NREMT P-medic: Trauma

You are assessing an adult patient with a head injury. He opens his eyes only when you speak to him, and when you ask him his name, he replies slowly by saying "No thank you." When you apply a painful stimulus by pinching his arm, he pulls his arm away from you. What is this patient's Glasgow Coma scale score?

10. The Glasgow Coma Scale (GCS) is a valuable tool when performing neurologic assessments of a head-injured patient. A single GCS assessment cannot reliably capture the patient's clinical progression; therefore, you should obtain a baseline GCS score and frequently (at least every 5 minutes) reassess it. Furthermore, when relaying the patient's GCS to the emergency department physician, state where the patient's deficits are; don't simply give a number. Your patient's present GCS score is a 10. He opens his eyes only when you speak to him; under the "eye opening" component of the GCS, this equates to a score of 3. Using inappropriate words—stating "No thank you" when you ask him his name—equates to a score of 3 under the "verbal response" component of the GCS. Withdrawal from pain (ie, pulling his arm away when a painful stimulus is applied) equates to a score of 4 under the "motor response" component of the GCS. A GCS score of 13 to 15 indicates a mild traumatic brain injury (TBI), a score of 8 to 12 indicates a moderate TBI, and a score of 3 to 8 indicates a severe TBI.

Which of the following vehicle impacts will create the greatest amount of kinetic energy?

150-lb patient who is traveling at 60 mph. Kinetic energy (KE) is a function of an object's mass (weight) and velocity (speed). The greater than amount of KE, the greater the potential for serious injury or death. The relationship between weight and speed as it affects KE is as follows: KE equals one-half the mass times the velocity square (KE = 1/2mv2). According to this formula, doubling the mass doubles the amount of KE; however, doubling the velocity quadruples the amount of KE. A 150-lb patient who strikes a fixed object while traveling at 60 mph will create 270,000 units of KE, as follows: 150 ÷ 2 (75) × 60 squared (3,600) = 270,000. A 160-lb patient traveling at 45 mph will create 162,000 units of KE, a 170-lb patient traveling at 55 mph will create 257,125 units of KE, and a 180-lb patient traveling at 50 mph will create 225,000 units of KE.

A 22-year-old male experienced blunt abdominal trauma. He is conscious and alert, but appears anxious. His blood pressure is 100/62 mm Hg, his pulse is 118 beats/min, and his respirations are 22 breaths/min. Further assessment reveals that his radial pulses are easily palpable. What is the MOST appropriate IV fluid regimen for this patient?

25 mL/hr. The patient's vital signs, although abnormal for his age, are relatively stable. Furthermore, he is conscious and alert and has easily palpable radial pulses. Given the mechanism of blunt trauma, you should suspect intraabdominal bleeding; however, his present clinical presentation indicates that he is compensating. At present, fluid boluses are not indicated. Set the IV flow rate at 25 mL/hr, which will keep the vein open (KVO) in case his condition deteriorates to a point where volume replacement is warranted. If needed, boluses of 20 mL/kg should be given to maintain perfusion (ie, radial pulses, adequate mental status), not to raise blood pressure. Increasing blood pressure too much with IV fluids not only dilutes remaining blood volume, thereby decreasing the proportion of hemoglobin, but also may increase internal bleeding by destroying clots that were formed by the process of hemostasis—the body's internal blood-clotting mechanism. Exercise caution when administering IV fluids to patients with a noncompressible hemorrhage (eg, internal bleeding).

Which of the following patients is MOST in need of rapid extrication following a motor vehicle crash?

28-year-old man with a unilateral femur fracture and confusion. The patient with confusion would be the best candidate for rapid extrication from an automobile. Any altered mental status following trauma should be assumed to be the result of head injury, cerebral hypoxia, or both. An open head injury with exposed brain mater is an ominous finding that is generally not compatible with life. Rapid extrication is also indicated if a stable patient blocks access to a more critical patient.

A 39-year-old man, who weighs approximately 160 pounds, was trapped inside his burning house and sustained full-thickness burns to approximately 40% of his body. On the basis of the Parkland formula, how much IV crystalloid solution should he receive within the first hour?

730. 160/2.2= 72.72 x 4ml x % =11,636/2 = 5818/ 8

A 19-year-old female with blunt head trauma presents with a respiratory rate of 8 breaths/min and irregular, a blood pressure of 160/96 mm Hg, and a Glasgow Coma scale score of 8. What is her revised trauma score?

8. The revised trauma score (RTS) is a reliable assessment tool that has demonstrated high interuser reliability for predicting outcomes in patients with blunt or penetrating trauma. Studies have shown that the RTS has a high sensitivity in evaluating patients with head trauma. The RTS utilizes the Glasgow Coma Scale (GCS) score, as well as the patient's respiratory rate and systolic blood pressure, to assign a numeric value (1 to 12) that represents the extent of the patient's injury. The lower the RTS (overall numeric value), the more severe the injury and the greater the chance of death.

A 170-pound male experienced partial- and full-thickness burns to 45% of his body surface area. Transport to the closest appropriate facility will take longer than an hour, so medical control has ordered you to begin IV fluid therapy based on the Parkland formula. According to this formula, how much IV fluid should the patient receive per hour?

870 ml. The Parkland formula is used to determine how much IV fluid a burn patient should receive over the first 24 hours following the burn; it is calculated as follows: 4 mL × body weight (in kg) × percentage of body surface area (BSA) burned. Thus, a 170-pound (77 kg) patient with burns to 45% of his BSA should receive 13,860 mL in the first 24 hours, as follows 4 mL × 77 (kg) × 45 (BSA burned) = 13,860 mL. The Parkland formula further states that half of the 24-hour fluid volume should be given during the first 8 hours; for this patient, that amount is 6,930 mL (13,860 ÷ 2). Therefore, you should administer 870 mL of IV fluid per hour (6,930 ÷ 8 = 866.25 [round to 870]).

Using the adult Rule of Nines, the anterior thorax accounts for ___ percent of the total body surface area.

9. According the adult Rule of Nines, the anterior trunk (thorax and abdomen) accounts for 18% of the total body surface area (TBSA). Therefore, the anterior thorax (half of the trunk) would account for 9% of the TBSA.

Mastoid bruising and cerebrospinal otorrhea following diffuse impact to the head are MOST indicative of:

A basilar skull fracture. Mastoid bruising (Battle's sign) and cerebrospinal otorrhea (cerebrospinal fluid [CSF] leakage from the ears) are classic signs of a basilar skull fracture. Basilar skull fractures are associated with high-energy trauma, and usually occur following diffuse impact to the head (eg, falls, motor-vehicle crashes). A basilar skull fracture generally results from extension of a linear fracture to the base of the skull. Cerebrospinal rhinorrhea (CSF draining from the nose) suggests a fractured cribriform plate. The cribriform plate of the ethmoid bone is a horizontal bone that is perforated with numerous foramina (openings) that allow passage of the olfactory nerve filaments from the nasal cavity. Cerebral edema (swelling of the brain) can result from any significant head injury; it is not exclusive to a basilar skull fracture. Signs of brainstem herniation—which represent significant intracranial pressure—include abnormal respiratory patterns (ie, Biot's respirations, ataxic respirations), posturing (flexor or extensor), and pupillary abnormalities (asymmetric or fixed and dilated pupils).

During your assessment of a patient with a closed head injury, you note the presence of a pinkish fluid draining from the nose. This is MOST indicative of:

A cribriform plate fracture. Bleeding or other fluid drainage from the nose following head trauma is indicative of a fracture of the cribriform plate. The cribriform plate is essentially the floor of the cranial vault. When a fracture to this plate occurs, cerebrospinal fluid (CSF) may leak into the sinuses and drain from the nose (cerebrospinal rhinorrhea). CSF drainage from the ears (cerebrospinal otorrhea) is indicative of a basilar skull fracture.

Which of the following signs would indicate a severe pericardial tamponade?

A drop in the blood pressure of greater than 10 mm Hg during inhalation Signs of a pericardial tamponade include a narrowing pulse pressure (falling systolic and rising diastolic), muffled or distant heart tones, and jugular venous distention (JVD). This trio of findings is known as Beck's Triad. In addition, pulsus paradoxus, in which the blood pressure drops greater than 10 mm Hg during inhalation, may be observed in patients who have a severe tamponade. You may also note a marked weakening or disappearance of a pulse during inhalation. JVD is optimally assessed with the patient sitting at a 45-degree angle. The presence of JVD in this position indicates increased systemic venous pressure, such as what occurs with a pericardial tamponade.

You are assessing a patient who experienced a penetrating injury to his left anterior chest. His blood pressure is 100/60 mm Hg and his pulse rate is 110 beats/min. Which of the following clinical findings is MOST suggestive of a pericardial tamponade?

A repeat blood pressure of 90/66 mm Hg. As pressure builds within the pericardial sac, the ability of the heart to contract (systole) and relax (diastole) is impaired. This results in a narrowing pulse pressure—the difference between the systolic and diastolic blood pressure. This patient's initial blood pressure of 100/60 mm Hg yielded a pulse pressure of 40 mm Hg; however, his repeat blood pressure of 90/66 mm Hg yields a pulse pressure of only 24 mm Hg. If pericardial tamponade is left untreated, both the systolic and diastolic blood pressures will drop and the patient will die. Beck's triad—jugular venous distention, narrowing pulse pressure, and muffled/distant heart tones—is a classic clinical presentation seen with severe pericardial tamponade. Jugular venous distention that occurs when manual pressure is applied over the liver is called hepatojugular reflux; it is a sign of right heart failure.

Which of the following injury mechanisms involves axial loading?

A rollover motor-vehicle crash in which the unrestrained occupant strikes his head on the interior of the roof . Axial loading causes vertical compression of the spine when direct forces are transmitted down the spinal column. The point of impact may be the head or the feet. Significant mechanisms of injury involving axial loading often cause compression fractures or crushing of one or more of the vertebral bodies; spinal cord injury may or may not occur. Common mechanisms of injury that cause axial loading include striking the top of the head on the interior roof of a vehicle during a rollover motor-vehicle crash, falls from a significant height in which the patient lands on his or her feet, diving head-first into shallow water, and a direct blow to the top of the head with a heavy object. None of the other injury mechanisms described involve vertical compression of the spine.

The MOST significant complication associated with an open-book pelvic fracture is:

An increase in pelvic volume with more internal blood loss than pelvic fractures caused by lateral compression. Anteroposterior compression of the pelvis, which can result from a head-on collision, may cause an "open-book" pelvic fracture in which the pubic symphysis spreads apart. The subsequent increase in volume of the pelvis means a patient with internal pelvic bleeding may lose a much larger volume of blood than someone without an open-book fracture. Such patients will require IV fluid boluses with an isotonic crystalloid solution, but may still remain hypotensive in the field. Lateral compression of the pelvis results from a side impact and generally does not result in an unstable pelvis. Because the volume in the pelvis is reduced, not increased, the risk of life-threatening hemorrhage is lower than with an open-book fracture. If you suspect an open-book pelvic fracture in a hypotensive patient, tie a sheet around the patient's hips at the level of the superior anterior iliac crests; this reduces the pelvic volume. There are several devices specific to the management of this type of pelvic injury that provide superior stabilization and are easy to apply. One device, the Sam Sling, has a patented "autostop" buckle to provide the correct circumferential force to stabilize open-book pelvic fractures. Pelvic fractures occasionally cause urinary bladder damage as a result of penetration by bony fragments. Although this complicates the clinical picture, internal hemorrhage is clearly a more significant concern.

A middle-aged male experienced partial-thickness splash burns to 36% of his body surface area. The burns are all located above his waist. What parts of his body have been burned?

Anterior torso and both arms. According to the adult Rule of Nines, the head (including the face and neck) represents 9% of the total body surface area (TBSA), the anterior torso (chest and abdomen) represents 18% of the TBSA, and each entire upper extremity represents 9% of the TBSA. Given that all of the patient's burns are located above the waist, the only combination in this question that equals 36% is the anterior torso (18%) and both arms (18%). The chest is one-half of the torso; therefore, it represents 9% of the TBSA. The abdomen is also one-half of the torso; therefore, it also represents 9% of the TBSA. Burns to the abdomen and one arm would equal 18% of the TBSA. Burns to the chest, head, and one arm would equal 27% of the TBSA. Burns to the chest, neck, and both arms would equal ± 30% of the TBSA.

Initial care for a patient with a large bleeding avulsion to the leg includes:

Application of a sterile dressing. Initial care for any soft-tissue injury includes controlling external bleeding. This is best accomplished by applying direct pressure with a sterile dressing. Assessing distal pulse, motor, and sensory functions should occur after the bleeding has been controlled. Irrigation of open, bleeding wounds is not routinely performed in the field. After controlling external bleeding from an extremity wound with direct pressure, placement of a splint may facilitate hemostasis (spontaneous clotting of blood) by minimizing movement of the affected extremity. If you apply a splint, check pulse, motor, and sensory functions before and after its application.

A man has a large laceration to his inner thigh and is bleeding heavily. You apply direct pressure, which controls the bleeding. The patient is conscious, but restless, and is diaphoretic. Your next action should be to:

Apply a pressure bandage. In most cases, external bleeding can be controlled with direct pressure. If direct pressure successfully controls the bleeding, your next priority should be to maintain pressure on the wound with a pressure bandage. After the bleeding is controlled, you can focus on administering oxygen (if indicated) and establishing vascular access. If direct pressure fails to immediately control severe external bleeding, a proximal tourniquet should be applied.

You are treating a young male with an arterial hemorrhage from a large laceration to his inner arm. Despite direct pressure with a sterile dressing, the wound continues to bleed heavily. You should:

Apply a proximal tourniquet until the bleeding stops. Most external bleeding can be controlled with firm, direct pressure. If direct pressure controls external bleeding, you should apply a pressure bandage. However, if you are unable to immediately stop severe external bleeding with direct pressure, you should apply a proximal tourniquet until the bleeding stops. Evidence has shown that attempting to locate an arterial pressure point and applying adequate pressure to it is difficult and time-consuming. If the wound is bleeding so profusely that direct pressure is unsuccessful, elevation of the extremity will likely not be effective.

You and your partner arrive at the scene of a motorcycle crash. You find the patient lying supine approximately 30 feet from his bike. As you approach him, you can see that he has bilaterally closed femur deformities and multiple abrasions and lacerations to his arms and legs. Bystanders removed his helmet prior to your arrival. You should:

Ask your partner to stabilize the patient's head as you assess his airway. When assessing a patient with severe trauma, do not be distracted by visually impressive injuries! It is essential to complete the primary assessment of the patient and treat what will kill him or her first. Unless associated with severe external bleeding, musculoskeletal injuries—as grotesque as they may be—are not going to immediately kill your patient. Based on this patient's mechanism of injury, you should immediately direct your partner to manually stabilize the patient's head while you assess airway, breathing, and circulation. If you find an immediate life threat in any of these areas, fix it and then move on with your assessment. A rapid head-to-toe assessment should then be performed to identify and treat other critical injuries. Remember, it is the ugliest injuries that are often the least life-threatening.

Common signs of a maxillofacial fracture include all of the following, EXCEPT:

Asymmetric pupils. Unless accompanied by a traumatic brain injury and increased intracranial pressure, asymmetric (unequal) pupils are not commonly observed in patients with maxillofacial fractures. However, patients with orbital "blowout" fractures often complain of diplopia (double vision) and lose sensation above the eyebrow or over the cheek secondary to associated nerve damage. Fractures of the inferior orbit—the most common type—may cause paralysis of upward gaze; the patient's injured eye will not be able to follow your finger above the midline. Maxillofacial structures that may be fractured include the mandible, maxilla, orbit, and nasal bone. Crepitus, ecchymosis, instability, and swelling are common to all maxillofacial fractures. In addition, mandibular fractures often present with dental malocclusion (misalignment of the teeth), and nasal fractures are often accompanied by anterior or posterior epistaxis (nosebleed).

When an adult is struck by an automobile, a typical sequence of events includes the person turning:

Away from the vehicle and being thrown onto the hood. Typically, when an adult is struck by an automobile, his or her initial instinct is to turn away from the vehicle. The initial point of impact is generally to the lateral aspect of the body. The patient is then thrown onto the hood and/or windshield, and then propelled away from the vehicle.

You are treating a patient with a closed head injury. His initial vital signs reveal a blood pressure of 132/82 mm Hg, a pulse of 76 beats/min, and respirations of 28 breaths/min. Which of the following set of repeat vital signs is MOST suggestive of increased intracranial pressure?

BP 180/88, pulse 64 and bounding, respirations 36 and irregular. Relative to the baseline vital signs, an increase in the blood pressure and a decrease in the pulse rate are most indicative of increased intracranial pressure (ICP). The trio of hypertension, bradycardia, and altered (often irregular or deep) breathing is referred to as Cushing's Triad and is a classic finding in patients with increased ICP. Hypotension, tachypnea, tachycardia, and shallow (reduced tidal volume) breathing are consistent with shock, not increased ICP. Hypotension, bradycardia, and tachypnea are consistent with neurogenic shock.

You are treating a patient with penetrating chest trauma. His initial vital signs revealed a blood pressure of 100/60 mm Hg, a pulse of 120 beats/min, and respirations of 28 breaths/min. Which of the following repeat vital signs is MOST suggestive of a pericardial tamponade?

BP of 90/70, pulse rate of 128.

Which of the following sets of vital signs is MOST indicative of neurogenic shock?

BP, 70/50 mm Hg; pulse rate, 56 beats/min; respirations, 24 breaths/min. Neurogenic shock (also called vasomotor shock) results from the loss of normal sympathetic nervous system tone; it is commonly caused by a spinal injury. In neurogenic shock, there is no release of the catecholamines epinephrine and norepinephrine. This causes widespread vasodilation and hypotension (relative hypovolemia); pink, dry skin below the level of the injury; and relative bradycardia. The classic signs of shock—tachycardia, diaphoresis, and pallor—are not observed in patients with neurogenic shock. Unless concomitant head injury is present, the patient's respirations are generally rapid and shallow. Hypotension, tachycardia, and tachypnea are consistent with shock not involving a loss of sympathetic nervous system tone (ie, hypovolemia, anaphylaxis). Hypertension, bradycardia, and abnormal respirations (Cushing's triad) are consistent with increased intracranial pressure.

Which of the following spinal cord injuries classically presents with weakness of the upper and lower extremities on the ipsilateral side and loss of pain and temperature sensation on the contralateral side?

Brown-Séquard syndrome. Brown-Séquard syndrome is caused by partial transection (hemitransection) of the spinal cord, typically from intervertebral disk rupture or an unstable vertebral fragment that puts pressure on the spinal cord. Classically, pressure on half of the spinal cord causes extremity weakness on the ipsilateral (same) side as the cord injury, and loss of pain and temperature sensation on the contralateral (opposite) side. In central cord syndrome, the patient experiences greater motor deficit to the upper extremities; he or she often has paralyzed arms, but retains the ability to move his or her legs. Anterior cord syndrome is caused by pressure on the anterior part of the spinal cord by a vertebral fragment that is forced posteriorly into the spinal canal; signs and symptoms include decreased sensation of temperature and pain distal to the injury, while light touch and position sensation (proprioception) remain intact. Complete cord transection results in loss of all sensory and motor function distal to the site of the injury; nothing is spared.

You are caring for a patient with an open fracture of the forearm in which the bone is protruding from the wound. The MOST appropriate care for this type of injury includes:

Brushing away any obvious debris on the skin surface before applying a dressing. As with any open injury, your priority in caring for an open fracture is to control bleeding. Then, you should gently brush away any obvious debris from the skin surface surrounding the wound; apply dry, sterile dressings; and splint the extremity appropriately. Do not irrigate the wound; this may force outside contaminants into the wound, increasing the risk of infection. Entering or probing the open fracture site in an attempt to retrieve any debris also increases the risk of infection. Never attempt to replace exposed bone ends back into the wound; this significantly increases the risk of infection.

You and your partner are standing by at a community softball tournament when you witness the collapse of a 39-year-old male immediately after he was struck in the chest by a softball. You quickly assess him and determine that he is apneic and pulseless. This patient's cardiac arrest was MOST likely caused by:

Cardiac dysrhythmia. If the chest receives a direct blow during the critical portion of the heart's repolarization period (relative refractory period), the result may be immediate cardiac arrest. This phenomenon, called commotio cortis, has been documented to have occurred after otherwise healthy patients were struck in the chest with softballs, baseballs, bats, snowballs, fists, and even kicks during kickboxing. Such a patient typically presents with ventricular fibrillation that responds positively to defibrillation if provided early. For this reason, public access to defibrillators in schools and sports venues is essential. Myocardial contusions are common when the chest strikes the steering wheel of a vehicle following rapid deceleration, and the heart collides with the posterior aspect of the sternum. Most myocardial contusions do not result in cardiac arrest, although cardiac dysrhythmias (ie, PVCs, PACs) may occur. Shearing injuries of the great vessels—the aorta and vena cavae—are also the result of rapid deceleration of the body with resultant separation (shearing or tearing) of the structures from which these vessels are suspended.

The baroreceptors in the aortic arch and carotid sinuses are extremely sensitive to:

Changes in arterial perfusion pressure. Baroreceptors, also known as "pressure" receptors, are located within the carotid arteries and aorta. They are extremely sensitive to changes in arterial perfusion pressure (ie, blood pressure). When the baroreceptors sense a drop in arterial blood pressure, they send signals via the sympathetic nervous system, resulting in the release of catecholamines (epinephrine and norepinephrine). Catecholamine release causes an increase in systemic vascular resistance, resulting in vasoconstriction, as well as increases in heart rate (positive chronotropy) and myocardial contraction force (positive inotropy). Central and peripheral chemoreceptors constantly monitor the pressure of gases (oxygen and carbon dioxide) in the blood, as well as the pH of the cerebrospinal fluid, and help regulate ventilation rate and depth.

General assessment and treatment guidelines for a patient with a large avulsion injury include all of the following, EXCEPT:

Cleaning the wound with betadine solution. Other than sterile saline for irrigation purposes, you should never put anything into an open soft tissue injury; this only increases the risk of infection. If gross contaminants (eg, glass, dirt) are visible in and around the wound, carefully remove them and then cover the wound with a sterile dressing. If a flap of tissue is still attached, gently replace it back to its normal position after removing any gross contaminants, and then cover the wound with a dry, sterile dressing. When gathering information for your SAMPLE history, you should ask the patient when he or she last had a tetanus vaccination. Although paramedics do not administer tetanus vaccinations, this is pertinent information to obtain for patients with any open injury, and should be included in your verbal report when you transfer patient care to the staff at the receiving facility. Tetanus is a serious and potentially fatal disease of the central nervous system that occurs when Clostridium tetani—a bacterium—enters the bloodstream through an open wound.

When assessing a patient with a closed head injury, you note the presence of trismus. This is defined as:

Clenching of the teeth. Trismus is defined as clenching of the teeth due to spasm of the jaw muscles; it is a common finding in patients with severe head trauma. To most effectively control the airway, patients with trismus often require rapid sequence intubation (RSI). The condition in which the pupils are unequal is called anisocoria. In the context of head trauma, anisocoria is an ominous sign and indicates significantly increased intracranial pressure.

A 22-year-old male was involved in a fight and sustained a large laceration to his abdomen when he was cut. Law enforcement personnel have secured the scene. The patient is conscious, has slurred speech, and is in severe pain. You note the possible smell of alcohol on his breath. Your assessment reveals a loop of bowel protruding through the laceration to his abdomen; bleeding is minimal. His blood pressure is 84/60 mm Hg, pulse is 120 beats/min, and respirations are 24 breaths/min. In addition to administering high-flow oxygen, you should:

Cover the exposed bowel with a moist, sterile dressing; establish vascular access with a large-bore IV catheter; assess his blood glucose level; and prepare for rapid transport. Treatment for an abdominal evisceration involves applying a moist, sterile dressing over the wound and covering the moist dressing with a dry, sterile dressing. Never replace eviscerated organs back into the abdominal cavity; this increases the risk of infection. Applying a pressure dressing to an evisceration may force the organs back into the wound; don't do it! Although the patient appears intoxicated (eg, slurred speech, breath odor), you must rule out blood glucose derangements. Give IV dextrose if he is hypoglycemic. His vital signs contraindicate narcotic analgesia. Establish at least one large-bore IV and give fluids as needed to maintain adequate perfusion. The pneumatic antishock garment (PASG) is contraindicated in patients with thoracoabdominal trauma. Minimize scene time; the patient needs prompt transport to a trauma center.

A 40-year-old construction worker fell approximately 10 feet and sustained an open fracture of the left femur. Further examination reveals that the distal femur is protruding through the skin. What is the MOST appropriate care for this injury?

Cover the wound with a sterile dressing and immobilize the leg. Injuries that are close to the knee, as in the case of a distal femur fracture, should not have a traction splint applied, especially if the fracture is open with the femur protruding through the skin. Instead, the fracture should be covered with a sterile dressing and immobilized in the position found. Any action that could cause the femur to retract back into the thigh significantly increases the risks of vessel damage and infection.

Which of the following signs is LEAST suggestive of an underlying arterial injury in a patient with a closed extremity fracture?

Disproportionate pain. An arterial injury may occur in conjunction with an open or closed fracture. In patients with a closed fracture, signs of an underlying arterial injury include a diminished or absent distal pulse, a pulsatile expanding hematoma (indicates rapid internal bleeding from an artery), and a palpable thrill (vibration) over the injury site that correlates with the patient's pulse. Searing or burning pain that is out of proportion to the injury is a common early sign of compartment syndrome—a condition associated with crush injuries, fractures, or dislocations—in which pressure builds within the osteofascial compartment (the space between groups of muscles surrounded by fascia) of an extremity.

You are assessing a patient with an injury to the left midshaft femur. Which of the the following is the LEAST reliable indicator of an underlying fracture?

Ecchymosis and swelling. Ecchymosis (bruising) and swelling are common clinical signs associated with any type of musculoskeletal injury—fractures, dislocations, fracture/dislocations, and sprains. In particular, swelling often obscures underlying deformity—one of the most reliable signs of a fracture. The most reliable symptom of an underlying fracture is pain that is well localized to the fracture site. Shortening occurs in fractures when the broken ends of a bone override one another; this is characteristic of femur fractures, for example, because the fractured femur can no longer serve as a strut to oppose spasm in the powerful thigh muscles.

A deep partial-thickness burn is characterized by:

Edema, blister formation, and decreased sensation around the burn. Superficial (first-degree) burns are characterized by pain and erythema (redness), and damage that is limited to the superficial layer of the epidermis. Partial-thickness (second-degree) burns are categorized as being superficial partial-thickness and deep partial-thickness burns. In both types of partial-thickness burn, injury extends through the epidermis and into the dermis and fluid infiltrates in between the dermis and epidermis, creating edema and blisters. Unlike a superficial partial-thickness burn, however, a deep partial-thickness burn damages the basal layer of the dermis. As a result, sensation in and around the burn is decreased owing to damage to the nerve endings in the basal layer. A full-thickness (third-degree) burn damages the entire epidermis and dermis, including the nerve endings; this explains why full-thickness burns are usually painless. A full-thickness burn is characterized by charred, white, or leathery skin.

You are assessing a 21-year-old male who was stabbed in the left anterior chest. His blood pressure is 84/58 mm Hg, pulse rate is 118 beats/min and weak, and respirations are 28 breaths/min and shallow. Further assessment reveals that he is profusely diaphoretic, has engorged jugular veins, and bilaterally equal breath sounds. What additional clinical finding is MOST consistent with this patient's injury?

Electrical alternans. This patient's clinical presentation is consistent with a pericardial tamponade. Beck's triad—muffled/distant heart tones, narrowing pulse pressure, and jugular venous distention—is a classic combination of clinical findings in patients with pericardial tamponade, although it is only observed in approximately 30% of patients. Another classic sign of pericardial tamponade—albeit one that is not always present—is an ECG finding called electrical alternans. As fluid accumulates within the pericardial sac, the heart begins to oscillate with each beat. As the heart swings back and forth within the pericardium, its electrical axis changes; this results in QRS complexes that vary in amplitude (size and height). Kehr's sign—referred pain to the left shoulder—is often observed in patients with a splenic injury. Subcutaneous emphysema occurs when air infiltrates the subcutaneous (fatty) layer of the skin; it may be observed in patients with injuries such as pneumothorax or tracheal rupture.

A man was stabbed in the abdomen during an altercation. He is unresponsive and has a 2-inch loop of bowel protruding from the wound. Your first action should be to:

Ensure his airway is patent. No airway, no patient! Prior to administering further care to a patient, especially one who is unresponsive, airway patency and adequate oxygenation and ventilation must be ensured. Severe bleeding from the evisceration, if present, should be immediately controlled by the paramedic who is not managing the airway. Proper care for an abdominal evisceration involves covering the protruding bowel with a moist, sterile dressing and then covering the moist dressing with a dry one. Never replace the bowel back into the abdominal cavity; this significantly increases the risk of infection.

After being struck in the head with a baseball bat, a 9-year-old boy immediately loses consciousness. On your arrival, he is conscious but confused. Shortly into your assessment, he becomes unresponsive. Which of the following injuries has this child MOST likely sustained?

Epidural hemorrhage. An epidural hemorrhage, which is usually the result of damage to the middle meningeal artery, produces a loss of consciousness immediately after impact, after which the patient typically has a brief return of consciousness. As the arterial bleeding begins to increase the pressure within the cranium, however, the patient's mental status rapidly deteriorates. Subdural hemorrhages are usually venous in nature; signs and symptoms may not present for up to 24 hours or longer.

A 170-lb adult lost a large amount of blood from an external wound. He is conscious and alert, but restless, and has cool, clammy skin. His blood pressure is 112/70 mm Hg and his pulse is 110 beats/min and strong. Which of the following statements regarding IV therapy in this patient is MOST correct?

Establish at least one large-bore IV and give enough crystalloid solution to maintain perfusion. Restlessness, tachycardia, and cool, clammy skin are obvious signs of shock. At the present time, however, the patient is conscious and alert and has a systolic blood pressure greater than 90 mm Hg; therefore, he is in compensated shock. That said, his clinical status could deteriorate at any time and you must be prepared to aggressively treat him. Establish at least one large-bore IV line and administer enough crystalloid solution (ie, normal saline, lactated ringers) to maintain adequate perfusion (ie, radial pulses, adequate mental status, etc). This may require as little as 250 to 500 mL or as much as 20 mL/kg (1,540 mL [1.5 L] in a 170-lb [77 kg] adult).

External bleeding would be the MOST difficult to control in a patient who has a laceration to the:

Femoral artery and a blood pressure of 160/90 mm Hg. The larger the blood vessel and the higher the blood pressure, the more difficult external bleeding would be to control. Of the injuries and blood pressures listed, bleeding from a lacerated femoral artery in a patient with a hypertensive BP would be the most difficult to control. The femoral artery is very large and hypertension increases the force of blood through the artery, thus increasing the severity of the bleeding. As the blood pressure falls, arterial blood loses it driving force, thus making it easier to control. This is unfortunate, however, because hypotension indicates decompensated shock.

Which of the following injuries would MOST likely result from a motorcycle striking a fixed object?

Femur fractures and head injury. If you can imagine a motorcycle striking a fixed object, the operator will be ejected, striking his or her legs on the handlebars, which fractures one or both of the femurs. The operator then typically strikes the ground or object head first. Motorcycle helmets arguably decrease the risk of a serious head injury; however, they do not prevent a head injury altogether.

According to current Guidelines for Field Triage of Injured Patients, which of the following patients should be transported to a trauma center that provides the highest level of care within the defined trauma system?

Fractured humerus and femur; systolic BP of 110 mm Hg; heart rate of 120 beats/min. According to the 2011 Guidelines for Field Triage of Injured Patients, published by the Centers for Disease Control and Prevention (CDC), the paramedic should assess four components when determining the appropriate transport destination for a trauma patient: physiologic criteria, anatomic criteria, mechanism of injury, and special patient/system considerations. According to the guidelines, two or more long bone fractures meets the anatomic criteria for preferential transport to a trauma center that provides the highest level of care within the defined trauma system. Other anatomic criteria include open or depressed skull fractures, pelvic fractures, and chest wall instability or deformity (ie, flail chest). Physiologic criteria include a systolic BP less than 90 mm Hg or a Glasgow Coma Scale (GCS) score that is equal to or less than 13, among others. A high-risk vehicle crash includes intrusion (including the roof) of greater than 12 inches to the occupant site or greater than 18 inches to any site. Refer to the 2011 CDC Guidelines for Field Triage of Injured Patients for more information.

A 40-year-old male experienced blunt abdominal trauma and presents with tachycardia, weakly palpable radial pulses, diaphoresis, and restlessness. Further assessment reveals that his blood pressure is 78/60 mm Hg. After establishing vascular access, you should administer crystalloid fluids until:

HIV fluid therapy can be helpful in supplementing shock treatment (eg, oxygen, thermal management) in patients with controlled external bleeding. However, IV fluids should be administered with caution in patients with hypovolemic shock caused by bleeding that cannot be controlled (eg, internal bleeding). The patient in this scenario has obvious signs of shock, which is likely the result of intraabdominal hemorrhage. Internal hemorrhage cannot be controlled in the prehospital setting; it requires prompt surgical intervention. Therefore, the goal of volume replacement is to maintain perfusion without increasing internal bleeding. A rapid increase in blood pressure caused by excessive volume replacement can interfere with hemostasis—the body's natural physiologic process that slows or halts bleeding. For this reason, most protocols advise administration of isotonic crystalloid fluids (eg, normal saline, lactated Ringer's) in sufficient quantity (typically 20 mL/kg boluses) to restore, or in the case of this patient, improve, radial pulses. The presence of radial pulses equates to a systolic BP of 80 to 90 mm Hg, which in most people, is sufficient to adequately perfuse the brain and other vital organs. Some studies suggest that fluid therapy to maintain the systolic BP at approximately 80 mm Hg—provided that the patient's mental status is adequate—may be safer than attempting to restore normotension, which may aggravate ongoing bleeding. Remember, the goal of volume replacement is to maintain adequate perfusion, not increase blood pressure.is radial pulses are easily palpable.

During your rapid assessment of a man who sustained blunt trauma to the anterior chest, you note paradoxical movement to the left hemithorax. You should:

Have your partner stabilize the segment with his or her hand. Paradoxical chest wall movement is a classic sign of a flail chest. Once this is discovered, immediate hand stabilization should be applied until the flail segment can be stabilized with a bulky dressing. Circumferentially taping the chest wall may impair ventilation and should be avoided. It is important to note that even when an injury of this type is discovered and treated, the rapid assessment should continue; this may not be the only life-threatening injury the patient has. Some flail chests are accompanied by a pneumothorax; however, you should confirm this by auscultating breath sounds before performing a needle thoracentesis (chest decompression). Flow-restricted oxygen-powered ventilation devices (ie, demand valve, manually-triggered ventilator) should not be used on patients with chest trauma as this may cause barotrauma and exacerbate the patient's injury. Use a bag-mask device if ventilatory support is required.

A 30-year-old man has an obvious head injury. You are unable to locate any other injuries during your rapid assessment. He has a blood pressure of 88/62 mm Hg, a weak pulse rate of 118 beats/min, and respirations of 28 breaths/min. Which of the following represents the MOST appropriate treatment for this patient?

High-flow oxygen and IV fluids to maintain adequate perfusion. Patients with isolated head trauma typically do not present with signs of shock; they are usually hypertensive and bradycardic. If a patient with a seemingly isolated head injury presents with signs of shock, you should assume the presence of occult hemorrhage from another injury. Treatment for the patient in this scenario includes high-flow oxygen, assisted ventilation as needed (do NOT hyperventilate!), and IV fluids as needed to maintain adequate perfusion. The Brain Trauma Foundation (BTF) recommends maintaining a systolic BP of at least 90 mm Hg in the adult patient with a traumatic brain injury. Even a single episode of hypotension in the brain-injured patient can be catastrophic. Furosemide (Lasix) is contraindicated for patients with hypotension and/or known hypovolemia, and is rarely given in the prehospital setting to patients with a head injury.

You should be MOST suspicious that your patient has experienced a cardiac tamponade if he or she presents with:

Hypotension, jugular venous distention, and normal lung sounds. Cardiac tamponade is almost always the result of penetrating chest trauma; it is rarely caused by blunt force trauma. Hypotension and jugular venous distention in the presence of normal lung sounds (which rules out pneumothorax), combined with an appropriate history—penetrating chest trauma—suggests cardiac tamponade. Retrosternal chest pain, tachycardia, and an irregular pulse are suggestive of a cardiac contusion. The presence of hemoptysis following chest trauma is not common with cardiac tamponade; it is more suggestive of an intrapulmonary injury. Profound shock following blunt force trauma to the chest is common with a massive hemothorax. Any bruising of the chest following trauma warrants a careful assessment. A midline trachea does not rule out a tension pneumothorax; contralateral shifting of the trachea is a very late sign.

A 60-year-old woman was just extricated from her badly wrecked automobile. She is unresponsive and has multiple extremity fractures. Which of the following will afford your patient the BEST chance for survival?

Immediate transport Patients with trauma to multiple body systems must be transported expeditiously to a trauma center. At best, you can attempt to stabilize the patient's condition and prevent further deterioration; this is accomplished by managing the airway, controlling hemorrhage, and providing fluid resuscitation to maintain perfusion. While these are all critical interventions, they are not definitive care. You must not lose sight of your ultimate goal when caring for a critically injured patient—rapid transport to a trauma center. You can control the amount of time you spend at the scene; you cannot control the distance between the scene and the hospital. Do what must be done to prevent immediate death at the scene, get on the road, and continue your attempts to stabilize the patient en route.

Following a motorcycle accident, a woman presents with deformity to the fifth and sixth thoracic vertebrae, a blood pressure of 74/52 mm Hg, and a pulse rate of 74 beats/min. Her skin is pink, warm, and dry. Her clinical presentation is MOST likely the result of:

Impairment of the sympathetic nervous system. Hypotension and a normal or slow heart rate, especially with accompanying trauma to the spine, are indicative of neurogenic (spinal) shock. Because the sympathetic nerves originate from the thoracic spine, injury to this area may block the nerve pathways and inhibit the release of epinephrine and norepinephrine, which produces the typical tachycardia, pallor, and diaphoresis seen in other types of shock (ie, hypovolemic, septic, etc).

Which of the following is considered one of the earliest signs of shock?

Increased rate of respirations. Early signs of shock include tachypnea (increased respirations), a narrowing pulse pressure, pallor and diaphoresis, and restlessness and anxiety. Later signs of shock include weak central pulses (carotid or femoral), absent peripheral pulses (radial), and a decreasing level of consciousness. These findings indicate a low cardiac output state. One of the latest signs of shock is hypotension, which marks the onset of hemodynamic decompensation.

The diaphoresis seen in patients with shock is the result of:

Increased secretion by the sweat glands. Sympathetic nervous system stimulation causes increased secretion of sweat, which explains why patients in shock are diaphoretic. Peripheral vasoconstriction results in shunting of blood to the central organs and gives the skin a pale appearance because of the absence of peripheral blood flow.

Which of the following statements regarding compression injuries of the chest is correct?

Injury tolerance to compression decreases as velocity increases. In a healthy adult, the chest has a compression tolerance of 20%, which means that the chest can be compressed by up to 20% from its original diameter without injury. Twenty- to thirty-percent compression of the chest typically results primarily in skeletal injuries (ie, rib fractures). Blunt trauma that causes greater than 30% compression of the chest will likely produce injury to the intrathoracic organs. When velocity increases, however, the chest wall becomes much less tolerant to compression. Lethal intrathoracic injuries can occur following a high-velocity impact that causes as little as 15% to 20% compression of the chest.

A 30-year-old man has a closed head injury and is unresponsive. His left pupil is dilated and he has extensor posturing. His BP is 180/100 mm Hg, his pulse rate is 50 beats/min, and his respirations are 8 breaths/min and irregular. Treatment for him should include:

Intubation with ventilations aimed at maintaining an ETCO2 of 30 to 35 mm Hg. The patient has a severe traumatic brain injury (TBI) with a classic Cushing's triad presentation (ie, hypertension, bradycardia, irregular breathing). There is also clear evidence of cerebral herniation (ie, unresponsive, asymmetric pupils, extensor [decerebrate] posturing). His airway should be secured with an ET tube, after a period of preoxygenation with a bag-mask device. The Brain Trauma Foundation (BTF) recommends hyperventilation (20 breaths/min in adults) if signs of cerebral herniation are present. Optimally, you should ventilate the patient to maintain an ETCO2 between 30 and 35 mm Hg. In such brain-injured patients, brief periods of hyperventilation may be beneficial. The patient's BP clearly does not warrant fluid boluses; in fact, fluid boluses would likely only worsen his intracranial pressure. Other than medications used to facilitate intubation (ie, sedation, paralytics), prehospital pharmacological therapy is usually not administered to patients with a TBI.

Which of the following injuries would pose the MOST immediate threat to a patient's life?

Laryngeal fracture. Any problem with the airway poses an immediate threat to life. Examples include laryngeal fracture, crushing injury to the trachea, and airway obstruction, among others. Bilateral femur fractures and crushing injuries to the pelvis frequently cause severe internal bleeding, but airway problems, especially those previously mentioned, always pose an immediate threat to life. Cerebral contusions uncommonly result in death.

Which of the following factors or conditions would MOST likely impair hemostasis and increase the risk of complications from blunt trauma?

Liver disease. Hemostasis is the body's natural response to an injury. The hemostatic process involves vasoconstriction, formation of a platelet plug, coagulation, and the growth of fibrous tissue that permanently seals the damaged blood vessel. Numerous factors or conditions can interfere with the blood's ability to clot (the clotting cascade), thereby impairing the process of hemostasis. Hemophilia, a genetic disease that impairs the body's ability to control coagulation, would clearly impair hemostasis. Liver dysfunction or disease (ie, cirrhosis, cancer) would also impair hemostasis. The liver produces many of the body's coagulation factors. Medications such as warfarin sodium (Coumadin) and aspirin both impair hemostasis. Coumadin suppresses the liver's ability to produce certain clotting factors, and aspirin decreases the ability of the platelets to aggregate (clump together). Other medications that can lead to continued bleeding include ticlodipine (Ticlid) and clopidogrel bisulfate (Plavix). Although beta-blockers do not have an affect on hemostasis, they can affect the ability of a person to compensate for blood loss. By suppressing the sympathetic nervous system, beta-blockers may blunt the compensatory responses of tachycardia and increased cardiac contractility. Pancreatitis would likely result in blood glucose derangements due to insufficiencies of glucagon and insulin. Polycythemia—an overproduction of red blood cells—is a common finding in patients with emphysema (hence the term, "pink puffer"); this condition would not affect the process of hemostasis. Patients with impaired hemostasis can die from minor internal bleeding that an otherwise healthy person would survive.

Which of the following organs would produce the MOST severe blood loss following trauma to the abdomen?

Liver. The liver is a very large, highly vascular organ that contains a large volume of blood at any given time. It produces several blood coagulation factors, including fibrinogen (I), prothrombin (II), ionized calcium (IV), labile factor/proaccelerin (V), VI, and stable factor/proconvertin (VII). If the liver is damaged or diseased, it can take longer for the body to form clots. This would result in increased bleeding time and a large volume of blood loss.

Which of the following represents the MOST appropriate technique for performing a rapid extrication from a motor vehicle?

Manually stabilize the head, apply a cervical collar, rotate the patient onto the long spine board, and remove him from the vehicle. A rapid extrication, which is indicated for patients who are hemodyamically unstable, is performed by maintaining manual stabilization of the head, applying a cervical collar, rotating the patient onto a long backboard, and removing him or her from the vehicle. Vest-style extrication devices and short backboards take too long to correctly apply and are therefore impractical for critically injured patients. If the patient or the paramedic's life is in imminent danger, the patient is literally grabbed and dragged from the car while providing as much protection of the spine as possible (emergency move).

A 30-year-old man sustained multisystem trauma after being struck by a car that was traveling at a high rate of speed. Which of the following is the MOST critical to his survival?

Minimal on-scene time and rapid transport. The "Golden Period" is crucial to the survival of critically injured patients; it represents the critical period of time between the occurrence of the injury and the provision of definitive care. Unless extinuating circumstances exist (ie, entrapment in an automobile), no more than 10 minutes should be spent on scene when caring for patients with serious injuries. It is important to remember that EMS does not provide definitive care. EMTs and paramedics recognize injuries, stabilize the patient to the extent possible, and promptly transport to an appropriate hospital where definitive care can be provided. Time-consuming procedures, such as IV therapy, should be performed en route to the hospital.

In an otherwise healthy 70-kg adult, hypotension is typically noted after he or she has lost ____________ of his or her blood volume.

More than 1,500 mL. The average adult has a total blood volume (TBV) of about 5 liters. By assessing certain hemodynamic parameters, you can estimate the percentage of blood loss, and thus, the severity of hemorrhagic shock. Hemorrhagic shock is categorized into four classes. A healthy adult can safely tolerate up to 15% (750 mL) TBV loss (Class I). This volume of blood loss falls well within the body's ability to compensate. Loss of 15% to 30% (750 to 1,500 mL) of a person's TBV (Class II) requires more sophisticated compensation; it is characterized by tachycardia (> 100 beats/min), tachypnea (20 to 30 breaths/min), mild anxiety, and a narrowing pulse pressure. The BP, however, is still maintained; thus, the patient is said to be in compensated shock. Hypotension usually appears after the patient has lost more than 30% (1,500 mL) of his or her TBV (Class III). Compensatory mechanisms are failing and the BP can no longer be maintained (decompensated shock). The patient has more pronounced tachycardia (> 120 beats/min) and tachypnea (30 to 40 breaths/min), narrowed pulse pressure, and marked anxiety or confusion. Survival is possible with early recognition and rapid transport to a trauma center. Class IV hemorrhage occurs when the patient loses more than 40% (2,000 mL) of his or her TBV. The patient is markedly tachycardic (> 140 beats/min), tachypneic (> 40 breaths/min), and hypotensive, and is usually lethargic or comatose. Many patients with Class IV hemorrhage die in the prehospital setting because immediate definitive care is not available. For this reason, they are often said to be in irreversible shock.

Which of the following statements regarding vehicle airbags is correct?

Most airbag-related deaths are the result of the occupant being too close to the airbag when it deploys. According to the National Highway Traffic Safety Administration (NHTSA), most airbag-related deaths occur when the occupant is too close to the airbag when it deploys. Specifically, death occurs more often when a child less than 12 years of age is in the passenger seat and is improperly restrained at the time of impact. Airbags afford the greatest protection from severe injury when used in conjunction with properly worn seatbelts and when the occupant is far enough away (> 10" for the driver, > 18" for the front seat passenger) from the airbag. Children under 12 years of age should ride in the back seat and should be properly restrained with a device appropriate for their size. Vehicle airbags are supplemental restraint systems (SRS); they are designed to be used in conjunction with properly worn lap and shoulder belts. Airbags alone do not provide adequate protection from serious injury. Since the airbag only deploys once before rapidly deflating, it is only effective in minimizing the risk of severe injury during the initial impact; it does not provide protection from subsequent impacts. Furthermore, airbags are ineffective in preventing serious injuries during rollover collisions; these collisions are often associated with multiple impacts within the vehicle.

Immediate care for a severely burned patient includes:Immediate care for a severely burned patient includes:

Moving the patient to safety. Prior to providing care to ANY patient, you must ensure that you and the patient are in a place of safety. Once this is ensured, begin the assessment and treatment process. In the burn patient, your next priority is to stop the burning process.

A 30-year-old unrestrained woman struck the steering wheel when her car hit a tree while traveling at 40 miles per hour. She reports pain to the midsternal area, which is point tender to palpation. Her blood pressure is 100/60 mm Hg, pulse is 118 beats/min and irregular, and respirations are 26 breaths/min and shallow. The remainder of your assessment is unremarkable. You should suspect:

Myocardial contusion. The mechanism of and location of the injury as well as the irregularity of the patient's pulse are suggestive of a myocardial contusion. Patients with this type of injury can experience all of the same deleterious effects associated with an acute myocardial infarction, including cardiogenic shock, arrhythmias, and cardiac arrest. Although a flail chest, pericardial tamponade, or esophageal injury cannot be completely ruled out in the field, there are no physical exam findings that suggest any of these injuries.

You are assessing a trauma patient and suspect that he is experiencing hemorrhagic shock. Which of the following assessment findings would support this suspicion?

Narrowing pulse pressure. Signs of hemorrhagic shock include tachycardia, diaphoresis, pallor, restlessness and anxiety, narrowing pulse pressure, and as a later sign, hypotension. Jugular venous distention is observed, as a later sign, in patients with a tension pneumothorax or pericardial tamponade. Collapsed jugular veins, however, are observed in patients with a massive hemothorax, in which case the patient is losing blood in the thoracic cavity. Slurred or disorganized speech is commonly observed in patients with neurologic trauma (ie, head injury) and in patients experiencing a stroke.

A 17-year-old female was ejected from her car during a motor vehicle crash. You find her in a supine position lying motionless. She is conscious, but confused, and her skin is warm and dry. Her blood pressure is 76/50 mm Hg, her pulse rate is 54 beats/min, and her respiratory rate is 26 breaths/min. You should treat this patient for:

Neurogenic shock. Taking into consideration the mechanism of injury, the fact that the patient is motionless (likely from a spinal injury), and the absence of tachycardia, pallor, and diaphoresis, neurogenic shock should be suspected. Neurogenic shock occurs when sympathetic nervous system pathways are interrupted (for example, by a spinal injury), thereby inhibiting the release of catacholamines (epinephrine and norepinephrine). Catecholamines are responsible for the signs of shock that are classically observed in patients with hypovolemic shock (eg, tachycardia, pallor, and diaphoresis). Patients with a severe head injury typically present with hypertension, bradycardia, and abnormal breathing (Cushing's triad). If a head-injured patient is hypotensive, you should suspect occult hemorrhage elsewhere.

A 44-year-old male was struck across the face with a steel pipe during an assault. Your assessment reveals marked swelling and ecchymosis to his midfacial area. He has nasal discharge, blurred vision, and is unable to follow your finger above the midline with his left eye. These clinical findings are MOST indicative of a/an:

Orbital skull fracture. Your patient has an orbital fracture, also called a blowout fracture. The orbits are cone-shaped fossae that enclose and protect the eyes. In addition to the eyeball (globe) and muscles that move it, the orbit contains blood vessels, nerves, and fat. A direct blow to the eye may fracture the orbital floor because the bone is thin and breaks easily. An orbital fracture results in transmission of forces away from the eyeball itself to the bone. Blood and fat then leak into the maxillary sinus. The patient may complain of visual disturbances, have massive nasal discharge, and may lose sensation above the eyebrow or over the cheek secondary to associated nerve damage. Periorbital ecchymosis (raccoon eyes) is often present. Fractures of the inferior orbit are the most common and can cause paralysis of upward gaze; the patient's injured eye is unable to follow your finger above the midline. A Le Fort III fracture (craniofacial disjunction) involves a fracture of all the midfacial bones, separating the entire midface from the cranium. Basilar skull fractures are associated with high-energy trauma, but usually occur following diffuse impact to the head. Signs of a basilar skull fracture include cerebrospinal fluid (CSF) drainage from the ear (CSF otorrhea) and bruising over the mastoid bone behind the ear (Battle's sign). Fractures of the cribriform plate of the ethmoid bone, a bone that separates the nasal cavity from the brain, are often caused by a sharp upward blow to the nose; bony fragments are forced through the cribriform plate into the meninges or brain. CSF drainage from the nose (CSF rhinorrhea) is common in patients with a cribriform plate fracture.

A woman was struck by lightning while working in her garden. Her husband tells you that when he first found her, she was unconscious and not breathing. Your assessment reveals that she is conscious and alert, but has no recollection of the event. Her airway is patent and her breathing is adequate. Her blood pressure is 134/74 mm Hg, pulse is 88 beats/min, and respirations are 20 breaths/min. The cardiac monitor reveals a sinus rhythm without ectopy. She is moving all of her extremities and has no obvious burns or musculoskeletal injuries. She refuses to allow you to apply a cervical collar and place her onto a backboard, but consents to other treatment and transport. The MOST appropriate treatment for this patient includes:

Oxygen via nasal cannula or nonrebreathing mask, 12-lead ECG acquisition, continuous cardiac monitoring, an IV line set to keep the vein open, and transport. Retrograde amnesia and an absence of burns or other trauma suggests that the patient experienced the effects of a side flash, also called the splash effect, when lightning struck a nearby object; it is doubtful she took a direct hit. However, do not ignore her husband's report that she was unresponsive and not breathing. Brief asystole that spontaneously converts to a perfusing rhythm is not uncommon following a lightning strike. Treatment includes supplemental oxygen, vascular access, and transport with cardiac monitoring. Obtain a 12-lead ECG and assess for signs of cardiac ischemia or injury. Your patient has no signs of hypovolemia; therefore fluid boluses are not indicated. Antidysrhythmics (eg, lidocaine, amiodarone) are not indicated; she is not experiencing a cardiac dysrhythmia. Benzodiazepines (eg, Valium, Ativan) are given to actively seizing patients.

A 72-year-old female slipped on a throw rug and fell, landing on her left hip. She is conscious and alert and in severe pain. Her left knee is flexed and she has a strong pedal pulse. Further assessment reveals no other obvious injuries and her vital signs are stable. The MOST appropriate method for splinting this patient's hip involves:

Padding beneath the knee, placing her onto a scoop stretcher, padding around her hip, and securing her to the scoop stretcher. Hip fractures and dislocations are common in older adults who have fallen. Remember the first rule of medicine—first do no harm? The patient has a strong pedal pulse, which indicates perfusion distal to her injury. Do not manipulate her leg; doing so will only aggravate her pain and may cause neurovascular compromise. Splint her hip in the position in which it was found. Keep her knee in the flexed position; padding beneath her knee will facilitate this. The scoop (orthopaedic) stretcher makes an ideal device for moving patients with hip injuries. Unlike the long backboard, it does not require you to logroll the patient and makes padding around the injury easier. A commercial pelvic binder is used to stabilize an unstable pelvis, not splint a hip injury.

Which of the following is of LEAST pertinence when assessing the mechanism of injury of a patient who was involved in a motor-vehicle crash?

Patient's weight. Assessing the mechanism of injury (MOI) allows the paramedic to predict the type and severity of injuries by noting certain findings pertaining to how the injury occurred. These include, among others, the type of object struck (there is a BIG difference between striking a stop sign pole and a bridge pillar), the speed of the vehicle upon impact, whether or not safety devices (ie, lap belt and shoulder harness) were in use at the time of impact, and whether or not the airbag—if equipped with one—deployed upon impact. The age of the patient is also an important factor to consider; a 70-year-old patient, who has a greater likelihood of having an underlying medical condition (eg, osteoporosis, cardiovascular disease) is more likely to sustain serious injury from mechanisms that may not otherwise significantly injure a younger patient. You should routinely note the patient's approximate weight; however, this is not as important a factor when assessing the MOI as those previously mentioned.

In which of the following traumatic injuries would you MOST likely encounter pulsus paradoxus?

Pericardial tamponade. Pulsus paradoxus, which is defined as a 10 to 15 mm Hg drop in the systolic blood pressure during inhalation, is seen in patients with pericardial tamponade (as a later sign), severe asthma, and COPD. In pericardial tamponade, the heart is already restricted from contracting. When the lungs expand during inhalation, this puts even more pressure on the heart and literally stops it until the patient exhales. You can assess for pulsus paradoxus by palpating the radial pulse and noting that it disappears when the patient inhales and returns when the patient exhales. This is the equivalent to a 10 to 15 mm Hg drop in the systolic blood pressure.

A 21-year-old man sustained a large laceration to the left groin area while using a chainsaw. The patient is attempting to control the severe bleeding himself, without success, and tells you that he cannot feel his left leg. You should:

Place a trauma dressing over the wound and apply firm direct pressure. The quickest and most effective method for controlling severe external bleeding is with the use of direct pressure. If direct pressure does not immediately control the bleeding, you should apply a tourniquet proximal to the wound. Because of the anatomic location of this patient's injury (the groin), however, a tourniquet would likely be extremely difficult to apply and would probably be ineffective. Therefore, if direct pressure is ineffective with this patient, you should locate the bleeding vessel and apply direct digital pressure to it. After the bleeding has been controlled, begin shock treatment (ie, oxygen, thermal management). Transport the patient promptly and establish vascular access en route.

Which of the following is an abnormal physiologic process that occurs at the capillary level during shock?

Precapillary sphincter relaxation in response to lactic acid buildup. As perfusion decreases, cellular ischemia occurs. Minimal blood flow passes through the capillaries, causing cellular conversion from aerobic metabolism to anaerobic metabolism, which produces lactic acid and can quickly lead to metabolic acidosis. With less circulation, blood stagnates in the capillaries. The precapillary sphincter relaxes in response to the buildup of lactic acid, vasomotor center failure, and increased carbon dioxide levels. The postcapillary sphincters remain constricted, causing the capillaries to become engorged with fluid. The capillary sphincters—circular muscular walls that constrict and dilate—regulate blood flow through the capillary beds and are under the control of the autonomic nervous system. Among other factors (ie, heat, cold), capillary sphincters respond to an increased demand for oxygen and the need for waste removal. Thus, regulation of blood flow is determined by cellular need and is accomplished by vascular constriction or dilation, working in tandem with capillary sphincter constriction or dilation.

A 66-year-old man tripped on a throw rug and fell on his outstretched left hand. He presents with swelling, ecchymosis, and severe pain to his left shoulder. He is conscious and alert, and denies striking his head or losing consciousness. His blood pressure is 148/88 mm Hg, pulse is 76 beats/min and strong, and respirations are 20 breaths/min and adequate. Pulse, sensory, and motor functions are grossly intact in all of his extremities. The MOST appropriate treatment for this patient includes:

Premedicating with fentanyl or morphine and splinting his shoulder in a comfortable position. Based on the mechanism of injury (MOI) and clinical findings, it is likely that your patient has fractured his shoulder. Most shoulder fractures are caused by a fall onto an outstretched hand and usually occur in elderly patients; younger patients tend to dislocate the shoulder following the same MOI because they have stronger bones. Because your patient is hemodynamically stable, you should consider administering analgesia (ie, fentanyl [Sublimaze], morphine [Astromorph, Duramorph]) prior to splinting his injury. It hurts to have an injured extremity held in the proper position for splinting. Analgesia may make it possible for the patient to tolerate that position longer, thus allowing the splint to be applied properly. Midazolam (Versed) and diazepam (Valium) are effective sedatives; however, they do not provide pain relief. Given the absence of head injury or loss of consciousness, spinal precautions are likely not indicated. Never assess range of motion in any musculoskeletal injury; doing so may cause further injury.

When assessing the pupils of a patient with a severe closed head injury, you note that they are bilaterally dilated and nonreactive. What does this specifically indicate?

Pressure on the oculomotor nerve. The oculomotor nerve (cranial nerve III) arises from the midbrain and exits the brain to each eye. It controls the upper eyelid muscle, which raises the eyelid; the extraocular muscle, which moves the eye inward; and the pupillary muscle, which constricts the pupil. Damage to or pressure on this nerve will cause the pupils to dilate and fail to constrict when light is shone into them. Common causes of this include increased intracranial pressure, stroke (both ischemic and hemorrhagic), and cerebral hypoxia.

Which of the following is your MOST immediate priority when caring for a patient with a closed, painful, and deformed extremity?

Prevent further injury. After ensuring the safety of you and your partner, preventing further harm or injury to your patient is your next priority. In a patient with a swollen, painful deformity, the injury should be manually stabilized until completely splinted. Assess pulse, motor, and sensory functions before and after splinting the injury.

A 50-year-old man has an open abdominal wound with a small loop of bowel protruding from the wound. He is conscious and alert and is in severe pain. His blood pressure is 146/92 mm Hg, pulse rate is 120 beats/min and strong, and respirations are 20 breaths/min with adequate depth. All of the following treatment interventions would be appropriate for this patient, EXCEPT:

Protecting the exposed viscera from injury by covering it with a dry, sterile dressing and stabilizing it in place. Appropriate care for an abdominal evisceration includes covering the exposed viscera with sterile dressings moistened with saline and then covering the moist dressings with dry, sterile dressings and securing them in place. Do not apply dry dressings directly to the wound and never attempt to replace the protruding viscera back into the wound. The patient in this scenario is clearly in severe pain, and because his vital signs indicate hemodynamic stability, IV analgesia (eg, fentanyl) should be provided; just be sure to monitor his vital signs. The patient does not need IV fluid boluses at present; however, you should establish at least one large-bore IV line en route to the hospital in the event that his hemodynamic status deteriorates.

Appropriate management for a patient with a closed chest injury and signs of shock includes:

Put patient on cardiac monitor and assess for arrythmias. You should routinely apply the cardiac monitor to any critically injured patient in order to monitor heart rate and to detect any dysrhythmias. Use of a PASG is generally contraindicated for a patient who has injuries above the last rib. Bleeding into the chest cavity can be severe and may require fluid boluses, not a maintenance infusion. A needle thoracentesis is not routinely performed unless the patient has signs and symptoms of a tension pneumothorax.

When caring for a patient with suspected internal hemorrhage and a systolic blood pressure of 70 mm Hg, it is MOST important to:

Rapidly transport the patient to a trauma center. Internal hemorrhage cannot be controlled in the prehospital setting—period! After completing your assessment, treating any immediately life-threatening injuries, and initiating basic shock treatment (ie, oxygen, thermal management), your priority must be to rapidly transport the patient to a trauma center where definitive care (ie, surgical intervention) can be provided. All time-consuming procedures, such as IV therapy, should be performed en route. The goal of IV therapy for a patient with internal hemorrhage is to maintain adequate perfusion (ie, improve mental status, restore peripheral pulses), not to raise the blood pressure. Increasing the patient's blood pressure may interfere with hemostasis by destroying clots that may have formed at the site of hemorrhage. The pneumatic antishock garment (PASG), which increases systemic vascular resistance, may also interfere with hemostasis—thus exacerbating internal hemorrhage—and should be avoided.

When administering isotonic crystalloid boluses to a hypotensive patient who lost a significant volume of blood from a lacerated femoral artery, you should:

Recall that isotonic crystalloids are not capable of carrying oxygen. Isotonic crystalloid solutions—normal saline and lactated ringers—are salt and sugar crystals that are dissolved in water. Although they increase circulating volume, they do not have the ability to carry oxygen. Only whole blood and packed red blood cells can carry oxygen. Crystalloid fluids for a patient in shock are generally given in 20 mL/kg increments as needed to maintain adequate perfusion (ie, improved mental status, improved peripheral pulse quality). Because two thirds of infused isotonic crystalloid leaves the vascular space within 45 minutes after administration, 3 mL of crystalloid should be infused for every 1 mL of estimated blood loss. In a patient who has lost blood, isotonic crystalloids transiently expand circulating volume to facilitate the delivery of remaining red blood cells (and oxygen) to the cellular level.

A construction worker fell approximately 30 feet and landed on a concrete surface. He is responsive to pain only; has rapid, shallow respirations; and has a slow, weak pulse. As your partner maintains manual stabilization of his head and assists his ventilations, you perform a rapid head-to-toe assessment. The patient has a closed deformity to his right femur, numerous abrasions, an open deformity to his right humerus, and deformity in the area of the fifth thoracic vertebra. His blood pressure is 74/50 mm Hg. What is the MOST likely pathophysiology of this patient's clinical presentation?

Relative hypovolemia due to impaired adrenergic function. Neurogenic shock, often the result of a spinal injury, is caused by impaired sympathetic nervous system tone, which results in vasodilation. In neurogenic shock, vascular smooth muscle does not receive impulses that cause it to contract. As a result, vessels distal to the spinal injury dilate, increasing the size of the vascular space. The normal volume blood can no longer fill the enlarged vascular space. Perfusion of organs and tissues becomes inadequate and hypotension occurs, even though blood loss has not (relative hypovolemia). Bradycardia occurs due to unopposed parasympathetic stimulation and an absence of catecholamine release. Pallor and diaphoresis, signs of sympathetic stimulation and shunting of blood from the periphery, is often observed above the level of the spinal injury. However, the skin below the level of the injury is warm and dry due to vasodilation caused by a loss of vasomotor control. Relative to other types of shock, neurogenic shock presents differently; the patient is hypotensive, but does not have the classic signs of pallor, diaphoresis, and tachycardia.

You are transporting a 43-year-old male who experienced partial- and full-thickness burns to his head, face, anterior torso, and both upper extremities. When calling your radio report to the hospital, it is MOST important that you:

Relay the anatomic locations of his burns. When calling your radio report on a patient with burns, simply stating the percentage of body surface area (BSA) burned tells the receiving facility very little; it only gives them a number. That's no different than stating that your patient has a Glasgow Coma Scale (GCS) score of 10, but not stating the areas of the GCS in which the deficits were found. This patient does have burns that cover 45% of his BSA; however, it is far more important to relay the anatomic location of his burns—particularly his face—than to simply state the percentage of his BSA that is burned. Information such as past medical history, current medications, and prehospital treatment should be included in your radio report; however, you must first make the hospital acutely aware of the criticality of the patient's burns; tell them where, not just what!

You respond to the scene of a local knife-throwing contest where a man has a large knife impaled in the precordial area, just to the left of the lower sternum. He is unresponsive, apneic, and pulseless. You should:

Remove the knife, control bleeding, and begin CPR. There are two indications for removing impaled objects: when they compromise the airway and/or impede breathing, and when they interfere with your ability to perform CPR. Because chest compressions are performed in the precordial area, you must remove the knife, control any external bleeding, and begin CPR. After CPR has been initiated, you should assess the patient's cardiac rhythm and treat accordingly.

A 19-year-old male was ejected from his vehicle when it struck a tree head-on. The patient is found lying in a prone position on the road. After log-rolling him to a supine position, your partner, who is manually stabilizing the patient's head, opens his airway with the jaw-thrust maneuver. The patient is unresponsive; has copious amounts of blood and large debris in his mouth; and has slow, irregular respirations. You should:

Remove the large visible debris from his mouth with a finger sweep. This patient's airway is in immediate jeopardy. You must first remove any large visible debris from the patient's mouth using a finger sweep. Next, suction his oropharynx—for no longer than 15 seconds—to remove thinner secretions. After you have cleared the patient's mouth of blood and debris, insert an oral airway and begin assisting his ventilations with a bag-mask device and 100% oxygen. The patient will likely require intubation; however, this should not be performed until you have cleared his airway and adequately preoxygenated him. Clearly, you should not turn the patient's head to the side; doing so may aggravate an existing spinal injury. Instead, log-roll him onto his side as a unit.

A 51-year-old male experienced partial thickness burns to his face, chest, and arms while trying to ignite a brush pile using gasoline. Upon arriving at the scene, the patient is found sitting on the ground in a safe area. He is conscious and alert and complains of intense pain. He is still wearing his shirt, but there are areas of smoldering fabric that have adhered to his skin. You should:

Remove the part of his shirt that is not adhered to the skin and apply water to the adhered fabric to ensure the burning process has stopped. After ensuring your own safety, your next priority when caring for a burn patient is to ensure that the burning process has stopped. You should remove the patient's clothing completely while simultaneously cooling the burn with sterile water or saline; this will ensure that heat is not trapped under the clothing. Smoldering pieces of fabric that are adhered to the skin should be cut, not pulled, away from the skin. Smoldering pieces of fabric that cannot be removed from the skin should be soaked with sterile water to ensure that the burning process has stopped. After ensuring that the burn has been appropriately cooled, apply a sterile burn sheet to the burned area(s). Establish vascular access—preferably in an unburned area—and administer analgesia (eg, fentanyl, morphine) as needed for pain relief.

A trauma patient has signs of shock, but no external signs of injury. Which of the following should you suspect?

Retroperitoneal hemorrhage. Because bleeding into the retroperitoneal space may not produce the obvious signs of abdominal injury (ie, distention, rigidity, bruising, etc), trauma patients with unexplained shock should be assumed to have an intraabdominal hemorrhage. The retroperitoneal space is a common area for hidden bleeding.

A patient struck the steering wheel when his vehicle crashed into a tree. Assessment reveals respiratory distress, diminished breath sounds to the left lower hemithorax, a scaphoid abdomen, and jugular venous distention. This clinical presentation is MOST consistent with a:

Ruptured diaphragm. Injuries to the diaphragm, although rare, result from both blunt and penetrating trauma. Blunt force trauma following a high-speed motor vehicle crash is one of the most common mechanisms of injury. During a frontal impact, the unrestrained patient strikes the steering wheel or column, causing a sudden increase in intraabdominal pressure that may tear the diaphragm. Because the left side of the diaphragm is embryonically weak and the right side is protected by the liver, ruptures—particularly those caused by blunt trauma—are more common on the left side. In most cases, a portion of the large intestine enters the thoracic cavity through the diaphragmatic tear, causing ventilatory impairment by compressing the lung. In larger diaphragmatic tears, cardiac output may be decreased secondary to impaired ventricular filling, resulting in hypotension, tachycardia, and increased jugular venous pressure. Signs of diaphragmatic rupture include labored breathing, asymmetric chest wall movement, jugular venous distention, and a scaphoid abdomen (the abdominal wall is sunken and presents with a concave rather than a convex contour). In some cases, bowel sounds can be heard in the lower to middle part of one of the hemithoraces; however, unilaterally diminished breath sounds are more common.

Other than sterile saline for irrigation purposes, you should never put anything into an open soft tissue injury; this only increases the risk of infection. If gross contaminants (eg, glass, dirt) are visible in and around the wound, carefully remove them and then cover the wound with a sterile dressing. If a flap of tissue is still attached, gently replace it back to its normal position after removing any gross contaminants, and then cover the wound with a dry, sterile dressing. When gathering information for your SAMPLE history, you should ask the patient when he or she last had a tetanus vaccination. Although paramedics do not administer tetanus vaccinations, this is pertinent information to obtain for patients with any open injury, and should be included in your verbal report when you transfer patient care to the staff at the receiving facility. Tetanus is a serious and potentially fatal disease of the central nervous system that occurs when Clostridium tetani—a bacterium—enters the bloodstream through an open wound.

She takes a beta-blocking medication for hypertension. The patient is likely in hypovolemic shock secondary to a pelvic fracture with internal bleeding. However, her pulse rate and skin condition are not what you would expect to find. Beta-blocking medications (ie, propranolol hydrochloride [Inderal], metoprolol tartrate [Lopressor], atenolol hydrochloride [Tenormin]), which are commonly prescribed to patients with hypertension, atrial fibrillation, and various tachydysrhythmias, inhibit the sympathetic nervous system discharge of catecholamines (epinephrine, norepinephrine). These catecholamines cause the tachycardia, pallor, and diaphoresis that are classically observed in patients with shock.

A 19-year-old male fell during a basketball game and landed directly on his right elbow when his arm was flexed. He is in moderate pain. Your assessment reveals obvious deformity to the elbow. You are unable to feel a radial pulse, and his forearm is cool and pale. You should:

Splint the injury in the position found and transport without delay. A fractured or dislocated elbow—especially when associated with neurovascular compromise—is a true orthopedic emergency. In some cases, grossly deformed musculoskeletal injuries can be carefully realigned to facilitate splinting or restore distal circulation. This does not apply to elbow injuries! You should not manipulate a deformed elbow in the prehospital setting, even if signs of neurovascular compromise are present. The elbow is highly vascular and rich with nerves, and any manipulation may cause further damage (eg, severing an artery or nerve that was otherwise compressed). Splint all elbow injuries in the position found and transport without delay. En route, notify the receiving facility so they can arrange for an orthopedic surgeon to be available. If the patient is in severe pain, administer analgesia (eg, fentanyl, morphine) as needed.

You are assessing an injured football player who you suspect has injured his Achilles tendon. To determine if the Achilles tendon is intact, you should:

Squeeze the calf muscles of the injured leg and observe for plantar flexion of the foot. Rupture of the Achilles tendon usually occurs in athletes older than 30 years of age who are involved in start-and-stop sports such as basketball or football. The most immediate indications of Achilles tendon rupture are pain from the heel to the calf and a sudden inability for plantar flexion of the foot—extension of the ankle resulting in the forefoot moving away from the body. The Thompson test can be performed in the field to identify an Achilles tendon rupture. To perform this test, have the patient assume a prone position and then squeeze the calf muscles of the injured leg. If the foot plantar flexes while squeezing the calf muscles, the tendon is likely intact. If there is no movement of the foot, the Achilles tendon has likely been torn. If a patient experiences sharp calf muscle pain upon dorsiflexion of his or her foot, Homan's sign is said to be present; this finding indicates a deep venous thrombosis. A Babinski response is present if the patient's big toe moves upward when you stroke the sole of the foot with a blunt object. A present Babinski response is normal in infants; however, it is a sign of nervous system injury if it is present in older children and adults. The term "foot drop" is used to describe a neuromuscular disorder that affects the patient's ability to dorsiflex the foot. Foot drop is often caused by injury to the peroneal nerve—a division of the sciatic nerve that runs along the outside of the lower leg and branches off into each ankle, foot, and first two toes. It transmits signals to muscle groups responsible for ankle, foot, and toe movement and sensation.

Following assessment of a patient with trauma to multiple body systems, it is MOST important to:

Stabilize the most immediate threats to airway, breathing, and circulation, and transport without delay. Patients with trauma to multiple body systems are critically injured and need definitive care; this cannot be provided in the prehospital setting. As a paramedic, your job is to rapidly assess the patient, stabilize the most immediate threats to life, and initiate rapid transport to a trauma center. Unless extenuating circumstances exist (eg, safety issues, entrapment), you should spend no more than 10 minutes at the scene of a critically injured patient. Time-consuming procedures (ie, IV therapy) should be performed while you are en route to the hospital. If you treat all of the patient's injuries prior to transport, your patient will die at the scene! Isolated closed extremity deformities, for example, are not an immediate threat to the patient's life; however, staying at the scene to splint them is. Early notification of the receiving trauma center is important to ensure they are adequately prepared to care for the patient, but this can be done en route as well. If you are unable to notify the hospital because of patient care demands, have the dispatcher relay a report for you.

Assessment of a patient with blunt chest trauma reveals labored breathing, tachycardia, pallor, diaphoresis, collapsed jugular veins, and absent breath sounds in the right hemithorax. You should:

Support ventilations, treat for shock, and prepare for transport. Your patient's clinical presentation indicates a hemothorax, an accumulation of blood in the pleural space. Injuries to the lung parenchyma cause most hemothoraces. Assessment of a patient with a large hemothorax will reveal signs of both ventilatory insufficiency (ie, hypoxia, agitation, anxiety, tachypnea, dyspnea) and hypovolemic shock (ie, tachycardia, hypotension, pallor, diaphoresis). In addition to shock, hallmark signs of a massive hemothorax include collapsed jugular veins and unilaterally diminished or absent breath sounds. Hemothorax is a life-threatening emergency that requires prompt surgical intervention. Support the patient's ventilations, keep him or her warm, and transport without delay. Perform time-consuming procedures (ie, IV therapy) en route to the hospital. If oxygenation and ventilation cannot be maintained with basic techniques, intubation should be performed. Needle thoracentesis (chest decompression) is indicated for patients with a tension pneumothorax, not a hemothorax.

Which of the following injuries would MOST likely cause obstructive shock?

Tension pneumothorax. The term "obstructive shock" refers to inadequate tissue perfusion secondary to any injury or condition that physically obstructs cardiopulmonary function. A pulmonary embolism, for example, causes obstructive shock because of a clot in a pulmonary artery that obstructs blood flow to the lungs for reoxygenation. A tension pneumothorax occurs when excessive air in the pleural space causes tension, which collapses the lung and then shifts to the contralateral (opposite) side of the chest. As pressure shifts across the mediastinum, preload is impaired due to kinking of the vena cavae, and cardiac output is obstructed due to myocardial compression and kinking of the aorta. Pericardial tamponade is another injury that can result in obstructive shock. As the pericardium fills with blood, the more pliable structures—namely the atria and vena cavae—become compressed, which reduces the preload being delivered to the heart and thereby diminishes stroke volume and cardiac output. Shearing injuries of the aorta cause profound hemorrhage, often to the point of exsanguination (bleeding to death). A fractured pelvis may injure the femoral artery, vein, or both, also resulting in severe hemorrhage. A myocardial contusion, if severe enough, can result in impaired cardiac output—not because blood flow is obstructed, but because stroke volume is impaired due to cardiac damage.

A 44-year-old male was near a building when it exploded. He presents with widespread burns, hemoptysis, and blunt head trauma with signs of increased intracranial pressure. This patient MOST likely experienced his head injury during the ___________ phase of the explosion.

Tertiary. Injuries during an explosion can occur by any of four mechanisms. Primary blast injuries—those that are caused by the pressure wave of the explosion itself—include rupture of hollow organs and the tympanic membranes. Secondary blast injuries are caused by debris or fragments from the explosion; such injuries include lacerations and impaled objects. The tertiary blast injury is produced when the victim is propelled away from the explosion and strikes another object; it is in this phase that blunt injuries to the head, spine, and chest typically occur. Miscellaneous blast injuries include burns and respiratory injuries from hot gases or chemicals.

During your assessment of an unresponsive 21-year-old male with a suspected spinal injury, you test for a Babinski reflex. A Babinski reflex is present if:

The big toe turns upward when a blunt object is stroked along the sole of the foot. Any unresponsive trauma patient—especially one with a suspected head or spinal injury—should be assessed for his or her response to pain, for decerebrate and decorticate posturing (indicates brain stem injury), and for the presence of a Babinski reflex, also referred to as the plantar response. A Babinski reflex is present if the big toe turns upward when a blunt object is stroked along the sole of the foot; it is absent if the big toe turns downward. The Babinski reflex is not reported as being positive or negative; it is either present or absent. In newborns and small infants, a present Babinski reflex exists as a primitive reflex and is therefore a normal finding. In older children and adults, however, it is grossly abnormal and indicates central nervous system injury.

The ratio of red blood cells to plasma is called:

The hematocrit. The ratio of red blood cells to plasma is called the hematocrit. This test is used to determine the presence of internal bleeding in trauma patients. If the hematocrit is low, which indicates a greater volume of plasma, the patient is most likely bleeding internally. Likewise, if the hematocrit is elevated, plasma is being lost (ie, severe burns). The normal hematocrit value varies with the gender of the person, but on average is approximately 45%. Carboxyhemoglobin (COHb) reflects the percentage of carbon monoxide that is attached to the hemoglobin molecule. A complete blood count (CBC) is a lab test that measures a variety of blood components, including red blood cells, white blood cells, hemoglobin and hematocrit, and platelets, among others. Partial thromboplastin time (PTT) is a lab test that evaluates how long it takes the blood to clot.

Following a spinal injury, your patient experiences a loss of proprioception. This means that:

The patient is unaware of one body part in relation to another. Proprioception is the ability to sense the position, location, orientation and movement of a part of the body in relation to another. Muscles, tendons, joints and the inner ear contain proprioceptors, which relay positional information to the brain. The brain then analyzes this information and provides us with a sense of body orientation and movement. The inability of a patient to comprehend questions is called receptive aphasia. A spinal cord injury results in compromised sensory and motor functions distal to the injury site, not proximal. The condition in which the body's temperature assumes that of the environment is called poikilothermia.

The initial trauma sustained by a person because of an explosion is usually the result of:

The pressure wave. The blast from an explosion causes a wave of pressure. This wave causes the initial trauma to the patient, usually in the form of barotrauma, in which case hollow organs and the tympanic membrane (eardrum) can rupture. Burns are also common during the blast phase. Secondary injuries occur when the patient is struck by flying debris, and tertiary injuries result from the patient being thrown into fixed structures or other hard surfaces.

Which of the following is a criterion for transporting an adult patient to a trauma center capable of providing the highest level of care?

Two proximal long bone fractures. According to the 2011 Guidelines for Field Triage of Injured Patients, published by the Centers for Disease Control and Prevention (CDC), the paramedic should use certain predefined criteria when determining the most appropriate transport destination for the injured patient; these criteria are based on physiologic findings, anatomic findings, mechanism of injury, and special patient considerations. According to the guidelines, two or more proximal long bone fracture is an anatomic criterion for preferential transport to the highest level of care within the defined trauma system. A Glasgow Coma Scale (GCS) score that is equal to or less than 13 or a respiratory rate less than 10 breaths/min or greater than 29 breaths/min are physiologic criteria for transport to the highest level of trauma care. If an adult falls from greater than 20 feet, but does not meet any of the physiologic or anatomic criteria, he or she should be transported to a trauma center; depending on the defined trauma system, this need not be the highest level trauma center. If the patient does not meet any of the predefined criteria for transport to the highest level of trauma care, the paramedic should use his or her judgment or follow local protocol.

A semiconscious young female has just been extricated from her wrecked vehicle. Her airway is patent, her respirations are rapid and shallow, and her pulse is rapid and weak. She has closed deformities to both femurs; an open deformity to her right humerus with active bleeding; a rigid, distended abdomen; and a large hematoma to her forehead. The closest trauma center is 25 miles away. What interventions should you perform at the scene?

Ventilatory assistance with a bag-mask device and 100% oxygen, bleeding control, and full spinal precautions. This patient needs rapid transport to a trauma center for definitive care of her injuries. With the closest trauma center being 25 miles away, treatment at the scene should focus on preventing further injury and immediate death; this includes protecting her spine, assisting her ventilations, and controlling all active bleeding. The patient requires IV fluid boluses to maintain perfusion, but this should be done en route to the hospital; staying at the scene to start IVs will only delay definitive care. Pharmacologically assisted intubation (PAI) is not indicated at this point; although the patient requires ventilatory assistance, her airway is patent. Traction splints are not practical in this case; they take too long to apply. Rapid, shallow respirations in a semiconscious patient are likely not producing adequate minute volume; they should be treated with ventilatory assistance, not a nonrebreathing mask. Hyperventilation may decrease venous return to the heart (preload) secondary to increased intrathoracic pressure and should be avoided.

Most chemical burn injuries are treated with:

Water. According to the American Burn Association, nothing has been found to be superior to water when treating most chemical burn injuries. Because many neutralizing agents produce heat and may increase injury severity, antidotes and neutralizing agents should generally be avoided in the prehospital setting. Alkali metals—sodium and potassium—can react violently with water and produce large amounts of heat; therefore, burns caused by these chemicals should not be irrigated with water. Depending on your local protocol, 10% calcium gluconate may be used in the prehospital setting as a neutralizing agent for hydrofluoric acid burns.

You are caring for a 44-year-old female who experienced a closed head injury. She is responsive only to pain, has a respiratory rate of 8 breaths/min and irregular, a pulse of 120 beats/min and weak, and a blood pressure of 80/50 mm Hg. Which of the following statements regarding this patient is MOST correct?

You should intubate the patient and give IV fluid boluses to maintain a systolic blood pressure of at least 90 mm Hg. Because of this patient's markedly decreased level of consciousness following her head injury, her airway should be definitively secured to prevent aspiration if she vomits. Because she is not completely unresponsive, sedation and neuromuscular blockade will likely be required to facilitate intubation. Once she has been intubated, ventilate her at a rate of 10 breaths/min. There is no evidence of brain herniation (eg, unresponsiveness, decerebrate posturing, asymmetric pupils), so do NOT hyperventilate her! Her vital signs—hypotension and tachycardia—are not consistent with an isolated closed head injury; they are more consistent with shock, probably from an occult hemorrhage. If an adult with a seemingly isolated head injury presents with signs of shock, look for other injuries! A single episode of hypotension (< 90 mm Hg) in the head-injured adult can cause cerebral ischemia and increase mortality significantly. Give isotonic crystalloid fluid boluses as needed to maintain a systolic BP of at least 90 mm Hg. It is unlikely that the patient is in neurogenic shock, which is characterized by hypotension and a slow (or relatively slow) heart rate; she is tachycardic, which indicates that her sympathetic nervous system is intact and is releasing catecholamines. Vasopressor drugs may be useful in treating patients with neurogenic shock that is refractory to IV fluid boluses; however, this patient is not in neurogenic shock.

While performing a rapid assessment on a shooting victim, you discover an open wound to the right anterior chest. You should:

take action to prevent air from entering the open wound. An open wound to the chest (sucking chest wound), also called an open pneumothorax, must be sealed immediately upon discovery so that air is not sucked into the wound, resulting in inadequate ventilation of the affected lung. Use an occlusive dressing or any non-porous material that will prevent air from entering the wound. If these are not immediately available, place your gloved hand over the wound. After the wound is sealed, continue with your assessment, treat other life-threatening injuries as you discover them, and prepare for rapid transport.