TERMS AND CONDITIONS OF SALE
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The purchaser acknowledges that all sales conducted by the auctioneer are on the basis of being &#; GST &#; exclusive, and as such a GST amount of 10% (or whatever prescribed amount is in force by legislation) will be added to the bid price. Further, the purchaser acknowledges and agrees that in the absence of advice to the contrary, that all bids by the purchaser will be deemed to be exclusive of GST and that GST will be added to the bid price of all lots.
The purchaser acknowledges that at all sales conducted by the auctioneer, a buyer&#;s premium will be charged on the bid price.
As soon as practicable after the fall of the hammer the Purchaser shall sign the agreement (if any) for sale.
The Purchaser shall be deemed to purchase as principal unless prior to the sale &#;
The purchaser shall have disclosed to the Auctioneer that he will be bidding on behalf of a principal and shall supply the full name and address of his principal; and
The purchaser has given to the auctioneer a copy of a written authority to bid for, or on behalf of, another person.
The Auctioneer and Vendor reserve the following rights which may be exercised by the Auctioneer without giving any reason therefore &#;
to withdraw any lots from the sale;
not to offer for sale part only of any lot described in the catalogue;
to offer two (2) or more of the lots described in the catalogue as separate lots for sale together, as one (1) lot;
should such lots referred to in c) of these Terms and Conditions not be knocked down at the online auction to a successful bidder, to offer such lots as separate lots;
to refuse to accept a bid or bids from any person or persons which in the opinion of the Auctioneer is not in the best interest of the Vendor;
to refuse admission to/or eject from the selling place any person or persons;
to refuse to accept any bid for a lot being less than a sum nominated from time to time by the Auctioneer;
to keep secret the existence and amount of the reserve price (if any) of a lot prior to the close of bidding or withdrawal from sale of the lot;
if the Purchaser shall successfully bid for more than one lot at the auction;
to appropriate any moneys received from that Purchaser in satisfaction or partial satisfaction of the purchase price (and any taxes, if applicable) due in respect of any one or more of such lots to the total or partial exclusion of amounts due in respect of any other such lot, or lots, as the Auctioneer shall see fit;
to elect at any time to treat each contract for the sale of each such lot as interdependent with each other such contract or contracts and default under any such contract shall be treated as default under all such contracts;
to bid on behalf of any vendor, prospective Purchaser or Purchaser&#;s with or without disclosure; and
if any lot is not sold at the auction to offer to sell same thereafter by private treaty but otherwise subject to these conditions.
The Vendor or any person on his behalf reserves the right to bid at the auction in respect to any lot. The Vendor acknowledges that for any successful bids he/she shall still be liable for the payment of any relevant commissions.
Any bidder shall give his full name and residential address at the time of registering to bid and when called upon to do so by the Auctioneer and &#;
Prior to the end of the auction or at any time thereafter specified by the Auctioneer the Purchaser shall pay to the Auctioneer the full price for the lot, plus any GST, license fee or any other government charge applicable to the goods.
The Auctioneer at his discretion may require immediate payment or part payment for a lot.
The purchase price and, where applicable, any part payment thereof, and GST shall be paid in either cash, bank cheque, credit card or bank transfer
Any balance of the purchase price for a lot shall be paid to the Auctioneer no later than the expiration of the period during which the Purchaser is required by the conditions to take delivery of the lot and he shall not be entitled to require delivery until the purchase price and, where applicable, GST, license fee or government charge shall have been paid in full; and
Time shall be of the essence in relation to the interpretation and observance of these conditions.
On the fall of the hammer, the Auctioneer may require, and the Purchaser shall pay a deposit in cash of twenty five percent (25%) in part payment of the purchase price for the lots purchased by the Purchaser. In default, the lot or lots so purchased may at the absolute discretion of the Auctioneer be immediately re-offered for sale and re-sold.
No error in description or deficiency in quantity shall void the sale and the Purchaser shall be bound to take the delivery of the lot without any allowance or abatement in price. Any warranties which might otherwise be implied by the Sale of Goods Act, , are hereby excluded and shall not apply. The Auctioneer and the Vendor make no warranties other than those implied by Common Law or by statute, the exclusion of which warranty would render this condition void or voidable, or which would constitute an offence by the auctioneer or the Vendor. Intending bidders must satisfy themselves by inspection or otherwise as to the nature of the lot or lots offered for sale and must accept same with all faults, patent or latent (if any). Furthermore, no warranty shall be implied from any affirmation made at the auction or otherwise but in all cases where an express warranty is intended, the same shall only be enforceable of reduced to writing and signed by the Vendor or by the Auctioneer as agent for the Vendor.
Each lot shall lie at the purchaser&#;s risk from the fall of the hammer and neither the auctioneer nor the Vendor shall be accountable for any deficiency, damage or loss which may arise thereafter. The property in such lot shall not pass until payment in the approved manner as advertised at the auction in full of the purchase price and, where applicable, GST, buyers&#; premium, license fee or government charges.
No lot shall be removed during the sale without the consent of the auctioneer, but subject to condition 10 hereof, delivery is to be taken and the lot removed by the Purchaser with two (2) full working days of the day of the auction or such other period of time as may be specified by the Auctioneer at the time of sale and, in this respect, time is of the essence. Any removal shall be at the expense and risk of the Purchaser but, in such removal, the Purchaser shall do no damage, or shall forthwith make good any damage, which may be occasioned. Any lot or part thereof which the Purchaser does not remove may thereafter be removed by the Auctioneer or by some person, firm or company engaged by the Auctioneer or the Vendor and/or stored at the place at which the auction took place or elsewhere by the Auctioneer or by some other person, firm or company engaged by the Auctioneer. Such removal and/or storage shall be deemed to have been made by the Auctioneer at the request of the Purchaser and all costs incurred by the Auctioneer or the Vendor in relation thereto together with an amount of $10.00 plus GST per lot per day (inc. weekends) penalty shall be immediately payable by the Purchaser to the Auctioneer and the Auctioneer may sue for and recover the same as liquidated damages.
In addition to the purchase price, the Purchaser shall pay to the Auctioneer a fee calculated at the rate of up to thirteen and a half per cent (13.5%) of the full purchase price excluding GST State or Federal taxes that may be applicable.
If the Purchaser shall default in the observance or performance of his obligation under these conditions or any one or more of the then any moneys which the Purchaser shall have paid to the Auctioneer shall be absolutely forfeited and, without notice to the Purchaser, such lot or lots may be re-sold either by public auction or private contract and upon such terms and conditions as either the Auctioneer or the Vendor shall deem fit at the risk and expense of the Purchaser who shall be liable for any deficiency together with all expenses of removal, commission, warehousing and other charges arising out of such default and the Auctioneer or the Vendor shall be entitled to recover same as and for liquidated damages. Without limiting the generality of the foregoing, the Auctioneer shall be entitled to recover from the purchaser -
the amount of any commission upon the purchase which the Purchaser did not complete, the commission being determined by the agreement between the parties;
such sum for expenses and charges incurred by the Auctioneer in connection with or incidental to the auction and in respect of any such re-sale; and
where applicable, any GST, value added tax or any other tax relating to or arising from the sale of the property or any part thereof of the Vendor.
NOTES FOR REGISTERED BIDDERS
The following notes for registered bidders are supplementary to the above noted Terms and Conditions of Sale and are only intended to assist bidders in properly and conveniently affecting their purchases.
Special Notes:
A buyer&#;s premium of 13.5% + GST will apply on all lots sold.
The hammer price of all lots is GST exclusive and as such, GST of 10% will be added to the bid price and buyer&#;s premium.
Example:
Site Management:
The Site Managers and contact details for this auction are: Mark Tallon: 151 664 and Andrew Cai 330 589
Registration:
Buyers must register prior to bidding and obtain a bidder number which will be issued by the website prior to bidding. The registration application will be approved by Hymans staff and a notification will be forwarded to the registrant via .
Deposits:
A deposit of $100.00 is required at registration. The deposit will be immediately refunded in full if no lots are purchased by the buyer.
If a buyer makes substantial purchases (to be determined by the auctioneer) a deposit of between 10% and 25% may be required prior to the conclusion of the auction.
Payment Options:
Payment must be made within 48 hours of receiving an invoice.
Direct deposit to the auctioneer&#;s trust account is available. Account details are as follows:
Bank:
NAB
Account Name:
Hymans Asset Management &#; Trust Account
BSB:
084-435
Account Number:
44-596-
Payment of invoices can also be made via Visa Card, MasterCard, American Express, or EFTPOS only. Please note that a surcharge of 2% for Visa and MasterCard and 3% for American Express will be applied to all credit and debit card payments.
Insurance:
The bidder is at risk on the fall of the hammer on each lot and is therefore strongly advised to effect insurance immediately. Neither the auctioneer nor the vendor will be held responsible for any loss or damage to any lot after the fall of the hammer and buyers should be aware of the other terms affecting the sale that may preclude them from taking delivery of their lots immediately upon the fall of the hammer.
Transfer of Title:
Title shall only pass at such time that accounts are fully paid.
Collection of Lots:
Full payment must be made before any goods will be released.
All items must be removed 14 days from the issue date of the invoice to the successful bidders.
All lots must be paid for and removed by 5:00PM AEST Wednesday 7th August from all locations.
Equipment that requires disconnection from water, electricity, gas, or other such services is at the expense of the purchaser and disconnection work must be carried out by a GOLD LICENCE trade person. The licence must be presented prior to the commencement of works. Disconnection must be completed carefully and left in a safe and neat manner.
Hymans recommends that any purchasers interested in the larger tanks make enquiries as to movement of these tanks from their respective sites as special permissions may be required.
All removal work will be inspected to ensure it complies with the above. If we are not satisfied with the removal work, we reserve the right to request further work be carried out or undertake rectification work ourselves which will be charged to the Purchaser.
Special Note: Two forklifts and an Elevating Work Platform located at the site may be utilised by appropriately licenced operators during the removal process. You, or your staff, must always carry a forklift licence. Any damage to the forklifts or the Elevating Work Platform incurred during operation will be repaired and charged to the person operating it at the time.
The forklifts each have a capacity of 1.8 tonnes and 2.23 tonnes and will only be available for collection on Tuesday 6th August from 3pm until the site is closed at 5.00pm. If any of your purchases exceed 1.8 tonnes or 2.23 tonnes you will need to arrange your own lifting equipment.
Special Note: All vehicles will be sold WITHOUT registration. Plates will be REMOVED prior to collection.
Payment will only be accepted from, and delivery given to the Purchaser, of the lots at the auction sale. Any transfer of lots between buyers can only occur after the lots have been removed from the site by the Purchaser at the auction sale.
First Right of Refusal
During the sale, we may offer the highest bidder the &#;first right of refusal&#; over similar lots. For example, if there are ten identical units, the highest bidder on the first unit may choose to take one or all ten at the initial hammer price. Live simulcast bidders &#; watch the chat box to find out more. If the highest bidder chooses to take multiple lots, they will be sold to the highest bidder and will not be offered individually.
Mixed Lots:
Any buyer who purchases a mixed lot, a scrap lot, an &#;allowance for items,&#; or &#;contents,&#; is responsible for the removal of all items within the scope of that lot. Any remaining items left onsite will be disposed of at the expense of the buyer. &#;
RISK KEY CODE
Purchasers are required to carefully assess all risks associated with the operation of the asset in line with but not limited to, the following schedule of identifiable hazards:
Risk Code
Hazard Advice / Action Required
0
No Apparent Hazards
Should only be used as per manufacturers specifications
1
Manuals & Service History
There are no manuals or instructions available
There is no service history or maintenance records
2
Electrical Items
Requires testing prior to use
All leads and adaptors should be tested by an accredited tester or electrician for faults and tagged in accordance with AS/NZS and AS/NZS
Power must be isolated during cleaning or servicing
Must only be used with an earth leakage circuit breaker
3
Safety Apparel
Ear protection must be worn during operation; and/or
Face protection must be worn during operation; and/or
Eye protection must be worn during operation; and/or
Hand protection must be worn during operation; and/or
Foot protection must be worn during operation; and/or
4
Clothing
Appropriate clothing must be worn by the operator
Loose fitting clothing must not be worn
5
Safety Guards
Safety guards are fitted which must not be removed as detailed in AS
6
Safety Guards
Safety guards are missing
Should not be operated until safety guards which meet with the manufacturers&#; standards are fitted
7
Manual Handling
Care must be taken when lifting heavy items
Item containing glass or other fragile components must be carefully transported
Be careful when removing items attached to walls in case they fall
Secure all moving and removable parts prior to transporting items
8
Damaged Items
Item is damaged as will be offered for sale as scrap only
9
Noise
Must have the sound pressure level tested prior to commissioning and if over 85db(A) or if the impact noise is greater than 140db(A), then signage warning the users to wear hearing protection must be attached
10
Fire Fighting Equipment
An accredited contractor must inspect and allocate a date tag in accordance with AS - Sect. 15 & 16 (6 monthly) and assess to AS (annually)
Fire extinguishers - Clearly visible signs of both the fire extinguisher icon and fire extinguisher type must be installed above the fire extinguisher in accordance with AS
All fire extinguishers must be mounted not less than 100mm from the ground and not higher than mm for the floor as detailed in AS
Once installed, all fire extinguishers should made easily accessible and cleared of any obstacles
Staff must be trained to use fire protection equipment in accordance with AS and OH & S Chapter 4
11
Paper Shredders
The company is the world’s best lenticular patches contractor supplier. We are your one-stop shop for all needs. Our staff are highly-specialized and will help you find the product you need.
The operator must not place hands close to shredding blades
12
First Aid and Safety Equipment
All contents to first aid kits / boxes / cabinets must be carefully checked and any expired stock must be disposed
Once installed, a clearly visible sign of the first aid icon (green cross) must be installed above the first aid station
All safety apparatus should be tested for relevant compliance prior to use or installation.
13
Decommission & Removal
Requires a licensed tradesman or technician for decommissioning and re-installation
14
Calibrated Equipment
Must be re-calibrated by a certified contractor prior to use
15
Contaminates
Must be carefully checked and cleaned of contaminates from prior use
16
Equipment Under Pressure
Must be certified by an accredited contractor in accordance with AS/NZS (bi-annually) and once relocated and installed, a certificate of currency must be displayed nearby
17
Forklifts & Attachments
Where applicable, the operator must have a certificate of competency as per WorkCover regulations
If ride-on, must be fitted with roll over protection
If to be used on roads or public traffic areas, must be registered ( NSW Conditional)
Only attachments designed to be used with this model of forklift should be used
The advised safe working load of all lifting attachments must not be exceeded
18
Pneumatic Tools
Must be carefully inspected prior to deployment
19
Lifting Equipment
Must be used only in line with manufacturers specifications
The advised safe working loads must not be exceeded
20
Hydraulic Tools
Must be carefully inspected prior to deployment
21
Gas Cylinders
Must be adequately secured - by chain and/or with warning signage
Must have a valid date stamp
Must not be transported in an enclosed vehicle
22
Explosives
Fastening charges must only be used as detailed in the Dangerous Goods Act
23
Equipment Used at Heights
Must be only be used in accordance with the manufacturers&#; specifications
24
Dangerous Goods
If classified as such under the NSW Dangerous Goods Act, Australian Dangerous Goods Code must be stored in accordance with that Act and Code
25
Ventilation & Extraction
Adequate equipment must be used with this item
This item must only be used in an area with adequate ventilation
26
Registration
All mobile plant if to be used on roads or public traffic areas, must be appropriately registered
All mobile plant must be roadworthy in addition to the above i.e. all warning lights and signals must be working
27
Professional Competency
Must only be utilized by a skilled operator
28
Machinery Space
Plant must have adequate workspace surrounding it when commissioned to allow for loading and unloading of work pieces and materials and the safe working space for operators
29
Conveyors
Must comply with AS regarding design, construction, installation, and operations
30
Pipelines & Ducts
Signs indicating the contents of pipelines must be installed in accordance with AS
31
Licensing
Only appropriately licensed personnel must operate
A 28-year-old man arrives to the ED following a high-speed MVC. He is in severe pain and breathing rapid shallow breaths. His blood pressure is 80/60 mmHg, heart rate is 120/min, and respiratory rate is 30/min. A segment of his right anterolateral chest wall exhibits paradoxical inward motion on inspiration. Despite supplemental oxygen, the respiratory rate remains the same. Breath sounds are equal bilaterally. The trachea is midline. What is the next best step in management?
A 30-year-old male presents to the ED with a GSW to the right chest, just above his right nipple. In the ED, he complains of shortness of breath and severe right chest pain. His blood pressure is 110/70 mmHg, heart rate is 100/min, and respiratory rate is 20/min. On physical examination, his breath sounds are slightly diminished on the right. The trachea is midline. Neck veins are flat. The abdomen is non-tender. Upper extremity pulses are equal. A chest x-ray demonstrates a moderate right hemo- and pneumothorax. The bullet is seen in the upper chest. A chest tube is inserted into the right chest with an immediate output of 500 cc of dark blood, and after which the bleeding appears to slow down. What is the next step in the management?
A 58-year-old intoxicated homeless man arrives to the ED after getting struck by an auto. His blood pressure on arrival was 98/55 mmHg with a pulse of 120/min. Following fluid resuscitation, his blood pressure increases to 120/70 mmHg, and pulse decreases to 80/min. His abdomen is distended and mildly tender, and he has no obvious source of blood loss. A CT scan of the abdomen and pelvis shows no intraperitoneal fluid, but demonstrates bilateral pelvic fractures and a large pelvic fluid collection adjacent to the fracture with a contrast blush within it. What is the best next step in management?
A 25-year-old male suffers a GSW to his right mid-thigh. On physical examination, there is no hematoma, no palpable thrill, and no bleeding from the wound. He has diminished but present pedal pulses on the right and normal pulses on the left. Neurological exam is normal. Ankle-brachial index on the right is 0.8 and 1.0 on the left. What is the next step in the management?
A 18-year-old man arrives to the ED combative and with severe shortness of breath, after suffering a stab wound to the chest. His blood pressure is 94/76 mmHg with a pulse of 120/min and respiratory rate of 28/min. Physical exam reveals a 2 cm stab wound on the left chest. Lung fields on the left have decreased breath sounds and are hyperresonant to percussion. His neck veins are distended. A needle is placed in the left second intercostal midclavicular line and aspirated until a gush of air is heard escaping the chest wall. A liter of normal saline is given, and blood pressure improves to 120/70 mmHg, and pulse decreases to 100/min. What is the best next step in management?
A 65-year-old former firefighter arrives for follow-up for chronic wound in his right leg from a burn he suffered 25 years earlier. The wound has failed to heal despite repeat skin grafting. Recently, the wound has become more painful and larger, measuring 2 × 2 cm, and continuously drains. Multiple biopsies of the wound are taken. Which of the following is the most important contributing factor to this patient&#;s presenting condition?
A 7-year-old boy presents to his pediatrician with a tense, painful, weak, and shortened forearm with a claw-like deformity of the hand. The mother states that 1 year earlier, the child fell backwards on his outstretched hand and suffered a supracondylar fracture that was treated with closed reduction and casting. The most likely explanation for the current physical exam findings is:
A construction worker is digging a trench when he cuts his arm on a rusty nail in the soil. He is 45 years old and has not been to the doctor since he was a teenager, but he is confident he received all of his vaccinations up to age 18. What is the next step in treatment?
A 25-year-old male is at a pool party and is heavily intoxicated. He dives into the shallow end of the pool and is subsequently found to be floating face down in the pool. He is rushed to the ED by paramedics in a cervical collar. In the ED he opens his eyes, nods his head appropriately to questions, and his pupils are equally round and reactive to light. However, he is not moving his arms or legs. There is no evidence of external bleeding. His blood pressure is 85/45 mmHg, and his heart rate is 70/min. Which of the following would most likely be seen in association with the injury described?
A 38-year-old obese construction worker arrives to the trauma bay after accidentally getting struck by a bulldozer at his job site. In the ED, his mental status is altered, with a GCS of 10. His blood pressure is 80/66 mmHg with a pulse of 112/min. He is given 2 liters of intravenous fluids, but his blood pressure and pulse remain the same. A FAST exam is inconclusive. A portable chest x-ray is negative, and a pelvic x-ray demonstrates bilateral pubic rami fractures. What is the best next step in management?
A 30-year-old unrestrained driver is brought in by paramedics after a high-speed MVC. In the ED, his heart rate is 110/min, blood pressure is 104/75 mmHg and decreases to 92/68 mmHg during inspiration. His tachycardia and hypotension persist despite aggressive fluid resuscitation. He appears pale, and his neck veins are distended. He has multiple bruises on his chest and abdomen. His chest x-ray is unremarkable. What is the most likely diagnosis?
A 60-year-old man is recovering in the ICU after being rescued from a fire within a restaurant kitchen. He was trapped for a prolonged period of time. He received deep partial and full-thickness burns in over 30 % of his body. He has a past medical history of psoriasis controlled with topical steroids. On the seventh postoperative day, he becomes confused. His temperature is 96.1 °F, blood pressure is 98/72 mmHg, and pulse is 122/min. His burn wounds have focal areas with a brown color. His laboratory examination demonstrates a white blood count of 14.7 × 10/μL (normal 4.1&#;10.9 × 10/μL) and a serum glucose of 250 mg/dL. What is the most likely etiology for this patient&#;s acute condition?
A 25-year-old male arrives to the ED with a stab wound lateral to his umbilicus after being involved in a drunken fight at a local bar. You can smell alcohol on his breath, and he is uncooperative during the exam. His temperature is 99.2 °F, blood pressure is 90/60 mmHg, and pulse is 120/min. His abdomen is soft, non-tender with no rebound or guarding. What is the most appropriate next step in management?
A 32-year-old female is stabbed in the right lateral neck 1 cm above the clavicle. There is an expanding hematoma in her neck, and she is having great difficulty speaking. Breath sounds are absent on the right. Subcutaneous air is noted in her neck. What is the next step in management?
A 5-year-old girl arrives to the ED with complaints of nausea, vomiting, and abdominal pain for the past day. She has no significant past medical history, but her mother reports that she was involved in a MVC about a month ago. She was restrained in a car seat and had blunt trauma to her abdomen. She had no complaints at the time. Her vital signs were normal, and she was subsequently discharged a few hours later. Her blood pressure is currently 112/82 mmHg, pulse is 90/min, and respiratory rate is 28/min. Her chest x-ray is shown above (Fig. ). What is the most likely diagnosis?
A 40-year-old alcoholic presents to the ED with a markedly swollen right forearm that is diffusely tender. He states that following an alcohol and heroin binge, he fell asleep on his arm for 12 h. He woke up to find his hand completely numb and unable to move it. On physical exam, he has normal brachial and radial pulses. His heart has a regular rate and rhythm. He is unable to extend his wrist when the hand is palm down. ECG reveals peaked T waves, and CPKs are 20,000 IU/L (normal 60&#;400 IU/L). What is the next step in management?
A 10-year-old boy presents to the ED with severe abdominal pain after falling over his bicycle handles while attempting a trick and sustaining blunt injury to the abdomen. A CT scan shows oral contrast extravasation into the retroperitoneum that is coming from the posterior aspect of the duodenum. Which of the following is the best management recommendation?
A 62-year-old man with atrial fibrillation presents to the ED with a painful right lower leg. He has refused warfarin in the past. His physical exam is significant for an irregularly irregular heart rate and a painful right leg that is cool to touch with absent distal pulses. Pulses in the left foot are normal. He has significant motor weakness and sensory deficit in the right foot. Duplex scan reveals an occlusion of the right popliteal artery. He receives heparin and undergoes open surgical embolectomy. Following the procedure, his motor and sensory deficit dramatically improves. The next day, he experiences intense pain in the right calf. His right calf is swollen and tense, and the pain is worsened with passive dorsi and plantar flexion of his right foot. He has palpable distal pulses. What is the most likely underlying etiology for his acute condition?
A 22-year-old male arrives to the ED by paramedics with a gunshot wound in the RUQ of his abdomen. He is anxious and complains of pain near his wound. His temperature is 99.1 °F, blood pressure is 114/78 mmHg, and pulse is 90/min. His abdomen is soft, and he has no rebound or guarding. A portable chest x-ray is normal, and nasogastric tube (NGT) demonstrates clear fluid with no blood. His rectal examination shows no blood. What is the most appropriate next step in management?
A 40-year-old man is in a head-on MVC with a drunk driver on the freeway and is brought to the ED. He has a dark bruise from his seat belt across the left side of his neck. On physical examination, he is neurologically intact. However, his left eyelid is drooping, and his left pupil is constricted as compared to his right. CT scan with contrast demonstrates dissection of the left internal carotid that extends into the base of the skull. CT of the head and abdomen are negative. Which of the following would be the most appropriate management?
A 30-year-old male arrived via paramedics after getting struck in the abdomen by a golf cart while vacationing with his family. He had no head trauma and only complained of mild abdominal pain. His vitals were normal and stable. A CT scan revealed no abnormal findings, and he was discharged on the same day. Three days later, he comes back to the ED complaining of fevers, nausea, poor appetite, and abdominal pain. A repeat CT scan shows a laceration at the neck of the pancreas with disruption of the pancreatic duct. What is the best next step in management?
A 25-year-old football player presents to the ED after sustaining a devastating tackle and hyperextension of his right knee. The knee appears to be posteriorly dislocated and the leg is swollen. Pedal pulses on the right appear to be diminished but present, whereas they are normal on the left. The remainder of his exam does not reveal any obvious signs of bleeding. What is the appropriate next step in management?
A 40-year-old man falls down approximately three stories in an attempt to commit suicide. EMS arrives on scene within 5 min, and he is rushed to the ED but loses vitals in the field and is dead on arrival (DOA). What is the most likely cause of death?
A 40-year-old policeman is brought to the ED having suffered burns after helping to rescue a woman from a burning warehouse. His temperature is 99.8 °F, blood pressure is 100/70 mmHg, pulse is 95/min, and respiratory rate is 24/min. On physical examination, he has 40 % total body surface area deep partial and full-thickness burns to his face, arms, and back as well as a circumferential burn of his neck. He has singed nasal hairs, and there is carbonaceous sputum coming out of his mouth. His lungs are clear to auscultation bilaterally. ECG demonstrates premature ventricular contractions. What is the most appropriate next step in management?
A pregnant woman in her second trimester arrives to the ED after a minor MVC. She has no injuries or complaints but is worried that her pregnancy is in danger. She has a nonstress test that shows two accelerations of fetal heart rate, each at least 15 beats per minute above baseline and lasting at least 15 s. She has no contractions, vaginal bleeding, or abdominal pain. A FAST exam is negative. What is the next best step in management?
A 41-year-old patient presents to the emergency department following a stab wound to the chest, just above the left nipple line. On initial exam, his blood pressure is 94/70 mmHg, and respiratory rate is 16/min. He has distended neck veins, and his heart sounds are muffled. A FAST exam demonstrates fluid in the pericardial sac. What is considered the first sign of this condition?
A 23-year-old male is rushed to the ED by paramedics after sustaining a gunshot wound to the lateral neck at the level of the thyroid cartilage. The patient is hemodynamically stable and is able to speak. Physical exam shows no signs of hematoma, pulsatile bleeding, thrill, or bruit. Which of the following is the next step in management?
The FAST (focused abdominal sonogram for trauma) scan is a bedside ultrasound that is used to detect free fluid in the peritoneal cavity, around the pericardium, and in the thorax. The four areas of focus in a FAST exam are the hepatorenal space (C), perisplenic space (E), pouch of Douglas/rectovesical pouch, and pericardial space. FAST exam cannot distinguish blood from ascites and/or enteric content, is unable to detect retroperitoneal bleeds (from, for instance, a pelvic fracture), and is often times limited by obesity. FAST exam will be able to detect bowel perforation if there is free fluid and only if the bowel is within the peritoneum (so would miss injuries to parts of the duodenum, posterior walls of cecum, sigmoid). For detecting pericardial effusion (A), the sensitivity approaches nearly 100 %. Although bilateral pneumothoraces may limit comparison of sides, a single pneumothorax (B) has a sensitivity of 95 % and specificity approaching 100 %.
Penetrating neck trauma may result in injury to major blood vessels, the pharynx, esophagus, trachea, and/or cervical spine. Immediate surgical exploration (A) would be indicated if there were hard signs of vascular injury such as a pulsatile bleeding from the wound or rapidly expanding hematoma (the latter only after intubation {D} first to prevent airway compression). In the absence of hard signs of vascular injury, immediate surgical exploration is not necessary. Since physical examination is unreliable in terms of ruling out major injury, further imaging with CT angiogram (C) should be obtained. CT angiogram has largely replaced formal angiography (E) which was once considered the gold standard. Formal angiogram is invasive (requires a femoral artery catheterization), time consuming, costly, and is only useful to rule out arterial injuries. Wound closure (B) would only be appropriate for injuries that do not penetrate the platysma.
In a patient presenting with hypotension, distended neck veins, and muffled heart sounds (Beck&#;s triad) following a stab wound to the chest, the most likely diagnosis is cardiac tamponade. The first sign in cardiac tamponade is impaired diastolic filling, which compromises cardiac output, and ultimately results in hypotension and distended neck veins (D, E). Electrical alternans (B) is characterized by varying alterations in the amplitude of the QRS complex between beats. It can occur in various other conditions and is not always present in patients with cardiac tamponade. Radiographic images are often negative initially, but some may develop the characteristic &#;water-bottle&#; shape later in the course of the disease (C).
Many worried pregnant patients arrive to the ED following minor trauma. Most patients do not have any significant clinical findings. Her nonstress test showed a normal strip. The criteria to discharge pregnant patients following minor trauma include contractions no more than every 10 min, no vaginal bleeding, no abdominal pain, and a normal fetal heart tracing. This patient meets the discharge criteria and does not need to be monitored overnight (A). Biophysical profile (B) is indicated in patients with an abnormal nonstress test. CT of the abdomen (D) would be inappropriate in a pregnant patient because of the high radiation risk to the fetus. Although there have been no ill effects reported from MRI use during pregnancy, there are no indications to warrant MRI use in this patient (E).
Do not forget the ABCs of trauma. The airway should always be addressed first in the primary survey. Burn victims are at high risk for respiratory compromise since the supraglottic airway is susceptible to direct thermal injury and does not have the protection afforded to the infraglottic airway via the reflexive closure of vocal cords to intense heat. Circumferential burns of the neck further increase the risk of respiratory compromise by way of inelastic, circumferential eschars that may constrict the airway. Endotracheal intubation should be performed for all burn patients with acute respiratory distress, circumferential neck burns, full-thickness burns of the face or orpharynx, supraglottic edema, and progressive hoarseness, stridor, or wheezing. Broad-spectrum antibiotics (A) are not routinely recommended for the management of burn victims. Burn patients are also at risk for severe intravascular collapse and require significant volume replacement with IV fluid resuscitation (C). However, this should be addressed after securing the airway. Premature ventricular contractions are usually benign (D). If the patient did not have indications for immediate intubation (circumferential neck burn), bronchoscopy (E) would be indicated in the presence of singed nasal hairs and carbonaceous sputum to determine the presence of thermal damage to the airway.
High-energy rapid deceleration chest trauma is most commonly caused by a fall from greater than two stories or from a motor vehicle accident (e.g., steering wheel striking the chest). This mechanism of injury is known to cause aortic injuries which may lead to aortic transection, and ultimately death. Autopsy studies of aviation accidents demonstrate that more than 30 % of deaths are due to aortic transection. Overall, immediate mortality is greater than 70 %. The majority of patients die instantly of exsanguination. Of those who survive, 49 % will die within 24 h. Patients will present with a widened mediastinum, deviation of the trachea to the right, and left-sided hemothorax on chest radiographs. They may also have fractures of bones (e.g., first rib, sternum, scapula) that are uncommonly broken as high energy is required to break them. The aortic tear is usually at the ligamentum arteriosum, located just distal to the subclavian take off, as the aortic arch is relatively fixed to that point. CT angiogram can confirm the diagnosis, and definitive management includes operative repair. Although a ruptured spleen (D) can lead to significant blood loss, instant death is highly unlikely. The remaining choices (B, C, E) can all cause instant death, but they occur in less frequency than thoracic aortic transection with this mechanism of injury. Abdominal aortic transection is extremely rare following blunt trauma as it is more mobile than the thoracic aorta.
A dislocated limb has the potential of compromising arterial blood flow. As such prompt reduction is essential. However, prior to reduction, the first step is to obtain a plain film of the limb to confirm the dislocation and to rule out associated fractures. Following reduction, a postreduction film is needed to confirm proper alignment. Fasciotomy (A) would be indicated if there is concern for compartment syndrome (pain in calf muscles on passive motion, tense swelling, paresthesias); however, reduction of a dislocated knee would still take priority. CT angiography (B) would be performed after reduction if there is concern for arterial injury (ankle-brachial index <0.9). Heparinization (C) would be initiated after limb ischemia is diagnosed (e.g., cold, pulseless limb). MRI of the knee (E) is seldom indicated in the acute setting for knee injuries.
The diagnosis of isolated pancreatic injury is often delayed as it is notoriously known to be missed initially on CT. If there is no associated splenic injury to cause bleeding or bowel injury to cause peritonitis, initial physical examination findings may be unremarkable. In addition, a serum amylase level (A) is neither specific nor sensitive for pancreatic injury. However, if there is pancreatic duct disruption, the release of enzymes will eventually lead to symptoms as in the patient presented above. Surgery is recommended for such major injuries. Minor pancreatic injuries without pancreatic duct disruption can be managed nonoperatively. In such cases, ERCP (B) is more sensitive and specific than MRCP (D) for ductal injury. CT-guided drainage (C) will not address the underlying pancreatic injury and would not be appropriate for this patient.
The patient has sustained a blunt injury to the carotid artery as evidenced by a dissection in the left internal carotid artery. Such an injury should be suspected whenever there is high-energy force to the head and/or neck. He is exhibiting evidence of Horner&#;s syndrome (ptosis, meiosis, anhidrosis), as sympathetic nerve fibers can be interrupted with carotid injury. A dissection is a partial-thickness tear in an artery that begins in the intima and extends into the media. It can narrow or occlude the lumen. Most blunt carotid injuries are managed nonoperatively with anticoagulation (provided there is no contraindication). Thus observation (E) alone would be inappropriate for such a patient. Since the dissection extends to the base of the skull, it would be impossible to access and repair through a standard neck incision (A). Conservative management using heparin (B) is the most appropriate option and has been shown to reduce or prevent cerebral infarction in patients with blunt carotid injury. Carotid stenting (C) has a risk of causing a stroke and would not be appropriate for a dissection that extends to the base of the skull. Thrombolysis (D) is contraindicated in a patient with a carotid dissection and in patients with trauma causing acute vascular injury.
Immediate exploratory laparotomy is recommended in the majority of patients with a GSW to the abdomen, particularly if the patient is hemodynamically unstable, has evidence of peritonitis, or has bowel evisceration. However, cooperative patients with gunshot wounds (GSW) to the abdomen that are hemodynamically stable, with no evidence of peritonitis, are candidates for nonoperative management (NOM). They should be evaluated further for injuries requiring surgical repair with an abdominal CT scan. This approach may avoid an unnecessary exploratory laparotomy (B) that carries significant morbidity. CT scan should still be done even for patients with wounds that appear to only be superficial. If the CT scan is normal, the patient can be managed with serial physical exams (A) and serial laboratory exams (e.g., white blood count). NGT can help identify gastric injuries, while rectal examination can help identify rectal or colon penetration by the bullet. Though occasionally utilized for penetrating trauma, DPL and FAST (D, E) are more appropriate for blunt trauma.
It is important to note that acute limb ischemia (in this instance due to embolization of atrial thrombus secondary to atrial fibrillation), followed by reperfusion, is a well-recognized risk for the subsequent development of compartment syndrome. Ischemia-reperfusion results in an increase in vascular permeability to plasma proteins and progressive interstitial edema. This leads to an increase in interstitial pressure. When interstitial pressure exceeds capillary perfusion pressure, muscle ischemia and necrosis ensue. It is important to note that palpable pulses do not rule out compartment syndrome. Treatment is an emergent 4-compartment fasciotomy. The lymph system (E) is not involved in the development of acute compartment syndrome. A recurrent embolus (B) would not be expected to present with a swollen leg and palpable distal pulses. DVT (C) can present with calf tenderness that is worsened with passive extension (Homan sign). However, the temporal relation to his presenting problem and the physical exam findings are more supportive for compartment syndrome. Atherosclerotic plaque (D) would be expected in a patient presenting with claudication secondary to peripheral arterial disease.
Infections in burn patients can be problematic for multiple reasons. It may delay wound healing, encourages scarring, and can result in bacteremia which may lead to sepsis. Pseudomonas aeruginosa is a gram-negative bacillus and is considered to be the most common cause of infections in burn patients. Methicillin-resistant Staphylococcus aureus (A) is also commonly seen in burn patients and difficult to treat due to a large number of virulence factors. Streptococcus pyogenes (B) is more of a concern in pediatric burn patients because they may have colonization of Streptococcus pyogenes in their oropharynx. Streptococcus agalactiae (C) is not an organism thought to infect burn patients. This organism can colonize the genitourinary tract and be transmitted to the neonate during birth which may result in bacteremia, pneumonia, or meningitis. Fungal infections tend to occur in burn patients during the later stages of recovery because by this time the majority of bacteria have been eliminated by the use of antibiotics. The most common cause of fungal infection in burn patients is by Candida albicans (E).
Duodenal injury following blunt abdominal trauma is rare. When it does occur, it is usually accompanied by other abdominal injuries. Isolated duodenal injuries are even more uncommon. In children, they have classically been reported following a direct blow to the epigastrium such as a bicycle handlebar injury. The retroperitoneal location of some portions of the duodenum may lead to a delay in diagnosis, as enteric contents spilling from the injury may not cause peritonitis. Contrast-enhanced CT scan of the abdomen can help confirm the diagnosis by detecting extravasation of oral contrast, the presence of retroperitoneal air, or a paraduodenal hematoma. Some duodenal injuries can be managed nonoperatively. Specifically, a duodenal wall hematoma, without contrast extravasation does not require surgery. On the other hand, the presence of contrast extravasation confirms a full-thickness injury that mandates exploratory laparotomy. Depending on the extent of injury, primary repair can be performed. Because of the close relationship of the duodenum to the pancreas and the bile duct, resection of the duodenum is often not possible. Upper endoscopy (D) would be contraindicated in the presence of bowel perforation. CT-guided drainage (E) will not address the underlying duodenal injury and would not be appropriate for this patient. Laparoscopy (A) would not likely be able to adequately assess and repair the duodenal injury.
This patient has evidence of compartment syndrome that has led to muscle necrosis (as evidenced by high CPKs and hyperkalemia). Though compartment syndrome is mostly thought of as caused by severe bleeding after trauma, there are many other causes. In this case, it occurred secondary to prolonged compression of the forearm muscles due to his alcohol and drug binge. This resulted in ischemia, followed by reperfusion, and then swelling and death of the muscles. An alcohol binge can also lead to Saturday night palsy, a colloquial term referring to radial neuropathy from falling asleep with one&#;s arm hanging over a park bench (compressing the spiral groove which houses part of the radial nerve). Hyperkalemia is a known complication of muscle necrosis from compartment syndrome and can lead to peaked T waves, and if left untreated, fatal arrhythmias. Although all the options listed (A, B, D, E) are appropriate management options for hyperkalemia, calcium gluconate should be administered first to stabilize cardiac myocytes and prevent further damage, particularly because the electrolyte imbalance has already begun to affect the heart (e.g., peaked T waves).
The key to the diagnosis is the history of trauma combined with the chest x-ray. On initial inspection, the chest x-ray could be confused with a hemothorax (D) or pneumonia (E). However, the presence of multiple air pockets within the left lung field indicates that there are loops of bowel in the left chest, likely due to a traumatic left-sided diaphragmatic hernia. Traumatic diaphragmatic hernia (TDH) can occur following blunt abdominal trauma secondary to a sudden increase in intra-abdominal pressure. Diagnosis is frequently delayed since patients may be asymptomatic immediately following the traumatic episode. The stomach and colon are the most frequently herniated structures. Patients with TDH can present with both GI and respiratory symptoms. Gastroenteritis (A) is unlikely to present with an increased respiratory rate or an abnormal chest x-ray. Following blunt trauma, patients can very rarely present with a delayed splenic rupture, and this could cause a reactive left pleural effusion. However, once again, this would not cause loops of the bowel in the chest.
This patient has likely sustained damage to several structures of zone 1 of the neck. The first steps in management are always ABC. Given that there is an expanding hematoma and she is having difficulty speaking, there is concern that her airway is compromised, so she should be intubated. Since the apices of the lungs are contained within zone 1 of the neck, and she has absent breath sounds, she likely has a pneumothorax and will also need a chest tube (B). Duplex ultrasound of the carotid (C) is not necessary since there is a hard sign of vascular injury. The patient requires operative repair (D), but the airway should be protected first. This patient may have sustained esophageal injury that will require repair as well, but esophagoscopy (E) should not be performed since she has a hard sign of vascular injury.
This patient has a penetrating abdominal wound which is concerning for an intraperitoneal injury. Immediate exploratory laparotomy is recommended in patients with a penetrating injury to the abdomen if the patient is hemodynamically unstable, has evidence of peritonitis, has bowel evisceration, or is uncooperative (e.g., intoxicated). Further work-up (B&#;E) can be considered for patients that are hemodynamically stable, with no evidence of peritonitis.
The muscle is the first structure to be affected by ischemic changes in acute limb ischemia, and since it is the primary mass of the tissue in the extremity, the extent and duration of muscle damage are the most critical aspects of limb reperfusion syndrome and subsequent compartment syndrome. The muscle can be tolerant of ischemia for up to 4 h. Irreversible nerve damage (B) occurs after 8 h of ischemia. Fat (A) changes remain reversible for up to 13 h, the skin (D) up to 24 h, while the bone (E) damage does not typically occur until after 4 days of ischemia.
Patients with severe burns are at increased risk of burn wound sepsis. This patient has hypothermia, leukocytosis, and tachycardia. Thus he meets the diagnostic criteria for systemic inflammatory response syndrome (SIRS). Patients must have two of the following four in order to be diagnosed with SIRS: fever of more than 100.4 °F or less than 96.8 °F, heart rate of more than 90, respiratory rate of more than 20, or white blood count of >12,000/μL or <4,000/μL. SIRS due to an infection is called sepsis and can manifest with confusion or altered levels of consciousness (i.e., end-organ damage). Burn patients in particular are susceptible to bacterial infections. Changes in the color of the burn wound (to red, brown, or black) should raise suspicion for wound sepsis. Intercompartmental fluid shifts (A), or third spacing, occur when fluid that accumulated in the interstitium of tissues during the postoperative period shifts back into the intravascular space, typically on postoperative day three. This will present with a patient that appears to be fluid overloaded. Tertiary corticoadrenal insufficiency (B) should always be on the differential for patients with long-term steroid use that develop hypotension. This occurs because of insufficient corticotropin-releasing hormone secretion by the hypothalamus. However, the risk is less in patients using topical steroids because of its decreased potency and limited systemic exposure. In addition, hypothermia would not be expected with adrenal insufficiency. Alcohol withdrawal (C) would be expected to begin within 24 h of the last drink (not 7 days later). It can present with a wide range of symptoms including tremulousness, insomnia, anxiety, diaphoresis, and autonomic hyperactivity. Burn patients are at risk of carbon monoxide poisoning (D), particularly when they are confined to a close space. However, carbon monoxide poisoning will present acutely (not 7 days later) with headaches, dizziness, and nausea.
Patients with blunt chest trauma that present with persistent hypotension, tachycardia, and elevated JVP should be suspected of having an injury to the heart. Furthermore, this patient had a drop &#;10 mmHg in systolic blood pressure during inspiration (pulsus paradoxus) which supports a diagnosis of cardiac tamponade. Although cardiac tamponade classically causes a globular appearance of the heart on CXR, the cardiac silhouette may be normal. A lung contusion (C) would cause respiratory distress but not features of tamponade. An aortic transection (A) presents with a wide mediastinum and would not cause neck vein distention. Tension pneumothorax (D) may have distended neck veins, but the collapsed lung would be apparent on CXR combined with tracheal deviation. Diaphragmatic injury (D) can occur following blunt abdominal trauma and often present with GI and respiratory complaints though they may initially be asymptomatic.
Hypotension after blunt trauma should be considered due to hemorrhage until proven otherwise. Head injury should not be considered the source of hypotension. The most likely sources of bleeding are the abdomen, pelvis, and chest. However, major chest bleeding has been ruled out by the negative CXR. In the stable patient, an abdominal CT (E) is the best test to rule out bleeding. However, the patient&#;s hemodynamic instability precludes such a study. FAST scan is the test of choice in the unstable patient, but its utility is often limited in obese patients because of poor image quality. In equivocal cases, the next best choice is to perform a DPL to detect free fluid in the peritoneum, which would be an indication for exploratory laparotomy. Proceeding directly to exploratory laparotomy (C) would be appropriate if the patient manifested peritoneal signs. However, his altered mental status precludes a proper physical examination. Pelvic bleeding is another potential source of bleeding, although pubic rami fractures rarely cause major bleeding (more likely with fractures of the posterior pelvis). If the DPL was negative, one would then pursue pelvic angiography (B) to rule out pelvic bleeding. Given the GCS of 10, a head CT (D) is indicated, but this would not take precedence over identifying the source of hemorrhagic shock first.
The patient is displaying evidence of neurogenic shock with hypotension and an inappropriately normal heart rate (or bradycardia). Neurogenic shock is associated with a high cervical spinal cord injury (not thoracic spine injury {E}). Priapism (a sustained erection due to unopposed parasympathetic tone) is often a presenting sign of acute spinal cord injury. Neurogenic shock would be expected to present with a normal/high cardiac output (A), decreased SVR (B), and sympathetic blockade (D). Treatment is with intravenous fluids and if needed, pressor support (with an alpha agent for vasoconstriction).
This patient has a dirty wound, but has likely had all three tetanus vaccinations. Based on the table below, the correct treatment is tetanus vaccination only. Antibiotics (E) are not indicated since the patient is not infected. Since this is a dirty wound, primary closure (D) may not be attempted in this case, and the wound may be packed instead (Table ).
Children with supracondylar fractures are at risk for acute compartment syndrome. There are three mechanisms as to why this occurs: (1) the fracture is associated with an often unrecognized brachial artery injury that leads to ischemia in the compartments of the arm; (2) if the subsequent cast is placed too tightly, this may contribute to compartment syndrome; (3) initial bleeding and muscle damage/edema causes high pressures in the compartments of the arm leading to compartment syndrome. Compartment syndrome presents with the 6 Ps (pain, pallor, pulselessness, paresthesias, paralysis, and poikilothermia). Treatment is fasciotomy. Volkmann&#;s contracture is the manifestation of unrecognized and untreated compartment syndrome. This occurs because prolonged ischemia can lead to muscle death and subsequent fibrotic changes within the tissue. Volkmann&#;s contracture presents with a tense, painful, weak, and shortened forearm with a claw-like deformity of the hand. Nerve entrapment (A) is more likely to present acutely after the injury and will have deficits consistent with the distribution of a particular nerve. Suppurative tenosynovitis (B) is characterized by the four cardinal signs (Kanaval signs): flexor tendon sheath tenderness, fusiform swelling (sausage-shaped digits), pain with passive extension, and a semi-flexed posture of the involved digit. Complex regional pain syndrome (D) is a poorly understood phenomenon that occurs in patients that have had a crushing or soft tissue injury, typically to the distal extremities. They can present within days or months with intermittent pain, difficulty using the extremity, neglect-like symptoms, and rapid fatigability. An improperly reduced fracture would have been recognized earlier and corrected and would be unlikely to result in the deficits seen in this patient.
Cutaneous squamous cell carcinoma arising from a chronic non-healing wound (such as a burn) is known as Marjolin&#;s ulcer. Although all the answer choices (A&#;D) are considered independent risk factors for skin cancer, chronic inflammation is the most important contributing factor in Marjolin&#;s ulcer and can be seen in burn wounds, scars, chronic ulcers, or sinus tracts. Carcinoma develops on average 20&#;30 years after the original burn. All chronic wounds that fail to heal after a long period should undergo a skin biopsy to rule out malignancy.
This patient has a left-sided tension pneumothorax as confirmed by hypotension, distended neck veins, decreased breath sounds, and hyperresonant left chest. Immediate treatment is with needle thoracostomy, allowing for immediate thoracic decompression. This is preferred in the setting of a tension pneumothorax as it is faster than a chest tube, but provides only temporary relief. All these patients require a tube thoracostomy (chest tube) immediately following needle thoracostomy. Operative management (E) is not routinely indicated for patients with tension pneumothorax as needle decompression and subsequent tube thoracostomy are able to resolve most cases. If he had a significant hemothorax that continued to hemorrhage despite tube thoracostomy, surgical management could be considered as well as blood products (A). Tension pneumothorax is considered a clinical diagnosis, and confirmation with imaging (C, D) is not recommended as it delays definitive care in the unstable patient.
Penetrating trauma to the extremities should be assessed for neurovascular injuries. Prompt surgical exploration (A) would be indicated if the patient had hard signs of vascular injury (e.g., pulsatile bleeding, expanding hematoma). In the absence of such signs, an ABI should be checked. If the ABI is <0.9, suspicion for an arterial injury is high, and as such, imaging with CT angiography is the most appropriate management option. Formal angiography (C) can be considered if CT results are equivocal. Observation would be appropriate if he had a normal ABI. Systemic heparinization is sometimes used during the course of arterial repair if the injury led to thrombosis and an interposition vein graft is used.
This patient&#;s mechanism of injury and blood pressure drop are highly suggestive of hemorrhagic shock. Given that the patient responded well to IV fluids, it is appropriate to obtain CT imaging to look for the source of bleeding. If the source was intra-abdominal bleeding, the next step would be exploratory laparotomy (D). However, the CT indicates that the source is pelvic bleeding, likely from the pelvic fracture. Such bleeding is best managed via emergent pelvic angiography, which could be diagnostic and therapeutic (with embolization). MAST (A) suits were at one time popular as the compression was thought to tamponade bleeding. However, they have not been shown to be effective. External pelvic fixation (B) can reduce and stabilize fractures and thus lead to a slowing of bleeding, but is not considered as effective as angiographic emoblization. Open reduction, internal fixation (C) is the definitive treatment for a pelvic fracture. But given the technical difficulty and long length of such an operation, it is not recommended acutely, and especially not in someone who is actively bleeding. Pelvic packing is emerging as an alternative to angiography for pelvic bleeding.
This patient presents with a right hemo- and pneumothorax, and tube thoracostomy was able to evacuate 500 cc of dark blood. The most appropriate next step in management is to perform a repeat chest x-ray to ensure that the tube thoracostomy is in the right position and that the hemo- and pneumothorax have resolved. Exploratory right thoracotomy (A) would be indicated only if the initial output after chest tube placement was >1,500 cc or if the patient continued to bleed briskly (>200 cc/h for 3 h). VATS (D) is indicated if the chest tube has inadequately drained the hemothorax. But such a residual hemothorax would be drained via VATS only after failure of a second chest tube and only after waiting a few days (not acutely). CT of the chest is generally not needed if the CXR shows that the hemothorax is resolved, and CT of the abdomen (E) is unnecessary at this time as the bullet entered just above the nipple (and thus above the diaphragm) and is visualized in the chest, thus sparing the abdominal cavity.
This is concerning for a flail chest, most commonly caused by blunt trauma. Although the diagnosis is made clinically with a paradoxical inward motion of the chest wall during inspiration, it is supported by imaging studies demonstrating two or more consecutive ribs broken at two or more sites. The primary morbidity related to flail chest is the frequent underlying pulmonary contusion that accompanies it and compromises adequate respiration. Furthermore, severe pain may also affect respiration. Always start with the ABCs of trauma. The best course of management for the above patient (given the marked tachypnea and flail chest) is to first ensure an airway with endotracheal intubation. This can be followed by two large bore IVs and fluids (A). Blood products (D) may be needed if he does not respond to fluids and continues to remain hemodynamically unstable. There is no indication for a needle thoracostomy (B) or chest tube given that the breath sounds are equal. Chest tube (E) may be indicated if the patient had a concurrent pneumothorax on subsequent CXR.
Acute carbon monoxide (CO) poisoning affects the organs with the highest oxygen demand first. Patients will present in the early stages with neurologic complaints (e.g., headaches, dizziness, confusion) and cardiac symptoms (e.g., chest pain, arrhythmias). All these patients should be started on 100 % oxygen via nonrebreather facemask. CO has nearly 250× more affinity for hemoglobin than oxygen. Thus the hemoglobin-oxygen dissociation curve shifts to the left, and more hemoglobin is bound by CO than it is by oxygen. This decreases both the hemoglobin saturation (of oxygen) and the oxygen content in the blood. The arterial partial pressure of oxygen is not affected in CO poisoning (B), and so a compensatory increased alveolar ventilation would not be expected (E). CO poisoning is not a consumptive or destructive process, and so hemoglobin would not be expected to change (A). Oxidized hemoglobin, also known as methemoglobin, has a higher affinity for cyanide, and so patients with cyanide poisoning are oftentimes given nitrates to induce the oxidization of hemoglobin to help bind the cyanide for renal clearance.
Electrical burns are deceptive as at the skin level there may be a relatively minor burn wound. Yet, the electrical current can penetrate deep into the soft tissues, leading to extensive injury to the soft tissues and muscle. Thus electrical burns are associated with the development of compartment syndrome. The best indication for fasciotomy is in the presence of compartment syndrome. Choice E is the only choice in which there is an absolute indication for fasciotomy as the patient has clear evidence of compartment syndrome. Numbness of the first web space is the classic finding of anterior compartment syndrome, as the deep peroneal nerve travels within it, and it supplies sensation to the first web space. Options B, C, and D are relative indications for prophylactic fasciotomy, as they place the patient at increased risk of subsequently developing compartment syndrome, although prophylactic fasciotomies are controversial. A crush injury (A) by itself is not considered an indication for prophylactic fasciotomy.
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