ATLS Study

An 18-year-old, unhelmeted motorcyclist is brought by ambulance to the ED following a crash. He had decreased level of consciousness at the scene, but then was alert and conversational during transportation. Now his GCS is only 11. Which of the following statements is TRUE? A. Cerebral perfusion is intact B. Intravascular volume status is normal C. The patient is in a postictal state D. Intra-abdominal visceral injury is unlikely E. The patient probably has an acute epidural hematoma

E

A 20-year-old woman, at 32 weeks gestation, is stabbed in the upper right chest. In the ED, her blood pressure is 80/60 mmHg. She is gasping for breath, extremely anxious, and yelling for help. Breath sounds are diminished in the right chest. The most appropriate first step is to: A. Perform tracheal intubation B. Insert an oropharyngeal airway C. Perform needle decompression of the right chest D. Manually displace the gravid uterus to the left side of the abdomen E. Initiate 2 large-caliber peripheral IV lines and crystalloid infusion

C

A 25-year-old man, injured in a motor vehicular crash, is admitted to the ED. His pupils react sluggishly and his eyes open to painful stimuli only, He does not follow commands, but he does moan periodically. His right arm is deformed and does not respond to painful stimulus; however, his left hand reaches purposefully toward the painful stimulus. Both legs are stiffly extended. His GCS score is: A. 7 B. 8 C. 9 D. 10 E. 11

C

The best guide for adequate fluid resuscitation of the burn patient is: A. Adequate urinary output B. Reversal of systemic acidosis C. Normalization of the heart rate D. A normal central venous pressure E. 4 ml/kg/percent body burn/24 hours

A

The following are contraindications for tetanus toxoid administration: A. History of neurological reaction or severe hypersensitivity to the product B. Local side effects C. Muscular spasm D. Pregnancy E. All of the above

A

Which of the following statements regarding injury to the central nervous system is true? A. Children suffer spinal cord injury without x-ray abnormality more commonly than adults B. An infant with a traumatic brain injury may become hypotensive from cerebral edema C. Initial therapy for the child with traumatic brain injury includes the administration of methylprednisolone intravenously D. Children have more focal mass lesions as a result for traumatic brain injury when compared to adults E. Young children are less tolerant of expanding intracranial mass lesions than adults

A

Which of the following statements regarding patients with thoracic spine injuries is TRUE? A. Log-rolling may be destabilizing to fractures T12 to L1 B. Adequate immobilization can be accomplished with the scoop stretcher C. Spinal cord injury below T10 usually spares bowel and bladder function D. Hyperflexion fractures in the upper thoracic spine are inherently unstable E. These patients rarely present with neurogenic shock in association with cord injury

A

A 33-year-old woman is involved in a head-on motor vehicle crash. It took 30 minutes to extricate her from the car. Upon arrival in the ED, her heart rate is 120 beats per minute, BP is 90/70 mmHg, respiratory rate is 16 breaths per minute, and GCS is 15. Examination reveals bilaterally equal breath sounds, anterior chest wall ecchymosis, and distended neck veins. Her abdomen is flat, soft, and not tender. Her pelvis is stable. Palpable distal pulses are found in all 4 extremities. Of the following, the most likely diagnosis is: A. Hemorrhagic shock B. Cardiac tamponade C. Massive hemothorax D. Tension pneumothorax E. Diaphragmatic rupture

B

For the patient with severe traumatic brain injury, profound hypocarbia should be avoided to prevent: A. Respiratory alkalosis B. Metabolic acidosis C. Cerebral vasoconstriction with diminished perfusion D. Neurogenic pulmonary edema E. Shift of the oxyhemoglobin dissociation curve

C

For the trauma patient with cerebral edema, hypercarbia should be avoided to prevent: A. Metabolic acidosis B. Respiratory acidosis C. Cerebral vasodilatation D. Neurogenic pulmonary edema E. Reciprocal high level of PaCO2

C

Immediate chest tube insertion is indicated for which of the following conditions? A. Pneumothorax B. Pneumomediastinum C. Massive hemothorax D. Diaphragmatic rupture E. Subcutaneous emphysema

C

Prior to passage of urinary catheter in a man, it is essential to: A. Examine the abdomen B. Determine pelvic stability C. Examine the rectum and perineum D. Perform a retrograde urethrogram E. Know the history and mechanism of injury

C

Systolic blood pressure starts to decrease in which class of hemorrhage? A. Class 0 B. Class 1 C. Class 2 D. Class 3 E. Class 4

C

A 5-year-old boy is struck by an automobile and brought to the emergency department. He is lethargic, but withdraws purposefully from painful stimuli. His blood pressure is 90 mmHg systolic, heart rate is 140 beats per minute, and his respiratory rate is 36 breaths per minute. The preferred route of venous access in this patient is A. Percutaneous femoral vein cannulation B. Cutdown on the saphenous vein at the ankle C. Intraosseous catheter placement in the proximal tibia D. Percutaneous peripheral veins in the upper extremities E. Central venous access via the subclavian or internal jugular vein

D

A 17-year-old helmeted motorcyclist loses consciousness when he is struck broadside by an automobile at an intersection. He arrives in the ED with a blood pressure of 140/92, pulse rate 88 beats per minute, a respiratory rate of 18 breaths per minute, and a GCS of 7. Appropriate initial immobilization of this patient should include a semi-rigid cervical collar and: A. A scoop stretcher B. A long spine board C. A short spine board D. Cervical traction tongs E. Pneumatic antishock

B

A 24-year-old woman passenger in an automobile strikes the windshield with her face during a head-on collision. In the ED, she is talking and has marked facial edema and crepitus. The highest priority should be given to: A. Lateral c-spine x-ray B. Upper airway protection C. Carotid pulse assessment D. Management of blood loss E. Determination of associated injuries

B

A 7-year-old boy is brought to the ED by his parents several minutes after he fell through a window. He is bleeding profusely from a 6-cm wound of his medial right thigh. Immediate management of the wound should consist of: A. Application of a tourniquet B. Direct pressure on the wound C. Packing the wound with gauze D. Direct pressure on the femoral artery at the groin E. Debridement of devitalized tissue

B

A 22-year-old man is hypotensive and tachycardic after a shotgun wound to the left shoulder. His BP is initially 80/40 mmHg. After 2 liters of crystalloid solution his blood pressure increases to 122/84 mmHg. His heart rate is now 100 beats per minute and his respiratory rate is 28 breaths per minute. His breath sounds are decreased in the left hemithorax, and after initial IV fluid resuscitation, a closed tube thoracostomy is performed for decreased left breath sound with the return of small amount of blood and no air leak. After chest tube insertion, the appropriate next step is to: A. Reexamine the chest B. Perform an aortogram C. Obtain a CT scan of the chest D. Obtain arterial blood gas analyses E. Perform transesophageal echocardiography

A

A 28-year-old male is brought to the ED. He was involved in a fight in which he was beaten with a wooden stick. His chest shows multiple severe bruises. His airway is clear, RR is 22, HR is 126, and systolic BP is 90 mmHg. Which one of the following should be performed during the primary survey? A. GCS B. Cervical spine x-ray C. TT administration D. Blood alcohol level E. Rectal exam

A

A 42-year-old man is trapped from the waist down beneath his overturned tractor for several hours before medical assistance arrives. He is awake and alert until just before arriving in the emergency department. He is now unconscious and responds only to painful stimuli by moaning. His pupils are 3 mm in diameter and symmetrically reactive to light. Prehospital personnel indicate that they have not seen the patient move either of his lower extremities. On examination in the emergency department, no movement of his lower extremities is detected, even in response to painful stimuli. The most likely case for this finding is: A. An epidural hematoma B. A pelvic fracture C. Central cord syndrome D. Intracerebral hemorrhage E. Bilateral compartment syndrome

A

A young man sustains a rifle would to the mid abdomen. He is brought promptly to the ED by prehospital personnel. His skin is cool and diaphoretic, and his systolic blood pressure is 58 mmHg. Warmed crystalloid fluids are initiated without improvement in his vital signs. The next, most appropriate, step is to perform: A. A laparotomy B. An abdominal CT scan C. Diagnostic laparoscopy D. Abdominal ultrasonography E. A diagnostic peritoneal lavage

A

Absence of breath sounds and dullness to percussion over the left hemithorax are findings best explained by: A. Left hemothorax B. Cardiac contusion C. Left simple pneumothorax D. Left diaphragmatic rupture E. Right tension pneumothorax

A

A four-year-old girl, weighing approximately 20 kg is admitted in shock after an automobile crash. The initial fluid challenge or bolus should consist of Ringers lactate solution in the volume of A. 200 ml B. 400 ml C. 440 ml D. 600 ml E. 880 ml

B

All of the following are true of the Mallampati classification EXCEPT: A. Class IV is easiest intubation, while Class I is the most difficult B. It helps assess for difficult intubations C. It is part of the LEMON assessment D. It comprises a visual assessment of the distance from the tongue base to roof of mouth, and therefore the amount of space there is to work E. A poor Mallampati score is associated with a higher incidence of obstructive sleep apnea

A

An 18-year-old male is brought to the ED after having been shot. He has one bullet wound just below the right clavicle and another just below the costal margin in the right posterior axillary line. His BP is 110/60, HR is 90 bpm, and RR is 34 breaths per minute. After ensuring a patent airway and inserting 2 large caliber IV line, the next appropriate step is to: A. Obtain a chest x-ray B. Administer a bolus of additional IV fluid C. Perform a laparotomy D. Obtain abdominal CT scan E. Perform DPL

A

A 17-year-old helmeted motorcyclist is struck broadside by an automobile at an intersection. He is unconscious at the scene with a blood pressure of 140/90 mmHg, heart rate of 90 beats per minute, and respiratory rate of 22 breaths per minute. His respirations are sonorous and deep. His GCS score is 6. Immobilization of the entire family may include the use of all the following EXCEPT: A. Air splints B. Bolstering devices C. A long spine board D. A scoop style stretcher E. A semirigid cervical collar

A

A 20-year-old athlete is involved in a motorcycle crash. When he arrives in the ED, he shouts that he cannot move his legs. On physical examination, there are no abnormalities of the chest, abdomen, or pelvis. The patient has no sensation in his legs and cannot move them, but his arms are moving. The patient's RR is 28 bpm, HR is 88 bpm and BP is 80./60 mmHg. He is pale and sweaty. What is the most likely cause of this condition? A. Neurogenic shock B. Cardiogenic shock C. Abdominal hemorrhage D. Myocardial contusion E. Hyperthermia

A

In managing the head-injury patient, the most important initial step is to: A. Secure the airway B. Obtain c-spine film C. Support the circulation D. Control scalp hemorrhage E. Determine GCS score

A

A young woman sustains a severe head injury as the result of a motor vehicle crash. In the emergency department, her GCS is 6. Her blood pressure is 140/90 mm Hg and her heart rate is 80 beats per minute. She is intubated and mechanically ventilated. Her pupils are 3 mm in size and equally reactive to light. There is no other apparent injury. The most important principle to follow in the early management of her head injury is to: A. Administer an osmotic diuretic B. Prevent secondary brain injury C. Aggressively treat systemic hypertension D. Reduce metabolic requirements of the brain E. Distinguish between intracranial hematoma and cerebral edema

B

All of the following are indicators of inhalation injury EXCEPT: A. Singeing of the eyebrows and nasal vibrissae B. Carboxyhemoglobin level >4% C. Carbon deposits in the mouth or nose and carbonaceous sputum D. Hoarseness E. Face or neck burns

B

An electrician is electrocuted by a downed power line after a thunderstorm. He apparently made contact with the wire at the level of the right mid-thigh. In the emergency department, his vital signs are normal and no dysrhythmia is noted on EKG. On examination, there is an exit wound on the bottom of the right foot. His urine is positive for blood by dipstick but no RBCs are seen microscopically. Initial management should include: A. Immediate angiography B. Aggressive fluid infusion C. Intravenous pyleography D. Debridement of necrotic muscle E. Admission to the intensive care unit for observation

B

During the third trimester of pregnancy, all of the following changes occur normally, EXCEPT a: A. Decrease in PaCO2 B. Decrease in the leukocyte count C. Reduce gastric emptying rate D. Diminished residual lung volume E. Diminished pelvic ligament tension

B

The response to catecholamines in an injured, hypovolemic pregnant woman can be expected to result in: A. Placental abruption B. Fetal hypoxia and distress C. Fetal/maternal dysrhytmia D. Improved uterine blood flow E. Increased maternal renal blood flow

B

Which of the following statements concerning intraosseous infusion is TRUE? A. Only crystalloid solutions may be safely infused through the needle B. Aspiration of bone marrow confirms appropriate positioning of the needle C. Intraosseous infusion is the preferred route for volume resuscitation in small children D. Intraosseous infusion may be utilized indefinitely E. Swelling in the soft tissues around the intraosseous site is not a reason to discontinue infusion

B

Which one of the following statements regarding abdominal trauma in the pregnant patient is TRUE? A. The fetus is in jeopardy only with major abdominal trauma B. Leakage of amniotic fluid is an indication for hospital admission C. Indications for peritoneal lavage are different from those in the non-pregnant patient D. Penetration of an abdominal hollow viscus is more common late than in early pregnancy E. The secondary survey follows a different pattern from that of the non-pregnant patient

B

A 25-year-old woman is brought to the ED after a motor vehicle crash. She was initially lucid at the scene and then developed a dilated pupil and contralateral extremity weakness. In the ED, she is unconscious and has a GCS score of 6. The initial management step for this patient should be to: A. Obtain a CT-scan of the head B. Administer decadron 20 mg IV C. Perform endotracheal intubation D. Administer mannitol 1g/kg IV E. Perform an emergency bone flap craniotomy on the side of the dilated pupil

C

A 32-year-old is brought to the hospital unconscious with severe facial injuries and noisy respirations after an automobile collision. In the ED, he has no apparent injury to the anterior aspect of his neck. He suddenly becomes apneic, and attempted ventilation with a face mask is unsuccessful. Examination of his mouth reveals a large hematoma of the pharynx with loss of normal anatomic landmarks. Initial management of his airways should consist of: A. Inserting an oropharyngeal airway B. Inserting a nasopharyngeal airway C. Performing a surgical cricothyroidotomy D. Performing fiberoptic-guided nasotracheal intubation E. Performing orotracheal intubation after obtaining a lateral c-spine x-ray

C

A 32-year-old man is brought to the hospital unconscious with severe facial injuries noisy respirations after an automobile collision. In the emergency department, he has no apparent injury to the anterior aspect of his neck. He suddenly becomes apneic, and attempted ventilation with a face mask is unsuccessful. Examination of his mouth reveals a large hematoma of the pharynx with loss of normal anatomic landmarks. Initial management of his airway should consist of: A. Inserting an oropharyngeal airway B. Inserting a nasopharyngeal airway C. Performing a surgical cricothyroidotomy D. Performing fiberoptic-guided nasotracheal intubation. E. Performing orotracheal intubation after obtaining a lateral c-spine x-ray

C

A 34-year-old man is brought to the ED after being pinned to the wall of a building by a cement truck. He is in obvious shock, and has deformities and marked swelling of both thighs. Although no open wound are present, his shock: A. Cannot be explained without concomitant pelvic fracture B. Signifies a loss of approximately 15% C. Is consistent with blood loss from bilateral femoral fractures D. Will likely be reversed if appropriate traction splint are applied E. Cannot be explained by his observed injuries unless a major arterial injury exist

C

A 40-year-old woman restrained driver is transported to the ED in full spinal immobilization. She is hemodynamically stable and found to be paraplegic at the level of T10. Neurologic examination also determines that there is loss of pain and temperature sensation with preservation of proprioception and vibration. These findings are consistent with the diagnosis of: A. Central cord syndrom B. Spinal shock syndrome C. Anterior cord syndrome D. Complete cord syndrome E. Brown-Sequard syndrome

C

A 42-year-old man, injured in a motor vehicle crash, suffers a closed head injury, multiple palpable left rib fractures, and bilateral femur fractures. He is intubated orotracheally without difficulty. Initially, his ventilations are easily assisted with a bag-valve device. It becomes more difficult to ventilate the patient over the next 5 minutes, and his hemoglobin oxygen saturation level decreases from 98% to 89%. The most appropriate next step is to: A. Obtain a chest x-ray B. Decrease the tidal volume C. Auscultate the patient's chest D. Increase the rate of assisted ventilations E. Perform needle decompression of the left chest

C

A 56-year-old man is thrown violently against the steering wheel of his truck during a motor vehicle crash. On arrival in the ED, he is diaphoretic and complaining of chest pain. His BP is 60/40 mmHg and his respiratory rate is 40 breaths per minute. Which of the following best differentiates cardiac tamponade from tension pneumothorax as the cause of his hypotension? A. Tachycardia B. Pulse volume C. Breath sounds D. Pulse pressure E. Jugular venous pressure

C

A 6-year-old boy walking across the street is struck by the front bumper of a sports utility vehicle traveling at 32 kph (20 mph). Which one of the following statements is TRUE? A. A flail chest is probable B. A symptomatic cardiac contusion is expected C. A pulmonary contusion may be present in the absence of rib fractures D. Transection of the thoracic aorta is more likely than in an adult patient E. Rib fractures are commonly found in children with this mechanism of injury

C

A patient arrives in the ED after being beaten about the head and face with a wooden club. He is comatose and has a palpable depressed skull fracture. His face is swollen and ecchymotic. He has gurgling respirations and vomitus on his face and clothing. The most appropriate step after providing supplemental oxygen and elevating his jaw is to: A. Request a CT scan B. Insert a gastric tube C. Suction of the oropharynx D. Obtain a lateral cervical spine x-ray E. Ventilate the patient with a bag-mask

C

A young man sustained a gunshot wound to the abdomen and is brought promptly to the ED by prehospital personnel. His skin is cool and diaphoretic, and he is confused. His pulse is thready and his femoral pulse is only weakly palpable. The definitive treatment in managing this patient is to: A. Administer O neg blood B. Apply external warming devices C. Control internal hemorrhage operatively D. Apply pneumatic antishock garment E. Infuse large volumes of IV crystalloid solution

C

A young man sustains a gunshot wound to the abdomen and is brought promptly to the ED by prehospital personnel. His skin is cool and diaphoretic, and he is confused. His pulse is thready and his femoral pulse is only weakly palpable. The definitive treatment in managing this patient is to: A. Administer O-negative blood B. Apply external warming devices C. Control internal hemorrhage operatively D. Apply a pneumatic antishock garment (PASG) E. Infuse large volumes of intravenous crystalloid solutions

C

After being involved in a motor vehicle crash, a 25-year-old man is brought to a hospital with a general surgeon on duty. He has a GCS of 13 and complains of abdominal pain. His blood pressure was 80 mmHg systolic by palpation at the hospital, but increases to 110/70 with the administration of 2L of IV-fluid. His heart rate remains 120 beats per minute. CT shows an aortic injury and splenic laceration with free abdominal fluid. His blood pressure falls to 70 mmHg after CT. The next step is A. Contrast angiography B. Transfer to a higher level trauma center C. Exploratory laparotomy D. Transfuse packed red blood cells E. Transesophageal echocardiography

C

Cardiac tamponade after trauma: A. Is seldom life-threatening B. Can be excluded by an upright AP chest x-ray C. Can be confused with a tension pneumothorax D. Causes a fall in systolic pressure of >15 mmHg with expiration E. Most commonly occurs after blunt injury to the anterior chest wall

C

The driver of a single car crash is orotracheally intubated in the field by prehospital personnel after they identify a closed head injury and determine that the patient is unable to protect his airway. In the ED, the patient demonstrate decorticate posturing bilaterally. He is being ventilated with a bag-valve device, but his breath sounds are absent in the left hemithorax. His blood pressure is 160/80mmHg, heart rate is 70 beats per minute, and the pulse oximeter displays a hemoglobin oxygen saturation of 96%. The next step in assessing and managing this patient should be to: A. Determine the arterial blood gases B. Obtain a lateral cervical spine x-ray C. Assess placement of the endotracheal tube D. Perform needle decompression of the left chest E. Insert a thoracostomy in the left hemithorax.

C

The first maneuver to improve oxygenation after chest injury is: A. Intubate the patient B. Assess arterial blood gases C. Administer supplemental oxygen D. Ascertain the need for a chest tube E. Obtain a chest x-ray

C

The primary indication for transferring a patient to a higher level trauma center is: A. Unavailability of surgeon or operating staff B. Multiple system injuries, including severe head injury C. Resource limitations as determined by the transferring doctor D. Resource limitations as determined by the hospital administration E. Widened mediastinum on chest x-ray following blunt trauma

C

When applying the Rule of Nines to infants: A. It is not reliable B. The body is proportionally larger in infants than in adults C. The head is proportionally larger in infants than in adults D. The legs are proportionally larger in infants than in adults E. The arms are proportionally larger in infants than in adults

C

Which one of the following necessitates a definitive airway in severe trauma patients? A. Facial lacerations B. Repeated vomiting C. Severe maxillofacial fracture D. Sternal fracture E. GCS score of 12

C

Which one of the following situations requires Rh immunoglobulin administration to an injured woman? A. Negative pregnancy test, Rh negative, and torso trauma B. Positive pregnancy test, Rh positive, and has torso trauma C. Positive pregnancy test, Rh negative, and has torso trauma D. Positive pregnancy test, Rh positive, and has an isolated wrist fracture E. Positive pregnancy test, Rh negative, and has torso trauma

C

Which one of the following statements is FALSE concerning Rh isoimmunization in the pregnant trauma patient? A. It occurs in blunt or penetrating abdominal trauma B. Minor degrees of fetomaternal hemorrhage produce it C. A negative Kleihauer-Betke test excludes Rh isoimmunization D. This is not a problem in the traumatized Rh-positive pregnant patient E. Initiation of Rh immunoglobulin therapy does not require proof of fetomaternal hemorrhage

C

Which one of the following statements is true regarding access in pediatric resuscitation? A. Intraosseous access should only be considered after five percutaneous attempts B. Cut down at the ankle is a preferred initial access technique C. Blood transfusion can be delivered through an intraosseous access D. Internal jugular cannulation is the next preferred opinion when percutaneous venous access fails E. Intraosseous cannulation should be first choice for access

C

A 60-year-old man sustains a stab wound to the right posterior flank. Witnesses state the weapon was a small knife. His heart rate is 90 beats per minute, blood pressure is 128/72 mmHg and respiratory rate is 24 breaths per minute. The most appropriate action to take at this time is to: A. Perform a colonoscopy B. Perform a barium enema C. Perform an intravenous pyelogram D. Perform serial physical examinations E. Suture repair the wound and outpatient follow up

D

A 29-year-old male is brought to the ED after being involved in an MVC when his car struck a bridge. He is intoxicated, has a GCS of 13 and complains of abdominal pain. His BP was 80 mmHg systolic over palpation on admission, but rapidly increased to 110/70 mmHg with the administration of IV fluid. His heart rate is 120/min. The chest x-ray shows loss of the aortic knob, widening of the mediastinum, no rib fractures or hemopneumothorax. Contrast angiography A. Is not indicated B. Should be performed after CT scan of the chest C. Is positive for aortic rupture in 80% of similar cases D. Is not necessary if the CT scan of the chest is normal E. Should be performed after DPL

D

A 30-year-old man sustains a severely comminuted, open, distal right femur fracture in a motorcycle crash. The wound is actively bleeding. Normal sensation is present over the lateral aspect of the foot but decreased over the medial foot and great toe. Normal motion of the foot is observed. Dorsalis pedis and posterior tibial pulses are easily palpable on the left, but heard only by Doppler on the right. Immediate efforts to improve circulation to the injured extremity should involve: A. Immediate angiography B. Tamponade of the wound with a pressure dressing C. Would exploration and removal of bony fragments D. Realignment of the fracture segments with a traction splint E. Fasciotomy of all four compartments in the lower extremity

D

A 32-year-old man right leg is trapped beneath his overturned car for nearly 2 hours before he is extricated. On arrival in the ED, his right lower extremity is cool, mottled, insensate, and motionless. Despite normal vital signs, pulses cannot be palpated inferior to the femoral artery, and the muscles of the lower extremity are firm and hard. During initial management of this patient, which of the following is most likely to improve chances for limb salvage? A. Apply skeletal traction B. Administering anticoagulant drugs C. Administering thrombolytic therapy D. Perform right lower extremity fasciotomy E. Immediately transferring the patient to a trauma center

D

Which one of the following statements concerning spine and spinal cord trauma is true? A. A normal lateral c-spine film excludes injury B. A vertebral injury is unlikely in the absence of physical findings of a cord injury C. A patient with a suspected injury requires immobilization on a short spine D. Diaphragmatic breathing in an unconscious patient who has fallen is a sign of spine injury E. Determination of whether a spinal cord lesion is complete or incomplete must be made in the primary survey

D

A 36-year-old woman is beaten about the head and face and is brought to the local community hospital in full spinal immobilization. Her BP is 130/88, HR is 70/min and RR is 18/min. Pulse oximetry indicated 98% while she was given 100% O2 via a nonrebreather mask. Her airway is clear. She has marked swellings on her face and several lacerations of her scalp that are not actively bleeding. She does not respond to verbal stimuli, but localizes to painful stimuli and opens her eyes. She moves all extremities equally. The remainder of her physical exam is normal. There is no neurosurgeon at the local hospital. After ensuring the patient airway, the most appropriate course of action is to: A. Admit the patient to the hospital for observation B. Obtain x-ray of her facial bones prior to transfer C. Obtain complete x-ray evaluation of the cervical spine D. Transfer the patient to a neurosurgeon without performing a CT scan

D

A 22-year-old female athlete is stabbed in her left chest at the third interspace in the anterior axillary line. On admission to the ED and 15 minutes after the incident, she is awake and alert. Her heart rate is 100 beats per minute, BP 80/60 mmHg, and respiratory rate is 20 breaths per minute. A chest x-ray reveals a large left hemithorax. A left chest tube is placed with an immediate return of 1600 ml of blood. The next management step for this patient is: A. Perform a thoracoscopy B. Perform an arch aortogram C. Insert a second left chest tube D. Prepare for an exploratory thoracotomy E. Perform a chest CT

D

A 22-year-old man sustains a gunshot wound to the left chest and is transported to a small community hospital at which surgical capabilities are not available. In the ED, a chest tube is inserted and 700 ml of blood is evacuated. The trauma center accepts the patient in transfer. Just before the patient is placed in an ambulance for transfer, his blood pressure decreases to 80/68 mmHg and his heart rate increases to 136 beats per minute. The next step should be to: A. Clamp the chest tube B. Cancel the patient's transfer C. Perform an ED thoracotomy D. Repeat the primary survey and proceed with transfer E. Delay the transfer until the referring doctor can contact a thoracic surgeon

D

A 23-year-old man is brought immediately to the ED from the hospital's parking lot where he was shot in the lower abdomen. Examination reveals a single bullet wound. He is breathing and has a thready pulse. However, he is unconscious and has no detectable blood pressure. Optimal immediate management is to: A. Perform a diagnostic peritoneal lavage B. Initiate infusion of packed red blood cells C. Insert a nasogastric tube and urinary catheter D. Transfer the patient to the operating room, while initiating fluid therapy E. Initiate fluid therapy to return his blood pressure to normotensive

D

A 23-year-old man sustains three stab wounds to the upper right chest during an altercation and is brought by ambulance to a hospital that has full surgical capabilities. His wounds are all above the nipple. He is endotracheally intubates, closed tube thoracostomy is performed, and 2 liters of crystalloid solution are infused through 2 large-caliber IVs. His BP is 60/0 mmHg, heart rate is 160 beats per minute, and respiratory rate is 14 breaths per minute (ventilated with 100% O2). 1500 ml of blood has drained from the right chest. The most appropriate next step in managing this patient is to: A. Perform FAST B. Obtain a CT of the chest C. Perform angiography D. Urgently transfer the patient to the operating room E. Immediately transfer the patient to a trauma center

D

A 39-year-old man is admitted to the ED after an automobile collision. He is cyanotic, has insufficient respiratory effort, and has a GCS score of 6. His full beard makes it difficult to fit the oxygen face mask to his face. The most appropriate next step is to: A. Perform a surgical cricothyroidotomy B. Attempt nasotracheal intubation C. Ventilate him with a bag-mask device until c-spine injury can be excluded D. Attempt orotracheal intubation using 2 people and inline stabilization of the cervical spine E. Ventilate the patient with a bag-mask device until his beard can be shaved for a better mask fit

D

A 64-year-old man, involved in a high-speed car crash, is resuscitated initially in a small hospital with limited resources. He has a closed head injury with a GCS score of 13. He has a widened mediastinum on chest x-ray with fractures of left ribs 2 through 4 but no pneumothorax. After infusing 2 liters of crystalloid solution, his blood pressure is 100/74, heart rate is 110 beats per minute, and respiratory rate is 18 breaths per minute. He has gross hematuria and a pelvic fracture. You decide to transfer this patient to a facility capable of providing a higher level of care. The facility is 128 km (80 miles) away. Before transfer, you should first: A. Intubate the patient B. Perform the diagnostic peritoneal lavage C. Apply the pneumatic antishock garment D. Call the receiving hospital and speak to the surgeon on call E. Discuss the advisability of transfer with the patient's family

D

A hemodynamically normal 10-year-old girls is admitted to the pediatric intensive care unit for observation after a grade III (moderately severe) splenic injury has been confirmed by CT. Which of the following mandates prompt laparotomy? A. Serum amylase of 200 B. Leukocyte count of 14000 C. Extraperitoneal bladder rupture D. Free peritoneal air demonstrated on follow up CT E. A fall in hemoglobin level from 12 g/dl to 8 g/dl over 24 hours

D

A previously healthy, 70kg (175 pound) man suffers an estimated acute blood loss of two liters. Which one of the following statements apply to this patient? A. His pulse pressure will be widened B. His urinary output will be at the lower limits of normal C. He will have tachycardia, but no change in systolic blood pressure D. His systolic blood pressure will be decreased with a narrowed, pulse pressure E. His systolic blood pressure will be maintained with an elevated diastolic pressure

D

A teen-aged bicycle rider is hit by a truck traveling at high speed. In the ED, she is actively bleeding from open fractures of her legs, and has abrasions on her chest and abdominal wall. Her blood pressure is 80/50 mmHg, heart rate is 140 beats per minute, respiratory rate is 8 breaths per minute, and GCS score is 6. The first step in managing this patient is to: A. Obtain a lateral cervical spine x-ray B. Insert a central venous pressure line C. Administer 2 liters of crystalloid solution D. Perform endotracheal intubation and ventilation E. Apply a pneumatic antishock garment (PASG) and inflate the leg compartments

D

An 8-year-old boy falls 4.5 meters (15 feet) from a tree and is brought to the ED by his family. His vital signs are normal, but he complains of left upper quadrant pain. An abdominal CT-scan reveals a moderately severe laceration of the spleen. The receiving institution does not have 24-hour-a-day operating room capabilities. The most appropriate management of this patient would be to A. Type and crossmatch for blood B. Request consultation of a pediatrician C. Transfer the patient to a trauma center D. Admit the patient to the intensive care unit E. Prepare the patient for surgery the next day

D

An 8-year-old girl is an unrestrained passenger in a vehicle struck from behind. In the ED, her blood pressure is 80/60 mmHg, heart rate is 80 beats per minute, and respiratory rate is 16 breaths per minute. Her GCS score is 14. She complains that her legs feel "funny and won't move right". However, her spine x-rays do not show a fracture or dislocation. A spinal cord injury in this child: A. Is most likely a central cord syndrome B. Must be diagnosed by magnetic resonance imaging C. Can be excluded by obtaining a CT-scan of the entire spine D. May exist in the absence of objective findings on x-ray studies E. Is unlikely because of the incomplete calcification of the vertebral bodies

D

During resuscitation, which one of the following is the most reliable as a guide to volume replacement? A. Heart rate B. Hematocrit C. Blood pressure D. Urinary output E. Jugular venous pressure

D

Hemorrhage of 20% of the patient's blood volume is associated usually with: A. Oliguria B. Confusion C. Hypotension D. Tachycardia E. Blood transfusion requirement

D

Important screening x-rays to obtain in the multiple system trauma patient are: A. Skull, chest and abdomen B. Chest, abdomen and pelvis C. Skull cervical spine and pelvis D. Cervical spine, chest and pelvis E. Cervical spine, chest and abdomen

D

In comparison with young adults, elderly patients exhibit which of the following regarding brain injuries? A. Increased cerebral blood flow B. Less stretching of the bridging veins C. Less subdural hematomas D. Less brain contusions E. Less mobility with angular acceleration and deceleration

D

Regarding shock in the child, which of the following is FALSE? A. Vital signs are age-related B. Children have greater physiologic reserves than do adults C. Tachycardia is the primary physiologic response to hypovolemia D. The absolute volume of blood loss required to produce shock is the same as in adults E. An initial fluid bolus for resuscitation should approximate 20ml/kg Ringers Lactate

D

The most important, immediate step in the management of an open pneumothorax is: A. Endotracheal intubation B. Operation to close the wound C. Placing a chest tube through the chest wound D. Placement of an occlusive dressing over the wound E. Initiation of 2 large-caliber IVs with crystalloid solution

D

The physiologic hypervolemia of pregnancy has clinical significance in the management of the severely injured gravid woman by A. Reducing the need for blood transfusion B. Increasing the risk of pulmonary edema C. Complicating the management of closed head injury D. Increasing the volume of blood loss to produce shock/maternal hypotension E. Reducing the volume of crystalloid required for resuscitation

D

Which of following is NORMAL in pregnancy? A. Increased residual lung volume B. Decreased plasma volume C. Decreased total RBC mass D. Widened symphysis pubis

D

Which of the following physical findings suggest a cause of hypotension other than spinal cord injury? A. Priapism B. Bradycardia C. Diaphragmatic breathing D. Presence of deep tendon reflexes E. Ability to flex forearms but not extend them

D

Which of the following signs is LEAST reliable for diagnosing esophageal intubation? A. Symmetrical chest movement B. End-tidal CO2 presence by colorimetry C. Bilateral breath sounds D. Oxygen saturation >92% E. ETT above carina chest x-ray

D

A trauma patient present to your emergency department with inspiratory stridor and a suspected C-spine injury. Oxygen saturation is 88% on high-flow oxygen via a nonrebreathing mask. The most appropriate next step is to: A. Apply cervical traction B. Perform immediate tracheostomy C. Insert bilateral thoracostomy tubes D. Maintain 100% oxygen and obtain immediate c-spine x-rays E. Maintain inline immobilization and establish a definitive airway

E

All of the following are considered minimal precautions for the prevention of the spread of communicable diseases during resuscitation, EXCEPT: A. Goggles B. Face mask C. Water impervious gown D. Water impervious leggings E. Needle-impenetrable sterile gloves

E

A 22-year-old male sustains a shotgun wound to the left shoulder and chest at close range. His BP is 80/40 mmHg and his HR is 130 bpm. After 2 liters of crystalloid solutions are rapidly infused, his BP increases 122/84, and HR decreases to 100 bpm. He is tachypneic with RR of 28. On physical examination, his breath sounds are decreased at the left upper chest with dullness on percussion. A large caliber (36 french) tube thoracostomy is inserted in the fifth intercostal space with the return of 200 ml of blood and no air leak. The most appropriate next step is to: A. Insert a foley catheter B. Begin to transfuse O-negative blood C. Perform thoracotomy D. Obtain a CT-scan of chest and abdomen E. Repeat the physical examination of the chest

E

A 22-year-old man is brought to the hospital after crashing his motorcycle into a telephone pole. He is unconscious and in profound shock. He has no open wounds or obvious fractures. The cause of his shock is MOST LIKELY caused by: A. A subdural hematoma B. An epidural hematoma C. A transected lumbar spinal cord D. A basilar skull fracture E. Hemorrhage into the chest or abdomen

E

A 22-year-old man is brought to the hospital after crashing his motorcycle into a telephone pole. He is unconscious and in profound shock. He has no open wounds or obvious fractures. The cause of his shock is MOST LIKELY caused by: A. A subdural hematoma B. An epidural hematoma C. A transected lumbar spinal cord D. A transected cervical spinal cord E. Hemorrhage into the chest or abdomen

E

A 24-year-old man sustains multiple fractured ribs bilaterally as a result of being crushed in a press at a plywood factory. Examination in the ED reveals a flail segment of the patient's thorax. Primary resuscitation includes high-flow oxygen administration via a nonrebreathing mask, and initiation of Ringers lactate solution. The patient exhibits progressive confusion, cyanosis and tachypnea. Management at this time should consist of: A. Intravenous sedation B. External stabilization of the chest wall C. Increasing the FiO2 in the inspired gas D. Intercostal nerve blocks for pain relief E. Endotracheal intubation and mechanical ventilation

E

A 30-year-old man is struck by a car traveling at 56 kph (35 mph). He has obvious fractures of the left tibia near the knee, pain in the pelvic area, and severe dyspnea. His heart rate is 180 beats per minute, and his respiratory rate is 48 breaths per minute with no breath sounds heard in the left chest. A tension pneumothorax is relieved by immediate by immediate needle decompression and tube thoracostomy. Subsequently, his heart rate decreases to 140 beats per minute, his respiratory rate decreases to 36 breaths per minute, and his blood pressure is 80/50 mmHg. Warmed Ringer's lactate is administered intravenously. The next priority should be to: A. Perform a urethrogram and cystogram B. Perform external fixation of the pelvis C. Obtain abdominal and pelvic CT scans D. Perform arterial embolization of the pelvic vessels E. Perform diagnostic peritoneal lavage or abdominal ultrasound

E

A contraindication to nasogastric intubation is the presence of a: A. Gastric perforation B. Diaphragmatic rupture C. Open depressed skull fracture D. Fracture of the cervical spine E. Fracture of the cribriform plate

E

A crosstable, lateral x-ray of the cervical spinal A. must precede endotracheal intubation B. Excludes serious cervical spine injury C. Is an essential part of the primary survey D. Is not necessary for unconscious patients with penetrating cervical injuries E. Is unacceptable unless 7 cervical vertebrae and the C7 to T1 relationship are visualized

E

A patient is brought to the ED 20 minutes after a motor vehicle crash. He is conscious and there is no obvious external trauma. He arrives at the hospital completely immobilized on a long spine board. His blood pressure is 60/40 mmHg and his heart rate is 70 beats per minute. His skin is warm. Which of the following statements is true? A. Vasoactive medications have no role in the patients management B. The hypotension should be managed with volume resuscitation alone C. Flexion and extension views on the c-spine should be performed early D. Occult abdominal visceral injuries can be excluded as a cause of hypotension E. Flaccidity of the lower extremities and loss of deep tendon reflexes as expected

E

During an altercation, a 36-year-old man sustains a gunshot wound above the nipple line on the right, with an exit wound posteriorly above the scapula on the right. He is transported by ambulance to a community hospital. He is endotracheally intubated, close tube thoracostomy is performed, and 2 liters Ringers lactate solution are infused via 2 large-caliber IV's. His blood pressure now is 60/0 mmHg, heart rate is 160 beats per minute, and respiratory rate is 14 breaths per minute (ventilated with 100% O2). The most appropriate next step in managing this patient is: A. Laparotomy B. Diagnostic peritoneal lavage C. Arterial blood gas determination D. Administer packed red blood cells E. Chest X-ray to confirm tube placement

E

Early central venous pressure monitoring during fluid resusciation in the ED has the greatest utility in a: A. Patient with a splenic laceration B. Patient with a inhalation injury C. 6 year-old child with a pelvic fracture D. Patient with a severe cardiac contusion E. 24-year-old man with a massive hemothorax

E

The following are criteria for transfer to a burn center, EXCEPT for: A. Partial-thickness and full-thickness burns on greater than 10% of the BSA B. Any full-thickness burn C. Partial-thickness and full-thickness burn involving the face, hands, feet, genitalia, perineum, and skin overlying joints D. Elevated central venous pressure E. Inhalation injury

E

To establish a diagnosis of shock, A. Systolic blood pressure must be below 90 mmHg B. The presence of a closed head injury should be excluded C. Acidosis should be present by arterial blood gas analysis D. The patient must fail to respond to intravenous fluid infusion E. Clinical evidence of inadequate organ perfusion must be present

E

Twenty-seven patients are seriously injured in an aircraft accident at a local airport. The basic principle of triage should be to: A. Treat the most severely injured patients first B. Establish a field triage area directed by a doctor C. Rapidly transport all patients to the nearest appropriate hospital D. Treat the greatest number of patients in the shortest period of time E. Produce the greatest number of survivors based on available resources

E

Which one of the following findings in an adult should prompt immediate management during primary surveyte? A. Distended abdomen B. GCS of 11 C. Temperature of 36.5 D. Heart rate of 120 beats per minute E. Respiratory rate of 40 breaths per minute

E

Which one of the following statements is correct? A. Cerebral contusion may coalesce to form an intracerebral hematoma B. Epidural hematomas are usually seen in frontal region C. Subdural hematomas are caused by injury to the middle meningeal artery D. Subdural hematomas typically have a lenticular shape on CT scan E. The associated brain damage is more severe in epidural hematomas

E