediate; if the defect is approximately two-thirds the tracheal
width then the air follows the path of least resistance, through the defect,
impairing ventilation. The paramedics were correct to close the defect; however,
the dressing should only have been securely taped on three sides so as to
create a flutter-type valve effect; this ensures the dressing is sucked over the
defect on inspiration preventing air entering, while the open end allows air to
escape on exhalation. By securing the dressing on all sides, air progressively
accumulates in the thoracic cavity, collapsing the lung on the affected side. The
mediastinum is displaced to the opposite side, decreasing venous return and
compressing the opposite lung. The most common cause of tension
pneumothorax is mechanical (positive-pressure) ventilation in the patient with a
visceral pleural injury. Rapid decompression is required to prevent death.

Scenario 2
A 65-year-old lady is brought to The Emergency Department having been involved in a
road traffic accident; it was a head-on collision in which she was the driver. Her signs
are initially stable, and examination only reveals bruising over and to the left of the
sternum. A chest X-ray is normal. A few hours later she develops an irregular
tachycardia confirmed by electrocardiogram to be atrial fibrillation.

G - Myocardial contusion « CORRECT ANSWER

G – Myocardial contusion
Blunt thoracic trauma can result in cardiac injury: myocardial muscle contusion,
cardiac chamber rupture, or valvular disruption. Patients with myocardial
contusion may complain of chest discomfort but this is often attributed to chest
wall contusion or fractures of the sternum and/or ribs. The clinically important
sequelae are hypotension, significant conduction abnormalities on
electrocardiogram (ECG) or wall motion abnormality on two-dimensional
echocardiography. Multiple premature ventricular contractions, unexplained
sinus tachycardia, atrial fibrillation, bundle branch block (usually right), and ST
segment changes are the most common ECG findings. Patients with myocardial
contusion diagnosed by conduction abnormalities are at risk of sudden
dysrhythmias and should be monitored for 24 h. After this time, the risk of
sudden dysrhythmia substantially decreases.

Scenario 3
A 50-year-old builder presents to The Emergency Department having been hit by
falling scaffolding. He did not initially attend The Emergency Department; however,
over the past few hours he has become increasingly dyspnoeic. On examination he
has a respiratory rate of 30 breaths/min and a SaO2 of 89%. He has equal air entry
bilaterally and normal percussion. Chest X-ray reveals fractures of ribs 2 to 6 on the
left side.

J - Pulmonary contusion « CORRECT ANSWER

J – Pulmonary contusion
Pulmonary contusion is the most common potentially lethal chest injury,
commonly occurring secondary to multiple rib fractures or flail chest, as a result
of blunt trauma. Respiratory failure may be subtle and develop over time as a
result of underlying lung injury, rather than occur instantaneously. Patients with
significant hypoxia (ie pA(02) < 8.0 kPa on room air, Sa02 < 90%) and/or chronic
lung disease will require intubation and ventilation.

23

Theme: Lung and oesophageal cancer

A Computed tomography (CT)-guided biopsy

B Mediastinoscopy
C Rigid bronchoscopy
D Exploratory thoracotomy

For each of the following situations select the most useful next step in
management. Each option may be used once, more than once, or not at all.

Scenario 1
A 73-year-old female smoker presented with a persistent cough. A chest radiograph
revealed a suspicious lesion in the periphery of the left upper zone. Flexible
bronchoscopy was unremarkable. A CT scan confirms the presence of a spiculated
mass in the left upper lobe and also reveals some enlarged left paratracheal lymph
nodes.

A - Computed tomography (CT)-guided biopsy « CORRECT ANSWER

This patient requires a tissue diagnosis. Peripheral lesions may not be seen via
flexible bronchoscopy but are amenable to CT-guided biopsy.

Scenario 2
A 64-year-old man with a known right upper lobe squamous cell carcinoma is shown to
have a tumour abutting the superior vena cava on CT scan. There is also an enlarged
right hilar lymph node, but no other sign of metastatic disease.

D - Exploratory thoracotomy « CORRECT ANSWER

This patient has a potentially locally advanced tumour according to the CT scan.
However, the radiology may be deceptive, and a relatively young patient should
withstand an exploratory thoracotomy with a view to curative resection. The hilar
lymph node is not accessible with the mediastinoscope.

Scenario 3
A 55-year-old man presented with dysphagia for solids. Upper gastrointestinal
endoscopy demonstrated a mid-oesophageal tumour which could not be passed with
the endoscope. Biopsies confirmed a moderately differentiated squamous cell
carcinoma. A CT scan suggests the possibility of some local invasion, but no lymph
node, hepatic or pulmonary metastases.

C - Rigid bronchoscopy « CORRECT ANSWER

This patient has a potentially locally advanced mid-oesophageal squamous cell
cancer. Further staging with endoscopic ultrasound is not possible as the
instrument will not pass the stricture. The key with mid-oesophageal tumours is
to exclude tracheal involvement – thus a rigid bronchoscopy would be the
investigation of choice.

24

THEME: HAEMOTHORAX
A Electrocardiogram (ECG)
B Chest drain in affected side
C Chest drain and high suction
D Echocardiogram
E Pericardiocentesis
F Urgent thoracotomy within 1 hour

For each of the patients described below, select the single most appropriate
action from the options listed above. Each option may be used once, more than
once, or not at all.

Scenario 1
A young man has been stabbed in the right mid-axillary line. He has a tachycardia but
normal blood pressure (BP). A chest X-ray shows shadowing and small pneumothorax
at the right base.

B - Chest drain in affected side « CORRECT ANSWER

The most appropriate treatment for a haemopneumothorax is a chest drain. If there is
evidence of a massive haemothorax or if bleeding continues, emergency thoracotomy
is required.

Scenario 2
A young man has been stabbed in the pericardial region. He displays tachycardia, but
his BP and chest X-ray are normal.

D - Echocardiogram « CORRECT ANSWER

Echocardiography is the most widely used imaging technique for the detection of
pericardial effusion and/or thickening. A major advantage of echocardiography is its
portability to the bedside to examine critically ill patients. The technique is noninvasive
and is quite sensitive in imaging fluid-filled structures

25

THEME: HEART MURMURS

A Ejection systolic murmur

B Continuous systolic murmur
C Early diastolic murmur
D Machinery murmur
E Split second heart sound (HS II)

For each of the clinical scenarios below select the most appropriate answer.
Each option may be used once, more than once, or not at all.

Scenario 1
A patient presents with a ventricular septal defect (VSD).

B - Continuous systolic murmur « CORRECT ANSWER

A patient with a VSD has a continuous systolic murmur/pansystolic murmur.

Scenario 2
A patient presents with an atrial septal defect (ASD).

E - Split second heart sound (HS II) « CORRECT ANSWER

A patient with an ASD does not have a murmur. The split of the HS II is fixed
throughout diastole and systole.

Scenario 3
A patient presents with aortic regurgitation.

C - Early diastolic murmur « CORRECT ANSWER

A patient with aortic regurgitation has an early diastolic murmur.

26

Theme: Shock
A Cardiogenic shock
B Hypovolaemic shock
C Neurogenic shock
D Septic shock
For each of the following situations, select the most likely answer from the
above list. Each option may be used once, more than once, or not at all.
Scenario 1
A 58-year-old male cyclist has been involved in a road traffic accident (RTA). He
sustained an open femoral fracture, with wound contamination and a severe thigh
haematoma. Forty-eight hours postexternal fixation, the patient is behaving
aggressively on the ward and complaining of pain in his leg. On examination, the
patient is febrile with warm peripheries, tachycardic and mildly hypotensive. The
surgical site appears inflamed. The ECG shows a sinus tachycardia. What type of
shock is most likely?

D - Septic shock « CORRECT ANSWER

This patient is 48 hours post surgery with an obvious source of infection – an open
fracture with a contaminated wound. He is displaying signs of shock with signs of
vasodilatation – warm peripheries. The most likely type of shock is septic shock.

Scenario 2
A 65-year-old diabetic woman is feeling generally unwell 4 days following an elective
anterior resection for a Dukes’ A colorectal carcinoma. On examination, the patient is
afebrile, tachycardic and hypotensive with clammy skin. Her abdomen is mildly tender
with a clean dry wound and scanty but audible bowel sounds. Her urine output has
been poor for the last 6 hours. The ECG shows a new left-bundle branch block. What
type of shock is most likely?

A - Cardiogenic shock « CORRECT ANSWER

This patient has an important risk factor for ischaemic heart disease – diabetes mellitus
– which is associated with silent myocardial infarction. The patient feels generally
unwell with signs of shock and left-bundle branch block on the ECG. It is quite possible
that the patient may have had a myocardial infarction and now presents with
cardiogenic shock. The presence of bowel sounds and a mildly tender abdomen
suggest that an intra-abdominal problem is unlikely.

Scenario 3
A 44-year-old man with a short history of alcohol abuse presents with a 12-hour history
of persistent vomiting and abdominal pain following a drinking binge. On examination,
the patient has a low-grade pyrexia and is sweaty , tachypnoeic, tachycardic and
hypotensive with cool peripheries. Abdominal examination reveals marked epigastric
tenderness. The chest radiograph demonstrates a small left-pleural effusion, the
abdominal radiograph shows two central distended small bowel loops and the ECG
shows a sinus tachycardia. What type of shock is most likely?
B - Hypovolaemic shock « CORRECT ANSWER
This patient shows classical signs of significant hypovolaemia complicating alcohol-
induced acute pancreatitis. The circulating volume depletion can be attributed to a
combination of vomiting and third-space losses.