iBSc: Question 3

By Alan McLeod

Getting the best marks

Read the whole question – a latter section may give you a

clue about an earlier one.

To see how many points you need look at the marks

allocated – for example a 3 point question is generally looking for 3 salient points

If giving a list answer put the best answers first – examiners will not usually mark answers too

far down a list

Always write something – it may get you part of a mark and is anonymised so

no one will think you are stupid!

If you genuinely have no clue then re-write the question to see if this sparks

some ideas.

If not then move on and come back at the end. And remember – always

write something.

Good luck!

Question 3

Mr El-Hawrini, a 29 year old lawyer has been involved in a

motorcycle accident during which he lost

consciousness

• Q3.1• Describe the most

vital checks you would make when he arrives into A+E (5)

Question 3

A Diagnosis of extradural

haemorrhage is made.

Q3.2• What blood vessel is

responsible for this bleed. (1)

Q3.3• List three symptoms from

a typical history that might lead to this diagnosis (3)

Q3.4 Label the arrowed structures (8)

Skull

Potential space

Subarachnoid space Skull

Question 3

In addition to his head injury, Mr El-

Hawrini has sustained the

fracture pictured

Q3.5

What is this fracture (2)

Question 3

Bones are capable of self-healing under

the right circumstances.

Q3.6• Describe the typical

pattern of long-bone healing (4)

Q3.7• Describe four factors that

might interfere with this healing (4)

Question 3

Sadly, Mr El-Hawrini dies. You are given

the job of delivering the news

to his wife – you use the SPIKES

protocol.

• Q3.8• Describe the SPIKES

protocol (6)

Factors influencing Healing

Local• Tissue damage• Tissue loss• Infection• Foreign body

Systemic• Patient age• Nutritional status• Smoking / alcohol• Steroids• Systemic illnesses such as

diabetes, renal, lung, cardiac.

The Answers

View these on ‘note view’ rather than on full screen – additional

notes are provided for some slides

Emergency ManagementD Danger? Check that the scene is safe

R Run Check for response

H Happily Call for HELP!

A Away andCheck and secure airway and C-spine

B Buy Check breathing, Resp rate

C Chocolate! Pulse, Heart rate

Emergency Management

D ‘Disability’Neuro exam: minimum is pupil size / response + GCS or AVPU

E ‘Exposure’1: Expose to seek injuries

2: Keep warm + take temperature

DEFG Don’t Ever Forget Glucose!!!

Extradural Subdural SubarachnoidBetween skull and

periosteal duraBetween periosteal and

meningeal duraInto subarachnoid

space

Middle meningeal a. Cerebral vein Cerebral artery

Major trauma Trivial trauma in elderly Berry aneurysm

Loss of consciousness for a short time

Lucid period lasting hours – days (as

pressure builds up within the skull)

Drowsiness, coma, death if no intervention

Diagnosed by CT or MRI.

Days – months pass (as pressure builds up slowly

within the skull)

Headache, drowsiness and confusionPossible hemiparesis / sensory

loss

Coma, death if no intervention (or may resolve on their own)

Diagnosed by CT or MRI.

Sudden onset intense headache with stiff neck (as aneurysm bursts).

Possible papilloedema and retinal haemorrhage

Usually vomiting, possible loss of

consciousness for hours days

Diagnosed by CT or MRI.

Head Trauma

SkullPeriosteal Dura mataMeningeal Dura mataPotential spaceArachnoid mataSubarachnoid spacePia mata

Middle Meningeal A.Cerebral Artery

Cerebral Vein

Extradural Haemorrhage

SkullPeriosteal Dura mataMeningeal Dura mataPotential spaceArachnoid mataSubarachnoid spacePia mata

Middle Meningeal A.Cerebral Artery

Cerebral Vein

Subdural Haemorrhage

SkullPeriosteal Dura mataMeningeal Dura mataPotential spaceArachnoid mataSubarachnoid spacePia mata

Middle Meningeal A.Cerebral Artery

Cerebral Vein

Subarachnoid Haemorrhage

SkullPeriosteal Dura mataMeningeal Dura mataPotential spaceArachnoid mataSubarachnoid spacePia mata

Middle Meningeal A.Cerebral Artery

Cerebral Vein

Monteggia and Galleazzi

Medics Monteggia (a)

Under Ulnar shaft

Pressure Proximal Radio-ulnar Joint

Get Galleazzi (b)

Really Radial Shaft

Drunk Distal RUJ

Fracture-dislocations

Bone Healing

Mins – 3 days

• Haematoma and Necrotic tissue

2 days – 2 weeks

• Phagocytosis

• Provisional callus

3 weeks on

• Firm callus

• Mineralisation

Weeks - months

• Remodeling

SPIKES – Bad News…

S SETTING UP: Having info ready; involving family as appropriate; location and privacy; time constraints, sit down; connect.

P Perception: What does the patient already know of believe?

I Invitation: find out what sort of invitation the patient is extending – do they want to know everything or do they wish to be told less

K Knowledge: as Invited in simple language

E Emotion and Empathy: Assessing the patients emotions and dealing with them empathically

S Summary and Strategy: Going back though it all again, identifying points that need futher expalnation and formulating a plan.

The End

The slides here should allow you to mark your own work – remember 1 mark per

answer up to the maximum for the question. Multiply by 3 to get percentage points. I assume a 60% pass mark. Sorry but I am unable to give further advice on

answers due to time constraints.