Emergency surgery and trauma
Domain 4 - Emergency surgery and trauma
These EMQs test prioritisation under time pressure: what kills first, what can wait, and what must never be done. Trauma and the acute abdomen share one logic - resuscitate, identify the source of bleeding or contamination, and control it.
Core rules
- Primary survey (ATLS): catastrophic haemorrhage, airway with cervical spine protection, breathing, circulation, disability, exposure. Tension pneumothorax is a clinical diagnosis - absent breath sounds, hypotension, distended neck veins, tracheal shift - treated by immediate needle decompression (5th intercostal space, anterior axillary line) before a chest drain.
- Haemorrhagic shock: hypotensive patients get blood, not crystalloid. Activate a massive transfusion protocol with a 1:1:1 ratio of red cells, plasma and platelets, give tranexamic acid within 3 hours, and use permissive hypotension (SBP 80–90 mmHg) in penetrating torso trauma - but not in traumatic brain injury, where SBP should stay ≥110 mmHg.
- FAST in the unstable patient: pericardial or Morison's pouch fluid means theatre, not CT. Pelvic fracture bleeding is controlled with a binder, then angioembolisation or preperitoneal packing.
- Acute abdomen: perforated viscus gives free gas and generalised peritonitis - antibiotics and laparotomy or laparoscopy; mesenteric ischaemia gives pain out of proportion with raised lactate and atrial fibrillation - CT angiography and resection of dead bowel; ruptured AAA gives back pain, hypotension and a pulsatile mass - theatre, and no CT if unstable.
- Necrotising fasciitis: pain out of proportion, crepitus, bullae, raised LRINEC score - urgent surgical debridement, not imaging.
Worked example
A 30-year-old pedestrian is hypotensive (80/40) and tachycardic (130) with equal breath sounds and a soft but tender abdomen; FAST shows fluid in Morison's pouch. This is haemoperitoneum with shock: activate the massive transfusion protocol and tranexamic acid, give blood rather than crystalloid, and go to theatre for damage-control laparotomy. CT is for the stable patient only; packing with temporary closure precedes definitive repair in the physiologically deranged.
Traps
Requesting CT in an unstable patient; inserting a chest drain before needle decompression in tension pneumothorax; over-resuscitating with saline; catheterising a patient with blood at the urethral meatus; omitting tetanus prophylaxis in open wounds.