JBL Trauma

Which of the following injuries has the potential to produce the greatest amount of internal blood loss? A) Pelvic fracture B) Femur fracture C) Tibial fracture D) Humeral fracture

A (The pelvis is an incredibly vascular bone. In addition to the fact that numerous major blood vessels lie nearby, a pt can lose multiple liters of blood into the pelvic cavity. A single femur fx is capable of producing ~1-1.5 L of blood loss. An isolated humeral fx could cause a loss of blood up to 750mL. Tibial fx fo not produce significant internal blood loss)

Appropriate treatment for a patient with widespread full-thickness burns includes: A) dry, sterile dressings; and keeping the patient warm. B) dry, sterile dressings; burn ointment, and cooling the patient. C) moist, sterile dressings; and keeping the patient warm. D) moist, sterile dressings; burn ointment; and cooling the patient

A (Treatment: high-flow O2 [or assisted ventilations if needed]; dry, sterile dressings; thermal management; and providing rapid transport)

What type of injury occurs when a joint is twisted or stretched beyond its normal range of motion, resulting in swelling but no deformity? A) Sprain B) Strain C) Fracture D) Dislocation

A A sprain occurs when a joint is twisted or stretched beyond its normal range of motion. As a result, the supporting capsule and ligaments are stretched or torn, resulting in injury to the ligaments, articular cartilage, synovial membrane, and tendons crossing the joint. Signs of a sprain include pain, swelling, ecchymosis, and increased motion of the joint. While a sprain is considered to be a partial dislocation, it is not associated with deformity. A dislocation is a disruption of a joint in which the bond ends are no longer in contact. The supporting ligaments are often torn, usually completely, allowing the bone ends to separate from each other; this results in deformity of the joint. A strain (pulled muscle) is a stretching or tearing of the muscle and/or tendon, causing pain, swelling, and bruising of the soft tissues in the area; deformity does not occur with a strain. A fracture is a break in the continuity of the bone. Non-displaced fractures may not be associated with deformity, whereas displaced fractures typically are. It takes radiographic evaluation to definitely determine the type of musculoskeletal injury a patient has; therefore, the EMT should treat any musculoskeletal injury as though an underlying fracture is present.

Following a head injury, a young woman is semiconscious and is bleeding from the nose and left ear. You should: A) place a pressure dressing over her ear to prevent blood loss. B) cover her ear and nose with a loose gauze pad to collect the blood. C) control the bleeding from her nose by pinching her nostrils closed. D) insert a nasal airway to keep her tongue from blocking the airway.

B Blood draining from the ears or nose following a head injury may contain cerebrospinal fluid (CSF) and indicates a skull fracture. In these cases, do NOT attempt to stop the flow of blood. Applying excessive pressure may force the blood leaking from the ears or nose to collect within the cranium, which could increase intracranial pressure and cause permanent damage. Loosely cover the ears or nose with a sterile gauze pad to collect the blood and help keep contaminants out (patients with a skull fracture and CSF leakage are at risk for meningitis). The nasopharyngeal (nasal) airway is contraindicated in patients with a possible skull fracture, especially if blood is draining from the nose. Although rare, the airway adjunct may inadvertently enter the cranial vault through the fracture.

A man was kicked in the head and chest and stabbed in the abdomen. He is conscious, but restless, and is coughing up blood. His breathing is rapid and shallow, his skin is cool and pale, and his pulse is rapid and weak. The EMT should recognize that this patient's signs and symptoms are MOST likely the result of: A) a non-patent airway. B) internal hemorrhage. C) a spinal cord injury. D) severe brain trauma.

B The classic symptoms of hemorrhagic shock are present in this patient. He is restless, tachypneic, tachycardic, pale, and diaphoretic. The EMT should suspect that he is bleeding into his abdomen, chest, or both. Although the patient's rapid, shallow breathing may be inadequate, there is no evidence that his airway is non-patent. Although a head injury cannot be ruled out, the patient's symptoms are not indicative of what you would expect to encounter with severe brain trauma (ie, decreased LOC, hypertension, bradycardia, irregular breathing, posturing). Spinal cord injury is also unlikely as the signs of neurogenic shock (ie, warm, dry skin; normal [or slow] heart rate) are not present.

A 40-year-old man has burns to the entire head, anterior chest, and both anterior upper extremities. Using the adult Rule of Nines, what percentage of his total body surface area has been burned? A) 18% B) 27% C) 36% D) 45%

B Using the adult Rule of Nines, the head accounts for 9% of the total body surface area (TBSA), the anterior chest for 9% (the entire anterior trunk [chest and abdomen] accounts for 18%), and the anterior upper extremities for 4.5% each (each entire upper extremity is 9% of the TBSA). On the basis of this, the patient has sustained 27% TBSA burns.

A 23-year-old male was struck across the face with a baseball bat. His eyes are swollen shut, he has massive facial bruising and deformities, and he has blood in his mouth. Your MOST immediate concern should be: A) spinal trauma. B) intracranial bleeding. C) airway compromise. D) permanent vision loss.

C

During your assessment of a patient with a gunshot wound to the chest, you note that his skin is pale. This finding is the result of: A) a critically low blood pressure. B) a significantly elevated heart rate. C) decreased blood flow to the skin. D) peripheral dilation of the vasculature.

C (When the body attempts to compensate for shock, peripheral vasoconstriction shunts blood away from the skin to the more vital organs in the body such as the brain, heart, lungs, and kidneys. When there is minimal or no peripheral blood flow, the skin assumes a pale appearance. By contrast, when peripheral circulation increases [vasodilation], the skin assumes a red [flushed] appearance. Pallor does not necessarily indicate hypotension. Tachycardia is a compensatory response of the nervous system in an attend two increase cardiac output and maintain adequate perfusion)

Following blunt injury to the anterior torso, a patient is coughing up bright red blood. You should suspect: A) intra-abdominal bleeding. B) gastrointestinal bleeding. C) bleeding within the lungs. D) severe myocardial damage

C Hemoptysis (coughing up blood) is a finding that suggests injury to or bleeding within the lungs. Vomiting of bright or dark red blood (hematemesis) suggests gastrointestinal bleeding. Intra-abdominal bleeding following trauma presents with signs of shock as well as abdominal pain, guarding, rigidity, bruising, or distention. Injury to the myocardium may cause cardiac dysrhythmias, but typically does not cause hemoptysis unless it is associated with pulmonary (lung) injury.

Emergency care for a 68-year-old male with partial- and full-thickness burns to his chest and upper extremities includes all of the following, EXCEPT: A) preparing to assist the patient's ventilations. B) covering the burns with dry, sterile dressings. C) avoiding the use of burn ointments or antiseptics. D) flushing the burns with cool water for 10 minutes.

D

An elderly woman complains of pain to her right groin area after she fell. Her right leg is shortened and externally rotated. Which of the following would be the MOST effective way of stabilizing her injury? A) Bind her legs together and position her on her left side B) Apply a long board splint and secure her to the stretcher C) Apply a traction splint and secure her to a long backboard D) Place her on a scoop stretcher and pad her hip with pillows

D (Traction splints are used on pts with a mid-shaft femur fracture; they should be avoided in pts with proximal or distal femur fractures)

Emergency care for a 68-year-old man with partial- and full-thickness burns to his chest and upper extremities includes all of the following, EXCEPT: A) preparing to assist the patient's ventilations. B) covering the burns with dry, sterile dressings. C) avoiding the use of burn ointments or antiseptics. D) flushing the burns with cool water for 10 minutes.

D Unless the patient is on fire, do not apply water to a full-thickness (third-degree) burn, especially if the patient is already prone to hypothermia and infection (ie, older adults, small children). Cover the burns with dry, sterile dressings or a sterile burn sheet. The use of burn creams, ointments, or antiseptics should be avoided; these increase the risk of infection and will only need to be removed at the hospital. Apply high-flow oxygen, treat any associated injuries, and rapidly transport the patient. If the patient is breathing inadequately (eg, fast or slow rate, shallow breathing [reduced tidal volume]), assist ventilations with a bag-mask device.

Which of the following BEST describes the mechanism of injury? A) The energy of an object in motion B) The way in which traumatic injuries occur C) Your concern for potentially serious injuries D) The product of mass, force of gravity, and height

B The mechanism of injury (MOI) is the way in which traumatic injuries occur; it describes the forces (or energy transmission) acting on the body that cause injury. Index of suspicion is your concern for potentially serious underlying and unseen (occult) injuries, which is based on your assessment of the MOI. A significant MOI (eg, fall from a significant height, ejection from a motor vehicle) should increase your index of suspicion for serious injuries. The energy of an object in motion is called kinetic injury. Potential injury is the product of mass (weight), force of gravity, and height; it is mostly associated with the energy of falling objects.

You are dispatched to the scene of a motorcycle crash. Upon arrival, you find the patient lying face down approximately 25 feet from his bike. He is not wearing a helmet and is moaning. You should: A) apply a cervical collar. B) stabilize his head manually. C) log roll him into a supine position. D) evaluate the status of his airway.

B The mechanism of injury for this patient was significant. In his present position (prone), you cannot effectively assess his airway. Therefore, your first action should be to manually stabilize his head. Then, you must log roll him into a supine position, keeping his head in an in-line position. If possible, log roll him directly onto a long backboard. After the patient is supine, assess the status of his airway, assess his breathing adequacy, administer high-flow oxygen or begin assisted ventilations if needed, and continue with your primary assessment. Apply a cervical collar as soon as possible, but assess his posterior neck first.

A 42-year-old man was ejected from his car after it struck a bridge pillar at a high rate of speed. You find him in a prone position approximately 50 feet from his car. He is not moving and does not appear to be breathing. You should: A) assess his breathing effort. B) manually stabilize his head. C) administer high-flow oxygen. D) use the jaw-thrust maneuver.

When a trauma pt is found in a prone position, especially if he or she is unresponsive, your first action should be to manually stabilize his or her head; the pt may have a spinal injury. Next, log roll the pt to a supine position [while continuing to manually stabilize the head], open the airway with the jaw-thrust maneuver, clear the airway with suction if needed, and assess for breathing)

Which of the following injury mechanisms is associated with hangings? A) Distraction B) Subluxation C) Axial loading D) Hyperextension

A Injury to the cervical spine following a hanging occurs via distraction, or stretching, of the vertebrae and spinal cord. A subluxation is a partial or incomplete dislocation; it is an injury, not an injury mechanism. Injuries related to hyperextension mechanisms are common in patients who strike their head on the windshield during a motor vehicle crash. Axial loading is a mechanism of injury in which the spinal column is compressed vertically. Injuries caused by axial loading include cervical spine injuries after diving head first into shallow water and lumbar spine injuries after a fall from a significant height in which the patient lands feet first.

Internal or external bleeding would be especially severe in a patient: A) with hemophilia. B) who takes aspirin. C) with heart disease. D) who is hypotensive.

A Hemophilia is a condition in which the patient lacks one or more of the blood's clotting factors. There are several forms of hemophilia, most of which are hereditary and some of which are severe. Sometimes bleeding occurs spontaneously in patients with hemophilia. Because the patient's blood does not clot, all injuries, no matter how minor they appear, are potentially serious. Aspirin does not destroy the blood's clotting factors; it decreases the ability of platelets to stick together. Although this may cause prolonged bleeding time, the patient with hemophilia, who lacks key clotting factors, will bleed for a much longer period of time. Many patients with heart disease take aspirin daily to prevent clot formation in a coronary artery. When blood pressure is low (hypotension), the driving force of the blood through the blood vessels is reduced; as a result, bleeding tends to be less severe relative to patients with high blood pressure. Unfortunately, hypotension indicates decompensated shock.

After covering a large open chest wound with an occlusive dressing, it becomes necessary to ventilate the patient with a bag-mask device. What should you do? A) Remove the occlusive dressing. B) Ventilate with greater volume. C) Ventilate at 24 breaths/min. D) Request a paramedic intercept.

A If it becomes necessary to ventilate a patient after covering an open chest wound, you should remove the occlusive dressing. With the wound closed, positive pressure ventilation will quickly increase intrathoracic pressure, resulting in a tension pneumothorax. Ventilating the patient with greater volume and/or a faster rate would only cause a more rapid increase in pleural tension and should be avoided. Excessive ventilation can also reduce venous return to the heart, causing a decrease in perfusion. Consider requesting a paramedic intercept, as long as it does not cause a delay in transporting the patient to a trauma center

Following blunt trauma to the chest, a 33-year-old man has shallow, painful breathing. On assessment, you note that an area to the left side of his chest collapses during inhalation and bulges during exhalation. These are signs of a/an: A) flail chest. B) pneumothorax. C) isolated rib fracture. D) pulmonary contusion.

A If two or more ribs are fractured in two or more places or if the sternum is fractured along with several ribs, a segment of the chest wall may be detached from the rest of the thoracic cage. This injury is called a flail chest. In a flail chest, the detached portion of the chest wall moves opposite of normal; that is, it moves in during inhalation and out during exhalation (paradoxical motion). Isolated (single) rib fractures are not associated with paradoxical motion because they are usually fractured in only one place. In a pneumothorax, the patient's respirations are often labored; in severe cases, an entire side of the chest may not move at all (asymmetrical chest movement). A pulmonary contusion (bruising of the lung tissue) does not cause paradoxical chest motion unless associated with a flail chest.

A man's arm was amputated during a car crash. The patient is unresponsive; has rapid, shallow breathing; and has a rapid, weak pulse. As you and your partner are treating him, other responders are attempting to locate his severed arm. Which of the following statements regarding this scenario is correct? A) If the patient's arm has not been recovered by the time you are ready to transport, you should transport without delay. B) Quickly move the patient to the ambulance, continue treatment, and wait for the other responders to recover his arm. C) You should transport the patient immediately, even if the other responders recover his arm before you depart the scene. D) Your priority should be to recover the man's arm because a vascular surgeon may be able to successfully reattach it.

A Life over limb! The patient is in shock and requires transport without delay. If the severed arm is recovered before you depart, take it with you. Otherwise, your priorities are to provide aggressive shock treatment and transport the patient to a trauma center. If the limb is recovered after you depart the scene, another provider can transport it to the trauma center, ensuring that it is wrapped in sterile dressings and kept cool.

Injury to which of the following organs would MOST likely cause hemorrhagic shock? A) Liver B) Kidney C) Stomach D) Bladder

A The liver is a large vascular organ that holds a significant amount of blood at any given time. Following abdominal trauma, liver injuries can be a source of significant blood loss and hemorrhagic shock. Although the kidneys are also solid organs, they are not as vascular as the liver; kidney injuries can contribute to hemorrhagic shock but are less commonly the sole cause. The stomach and bladder are hollow organs. Hollow organs, when injured, spill their contents into the abdominal cavity, resulting in intense peritoneal irritation and inflammation (peritonitis). The most significant complication associated with peritonitis is infection.

Assessment of a trauma patient reveals paradoxical movement to the left side of his chest. The patient is conscious, but restless, and is experiencing severe pain. His breathing is rapid and shallow and his pulse is rapid and weak. The EMT should: A) ventilate the patient with a bag-mask device. B) position the patient on the injured side and transport. C) administer high-flow oxygen via nonrebreathing mask. D) stabilize the unstable chest wall with bulky dressings.

A The patient in this scenario has a flail chest and inadequate ventilation (ie, rapid, shallow [reduced tidal volume] breathing). A flail chest occurs when several ribs are fractured in more than one place; the result is a free-floating section of ribs (flail segment) that collapses during inhalation and bulges out during exhalation (paradoxical chest movement). As the flail segment collapses, the lung is compressed and ventilation is impaired. Treatment should include positive pressure ventilation and prompt transport. In the past, treatment included splinting of the flail segment with bulky dressings; however, restricting chest wall movement is no longer recommended and positive pressure ventilation is now preferred

While assessing a patient who was ejected from his truck, the EMT notices that his chest collapses and his abdomen rises during inhalation. What should the EMT suspect? A) Spinal cord injury B) Fractured sternum C) Ruptured diaphragm D) Intraabdominal bleeding

A The patient is exhibiting diaphragmatic breathing, which explains why his abdomen moves but his chest does not. This indicates a spinal cord injury below the C5 level. The phrenic nerves, which innervate the diaphragm, arise from C3-C5. However, the intercostal nerves, which arise from below the C5 level, have been interrupted; this would explain the absence of chest wall movement. A fractured sternum, depending on the severity of the fracture, would be expected to cause the chest to collapse during inhalation and bulge during exhalation, similar to a flail chest. A ruptured diaphragm would be expected to present with a scaphoid (concave) abdomen and decreased abdominal movement; in some cases of diaphragmatic rupture, bowel sounds may be auscultated over the lung fields (usually the left side). Intraabdominal bleeding would present with a rigid, distended abdomen; it would not explain this patient's abnormal chest and abdominal movement.

Following blunt force trauma to the anterior chest, a man presents with difficulty breathing, distended jugular veins, absent breath sounds over the left side of the chest, and hypotension. Which of the following BEST describes the pathophysiology of this patient's injury? A) Increased pressure in the pleural space is compressing the great vessels B) Blood is filling the pleural space and is collapsing the lung on the left side C) Blood is filling the pericardial sac and is restricting cardiac relaxation D) The aorta has been injured and blood is rapidly filling the thoracic cavity

A The patient is experiencing a tension pneumothorax. This type of injury occurs when air fills the pleural space and progressively collapses the lung. In the process, the vena cavae are compressed and blood return to the heart is reduced; clinically, this manifests as jugular vein distention because blood is backing up into the systemic venous system. If blood return to the heart is reduced, the amount of blood that leaves the heart will also be reduced; as a result, cardiac output falls and the patient becomes hypotensive. Breath sounds are markedly decreased or absent on the affected side of the chest because the lung is being collapsed. In a hemothorax, blood fills the pleural space instead of air. Breath sounds are decreased or absent on the affected side; however, because the patient is losing blood volume into the chest, the jugular veins would be collapsed, not distended as they are with a tension pneumothorax. Pericardial tamponade also causes jugular vein distention; however, the patient's breath sounds are equal bilaterally (unless a pneumothorax is also present). Aortic injury would be expected to cause collapsed jugular veins; like the hemothorax, the patient is losing blood volume into the chest cavity. By itself, aortic injury does not cause unequal breath sounds

Which of the following injury mechanisms and clinical findings would MOST likely warrant transport to a facility that provides the highest level of trauma care? A) Motorcycle crash; pelvic instability; systolic BP of 80 mm Hg B) Fall from a standing position; no loss of consciousness; GCS of 14 C) Small-caliber gunshot wound to the calf; heart rate of 110 beats/min D) Rollerblade accident; humeral fracture; heart rate of 100 beats/min

A Transport destinations for trauma patients are based on the 2011 Centers for Disease Control and Prevention (CDC) guidelines for the field triage of injured patients. Regional protocols may be developed; however, they generally follow the CDC guidelines. Injuries or clinical findings that warrant transport to a facility that provides the highest level of trauma care include a GCS that is equal to or less than 13 following trauma; a systolic BP less than 90 mm Hg; a respiratory rate less than 10 or greater than 29 breaths/min, or the need for ventilatory support; all penetrating injuries to the head, neck, torso, or extremities proximal to the to the knee or elbow; chest wall instability or deformity (eg, flail chest); two or more proximal long bone fractures; a crushed, degloved, mangled, or pulseless extremity; amputation proximal to the ankle or wrist; pelvic fractures; open or depressed skull fracture; and paralysis. The motorcycle rider meets two of these criteria; he has pelvic instability and a systolic BP less than 90 mm Hg. The EMT should be familiar with the trauma triage criteria in his or her jurisdiction.

Appropriate treatment for a patient with widespread full-thickness burns includes: A) dry, sterile dressings; and keeping the patient warm. B) dry, sterile dressings; burn ointment, and cooling the patient. C) moist, sterile dressings; and keeping the patient warm. D) moist, sterile dressings; burn ointment; and cooling the patient.

A Treatment of a patient with full-thickness burns includes high-flow oxygen (or assisted ventilations if needed); dry, sterile dressings; thermal management (keep the patient warm); and providing rapid transport. Moist, sterile dressings should not be applied to full-thickness burns, as they increase the risks of hypothermia and infection. Do not apply ointments, creams, or any other substance to the burn; this will just have to be removed at the hospital and may increase the risk for infection.

A trauma patient opens his eyes slightly and moans when the EMT applies a painful stimulus. When the EMT palpates the patient's arm, he pulls it away. His Glasgow Coma Scale (GCS) score is: A) 7 B) 8 C) 9 D) 10

B (2 for eye opening: pt opens his or her eyes in response to pain. 2 for verbal response: pt moans or makes unintelligible sounds. 4 for motor response: pt withdraws from pain)

A soft-tissue injury that results in a flap of torn skin is called a/an: A) incision. B) avulsion. C) abrasion. D) laceration.

B An avulsion is a soft-tissue injury in which a portion of the skin is torn away, leaving a flap of skin. A laceration is a jagged soft-tissue injury that can be caused by glass or other sharp objects. An abrasion is the scraping away of the epidermis, causing oozing of serous fluid from the capillary bed. Road rash is a classic example of an abrasion. An incision is similar to a laceration, but has smooth edges. Scalpels or knives are examples of instruments that would make an incision.

A woman struck the steering wheel with her chest when her car collided with a tree. She is conscious and alert; however, she is tachypneic and diaphoretic and her pulse is rapid and irregular. What should you do? A) Apply the AED and administer oxygen. B) Administer oxygen and protect her spine. C) Administer oxygen and position her on her side. D) Ventilate with a bag-mask device and apply a cervical collar

B Based on the mechanism of injury and the patient's clinical presentation (especially her rapid, irregular pulse), a myocardial contusion should be suspected. Large myocardial contusions can reduce the pumping function of the heart, resulting in shock. One cannot diagnose a myocardial contusion in the prehospital setting, and there is no specific treatment for this type of injury; therefore, prompt transport is essential. Treatment for the patient in this scenario includes supplemental oxygen (nasal cannula or nonrebreathing mask, depending on her oxygen saturation), spinal motion restriction (ie, cervical collar, backboard, etc.), and keeping her warm. A lateral recumbent position would likely not be comfortable for her. She does not require ventilation assistance at this point. The AED is not indicated because she is not in cardiac arrest.

A man was struck in the head with a baseball bat. He is unresponsive, his breathing is slow and irregular, and his pulse is slow and bounding. What should you do? A) Insert a nasopharyngeal airway and give oxygen via nonrebreathing mask. B) Insert an oropharyngeal airway and ventilate with a bag-mask device. C) Administer oxygen via nonrebreathing mask and elevate his legs 6 to 12 inches. D) Administer oxygen via nasal cannula and elevate his torso to a 45-degree angle.

B Based on the mechanism of injury and the patient's signs and symptoms, you should suspect that he has a significant closed head injury with increasing intracranial pressure. Since he is unresponsive, you should insert an airway adjunct to obtain a patent airway; the oropharyngeal airway would be the best choice since nasopharyngeal airways should generally be avoided in patients with a head injury. Slow, irregular breathing is not adequate and should be treated with bag-mask ventilation; ventilate the patient at a rate of 10 breaths/min. Hypoxia can have disastrous effects on a patient with a severe head injury, so be sure to attach supplemental oxygen to the bag-mask device. Elevating the patient's lower extremities should be avoided; doing so may further increase intracranial pressure. Instead, consider elevating the patient's head and torso to 30 degrees.

A 30-year-old woman has an open deformity to her left leg and is in severe pain. She is conscious and alert, has a patent airway, and is breathing adequately. Your primary concern should be: A) administering high-flow oxygen. B) controlling any external bleeding. C) assessing pulses distal to the injury. D) covering the wound to prevent infection.

B Initial care for any open injury involves controlling external bleeding. Further care involves manually stabilizing the injury site; applying a sterile dressing to keep gross contaminants from entering the wound; assessing distal perfusion (eg, a pulse), motor, and sensory functions; and stabilizing the injury with an appropriate splint. The patient in this scenario is conscious and alert, has a patent airway, and is breathing adequately. Depending on other assessment findings, oxygen may be indicated. Your primary concern, however, should be to ensure that all external bleeding has been controlled.

A woman has a closed fracture to her midshaft tibia. You splinted the injury and are monitoring her during transport. During reassessment, she complains of rapidly increasing pain and you note that her leg is pale and cool. What should you suspect? A) The splint was applied too loosely B) She is developing compartment syndrome C) The fracture is accompanied by a dislocation D) She has another injury proximal to the tibia

B Compartment syndrome occurs when expanding, bleeding muscle increases pressure within the osteofascial compartment, the space in between the muscle and fascia. Because the fascia expands very little, increased compartment pressure can impair distal circulation (essentially, compartment syndrome is like an internal tourniquet). Compartment syndrome commonly develops in patients with injuries distal to the elbow and knee. This is because there are two bones in these areas and numerous muscle compartments. A hallmark sign of compartment syndrome is disproportionate pain; the patient's pain is worse that you would expect for the injury. As the condition develops, the extremity may become pale and cool to the touch, and the patient may complain of numbness and tingling (parasthesia) The skin over the injury may also become very tight. Eventually, the patient may lose all distal circulation, and potentially, their extremity. Prehospital treatment involves recognizing the developing signs and promptly transporting the patient to an appropriate facility. Treatment at the hospital involves a procedure called a fasciotomy, which is usually performed by a surgeon. A splint that is applied too tightly could also cause signs and symptoms similar to compartment syndrome, namely pallor; cool skin distal to the splint; and weak or absent distal pulses. Simply loosening the splint until distal circulation improves is often all that is needed. Fracture/dislocations occur at the joints, not the midshaft of a bone. There is no evidence to suggest that she has another injury proximal to the tibia; furthermore, the presence of one would not explain her symptoms.

A 78-year-old woman reports pain to her right groin area after she fell. Her right leg is straight but is externally rotated and shorter than the left. The EMT should suspect a: A) pelvic girdle fracture. B) proximal femur fracture. C) posterior hip dislocation. D) symphysis pubis fracture.

B Fractures of the proximal (upper) end of the femur are common fractures, especially in older patients and patients with osteoporosis. Although these fractures are often called hip fractures, they rarely involve the hip joint. Instead, the fracture occurs at the neck of the femur. Patient with displaced fractures of the proximal femur present with a very characteristic deformity. The leg is straight but is externally rotated and shorter than the uninjured leg. Pain is typically located in the hip region or in the groin or inner aspect of the thigh. Posterior dislocation of the hip most commonly occurs as a result of a motor vehicle crash in which the knee meets with a direct force, such as the dashboard, and the entire femur is driven posteriorly, dislocating the hip joint. Patients with a posterior hip dislocation typically lie with the hip joint flexed (the knee joint drawn up toward the chest) and the thigh rotated internally. Pelvic fractures, including those of the symphysis pubis, typically do not cause shortening or lengthening of an extremity, nor are they typically associated with internal or external rotation of the legs. Fracture of the symphysis pubis is characterized by palpable pain over the pubic bone

A 44-year-old man has a traumatic leg amputation just below the knee. He is lying in a large pool of blood and the wound is bleeding profusely. The EMT should: A) locate the femoral artery and apply pressure to it until the bleeding stops. B) cover the wound with a trauma dressing and apply a proximal tourniquet. C) apply an icepack to the wound to constrict the vessels and stop the bleeding. D) apply a pressure dressing and elevate the injured extremity at least 12 inches.

B In most cases, external bleeding can be controlled with direct pressure and a securely placed pressure dressing. However, if this is unsuccessful, you should apply a proximal tourniquet immediately or the patient will bleed to death. Of the options listed, covering the wound with a trauma dressing (while applying direct pressure) and then applying a proximal tourniquet will be the most effective means of controlling this severe hemorrhage. Evidence has shown that locating and applying adequate pressure to an arterial pressure point is often difficult and time-consuming; the patient in this scenario does not have that kind of time!

A patient is unresponsive with snoring respirations. His arm is amputated just above the elbow and is bleeding heavily. The EMT should: A) open the patient's airway. B) apply a proximal tourniquet. C) administer high-flow oxygen. D) ventilate with a bag-mask device.

B Major hemorrhage kills patients faster than a compromised airway, so in this case, bleeding control has the highest priority. The EMT should apply a proximal tourniquet and stop the bleeding immediately. Attention can then turn to the patient's airway and breathing status. As with any patient, treatment priorities must focus on injuries or conditions that will be the MOST immediately fatal.

An unresponsive patient with multi-system trauma has slow, shallow breathing; weak radial pulses; and severe bleeding from a lower extremity wound. You should direct your partner to: A) radio for a paramedic ambulance to respond to the scene. B) assist the patient's ventilations while you control the bleeding. C) apply oxygen via nonrebreathing mask while you control the bleeding. D) prepare the long spine board and straps for rapid spinal immobilization.

B The goal of the primary assessment is to rapidly identify and correct all life-threatening injuries or conditions. In the case of this patient, as your partner maintains in-line cervical spine control, he or she should assist the patient's ventilations. An unresponsive patient with slow, shallow breathing is not breathing adequately and should be treated with ventilatory assistance, not a nonrebreathing mask. As your partner is managing the patient's airway and providing ventilatory assistance, you should apply direct pressure (or a tourniquet, if needed) to the extremity wound to control the bleeding. It is important for you and your partner to work together so that all life threats can be corrected as soon as possible. Most EMS systems work with two-person crews and do not have the luxury of a third EMT. If the police or fire department is on the scene, you can ask them to gather equipment for you. The request for an ALS ambulance is based on factors such as the patient's condition and transport time to the closest appropriate hospital

A 70-year-old woman fell and struck her head two days ago, but did not seek medical attention. Today, she is confused, is vomiting, and has slurred speech. The EMT should suspect a/an: A) epidural hematoma. B) subdural hematoma. C) intracerebral hematoma. D) acute ischemic stroke.

B This case is classic for a subdural hematoma. A subdural hematoma occurs when bleeding occurs between the dura mater (the outer meningeal layer) and the surface of the brain; it is typically caused by venous bleeding. As such, subdural hematomas often do not present with symptoms until several hours, or even days, have past since a head injury. By contrast, epidural hematoma, bleeding between the skull and dura mater, is usually caused by arterial bleeding; patients with this type of injury usually present with symptoms immediately following the injury. Intracerebral hemorrhage, bleeding within the brain itself, would also be expected to produce immediate symptoms. While acute ischemic stroke could also explain this patient's symptoms, the fact that she recently experienced a head injury makes the diagnosis of a subdural hematoma more likely.

A 42-year-old man was ejected from his car after it struck a bridge pillar at a high rate of speed. You find him in a prone position approximately 50 feet from his car. He is not moving and does not appear to be breathing. You should: A) assess his breathing effort. B) manually stabilize his head. C) administer high-flow oxygen. D) use the jaw-thrust maneuver

B When a trauma patient is found in a prone (face-down) position, especially if he or she is unresponsive, your first action should be to manually stabilize his or her head; this action is based on the assumption that the patient has a spinal injury. Next, log roll the patient to a supine position (while continuing to manually stabilize the head), open the airway with the jaw-thrust maneuver, clear the airway with suction if needed, and assess for breathing. It would be extremely difficult to adequately open the patient's airway while he or she is in a prone position. Depending on the patient's breathing effort, administer high-flow oxygen or ventilate using a bag-mask device

Which of the following assessment findings is the MOST concerning in a patient with significant burns? A) Severe blisters to both hands B) Closed deformity of the wrist C) Dry cough and a hoarse voice D) Clothes adhered to burned skin

C Any condition or injury that involves airway, breathing, or circulation warrants the EMT's most immediate attention. A dry cough and hoarse voice are signs of inhalation injury and airway swelling. The EMT must carefully monitor the patient and be prepared to ventilate him if his breathing becomes inadequate. Transport the patient without delay; if tactically feasible, a paramedic intercept should be requested. If the patient's airway completely closes, more invasive airway management will be needed (ie, cricothyrotomy). Tend to the other injuries listed during transport to the hospital.

A baseball player was struck in the center of the chest by a line drive and immediately collapsed. He is unresponsive, apneic, and pulseless. The EMT should recognize that the MOST likely cause of this patient's collapse was: A) rupture of the aorta. B) myocardial contusion. C) ventricular fibrillation. D) shearing of the vena cava.

C Commotio cordis is a blunt chest injury caused by a sudden, direct blow to the chest (over the heart) during a critical phase of the person's heartbeat. This can cause immediate cardiac arrest from ventricular fibrillation, which can often be corrected with early defibrillation. Commotio cordis occurs most commonly during sports-related injuries, and has been reported after patients were struck with baseballs, softballs, bats, snowballs, fists, or kicks during kickboxing. The EMT should suspect commotio cordis if a patient presents with cardiac arrest following a sudden, direct blow to the chest. Myocardial contusion can also occur following blunt chest trauma; however, cardiac arrest with this type of injury is uncommon. Great vessel injury (ie, aortic rupture, shearing of the vena cavae) occurs more commonly following rapid deceleration, such as when the chest strikes the steering wheel during a high speed collision or when the patient falls from a significant height.

A 40-year-old man was hit in the nose during a fight. He has bruising under his left eye and a nosebleed. What should you do? A) Place a chemical ice pack over his nose. B) Determine if he has any visual disturbances. C) Ensure that he is sitting up and leaning forward. D) Apply direct pressure by pinching his nostrils together.

C During a nosebleed (epistaxis), much of the blood may pass down the throat into the stomach as the patient swallows; this is especially true if the patient is lying supine. Blood is a gastric irritant; a person who swallows a large amount of blood may become nauseated and vomit, which increases the risk of aspiration. Therefore, your first action should be to ensure that the patient is sitting up and leaning forward. This will prevent blood from draining down the back of the throat. Next, apply direct pressure by pinching the fleshy part of the nostrils together; you or the patient may do this. Placing a chemical ice pack over the nose may further help control the bleeding by constricting the nasal vasculature. After controlling the nosebleed, continue your assessment, which includes assessing for facial deformities and visual disturbances.

Which of the following sets of vital signs is the MOST consistent with hemorrhagic shock? A) BP, 80/40 mm Hg; pulse, 70 beats/min; respirations, 24 breaths/min B) BP, 190/100 mm Hg; pulse, 50 beats/min; respirations, 8 breaths/min C) BP, 88/50 mm Hg; pulse, 120 beats/min; respirations, 28 breaths/min D) BP, 160/70 mm Hg; pulse, 140 beats/min; respirations, 12 breaths/min

C Of the vital sign values listed, hypotension, tachycardia, and tachypnea are the most consistent with hemorrhagic shock. In fact, the presence of hypotension indicates decompensated shock. Hypotension and a normal (or slow) heart rate is consistent with neurogenic shock. Hypertension, bradycardia, and abnormal breathing (Cushing's triad) are consistent with increased intracranial pressure from a head injury. Hypertension, tachycardia, and normal breathing may be observed in a patient with a hypertensive emergency; they are not consistent with hemorrhagic shock.

A patient with a chest injury has a BP of 100/70 mm Hg and a heart rate of 100 beats/min. Reassessment reveals a BP of 90/74 mm Hg, a pulse of 120 beats/min, and the development of jugular venous distention. What should you suspect? A) Massive hemothorax B) Simple pneumothorax C) Pericardial tamponade D) Traumatic aortic rupture

C The EMT should suspect pericardial tamponade. Signs of pericardial tamponade include a narrowing pulse pressure and jugular venous distention (JVD). The first pulse pressure recorded was 30 mm Hg; however, it narrowed to 16 mm Hg during reassessment. The pulse pressure narrows in pericardial tamponade because pressure against the heart prevents full relaxation and filling; as a result, the diastolic BP increases. Because of inadequate ventricular filling, cardiac output decreases; this causes a decrease in the systolic BP. JVD occurs because blood backs up into the systemic venous system. Massive hemothorax and traumatic aortic rupture would not be expected to cause JVD because there is simply not enough blood in the venous system to distend the jugular veins. Simple pneumothorax typically does not present with signs of shock; the patient usually complains of pleuritic chest pain and shortness of breath. However, in some cases, a simple pneumothorax can progress to a tension pneumothorax and cause hemodynamic compromise.

A man was stabbed to the left side of the chest. His skin is cool and clammy, his blood pressure is 90/60 mm Hg, his respirations are 22 breaths/min, and his pulse is 120 beats/min and weak. His breath sounds are equal bilaterally and his jugular veins are distended. What should you do? A) Cover the wound and position him on his left side. B) Ventilate the patient, apply an AED, and transport. C) Cover the wound, administer oxygen, and transport. D) Suspect a pneumothorax and contact medical control

C The mechanism of injury and clinical presentation indicate a pericardial tamponade. Pericardial tamponade occurs when blood fills the pericardial sac and restricts the heart from relaxing. If the heart cannot relax, it cannot fill with blood. If the right side of the heart cannot fill with blood, there is nothing for it to send to the left side of the heart; as a result, the patient's cardiac output drops and shock develops. Signs of pericardial tamponade include muffled or distant heart tones (difficult to assess in the field); a rapid, weak pulse; hypotension; jugular venous distention; and a narrowing pulse pressure (difference between the systolic and diastolic blood pressures). A pneumothorax is unlikely in this patient; his breath sounds are equal bilaterally. Pericardial tamponade is a life-threatening emergency that requires prompt treatment. For this patient, you should cover the wound on his chest, administer oxygen, and transport without delay. Shock patients should be transported supine, not on their side. The AED is not indicated for this patient because he is not in cardiac arrest

When assessing and treating a patient with a gunshot wound, you should routinely: A) apply ice directly to the wound. B) determine why the patient was shot. C) look for the presence of an exit wound. D) evaluate the pulses proximal to the wound.

C When assessing a patient who sustained a gunshot wound, you should routinely look for an exit wound, which may be difficult to find. Exit wounds can be a source of continued bleeding, both externally and internally. They may or may not follow the same path as the entrance wound. This is why it is important to conduct a thorough examination of the patient. Ice can be applied to the wound, but only after the wound has been covered by a sterile dressing and any bleeding has been controlled. Determining why the patient was shot is the responsibility of law enforcement, not the EMT. If the wound is close to an extremity, pulse, motor, and sensory function should be assessed distal to the wound.

A 22-year-old woman fell on her knee and is in severe pain. Her knee is flexed and severely deformed. Her leg is cold to the touch and you are unable to palpate a distal pulse. You should: A) apply gentle longitudinal traction as you straighten her leg and then apply a traction splint. B) place a pillow behind her knee and stabilize the injury by applying padded board splints. C) carefully straighten her leg until you restore a distal pulse and then apply padded board splints. D) manually stabilize her injury and contact medical control for further stabilization instructions.

D A dislocated knee occurs when the proximal end of the tibia completely displaces from its juncture with the distal femur. In some cases, the popliteal artery behind the knee may be compressed, resulting in compromised distal blood flow. Signs of this include absent distal pulses and a pale extremity that is cool or cold. Manually stabilize the knee and assess for distal pulses. If distal pulses are absent, contact medical control immediately for further stabilization instructions. Medical control may instruct you to make ONE attempt to realign the knee to reduce compression of the popliteal artery and restore distal circulation. If you are unable to restore distal circulation or medical control advises you not to manipulate the injury, splint the knee in the position it was found and transport promptly. Traction splints are contraindicated in any injury to or near the knee.

A man's legs were pinned by a steel girder for 5 hours before he was found. He is conscious and alert with stable vital signs but cannot feel his legs. The EMT should anticipate that: A) a surgeon will respond to the scene and amputate the man's legs. B) he will be heavily sedated by paramedics to prevent further pain. C) he will be immediately freed and rapidly transported to the hospital. D) intravenous fluids and certain drugs may be given before he is freed.

D Crush syndrome occurs when a part of the body is pinned by a heavy object for more than 4 to 6 hours, although it can occur earlier. Since circulation distal to the crushed part of the body is minimal or absent, chemicals such as potassium and lactic acid can accumulate to dangerous levels. If the body part(s) is/are suddenly freed, these chemicals can be released into the bloodstream, potentially causing a fatal cardiac dysrhythmia. For this reason, the patient may need intravenous fluids and certain medications before being freed in order to prepare the body for the onslaught of these chemicals. In some cases, especially if the patient is hemodynamically unstable, a surgeon may respond to the scene to perform an emergency amputation. However, in this case, the patient is stable. It would not be advisable to heavily sedate the patient while he is still entrapped as this may cause airway compromise. Sedation may be indicated, however, after the patient has been freed.

A man was struck in the side of the head with a steel pipe. Blood-tinged fluid is draining from the ear and bruising appears behind the ear. The MOST appropriate treatment for this patient includes: A) elevating the lower extremities and providing immediate transport. B) applying high-flow oxygen and packing the ear with sterile gauze pads. C) controlling the drainage from the ear and immobilizing the entire spine. D) immobilizing the spine, administering oxygen, and monitoring for vomiting.

D Patients with significant head injury should be treated by applying high-flow oxygen, assisting ventilations as needed, immobilizing the entire spine, and transporting promptly. Closely monitor the patient for vomiting and be prepared to suction the airway. Elevation of the foot of the spine board may cause more blood to engorge the brain and may increase intracranial pressure (ICP). If possible, you should elevate the patient's torso to 30 degrees in an attempt to lower ICP. You should never attempt to control bleeding or fluid drainage from the ears of a patient with a head injury because this, too, may result in increased ICP. If a patient with an isolated head injury begins showing signs of shock (ie, tachycardia, diaphoresis, tachypnea, hypotension), you should assume that he or she has internal bleeding from another injury and treat accordingly (ie, keep the patient warm and supine).

A patient with a closed head injury opens his eyes in response to pain, is mumbling words that you cannot understand, and pushes your hand away when you apply a painful stimulus. His Glasgow Coma Scale (GCS) score is: A) 6 B) 7 C) 8 D) 9

D The Glasgow Coma Scale (GCS) is a valuable tool used when assessing patients with a neurologic injury. It assesses three parameters: eye opening, verbal response, and motor response. The minimum score on the GCS is 3 and the maximum score is 15. A patient who opens his or her eyes in response to pain would receive a score of 2. Mumbling speech, moaning, or incomprehensible words equate to a score of 2 for verbal response. Localization of a painful stimulus, such as pushing your hand away from the source of pain, equates to a score of 5. Therefore, the patient has a GCS score of 9. It is important to note that a patient's GCS score should be reassessed frequently. Review the entire GCS in your EMT text and commit it to memory!

A 33-year-old man struck a parked car with his motorcycle and was thrown from the motorcycle. He was not wearing a helmet. He is unresponsive and has a depressed area to his forehead, bilaterally deformed femurs, and widespread abrasions with capillary bleeding. Which of the following statements regarding this patient is false? A) You should suspect that the patient has a skull fracture and increased intracranial pressure. B) Femur fractures are a common injury when a rider is thrown from his or her motorcycle. C) Internal hemorrhage cannot be controlled in the field and requires prompt surgical intervention. D) You must stop the bleeding from his abrasions immediately or the patient will die from hypovolemic shock.

D The patient's abrasions (road rash) and capillary bleeding are the least of his problems. Capillary bleeding, blood that oozes from the capillary beds, is the least severe type of external bleeding and will not kill your patient. Wasting time at the scene to cover his abrasions, however, will delay definitive care at a trauma center; this may kill him! The patient likely has a depressed skull fracture, and the fact that he is unresponsive indicates a traumatic brain injury with increased intracranial pressure. When a rider is thrown from his or her motorcycle, the femurs typically strike the handlebars, resulting in unilateral or bilateral fractures. You cannot control internal hemorrhage in the field, regardless of your level of training. Internal bleeding requires surgical intervention; therefore, you must transport the patient without delay.

A young man has multiple injuries after he fell approximately 35 feet. He is semiconscious and has an unstable chest wall, numerous long bone fractures, and a large hematoma to his head. He will have the BEST chance for survival if you: A) request an ALS ambulance. B) give him high-flow oxygen early. C) keep him warm and elevate his legs. D) rapidly transport him to a trauma center.

D When caring for a patient with major trauma, rapid transport to a trauma center is essential and will afford the patient the best chance for survival. This is especially true if the patient has trauma to multiple body systems. Definitive care cannot be provided in the field; this requires resources and personnel at the hospital. Oxygen administration and shock treatment (eg, applying warm blankets, keeping the patient supine) may help delay patient deterioration, thus buying some time; although these measures are important, they are not definitive interventions. In certain situations, it would be prudent to request ALS personnel at the scene (eg, lengthy extrication, unavoidable scene delay); however, in the absence of such extenuating circumstances, it is clearly more important to transport without delay. En route to the trauma center, consider an ALS intercept if it is possible and does not delay transport.

Despite direct pressure, a large laceration continues to spurt large amounts of bright red blood. You should: A) elevate the extremity and apply a tight pressure dressing. B) apply pressure to the pulse point that is proximal to the injury. C) place additional dressings on the wound until the bleeding stops. D) apply a tourniquet proximal to the injury until the bleeding stops.

D You must control any and all external bleeding as soon as possible. In the case of arterial bleeding (ie, bright red blood is spurting from the wound), the patient will bleed to death if immediate action is not taken. In most cases, direct pressure will effectively control external bleeding. However, if the wound continues to bleed profusely despite direct pressure, you should apply a tourniquet proximal to the injury and tighten it until the bleeding stops. Packing additional dressings on a severe external hemorrhage will simply cause the patient to continue to bleed externally into the dressings. Locating and applying adequate pressure to a proximal arterial pressure point is often difficult and time-consuming.

A 44-year-old man experienced burns to his anterior trunk and both arms. He is conscious and alert, but is in extreme pain. Assessment of the burns reveals reddening and blisters. This patient has ________________ burns that cover _____ of his total body surface area. A) first-degree, 27% B) partial-thickness, 36% C) second-degree, 45% D) full-thickness, 18%

Partial-thickness (second-degree) burns damage the epidermis and part of the dermis, and are characterized by blistering and severe pain. Areas of superficial (first-degree) burns, which cause reddening of the skin, commonly surround a partial-thickness burn. The anterior trunk (chest and abdomen) accounts for 18% of the total body surface area (TBSA) and each entire arm accounts for 9%. Therefore, this patient has partial-thickness burns that cover 36% of his TBSA. Full-thickness (third-degree) burns are characterized by charred or white, leathery skin. Because the entire dermis, including the nerves, is destroyed, full-thickness burns are usually painless. The surrounding areas of partial-thickness burns, however, are very painful.

A patient with a spinal injury may still be able to use his or her diaphragm to breathe, but would lose control of the intercostal muscles, if the spinal cord is injured: A) above the C3 level. B) between C1 and C2. C) above the C5 level. D) below the C5 level.

D The nerves that supply the diaphragm (the phrenic nerves) exit the spinal cord at C3, C4, and C5. A patient whose spinal cord is injured below the C5 level will lose the ability to move his or her intercostal muscles (the muscles in between the ribs), but the diaphragm will still function. The patient may still be able to breathe because the phrenic nerves remain intact. Patients with spinal cord injuries at C3 or above often lose their ability to breathe entirely. Remember this: C3, 4, and 5 keep the diaphragm alive.

A construction worker spilled a bag of powdered chemical, covering both of his arms. He complains of intense pain. What should you do? A) Cover his arms with saline-soaked dressings B) Neutralize the chemical with a vinegar solution C) Irrigate his arms with copious amounts of water D) Brush the chemical away from the skin surface

D When caring for a patient who was exposed to a powdered chemical, it is important to brush the chemical from the skin first, then irrigate the site with copious amounts of water. Irrigating the chemical without brushing it off first may cause further injury; also bear in mind that some dry chemicals may react violently with water. Do not try to neutralize the chemical with vinegar, baking powder, or other similar agents; doing so may only cause further injury.

A man was stabbed in the cheek with a dinner fork, and the fork is still impaled in his cheek. He is conscious and alert, breathing adequately, and has blood in his oropharynx. You should: A) apply high-flow oxygen via a nonrebreathing mask, carefully remove the fork, and control any external bleeding. B) suction his oropharynx, control any external bleeding, stabilize the fork in place, and protect it with bulky dressings. C) carefully remove the fork, suction his oropharynx as needed, and pack the inside of his cheek with sterile gauze pads. D) suction his oropharynx, carefully cut the fork to make it shorter, control any external bleeding, and secure the fork in place.

B (An impaled object in the cheek should be removed if it interferes with your ability to manage the pt's airway)

Which of the following is an example of a primary blast injury? A) Depressed skull fracture B) Spinal injury with paralysis C) Stick impaled in the abdomen D) Ruptured tympanic membrane

D Primary blast injuries are a direct result of the pressure wave that occurs during an explosion. Hollow organs are the most susceptible to the primary blast wave, and ruptured tympanic membranes (eardrums) are a common injury. Secondary blast injuries occur when shrapnel and other debris are propelled away from the explosion; impalement injuries occur during this phase. Blunt traumatic injuries (ie, skull fracture, spinal injury) occur during the tertiary blast phase, when the person is propelled away from the explosion and strikes a solid object.

A man was stabbed in the lower right ribcage. He is diaphoretic; his pulse is rapid and weak; and his respirations are regular and unlabored at 24 breaths/min. Which of the following injuries should the EMT suspect? A) Liver laceration B) Ruptured diaphragm C) Massive hemothorax D) Tension pneumothorax

A (The liver is protected by the lower right ribcage. The lungs are not as low in the thoracic cavity. The pt's unlabored breathing tends to point away from a pneumothorax or hemothorax. Although a diaphragmatic injury cannot be ruled out, one would expect a certain degree of respiratory distress)

Assessment of a trauma patient reveals paradoxical movement to the left side of his chest. The patient is conscious, but restless, and is experiencing severe pain. His breathing is rapid and shallow and his pulse is rapid and weak. The EMT should: A) ventilate the patient with a bag-valve-mask device. B) position the patient on the injured side and transport. C) administer high-flow oxygen via nonrebreathing mask. D) stabilize the unstable chest wall with bulky dressings.

A (The pt has flail chest and inadequate ventilation [rapid, shallow {reduced tidal volume} breathing]. A flail chest occurs when several ribs are fractured in more than one place; the rest is a free-floating section of ribs [flail segment] that collapses during inhalation and bulges out during exhalation [paradoxical chest movement]. As flail segment collapses, the lung is compressed and ventilation and prompt transport)

A young male has an open abdominal wound through which a small loop of bowel is protruding. There is minimal bleeding. The BEST way to treat his injury is to: A) apply a sterile trauma dressing moistened with sterile saline directly to the wound and secure the moist dressing in place with a dry sterile dressing. B) apply dry sterile gauze pads to the wound and then keep them continuously moist by pouring sterile saline or water on them throughout transport. C) gently clean the exposed loop of bowel with warm sterile saline, carefully replace it back into the wound, and cover it with a dry sterile dressing. D) cover the wound with a dry sterile trauma dressing and tightly secure it in place by circumferentially wrapping roller gauze around the abdomen.

A (Abdominal evisceration: when a loop of bowel, an organ, or fat protrudes through an open abdominal injury. Some EMS protocols call for an occlusive dressing over the organs, secured b trauma dressings)

A 33-year-old factory worker was crushed between two pieces of machinery. You find him lying supine on the ground complaining of severe pain to his pelvis. He is restless, diaphoretic, and tachycardic. What should you do? A) Prepare for immediate transport B) Perform a detailed secondary exam C) Carefully log roll him to check his back D) Palpate his pelvis to assess for crepitus

A (Based on the MOI and the presence of signs of shock [restlessness, tachycardia, diaphoresis], you should suspect that the pt has a fractured pelvis and is bleeding internally. Therefore, after completing your primary assessment and initiating shock treatment, you should perform a rapid H>T assessment to assess for other injuries and then prepare for transport. You should also avoid palpating his pelvis; this will only cause further pain and may cause additional injury. Palpation of the pelvis is performed to assess stability, not to elicit crepitus. Consider applying a pelvic binder device or tying a sheet around his hips in order to reduce the space within the pelvis; doing so may help slow internal bleeding. A detached secondary exam of a critically injured pt at the scene is not appropriate; it takes too long to perform and should be done en route to the hospital if time permits)

Prior to your arrival at the scene, a young female was removed from a body of water after being submerged for an unknown period of time. You should manage her airway appropriately while considering the possibility of: A) spinal injury. B) hyperthermia. C) internal bleeding. D) airway obstruction.

A (When caring for a pt with a submersion injury [near drowning], you should consider the possibility of a spinal injury. Many water-related incidents occur when a pt dives into shallow water and strikes their head. Water can be aspirated into the lungs, but will not cause an obstruction of the upper airway. Another common finding in pts with a submersion injury is hypothermia. Although it is possible for the pt to have internal bleeding at the same time, especially if they experienced a traumatic injury before the submersion, spinal injuries are more common)

Which of the following assessment findings should alert the EMT that a patient with a closed lower extremity fracture is developing compartment syndrome? A) The pain is greater than one would expect for the injury B) The extremity becomes increasingly warmer and pinker C) The pain subsides during passive stretch of the extremity D) Distal pulses are bounding and reflexes are hyperactive

A (Compartment syndrome develops when edema and swelling result in increased pressure in the compartment between the fascia and muscle, the osteofascial compartment. Because the fascia is limited in the amount it can stretch or expand, pressure increases within the compartment, which in turn interferes with circulation. Compartment syndrome commonly develops in the extremities and may occur in conjunction with open or closed injuries or when swelling occurs under restrictive immobilization devices such as a cast. Hallmark sign of this: disproportionate pain [pain experienced by the pt is greater than one would expect]. The pain worsens during passive stretching of the extremity. Other signs: pallor of the affected extremity, numbness and tingling [parasthesia], and weakening or an absence of distal pulses. This is a time-sensitive emergency)

While assessing a patient who was ejected from his truck, the EMT notices that his chest collapses and his abdomen rises during inhalation. What should the EMT suspect? A) Spinal cord injury B) Fractured sternum C) Ruptured diaphragm D) Intra-abdominal bleeding

A (Diaphragmatic breathing: this explains why his abdomen moves but his chest does not. This indicates a spinal cord injury below C5 level. The phrenic nerves which innervate the diaphragm arise from C3-C5. The intercostal nerves, which arise from below C5 level, have been interrupted; this would explain the absence of chest wall movement. Fractured sternum: depending on the severity of the fracture, would be expected to cause the chest to collapse during inhalation and bulge during exhalation, similar to flail chest. Ruptured diaphragm: expected to present with a scaphoid [concave] abdomen and decreased abdominal movement; in some cases of diaphragmatic rupture, bowel sounds may be auscultated over the lung fields [usually left side]. Intra-abdominal bleeding would present with a rigid, distended abdomen)

Following blunt trauma to the chest, a 33-year-old male has shallow, painful breathing. On assessment, you note that an area to the left side of his chest collapses during inhalation and bulges during exhalation. These are signs of a/an: A) flail chest. B) pneumothorax. C) isolated rib fracture. D) pulmonary contusion.

A (Flail chest: if two or more ribs are fractured in two or more places or if the sternum is fractured along with several ribs, a segment of the chest wall may be detached from the rest of the thoracic cage; the detached portion of the chest wall moves opposite of normal. It moves in during inhalation and out during exhalation [paradoxical motion]. Isolated rib fractures are not associated with paradoxical motion because they are usually fractured in only now place. Pneumothorax: the pt's respirations are often labored; in severe cases, an entire side of the chest may not move at all. Pulmonary contusion: [bruising of there lung tissue] does not cause paradoxical chest motion unless associated with a flail chest)

A 42-year-old man has a large knife impaled in the center of his chest. He is unresponsive, pulseless, and apneic. You should: A) carefully remove the knife, control the bleeding, and begin CPR. B) carefully remove the knife, control the bleeding, and apply the AED. C) secure the knife in place with a bulky dressing and transport immediately. D) stabilize the knife with bulky dressings, begin CPR, and transport at once.

A (If impaled objects interfere with the pt's airway or your ability to perform CPR, they must be removed carefully. Carefully remove the knife, control any external bleeding, begin CPR, and transport immediately. The AED is not indicated for victims of traumatic cardiac arrest. Massive blood loss is the most common cause of traumatic cardiac arrest, not cardiac dysrhythmia)

Assessment of a patient with multisystem trauma reveals decerebrate posturing, rapid irregular breathing, and bradycardia. These clinical signs indicate injury to the: A) brainstem. B) myocardium. C) temporal lobe. D) thoracic spine.

A (Posturing, either decorticate [flexor] or decerebrate [extensor] is an ominous sign in a pt with a head injury because it indicates significant ICP. Posturing in conjunction with an abnormal breathing pattern [central neurogenic hyperventilation, Cheyene-Stokes breathing, ataxic breathing] indicates injury to the brainstem. Cushing's triad [hypertension, bradycardia, abnormal breathing] also indicates significant ICP. Temporal lobe injuries often manifest with loss of fine motor control. In order to posture, the spinal cord must be able to receive signals from the brain; therefore, a thoracic spine injury is unlikely. Myocardial injury would be more likely to present with signs of shock and possibly cardiac dysrhythmias)

A patient experienced blunt trauma to the left upper abdominal quadrant. When he is positioned supine, he experiences severe pain in his left shoulder. Which of the following should the EMT suspect? A) Ruptured spleen B) Lacerated bowel C) Injury to the kidney D) Perforated stomach.

A (Spleen is located in the LUQ. Furthermore, splenic injuries can present with referred pain to the left shoulder [Kehr's sign]. Injury to the kidney would be expected to produce flank pain and possibly hematuria. Injury to the gastrointestinal organs [stomach, bowel] typically do not present with referred pain. When managing a pt with abdominal trauma, especially one who is in shock, your main focus should be initiating appropriate treatment and providing prompt transport to the hospital)

Following blunt force trauma to the anterior chest, a man presents with difficulty breathing, distended jugular veins, absent breath sounds over the left side of the chest, and hypotension. Which of the following BEST describes the pathophysiology of this patient's injury? A) Increased pressure in the pleural space is compressing the great vessels B) Blood is filling the pleural space and is collapsing the lung on the left side C) Blood is filling the pericardial sac and is restricting cardiac relaxation D) The aorta has been injured and blood is rapidly filling the thoracic cavity

A (Tension pneumothorax: occurs when air fills the pleural space and progressively collapses the lung. In the process, the vena cave are compressed and blood return to the heart is reduced; clinically this manifests as JVD because blood is backing up the systemic venous system. If blood return to the heart is reduced, the amount of blood that leaves the heart will also be reduced; as a result, cardiac output falls and pt becomes hypotensive. Breath sounds are markedly decreased or absent on the affected side of the chest because the lung is being collapsed. Hemothorax: blood fills the pleural space instead of air; breath sounds are decreased or absent on the affected side; however, since the pt is losing blood volume into the chest, the jugular veins would be collapse, not distended. Pericardial tamponade: causes JVD, however, the pt's breath sounds are equal bilaterally [unless a pneumothorax is also present]. By itself, aortic injuries does not cause unequal breath sounds)

A patient has an open chest wound, which has been covered with an occlusive dressing. He is receiving oxygen at 12 L/min by nonrebreathing mask. During transport, the patient's heart rate increases, he becomes pale and diaphoretic, and his oxygen saturation falls. What should you do? A) Remove the occlusive dressing B) Ventilate with a bag-mask device C) Increase the oxygen to 15 L/min D) Encourage him to take deep breaths

A (When placing an occlusive dressing over a sucking chest wound [open pneumothorax], it is important to remember that you have converted the injury to a closed pneumothorax. With no way for the air in the pleural space to escape, and depending on the size of the pneumothorax, the pt could develop excessive pleural tension that interferes with circulation [tension pneumothorax]. You should suspect that this is what is happening to the pt in this scenario. Your most immediate action should be to remove the occlusive dressing and allow air to escape from the pleural space. PPV [BVM] in a pt whose open chest injury has been covered with an occlusive dressing may rapidly lead to a tension pneumothorax; therefore, if the pt must be ventilated, the occlusive dressing should be removed)

In contrast to an incision, a laceration: A) is a jagged cut. B) is a superficial injury. C) bleeds more severely. D) usually involves an artery.

A A laceration is a jagged cut caused by a sharp object or a blunt force that tears the tissue, whereas an incision is a sharp, smooth cut. The depth of the injury can vary; it can extend through the skin and subcutaneous tissue or into the underlying muscles and adjacent nerves and blood vessels. Lacerations and incisions can involve arteries, veins, or both, potentially resulting in severe bleeding.

Which of the following patients would be MOST in need of a rapid head-to-toe assessment? A) responsive 22-year-old man with a small-caliber gunshot wound to the abdomen B) A responsive 25-year-old woman who fell 9 feet from a roof and landed on her side C) A 43-year-old woman with a unilaterally swollen, painful deformity of the midshaft femur D) A 60-year-old man who fell from a standing position and has small abrasions on his cheek

A A rapid head-to-toe assessment is indicated for any patient with abnormal findings in the primary assessment or when the mechanism of injury warrants it. Significant mechanisms of injury include falls in the adult of greater than 15 feet (or three times the patient's height); penetrating injuries to the head, neck, chest, or abdomen; and multiple long bone fractures, among others.

Appropriate care for an amputated body part includes : A) laying the wrapped body part on a bed of ice. B) placing it directly on ice to prevent tissue damage. C) keeping the part warm to prevent cellular damage. D) keeping the part at room temperature in a plastic bag.

A Appropriate care for an amputated body part includes wrapping the part in a sterile dressing and placing it in a plastic bag. Follow your local protocols regarding how to preserve amputated parts. In some areas, dry sterile dressings are recommended for wrapping amputated parts; in other areas, dressings moistened with sterile saline are recommended. Put the bag in a container filled with ice. Lay the wrapped part on a bed of ice; do not pack it in ice or place it in direct contact with ice. The goal is to keep the part cool without letting it freeze or develop frostbite. Freezing may cause cellular and tissue damage, which decreases the chance of successful reattachment.

A patient experienced blunt chest trauma and has asymmetrical chest wall movement. This finding indicates: A) decreased air movement into one lung. B) several ribs broken in numerous places. C) shallow breathing secondary to severe pain. D) accumulation of blood in both of the lungs.

A Asymmetrical chest wall movement, when one side of the chest moves less than the other, indicates decreased air movement into one lung (eg, pneumothorax, hemothorax). Bleeding into both lungs and shallow breathing due to severe pain would likely cause decreased movement to both sides of the chest. If more than two ribs are fractured in several places, a free-floating (flail) segment of fractured ribs is created. This flail segment (not necessarily an entire half of the chest) collapses during inhalation and bulges during exhalation; this is called paradoxical chest movement.

A man was stabbed in the right side of the chest, lateral to the nipple. He is tachypneic, tachycardic, and diaphoretic. His jugular veins are collapsed and breath sounds are difficult to hear on the right side. You should suspect a: A) hemothorax. B) ruptured spleen. C) liver laceration. D) pneumothorax.

A Based on the injury location and the patient's clinical presentation, you should suspect a hemothorax. In addition to the lung, there is a TON of vasculature in the thoracic cavity that can easily be injured by a penetrating injury. Because the patient is losing blood, one would expect flattened or collapsed jugular veins and profound shock. In addition, because blood is filling the right hemithorax, breath sounds may be weak or absent on the affected side. Although a liver injury cannot be completely ruled out, the injury is above where the liver is located anatomically. If a pneumothorax is present, it is likely in conjunction with the hemothorax (hemopneumothorax). The spleen is located in the upper left quadrant; this patient's injury is on the right side.

When assessing distal circulation in a patient with a swollen deformed femur, you should: A) palpate for a dorsalis pedis pulse. B) assess the pulse behind the knee. C) touch his foot with a blunt object. D) ask the patient to wiggle his toes.

A Care for a musculoskeletal injury includes assessing distal circulatory, sensory, and motor functions before and after applying a splint. In the case of a femur injury, the dorsalis pedis (pedal) pulse, located on top of the foot, is the most distal pulse relative to the injury. If a pedal pulse can be palpated, circulation distal to the injury is present. The popliteal pulse is located behind the knee; it is proximal to the pedal pulse. Touching the patient's foot and asking him if he can feel it and asking him to wiggle his toes are assessing sensory and motor functions, respectively, not circulatory function.

A hiker fell 25 feet from a ledge. There is obvious deformity to his thoracic spine and he has a large laceration on his forehead. His BP is 60/40 mm Hg, pulse is 50 beats/min, and respirations are 26 breaths/min. His face and chest are pale and cool, but his abdomen and lower extremities are pink and warm. Which of the following BEST describes the pathophysiology of these findings? A) Loss of nervous system control over the systemic vasculature B) Severe bleeding into the thoracic cavity from a ruptured aorta C) Systemic vasoconstriction due to nervous system hyperactivity D) Increased intracranial pressure due to bleeding within the brain

A On the basis of the mechanism of injury and assessment findings, the EMT should suspect that the patient is experiencing neurogenic shock. Neurogenic shock occurs when an injury or condition (in this case, a spinal injury) interrupts the nervous system's control over the diameter of the blood vessels. As a result, the blood vessels dilate and the patient's blood pressure falls. The nervous system releases epinephrine and norepinephrine when a patient is in shock, which results in tachycardia and vasoconstriction. However, if the nervous system is impaired, as with neurogenic shock, these catecholamines do not get released. Therefore, the patient with neurogenic shock is bradycardic, not tachycardic as you would expect with other types of shock that do not involve nervous system impairment (ie, hypovolemic, septic, anaphylactic). The blood vessels above the level of the injury are still able to constrict, so the skin is pale and cool; however, the blood vessels below the level of the injury are dilated, so the skin is pink and warm. If this patient had a head injury with increased intracranial pressure, you would expect him to be hypertensive, not hypotensive

A young man fell and landed on his outstretched hand, resulting in pain and deformity to the left midshaft forearm. Distal circulation should be assessed at which of the following pulse locations? A) Radial B) Brachial C) Pedal D) Popliteal

A The radius and ulna are the bones of the forearm. The radial pulse can be palpated on the lateral aspect (thumb side) of the wrist and is the most distal pulse site relative to the injury. The brachial pulse is located on the medial aspect of the arm. The popliteal pulse is located behind the knee. The pedal (dorsalis pedis) pulse is located on top of the foot

A patient has an open chest wound, which has been covered with an occlusive dressing. He is receiving oxygen at 12 L/min by nonrebreathing mask. During transport, the patient's heart rate increases, he becomes pale and diaphoretic, and his oxygen saturation falls. What should you do? A) Remove the occlusive dressing. B) Ventilate with a bag-mask device. C) Increase the oxygen to 15 L/min. D) Encourage him to take deep breaths.

A When placing an occlusive dressing over a sucking chest wound (open pneumothorax), it is important to remember that you have converted the injury to a closed pneumothorax. With no way for the air in the pleural space to escape, and depending on the size of the pneumothorax, the patient could develop excessive pleural tension that interferes with circulation (tension pneumothorax). You should suspect that this is what is happening to the patient in this scenario. Your most immediate action should be to remove the occlusive dressing and allow air to escape from the pleural space. Positive pressure ventilation (ie, bag-mask ventilation) in a patient whose open chest injury has been covered with an occlusive dressing may rapidly lead to a tension pneumothorax; therefore, if the patient must be ventilated, the occlusive dressing should be removed.

A 30-year-old man sustained partial-thickness burns to the anterior chest and both anterior arms. Based on the Rule of Nines, what percentage of his body surface area has been burned? A) 9% B) 18% C) 27% D) 36%

B (Anterior trunk [chest and abdomen] accounts for 18% of the TBSA and each entire arm accounts for 9%. Therefore, the anterior chest, which is one half of the trunk, would account for 9% of the TBSA, and both anterior arms [4.5%] would account for 9% TBSA)

Which of the following clinical findings is consistent with decompensated shock? A) Diaphoresis and pallor B) Falling blood pressure C) Restlessness and anxiety D) Tachycardia and tachypnea

B (During shock, the compensatory mechanisms of the body attempt to maintain the BP. This is accomplished by increasing the heart rate, shunting blood from the skin to more vital organs, and increasing the respiratory rate to increase the O2 content of the blood. Once these compensatory mechanisms fail, the BP will fall [hypotension]. Restlessness, anxiety, tachycardia, tachypnea, and cool, clammy skin [diaphoresis] are earlier signs of shock)

A 78-year-old woman complains of pain to her right groin area after she fell. Her right leg is straight but is externally rotated and shorter than the left. The EMT should suspect a: A) pelvic girdle fracture. B) proximal femur fracture. C) posterior hip dislocation. D) symphysis pubis fracture.

B (Fractures of the proximal end of the femur are common fractures, especially in older pts and pts with osteoporosis. These fractures are often called hip fractures. Posterior dislocation of the hip most commonly occurs as a result of a MVC in which the know meets with direct force, such as a dashboard, and the entire femur is driven posteriorly, dislocating the hip joint. Pelvic fractures, including those of the symphysis pubis, typically do not cause shortening or lengthening of an extremity, nor are they typically associated with internal or external rotation of the legs. Fracture of the symphysis pubis is characterized by palpable pain over the pubic bone)

A woman fell through a glass window and has a large laceration to her inner arm that is bleeding profusely. The EMT applies a trauma dressing and direct pressure to the wound, but the dressing immediately becomes soaked with blood. What should the EMT do next? A) Pack the wound cavity with a hemostatic-impregnated gauze B) Apply a proximal tourniquet and engage it until the bleeding stops C) Apply a second trauma dressing and elevate her arm above her heart D) Pack the wound with sterile gauze and then apply a pressure dressing

B (If direct pressure does not immediately stop massive hemorrhage, the EMT should apply a proximal tourniquet and engage it until the bleeding stops and the pulse distal to the injury is not palpable. Placing additional dressing over a massively hemorrhaging wound will NOT stop the bleeding, it will only hide it. The use of hemostatic-impregnated gauze is indicated for wounds that are too proximal for a tourniquet [junctional injuries])

A 44-year-old male experienced burns to his anterior trunk and both arms. He is conscious and alert, but is in extreme pain. Assessment of the burns reveals reddening and blisters. This patient has ________________ burns that cover _____ of his total body surface area. A) first-degree, 27% B) partial-thickness, 36% C) second-degree, 45% D) full-thickness, 18%

B (Partial-thickness [second degree] burns damage the epidermis and part of the dermis, and are characterized by blistering and severe pain. Areas of superficial [1st degree] burns, which cause reddening of the skin, commonly surround partial-thickness burns. The anterior trunk [chest and abdomen] accounts for 18% of the total body surface area [TBSA] and each entire arm accounts for 9%. Full thickness burns [3rd degree] are characterized by charred or white, leathery skin. Because the entire dermis, including the nerves, are destroyed, pts do not feel pain)

A 70-year-old female fell and struck her head two days ago, but did not seek medical attention. Today, she is confused, is vomiting, and has slurred speech. The EMT should suspect a/an: A) epidural hematoma. B) subdural hematoma. C) intracerebral hematoma. D) acute ischemic stroke.

B (Subdural hematoma: occurs when bleeding occurs between the dura mater [the outer meningeal layer] and the surface of the brain; it is typically caused by venous bleeding. They do not present with S/Sx until several hours, or even days, have past since a head injury. Epidural hematoma: bleeding between the skull and dura mater, is usually caused b arterial bleeding; pts with this type present with s/sx immediately following the injury. Intracerebral hemorrhage: bleeding within the brain itself, would be expected to produce immediate symptoms)

Which of the following sets of vital signs is MOST indicative of increased intracranial pressure in a patient with a head injury? A) BP, 84/42 mm Hg; pulse, 60 beats/min; respirations, 32 breaths/min B) BP, 176/98 mm Hg; pulse, 50 beats/min; respirations, 10 breaths/min C) BP, 92/60 mm Hg; pulse, 120 beats/min; respirations, 24 breaths/min D) BP, 160/72 mm Hg; pulse, 100 beats/min; respirations, 12 breaths/min

B (The body responds to a significant TBI by shunting more oxygenated blood to the injured brain; it does this by increasing systemic BP. In response to increased BP, the pulse rate decreases. Pressure on the brain stem often causes an irregular breathing pattern that is either slow or fast. Therefore, pts with increased ICP present with hypertension, bradycardia, and irregular respirations that are fast or slow [Cushing's triad]. Vital signs representative of shock [hypotension, tachycardia] are not common in pts with an isolated brain injury and increased ICP. If a pt with a seemingly isolated head injury is hypotensive and tachycardia, look for other injuries; internal or external bleeding is likely occurring elsewhere)

A man was struck in the head with a baseball bat. He is unresponsive, his breathing is slow and irregular, and his pulse is slow and bounding. What should you do? A) Insert a nasopharyngeal airway and give oxygen via nonrebreathing mask B) Insert an oropharyngeal airway and ventilate with a bag-valve-mask device C) Administer oxygen via nonrebreathing mask and elevate his legs 6 to 12 inches D) Administer oxygen via nasal cannula and elevate his torso to a 45-degree angle

B (This pt is suspected to have a significant closed head injury with increasing ICP. Since he is unresponsive, you should insert an airway adjunct to obtain a patent airway; the OPA would be the best choice since NPA should generally be avoided in pts with a head injury. Slow, irregular breathing is not adequate and should be treated by a BVM; ventilated the pt at a rate of 10-12 breaths/min. Hypoxia can have disastrous effect son a pt with a severe head injury. so be sure to attach supplemental O2 to the BVM. Elevating the pt's lower extremities should be avoided; doing so may further increase ICP. Instead, consider elevating the pt's torso to 30 degrees)

Which of the following clinical findings is MOST indicative of a skull fracture? A) Non-reactive pupils B) Blood in the ear canal C) Decorticate posturing D) Increased blood pressure

B All of the clinical signs listed in this question indicate a head injury. However, not all head injuries are accompanied by skull fractures. Blood coming from the ear canal following a head injury, however, is the most suggestive of a skull fracture. Specifically, it suggests a basilar skull fracture. In many cases, this blood contains cerebrospinal fluid (CSF). Bloody CSF draining from the nose indicates a fractured cribriform plate; when this bone is fractured, CSF leaks into the sinuses and manifests with rhinorrhea (nasal discharge).

A man was stabbed in the cheek with a dinner fork, and the fork is still impaled in his cheek. He is conscious and alert, breathing adequately, and has blood in his oropharynx. You should: A) apply high-flow oxygen via a nonrebreathing mask, carefully remove the fork, and control any external bleeding. B) suction his oropharynx, control any external bleeding, stabilize the fork in place, and protect it with bulky dressings. C) carefully remove the fork, suction his oropharynx as needed, and pack the inside of his cheek with sterile gauze pads. D) suction his oropharynx, carefully cut the fork to make it shorter, control any external bleeding, and secure the fork in place

B An impaled object in the cheek should be removed if it interferes with your ability to manage the patient's airway. In this case, however, the patient is breathing adequately and does not require aggressive airway care (eg, ventilatory assistance). The most practical approach is to suction the blood from his oropharynx, which will prevent him from swallowing it, vomiting it, or aspirating it. Stabilize the fork in place and protect it with bulky dressings; removing an impaled object from the cheek in the opposite direction it entered would clearly cause further soft-tissue injury and bleeding. Transport the patient in a sitting position and suction his oropharynx en route as needed. There is no reason to cut the fork to make it shorter; this will only unnecessarily manipulate it, potentially causing further soft tissue damage and increased bleeding.

A 22-year-old man had a strong acid chemical splashed into both of his eyes. He is conscious and alert, is experiencing intense pain, and states that he is wearing contact lenses. Treatment should include: A) leaving the contact lenses in and beginning irrigation of both eyes. B) removing the contact lenses and beginning irrigation of both eyes. C) leaving the contact lenses in and covering both eyes with sterile gauze. D) removing the contact lenses and covering both eyes with sterile gauze.

B As a general rule, contact lenses should be left in place. Chemical eye burns are an exception to this rule. If left in place, the chemical could get behind the contact lens and continue to cause injury. Therefore, you should remove the contact lenses and immediately irrigate the eyes with sterile saline or water. If needed, continue to irrigate the eyes throughout transport.

Which of the following injury mechanisms involves axial loading? A) skater slips and falls, landing on her outstretched arm B) A construction worker falls off a roof and lands feet first C) A woman's knees impact the dash during a frontal collision D) A man's neck is forced laterally during a side impact collision

B Axial loading injuries occur when a sudden, excessive compression force drives the long axis of the body toward the head, or the head toward the feet. Common injuries that involve axial loading are heavy objects falling on a patient's head, diving head first into shallow water, and falls in which the patient lands feet first. All of these mechanisms cause compression of the spine, potentially resulting in serious injury. None of the other injury mechanisms described are consistent with axial loading.

The presence of subcutaneous emphysema following blunt trauma to the anterior neck should make you MOST suspicious for a: A) pneumothorax. B) fractured larynx. C) ruptured esophagus. D) carotid artery injury.

B Crushing or blunt trauma to the anterior neck can injure the trachea or larynx. Once the cartilages of the upper airway and larynx are fractured, they do not spring back to their normal position. Such a fracture can lead to loss of voice, airway obstruction, and leakage of air into the soft tissues of the neck. Air leakage into the soft tissues is called subcutaneous emphysema. Subcutaneous emphysema may also be observed in patients with a tension pneumothorax, although it is typically located in the chest. Esophageal rupture would likely present with difficulty swallowing (dysphagia) and vomiting blood (hematemesis). You should suspect injury to a carotid artery or jugular vein if you observe a rapidly expanding hematoma to the neck following blunt trauma.

Which of the following factors would reduce the blood's natural ability to clot, thus worsening internal or external bleeding? A) Tachycardia B) Hypothermia C) Hypotension D) Vasoconstriction

B Hypothermia can cause an abnormality in blood clotting (coagulopathy), which can impair clotting factors and cause prolonged bleeding. This is why patients with hemorrhagic shock should be kept warm. Tachycardia, hypotension, and vasoconstriction do not impair the blood's ability to clot.

A trauma patient opens his eyes slightly and moans when the EMT applies a painful stimulus. When the EMT palpates the patient's arm, he pulls it away. His Glasgow Coma Scale (GCS) score is: A) 7 B) 8 C) 9 D) 10

B If a patient opens his or her eyes in response to pain, a score of 2 is assigned for eye opening. If the patient moans or makes unintelligible sounds, a score of 2 is assigned for verbal response. If the patient withdraws from pain, a score of 4 is assigned for motor response. In total, this patient's GCS is 8, which indicates severe neurologic impairment.

Which of the following signs would you expect to see in the early stages of shock? A) Hypotension B) Restlessness C) Thready pulses D) Unconsciousness

B In the early stages of shock, decreased perfusion to the brain causes the patient to become restless and anxious. As shock progresses, the pulse becomes thready (weak), signifying a falling blood pressure (hypotension), and the patient eventually loses consciousness. It is critical to recognize the early signs of shock and initiate immediate care and rapid transport. You should not rely on the blood pressure as an indicator of perfusion in any patient; by the time hypotension manifests, the patient's compensatory mechanisms have failed and he or she is in decompensated shock.

Which of the following is the MOST reliable indicator of a fractured spinal vertebra? A) Lack of pain at the site of the injury B) Palpable pain at the site of the injury C) Decreased movement on one side of the body D) Decreased grip strength in the upper extremities

B Of the options listed, the presence of palpable pain (specifically, point tenderness directly over the injury site) is the most reliable indicator of an underlying vertebral fracture. In fact, point tenderness, second only to gross deformity, is the most reliable indicator of an underlying fracture to any bone.

After completing a rapid assessment of a patient with a penetrating chest injury, the EMT tells her partner that she suspects a pericardial tamponade. Which of the following did the EMT MOST likely encounter during her assessment? A) Slow, bounding pulse B) Distended jugular veins C) Unequal breath sounds D) Widening pulse pressure

B Pericardial tamponade occurs when an injury to the heart causes blood to collect in the pericardial sac; the accumulation of blood puts pressure on the heart and impairs its ability to fill. If the right side of the heart cannot fill, there is nothing for it to send to the left side of the heart; as a result, the patient's blood pressure falls. Beck triad is a classic presentation of pericardial tamponade; it includes jugular vein distention (blood backs up into the venous system because of impaired cardiac filling), muffled or distant heart sounds, and a narrowing pulse pressure (the difference between the systolic and diastolic blood pressure). Other signs include tachycardia, weak pulses, and hypotension. The presence of unequal breath sounds should raise suspicion of a pneumothorax. A widening pulse pressure may be seen with increased intracranial pressure following a head injury.

An unrestrained driver was crushed in between the steering wheel and his seat when his truck collided with a tree. Assessment reveals cyanosis to his neck and face, jugular venous distention, and bleeding into the sclera of his eyes. The EMT should suspect: A) aortic dissection. B) traumatic asphyxia. C) massive hemothorax. D) pericardial tamponade.

B Rather classic signs of traumatic asphyxia are present in this patient. Traumatic asphyxia occurs when a sudden compressive force is applied to the chest, which results in a sudden massive amount of blood being shunted to the neck, face, and head. Signs include jugular venous distention (JVD); cyanosis to the neck, face, and head; bulging eyes; and scleral hemorrhage (blood in the whites of the eyes). Traumatic asphyxia has a high mortality rate, mainly because of the massive injuries that occur within the thoracic cavity. Aortic dissection and massive hemothorax do not present with JVD because both of these injuries are associated with massive blood loss; one would expect collapsed jugular veins. Pericardial tamponade can cause JVD; however, cyanosis to the upper body and scleral hemorrhage are not observed.

A patient presents with a swollen, painful deformity to the lateral bone of the left forearm. You should recognize that he has injured his: A) ulna. B) radius. C) clavicle. D) humerus.

B Recalling the body in the anatomic position, the radius is the lateral (thumb side) bone of the forearm and the ulna is the medial (pinky side) bone. The humerus is the long bone of the arm and the clavicle is the collarbone, which extends from the sternum laterally to the shoulder.

Shock following major trauma is MOST often the result of: A) head injury. B) hemorrhage. C) spinal injury. D) long bone fractures.

B Shock following major trauma is usually caused by hemorrhage (bleeding), which can be external and obvious (gross), internal and hidden (occult), or both. Trauma to the chest and/or abdomen and multiple long bone fractures are common causes of hemorrhage that result in shock. An isolated head injury usually does not cause shock; rather, it causes increased intracranial pressure. If the patient with a seemingly isolated head injury has signs of shock, look for other injuries. Major trauma may also be associated with spinal injury. If the spinal cord is injured, the patient may develop shock because the nerves that control the diameter of the blood vessels are damaged, resulting in widespread vasodilation (neurogenic shock).

A trauma patient has a BP of 172/94 mm Hg, a pulse rate of 45 beats/min, and a respiratory rate of 6 breaths/min. Which of the following conditions would MOST likely produce this vital sign pattern? A) Severe internal hemorrhage B) Increased intracranial pressure C) Increased intrathoracic pressure D) Bleeding into the pericardial sac

B The classic vital sign pattern of Cushing's Triad (hypertension, bradycardia, abnormal breathing) is present. This vital sign pattern is seen in patients with increased intracranial pressure (ICP) secondary to a head injury; it can also be observed in patients who have experienced a severe hemorrhagic stroke. With a head injury, the blood pressure increases in an effort to push more blood to the brain; bradycardia occurs as a reflex response to the increased in blood pressure. Excessive ICP can produce a variety of abnormal breathing patterns, from slow and irregular to rapid with no identifiable pattern. Severe internal hemorrhage would be expected to present with signs of shock (ie, hypotension, tachycardia, tachypnea), not hypertension, bradycardia, and bradypnea. Likewise, an increase in intrathoracic pressure can also produce symptoms similar to shock; as intrathoracic pressure increases, venous return to the right side of the heart decreases. This can cause decreased cardiac output and hypotension. Bleeding into the pericardial sac (ie, pericardial tamponade) causes hypotension with a narrowing pulse pressure and tachycardia.

A scuba diver complains of shortness of breath and severe muscle and joint pain immediately after ascending from a dive. He is cyanotic and is coughing up bloody froth. What should you suspect? A) The bends B) Air embolism C) Decompression sickness D) Nitrogen bubbles in the blood

B The most dangerous, and most common, emergency in scuba diving is an air embolism, a condition involving bubbles of air in the blood vessels. An air embolism may occur on a dive as shallow as 6 feet. The problem starts when the diver holds his or her breath during a rapid ascent. The air pressure in the lungs remains at a high level while the external pressure on the chest decreases. As a result, the air inside the lungs expands rapidly, causing alveolar rupture. The air released from the ruptured alveoli can cause air bubbles in the bloodstream (air emboli), pneumothorax, or pneumomediastinum. Signs and symptoms of an air embolism include skin mottling; pink or bloody froth at the nose and mouth; severe pain in the muscles, joints, or abdomen; dyspnea and/or chest pain; cough; cyanosis; and dizziness, nausea, and vomiting. Decompression sickness, also called the bends, is also an ascent problem. It occurs when bubbles of gas, especially nitrogen, obstruct the blood vessels. The most striking symptom of decompression sickness is abdominal and/or joint pain so severe that the patient literally doubles over or "bends." It can be difficult to distinguish between air embolism and decompression sickness. As a general rule, air embolism occurs immediately on return to the surface, whereas the symptoms of decompression sickness may not occur for several hours. Treatment at the hospital is the same for air embolism and decompression sickness and involves placing the patient in a hyperbaric chamber.

An elderly woman, who was removed from her burning house by firefighters, has full-thickness burns to approximately 50% of her body. Appropriate treatment for this patient would include: A) applying moist, sterile dressings to the burned areas and preventing hypothermia. B) cooling the burns with sterile saline and covering them with dry, sterile burn pads. C) covering the burns with dry, sterile dressings and preventing further loss of body heat. D) peeling burned clothing from the skin and removing all rings, necklaces, and bracelets.

C (After moving the pt to safety, stopping the burning process, and supporting the ABC's, full-thickness burns should be cared for by applying dry, sterile dressings or sterile burn pads and preventing hypothermia. Cooling full-thickness burns [applying moist dressings, pouring saline or water on the burn] should be avoided, as this increases the risks of hypothermia and infection. Rings, necklaces, and other potentially constrictive devices should be removed in the event that severe swelling occurs. If portions of clothing are adhered to the skin, they should be cut around, not peeled from the skin, to prevent further soft-tissue damage)

EMTs are assessing a man who was injured while trying to rescue a pet from his burning house. Which of the following assessment findings should be the MOST immediately concerning? A) Severe blisters to both hands B) Closed deformity of the wrist C) Dry cough and a hoarse voice D) Clothes adhered to burned skin

C (Any condition or injury that involves airway, breathing, or circulation warrants the EMT's most immediate attention. A dry cough and hoarse voice are signs of inhalation injury and airway swelling. Carefully monitor the pt and be prepared to ventilate him if his breathing becomes inadequate. Transport without delay; a paramedic intercept should be requested. If the pt's airway completely closes, more invasive airway management will be needed [cricothyrotomy]. Tend to the other injuries listed during transport)

If a passenger strikes his or her head on the windshield during a motor-vehicle crash: A) the posterior portion of the brain will receive the initial impact, resulting in severe intracerebral hemorrhage. B) he or she will likely experience a hyperflexion injury, resulting in fractures of the vertebrae in the cervical spine. C) the anterior part of the brain sustains a compression injury, while the posterior part sustains a stretching injury. D) you will always see a starburst fracture of the windshield at the location where the patient struck his or her head.

C (As the passenger's head strikes the windshield, the brain continues its forward movement until is collides with the inside of the skull. Direct injury to the anterior part of the brain results in compression injuries. Indirect injury occurs to the posterior part of the brain due to stretching or tearing. This is a coup-contracoup injury. Although hyperflexion injuries of the neck can occur when the head impacts the windshield, hyperextension injuries are more common)

A baseball player was struck in the center of the chest by a line drive and immediately collapsed. He is unresponsive, apneic, and pulseless. The EMT should recognize that the MOST likely cause of this patient's collapse was: A) rupture of the aorta. B) myocardial contusion. C) ventricular fibrillation. D) shearing of the vena cava.

C (Commotio cordis: blunt chest injury caused by a sudden, direct blow to the chest [over the heart] during a critical phase of the person's heartbeat. This can cause immediate cardiac arrest from ventricular fibrillation, which can often ben corrected with early defibrillation. Commotio cordis occurs most commonly during sporting injuries. EMT should suspect commotio cordis if a pt presents with cardiac arrest following a sudden, direct blow to the chest. Myocardial contusion: can also occur following blunt chest trauma; however, cardiac arrest with this type of injury is uncommon. Great vessel injury: [aortic rupture, shearing of the vena cava] occurs more commonly following rapid deceleration, such as when the chest strikes the steering wheal during high speed collision or when the pt falls from a significant height)

A 40-year-old man was hit in the nose during a fight. He has bruising under his left eye and a nosebleed. What should you do? A) Place a chemical icepack over his nose B) Determine if he has any visual disturbances C) Ensure that he is sitting up and leaning forward D) Apply direct pressure by pinching his nostrils together

C (During epistaxis, much of the blood may pass down the throat into the stomach as the pt swallows; this is especially true if the pt is lying supine. Blood is a gastric irritant; a person who swallows a large amount of blood may become nauseated and vomit, which increases the risk of aspiration. After sitting them up and leaning them forward, apply pressure by pinching the fleshy part of the nostrils together; you or the pt may do this. Placing a chemical icepack over the nose may further help control the bleeding by constricting the nasal vasculature)

Following blunt injury to the anterior torso, a patient is coughing up bright red blood. You should suspect: A) intra-abdominal bleeding B) gastrointestinal bleeding C) bleeding within the lungs D) severe myocardial damage

C (Hemoptysis: coughing up blood; suggests injury to or bleeding within the lungs. Hematemesis: vomiting up bright or dark red blood; suggests gastrointestinal bleeding. Intra-abdominal bleeding following trauma presents with signs of shock as well as abdominal pain, guarding, rigidity, bruising, or distention. Injury to the myocardium may cause cardiac dysrhythmias, but typically does not cause hemotysis unless it is associated with pulmonary [lung] injury)

If a vehicle strikes a tree at 60 mph, the unrestrained driver would likely experience the MOST severe injuries during the: A) first collision. B) second collision. C) third collision. D) fourth collision.

C (MVC consist of three separate collisions. 1st collision: vehicle strikes another object. 2nd collision: passenger collides with the interior of the vehicle. 3rd: occupant's internal organs collide with the solid structures of the body)

A man was stabbed to the left side of the chest. His skin is cool and clammy, his blood pressure is 90/60 mm Hg, his respirations are 22 breaths/min, and his pulse is 120 beats/min and weak. His breath sounds are equal bilaterally and his jugular veins are distended. What should you do? A) Cover the wound and position him on his left side B) Ventilate the patient, apply an AED, and transport C) Cover the wound, administer oxygen, and transport D) Suspect a pneumothorax and contact medical control

C (Pericardial tamponade: occurs when blood fills the pericardial sac and restricts the heart from relaxing. If the heart can not relax, it cannot fill with blood. If the right side of the heart cannot fill with blood, there is nothing for it to send to the leg side of the heart; as a result, the pt's cardiac output drops and shock develops. Signs of pericardial tamponade: muffled or distant heart tones [diff to assess in the field]; a rapid, weak pulse; hypotension; JVD; and a narrowing pulse pressure [difference between systolic and diastolic BP]. A pneumothorax is unlikely in this pt; his breath sounds are equal bilaterally. For this pt, cover the wound, administer O2, and transport)

Factors that affect a person's ability to compensate for internal or external blood loss include all of the following, EXCEPT: A) advanced age. B) the rate of blood loss. C) high cholesterol in the blood. D) blood-thinning medications.

C (The compensatory responses of tachycardia and peripheral vasoconstriction decrease as a person ages; thus, older pts are not able to compensate as effectively as younger pts. Older pts commonly take medications to treat high BP, such as beta blockers; these drugs may blunt the body's release of the catecholamines necessary to increase the heart rate. The ability to compensate for blood loss is also related to how rapidly blood loss occurs. Pts who take blood-thinning medications [warfarin {Coumadin}] bleed longer than those not taking such medications. There is no known correlation between high cholesterol and a person's ability to compensate for blood loss)

During a soccer game, an 18-year-old woman injured her knee. Her knee is in a flexed position and is obviously deformed. You should: A) assess circulatory function distal to her injury. B) straighten the knee to facilitate immobilization. C) manually stabilize the leg above and below the knee. D) immobilize the knee in the position in which it was found.

C (Treatment for any musculoskeletal injury begins by providing manual stabilization above and below the injury. Distal circulatory pulse, sensory, and motor functions should then be assessed. After manually stabilizing the injury and assessing distal circulatory, sensory, and motor functions, you should appropriately splint the injury. Reassess CSM after splinting. Joint injuries should be immobilized in the position found. If there is no distal pulse and transport will be delayed, medical control may authorize you to make one attempt to gently manipulate the joint to restore a pulse)

If a passenger strikes his or her head on the windshield during a motor vehicle crash: A) the posterior portion of the brain will receive the initial impact, resulting in severe intracerebral hemorrhage. B) he or she will likely experience a hyperflexion injury, resulting in fractures of the vertebrae in the cervical spine. C) the anterior part of the brain sustains a compression injury, while the posterior part sustains a stretching injury. D) you will always see a starburst fracture of the windshield at the location where the patient struck his or her head.

C Although the presence of a starburst fracture on the windshield is a good indicator that the patient impacted the windshield with his or her head, it is not always present or grossly obvious, especially if the windshield is broken in multiple places. As the passenger's head strikes the windshield, the brain continues its forward movement until it collides with the inside of the skull. Direct injury to the anterior part of the brain results in compression injuries. Indirect injury occurs to the posterior part of the brain due to stretching or tearing. This is an example of a coup-contracoup injury. Although hyperflexion injuries of the neck can occur when the head impacts the windshield, hyperextension injuries are more common.

Patients with significant closed head injuries often have pupillary abnormalities and: A) paralysis. B) paresthesia. C) hypertension. D) tachycardia.

C Closed head injuries can cause a variety of signs and symptoms. In addition to pupillary abnormalities (ie, unequal pupils, sluggishly reactive pupils), a classic finding that indicates a significant increase in intracranial pressure is Cushing's triad. This trio of findings includes hypertension; bradycardia; and abnormal breathing, which can vary from slow and irregular to rapid and deep.

During which part of your assessment would you MOST likely discover a small-caliber gunshot wound to the back with minimal bleeding? A) General impression B) Primary assessment C) Rapid head-to-toe assessment D) Detailed secondary assessment

C During both the general impression and the primary assessment, you should assess for major bleeding. If there is no obvious bleeding, you should continue your assessment as usual. It is during the rapid head-to-toe assessment, when log rolling the patient to assess the posterior (back), that you would most likely find a small-caliber gunshot wound, especially if there is little or no bleeding. A secondary assessment should be performed, and focuses primarily on the patient's chief complaint; however, this may not be practical with a critically ill or injured patient. If a secondary assessment is performed on a critically ill or injured patient, it should occur en route to the hospital. All bleeding should have been controlled long before performing a secondary assessment.

Which of the following is MOST indicative of compensated shock in an adult? A) Unresponsive, pallor, absent radial pulses, tachypnea B) Confusion, mottling, tachycardia, BP of 88/60 mm Hg C) Restless, diaphoresis, tachypnea, BP of 104/64 mm Hg D) Weak carotid pulse, cool skin, increased respiratory rate

C In compensated shock, the nervous system is mounting a physiologic response to an underlying illness or injury in an attempt to maintain perfusion to vital organs such as the brain, heart, and kidneys. The patient with compensated shock is restless or anxious, has poor peripheral perfusion (eg, pallor), tachycardia, diaphoresis, and increased respirations (tachypnea). However, his or her blood pressure is maintained, usually above 90 to 100 mm Hg. In decompensated shock, the body's compensatory mechanisms fail, blood pressure begins to fall, and perfusion to vital organs decreases. Other signs of decompensated shock include a decreased level of consciousness, absent peripheral pulses (radial), and weak central pulses (carotid, femoral).

During a soccer game, a 20-year-old man collided shoulder-to-shoulder with another player. He has pain and a noticeable anterior bulge to the left shoulder. Which of the following is the MOST effective method of immobilizing this injury? A) An air-inflatable splint with the left arm immobilized in the flexed position B) A long board splint with the left arm immobilized in the extended position C) A sling to support the left arm and swathes to secure the arm to the body D) A sling to support the left arm and swathes to maintain downward traction

C Injuries to the shoulder are most effectively immobilized with the use of a sling and swathe. The sling will provide support and relieve pain to the shoulder, and the swathe will secure the arm to the body. The purpose of the swathe is not to facilitate traction. Patients with dislocated or fractured shoulders will not allow you to extend their arm, so any attempt to immobilize the injury in such a fashion will not be possible and could worsen the injury.

A patient with severe hypothermia should be actively rewarmed: A) before he or she is moved. B) in the back of the ambulance. C) at the emergency department. D) as soon as paramedics arrive.

C Prehospital treatment for hypothermia depends on the patient's body temperature. For patients who are alert, actively shivering, and responding appropriately (mild hypothermia [90 to 95 degrees Fahrenheit]), you should begin passive rewarming. This includes moving the patient to a warm environment, removing any wet clothing, turning up the heat in the ambulance, and applying warm blankets. Some protocols may call for heat packs or hot water bottles applied to the groin, axillae, and cervical regions; this is a form of active external rewarming. However, if the patient has moderate or severe hypothermia (less than 90 degrees Fahrenheit), active rewarming is best accomplished in the emergency department utilizing aggressive strategies to introduce heat into the body's core. Such therapies might include warm intravenous fluids, lavage with warm fluids, and rewarming blood outside the body before reintroducing it (extracorporeal rewarming). Rewarming too quickly may cause a fatal cardiac dysrhythmia or other significant complications. For this reason, local protocols may dictate the appropriate type of rewarming strategies based on the patient's body temperature.

During your assessment of a patient who experienced blunt facial trauma, you note the presence of a hyphema. This indicates: A) a fracture of the nasal bone. B) an orbital blowout fracture. C) direct trauma to the eyeball. D) that the pupils are unequal.

C Some patients with blunt trauma to the eyeball (globe) may present with a hyphema, or bleeding into the anterior chamber of the eye, that obscures a portion of or the entire iris. This condition may seriously impair vision and should be considered a sight-threatening emergency. A fracture of the orbital floor (blowout fracture) is characterized by double vision and an inability of the patient to move his or her eyes above the midline (paralysis of upward gaze) following blunt facial trauma. In an orbital blowout fracture, fragments of fractured bone can entrap some of the muscles that control eye movement. Anisocoria is the term used to describe unequal pupils. Unequal pupils following head trauma indicates increased intracranial pressure.

An adult patient opens his eyes in response to a painful stimulus, moans when you ask him questions, and pulls his arm away when you palpate it. What is his Glasgow Coma Scale (GCS) score? A) 6 B) 7 C) 8 D) 9

C The Glasgow Coma Score (GCS) assesses three neurologic parameters: eye opening, verbal response, and motor response. Your patient's GCS score is 8. For eye opening, he receives 2 points for opening his eyes in response to pain. For verbal response, he receives 2 points for moaning or making unintelligible sounds. For motor response, he receives 4 points for withdrawing from pain. The GCS is a valuable neurologic assessment tool; it should be reassessed frequently in seriously injured patients, especially those with a head injury.

Assessment of an injured man reveals that he opens his eyes when the EMT speaks to him and pulls his arm away when the EMT palpates it. He knows his name, but cannot remember what happened and does not know what day it is. He should be assigned a Glasgow Coma Scale (GCS) score of: A) 9 B) 10 C) 11 D) 12

C The patient's GCS is calculated at 11. He opens his eyes in response to verbal stimuli, which equates to a score of 3 for eye opening. Although he knows his name, he is confused in that he cannot remember what happened or what day it is; this equates to a score of 4 for verbal response. Because the patient withdraws from pain, he receives a score of 4 for motor response.

Which of the following will provide you with the MOST information regarding a head-injured patient's condition? A) Pupil size B) Heart rate C) Mental status D) Blood pressure

C The patient's mental status provides you with the most information regarding overall perfusion status, especially when assessing a patient with a head injury. Frequent neurologic assessments, which includes assessing the patient's pupils, are critical in determining if the patient's condition is improving or deteriorating. Vital signs should be monitored according to the patient's condition, at least every 5 minutes if he or she is unstable and at least every 15 minutes if he or she is stable.

During a soccer game, an 18-year-old woman injured her knee. Her knee is in a flexed position and is obviously deformed. What should you do? A) Assess for the presence of a femoral pulse B) Straighten the knee to facilitate immobilization C) Manually stabilize the leg above and below the knee D) Ask her to flex her knee even more to help with pain

C Treatment for any musculoskeletal injury begins by providing manual stabilization above and below the injury (in this case, the distal femur and proximal tibia); this will prevent further injury. Distal circulatory (pulse), sensory, and motor functions should then be assessed; in this case, the dorsalis pedis or posterior tibial pulse (the femoral pulse is proximal to the knee). After manually stabilizing the injury and assessing distal circulatory, sensory, and motor functions, you should appropriately splint the injury. Reassess distal circulatory, sensory, and motor functions after the splint has been applied. Because of the vascularity of the knee, as well as the presence of major nerves in that area, you should not straighten or flex an injured knee. Joint injuries should be immobilized in the position found. If there is no distal pulse and transport will be delayed, medical control may authorize you to make one attempt to gently manipulate the joint to restore a pulse.

A 33-year-old male struck a parked car with his motorcycle and was thrown from the motorcycle. He was not wearing a helmet. He is unresponsive and has a depressed area to his forehead, bilaterally deformed femurs, and widespread abrasions with capillary bleeding. Which of the following statements regarding this patient is false? A) You should suspect that the patient has a skull fracture and increased intracranial pressure. B) Femur fractures are a common injury when a rider is thrown from his or her motorcycle. C) Internal hemorrhage cannot be controlled in the field and requires prompt surgical intervention. D) You must stop the bleeding from his abrasions immediately or the patient will die from hypovolemic shock.

D

A 22-year-old female fell on her knee and is in severe pain. Her knee is flexed and severely deformed. Her leg is cold to the touch and you are unable to palpate a distal pulse. You should: A) apply gentle longitudinal traction as you straighten her leg and then apply a traction splint. B) place a pillow behind her knee and stabilize the injury by applying padded board splints. C) carefully straighten her leg until you restore a distal pulse and then apply padded board splints. D) manually stabilize her injury and contact medical control for further stabilization instructions.

D (A dislocated knee occurs when the proximal end of the tibia completely displaces from its juncture with the distal femur. In some cases, the popliteal artery behind the knee may be compressed, resulting in compromised distal blood flow. Signs of this include absent distal pulses and a pale extremity that is cool or cold. Manually stabilize the knee and assess for distal pulses. If distal pulses are absent, contact medical control immediately for further stabilization instructions. Medical control may instruct you to make ONE attempt to realign the knee to reduce compression of the popliteal artery to restore circulation. If you are unable to restore distal circulation or medical control advises you no two manipulate the injury, splint the knee in the position it was found and transport. Traction splints are contraindicated in any injury to to near the knee)

A man's legs were pinned by a steel girder for 5 hours before he was found. He is conscious and alert with stable vital signs but cannot feel his legs. The EMT should anticipate that: A) a surgeon will respond to the scene and amputate the man's legs. B) he will be heavily sedated by paramedics to prevent further pain. C) he will be immediately freed and rapidly transported to the hospital. D) IV fluids and certain drugs may be given before he is freed.

D (Crush syndrome: when a part of the body is pinned by a heavy object for more than 4 to 6 hours. Since circulation distal to the crushed part of the body is minimal or absent, chemicals such as potassium and lactic acid can accumulate to dangerous levels. If the body parts is/are suddenly freed, these chemicals can be released into the bloodstream, potentially causing fatal cardiac dysthymia. For this reason, the pt may need IV fluids and certain medications before being freed in order to prepare the body for the onslaught of these chemicals. In some cases, if the pt is hemodynamically unsubtle, a surgeon may respond to the scene to perform an emergency amputation. It would not be advisable to heavily sedate the pt while he is still entrapped as this may cause airway compromise. Sedation may be indicated, however, after the pt has been freed)

Following penetrating trauma to the abdomen, a 50-year-old woman has a large laceration with a loop of protruding bowel. How should you manage this injury? A) Carefully replace the bowel and apply an occlusive dressing. B) Apply a tight pressure dressing to control any external bleeding. C) Apply a dry, sterile dressing covered by an occlusive dressing. D) Apply a moist, sterile dressing covered by a dry, sterile dressing.

D (Eviscerated bowel management: controlling any external bleeding, covering the exposed bowel with a moist, sterile dressing, and covering that with a dry, sterile dressing. Applying a dry dressing directly to the exposed bowel will cause the bowel to dry)

A young male has a large laceration to his lateral neck, directly over his jugular vein. His airway is patent and his breathing is adequate. Your MOST immediate priority should be to: A) apply high-flow oxygen via a nonrebreathing mask. B) perform a rapid assessment to detect other injuries. C) obtain vital signs to determine if he is hypotensive. D) keep air out of the wound and control the bleeding.

D (Jugular vein lacerations pose two immediate life threats: entrainment of air into the wound [which may cause a fatal air embolism] and severe external bleeding. Apply an occlusive dressing directly over the wound. which will keep air from entering the venous circulation, and then cover the occlusive dressing with bulky dressings to control the external bleeding)

A man was struck in the side of his head with a steel pipe. Blood-tinged fluid is draining from the ear and bruising appears behind the ear. The MOST appropriate treatment for this pt includes: A) elevating the lower extremities and providing immediate transport B) applying high-flow O2 and packing the ear with sterile gauze pads C) controlling the drainage from the ear and immobilizing the entire spine D) immobilizing the spine, administering O2, and monitoring for vomiting

D (Pts with significant head injury should ben treated by applying high-flow O2, assisting ventilations as needed, immobilizing the entire spine, and transporting promptly. Closely monitor the pt for vomiting and be prepared to suction the airway. Elevation of the foot of the spine board may cause more blood to engorge the brain and may increase ICP. If possible, you should elevate the pt's torso to 30 degrees in an attempt to lower ICP. You should never attempt to control bleeding or fluid drainage from the ears of a pt with a head injury because this, too, may result in increased ICP. If a pt has an isolated head injury begins showing signs of shock [tachycardia, diaphoresis, tachypnea, hypotension], you should assume that he or she has internal bleeding from another injury and treat accordingly [keep the pt warm and supine])

A woman has a painful, deformed humerus after she fell. The injured arm is cool and pale, and a radial pulse cannot be palpated. The EMT should: A) allow her to stabilize the arm on her own and transport. B) splint the arm in the position found and transport at once. C) realign the arm to its normal anatomic position and splint it. D) apply gentle traction in order to reestablish distal circulation.

D (When treating an orthopedic injury in which distal circulation is compromised, you should apply gentle traction in an effort to restore distal circulation. This practice doe NOT apply to injuries involving joints. Once distal circulation is restored, splint the injury appropriately and transport. If you are unable to restore distal circulation, contact medical control; depending on your transport time, he or she may request you to make another effort to restore distal circulation. Fractures, with or without distal circulation, should be splinted in the most comfortable position for the pt; attempting to realign a fractured extremity to its normal anatomic position would cause the pt unnecessary pain)

Firefighters have rescued a man from his burning house. He is conscious and alert, but is experiencing significant respiratory distress. He has a brassy cough and singed nasal hairs. The MOST immediate threat to this patient's life is: A) hypothermia. B) severe burns. C) severe infection. D) airway swelling.

D Because of the patient's signs and symptoms, your most immediate concern should be the potential for swelling and closure of the upper airway; be prepared to assist the patient's ventilations. Signs of upper airway burns include respiratory distress, singed facial and/or nasal hairs, a brassy cough, difficulty breathing, and coughing up sooty sputum. Infection, the burns themselves, and hypothermia should concern you; however, airway problems pose the most immediate life threat.

Displaced fractures of the proximal femur are characterized by: A) lengthening and internal rotation of the leg. B) a flexed hip joint and inward thigh rotation. C) hip joint extension and external leg rotation. D) shortening and external rotation of the leg.

D Fractures of the proximal (upper) part of the femur are especially common in older people, particularly those with osteoporosis, but may also occur as a result of high-energy trauma in younger patients. Although they are usually called hip fractures, they rarely involve the hip joint. Instead, the break goes through the neck of the femur, the middle region, or across the proximal shaft. Patients with displaced fractures of the proximal femur display a very characteristic deformity. They lie with the leg externally rotated, and the injured leg is usually shorter than the uninjured leg. If the fracture is not displaced, this deformity is not present. A flexed hip joint and internal rotation of the thigh are characteristic of a posterior hip dislocation. With the less common anterior hip dislocation, the limb is in the opposite position, extended straight out, externally rotated, and pointing away from the midline of the body.

A man has a large laceration to his right calf after the chainsaw he was using slipped. The wound extends down to the muscle and dark red blood is flowing heavily from the wound. The EMT should: A) apply a tourniquet proximal to the wound. B) position the patient supine and elevate his leg 12 inches. C) check distal circulation and then splint the entire extremity. D) apply manual pressure to the wound with a sterile dressing.

D Immediate treatment for external hemorrhage involves applying direct pressure to the wound. In many cases, this will be all that is required. However, if the wound continues to bleed despite the use of direct pressure, a proximal tourniquet should be applied. The patient with hemorrhage and shock should be positioned supine; do not elevate his or her legs. If direct pressure alone controls the bleeding, it would not be unreasonable to splint the affected extremity; doing so minimizes movement of the extremity and may further assist in bleeding control by facilitating hemostasis.

In which of the following situations would external bleeding be the MOST difficult to control? A) Scalp laceration, BP of 130/70 mm Hg B) Jugular vein laceration, BP of 104/60 mm Hg C) Carotid artery laceration, BP of 70/50 mm Hg D) Femoral artery laceration, BP of 140/90 mm Hg

D In general, the larger the size and type (eg, artery versus vein) of blood vessel injured, and the higher the patient's blood pressure, the more difficult the external bleeding will be to control. Of the choices listed, bleeding from a lacerated femoral artery (large, high-pressure vessel) in a patient with a blood pressure of 140/90 mm Hg (the highest BP listed) would be the most difficult to control. As a patient's blood pressure begins to fall, the driving force of blood in the arteries decreases and the bleeding becomes easier to control. Unfortunately, the patient is usually in decompensated shock at this point. The scalp contains many small blood vessels and tends to bleed heavily; however, direct pressure usually controls the bleeding with relative ease, regardless of the patient's blood pressure.

In which of the following circumstances would external bleeding be the LEAST difficult to control? A) Lacerated brachial artery; BP of 140/90 mm Hg B) Lacerated jugular vein; BP of 100/60 mm Hg C) Lacerated carotid artery; BP of 90/50 mm Hg D) Lacerated femoral vein; BP of 70/40 mm Hg

D It is generally less difficult to control external bleeding from a lacerated vein rather than an artery. Unlike arteries, veins are under low pressure. Furthermore, the presence of a low blood pressure (hypotension), which causes less pressure against the vascular wall, would make external bleeding that much easier to control. Remember, if direct pressure does not immediately control severe external bleeding from an extremity, apply a proximal tourniquet.

A man was cut on the left side of the neck and is bleeding heavily from the wound. His airway is patent and his breathing is adequate. You should immediately: A) apply high-flow oxygen via a nonrebreathing mask at 15 L/min. B) apply a tight pressure dressing and secure it in place with tape. C) perform a head-to-toe assessment to find and treat other injuries. D) cover the wound with an occlusive dressing and apply direct pressure.

D Neck lacerations are extremely dangerous and can result in severe bleeding and shock, air embolism, or both. If a jugular vein is lacerated, air can be sucked into the wound, enter the circulatory system, and cause a pulmonary embolism. You should immediately apply an occlusive dressing to the wound (prevents entrainment of air), place a bulky dressing over the occlusive dressing, and apply direct pressure. Your patient has a patent airway and is breathing adequately; although high-flow oxygen is important and should be given as soon as possible, it does not take priority over control of life-threatening external hemorrhage. After treating all airway, breathing, and circulation problems, perform a head-to-toe assessment (if indicated) and prepare for rapid transport.

A patient with multiple injuries presents with pallor, diaphoresis, a heart rate of 120 beats/min, and a BP of 112/64 mm Hg. The EMT should recognize that these signs are the result of: A) the shunting of blood to the periphery of the body. B) increased parasympathetic nervous system activity. C) nervous system failure and decompensated shock. D) increased epinephrine and norepinephrine release.

D The patient's signs and symptoms are consistent with compensated shock. Decompensated shock occurs when the body's compensatory mechanisms have failed and the patient becomes hypotensive. The body responds to inadequate perfusion in a number of ways, including increasing the respiratory rate and releasing catecholamines (epinephrine and norepinephrine). Catecholamine release causes profuse sweating (diaphoresis), increased heart rate, and central and peripheral vasoconstriction. Because the peripheral blood vessels are constricted as blood is shunted away from the periphery, the skin becomes pale. The net effect of vasoconstriction is to increase blood pressure and maintain perfusion. Increased parasympathetic nervous system activity would cause bradycardia, not tachycardia.

Damaged small blood vessels beneath the skin following blunt trauma cause: A) mottling. B) cyanosis. C) hematoma. D) ecchymosis.

D When small blood vessels beneath the skin are damaged, blood seeps into the soft tissues. This manifests as a bruise, also referred to as ecchymosis. A hematoma develops when larger blood vessels are ruptured and the internal bleeding forms a noticeable lump. Cyanosis is a blue or purple discoloration of the skin and signifies a low content of oxygen in the blood. Mottling occurs when the skin takes on a blotched, purple appearance and is a sign of shock (hypoperfusion).