Trauma

A 30-year-old man sustained partial-thickness burns to the anterior chest and both anterior arms. Based on the Rule of Nines, what percentage of his body surface area has been burned? A) 0.09 B) 0.18 C) 0.27 D) 0.36

B According to the adult Rule of Nines, the anterior trunk (chest and abdomen) accounts for 18% of the total body surface area (TBSA) and each entire arm accounts for 9%. Therefore, the anterior chest, which is one half of the trunk, would account for 9% of the TBSA, and both anterior arms (4.5% each) would account for 9% TBSA, for a total of 18% TBSA burned.

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

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

When applying a vest-style spinal immobilization device to a patient with traumatic neck pain, you should: A) immobilize the head prior to securing the torso straps. B) secure the torso section prior to immobilizing the head. C) ask the patient to fully exhale as you secure the torso. D) gently flex the head forward as you position the device.

BWhen you apply a vest-style immobilization device such as a KED, you must immobilize the patient's head after the torso is adequately secured. If you immobilize the head first, the cervical spine may be unnecessarily manipulated as you secure the torso. Prior to securing the torso straps, you should ask the patient to inhale as much as possible so that when the straps are secured, enough space is allowed for the patient to breathe adequately. After full immobilization, the patient's spine should be completely in-line, from the head to the pelvis. During the entire immobilization procedure, the patient's head must be maintained in a neutral in-line position.

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

D Jugular vein lacerations pose two immediate life threats: entrainment of air into the wound (which may cause a fatal air embolism) and severe external bleeding. The patient's airway is patent and his breathing is adequate; therefore, your most immediate priority is to apply an occlusive dressing directly over the wound, which will keep air from entering the venous circulation, and then cover the occlusive dressing with bulky dressings to control the external bleeding. Apply high-flow oxygen via a nonrebreathing mask (your partner can do this as you are treating the neck wound). The need to perform a rapid head-to-toe assessment is based on the presence of a significant mechanism of injury (MOI). If a significant MOI is present, the rapid assessment is performed only after problems with the airway, breathing, and circulation have been addressed. Vital signs are typically obtained after the rapid assessment, although they can be obtained by another EMT as you perform the rapid assessment.

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

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

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

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

A football player complains of severe neck pain and tingling in his arms and legs after being tackled. He is conscious and alert, has a patent airway, and is breathing adequately. He is in a supine position and is still wearing his helmet, which is tight-fitting. The MOST appropriate treatment for this patient includes: A) manually stabilizing his head with his helmet still on, removing the face mask, securing him onto a long backboard, and restricting spinal motion with a lateral head stabilizer. B) manually stabilizing his head, carefully removing his helmet, applying a cervical collar, securing him onto a long backboard, and restricting spinal motion with a lateral head stabilizer. C) carefully removing his helmet, manually stabilizing his head, applying a cervical collar, applying a vest-style spinal immobilization device, and placing him in a seated position. D) manually stabilizing his head, leaving his helmet on, applying a vest-style spinal immobilization device, securing him onto a long backboard, and restricting spinal motion with a lateral head stabilizer.

A A helmet that fits well prevents the patient's head from moving and should be left on, provided there are no impending airway or breathing problems, it does not interfere with your assessment and treatment of airway or ventilation problems, and you can properly restrict spinal motion. You should also leave the helmet on if there is any chance that removing it will further injure the patient. The mask on most sports helmets can be removed, without affecting helmet position or function, by using a trainer's tool designed for cutting retaining clips or unscrewing the retaining clips from the face mask. Your patient has severe neck pain and tingling in his extremities; these are obvious signs of a spinal injury. However, he is conscious and alert, has a patent airway, is breathing adequately, and his helmet is tight-fitting. Thus, the safest approach is to leave his helmet on and remove the face mask. Secure him to a long backboard, keeping him supine, and restrict lateral movement of his head with a commercial stabilizer or rolled towels. A vest-style device is more suitable for seated patients; it is impractical to use on supine patients.

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

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

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

A An abdominal evisceration occurs when a loop of bowel, an organ, or fat protrudes through an open abdominal injury. Never try to replace an organ that is protruding from an open abdominal wound, whether it is a small fold of peritoneum or nearly all of the intestines; this significantly increases the risk of infection. Instead, cover it with sterile gauze pads or a sterile trauma dressing moistened with sterile saline and secure the moist dressing in place with a dry sterile dressing. Some EMS protocols call for an occlusive dressing over the organs, secured by trauma dressings. Do not apply excessive pressure when dressing and bandaging the wound; this may force the protruding organ or loop of bowel back into the abdominal cavity.

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

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

A 33-year-old factory worker was pinned between two pieces of machinery. When you arrive at the scene, you find him lying supine on the ground complaining of severe pain to his pelvis. He is restless, diaphoretic, and tachycardic. After performing a rapid head-to-toe assessment, you should: A) prepare for immediate transport. B) perform a detailed secondary exam. C) carefully log roll him to check his back. D) palpate his pelvis to assess for crepitus.

A Based on the mechanism of injury and the presence of signs of shock (eg, restlessness, tachycardia, diaphoresis), you should suspect that the patient has a fractured pelvis and is bleeding internally. Therefore, after completing your primary assessment and initiating shock treatment (eg, high-flow oxygen, applying blankets), you should perform a rapid head-to-toe assessment to assess for other injuries and then prepare for immediate transport. Spinal precautions should be considered. Do not log roll the patient; doing so compresses the pelvis and may cause further injury. You should also avoid palpating his pelvis; this will only cause further pain and may cause additional injury. Palpation of the pelvis is performed to assess its stability, not to elicit crepitus. A detailed secondary exam of a critically injured patient at the scene is not appropriate; it takes too long to perform and should be done en route to the hospital if time permits.

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

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

A 19-year-old female has a closed, swollen deformity to her left forearm. You are unable to palpate a radial pulse and the skin distal to the injury is cold and pale. Several attempts to contact medical control have failed and you are approximately 45 miles away from the closest hospital. You should: A) make one attempt to restore distal circulation by applying gentle manual traction in line with the long axis of the limb. B) splint her entire arm with rigid board splints, elevate the limb above the level of her heart, and transport immediately. C) begin transport at once, gently manipulate her arm en route until distal circulation is restored, and apply an air splint. D) apply an air splint to her forearm, keep her arm below the level of her heart, place an icepack over the injury, and transport.

A Cold, pale skin and an absent distal pulse indicates that blood flow distal to the injury is compromised. You should notify medical control, who will likely direct you to attempt to restore distal circulation. However, if you are unable to contact medical control and your transport time will be lengthy, you should make ONE attempt to restore distal circulation by applying gentle manual traction in line with the long axis of the limb. Be careful, as excessive manipulation can further compromise distal circulation. If you are unsuccessful after one attempt, splint the limb in the most comfortable position for the patient and transport at once. If distal circulation is restored, splint the limb in whatever position allows the strongest distal pulse. You should elevate the limb above the level of the heart to help minimize swelling. An icepack may also help reduce pain and swelling.

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

A Generally, impaled objects should be stabilized in place and not removed; however, if they interfere with the patient's airway or your ability to perform CPR, they must be carefully removed. The knife in this patient is impaled in the center of his chest (the precordium), which is where chest compressions are performed. Carefully remove the knife, control any external bleeding, begin CPR, and transport immediately. The AED is generally not indicated for victims of traumatic cardiac arrest. Massive blood loss is the most common cause of traumatic cardiac arrest, not a cardiac dysrhythmia.

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

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

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

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

You arrive at a residence where you find a man lying unresponsive in his front yard. There were no witnesses to the event. In assessing this man, you should assume that he: A) has sustained an injury. B) is having a heart attack. C) is having a diabetic reaction. D) has a heat-related emergency.

A In the absence of any witnesses, you should assume that any patient who is found unresponsive has an injury until that possibility is ruled out at the hospital. Apply spinal motion restriction precautions as needed. Do not be so hasty to label your patient as a "medical" or "trauma" patient. Many patients have injuries and medical conditions at the same time. For example, a patient can be driving his or her vehicle, experience a heart attack, and run off the road and strike a tree.

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

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

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

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

A 56-year-old man was the unrestrained driver of a small passenger car that rolled over twice after he rounded a corner too fast. He is unresponsive; has rapid, shallow respirations; and has a rapid, weak pulse. His left arm is completely amputated just below the elbow. As you and your partner are treating the patient, other responders are trying to find the amputated arm. Which of the following statements regarding this scenario is correct? A) If the patient's arm has not been recovered by the time you are ready to transport, you should transport without delay. B) Quickly move the patient to the ambulance, continue treatment, and wait for the other responders to recover his arm. C) You should transport the patient immediately, even if the other responders recover his arm before you depart the scene. D) Your priority should be to recover the man's arm because a vascular surgeon may be able to successfully reattach it.

A Life takes priority over limb. The patient is in shock, which may be complicated by a head injury; therefore, he requires rapid transport to a trauma center. Although efforts should be made to recover an amputated body part, this must not delay transport of a critically injured patient. If the arm has not been recovered by the time you are ready to transport, you must transport without delay. If his arm is located after you depart the scene, it can be transported separately. If his arm is recovered before you depart the scene, however, you should take it with you; surgeons may be able to successfully reattach it. Care for the amputated part in accordance with your local protocols.

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

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

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

A The patient in this scenario has a flail chest and inadequate ventilation (ie, rapid, shallow [reduced tidal volume] breathing). A flail chest occurs when several ribs are fractured in more than one place; the result is a free-floating section of ribs (flail segment) that collapses during inhalation and bulges out during exhalation (paradoxical chest movement). As the flail segment collapses, the lung is compressed and ventilation is impaired. Treatment should include positive-pressure ventilation and prompt transport. Do not place anything over the unstable chest wall as this may restrict chest movement and further impair ventilation.

In addition to high-flow oxygen, the MOST appropriate treatment for a patient with widespread full-thickness burns would include: A) dry, sterile dressings; warmth; and rapid transport. B) dry, sterile dressings; burn ointment; and rapid transport. C) moist, sterile dressings; warmth; and rapid transport. D) moist, sterile dressings; burn ointment; and rapid transport.

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

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

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

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

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

When caring for a critically injured patient, it is MOST appropriate to perform your secondary assessment: A) while you are en route to the hospital. B) after all life threats have been ruled out. C) immediately after taking baseline vital signs. D) immediately following the primary assessment.

A The secondary assessment is a detailed exam of the patient; it focuses on detecting and correcting injuries or conditions that were not grossly obvious during the primary assessment. Because the secondary assessment can be time-consuming, it should be performed en route to the hospital if your patient is critically ill or injured. The only actions that you should perform at the scene of a critically ill or injured patient are the primary assessment, correction of immediate life threats (eg, problems with the ABCs), and spinal precautions if necessary. The more quickly you begin transport of a critically ill or injured patient, the more quickly the patient will receive definitive care at the hospital. With some patients, you may not have time to perform a secondary assessment; this is especially true with critically ill or injured patients who have ongoing problems with their airway, breathing, or circulation.

You are called to a local nightclub for an injured patient. Law enforcement personnel have secured the scene. Upon arrival, you see a young man who is lying on the ground screaming in pain; bright red blood is spurting from an apparent stab wound to his groin area. You should: A) control the bleeding. B) apply 100% oxygen. C) ensure an open airway. D) prevent hypothermia.

A This patient's airway is obviously patent; he is screaming in pain. Blood spurting from the groin area indicates arterial bleeding from the femoral artery. If this bleeding is not controlled immediately, the patient will die. Oxygen and other shock treatment (ie, keeping him warm) should be initiated after this life-threatening bleeding is controlled. If you take the time to set up and administer oxygen prior to managing the bleeding, the patient will die. Base your treatment priorities on what will kill the patient first.

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

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

Upon discovering an open chest wound, you should: A) prevent air from entering the open wound. B) begin assisted ventilation and prepare for transport. C) immediately reassess the patient's ventilatory status. D) quickly cover the wound with a porous trauma dressing.

A Upon discovering an open chest wound (ie, sucking chest wound), you must take immediate action to prevent air from entering the wound. This is most effectively accomplished by applying an occlusive dressing or similar material to the wound. A porous (non-occlusive) trauma dressing will not prevent air from entering the wound. Tape three sides of the occlusive dressing and closely monitor the patient. If worsened respiratory distress and signs of shock are noted, a tension pneumothorax is probably developing, and you must release pressure from the pleural space by lifting up the unsecured portion of the occlusive dressing.

A 21-year-old man partially amputated his right arm when the chainsaw he was using to trim trees slipped. You can feel a weak radial pulse and his arm is cool to the touch. Dark red blood is flowing heavily from the wound. You should: A) apply bulky compression dressings to the wound and splint the extremity. B) carefully pack sterile dressings into the wound and fully splint the extremity. C) apply a tourniquet proximal to the injury and tighten it until the bleeding stops. D) control the bleeding, manipulate the arm to improve circulation, and apply a splint.

A When caring for a partially amputated extremity, control bleeding with bulky compression (pressure) dressings and splint the extremity to prevent further injury. If direct pressure does not immediately control the bleeding, however, a proximal tourniquet should be applied without delay. Never pack dressings into a wound; this may cause further damage and increases the risk of infection. Although your patient's radial pulse is weak, it is present and indicates blood flow distal to the injury. Do not manipulate his arm; doing so may lacerate or compress an artery and compromise distal circulation.

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

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

A 19-year-old male was assaulted and has trauma to multiple body systems. After performing your primary assessment and treating any immediate life-threatening injuries, you should: A) obtain a full set of baseline vital signs. B) perform a rapid head-to-toe assessment. C) fully immobilize his spine and transport. D) transport at once and intercept with ALS.

B After treating all life-threatening conditions found in the primary assessment, you should perform a rapid head-to-toe assessment to look for and treat other life threats. In many cases, patients with trauma to multiple body systems have other life-threatening injuries that are not readily apparent during the primary assessment. You should obtain baseline vital signs as soon as possible; however, this should not delay or interrupt your primary or rapid head-to-toe assessments. After performing the primary and rapid head-to-toe assessments, fully immobilize the patient's spine and transport to an appropriate hospital. Consider an advanced life support (ALS) intercept, as long as it does not cause a significant delay in transport.

Which of the following assessment parameters is the MOST reliable when determining if a patient with a head injury is improving or deteriorating? A) Pupillary reaction B) Level of consciousness C) Systolic blood pressure D) Rate and depth of breathing

B All of the options in this question are important parameters to monitor in a patient with a head injury. However, the single most reliable parameter is the patient's level of consciousness (LOC); a person's LOC indicates how the brain is functioning from a global perspective. It should be monitored frequently to determine whether the patient's condition is improving (ie, concussion) or deteriorating (ie, intracerebral hemorrhage). In general, level of consciousness serves as the most reliable indicator of perfusion. The EMT should also obtain serial Glasgow Coma Score (GCS) assessments, document them, and pass the information along to the receiving facility.

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

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

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

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

Appropriate care for an amputated body part includes all of the following, EXCEPT: A) laying the wrapped body part on a bed of ice. B) placing it directly on ice to prevent tissue damage. C) keeping the part cool, but not allowing it to freeze. D) wrapping it in a sterile dressing and placing it in a plastic bag.

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

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

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

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

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

Despite direct pressure, a large laceration to the medial aspect of the arm continues to bleed profusely. You should: A) pack the inside of the laceration with sterile gauze. B) quickly apply a tourniquet proximal to the injury. C) continue direct pressure and elevate the extremity. D) locate and apply pressure to the brachial artery.

B In most cases, external bleeding can be controlled with direct pressure. However, if a wound continues to bleed profusely despite direct pressure, a proximal tourniquet should be applied without delay. If the external bleeding is that severe, elevating the extremity would be of little help. Unless your EMS system carries hemostatic gauze (ie, QuikClot) and your protocols allow for wound packing, you should not place anything in an open wound. Locating and applying adequate pressure to an arterial pressure point is often difficult and unsuccessful. If not promptly controlled, severe external bleeding will result in hemorrhagic shock and death. When it comes to external bleeding control, remember this: if it will not quit, tourniquet!

A high school student was splashed in the eyes with a strong acid chemical during a lab experiment. He is in severe pain and is unable to open his eyes. You should: A) flush both eyes with sterile water for no more than 5 minutes. B) continuously flush his eyes with saline for at least 20 minutes. C) force his eyes open and assess for the presence of severe burns. D) cover both of his eyes with sterile gauze and transport at once.

B Chemical burns to the eyes, usually caused by acid or alkaline solutions, require immediate emergency care. This consists of flushing the eyes with water or a sterile saline irrigation solution. Forcing the eyes open for the expressed purpose of assessing for burns is impractical and wastes time. You may have to force the eyes open, however, to effectively irrigate them. If sterile water is not available, use any clean water. Irrigate the eyes for at least 5 minutes. If the burn was caused by an alkali or strong acid, you should irrigate the eyes continuously for 20 minutes. If irrigation can be carried out effectively in the ambulance, it should be done during transport to save time. Strong acids and alkaline solutions can penetrate deeply, requiring prolonged irrigation. After you have completed irrigation, cover the eyes with clean, dry dressings.

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

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

Which of the following indicates that a patient is in decompensated shock? A) Diaphoresis and pallor B) Falling blood pressure C) Restlessness and anxiety D) Tachycardia and tachypnea

B During shock, the compensatory mechanisms of the body attempt to maintain the blood pressure. This is accomplished by increasing the heart rate, shunting blood from the skin to more vital organs, and increasing the respiratory rate to increase the oxygen content of the blood. Once these compensatory mechanisms fail, the blood pressure will fall (hypotension). Hypotension signifies a state of decompensated shock. You must not rely on the patient's blood pressure as an indicator of overall perfusion. Restlessness, anxiety, tachycardia, tachypnea, and cool, clammy skin (diaphoresis) are earlier signs of shock and do not necessarily indicate a decompensated state.

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

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

A 44-year-old man has a traumatic leg amputation just below the knee. He is unresponsive; is breathing rapidly and shallowly; and has pale, cool, clammy skin. He is lying in a large pool of blood and the wound is bleeding profusely. To control this bleeding, you should: A) locate the femoral artery and apply pressure to it until the bleeding stops. B) cover the wound with a trauma dressing and apply a proximal tourniquet. C) apply an icepack to the wound to constrict the vessels and stop the bleeding. D) apply a pressure dressing and elevate the injured extremity at least 12 inches.

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

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

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

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

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

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

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

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

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

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

B Pericardial tamponade occurs when an injury to the heart causes blood to collect in the pericardial sac; the accumulation of blood puts pressure on the heart and impairs its ability to fill and contract. Beck's triad is a classic presentation of pericardial tamponade; it includes jugular vein distention (blood backs up into the venous system because of impaired cardiac filling), muffled or distant heart sounds, and a narrowing pulse pressure (the difference between the systolic and diastolic blood pressure). Other signs include tachycardia, weak pulses, and hypotension. The presence of unequal breath sounds should raise suspicion of a pneumothorax. A widening pulse pressure may be seen with increased intracranial pressure following a head injury.

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

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

Which of the following mechanisms of injury would necessitate performing a rapid head-to-toe assessment? A) 5 foot, 9 inch tall adult who fell 12 feet from a roof and landed on his side B) A stable patient involved in a motor-vehicle crash, whose passenger was killed C) Amputation of three toes from the patient's left foot with controlled bleeding D) An impaled object in the patient's lower extremity with minimal venous bleeding

B Significant mechanisms of injury include, among others, falls of greater than 15 feet (or three times the patient's height), penetrating injuries to the trunk and head, high-speed motor vehicle crashes, rollover motor vehicle crashes, ejection from a motor vehicle, and motor vehicle crashes in which another person in the same passenger compartment was killed. In cases such as this, you must assume that the same violent forces that killed the passenger were sustained by the patient, regardless of whether the patient is stable.

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

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

A 23-year-old unrestrained female struck the steering wheel with her chest when her passenger car collided with a tree at a high rate of speed. Your assessment reveals that she is conscious, but has signs of shock and an irregular pulse. The MOST appropriate treatment for this patient includes: A) insertion of an oral airway, assisted ventilations with a bag-valve-mask device, full spinal precautions, and rapid transport. B) high-flow oxygen or assisted ventilations as needed, full spinal precautions, blankets to keep her warm, and rapid transport. C) applying an AED in case she develops cardiac arrest, high-flow oxygen, full spinal precautions, and rapid transport. D) high-flow oxygen, summoning a paramedic unit to the scene to assess her cardiac rhythm, a cervical collar, and transport as soon as possible.

B The cause of this patient's shock may be a myocardial contusion, or bruising of the heart muscle. Blunt trauma to the chest can injure the heart, making it unable to maintain adequate blood pressure. In a myocardial contusion, the pulse is often irregular, but dangerous rhythms (eg, V-Fib, V-Tach) are relatively uncommon. There is no special diagnostic test at this time, and there is no prehospital treatment for the condition. Therefore, waiting at the scene for a paramedic unit would only waste time. Apply high-flow oxygen, assist ventilations if the patient is breathing inadequately (eg, slow or fast respirations, shallow breathing [reduced tidal volume]), treat the patient for shock (eg, keep her warm and supine), and transport rapidly. Because of the mechanism of injury, full spinal precautions should be taken. The patient is conscious and likely has an intact gag reflex; therefore, an oral airway is contraindicated. The AED is applied only to patients who are in cardiac arrest.

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

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

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

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

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

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

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

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

A 40-year-old man has burns to the entire head, anterior chest, and both anterior upper extremities. Using the adult Rule of Nines, what percentage of his total body surface area has been burned? A) 0.18 B) 0.27 C) 0.36 D) 0.45

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

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

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

Which of the following questions is of LEAST pertinence initially when assessing a responsive 40-year-old woman who fell from a standing position? A) Did you hit your head? B) Have you fallen before? C) Did you faint before you fell? D) Can you move your hands and feet?

B Your physical exam of a patient who fell should focus on determining if the patient is injured and what happened prior to the fall. Did the patient simply trip and fall, or did the patient experience a syncopal episode (fainting) and then fall? If the patient fainted and then fell, you should suspect both a medical problem (caused the fall) and a traumatic injury (resulted from the fall). When assessing a patient who fell, do not be so quick to label him or her as a trauma patient before performing a thorough assessment; an underlying medical problem (eg, stroke, hypoglycemia, cardiac event) may have caused the fall. Determining if the patient has fallen before, which may help to establish a pattern, is pertinent and should be attempted. However, your initial priority should be to determine why the patient fell and whether the fall caused an injury.

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

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

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

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

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

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

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

C Commotio cordis is a blunt chest injury caused by a sudden, direct blow to the chest (over the heart) during a critical phase of the person's heartbeat. This can cause immediate cardiac arrest from ventricular fibrillation, which can be corrected with early (within 2 minutes) defibrillation. Commotio cordis occurs most commonly during sports-related injuries, and has been reported after patients were struck with baseballs, softballs, bats, snowballs, fists, or kicks during kickboxing. The EMT should suspect commotio cordis if a patient presents with cardiac arrest following a sudden, direct blow to the chest. Myocardial contusion can also occur following blunt chest trauma; however, cardiac arrest with this type of injury is uncommon. Great vessel injury (ie, aortic rupture, shearing of the vena cavae) occurs more commonly following rapid deceleration, such as when the chest strikes the stearing wheel during a high speed collision or when the patient falls from a significant height.

A 40-year-old man was hit in the nose during a fight. He has bruising under his left eye and a nosebleed. After taking standard precautions, you should: A) place a chemical icepack over his nose. B) determine if he has any visual disturbances. C) ensure that he is sitting up and leaning forward. D) apply direct pressure by pinching his nostrils together.

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

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

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

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

C Few things will kill a patient more quickly than uncontrolled external hemorrhage and/or a compromised airway. Blood in a patient's mouth must be removed immediately. It may be aspirated into the lungs or, if clotted, obstruct the airway. Spinal trauma, intracranial bleeding, and vision loss are all possible in a patient with blunt trauma to the face; however, airway compromise is the most immediate life threat with this patient. Remember, treat what will kill your patient first.

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

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

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

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

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

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

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

C Motor-vehicle crashes typically consist of three separate collisions. Understanding the events that occur during each collision will help you remain alert for certain types of injury patterns. During the first collision, the vehicle strikes another object. Damage to the car is perhaps the most dramatic part of the collision, but it does not directly affect patient care. It does, however, provide information about the severity of the collision; thus, it has an indirect effect on patient care. During the second collision, the passenger collides with the interior of the vehicle. Just like the obvious damage to the exterior of the car, the injuries that result are often dramatic and usually apparent during your primary assessment. During the third collision, the occupant's internal organs collide with the solid structures of the body. Although the injuries that occur during the third collision may not be as obvious as those that occur during the second collision, they are often the most life-threatening.

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

C Numerous factors affect a person's ability to compensate for blood loss. The compensatory responses of tachycardia and peripheral vasoconstriction decrease as a person ages; thus, older patients are not able to compensate as effectively as younger patients. The ability to compensate for blood loss is also related to how rapidly blood loss occurs. A normal, healthy adult can comfortably donate 1 unit (500 mL) of blood during a period of 10 to 20 minutes and adapts well to this decrease in blood volume. However, if a similar blood loss occurs in a much shorter period, the person's compensatory mechanisms may be overwhelmed, resulting in hypovolemic shock. Patients who take blood-thinning medications (eg, warfarin [Coumadin]) bleed longer than those not taking such medications; in these patients, bleeding from an otherwise minor injury can be significant. There is no known correlation between high cholesterol and a person's ability to compensate for blood loss.

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

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

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

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

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

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

You are assessing a young male who was stabbed in the right lower chest. He is tachypneic, tachycardic, and diaphoretic. His jugular veins are collapsed and his breath sounds are equal bilaterally. You should suspect a: A) hemothorax. B) ruptured spleen. C) liver laceration. D) pneumothorax.

C The liver is protected, in large part, by the lower ribcage on the right. This is why trauma at or below the nipple line should be considered to be BOTH an intrathoracic and an intra-abdominal injury. The patient in this scenario is clearly in shock (ie, tachycardia, tachypnea, diaphoresis). Collapsed jugular veins are a manifestation of decreased circulating blood volume; in this case, the blood is collecting in the patient's abdomen. Jugular vein distention is seen with injuries such as tension pneumothorax and pericardial tamponade. Hemothorax and pneumothorax are less likely because the patient's breath sounds are equal bilaterally, and although he is tachypneic, there is no evidence of labored breathing. Splenic injury is unlikely; the patient's injury is on the right side and the spleen is on the left.

During transport of a patient with a head injury, which of the following will provide you with the MOST information regarding the patient's condition? A) Pupil size B) Heart rate C) Mental status D) Blood pressure

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

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

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

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

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

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

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

A 45-year-old male was stabbed in the left anterior chest. He is conscious, but restless. His skin is cool and clammy, his blood pressure is 90/60 mm Hg, his respirations are rapid and shallow, and his heart rate is 120 beats/min and weak. Further assessment reveals that his breath sounds are clear and equal bilaterally and his jugular veins are distended. In addition to giving him high-flow oxygen, you should: A) control the bleeding from the stab wound with a sterile porous dressing and reassess his vital signs. B) perform a detailed physical exam at the scene to ensure that you locate and treat less obvious injuries. C) cover the stab wound with an occlusive dressing, support ventilation as needed, and transport rapidly. D) suspect that the patient has a tension pneumothorax and notify the trauma center as soon as possible.

C Your patient has signs of pericardial tamponade, a condition usually caused by penetrating chest trauma. In pericardial tamponade, blood collects in the pericardial sac; this prevents the heart from filling during the diastolic phase, causing a decrease in cardiac output and blood pressure. Signs of pericardial tamponade include muffled or distant heart tones (difficult to assess in the field); a rapid, weak pulse; hypotension; jugular venous distention; and a narrowing pulse pressure (difference between the systolic and diastolic blood pressures). A tension pneumothorax is unlikely in this patient; his breath sounds are clear and equal bilaterally. Treatment for pericardial tamponade includes ensuring adequate oxygenation and ventilation, covering the chest wound with an occlusive dressing (cover all open chest wounds with an occlusive dressing), controlling any external bleeding, and transporting rapidly. Pericardial tamponade is a life-threatening condition that requires definitive treatment at the hospital.

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

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

A 21-year-old male was bitten on the left forearm by a dog. He is conscious and alert and denies any other injuries. An animal control officer is at the scene and has restrained the dog. Your assessment of the patient's arm reveals a large avulsion with a peeled-back flap of skin. Distal circulation is adequate and the patient is able to feel and move his fingers. In addition to bleeding control, you should: A) perform a rapid head-to-toe assessment. B) apply oxygen via a nonrebreathing mask. C) irrigate the wound for at least 15 minutes. D) replace the avulsed flap to its original position.

D An avulsion is an injury that separates various layers of soft tissue, usually between the subcutaneous layer and fascia, so that they become completely detached or hang as a flap. The patient's injury is isolated and not life-threatening; therefore, a rapid head-to-toe assessment is not indicated. Unless your protocols specify otherwise, oxygen is usually not necessary for patients with isolated, non-life-threatening soft-tissue injuries. If the avulsed tissue is hanging from a small piece of skin, circulation through the flap may be at risk. If you can, replace the avulsed flap to its original position, as long as it is not visibly contaminated with dirt and/or other foreign materials, and then cover the wound with a dry sterile dressing. Unless the wound is grossly contaminated with dirt or debris, irrigation is usually deferred until the patient is evaluated by a physician. Furthermore, flushing an open wound may force dirt or other debris into the wound, increasing the risk of infection.

You are performing a secondary assessment on a severely injured patient while en route to a trauma center. During the assessment, you note that the patient's respiratory rate has increased. You should: A) immediately notify the receiving facility. B) count the number of respirations per minute. C) assess his oxygen saturation with a pulse oximeter. D) repeat the primary assessment and treat as needed.

D Anytime a patient's condition deteriorates, such as your patient whose respirations have increased, you should immediately repeat the primary assessment and adjust your treatment accordingly. For example, a patient who initially had adequate breathing may now require assisted ventilation. After stabilizing the patient's condition, reassess his or her vital signs, including oxygen saturation, and notify the receiving facility.

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

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

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

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

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

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

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

D Management of an open abdominal wound with an eviscerated bowel includes controlling any external bleeding, covering the exposed bowel with a moist, sterile dressing, and covering that with a dry, sterile dressing. Applying a dry dressing directly to the exposed bowel will cause the bowel to dry. You must never replace the exposed bowel into the abdominal cavity or apply pressure to the wound. Doing so significantly increases the patient's risk for infection as well as further trauma.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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