General Principles
A 22-year-old man is hypotensive and tachycardic after a shotgun wound to the left shoulder. His blood pressure is initially 80/40 mm Hg. After initial fluid resuscitation his blood pressure increases to 122/84 mm Hg. His heart rate is now 100 beats per minute and his respiratory rate is 28 breaths per minute. A tube thoracostomy is performed for decreased left chest breath sounds with the return of a small amount of blood and no air leak. After chest tube insertion, the most appropriate next step is:
Choose one
re-examine the chest
perform an aortogram
obtain a CT scan of the chest
obtain arterial blood gas analysis
perform transesophageal echocardiography
re-examine the chest
The best assessment of fluid resuscitation of the adult burn patient is:
Choose one
urinary output of 0.5 mL/kg/hr
normalization of blood pressure
normalization of the heart rate
measuring a normal central venous pressure
providing 4 mL/kg/percent body burn/24 hours of crystalloid fluid
urinary output of 0.5 mL/kg/hr
A 40-year-old woman who was a restrained driver in a motor vehicle crash is evaluated in the emergency department. She is hemodynamically normal and found to be paraplegic at the level of T10. Which of the following are true regarding her evaluation and management?
Choose one
Neurogenic shock is likely to develop.
Imaging of her complete spine is required prior to transfer to a trauma center.
Given the injury level knee extension would be expected.
Log rolling using 4 people is a safe approach to restrict spinal motion when moving her.
Presence of bulbocarvenous reflex indicates a better prognosis.
Log rolling using 4 people is a safe approach to restrict spinal motion when moving her.
A young woman sustains a severe head injury as the result of a motor vehicle crash. In the emergency department, her GCS is 6. Her blood pressure is 140/90 mm Hg and her heart rate is 80 beats per minute. She is intubated and mechanically ventilated. Her pupils are 3 mm in size and equally reactive to light. There is no other apparent injury. The most important principle to follow in the early management of her head injury is to:
Choose one
avoid hypotension
administer an osmotic diuretic
aggressively treat systemic hypertension
reduce metabolic requirements of the brain
distinguish between intracranial hematoma and cerebral edema
avoid hypotension
When applying the Rule of Nines to infants:
Choose one
It is not reliable.
The body is proportionally larger in infants than in adults.
The head is proportionally larger in infants than in adults.
The legs are proportionally larger in infants than in adults.
The arms are proportionally larger in infants than in adults.
The head is proportionally larger in infants than in adults.
In managing a patient with a severe traumatic brain injury, the most important initial step is to:
Choose one
secure the airway
obtain a c-spine film
support the circulation
control scalp hemorrhage
determine the GCS score
secure the airway
The diagnosis of shock must include:
Choose one
hypoxemia
acidosis
hypotension
increased vascular resistance
evidence of inadequate organ perfusion
evidence of inadequate organ perfusion
A 33-year-old woman is involved in a head-on motor vehicle crash. It took 30 minutes to extricate her from the car. Upon arrival in the emergency department, her heart rate is 120 beats per minute, BP is 90/70 mm Hg, respiratory rate is 16 breaths per minute, and her GCS score is 15. Examination reveals bilaterally equal breath sounds, anterior chest wall ecchymosis, and distended neck veins. Her abdomen is flat, soft, and not tender. Her pelvis is stable. Palpable distal pulses are found in all 4 extremities. Of the following, the most likely diagnosis is:
Choose one
hemorrhagic shock
cardiac tamponade
massive hemothorax
tension pneumothorax
diaphragmatic rupture
cardiac tamponade
The most important, immediate step in the management of an open pneumothorax is:
Choose one
endotracheal intubation
operation to close the wound
placing a chest tube through the chest wound
placement of an occlusive dressing over the wound
initiation of 2, large-caliber IVs with crystalloid solution
placement of an occlusive dressing over the wound
Bronchial intubation of the right or left mainstem bronchus can easily occur during infant endotracheal intubation because:
Choose one
The trachea is relatively short.
The distance from the lips to the larynx is relatively short.
The use of cuffed endotracehal tubes eliminates this issue.
The mainstem bronchi are less angulated in their relation to the trachea.
So little friction exists between the endotracheal tube and the wall of the trachea.
The trachea is relatively short.
For the patient with severe traumatic brain injury, profound hypocarbia should be avoided to prevent:
Choose one
respiratory acidosis
metabolic acidosis
cerebral vasoconstriction with diminished perfusion
neurogenic pulmonary edema
shift of the oxyhemoglobin dissociation curve
cerebral vasoconstriction with diminished perfusion
Which of the following is true regarding the initial resuscitation of a trauma patient?
Choose one
A patient with a torso gunshot wound and hypotension should receive crystalloid fluid resuscitation until the blood pressure is normal
Evidence of improved perfusion after fluid resuscitation could include improvement in Glasgow Coma Scale score on reevaluation
Massive transfusion is defined as transfusion of more than 10 units of packed red blood cells and plasma within 24 hours
When tranexamic acid is administered by pre-hospital providers, a second dose is required within 24 hours
Fluid resuscitation is far more important than bleeding control in trauma patients
Evidence of improved perfusion after fluid resuscitation could include improvement in Glasgow Coma Scale score on reevaluation
A patient arrives in the emergency department after being beaten about the head and face with a wooden club. He is comatose and has a palpable depressed skull fracture. His face is swollen and ecchymotic. He has gurgling respirations and vomitus on his face and clothing. The most appropriate step after providing supplemental oxygen and elevating his jaw is to:
Choose one
request a CT scan
insert a gastric tube
suction the oropharynx
obtain a lateral cervical spine x-ray
ventilate the patient with a bag-mask
suction the oropharynx
A 20-year-old woman who is at 32 weeks gestation, is stabbed in the upper right chest. In the emergency department, her blood pressure is 80/60 mm Hg. She is gasping for breath, extremely anxious, and yelling for help. Breath sounds are diminished in the right chest. The most appropriate first step is to:
Choose one
perform tracheal intubation
insert an oropharyngeal airway
perform needle or finger decompression of the right chest
manually displace the gravid uterus to the left side of the abdomen
initiate 2, large-caliber peripheral IV lines and crystalloid infusion
perform needle or finger decompression of the right chest
The physiological hypervolemia of pregnancy has clinical significance in the management of the severely injured, gravid woman by:
Choose one
reducing the need for blood transfusion.
resulting in an elevated hematocrit.
complicating the management of closed head injury.
reducing the volume of crystalloid required for resuscitation.
increasing the volume of blood loss to produce maternal hypotension.
increasing the volume of blood loss to produce maternal hypotension.
The first maneuver to improve oxygenation after chest injury is:
Choose one
intubate the patient
assess arterial blood gases
administer supplemental oxygen
ascertain the need for a chest tube
obtain a chest x-ray
administer supplemental oxygen
Which one of the following statements concerning intraosseous infusion is TRUE?
Choose one
Only crystalloid solutions may be safely infused through the needle.
Aspiration of bone marrow confirms appropriate positioning of the needle.
Intraosseous infusion is the preferred route for volume resuscitation in small children.
Intraosseous infusion may be utilized indefinitely.
Swelling in the soft tissues around the intraosseous site is not a reason to discontinue infusion.
Aspiration of bone marrow confirms appropriate positioning of the needle.
A 56-year-old man is thrown violently against the steering wheel of his truck during a motor vehicle crash. On arrival in the emergency department he is diaphoretic and complaining of chest pain. His blood pressure is 60/40 mm Hg and his respiratory rate is 40 breaths per minute. Which of the following best differentiates cardiac tamponade from tension pneumothorax as the cause of his hypotension?
Choose one
tachycardia
pulse volume
breath sounds
pulse pressure
jugular venous pressure
breath sounds
A 39-year-old man is admitted to the emergency department after an automobile collision. He is cyanotic, has insufficient respiratory effort, and has a GCS score of 6. His full beard makes it difficult to fit the oxygen facemask to his face. The most appropriate next step is to:
Choose one
perform a surgical cricothyroidotomy
attempt nasotracheal intubation
ventilate him with a bag-mask device until c-spine injury can be excluded
restrict cervical motion and attempt orotracheal intubation using 2 people
ventilate the patient with a bag-mask device until his beard can be shaved for better mask fit
restrict cervical motion and attempt orotracheal intubation using 2 people
Which one of the following statements regarding abdominal trauma in the pregnant patient is TRUE?
Choose one
The fetus is in jeopardy only with major abdominal trauma.
Leakage of amniotic fluid is an indication for hospital admission.
Indications for peritoneal lavage are different from those in the nonpregnant patient.
With penetrating trauma, injury to the mother’s abdominal hollow viscus is more common in late than in early pregnancy.
The secondary survey follows a different pattern from that of the nonpregnant patient.
Leakage of amniotic fluid is an indication for hospital admission.
Which one of the following findings in an adult is most likely to require immediate management during the primary survey?
Choose one
distended abdomen
Glasgow Coma Scale score of 11
temperature of 36.5°C (97.8°F)
deforming of the right thigh
respiratory rate of 40 breaths per minute
respiratory rate of 40 breaths per minute
Hemorrhage of 20% of the patient's blood volume is associated usually with:
Choose one
oliguria
confusion
hypotension
tachycardia
blood transfusion requirement
tachycardia
A 25-year-old man, injured in a motor vehicular crash, is admitted to the emergency department. His pupils react sluggishly and his eyes open to pressure. He does not follow commands, but he does moan periodically. His right arm is deformed and does not respond to pressure; however, his left hand reaches purposefully toward the stimulus. Both legs are stiffly extended. His GCS score is:
Choose one
2
4
6
9
12
9
A 22-year-old man sustains a gunshot wound to the left chest and is transported to a small community hospital no surgical capabilities are available. In the emergency department, a chest tube is inserted and 700 mL of blood is evacuated. The trauma center accepts the patient in transfer. Just before the patient is placed in the ambulance for transfer, his blood pressure decreases to 80/68 mm Hg and his heart rate increases to 136 beats per minute. The next step should be to:
Choose one
clamp the chest tube
cancel the patient's transfer
perform an emergency department thoracotomy
repeat the primary survey and proceed with transfer
delay the transfer until the referring doctor can contact a thoracic surgeon
repeat the primary survey and proceed with transfer
Which one of the following situations requires Rh immunoglobulin administration to an injured woman?
Choose one
negative pregnancy test, Rh negative, and has torso trauma
positive pregnancy test, Rh positive, and has torso trauma
positive pregnancy test, Rh negative, and has torso trauma
positive pregnancy test, Rh positive, and has an isolated wrist fracture
positive pregnancy test, Rh negative, and has an isolated wrist fracture
positive pregnancy test, Rh negative, and has torso trauma