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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
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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
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
Scenario 2
Neural tumours
C - Posterior mediastinum « CORRECT ANSWER
C – Posterior mediastinum
Scenario 3
Thyroid mass
Scenario 4
Lymphoma
11
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
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.
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.
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
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
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.
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.
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.
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.
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
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
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
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.
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.
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.
Scenario 5
A 23-year-old basketball player with sudden-onset chest pain associated with
shortness of breath.
20
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:
21
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
Scenario 2
Stab wound to the right ventricle
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
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.
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.
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.
23
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.
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.
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.
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.
Scenario 2
A young man has been stabbed in the pericardial region. He displays tachycardia, but
his BP and chest X-ray are normal.
25
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).
Scenario 2
A patient presents with an atrial septal defect (ASD).
Scenario 3
A patient presents with aortic regurgitation.
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?
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?
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.