see also [pelvic trauma ETM](https://etmcourse.com/knowledgebase/pelvic-trauma/), [Moore - pelvis trauma](x-devonthink-item://3673A856-E48F-44F0-83B7-25775BEEF8BF?page=702) > [!Key Points] > 1. like a pretzel, it is difficult to break only one bone in the pelvic ring. look for second fractures if one is found (eg [[#Sacral alar fracture (and superior/inferior pubic rami fracture)|sacral alar fracture]] if pubic rami fracture) > 2. mechanical and haemodynamic stability are very different things: if concern of bleed or significant mechanism, need contrast CT scan of pelvis > 3. Rapid sequence intubation should occur after pelvic binder has been applied, as administration of paralytic agent can lead to loss of pelvic tone, and subsequent haemorrhage (rapid) # Classify Pelvic trauma - based on force being applied to pelvis (Young & Burgess) ![[Pasted image 20230413204257.png]] ## Lateral compression - due to direct lateral impact on the iliac crest or indirect transmission of force from the hip **LC I** - transverse fracture through pubic rami with impaction fracture of sacrum (may involve the neural foramina). > sometimes seen with elderly patients falling with osteoporosis **LC II** - LC I with fracture dislocation of SI joint, causing ligamentous disruption of inferior SI joint, vertical fracture of posterior ilium from middle of SI joint through to iliac crest . Internal rotation of the fractured hemipelvis eleates the anterior pelvis and may result in internally rotated, shorted lower extremity. **LC III** - occur when an individula receives a laterally-directed force on one side of the pelvis and is trapped against and immobile object on the contralateral side. Also causes external rotation injury on contralateral side, producing an injury pattern similar to APC injuries (eg with disruption of anterior SI ligaments and sacrospinous and sacrotuberous ligaments), sometimes called a **windswept pelvis** ## AP compression - can cause vertical fractures through pubic rami - AP Compression injury (I, II, III) eg [[#Open book fracture]] **APC I** - separation of pubic symphysis <2cm. SI ligaments not torn **APC II** - pubic sympysis separation >2cm. anterior SI ligaments torn as well as sacrotuberous and sacrospinous ligaments torn and joint *diastasis*, but posterior SI ligaments intact (creates hinge that allows external rotation but prevents vertical displacememnt) **APC III** - hemipelvis rotates externally, with rupture of anterior and posterior SI ligaments. complete ligamentous dissociation of involved hemipelvis from axial skeleton, causing both rotational and vertical instability ^04ff93 ## Vertical sheer - usually from a fall from height onto lower limbs - a shearing force - anteriorly there is a separation of the pubic symphysis or vertical fractures through one or both obturator rings - posteriorly there is a disruption of the SI joint or fractures through the ilium or sacrum - classic injury is [[#Malgaigne fracture]], which is a vertical fracture through the anterior and posterior pelvis with superior displacemenet of the lateral "acetabulum-containing" fragment of the pelvis # anatomy ![[Pasted image 20230413210141.png]] # mechanical stability vs haemodynamic stability - can have a very mechanically unstable fracture that does not cause haemodynamic instability - can have a [[#small pubic rami fracture with enormous haematoma|very minor pelvic fracture]] with extreme bleeding and haemodynanic instability ## Sources of bleeding - 90% from venous - will generally stop spontaneously when local venoush pressure and pressure of retroperitoneal space are equal - Fractures that cause marked displacement of the pelvic bone (eg [[#^04ff93|APC-III]] [[#Open book fracture]]) may **increase the volume of the retroperitoneal space by 4 litres** allowing an equivolent volume of venous bleeding - arterial bleeding only occurs in 10% of patients - 57% posterior, 43% anterior - intraperitoneal bleeding occurs in 32% of haemodynamically unstable patients with major pelvic fractures - spleen, liver, bladder, bowel, renal # Management of pelvic fracture by fracture type ![[Pasted image 20230414191632.png]] ![[Pasted image 20230414192028.png]] # Physical exam **Destot sign** - a superficial haematoma above the inguinal ligament, in the scrotum, or the thigh can indicate a pelvic fracture Bruising and swelling over the greater trochanter, flank, or lumbar area can be due to a shear injury where the s/c tissue is torn >[!Key physical exam tips] >1. anterior-posterior compression at pubic symphysis is no longer recomended >2. "springing" the pelvis is not safe and can lead to significant blood loss (i.e. applying an alternate compressing and distracting force to the ilia) >3. apply [[#Pelvic binder]] prior to log roll >4. Check neurology; high rate of neurological injuries with sacral fractures > # Sacral fractures and neuro deficits ![[Pasted image 20230414230056.png]] - Zone I sacral fractures have a 5.9% incidence of neurologic injury. - Zone II sacral fractures have a 28% neurologic injury rate, usually involving L5, S1, and S2 nerve roots. - Zone III sacral fractures have a 56% incidence of neurologic injury. ![[Pasted image 20230414225942.png]] # Pelvic XR 1. assess sacro-illiac joints 2. assess pubic symphesis for widening; normal to have small degree of asymmetry. >2cm concern for rupture of pelvic floor ligaments and/or sacro-illiac joint disruption --> **unstable** 3. Assess the "sacral eyebrows" (sacral arcuate lines) 4. shenton's line -- lower portion of superior pubic ramus line curves with inferior line of femoral neck 5. superior acetabular margin corresponding with femoral head (easy to miss posteiror dislocation) 6. smooth line inside pelvis and to ischeal spine 7. ![[Pasted image 20230413203813.png]] ^ normal ## Sacral alar fracture (and superior/inferior pubic rami fracture) ![[Pasted image 20230413205743.png]] ^ note disruption of the **sacral arcuate lines** (aka "sacral eyebrows). in the setting of the right-sided pubic rami fracture, concerning AP mechanism for fracture in posterior area. note that the sacral iliac joint looks OK CT scan demonstrating this: ![[Pasted image 20230413210025.png]] CT soft tissue windows showing trace haemorrhage in front of the sacrum: ![[Pasted image 20230413210429.png]] another example: ![[Pasted image 20230414225757.png]] ### another example sacral alar fracture ![[Pasted image 20230513143000.png]] ^ note obvious inferior pubic rami fracture, and subtle disruption of sacral arcuate lines on the right ## Open book fracture ### case 1 ![[Pasted image 20230413210633.png]] ### case 2 ![[Pasted image 20230413210913.png]] ^ **sacral-illiac joint disruption**. note widened pubic symphesis <2cm, with associated right-sided disruption of sacro-illiac joint. case 2 post pelvic binder: ![[Pasted image 20230413211054.png]] ^ pelvic binder brings pubic symphesis back together ## posterior hip dislocation ![[Pasted image 20230413204046.png]] ^ left side, equivocal, but note the femoral head is above the acetabular margin CT scan: ![[Pasted image 20230413204145.png]] ^ posterior dislocation! # small pubic rami fracture with enormous haematoma ![[Pasted image 20230413212343.png]] ^ note the contrast blush just behind pubic rami fracture on the right, demonstrating active bleeding. arterial phase study. needs **embolisation** also note pre-sacral haemorrhage: ![[Pasted image 20230413212641.png]] # Malgaigne fracture - result of vertical sheering injury - a vertically oriented fracture through the anterior and posterior pelvis together with superior displacement of the lateral “acetabulum-containing” fragment of the pelvis ![[Pasted image 20230414191337.png]] # urethral injury - consider need for [[Retrograde urethrogram]] to establish damage and insert suprapubic catheter - anterior-posterior pelvic compression is associated with posterior urethral injury # Pelvic binder > Unstable pelvic fractures bleed because of ongoing injury to small vessels, as the fracture elements continue to move, and because of increased volume in the pelvis. **Efficacy?** - help with mechanical stability - reduce the retroperitoneal volume - ==best for open book fractures== - equivocal evidence for helping haemodynamic stability eg. mortality, bleeding, transfusion requirement. - Indication is any actual or suspected pelvic fractures associated with persisting hypotension - can use with associated femoral fractures - also strap legs together above knees # Surgery vs. angiography - in a haemodynamically unstable patient with pelvic and intraabdominal haemorrhage, decision between laparotomy vs. angioembolisation - unnecessary laparotomy may increase mortality rate - a rationale for packing rather than angiography is that pelvic bleeding is more commonly venous in origin, for which arteriography and embolisation have no benefit - ideally, pelvis needs to be stabilised prior to packing to provide solid structural support - *REBOA* (resuscitative endovascular balloon occlusion of the aorta) is another option for control of bleeding from pelvic fractures - risk of vascular injury and limb ischemia, so restricted to pts in extremis, as with [[Resuscitative Thoracotomy]] aortic cross-clamping - ~1/4 angiographies performed on pelvic fractures find [no direct or indirect evidence of bleeding](x-devonthink-item://3673A856-E48F-44F0-83B7-25775BEEF8BF?page=709&start=1762&length=201&search=The%20first%20challenge%20for%20the%20clinician%20is%20to%20identify%20the%20cor-%20rect%20indications%20for%20angiography.%20Approximately%20one-fourth%20of%20the%20angiographies%20performed%20find%20no%20direct%20or%20indirect%20evi-%20dence%20of%20bleeding) > Preperitoneal packing can be lifesaving in patients who are frankly unstable and cannot tolerate transport to the angiography suite ## Indications for angiography for embolisation in pelvic trauma 1. haemodyanmic instability or signs of ongoing bleeding after non-pelvic sources of blood loss ruled out (level 1) 2. Arterial contrast extravasation on CT regardless of haemodynamic status (level 1) 3. older than 60 with major pelvic trauma regardless of of haemodyanmic status (level 2) 4. signs of ongoing bleeding after pelvic angiography has already been performed (level 2) ## Pelvic embolisation - finding source of bleeding ranges 50-80% - single vessel bleeding: selective embolisation - multi vessel bleeding: "shotgun" embolisation, 95% successful *see further explanation below about angioembolisation vs. pre-peritoneal packing* ## preperitoneal packing see [Preperitoneal packing versus angioembolization for the initial management of hemodynamically unstable pelvic fracture: A systematic review and meta-analysis 2022](bookends://sonnysoftware.com/ref/DL/168016) - [web link](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9038232/) [Moore Trauma - preperitoneal pelvic packing](x-devonthink-item://3673A856-E48F-44F0-83B7-25775BEEF8BF?page=711) - note that most studies that support **angioembolisation** have documented evidence of arterial vessel damage - 27% of patients with preperitoneal packing go on to require secondary angioembolisation to control ongoing active haemorrhage - Preperitoneal pelvic packing isperformed through a separate incision "**Preperitoneal packing** attempts to *tamponade the venous sources of intrapelvic bleeding*, and in case of tight packing, it may also play a role in arterial hemorrhage control. This procedure is usually performed in an operating room where other interventions such as a laparotomy or skeletal stabilization may also be performed. However, ==a prerequisite of PPP is the temporary or definitive stabilization of the disrupted pelvic ring to provide abutment against the displacing forces of the packs.== **Angioembolization** uses interventional radiology or endovascular surgery to selectively embolize vessels, typically in an interventional radiology suite or in a hybrid OR. *Advocates of PPP* argue that it is both effective and more accessible than AE. Delays to AE, for instance, due to staff availability or a potentially unnecessary trip to the OR, have been shown to confer a significantly increased mortality.[1](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9038232/#bib9) More recently, PPP was taken up in North America, and a large nonrandomized series showed shorter time to intervention and improved outcomes but also identified a consistent need for AE among the most critical patients to achieve hemorrhage control" #trauma #radiopaedia # Related Questions ## ards - 1Q: [Respiratory Failure](x-devonthink-item://B74AA648-7583-42CC-9AC9-1FDBD09A2750?page=10) -- [Answer](x-devonthink-item://2088AEED-9FCF-4CF0-B58D-E4279D4BCC76?page=12) ## ct - 2Q: [Flank pain](x-devonthink-item://8A1FC024-FD4E-4202-A93D-77C4E8234DC5?page=4) -- [Answer](x-devonthink-item://7EEBE66F-C2B1-4EF7-B29C-FB52D469C8CD?page=3) ## dic - 3Q: [Thrombocytopenia](x-devonthink-item://1A14F7A1-E434-47A6-BC68-AF2DD1A7C090?page=1) -- [Answer](x-devonthink-item://736EC9CD-AC9C-4588-BA1E-F4AD190CBA47?page=25) ## fall - 4Q: [Elderly Collapse](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=50) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=54) - 5Q: [Complex Elderly Presentation](x-devonthink-item://CA4D5561-277D-47A1-9EC2-E0DB4C59DCFD?page=6) -- [Answer](x-devonthink-item://2551B51B-0E7C-448E-9FB5-3B547E74974A?page=6) ## fall from height - 6Q: [Ankle injury](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=51) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=55) ## fractures - 7Q: [Leg Injury](x-devonthink-item://C88FD92C-E0CB-48A1-8D73-F20489FA4E6C?page=13) -- [Answer](x-devonthink-item://98D17FA0-225B-4E94-B21C-4E36D5C76A7C?page=38) ## haematoma - 8Q: [Crush Injury of Leg](x-devonthink-item://73409C77-B2FA-4E0A-AEB3-5EB284457F0C?page=21) -- [Answer](x-devonthink-item://5A848952-80E3-4184-B553-368412A69917?page=12) ## haemorrhage - 9Q: [Variceal Upper GI Bleeding](x-devonthink-item://C1DDA3AB-2DA2-4922-A8A6-F597AB7E2558?page=16) -- [Answer](x-devonthink-item://A10DE51E-92FA-42D1-8AA0-7AE68C2FA743?page=18) - 10Q: [Haemorrhagic Stroke](x-devonthink-item://B74AA648-7583-42CC-9AC9-1FDBD09A2750?page=2) -- [Answer](x-devonthink-item://2088AEED-9FCF-4CF0-B58D-E4279D4BCC76?page=2) ## hip dislocation - 11Q: [Hip Injury](x-devonthink-item://C4CCEB12-61D5-4308-AA41-5078F3D96CC0?page=11) -- [Answer](x-devonthink-item://75D8E35B-EE77-4D1B-A665-438451C976AE?page=17) ## hypotension - 12Q: [Hypotension and Fever](x-devonthink-item://5DC0999B-D537-4002-86AF-FD7B54B45E2E?page=62) -- [Answer](x-devonthink-item://406AF611-5CD4-4B3B-9795-327E8F4E3626?page=30) - 13Q: [Fall From Roof](x-devonthink-item://7FCD3940-4BB4-45FE-86A6-E5707E82D5B5?page=1) -- [Answer](x-devonthink-item://3263A68A-96A6-43EC-985B-43260C3509BF?page=0) - 14Q: [Fall From Ladder](x-devonthink-item://0987D972-A221-4F8A-B7D7-B0DCC349A2B3?page=1) -- [Answer](x-devonthink-item://C7FCB01A-E668-44AF-8C95-C298A40F8D68?page=0) ## intubation - 15Q: [Management of post arrest patient](x-devonthink-item://09493372-578D-4C97-972A-EEC617B38B53?page=5) -- [Answer](x-devonthink-item://A0D348CE-FCD4-4ECD-BE21-6CA73F6DE8CD?page=3) - 16Q: [Head Injury](x-devonthink-item://4134DDB3-6E12-474A-9F6F-64135C0C6048?page=14) -- [Answer](x-devonthink-item://AC92B5F1-8EE6-461A-B03E-F70AE7DC1275?page=14) - 17Q: [Trauma Resuscitation](x-devonthink-item://7FCD3940-4BB4-45FE-86A6-E5707E82D5B5?page=18) -- [Answer](x-devonthink-item://3263A68A-96A6-43EC-985B-43260C3509BF?page=6) - 18Q: [Post Tonsillectomy Bleed](x-devonthink-item://834C484F-DDAA-4819-8DF0-84AE5E70DA1D?page=10) -- [Answer](x-devonthink-item://D46998FE-62E2-4A3A-860D-C32C94B86E42?page=4) - 19Q: [Respiratory Failure](x-devonthink-item://D6654B01-83AA-4553-94F0-791FD96A636D?page=17) -- [Answer](x-devonthink-item://00427DF6-6D28-4FEB-A0CA-DF96DBBBCE97?page=9) - 20Q: [Head Injury](x-devonthink-item://F3284DF7-780A-48C2-B18F-86C7C6B2AC27?page=3) -- [Answer](x-devonthink-item://2088AEED-9FCF-4CF0-B58D-E4279D4BCC76?page=44) - 21Q: [Unwell Neonate](x-devonthink-item://7061D1B4-0AB9-4963-B3B0-23BDD975B2CD?page=34) -- [Answer](x-devonthink-item://3F30C77E-E23E-4200-89FE-48A41618E0C2?page=24) - 22Q: [Deteriorating Infant](x-devonthink-item://6092BF31-E542-4019-8E17-0C628DD3B0F1?page=13) -- [Answer](x-devonthink-item://E15CEB64-C6A5-4A7D-84B4-E7D1DC667B0E?page=8) ## pelvic fractures - 23Q: [Pelvic Fractures](x-devonthink-item://40193B7A-D362-4C39-9D2A-2D112B58104B?page=2) -- [Answer](x-devonthink-item://AADB7978-B533-4E12-B6E4-E994C0B685FF?page=1) ## pelvic trauma - 24Q: [Pelvic trauma](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=20) -- [Answer](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=22) - 25Q: [Pelvic trauma](x-devonthink-item://4BE7EDE1-1843-4BA0-B8D2-0DCEF50784D4?page=10) -- [Answer](x-devonthink-item://15F8F701-8EC8-4F9A-8DEC-5220C8561C8A?page=9) - 26Q: [Pelvic Trauma](x-devonthink-item://5DC0999B-D537-4002-86AF-FD7B54B45E2E?page=18) -- [Answer](x-devonthink-item://406AF611-5CD4-4B3B-9795-327E8F4E3626?page=6) - 27Q: [Fall off Horse](x-devonthink-item://FE3157C2-07B3-43F2-9ECE-AFACE1355E13?page=48) -- [Answer](x-devonthink-item://DDC959EB-0C1E-448A-8380-C397BF734322?page=28) - 28Q: [Pelvic trauma](x-devonthink-item://DE6BF2B6-53E9-4530-BC75-C00EC806A473?page=1) -- [Answer](x-devonthink-item://D25C2F83-6C30-4F45-8B5B-6E7E57BD24A3?page=10) - 29Q: [Pelvic Trauma](x-devonthink-item://0C18BB01-C981-4C61-B0E9-93B507919817?page=19) -- [Answer](x-devonthink-item://75D8E35B-EE77-4D1B-A665-438451C976AE?page=10) - 30Q: [Pelvic Trauma](x-devonthink-item://27CD16C2-557A-4CB1-B3CF-D01330708170?page=6) -- [Answer](x-devonthink-item://00427DF6-6D28-4FEB-A0CA-DF96DBBBCE97?page=14) - 31Q: [Pelvic Trauma](x-devonthink-item://09CFA1A7-00F1-4151-979E-8F3984924D54?page=25) -- [Answer](x-devonthink-item://CF5E9C2B-42F9-4F9C-AC29-877E20134927?page=17) - 32Q: [Pelvic Trauma Part 1](x-devonthink-item://1EA9311E-0B9E-49F7-8D6E-4C4187A838C4?page=43) -- [Answer](x-devonthink-item://B1CB2E8F-5D04-49EE-8274-043871389D28?page=28) - [pelvic trauma part 2](x-devonthink-item://1EA9311E-0B9E-49F7-8D6E-4C4187A838C4?page=45) -- [answer](x-devonthink-item://B1CB2E8F-5D04-49EE-8274-043871389D28?page=28) ## pelvic xr - DUPLICATE Q: [Pelvic trauma](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=20) -- [Answer](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=22) - DUPLICATE Q: [Pelvic trauma](x-devonthink-item://4BE7EDE1-1843-4BA0-B8D2-0DCEF50784D4?page=10) -- [Answer](x-devonthink-item://15F8F701-8EC8-4F9A-8DEC-5220C8561C8A?page=9) - DUPLICATE Q: [Pelvic Trauma](x-devonthink-item://5DC0999B-D537-4002-86AF-FD7B54B45E2E?page=18) -- [Answer](x-devonthink-item://406AF611-5CD4-4B3B-9795-327E8F4E3626?page=6) - DUPLICATE Q: [Fall off Horse](x-devonthink-item://FE3157C2-07B3-43F2-9ECE-AFACE1355E13?page=48) -- [Answer](x-devonthink-item://DDC959EB-0C1E-448A-8380-C397BF734322?page=28) - DUPLICATE Q: [Pelvic trauma](x-devonthink-item://DE6BF2B6-53E9-4530-BC75-C00EC806A473?page=1) -- [Answer](x-devonthink-item://D25C2F83-6C30-4F45-8B5B-6E7E57BD24A3?page=10) - DUPLICATE Q: [Pelvic Trauma](x-devonthink-item://0C18BB01-C981-4C61-B0E9-93B507919817?page=19) -- [Answer](x-devonthink-item://75D8E35B-EE77-4D1B-A665-438451C976AE?page=10) - DUPLICATE Q: [Hip Injury](x-devonthink-item://C4CCEB12-61D5-4308-AA41-5078F3D96CC0?page=11) -- [Answer](x-devonthink-item://75D8E35B-EE77-4D1B-A665-438451C976AE?page=17) - 33Q: [Hyponatraemia](x-devonthink-item://D6654B01-83AA-4553-94F0-791FD96A636D?page=2) -- [Answer](x-devonthink-item://00427DF6-6D28-4FEB-A0CA-DF96DBBBCE97?page=1) - DUPLICATE Q: [Pelvic Trauma](x-devonthink-item://27CD16C2-557A-4CB1-B3CF-D01330708170?page=6) -- [Answer](x-devonthink-item://00427DF6-6D28-4FEB-A0CA-DF96DBBBCE97?page=14) - DUPLICATE Q: [Pelvic Fractures](x-devonthink-item://40193B7A-D362-4C39-9D2A-2D112B58104B?page=2) -- [Answer](x-devonthink-item://AADB7978-B533-4E12-B6E4-E994C0B685FF?page=1) - 34Q: [Polytrauma](x-devonthink-item://40193B7A-D362-4C39-9D2A-2D112B58104B?page=14) -- [Answer](x-devonthink-item://AADB7978-B533-4E12-B6E4-E994C0B685FF?page=11) - DUPLICATE Q: [Pelvic Trauma](x-devonthink-item://09CFA1A7-00F1-4151-979E-8F3984924D54?page=25) -- [Answer](x-devonthink-item://CF5E9C2B-42F9-4F9C-AC29-877E20134927?page=17) - DUPLICATE Q: [Pelvic Trauma Part 1](x-devonthink-item://1EA9311E-0B9E-49F7-8D6E-4C4187A838C4?page=43) -- [Answer](x-devonthink-item://B1CB2E8F-5D04-49EE-8274-043871389D28?page=28) ## pid - 35Q: [RLQ pain in 22y old Female](x-devonthink-item://B9F58929-18E6-4557-B393-263A6C98DFEF?page=10) -- [Answer](x-devonthink-item://DE4A2FC7-79D2-4B5D-805E-E481F1189654?page=9) ## ppe - 36Q: [MERS](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=12) -- [Answer](x-devonthink-item://FD716379-1A77-4B5B-B257-1154995ECA6E?page=6) ## rsi - 37Q: [Altered level of consciousness](x-devonthink-item://D4C19F6F-0718-4AD7-BDC4-34B460451B98?page=9) -- [Answer](x-devonthink-item://736EC9CD-AC9C-4588-BA1E-F4AD190CBA47?page=17) - 38Q: [Unwell Neonate](x-devonthink-item://1EA9311E-0B9E-49F7-8D6E-4C4187A838C4?page=27) -- [Answer](x-devonthink-item://B1CB2E8F-5D04-49EE-8274-043871389D28?page=17) - 39Q: [Child with Difficult Airway](x-devonthink-item://7E9EF652-F67B-42C5-A536-2EE85BA1954F?page=20) -- [Answer](x-devonthink-item://2DE5FACA-6D8F-41A2-8EAA-8DFE1E76FA61?page=12) - 40Q: [Acute Respiratory Failure](x-devonthink-item://7E9EF652-F67B-42C5-A536-2EE85BA1954F?page=47) -- [Answer](x-devonthink-item://2DE5FACA-6D8F-41A2-8EAA-8DFE1E76FA61?page=30) - 41Q: [Severe Asthma Requiring Intubation](x-devonthink-item://73409C77-B2FA-4E0A-AEB3-5EB284457F0C?page=34) -- [Answer](x-devonthink-item://5A848952-80E3-4184-B553-368412A69917?page=24) - 42Q: [Unwell Neonate](x-devonthink-item://CDB16617-3785-40E5-B8BE-5668D2D7A3E7?page=19) -- [Answer](x-devonthink-item://A6CA01E8-9551-45E7-8617-441BE3DBB5D7?page=15) ## trauma - 43Q: [Traumatic arrest](x-devonthink-item://1A14F7A1-E434-47A6-BC68-AF2DD1A7C090?page=16) -- [Answer](x-devonthink-item://736EC9CD-AC9C-4588-BA1E-F4AD190CBA47?page=38) - 44Q: [Open ankle fracture](x-devonthink-item://09493372-578D-4C97-972A-EEC617B38B53?page=8) -- [Answer](x-devonthink-item://A0D348CE-FCD4-4ECD-BE21-6CA73F6DE8CD?page=4) - 45Q: [Motorbike accident](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=46) -- [Answer](x-devonthink-item://FD716379-1A77-4B5B-B257-1154995ECA6E?page=30) - 46Q: [Motorcycle Vs Kangaroo](x-devonthink-item://73409C77-B2FA-4E0A-AEB3-5EB284457F0C?page=36) -- [Answer](x-devonthink-item://5A848952-80E3-4184-B553-368412A69917?page=25) ## ttp - DUPLICATE Q: [Thrombocytopenia](x-devonthink-item://1A14F7A1-E434-47A6-BC68-AF2DD1A7C090?page=1) -- [Answer](x-devonthink-item://736EC9CD-AC9C-4588-BA1E-F4AD190CBA47?page=25) ## xr - 47Q: [Sore elbow, missed diagnosis](x-devonthink-item://B9C99BB4-DAF8-4D15-BBD3-40E82B279902?page=8) -- [Answer](x-devonthink-item://DF848F67-27AB-450A-988B-159784B72957?page=8)