Cardiothoracic and vascular emergencies

52 NEET-PG practice questions on Cardiothoracic and vascular emergencies, part of General Surgery. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Medium

   Chest X-ray of a car driver after a high-speed head-on collision shows a mediastinum widened to 9 cm, loss of the aortic knob, deviation of the nasogastric tube to the right and a left apical cap. BP is 118/70 mmHg. Which investigation should be done, and where is the injury most likely?

   1. AAortography; aortic root
   2. BEchocardiography; diaphragmatic aorta
   3. CCT angiography; aortic isthmus
   4. DCT angiography; ascending aorta

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   Answer: C · CT angiography; aortic isthmus

   Rapid deceleration tears the aorta where the mobile arch meets the fixed descending aorta, at the isthmus just beyond the left subclavian artery near the ligamentum arteriosum. Patients who survive to hospital have a contained haematoma. Mediastinal widening, a lost aortic knob, a deviated NG tube and an apical cap are warning signs, and helical CT angiography confirms it. TEVAR is now the usual repair. Key point: Blunt aortic injury occurs at the isthmus; confirm it with CT angiography.

   • A: Catheter aortography has been replaced by CT, and the root is not the usual site.
   • B: Echo cannot reliably image the isthmus, and the diaphragmatic aorta is not typical.
   • D: The ascending aorta is rarely the site in survivors.

2. Question 2 · Medium

   After a lap-belt road traffic injury, a chest X-ray shows the nasogastric tube coiled in the left hemithorax above an indistinct left hemidiaphragm, with bowel gas shadows in the lower left chest. What is the diagnosis?

   1. AEventration of the diaphragm
   2. BTraumatic rupture of left hemidiaphragm
   3. CLeft tension pneumothorax
   4. DLeft lower lobe pneumatocele

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   Answer: B · Traumatic rupture of left hemidiaphragm

   A nasogastric tube coiled above the diaphragm with bowel gas in the chest after blunt abdominal trauma means a ruptured left hemidiaphragm with herniated stomach. Left-sided ruptures are diagnosed more often because the liver protects and hides the right side. Acute ruptures are repaired, usually through a laparotomy so that associated abdominal injuries can be treated. Key point: NG tube in the left chest after trauma means left diaphragmatic rupture; repair via laparotomy.

   • A: Eventration is a congenital thin, raised diaphragm, not trauma with the stomach in the chest.
   • C: Tension pneumothorax shows a black hemithorax and mediastinal shift, not bowel gas.
   • D: A pneumatocele is an air cyst in the lung and does not contain the NG tube.

3. Question 3 · Hard

   A heavy smoker who has had calf claudication at 200 metres in both legs for 3 years develops sudden worsening pain in the right leg 18 hours ago. The right foot is cool and pale with slow capillary refill, but sensation and power are intact. Both femoral pulses are present; popliteal and foot pulses are absent on both sides. He is in sinus rhythm, and an echocardiogram is normal. He has been started on IV heparin. The surgical trainee wants to take him straight to theatre for a Fogarty embolectomy. What is the most appropriate next step?

   1. APrimary below-knee amputation
   2. BImmediate Fogarty embolectomy
   3. CCT angiography to plan lysis or bypass
   4. DStart cilostazol; review in clinic

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   Answer: C · CT angiography to plan lysis or bypass

   Previous claudication, absent pulses in the other leg, sinus rhythm and no cardiac source point to acute thrombosis on a chronic atherosclerotic stenosis rather than an embolus. Balloon embolectomy often fails on diseased vessels, so the anatomy must be imaged first with CT angiography or angiography. A viable limb like this is treated with catheter-directed thrombolysis followed by angioplasty, or by bypass. Key point: Acute-on-chronic thrombosis in a viable limb: image first, then lysis, angioplasty or bypass; embolectomy alone fails.

   • A: The limb is viable; amputation is not indicated.
   • B: Embolectomy alone rarely succeeds on diseased atherosclerotic arteries.
   • D: Cilostazol is for stable claudication, not acute ischaemia.

4. Question 4 · Medium

   Two years after an open aortic tube graft repair, a man has a single episode of haematemesis and fresh blood per rectum that stopped on its own. He is now stable with haemoglobin 9.8 g/dL. Which diagnosis must be excluded urgently?

   1. AHaemorrhoidal bleeding
   2. BColonic angiodysplasia
   3. CAortoenteric fistula
   4. DBleeding duodenal ulcer

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   Answer: C · Aortoenteric fistula

   Any GI bleed in a patient with an aortic graft is an aortoenteric fistula until proved otherwise, usually between the proximal anastomosis and the third or fourth part of the duodenum. A self-limiting 'herald bleed' often precedes a massive, fatal haemorrhage. CT angiography and an upper endoscopy that reaches the distal duodenum are done urgently, and treatment is surgical or endovascular. Key point: GI bleeding after aortic graft surgery is an aortoenteric fistula until proved otherwise; the herald bleed must not be dismissed.

   • A: Haemorrhoids do not cause haematemesis.
   • B: Angiodysplasia does not explain haematemesis after aortic grafting.
   • D: A duodenal ulcer is possible, but missing a fistula is fatal.

5. Question 5 · Medium

   Duplex scan shows a fresh embolus at the bifurcation of the right common femoral artery in a man with atrial fibrillation. The limb is marginally threatened (Rutherford IIa), and he has no history of claudication; the other leg has normal pulses. Which procedure is the definitive treatment?

   1. ALumbar sympathectomy
   2. BPrimary above-knee amputation
   3. CFogarty balloon embolectomy
   4. DFemoropopliteal vein bypass

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   Answer: C · Fogarty balloon embolectomy

   An embolus lodged in an otherwise healthy artery is removed by Fogarty balloon catheter embolectomy through a groin arteriotomy, often under local anaesthesia. The catheter is passed beyond the clot, the balloon inflated and withdrawn to extract it, and completion angiography confirms flow. Bypass is used when there is underlying atherosclerotic disease. Anticoagulation continues afterwards. Key point: Acute embolus in a healthy artery: Fogarty balloon embolectomy, then long-term anticoagulation.

   • A: Sympathectomy has no role in acute ischaemia.
   • B: Amputation is for an irreversibly ischaemic limb.
   • D: Bypass is for thrombosis on chronic atherosclerotic disease.

6. Question 6 · Easy

   In the Stanford classification of aortic dissection, what defines a type A dissection?

   1. AEntry tear distal to the left subclavian
   2. BInvolvement of the aortic arch alone
   3. CExtension below the renal arteries
   4. DInvolvement of the ascending aorta

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7. Question 7 · Easy

   Which is the most common predisposing factor for acute aortic dissection in older adults?

   1. ASystemic hypertension
   2. BMarfan syndrome
   3. CSyphilitic aortitis
   4. DBlunt chest trauma

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8. Question 8 · Hard

   On the cardiology ward at night, a man with long-standing, poorly controlled hypertension is admitted with severe chest pain that 'tore' through to his back 40 minutes ago. BP is 150/90 mmHg in the right arm and 110/70 mmHg in the left, and an early diastolic murmur is heard at the left sternal edge. ECG shows 2 mm ST elevation in II, III and aVF. The duty registrar has prepared streptokinase because the nearest PCI centre is 3 hours away. A bedside echo shows a dilated aortic root with a mobile linear flap. What should be done?

   1. AWithhold lysis; arrange emergency aortic surgery
   2. BGive streptokinase, then transfer for PCI
   3. CGive tenecteplase instead of streptokinase
   4. DAspirin and heparin; observe on the ward

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9. Question 9 · Medium

   Within an hour of rapid drainage of a large right pneumothorax that had been present for about 10 days, a man develops a cough with frothy pink sputum, hypoxia and crackles over the right lung. Chest X-ray shows alveolar opacities limited to the re-expanded lung. What is the most likely explanation?

   1. AAspiration pneumonia
   2. BHaemothorax from the drain
   3. CRe-expansion pulmonary oedema
   4. DAcute left ventricular failure

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10. Question 10 · Medium

    Ultrasound at a surgical OPD shows an infrarenal abdominal aortic aneurysm of 5.8 cm in a retired bank manager who has no abdominal or back pain. He walks 2 km daily, and his cardiac and renal function are satisfactory. CT angiography shows a neck suitable for a stent graft. What is the most appropriate management?

    1. ABeta-blocker to slow growth; review yearly
    2. BRepair only once it becomes painful
    3. CElective repair, open or endovascular
    4. DUltrasound surveillance every 3 months

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11. Question 11 · Medium

    Following a steering-wheel impact to the sternum, a driver has a sternal fracture, sinus tachycardia and frequent ventricular ectopics; BP is normal. Which pair of tests best screens for significant blunt cardiac injury?

    1. AChest X-ray and serum CK-MB
    2. B12-lead ECG and serum troponin
    3. CD-dimer and arterial blood gas
    4. DCoronary angiography and echo

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12. Question 12 · Hard

    On the fourth day after a stab wound to the right chest, a young driver's intercostal drain, placed in the casualty for a haemothorax that drained 600 mL, now drains under 50 mL a day. He is stable but has a low-grade fever. CT of the chest shows about 500 mL of clotted blood, loculated at the right base, with the upper lobe well expanded. The drain is patent and well placed. What is the best next step?

    1. AThoracotomy and decortication at 6 weeks
    2. BRemove the drain and await resorption
    3. CEarly VATS evacuation of the clot
    4. DA second drain at the right base

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13. Question 13 · Easy

    Gasping and cyanosed after his bike skidded into a lorry, a delivery rider has SpO2 80%, BP 74/40 mmHg, a trachea pushed to the right and a hyper-resonant left chest with no breath sounds. What should be done first?

    1. AUrgent chest X-ray
    2. BEndotracheal intubation
    3. CDecompress the left chest
    4. DCT scan of the chest

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14. Question 14 · Medium

    Tearing interscapular pain began suddenly while a tall, thin man with long fingers and a high-arched palate was lifting a gas cylinder. BP is 168/96 mmHg in the right arm and 132/80 mmHg in the left; he is alert and haemodynamically stable. Chest X-ray shows a widened mediastinum. Which investigation should be done next?

    1. ASerum troponin and repeat ECG
    2. BConventional catheter aortography
    3. CCT angiography of the aorta
    4. DTransthoracic echocardiography alone

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15. Question 15 · Easy

    At the trauma bay, a youth stabbed in the left parasternal region has hypotension, distended neck veins and muffled heart sounds, with equal breath sounds on both sides. What is the most likely diagnosis?

    1. AMassive haemothorax
    2. BTension pneumothorax
    3. CHypovolaemic shock
    4. DCardiac tamponade

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16. Question 16 · Hard

    Seen 30 hours after the onset of pain, the left leg of a man with atrial fibrillation shows fixed, non-blanching mottling up to mid-thigh. The calf muscles are hard and tender, he cannot move his toes or ankle, sensation is absent below the knee, and neither arterial nor venous Doppler signals are audible in the foot. Creatine kinase is 38,000 U/L and potassium 5.9 mmol/L. He is drowsy but rousable. His family asks the surgeon to try to save the leg with an embolectomy. What is the most appropriate management?

    1. ACatheter-directed thrombolysis
    2. BHeparin; wait for demarcation
    3. CPrimary major amputation
    4. DEmbolectomy with fasciotomy

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17. Question 17 · Medium

    Forty-eight hours of IV labetalol and morphine have settled the pain in a woman with an acute type B aortic dissection. BP is 118/70 mmHg, pulse 62/min, urine output and renal function are normal, and repeat CT shows no rupture, expansion or branch malperfusion. What is the best plan now?

    1. AEmergency open repair of the descending aorta
    2. BImmediate thoracic stent graft
    3. COral antihypertensives and serial imaging
    4. DReplacement of the ascending aorta

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18. Question 18 · Hard

    At a tertiary centre with an endovascular team on call, a man with sudden left loin and back pain is brought in. BP is 102/68 mmHg after 250 mL of saline, he is fully conscious, and bedside ultrasound shows a 7.2 cm infrarenal aneurysm with a retroperitoneal haematoma. Haemoglobin is 10.4 g/dL. He had a myocardial infarction 2 years ago and his creatinine is 1.6 mg/dL. The emergency physician wants to give 2 L of crystalloid and send him for open repair at once. Which is the best next step?

    1. ACT angiography to assess suitability for EVAR
    2. BObserve in ICU; repair if BP falls
    3. CTwo litres of crystalloid, then open repair
    4. DOpen repair at once without imaging

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19. Question 19 · Medium

    Sudden pain and coldness of the right leg began 3 hours ago in a woman with rheumatic mitral stenosis and atrial fibrillation who stopped her warfarin. The leg is pale and cold below the knee with no femoral pulse; sensation and power are normal, and the left leg pulses are normal. What should be given first, before she goes to theatre?

    1. ASubcutaneous fondaparinux injection
    2. BOral aspirin 300 mg
    3. CIV unfractionated heparin bolus
    4. DIV streptokinase infusion

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20. Question 20 · Medium

    On the second day after open repair of an infrarenal aortic aneurysm, the patient passes bloody diarrhoea and has left-sided abdominal tenderness; serum lactate is 3.4 mmol/L (normal below 2). The inferior mesenteric artery was ligated during surgery. Which investigation should be done next?

    1. AMesenteric angiography
    2. BBarium enema
    3. CStool culture
    4. DBedside flexible sigmoidoscopy

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21. Question 21 · Medium

    In the casualty, a man known to have an abdominal aortic aneurysm collapses with sudden back pain; BP is 70/40 mmHg, pulse 130/min, he is drowsy but responds to voice, and a tender pulsatile mass is felt. The vascular surgeon is in the hospital. What is the best immediate approach?

    1. APermissive hypotension; straight to theatre
    2. BCT angiography to plan the repair
    3. CTwo litres of crystalloid to normalise BP first
    4. DStabilise in ICU before any surgery

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22. Question 22 · Medium

    Two hours after admission with an acute type A aortic dissection, while awaiting theatre, a man suddenly becomes breathless and hypotensive (BP 76/50 mmHg). His neck veins are distended, heart sounds are faint and systolic BP falls by 14 mmHg on inspiration. What is the most likely cause of this deterioration?

    1. AOcclusion of the right coronary ostium
    2. BAcute severe aortic regurgitation
    3. CRupture into the left pleura
    4. DRupture into the pericardium

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23. Question 23 · Medium

    In the emergency department, a hypertensive woman with sudden chest pain radiating to the back becomes hypotensive (BP 84/50 mmHg) and a new early diastolic murmur is heard. She is too unstable to be moved to the CT scanner. Which test can confirm the suspected diagnosis at the bedside?

    1. ASerum D-dimer level
    2. BMR angiography of the aorta
    3. CTransoesophageal echocardiography
    4. DPlain chest radiograph

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24. Question 24 · Medium

    Breathlessness with a large left pneumothorax (rim 3 cm at the hilum) brings a slim student with no previous lung disease to casualty. SpO2 is 93% on room air and he is haemodynamically stable. Which intervention is recommended first for him?

    1. AThoracoscopic talc pleurodesis
    2. BHigh-flow oxygen alone for 48 hours in hospital
    3. CNeedle aspiration or ambulatory device
    4. DLarge-bore surgical chest drain

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25. Question 25 · Easy

    Which is the usual underlying cause of primary spontaneous pneumothorax in a tall, thin young male smoker?

    1. AUnderlying emphysema
    2. BRupture of apical subpleural blebs
    3. CPulmonary tuberculosis
    4. DRupture of a lung abscess

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