MCQs and EMQs in Surgery - A Bailey _ Love[Shared by Ussama Maqbool]

D EuroSCORE European System for Cardiac Operative Risk Evaluation EUS Endosonography EVLT endovascular laser treatment FAP familial adenomatous polyposis FAST focused assessment with son

companion guide to Bailey & Love’s Short Practice in Surgery The book assists readers in their

preparation for examinations and enables them to test their knowledge of the principles and

practice of surgery as outlined within Bailey & Love.

Sub-divided into 13 subject-specific sections, both MCQs and EMQs provide a comprehensive

coverage of the surgical curriculum as well as the core learning points as set out in Bailey & Love.

Each section emphasises the importance of self-assessment within effective clinical

examination and soundly based surgical principles, whilst taking into account the latest

developments in surgical practice.

MCQs and EMQs in Surgery is an excellent companion to Bailey & Love and provides a

valuable revision tool for those studying for MRCS.

About the authors

General Hospital, Wick, Member of Council and College Tutor, Royal College of Surgeons of

Edinburgh.

and Orthopaedic Surgeon, University of Oxford, Member of Council, Royal College of

Surgeons of Edinburgh.

Medical Education, Southend University Hospital, Honorary Senior Lecturer, Queen Mary,

University of London.

One of the world's pre-eminent medical textbooks beloved by

generations of surgeons.

Christopher J K Bulstrode MCh, FRCS (Orth), Professor and Honorary Consultant Trauma and Orthopaedic Surgeon, University of Oxford, Member of Council, Royal College of Surgeons of Edinburgh

B V Praveen MS, FRCS (Ed, Eng, Glasg, Irel, Gen), Consultant Surgeon and Associate Director of Medical Education, Southend University Hospital, Honorary Senior Lecturer, Queen Mary, University

of London

CRC Press

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PART 5: ELECTIVE ORTHOPAEDICS 217

31 Elective orthopaedics: musculoskeletal examination 219

PART 6: SKIN AND SUBCUTANEOUS TISSUE 271

39 Skin and subcutaneous tissue 273

■ Pradip Datta

■ Lynn Myles

■ Brian Fleck

42 Cleft lip and palate: developmental

PART 8: BREAST AND ENDOCRINE 361

48 Thyroid and the parathyroid gland 363

58 The peritoneum, omentum, mesentery

This innovative companion volume will certainly be considered as an

essential complement to Bailey & Love’s Short Practice of Surgery The

authors and contributors have recognised the fundamental changes that have occurred in surgical training and assessment where greater knowledge must be acquired in a shorter period of time, not only to ensure success in examinations but also to provide the comprehensive foundations on which to build clinical expertise The Silver Jubilee

edition of Bailey & Love in 2008 emphasised its enduring importance for generations of surgeons internationally MCQs and EMQs in Surgery will

define the indispensable elements for today’s surgical practitioners

John D Orr, FRCS (Ed)

Sanjay De Bakshi MS FRCS (Eng & Ed)

Consultant Surgeon, Calcutta Medical Research Institute (CMRI), Kolkata, India

Brian W Fleck FRCS (Ed), MD Consultant Ophthalmic Surgeon, Princess Alexandra Eye Pavilion and Royal Hospital for Sick Children, Edinburgh

Professor Pawanindra Lal MS DNB MNAMS FRCS (Ed & Eng)

Professor of Surgery, Maulana Azad Medical College, New Delhi, India

Professor Peter McCollum MCh, FRCS (Ed), FRCSI

Professor of Vascular Surgery, Hull/York Medical School

John C McGregor BSc (Hons) MBChB (with commendation) FRCS, FRCS (Edin)

Former Consultant in Plastic, Reconstructive and Cosmetic Surgery,

St John’s Hospital, West Lothian

Lynn Myles BSc (Hons), MB ChB, MD, FRCS (SN)

Consultant Neurosurgeon, Department of ClinicalNeurosciences, Western General Hospital, Edinburgh

Dumbor L Ngaage MB BS FRCS (Ed), FWACS, FRCS (C-Th), FETCS (Cardiovascular), FETCS (Thoracic), MS

Specialist Registrar in Cardiothoracic Surgery, Castle Hill Hospital, Hull

Honorary Clinical Tutor, Hull York Medical School, Universities of Hull &

York

Iain J Nixon MBChB FRCS (Edin.) Specialist Registrar in Otolaryngology Head and Neck Surgery, West of Scotland Rotation Clinical Research Fellow, Memorial Sloan Kettering Cancer Center, New York, USA

Charles S Perkins FDSRCS, FFDRCSI, FRCS

Consultant Oral and Maxillofacial Surgeon, Gloucestershire Royal and Cheltenham General Hospitals, Gloucestershire

Nandini P Rao, MRCP, Msc

Specialist Registrar in Chemical Pathology/Metabolic Medicine, Royal Free Hospital, London

Professor N R Webster MB ChB PhD FRCA FRCP FRCS

Institute of Medical Sciences, Foresterhill, Aberdeen

First published in 1932, Bailey & Love’s Short Practice of Surgery has

stood the test of time Perhaps this is an understatement, considering that all three of us have used the book as medical students! This book has been the result of good foresight on the part of Hodder Arnold to keep up with the changing trends in the pattern of surgical examinations, both at undergraduate and postgraduate levels The publishers should

be congratulated in bringing out this book – converting the original Silver Jubilee (25th) edition – all 77 chapters of it – as Multiple Choice Questions (MCQs) and Extended Matching Questions (EMQs)

The book is aptly titled as a companion to Bailey & Love We would

therefore hope that the reader, specifically preparing for a written examination, would use this book as the major reading material, referring

to the original for detailed elucidation of a particular point or operative detail

Most of the contributors are different from Bailey & Love’s Short

Practice of Surgery except for chapters 5, 25 the section on orthopaedics

and part of trauma Thus while retaining the essence of the original material, this book has been seasoned by different authors, thus giving

it a fresh flavour without losing any of its original ingredients We are grateful to all the contributors for their prompt response in spite of the pressures of work in the National Health Service

The images and pictures are mostly different to those in the original book, giving this tome an added attraction While the MCQs test knowledge, the EMQs with the illustrations give a good format for a self-assessment exercise The chapters are specifically geared towards helping the reader with preparation for the written papers of the MRCS and FRCS(Gen) examinations The undergraduate will also find this book equally stimulating for the same reasons In surgical examinations in the English-speaking world, where essays have been replaced by short-answer questions (short notes of yesteryear), the reader will find the EMQs ideal preparation

Any book must be dynamic, much more so a new venture such as this It was said in the preface of the parent book, “Whereas the past informs the present, it must never enslave the future.” As authors of this very exciting project we can stay true to the spirit of this statement only with help from you – our readers Therefore we look forward to your suggestions and constructive criticisms for the next edition

Pradip K DattaChristopher J K Bulstrode

An email from Gavin Jamieson to one of us (PKD) was the inspiration behind this publication, he being the catalyst who set alight our enthusiasm to write this book Thus to him we owe a huge debt of gratitude for getting this project off the ground Indeed it is a tribute to all concerned that this book was published in just over a year since the idea was born as his brainchild

All the contributors have done a tremendous job not only in producing comprehensive chapters but also delivering them on time – and this, in spite of the pressures of the present-day National Health Service; to them

we are grateful Francesca Naish, as editorial manager, has kept the team

on track by liaising with us all on a regular basis, thus bringing our efforts

to fruition We give our thanks to her To Jane Utting we are grateful for her meticulous proofreading Thanks are also due to Adam Campbell for his efficient and prompt copy-editing

We are very grateful to Mr John D Orr, immediate Past President of the Royal College of Surgeons of Edinburgh for writing the foreword

Finally, our great appreciation goes to our families (Swati, Sandip, Victoria, Harry, John-James, Jenny, Nandini and Prakruti) for their encouragement and support We dedicate this book to them

PKDCJKBBVP

List of Abbreviations Used

5-FU 5-fluorouracil

5-HIAA 5-hydroxyindoleacetic acid

AAAs abdominal aortic aneurysms

ABCD airways, breathing, circulation and

disabilityABGs arterial blood gases

ACTH adrenocorticotrophic hormone

ADH antidiuretic hormone

ADP adenosine diphosphate

AF atrial fibrillation

AFP alpha-fetoprotein

AIN anal intraepithelial neoplasia

ALG antilymphocytic globulin

ALP alkaline phosphatase

ALS antilymphocytic serum

ALT alanine transaminase

ANCA antineutrophil cytoplasmic antibodies

ANDI aberrations of normal development

and involutionANF atrial natriuretic factor

ANP atrial natriuretic peptide

AP anteroposterior

APC adenomatous polyposis coli

ARDS acute respiratory distress syndrome

AST aspartate transaminase

ATLS Advanced Trauma Life Support

AVC adrenal vein catheterisation

AVMs arteriovenous malformations

BCC basal cell carcinoma

BCG Bacillus Calmette Guérin

BOO bladder outflow obstruction

BPH Benign prostatic hypertrophy

BPPV benign paroxysmal positional vertigo

CABG coronary artery bypass graft

CAH congenital adrenal hyperplasia

CCD charge-coupled device

CCK cholecystokinin

CEA carcinoembryonic antigen

CECT contrast-enhanced computed tomography

CHD common hepatic ductCJD Creutzfeldt–Jakob DiseaseCMV cytomegalovirus

CNS central nervous systemCOAD Chronic obstructive airways diseaseCOPD chronic obstructive pulmonary diseaseCRF corticotrophin-releasing factorCRF chronic renal failure

CRH Cortisol-releasing hormoneCRP C-reactive proteinC/S cervical spineCSF cerebrospinal fluidCRH Cortisol-releasing hormone

CVA cardiovascular accidentCVP central venous pressureDHEA dehydroepiandrosteroneDHT dihydrotestosteroneDIC disseminated intravascular coagulationDISH diffuse idiopathic spinal hyperostosisDKA diabetic ketoacidosis

DL diagnostic laparoscopyDLC differential leucocyte countD-PAS diastase periodic acid-Schiff/diastase PAS

DPL diagnostic peritoneal lavageDRE digital rectal examinationDTPA diethyltriaminepentacetic acidDVT deep vein thrombosisEBV Epstein–Barr virusECF enterochromaffinECG electrocardiogramEDTA ethylenediaminetetra-acetic acidECL enterochromaffin-like

ELISA enzyme-linked immunosorbent assayERCP endoscopic retrograde

cholangiopancreatographyERP Enhanced Recovery ProgrammeESR erythrocyte sedimentation rateESWL extracorporeal shock wave lithotripsyEUA examination under anaesthesia

D EuroSCORE European System for Cardiac

Operative Risk Evaluation

EUS Endosonography

EVLT endovascular laser treatment

FAP familial adenomatous polyposis

FAST focused assessment with

sonography for trauma

FDG flurodeoxyglucose

FEV1 forced expiratory volume in 1 sec

hypocalcaemiaFISH fluorescence in-situ hybridisation

FNAC fine-needle aspiration cytology

FSH follicle-stimulating hormone

GALT gut-associated lymphoid tissue

GDT goal-directed therapy

GI gastrointestinal

GIST gastrointestinal stromal tumours

GOO gastric outlet obstruction

GORD gastro-oesophageal reflux disease

GSI genuine stress incontinence

GTN glyceryl trinitrate

GVHD graft-versus-host disease

HAART Highly Active Anti-Retroviral Therapy

HAI health care-associated infection

HNPCC hereditary non-polyposis colorectal

cancer

HPV human papillomavirusICP intracranial pressureICU intensive care unitIHD ischaemic heart disease

IM intramuscularINR international normalised ratioIPSS International Prostate Symptom ScoreITP idiopathic thrombocytopenic purpuraITU intensive treatment unit

IUCD intrauterine contraceptive device

IV intravenousIVC inferior vena cavaIVU intravenous urogramJVP jugular venous pressureKUB kidney, ureter and bladderLDH lactate dehydrogenaseLFTs liver function tests

LH luteinising hormoneLHRH luteinising hormone-releasing hormoneLIF left iliac fossa

LMA laryngeal mask airwayLMP last menstrual periodLOCM low-osmolality contrast mediaLOS lower oesophageal sphincter

LUTS lower urinary tract symptoms

LV left ventricularMALT mucosa-associated lymphoid tissueMAMA microsomal antibody

MAS minimal access surgeryMEN-1 multiple endocrine neoplasia type 1

MI myocardial infarctionMIBI technetium-99m-labelled sestamibi isotope

MSH melanocyte-stimulating hormoneMSOF multiple system organ failure

MUST Malnutrition Universal Screening Tool

NAI non-accidental injury

NETs neuroendocrine tumours

NOTES natural orifice transluminal surgery

NRES National Research Ethics Service

NSAIDs non-steroidal anti-inflammatory drugs

OCP oral contraceptive pill

OGD oesophagogastroduodenoscopy

OPSI opportunist post-splenectomy infection

OPT orthopantomogram

ORIF open reduction and internal fixation

PAS periodic acid-Schiff

PCA patient-controlled analgesia

PCNL percutaneous nephrolithotomy

PCR polymerase chain reaction

PDGF platelet-derived growth factor

PET positron emission tomography

PETs pancreaticoduodenal endocrine

tumoursPHA primary hyperaldosteronism

PID pelvic inflammatory disease

POC Per-Operative Cholangiogram

PPIs proton pump inhibitors

PSA prostate-specific antigen

PSARP posterior sagittal anorectoplasty

PSC primary sclerosing cholangitis

PTC percutaneous transhepatic

cholangiographyPTH parathyroid hormone

PTLD post-transplant lymphoproliferative

disorderPTT partial thromboplastin time

PUJ pelviureteric junction

PVP polyvinylpropylene

RT radiotherapy

RTA road traffic accident

RUQ right upper quadrant

RV right ventricular

SAH subarachnoid haemorrhage

SCC squamous cell carcinoma

SIADH syndrome of inappropriate antidiuretic

SPKT simultaneous pancreas and kidney transplant

SRUS solitary rectal ulcer syndromeSSIs surgical site infectionsSUFE slipped upper femoral epiphysisSVC superior vena cava

TAPP transabdominal preperitoneal repairTBSA total body surface area

TBW total body waterTED thromboembolic deterrent (stockings)TEP total extraperitoneal repair

TFTs thyroid function testsTGF transforming growth factorTIA transient ischaemic attackTIPSS transjugular intrahepatic portosystemic stent shunt

TIVA total intravenous anaestheticTLC total leucocyte countTNF tumour necrosis factorTNM classification of malignant tumours (tumour, nodes, metastasis)TPN total parenteral nutritionTPO thyroid peroxidase antibodiesTRUS transrectal ultrasound-guided biopsyTSH thyroid-stimulating hormoneTURP transurethral resection of the prostateU&E urea and electrolytes

UC ulcerative colitisUICC Union Internationale Contre le Cancer

US ultrasoundUTI urinary tract infectionVAC vacuum-assisted closureVATS video-assisted thoracoscopy

VP ventriculoperitonealVPC vapour pulse coagulationWCC white cell countWHO World Health Organization

Bailey & Love’s Short Practice of Surgery celebrated the publication of

its Silver Jubilee edition in 2008 It has certainly come a long way since the first edition was published in 1932 As authors of this book (CJKB

being one of the editors of Bailey & Love), dare we say that the title of

the book is a misnomer It is anything but a ‘Short Text Book’ Editions

of yesteryear consisted of some 1300 pages of single column text The current edition consists of over 1500 pages, each containing a double column

Arguably Bailey & Love is not just a text book Many students and

teachers of surgery the world over use it as a reference book too Today both postgraduate and undergraduate examinations lay emphasis on knowledge rather than presentation and the nuances of essay writing

Thus for many years, the candidate’s test of theory knowledge in examinations has been based on Multiple Choice Questions (MCQs) and Extended Matching Questions (EMQs), sometimes supplemented by Single Best Answers (SBAs)

Therefore for the first time in this book, all 77 chapters of Bailey &

Love have been converted into MCQs and EMQs We, as authors, along

with the other contributors, have reproduced the original text in this form of MCQs and EMQs We hope that we have accurately mirrored

the subject matter Most of the images in this book are not from Bailey &

Love, but are from the personal collection of one of the authors (PKD).

We hope that this book will be useful for medical students studying surgery in the English-speaking world and for those doing MRCS and FRCS (Gen) examinations in the UK As authors of the very first such undertaking, we would welcome suggestions for future editions from our readers

PKDCJKBBVP

1 The metabolic response to injury 3

2 Shock and blood transfusion 8

3 Wounds, tissue repair and scars 16

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1 The metabolic response to

injury

Multiple choice questions

➜ Homeostasis

1 Which of the following statements

about homeostasis are false?

A It is defined as a stable state of the

normal body

B The central nervous system, heart, lungs,

kidneys and spleen are the essential organs that maintain homeostasis at a normal level

C Elective surgery should cause little

disturbance to homeostasis

D Emergency surgery should cause little

disturbance to homeostasis

E Return to normal homeostasis after

an operation would depend upon the presence of co-morbid conditions

➜ Stress response

2 In stress response, which of the

following statements are false?

A It is graded

B Metabolism and nitrogen excretion are

related to the degree of stress

C In such a situation there are

physiological, metabolic and immunological changes

D The changes cannot be modified

E The mediators to the integrated response

are initiated by the pituitary

➜ Mediators

3 Which of the following statements

about mediators are true?

A They are neural, endocrine and

inflammatory

B Every endocrine gland plays an equal part

C They produce a model of several phases

D The phases occur over several days

E They help in the process of repair

➜ The recovery process

4 With regard to the recovery process, identify the statements that are true

A All tissues are catabolic, resulting in repair

at an equal pace

B Catabolism results in muscle wasting

C There is alteration in muscle protein breakdown

D Hyperalimentation helps in recovery

E There is insulin resistance

➜ Optimal perioperative care

5 Which of the following statements are true for optimal perioperative care?

A Volume loss should be promptly treated

by large intravenous (IV) infusions of fluid

B Hypothermia and pain are to be avoided

C Starvation needs to be combated

D Avoid immobility

E Helpful measures can be taken

The normal physiological state of the human body is referred to as homeostasis – a normal

internal environment (the milieu intérieur of Claude Bernard) All the vital organs – the

brain, heart, lungs, kidneys and, to a lesser extent, the spleen – play an important role in its

maintenance These organs are interdependent and thus help to maintain a normal fluid and

acid–base balance

In the elective situation, the patient is always optimised prior to any operation, thereby

minimising the homeostatic disturbance The extent of surgery also plays a part Disturbance in

the homeostasis to some degree occurs in emergency surgery; this depends upon the extent

of injury, presence of sepsis and any ongoing insults If the patient has co-morbid conditions,

postoperatively the return to normal homeostasis would take longer than in those with no

co-morbidity In such cases, care in a high-dependency or intensive care unit (ICU) is essential

➜ Stress response

The stress response is graded according to the injury inflicted An elective operation in a fit patient,

such as a laparoscopic cholecystectomy in a 30-year-old female, will elicit a minor transient

stress response from which the patient recovers quite quickly On the other hand, a severely

injured patient of 70 will elicit a major response, requiring care in the ICU (see Fig 1.1) There

is an increase in metabolism and nitrogen excretion in direct proportion to the injury There are

immunological and metabolic changes which are reflected in the physiology – pyrexia, tachycardia

and tachypnoea The body’s innate defence mechanisms can combat mild stress, and return to

normal physiology occurs very soon

Stress response depends upon

Severity of injury Type of injury

To get speedy resolution avoid (‘SO’)

Secondary insults – 3 Is: Ischaemia Infection Inadequate oxygenation (hypoxia)Ongoing trauma, e.g compartment syndrome (abdominal/limb)

In severe injury, the stress response can be modified by anticipating complications and

preventing them by judicious management in an ICU, i.e attention to nutrition and anticipation

and prevention of secondary insults such as ischaemia, infection, hypoxia and compartment

syndrome

play neural, endocrine and inflammatory responses The neural response that initiates and acts in

concert with the endocrines is referred to as the neuroendocrine response to trauma

➜ Mediators

3 A, B, E

Stress from injury travels along afferent pathways of the spinal cord to the hypothalamus

which secretes the corticotrophin-releasing factor (CRF) that acts on the pituitary to secrete

adrenocorticotrophic hormone (ACTH) and growth hormone (GH) This creates the ‘flight or fight’

response The pancreas increases glucagon secretion Other endocrines, thyroid and gonads play a

minor role This concerted neuroendocrine response results in lipolysis, hepatic gluconeogenesis,

protein breakdown, pyrexia and hypermetabolism Cytokines, interleukins (IL-1, IL-6) and tumour

necrosis factor-alpha (TNF␣) are simultaneously released (see Fig 1.2)

Catecholamine-mediated

‘fight or flight’ response

HypothalamusAdrenal medulla

Adrenaline Noradrenaline

from peripheralnerves

Cortisol-releasinghormone (CRH)

Anterior pituitaryAdrenocorticotrophic hormone

Cortisol and glucocorticoids

Cytokines

Inflammatoryresponse

Neurohormonalresponse

Stress response to injury

A model of two phases, ‘ebb and flow’, is created The term was coined by Sir David Cuthbertson in 1930 The ebb, or early, phase helps initiate a ‘holding pattern’ within the first

12 hours (clinically manifesting as shock) The flow phase lasts much longer depending upon

the extent of damage It can be divided into a catabolic phase lasting several days, followed by

a recovery and repair phase lasting several weeks The time factor depends upon the extent of

initial injury and any ongoing insults The mediators do help in the repair process by endogenous

cytokine antagonists, which controls the proinflammatory response, commonly called the systemic

inflammatory response syndrome (SIRS) If the response to SIRS is inadequate, multiple organ

dysfunction syndrome occurs (MODS), which is just a step away from death

Catabolism is an important aspect of recovery However, the body’s stress response has

a capacity to triage the catabolic effect The catabolic effect concentrates away from the

peripheries, such as muscle fat and skin, to the more important parts – the liver, the

immune system and the wound During catabolism, muscle wasting occurs from muscle

protein breakdown and a decrease in muscle protein synthesis The major site for such a

change is peripheral skeletal muscle; sometimes respiratory muscles are affected, resulting in

hypoventilation with resultant pulmonary problems; gut muscle may be affected to produce

paralytic ileus Therefore, clinically, patients are weak with malaise and function suboptimally

with increased risk of hospital-acquired infections

Hyperalimentation is not advisable as it enhances the metabolic stress Nutritional support

should therefore be at a modest level Hyperglycaemia is a normal response to stress This is due

to increased glucose production and decreased uptake in peripheral tissues as a result of insulin

resistance, a temporary effect of stress The severity of the stress determines the duration of the

hyperglycaemic state – stress-induced diabetes The patient is therefore at increased risk of diabetic

complications: sepsis, renal impairment and polyneuropathy Intravenous insulin infusion in the

ICU setting using a sliding scale has been shown to reduce morbidity and mortality

➜ Optimal perioperative care

5 B, C, D, E

As a result of hypovolaemia, receptors in the carotid artery, aortic arch and left atrium act to

release aldosterone and antidiuretic hormone (ADH) Aldosterone is also released by the renin–

angiotensin system activated by the juxtaglomerular apparatus (see Fig 1.3) Aldosterone and ADH

help in sodium and water retention Therefore large volumes of fluid infusion should not be used,

as it will result in oedema, peripheral and visceral, the latter causing delayed gastric emptying

Fluid and electrolyte conservation Hypovolaemia from haemorrhage

(’The three-line whip’)

Atrial natriuretic peptide (ANP) ↓

Renin-angiotensin system

Aldosterone ↑

Conservation of sodium and water at renal tubule

Hypothermia, due to increased production of adrenal steroids and catecholamines, causes

greater risk of cardiac arrythmias Therefore all efforts must be made to conserve heat in the

stressed patient

As a result of starvation, the body needs to produce glucose to sustain cerebral function This

is done by mobilising glycogen stores by hepatic gluconeogenesis Fat is mobilised from adipose

tissue followed by loss of lean tissue At least 2 L of 5 per cent dextrose intravenously provides

100 g of glucose a day; this has a protein-sparing effect Early institution of nutrition by the most

appropriate route will avoid loss of body mass

Immobility should be avoided as it induces muscle wasting Inactivity of skeletal muscle impairs protein synthesis Early mobilisation therefore helps in preventing muscle wasting besides

minimising the dreaded complications of deep vein thrombosis and pulmonary embolism

Perioperative care can be optimised by attention to feeding and preventing fluid overload

Epidural analgesia not only reduces stress from pain but also reduces the insulin resistance, by

blocking the cortisol stress response Beta-blockers and statins have a role in improving long-term

survival after recovery from a major stress response

Multiple choice questions

➜ Cell metabolism

1 Which of the following statements are

true?

A Cells change from aerobic to anaerobic

metabolism when perfusion to tissues is

D The accumulation of lactic acid in the

blood produces systemic respiratory

acidosis

E Lack of oxygen and glucose in the cell

will eventually lead to failure of sodium/

potassium pumps in the cell membrane

and intracellular organelles

➜ Hypovolaemic shock

2 Which of the following statements

regarding hypovolaemic shock are

true?

A It is associated with high cardiac output

B The vascular resistance is high

C The venous pressure is low

D The mixed venous saturation is high

E The base deficit is low

➜ Ischaemia-reperfusion

syndrome

3 Which of the following statements

about ischaemia-reperfusion syndrome

is correct?

A This refers to the cellular injury because

of the direct effects of tissue hypoxia

B It is seen after the normal circulation

is restored to the tissues following an

C Patients with implanted pacemakers

D Fit young adults with normal pulse rate

C Hypotension is one of the first signs of shock

D Beta-blockers may prevent a tachycardic response

E Blood pressure is increased by reduction

in stroke volume and peripheral vasoconstriction

B Tachycardia and cool peripheries may be the only clinical signs

C The perfusion to the skin, muscle and GI tract is increased

2: SHOC

D Systemic respiratory acidosis is seen

E Patients with occult hypoperfusion for

more than 12 hours have a significantly higher mortality rate

➜ Resuscitation in shock

7 Which of the following statements are

false?

A Administration of inotropic agents to an

empty heart will help to increase diastolic filling and coronary perfusion

B In all cases, regardless of classification,

hypovolaemia and preload must be addressed first

C Long, wide-bore catheters allow rapid

infusion of fluids

D The oxygen-carrying capacity of both

colloids and crystalloids is zero

E Hypotonic solutions are poor volume

expanders and should not be used in shock except in conditions of free water loss or sodium overload

➜ Inotropic support in shock

8 Which of the following are true

regarding inotropic support in shock?

A This is the first-line therapy in

hypovolaemic shock

B Phenylephrine and noradrenaline are

indicated in distributive shock states

C Dobutamine is the agent of choice

in cardiogenic shock or septic shock complicated by low cardiac output

D Vasopressin may be used when

the vasodilatation is resistant to catecholamines

E Use in the absence of adequate preload

may be harmful

➜ Mixed venous saturation

9 Which of these statements about

mixed venous saturation are false?

A The percentage saturation of oxygen

returning to the heart from the body is

a measure of the oxygen delivery and extraction by the tissues

B The normal mixed oxygen saturation

levels are 30–40 per cent

C Accurate measurements are via analysis

of blood drawn from a line placed in the superior vena cava (SVC)

D Levels below 50 per cent indicate inadequate oxygen delivery consistent with hypovolaemic shock

E High mixed venous saturation levels are seen in sepsis

C It is associated with infection

D It can be significant, requiring re-exploration

E It is usually venous

➜ Blood transfusion

11 Which of the following about blood transfusion are false?

A A haemoglobin level of 10 g/dL or less

is now considered a typical indication

B Fresh frozen plasma (FFP) is considered

as the first-line therapy in coagulopathic haemorrhage

C Cryoprecipitate is useful in fibrinogen states and in factor VIII deficiency

low-D Platelets have a shelf life of 3 weeks

E Patients can pre-donate blood up to

3 weeks before surgery for autologous transfusion

12 Which of the following is a complication of massive blood transfusions?

G Hypovolaemic shock – non-haemorrhagic

Choose and match the correct diagnosis with each of the scenarios given below:

1 A 7-year-old boy with nut allergy develops stridor and collapses after eating a snack He

requires airway and breathing support His BP is 60/38 mmHg

2 A 78-year-old man with known ischaemic heart disease (IHD) complains of chest pain and

collapses His pulse is irregular and BP is 74/48 mmHg ECG shows features of an anterolateral

myocardial infarction (MI)

3 A 76-year-old male is brought to the hospital with persistent diarrhoea and vomiting for the

past 4 days He has been unable to keep his food down and feels very tired On examination

he is very dehydrated His pulse is 128/min and his BP is 88/52 mmHg

4 A 55-year-old woman with poorly controlled hypothyroidism is found comatose She is

hypothermic Her pulse is irregular and her BP is 96/70 mmHg

5 An 86-year-old male has been complaining of increasing lower abdominal pain for the past

week On examination he looks very unwell with warm peripheries He has signs of generalised

peritonitis His pulse is 130/min and his BP 84/50 mmHg

6 A 28-year-old motorist is brought to the A&E after a road traffic accident (RTA) He has

sustained an isolated injury to his back and has motor and sensory deficits in both lower limbs

His pulse is 122/min and his BP 100/62 mmHg

7 A 19-year-old male is brought to the hospital after sustaining an abdominal injury while playing

rugby He is complaining of left upper abdominal pain and has some bruising over the same

area His pulse is 140/min and his BP is 100/82 mmHg

➜ 2 Vasopressor and inotropic support in shock

Choose and match the correct intervention with each of the scenarios given below:

1 Cardiogenic shock when myocardial depression complicates shock state

2 Distributive shock due to sepsis

3 Vasodilatation resistant to catecholamines due to relative or absolute steroid deficiency

4 Hypovolaemic shock due to splenic injury

5 Distributive shock due to spinal cord injury

2: SHOC

➜ 3 Complications of blood transfusion

A Haemolytic transfusion reaction due to incompatibility

B Fluid overload

C Disseminated intravascular coagulation (DIC)

D Hypocalcaemia

E Infection

Choose and match the correct diagnosis with each of the scenarios given below:

1 A 86-year-old woman is admitted with a haemoglobin (Hb) of 5.6 g/dL The HO prescribes

4 units of blood These 4 units are transfused over a period of 6 h Four hours later the patient

is found to be having difficulty in breathing Chest examination reveals fine creps bilaterally

Chest X-ray confirms pulmonary oedema

2 A 28-year-old male is taken to a nearby hospital after sustaining injuries while on a safari in

Africa He has lost a lot of blood and is hence given 2 units of blood transfusion He develops fever and chills with rigors the next day Peripheral blood smear demonstrates malarial parasite

3 A 38-year-old man requires several units of blood transfusion due to multiple injuries sustained

as a result of a fall He develops tetany and complains of cicumoral tingling

4 A 34-year-old motorcyclist sustains multiple injuries after an RTA He is brought to the hospital

in severe shock and requires multiple blood transfusions It is observed that the bleeding is still uncontrolled and the blood fails to clot

5 The ward is very busy and quite a few staff have phoned in sick There are two patients (with

the same surnames) needing blood transfusions The staff nurse points to the blood units

on the table and asks the HCA to start them as she is just going off for her break The blood transfusion is started Within a few minutes the patient is unwell and his urine is haemorrhagic

He collapses and becomes anuric He is also found to be jaundiced

Answers: Multiple choice questions

➜ Cell metabolism

1 A, E

Cells switch from aerobic to anaerobic metabolism when deprived of oxygen The product of

aerobic respiration is carbon dioxide This is eliminated efficiently through the lungs The product

of anaerobic respiration is lactic acid When enough tissue is underperfused, the accumulation

of lactic acid in the blood produces systemic metabolic acidosis As tissue ischaemia progresses,

the immune and complement systems are activated This also results in the complement and

neutrophil priming with the generation of oxygen-free radicals and cytokines This leads to

injury of the epithelial and endothelial cells, which leads to loss of integrity and ‘leaky’ walls

The resultant oedema further increases tissue hypoxia As glucose within the cells is exhausted,

anaerobic respiration ceases and there is a failure of the sodium/potassium pump Intracellular

lysosomes release autodigestive enzymes and cell lysis ensues Intracellular contents, including the

potassium, are released into the bloodstream

➜ Hypovolaemic shock

2 B, C (see Table 2.1)

During the period of reperfusion, cellular and organ damage progresses as a result of direct

effects of tissue hypoxia and local activation of inflammation Further injury occurs once the

normal circulation is restored This is termed ischaemia-reperfusion syndrome The acid and

potassium load that has built up can lead to direct myocardial depression, vascular dilatation and

further hypotension The cellular and humoral components flushed back into circulation cause

further endothelial injury and organ damage This can lead to multiple organ failure (MOF) and

death Ischaemia-reperfusion injury can be reduced by limiting the extent and duration of tissue

Hypotension may not be seen until the shock is well established The heart compensates initially

to maintain cardiac output by increasing both the rate and the stroke volume

➜ Compensated shock

6 C, D

Systemic metabolic acidosis is seen in shock (also see Table 2.2)

Table 2.1 Response in different types of shock

Type of shock Parameter Hypovolaemia Cardiogenic Obstructive Distributive

Table 2.2 Responses in different degrees of shock

Degree of shock

Level of consciousness Normal Mild anxiety Drowsy Comatose

Respiratory rate Normal Increased Increased Laboured

Pulse rate Mild increase Increased Increased Increased

Blood pressure Normal Normal Mild hypotension Severe hypotension

➜ Resuscitation in shock

7 A, C

Resuscitation should not be delayed in order to definitively diagnose the cause of the shocked

state The first-line therapy is intravenous (IV) access administration of IV fluids using short,

wide-bore catheters that allow rapid infusion of fluids Hypotonic fluids are poor volume

2: SHOC

expanders and should not be used in the treatment of shock (an exception is free water loss, as

in diabetes insipidus and sodium overload, e.g cirrhosis) If there is an initial doubt about the

cause of shock, it is safer to assume that it is hypovolaemia and begin with fluid resuscitation,

followed by an assessment of the response In patients who are actively bleeding (major trauma,

ruptured abdominal aortic aneurysm, GI bleed), it is counterproductive to institute high-volume

fluid therapy without controlling the site of bleeding Resuscitation should proceed in parallel

with surgery Conversely, a patient with bowel obstruction and hypovolaemic shock should be

adequately resuscitated before undergoing surgery Administration of inotropic agents to an empty

heart will rapidly and permanently deplete the myocardium of oxygen stores and dramatically

reduce diastolic filling and therefore coronary perfusion

➜ Inotropic support in shock

8 B, C, D, E

The first-line therapy in hypovolaemic shock is IV access and administration of fluids

Phenylephrine and noradrenaline are helpful in distributive shock states, such as those due to

sepsis and neurogenic causes These states are characterised by peripheral vasodilatation, a low

systemic vascular resistance and a high cardiac output If the vasodilatation is resistant to these

agents (e.g absolute or relative steroid deficiency), vasopressin may be used

➜ Mixed venous saturation

9 B, C

The percentage saturation of oxygen returning to the heart from the body is a measure of the

oxygen delivery and extraction by the tissues Accurate measurement is by a long line placed in

the right atrium Samples from the SVC give slightly higher values Normal mixed venous oxygen

saturation levels are 50–70 per cent Levels below 50 per cent indicate inadequate oxygen delivery

and increased oxygen extraction by the cells This is consistent with hypovolaemic or cardiogenic

shock High mixed venous saturation levels (>70 per cent) are seen in sepsis and some forms of

The transfusion trigger was historically 10 g /dL It is now believed, however, that a level of 6 g /dL

is acceptable in patients who are not bleeding, not symptomatic and not about to undergo major

surgery Levels between 6 and 8 g /dL are selectively transfused Also see Table 2.3

12 A, C, D, E

Hypocalcaemia is another complication of massive transfusion People who receive repeated

transfusions over long periods of time develop iron overload

Complications from a single transfusion include incompatibility haemolytic transfusion reaction, febrile transfusion reaction, allergic reaction, infection, air embolism, thrombophlebitis and

transfusion-related acute lung injury (usually from FFP)

➜ 2 Vasopressor and inotropic support in shock

1D, 2A (or 5), 3E, 4B, 5C (or 2)

➜ 3 Complications of blood transfusion

1B

Extreme caution should be exercised in prescribing transfusions/fluids to elderly patients Packed

cells are preferable to whole blood and the patient must be closely monitored for signs of fluid

overload Administration of frusemide following transfusion of units may be needed

2E

The other infections that can be transmitted through blood transfusion are hepatitis B and C,

bacterial infections, HIV and new-variant Creutzfeldt–Jakob Disease (CJD)

3D

Hypocalcaemia is a known complication after massive transfusions

4C

Coagulopathy is a known complication after massive multiple transfusions This should be

aggressively treated and, better still, avoided The standard guidelines are:

• FFP, if prothrombin time (PT) and partial thromboplastin time (PTT) > 1.5 times normal values

• cryoprecipitate, if fibrinogen < 0.8 g/L

• platelets, if platelet count < 50 × 109/L

Table 2.3 Components used in blood transfusions

Parameter Component Constituents Indications Storage Shelf life

Packed red cells Red blood cells spun

down and concentrated

Chronic anaemia SAG-M solution

2–6ºC

5 weeks Fresh frozen

plasma (FFP)

Coagulation factors Coagulopathic

haemorrhage

–40 to –50ºC 2 years Cryoprecipitate Supernatant precipitate

of FFP – rich in factor VIII and fi brinogen

Low fi brinogen states, factor VIII defi ciency

–30ºC 2 years

Platelets Platelet concentrates Thrombocytopenia,

platelet dysfunction

20–24ºC (special agitator)

of factors II, IX, X;

factor VII is also included/separate

Emergency reversal of anticoagulant (Warfarin)

in uncontrolled haemorrhage

This is completely avoidable and hence should never happen While prescribing and administering

blood, it is essential that the correct patient receives the correct transfusion Care should be taken

to ensure correct labelling of samples Two individuals should check the patient’s details against the

prescription and the label of the donor blood Additionally the donor blood serial number should be

checked against the issue slip for that patient

Multiple choice questions

2 Which of the following statements

about the process of wound healing

are true?

A The inflammatory phase begins 2–3 days

after the injury

B The proliferative phase lasts from 3 days

to 3 weeks following the injury

C The remodelling phase involves fibroblast

activity and production of collagen and

ground substance

D Fibroblasts require vitamin C to produce

collagen

E The white cells stick to the damaged

endothelium and release adenosine

diphosphate (ADP) and cytokines

3 Which of the following statements are

true?

A Healing by primary intention results in

minimum inflammation and the best

scar

B Granulation, contraction and

epithelialisation are seen in healing by

secondary intention

C Tertiary intention involves immediate

closure of the wound

D A crushed and contaminated wound

is best suited for healing by primary

intention

E Primary repair of all structures should be

attempted in an untidy wound

➜ Management of wounds

4 Which of the following statements regarding management of the acute wound are correct?

A A bleeding wound should be elevated and a pressure pad applied

B Clamps may sometimes need to be put

on bleeding vessels blindly

C Anaesthesia is usually not required in the assessment of wounds

D A thorough debridement is essential

E Repair of all damaged structures may be attempted in a tidy wound

5 Which of the following statements regarding the management of specific wounds are true?

A A haematomata should never require release

B Anaerobic and aerobic organism prophylaxis is needed in bite wounds

C Puncture wounds should always be explored

D Degloving injuries will require serial excision until viable tissue is confirmed

E Compartment syndrome typically occurs

in a closed lower limb injury

B Pressure sores occur in approximately

5 per cent of all hospitalised patients

C Surgical treatment is usually required in the treatment of leg ulcers

D Bed-bound patients should be turned every 4 h to prevent pressure sores

and scars

E Risk of tissue necrosis increases if the

external pressure exceeds the capillary occlusive pressure (30 mmHg)

➜ Pressure sores

7 Pressure sores can occur over which of

the following areas?

8 Which of the following statements

about necrotising soft-tissue infections are true?

A They are usually polymicrobial infections

B The onset is usually gradual and they run

a chronic course

C ‘Dishwater pus’ is a characteristic feature

D Clostridial species cause toxic shock

A Scars continue maturing for 3 months

B Keloids contain an excess of type B collagen

C Suture marks can be reduced by using polyfilament sutures

D The tensile strength of the scar never reaches that of the normal skin

E A hypertrophied scar extends beyond the boundaries of the previous incision

➜ Keloids

10 Which of the following are useful in the treatment of keloids?

A Elasticated garments

B Silicone gel sheeting

C Excision and steroid injection

D Excision and radiotherapy

Choose and match the correct diagnosis with each of the scenarios given below:

1 This occurs when the skin and subcutaneous fat are stripped from the underlying fascia by

avulsion, leaving the neurovascular structures, tendon or bone exposed

2 This is caused by crush or avulsion forces and usually has variable amount of tissue loss It is

invariably contaminated and has devitalised tissues

3 These are wounds caused by sharp objects such as needles X-ray may be needed to rule out a

retained foreign body

4 These wounds are defined as tissue necrosis with ulceration due to prolonged pressure They

should be regarded as preventable

5 These typically occur in closed lower limb injuries and are characterised by severe pain, pain on

passive movement, distal sensory disturbance and, finally, absent pulses

6 These are clean wounds and usually incised The tissues are healthy with seldom tissue loss

Choose and match the correct diagnosis with each of the scenarios below:

1 Multiple debridements followed by definitive closure/repair

2 Multiple Z-plasties or use of skin grafts/flaps

3 Primary repair of all structures – bone, tendon, vessel and nerve

4 Intralesional steroid injection and intralesional excision

5 Fasciotomy

6 Debridement and vacuum-assisted closure (VAC)

7 Surgical excision with tissue biopsies sent for culture Skin graft may be needed later on

8 Examination under anaesthesia (EUA) with radical excision of all non-bleeding skin Serial

excision is usually done until punctuate dermal bleeding is seen This is followed by split

skin graft

➜ 3 Phases of wound healing

A Early inflammatory phase

B Late inflammatory phase

C Proliferative phase

D Remodelling phase

E Mature scar

Choose and match the correct diagnosis with each of the scenarios below:

1 This phase is characterised by replacement of type 3 collagen by type 1 until a ratio of 4:1 is

achieved Realignment of collagen fibres along the lines of tension, decreased vascularity and

wound contraction are also seen in this phase

2 Platelet-enriched blood clot and dilated vessels are a feature of this phase

3 The contraction of the scar is now complete The vascularity has reduced and growth ceases

4 This phase has increased vascularity with plenty of neutrophils and lymphocytes

5 This phase consists mainly of fibroblast activity and collagen production The collagen produced

during this phase is type 3

Wound healing is also influenced by other factors, including structures involved, mechanism of

wounding (incision, crush or crush avulsion), contamination, loss of tissue, previous radiation,

pressure, vitamin and mineral deficiencies, medications (steroids, chemotherapy), HIV and any

other cause of immunodeficiency

2 B, D

The inflammatory phase begins immediately after the wounding and lasts 2–3 days Platelets

stick to the damaged endothelial lining of the vessels and release ADP and cytokines such as

platelet-derived growth factor (PDGF), platelet factor 4 and transforming growth factor (TGF)-beta

These attract inflammatory cells such as polymorphonuclear lymphocytes and macrophages

The proliferative phase lasts from the third day to the third week, consisting mainly of fibroblast activity with the production of collagen and ground substance, the growth of new

blood vessels as capillary loops and re-epithelialisation of the wound surface The remodelling

phase is characterised by maturation of collagen, with type 1 replacing type 3 until a ratio of

4:1 is achieved There is realignment of collagen fibres along the line of tension, decreased wound

vascularity and wound contraction due to fibroblast and myofibroblast activity

3 A, B

Tertiary intention is also called delayed primary intention and in this the wound is initially left open

and the edges later opposed when healing conditions are favourable A crushed and contaminated

wound is best managed by debridement on one or several occasions before definitive repair can

be carried out Primary repair of all structures should be attempted in a tidy wound

➜ Management of wounds

4 A, D, E

The surgeon should remember to examine the whole patient according to the Advanced Trauma

Life Support (ATLS) guidelines The wound itself should be examined, taking into consideration the

site and possible structures damaged Clamps should not be applied blindly as nerve damage is

likely and vascular anastomosis is rendered impossible In order to facilitate examination, adequate

analgesia and/or anaesthesia (local, regional or general) are required General anaesthesia is

preferred in children In limb injuries, particularly those of the hand, a tourniquet should be used

An ulcer is defined as a break in the epithelial continuity A prolonged inflammatory phase leads

to an overgrowth of granulation tissue, and attempts to heal by scarring leaves a fibrotic margin

Necrotic tissue, often at the ulcer centre, is called slough Most ulcers are managed by dressings

and simple treatments An ulcer not responsive to this treatment should be biopsied to rule out

malignant change (Marjolin’s ulcer) Effective treatment of any ulcer depends on treating the cause,

and diagnosis is hence vital Surgical treatment is only indicated if non-operative methods have

failed and the patient has intractable pain Meshed skin grafts are more successful than sheet grafts

➜ Pressure sores

7 A, B, C, D, E

A pressure sore is defined as tissue necrosis with ulceration due to prolonged pressure They occur

in about 5 per cent of all hospitalised patients and the incidence is higher in paraplegic patents, in

the elderly and the severely ill patients The stages of pressure sore are as follows:

• stage 1: non-blanchable erythema without a breach in the epidermis

• stage 2: partial-thickness skin loss involving the epidermis and dermis

• stage 3: full-thickness skin loss extending into the subcutaneous tissue but not through

underlying fascia

• stage 4: full-thickness skin loss through fascia with extensive tissue destruction, possibly

involving muscle, tendon, bone or joint

If external pressure exceeds the capillary occlusion pressure (over 30 mmHg), blood flow to

the skin ceases, causing tissue anoxia, necrosis and ulceration Prevention is the best treatment

with good skin care, special pressure, dispersion cushions or foams, the use of low loss and

air-fluidised beds and urinary/faecal diversion in appropriate cases The bed-bound patient should be

turned every 2 h, with the wheelchair-bound patient being taught to lift themselves off their seat

for 10 s every 10 min

Care of pressure sores follows the principles of acute wound management Debridement, use

of VAC and skin flaps may be helpful in achieving healing

➜ Necrotising soft-tissue infections

8 A, C

These are rare but often fatal infections that are usually seen after trauma or surgery with wound

contamination They are polymicrobial infections involving Gram-positive aerobes (S aureus,

S pyogenes), Gram-negative aerobes (E coli, P aeruginosa), Clostridia, Bacteroides and

beta-haemolytic Streptococcus The infections are characterised by sudden presentation and rapid

progression There are two main types of necrotising infections – clostridial and non-clostridial

(streptococcal gangrene and necrotising fasciitis) Streptococcus pyogenes causes toxic shock

syndrome and is often called ‘flesh-eating bug’ Treatment is surgical excision with tissue being

sent for culture Wide raw areas are often left behind which may require skin graft

➜ Scars

9 B, D

The maturation phase of healing results in scarring The mature scar becomes mature over a

period of a year or more At first, it is pink, hard, raised and itchy As the scar matures, it becomes

almost acellular as the fibroblasts and blood vessels reduce The scar then becomes paler, flat and

soft Most of the changes take place over the first 3 months but a scar will continue to mature for

1–2 years The strength gradually increases but will never reach that of normal skin Suture marks

can be reduced by using monofilament sutures A hypertrophic scar is defined as excessive scar

tissue that does not extend beyond the boundary of the original incision or wound It results from

a prolonged inflammatory phase of wound healing and from unfavourable siting of the scar

➜ Keloids

10 A, B, C, D

A keloid is defined as excessive scar tissue that extends beyond the boundaries of the original

incision or wound Its aetiology is unknown but it is associated with elevated levels of growth

factor, deeply pigmented skin, an inherited tendency and certain areas of the body (a triangle

whose points are the xiphisternum and each shoulder tip) Histology shows excess collagen with

hypervascularity and increased B type of collagen

Answers: Extended matching questions

Multiple choice questions

➜ Koch’s postulates

1 Which of the following are part of

Koch’s postulates?

A It must be found in considerable

numbers in the septic focus

B A reduction in the organisms should be

achieved by using appropriate antibiotics

C It should be possible to culture it in a

pure form from the septic focus

D Healing of a wound is possible without

pus formation

E It should be able to produce similar

lesions when injected into another host

➜ Natural barriers to infection

2 Which of the following is a natural

➜ Host resistance to infection

3 Which of the following is a cause

of reduced host resistance to

4 Which of the following is a risk factor

for wound infection?

A Poor perfusion

B Use of skin clips for wound closure

C Poor surgical technique

D Not using prophylactic antibiotics

E Inadequate air filtration in the theatre

➜ Surgical site infections

6 Which of the following statements about surgical site infections (SSIs) are true?

A Infection in the musculofascial tissues is known as deep SSI

B The patient may have systemic signs in a minor SSI

C Infection causing delay in hospital discharge is a major SSI

D The differentiation between major and minor SSIs is not important

E Surveillance for surgical site infection should be done for a year after implanted joint surgery

➜ Abscesses

7 Which of the following statements regarding abscesses are true?

A Staphylococcus aureus is one of the

most common causative organisms

B The abscess wall is composed of epithelium

C Most wound-site abscesses occur before the patient is discharged from the hospital

D Antibiotics are indicated if there is evidence of cellulitis

E Actinomyces can cause a chronic abscess.

8 Which of the following statements

regarding cellulitis are true?

A This is non-suppurative invasive

infection of tissues

B It is poorly localised

C It is commonly caused by Clostridium

perfringens.

D Systemic signs are not present

E Blood culture is usually positive

➜ Systemic inflammatory

response syndrome (SIRS)

9 Which if the following can be seen in

10 Which of the following statements

about severe sepsis (sepsis syndrome) are true?

A Acute respiratory distress syndrome

(ARDS) is common

B There is absence of documented

infection

C Multiple organ dysfunction syndrome

(MODS) is the systemic effect of infection

D Multiple system organ failure (MSOF)

is the end stage of uncontrolled MODS

E MSOF is mediated by released

cytokines such as interleukins (IL-6) and tumour necrosis factor (TNF)-alpha

➜ Clostridial wound

infections

11 Which of the following statements

regarding clostridial wound infections are true?

A Clostridia are Gram-positive aerobic

spore-bearing cocci

B Thin, brown and sweet-smelling exudate

is seen in gas gangrene

C Necrotic and foreign material in wounds increase risk

D The spores are widely spread in soil and manure

E The signs and symptoms are due to the endotoxins

B Wounds are best managed by delayed primary or secondary closure

C Subcuticular continuous skin closure decreases the incidence of wound infection

D Polymeric films can be useful in infected wounds

E Administration of antibiotic preparations locally is more effective than the oral route

E Local resistance strains

14 Which of the following may require more than one dose of prophylactic antibiotic?

➜ Surgical wound infection

15 Which of the following measures is useful in reducing surgical wound infection?

A Antiseptic skin preparation

B Shaving of area