True or false? Although the mechanism of injury may be similar to those for the younger population, data shows increased mortality with similar severity of injury in older adults.
True
In the elderly population, what is decreased physiological reserve?
aging is characterized by impaired adaptive and homeostatic mechanisms that caused an increased susceptibility to the stress of injury. Insults tolerated by the younger population can lead to devastating results in elderly patients.
Pre-existing conditions that affect morbidity and mortality include:
cirrhosis, coagulopathy, COPD, ischemic heart disease, DM
What is the most common mechanism of injury in the elderly?
Fall. Nonfatal falls are common in women and fractures are common in women who fall. Falls are the most common cause of TBI.
In the elderly population, what are risk factors for falls?
advanced age, physical impairment, history of previous fall, medication use, dementia, unsteady gait, and visual, cognitive impairment
Most of elderly traffic fatalities occur in the daytime and on weekends and typically involve other vehicles. Why?
Older people drive on more familiar roads and at lower speeds and tend to drive during the day. Older people have slower reaction time, a larger blind spot, limited cervical mobility, decreased hearing, and cognitive impairment.
True or False? Mortality associated with small to moderate sized burns in older adults remains high
True
Spilled hot liquids on the leg, which in younger patients may re-epithelialize due to an adequate number of hair follicles, will result in a full thickness burn in older patients.
this is true
Airway-patients may have dentures that may loosen or obstruct the airway. If dentures are not obstructing the airway, leave them in place for what?
bag mask ventilation, as it improves mask fitting.
When preforming rapid sequence intubation, the dose of benzos, barbiturates, and other sedatives should be reduced to what percentage to minimize the risk of cardiovascular depression?
20-40%
Functional changes in cardiac system include declining function, decreased sensitivity to catecholamines, atherosclerosis of coronary vessels, increased afterload, fixed heart rate (beta blockers)
this results in lack of classic response to hypovolemia, risk for cardiac ischemia, elevated BP at baseline, and increased risk of dysrythmias.
Functional changes in pulmonary system include decreased elastic recoil, reduced residual capacity, decreased gas exchange and decreased cough reflex
thus they are at increased risk for respiratory failure, increased risk for pneumonia, and poor tolerance to rib fractures
Functional changes in renal system include loss of renal mass, decreased GFR, and decreased sensitivity to ADH and aldosterone
resulting in drug dosing for renal insufficiency, decreased ability to concentrate urine, increased risk for AKI and urine flow may be normal with hypovolemia
Functional changes to MSK include loss of lean body mass, osteoporosis, changes in joints and cartilage, c spine degenerative changes and loss of skin elastin and subcutaneous fat
resulting in increased risk for fractures, decreased mobility, difficulty for oral intubation, risk of skin injury, increased risk for hypothermia, challenges in rehabiliation
Functional changes in Endocrine system include decreased production and response to thyroxin and decreased dehydroepiandrosterone (DHEA)
resulting in occult hypothyroidism, relative hypercortisone states and increased risk of infection
True or false: Arthritis can complicate the airway and cervical spine. Patients can have multilevel degenerative changes affecting disk spaces and posterior elements associated with severe central canal stenosis, cord compression, and myelomalacia
true
In elderly population, due to their changes in pulmonary system, placing a gauze between gums and cheek to achieve seal when using bag valve mask ventilation is okay. In addition, because aging causes a suppressed heart rate response to hypoxia……
respiratory failure may present insidiously in older adults.
Age related changes in the cardiovascular system place the elderly trauma patient at significant risk for being inaccurately categorized as hemodynamically stable.
Elderly patients have a fixed heart rate and fixed cardiac output, thus, their response to hypovolemia will involve increasing their systemic vascular resistance. Furthermore, since older patients have HTN, an acceptable BP may truly reflect a hypotensive state. A systolic BP of 110 is to be utilized as the threshold for identifying hypotension in patients 65 and older.
Do no equate blood pressure with shock in older patients
BP in older patients may look normal due to the medications they are on. Use lactate and base deficit to evaluate for evidence of shock
what 2 factors place elderly patients at risk for intracranial hemorrhage?
aging causes dura to become more adherent to the skull increasing risk of injury and older patients are on anticoagulant and antiplatelet medications.
Loss of subcutaneous fat, nutritional deficiencies, chronic medical conditions place elderly patients as risk for hypothermia and complications for immobility.
Rapid evaluation and when possible early liberation from spine boards and cervical collars will minimize complications.
True or False: Fall prevention is the mainstay of reducing the mortality associated with pelvic fractures.
true
poor hygiene, dehydration, oral injury, contusions affecting the inner arms, inner thighs, palms, soles, scalp, ear, nasal bridge and temple injury from being struck while wearing glasses, contact burns and scalds. These are all signs of…….?
Elder maltreatment. The presence of physical findings of maltreatment should prompt a detailed history. if history conflicts with findings, immediately report findings to authorities.
True of false: early activation of the trauma team may be required for elderly patients who do not meet traditional criteria for activation
True. A simple injury such as an open tibia fracture in a frail elderly patient may become life threatening.
Common mechanisms of injury include falls, MVC, burns, and penetrating injuries
common injuries in the elderly include rib fractures, TBI, pelvic fractures
The best initial treatment for the fetus is to provide optimal resuscitation of the mother. True or False?
True. Also if xray examination is indicated during the pregnant patient’s treatment, it should not be withheld because of the pregnancy.
What happens as the uterus enlarged and the bowel is pushed cephalad.
When the uterus enlarges it pushes the bowel cephalad and the uterus lies in the upper abdomen. As a result, the bowel is somewhat protected from blunt abdominal trauma, whereas the uterus and its contents (fetus and placenta) become more vulnerable. Uterus remains intrapelvic until 12 weeks and then at 20 weeks it is at the umbilicus, and at 34-36 weeks it reaches the costal margin.
Amniotic fluid can cause amniotic fluid embolism and disseminated intravascular coagulation following trauma if fluid enters maternal intravascular space. True or False
True
By the third trimester, what is the complication of trauma to the pelvis of the mother?
by the third trimester, the uterus is large and thin walled. In vertex presentation, fetal head is usually in the pelvis and the remainder of the fetus is exposed above the pelvic brim. Pelvic fractures in late gestation can result in skull fracture or intracranial injury to the fetus. Also we can have a placental abruption due to its little elasticity and vulnerability to sheer forces.
An abrupt decrease in maternal intravascular volume can result in a profound increase in uterine vascular resistance reducing fetal oxygenation despite reasonably normal maternal vital signs.
this is true
Physiological anemia of pregnancy
A smaller increase in red blood cell volume can occur resulting in a decreased hematocrit level. Thus, in late pregnancy a hematocrit of 31-33% is normal.
Healthy pregnancy patients can lose 1200-1500 mL of blood before exhibiting signs and symptoms of hypovolemia. How can this manifest?
this amount of hemorrhage may be reflected by fetal distress as evidenced by an abnormal fetal heart rate.
What are some of the lab changes in pregnancy?
WBC increases to 12000 and during labor can be 25000. Fibrinogen and other clotting factors are mildly elevated and PT and pTT are shortened, but bleeding time and clotting time are unchanged.
After the 10th week of pregnancy, cardiac output can increase 1.0-1.5 L/min because of the increase in plasma volume and decrease in vascular resistance of the uterus and placenta.
The placenta receives 20% of the patient’s cardiac output during the 3rd trimester. In supine position, vena cava compression can decrease cardiac output by 30% because of decreased venous return from lower extremities.
During pregnancy the heart rate increases to a maximum of 10-15 beats per minute over baseline by the third trimester.
this heart rate must be considered when interpreting a tachycardic response to hypovolemia.
Blood pressure falls 5-15 mm Hg in systolic and diastolic pressures during second trimester, although it returns to near normal levels at term.
some women experience hypotension when placed in the supine position due to the compression of teh inferior vena cava.
hypertension in the pregnant if accompanied by proteinuria may represent what?
pre-eclampsia.
EKG findings in pregnant patient
Flatted or inverted T waves in leads III and AVF and the precordial leads may be normal. Ectopic beats are increased during pregnancy.
Minute ventilation increases primarily due to an increase in tidal volume. Hypocapnia (30 mm Hg) is common in late pregnancy
Monitor ventilation in late pregnancy with arterial blood gas values. A PaCO2 of 35-40 mm Hg may indicate impending respiratory failure during pregnancy. Pregnant patients should be hypocapneic.
Anatomical alterations in the thoracic cavity seem to account for the decreased residual volume associated with diphragmatic elevation and chest x ray reveals increased lung marking and prominence of the pulmonary vessels.
oxygen consumption increases during pregnancy and its important when resuscitating injured pregnant patients to maintain adequate oxygenation above 95%
In patients with advanced pregnancy, those that require a chest tube placement, where should the test tube be placed?
it should be positioned higher to avoid intra-abdominal placement given the elevation of the diaphragm.
Urinary system: what happens to the GFR, serum creatinine and urea nitrogen levels?
GFR and renal blood increases during pregnancy, whereas levels of the serum creatinine and urea nitrogen fall to one half of the normal pre pregnancy levels. Glycosuria is common in pregnancy.
When interpreting x ray films of the pelvis in a pregnant patient, the symphysis pubis widens 4-8 mm and the sacroiliac joint spaces increase by the 7th month
keep this in mind
Eclampsia
Maintain a high index of suspicion for eclampsia when seizures are accompanied by HTN, proteinuria, hyperreflexia, and peripheral edema in pregnant trauma patients. This can mimic head injury.
External contusions and abrasions of the abdominal wall are signs of blunt uterine trauma.
true. Fetal injuries can occur when the abdominal wall strikes an object, such as the dashboard or steering wheel, or when a pregnant patient is struck by a blunt instrument.
Using a shoulder restraints in conjunction with a lap belt reduces the likelihood of direct and indirect fetal injury, presumably because the shoulder belt dissipates deceleration forces over a great surface area and helps prevent the mother from flexing forward over the gravid uterus.
the deployment of air bags in vehicles does not appear to increase pregnancy specific risks. Using lap belt alone allows for forward flexion and uterine compression with possible uterine rupture or placental abruption. Lap belt worn too high over uterus may produce uterine rupture.
Penetrating injury to pregnant women
As uterus grows larger, other viscera are protected from penetrating injury. Dense uterine musculature in early pregnancy can absorb significant amount of energy from penetrating objects decreasing their velocity and lowering risk of injury to other viscera. However, fetal outcome is generally poor with penetrating injury to uterus.
carefully observe pregnant patients with even minor injuries since occasionally minor injuries are associated with placental abruption and fetal loss.
True. AND to optimize outcomes for mother and baby, clinicians must assess and resuscitate the mother first and then assess the fetus before conducting second survey of the mother.
Failure to displace the uterus to the left side in a hypotensive pregnant patient
logroll all patients appearing clinically pregnant (second and third trimester) to the left 15-30 degrees and elevate the right side 4-6 inches and support with a bolstering device to maintain spinal motion restriction and decompression of the vena cava.
Due to increases intravascular volume, pregnant patients can lose a significant amount of blood before tachycardia, hypotension, and other signs of hypovolemia occur. Thus, what do stable vital signs in a pregnant patient indicate about the fetus?
The fetus may be in distress and the placenta deprived of vital perfusion while the mother’s condition and vital signs appear stable. Administer crystalloid fluid resuscitation and blood to support the physiological hypervolemia of pregnancy. vasopressers should be an absolute last resort in restoring maternal blood pressure as they further reduce uterine blood flow, resulting in fetal hypoxia.
What does a normal fibrinogen level indicate in a pregnant patient?
Fibrinogen level may double in late pregnancy and a normal level may indicate early disseminated intravascular coagulation
Most common cause of fetal death?
maternal shock and maternal death. Placental abruption is second. Placental abruption is suggested by vaginal bleeding, uterine tenderness, frequent uterine contractions, uterine tetany, and uterine irritability (uterus contracts when touched). In 30% of cases of abruption, bleeding may not occur. Uterine ultrasound may be helpful in diagnosis, but is NOT definitive.
Signs of uterine rupture
abdominal tenderness, guarding, rigidity, or rebound tenderness. Signs of peritonitis are hard to tell due to expansion and attenuation of the abdominal wall musculature. Other findings include abdominal fetal lie (oblique or transverse lie), easy palpation of the fetal parts because of their extrauterine location and inability to readily palpate the uterine fundus when there is fundal rupture. Xray evidence of rupture include extended fetal extremities, abnormal fetal position, and free intraperitoneal air.
Perform continuous fetal monitoring with a tocodynamometer beyond 20-24 weeks of gestation.
Patients with no risk factors for fetal loss should have continuous monitoring for 6 hours, whereas, patients with risk factors for fetal loss or placental abruption should be monitored for 24 hours. RISK FACTORS ARE: heart rate > 110, an injury severity score >9, evidence of placental abruption, fetal heart rate >160 or less than 120, ejection during MV, and motorcycle or pedestrian collisions
REMEMBER: maternal bicarbonate is low during pregnancy to compensate for respiratory alkalosis.
17-22 in pregnant patient. (non pregnant patient is 22-28)
Fetal heart rate is a sensitive indicator of maternal blood volume status and fetal well being.
normal range for fetus is 120-160. abnormal heart rate, repetitive decelerations, absence of accelerations or beat to beat variability and frequent uterine activity can be signs of impending maternal and or fetal decompensation (hypoxia or acidosis) and should prompt immediate obstetrical consultation.
If a DPL is to be placed in a pregnant trauma patient, place the catheter above the umbilicus using the open technique. Be alert to uterine contractions which suggest early labor and tetanic contractions which suggest placental abruption.
evidence of ruptured chorioamniotic membranes include amniotic fluid in vagina evidenced by a pH of 4.5
Bleeding in 3rd trimester may indicate placental abruption and impending death of the fetus, a vaginal exam is vital
however, avoid repeating vaginal examination, CT abdominal imaging can be done and radiation doses less than 50mGy are not associated with fetal anomalies or higher risk of fetal loss.
Admission to hospital for pregnant patients:
vaginal bleeding, uterine irritability, abdominal tenderness, pain or cramping, evidence of hypovolemia, changes in or absence of fetal heart tones and or leakage of amniotic fluid
With extensive placental separation or amniotic fluid embolization, widespread consumptive coagulopathy can emerge rapidly causing depletion of fibrinogen, other clotting factors, and platelets.
immediately perform uterine evacuation and replace platelets, fibrinogen, and other clotting factors.
As little as 0.01mL of RH+ blood will sensitize 70% of Rh- women.
All pregnany RH negative trauma patients should receive RH immunoglobulin therapy unless injury is remote from the uterus (isolated distal extremity injury)
Intimate partner violence in pregnant patient:
injuries inconsistent with history, diminished self image, depression or suicide attempts, self abuse, frequent ED visits, symptoms suggestive of substance abuse, isolated injuries to the gravid abdomen, parter insists on being present for the interview and exam and monopolizes discussion
What is the difference between burns and other injuries?
The biggest difference is that the consequences of burn injury are directly linked to the extent of the inflammatory response to the injury. The larger and deeper the burn, the worse the inflammation.
Flame injury is more evident than most chemical injuries.
Monitor IV lines closely to ensure they do not become dislodged as the patient becomes more edematous. Regularly check ties securing ET or NG to ensure they are not too tight.
Factors that increase the risk of upper airway obstruction are:
increasing burn size and depth, burns to the head and face, inhalation injury, associated trauma, and burns inside the mouth. Airway can become obstructed form direct injury such as inhalation injury, but also from massive edema resulting from burn injury.
How do you decontaminate burn areas?
Completely remove the patient’s clothing to stop burning process, but do not peel off adherent clothing. Synthetic fabrics can ignite, burn rapidly at high temps and melt into hot residue that continues to burn the patient. brush any dry chemical powder from wound. rinse with copious amounts of warm saline irrigation or rinsing in a warm shower. once the burning process has been stopped, cover the patient with warm, clean, dry linens to prevent hypothermia.
hoarseness, stridor, accessory respiratory muscle use, sternal retraction are signs of what?
airway obstruction. Clinical manifestations of inhalation injury may be subtle and may not show up within the first 24 hours. do not wait for the xray to show evidence of pulmonary injury or changes in blood gas because airway edema can preclude intubation and a surgical airway will be required.
A carboxyhemoglobin level greater than what percentage indicates a patient was involved in a fire and has inhalation injury?
10%
Indications for early intubation in burn patients:
full thickness circumferential neck burns, signs of airway obstruction, extent of the burn > 40%, burns inside the mouth, difficulty clearing secretions or swallowing, decreased level of consciousness,
Patient with inhalation injury are at risk for bronchial obstruction from secretions and debris and they may require bronchoscopy.
Make sure to place an adequately sized airway tube
Direct thermal injury to the lower airway is very rare and essentially occurs only after exposure to superheated steam or ignition of inhaled inflammable gases. Breathing concerns arise from what 3 general causes:
hypoxia, carbon monoxide poisoning, and smoke inhalation injury.
Always assume CO exposure in patients who were burned in enclosed areas. Patients with CO levels less than 20% may not show any symptoms
HA and nausea (20-30%), confusion (30-40%), coma (40-60%) and death (>60%). Cherry red skin color in patients may only be seen in moribund patients.
Measurements of arterial PaO2 do not reliably predict CO poisoning b/c a partial pressure of only 1 mm Hg results in an HbCO level of 40% or greater. Pulse ox cannot be relied on to rule out carbon monoxide poisoning b/c we cant distinguish oxyhemoglobin from carboxyhemoglobin. A discrepancy between pulse ox and arterial blood gas may be explained by presence of carboxyhemoglobin.
Cyanide inhalation poisoning can occur in confined spaces and sign of potential toxicity is persistent profound unexplained metabolic acidosis.
THERE IS NO ROLE for hyperbaric oxygen therapy in the primary resuscitation of a patient with critical burn injury.
American Burn Association states 2 requirements for diagnosis of smoke inhalation injury:
- exposure to combustible agent
- signs of exposure to smoke in the lower airway, below the vocal cords, seen on bronchoscopy.
A chest Xray and arterial blood gases should be ordered to evaluate the pulmonary status of a patient with smoke inhalation injury, but normal values on admission DO NOT exclude an inhalation injury.
The treatment of smoke inhalation injury is supportive.
Any patient with smoke inhalation injury and significant burns greater than 20% TBSA should be intubated. IF the patient’s hemodynamic condition permits and spinal injury has been excluded, elevate the patient’s head and chest 30 degrees to help reduce neck and chest wall edema.
True or false: Clinicians should provide burn resuscitation fluids for deep partial and full thickness burns larger than 20% TBSA
True. urine output monitoring is 0.5mL/kg/hr in adults and should be maintained at 30-50cc/hr to minimize over resuscitation
in a burn patient, cardiac dysrhytmias may be the first sign of hypoxia and electrolyte or acid base abnormalities.
therefore an ECG should be performed for cardiac rhythm disturbances. Persistent acidemia in patients with burn injuries may be due to under resuscitation or infusion of large volumes of saline.
Tachycardia is a poor indication for resuscitation in the burn patient.
Adjust the fluid rate up or down based on the urine output and recognize that factors such as inhalation injury, age of patient, renal failure, diuretics, and alcohol can affect the volume of resuscitation and urine output.
True of false: Burn patients should get tetanus.
true
Partial thickness burns
are characterized as either superficial partial thickness (moist, painfully hypersensitive, , potentially blistered, homogenously pink, and blanch to touch) or deep partial thickness ( drier, less painful, potentially blistered, red or mottled in appearance, and do not blanch to touch)
Full thickness burns
appear leathery and skin may be white or translucent or waxy white. surface area is painless to light touch or pinprick and generally dry
Compartment syndrome in burn patients:
Compartment syndrome can result from an increase in pressure inside the compartment that interferes with perfusion to the structures within that compartment. In burns, this condition results from a combination of decreased skin elasticity and increased edema in the soft tissue. A pressure > 30 mm Hg within the compartment can lead to muscle necrosis and once the pulse is gone it may be TOO LATE to save the muscle. so recognize the signs early:
pain greater than expected and out of proportion to the injury
pain on passive stretch of the affected muscle
tense swelling of the affected compartment
paresthesias or altered sensation distal to the affected compartment
compartment syndrome may be present with circumferential chest and abdominal burns
chest and abdominal escharotomies performed along the anterior axillary lines with cross incision at the clavicular line and the junction of the thorax and abdomen usually relieve this problem. relieve circulatory compromise in a circumferentially burned limb by eschartomy and these escharotimies are not needed within the first 6 hours.
Partial thickness burns are painful when air currents pass over the burned surface.
gently cover the burn with clean sheets will decrease the pain and deflect air currents. Do not break blisters or apply an antiseptic and application of cold compress can cause hypothermia. DO not apply cold water to a burn patient.
electrical burns are more serious than they appear on the body surface and extremities, particularly the digits.
current can travel inside blood vessels and nerves and can cause local thrombosis and nerve injury. So a severe electrical injury usually results in contracture of the affected extremity.
A clenched hand with a small electrical entrance wound should alert the clinician that a deep soft tissue injury is likely much more extensive than is visable to the naked eye
true. patients with severe electrical injuries require fasciotomies. Electricity can cause forced contraction of muscles, doctors need to examine patient for skeletal and muscular damage, especially for fractures of the spine and rhabdomyolysis
How do you dissolve a tar burn?
Use mineral oil
Abuse and burns
circular burns and burns with clear edges and unique patterns may reflect cigarette burns or iron. Burns on the sole of the feet usually suggest child was placed in hot water. A burn on the posterior aspect of the LE and buttocks
Patient with electrical burn can develop for acute renal failure
remember these burns can cause serious muscle damage without showing signs outright. Test urine for hemochromogen and administer proper volume. Assess for compartment syndrome and attach EKG leads as electrical injury can cause arrhythmias.
Frostbite is due to freezing of tissue with intracellular ice crystal formation, microvascular occlusion, and subsequent tissue anoxia.
first degree: hyperemia and edema are present w/o skin necrosis
second degree: large clear vesicles accompany the hyperemia and edema with partial thickness skin necrosis.
third degree frostbite: full thickness skin necrosis including muscle and bone with later necrosis
treatment is circulating water at constant 40 degrees C or 104F until pink color and perfusion return in 20-30 minutes.
In frostbite injury, warming large areas can result in reperfusion syndrome, with acidosis, hyperK and local swelling.
therefore monitor the patient’s cardiac status and peripheral perfusion during rewarming.
Sympathetic blockade agents and vasodilating agents have shown to be effective in altering the progression of acute cold injury
false
hypothermia is a core temp below 36C or 96.8F
hypothermia can worsen coagulopathy and affect organ function.
Rhabdomyolysis can lead to metabolic acidosis, hyperK, hypoC, and DIC.
Myoglobin induced renal failure can be prevented with intravascular fluid expansion, alkalinization of the urine by IV administration of Bicarbonate and osmotic diuresis.
For MSK trauma, loss of sensation in a stocking or glove distribution is an early sign of….
early sign of vascular impairment
Knee dislocations can reduce spontaneously and may not present with any gross external or radiographic anomalies until a physical exam of is joint is perfromed.
an ankle brachial index of less than 0.9 indicates abnormal arterial flow secondary to injury or peripheral vascular disease
Blanched skin associated with fractures and dislocations can lead to soft tissue necrosis. The purpose of promptly reducing this injury is to prevent pressure necrosis of the lateral left ankle soft tissue
the only reason to forgo an xray exam before treating a dislocation or fracture is the presence of vascular compromise or impending skin breakdown, often seen with fracture dislocations of the ankle
Treat all patients with open fractures as soon as possible with iv antibiotics
cephalosporins are necessary for all open fractures
operative revascularization to an avascular extremity is important to treat emergently.
muscle necrosis begins where there is a lack of blood flow for 6 hours. is there is an associated fracture deformity, correct it by gently pulling the limb out to length, realigning the fracture and splinting the injured extremity. This maneuver can restore the blood flow
High risk activities that can cause compartment syndrome include:
excessive exercise
burns
severe crush injury to muscle
localized prolonged external pressure to an extremity
increased capillary permeability secondary to reperfusion of ischemic muscle.
Compartment syndrome is a clinical diagnosis and pressure measurements are only an adjunct to aid in its diagnosis. a pressure greater than 30 can cause anoxia.
the absence of a palpable distal pulse is an uncommon or late finding and is not necessary to diagnose compartment syndrome.
Capillary refill times are also unreliable
weakness or paralysis of the involved muscle is a late sign and indicates nerve or muscle damage
the lower the systemic pressure, the lower the compartment pressure that causes compartment syndrome
risk of tetanus:
wounds that are more than 6 hours old
contused or abraded
more than 1cm in depth
from high velocity missiles
due to burns or cold
significantly contaminated
ischemic tissue or denervated wounds
True or false? on page 162. To exclude occult dislocation and concomitant injury, x ray films must include the joints above and below the suspected fracture site
true. unless life threatening, splinting of extremity injuries should be done during the secondary survey.
do not apply traction to patients with an ipsilateral tibia shaft fracture.
true
Laryngeal Trauma presents as hoarseness, subcutaneous emphysema, and palpable fracture
true. sounds of airway obstruction and include snoring, gurgling, stridor, hoarseness, cyanosis, agitation
LEMON assessment for difficult airway
Look, evaluate 3-3-2 rule, mallampati, obstruction, neck mobility
Do not give a nasopharyngeal airway to someone suspected of having a cribriform plate fracture.
also do not give nasotracheal intubation to patients with basillar skull fracture
A tube placed in the trachea with the cuff inflated below the vocal cords and the tube connected to oxygen enriched assisted ventilation and airway secured in place.
definitive airway
patients use the gum elastic bougie when vocal cords cannot be visualized on direct laryngoscopy.
using the GEB has allowed for rapid intubation of nearly 80% of prehospital patients in whom laryngoscopy was difficult. A GEB inserted into the esophagus will pass its full length without resistance
Reliable ways to detect proper intubation
proper placement of the tube is suggested but not confirmed:
- hearing equal breath sounds bilaterally
- detecting no borborygmi (rumbling or gurgling noises) in the epigastrium. the presence of this with inspiration suggestion esophageal intubation and warrants removal of tube
- A CO2 detector ideally capnograph or colorimetric CO2 monitoring device. If CO2 is not detected in exhaled air, then esophageal intubation has occurred.
- Proper position of the tube is best confirmed via chest xray
definitive control of hemorrhage and restoration of adequate circulating volume are the goals of treating hemorrhagic shock.
never give vasopressors as the first line treatment as they worsen tissue perfusion. most injured patients who are in hemorrhagic shock require early surgical intervention or angioembolization to reverse the shock state. The presence of shock in a trauma patient warrants the immediate involvement of a surgeon.
An injured patient who is cool to the touch and is tachycardic should be considered to be in shock until proven otherwise. Massive blood loss may only produce a slight decrease in HCT/Hgb.
relying solely on BP as an indicator of shock can delay recognition of the condition b/c compensatory mechanisms can prevent measurable fall in systolic pressure until up to 30% of the patient’s blood volume is loss. A narrowed pulse pressure suggests significant blood loss and involvement in compensatory mechanisms.
tachycardia is diagnosed as > 100 in adults
160 in infants
140 in preschool aged children
120 in children from school age to puberty.
Tachycardia, muffled heart sounds, dilated engorged neck veins, hypotension and insufficient response to fluid therapy is what?
cardiac tamponade, which is commonly caused by penetrating thoracic trauma, but can result from blunt injury to the thorax. Definitive treatment is operative intervention as pericardiocentesis is temporary measure.
Tension pneumothorax differs because it presents with distended neck veins and hypotension as well as absent breath sounds and hyperresonant percussion
Acute respiratory distress, subcutaneous emphysema, absent unilateral breath sounds, hyperresonance to percussion, and tracheal shift supports the diagnosis of????
tension pneumothorax. needle or finger decompression temporarily relieves this life threatening condition and follow this with a chest tube
isolated intracranial injuries do not cause shock, unless the brainstem is injured. A narrowed pulse pressure is not seen in neurogenic shock.
The classic presentation of neurogenic shock is hypotension (due to loss of sympathetic tone) without tachycardia. A narrowed pulse pressure is not seen in neurogenic shock. The failure of fluid resuscitation to restore organ perfusion and tissue oxygenation suggest either continuing hemorrhage or neurogenic shock
Less than 15% blood loss. no change in HR, BP, pulse pressure, RR, urine output.
this is class 1 hemorrhage and requires monitoring with base deficit of 0- -2
15-30% blood loss. increase in heart rate. decrease in pulse pressure. BP, RR, urine output do not change
class II hemorrhagic shock. possible need for blood products, but mostly crystalloid fluid and base deficit of -2 to -6. anxiety, fear
31-40% blood loss. heart rate increase, respiratory rate increase, blood pressure decrease, pulse pressure decrease, urine output and GCS decrease
class III and this is the least amount of blood loss that consistently causes a drop in systolic blood pressure. blood products needed and base deficit is -6 to -10
40% blood loss. heart rate increase, RR increase, BP decrease, pulse pressure decrease, urine output and GCS decrease
MTP and base deficit is -10 or less
A chest xray must be obtained after attempts at inserting a subclavian or IJ to document position of line and evaluate for pneumo or hemothorax.
do not use sodium bicarb to treat metabolic acidosis from hypovolemic shock
Hypothermia can be prevented and reversed by storing crystalloids in a warmer or infusing them through intravenous fluid warmers.
blood products cannot be store in a warmer, but they can be heated by passage through intravenous fluid warmers. Fluids should be warmed to 39C or 102.2F before infusing them.
Massive fluid resuscitation with the resultant dilution of platelets and clotting factors (severe hemorrhage and injury results in consumption of coagulation factors and early coagulopathy) contributes to coagulopathy in injured patients.
The response of elderly patients, athletes, pregnant patients, patients on medications, hypothermic patients, and patients with pacemakers or implantable devices may have different set of vitals in response to shock.
Older patients are unable to increase their HR when stressed by blood volume loss. A systolic BP of 100 may represent shock in an elderly patient. Due to medications, HR may not increase in the elderly population when in shock.
Blood volumes may increase 15-20% in athletes, cardiac output can increase 6 fold and the rest HR can be 50. Trained athletes have a remarkable ability to compensate for blood loss and they may not manifest the usual way to hypovolemia, even with significant blood loss.
Patients suffering from hypothermia and hemorrhagic shock do not respond as expected to the administration of blood products and fluid resuscitation. IN hypothermia, coagulopathy may develop and worsen.
When a patient fails to respond to fluid therapy one or more of these causes may be: tension pneumothorax, cardiac tamponade, undiagnosed bleeding, unrecognized fluid loss, acute gastric distention, MI, diabetic acidosis, neurogenic shock
Tracheobronchial injury will present with hemoptysis, cervical subcutaenous emphysema, tension pneumothorax, and/or cyanosis.
A bronchoscopy can confirm the diagnosis, but these patients require immediate surgical consultation. intubation of these patients may be difficult, so they may need fiber optic assisted ET
what are these signs and symptoms describing? chest pain, air hunger, tachypnea, respiratory distress, tachycardia, hypotension, tracheal deviation away from side of injury, unilateral absence of breath sounds, neck vein distention, cyanosis (late manifestation), hyperresonance on percussion
tension pneumothorax. initially, you can do a needle decompression or finger thoracostomy. place tube in afterwards
pain, difficulty breathing, tachypnea, decreased breath sounds on affected side, and noisy movement of air through chest wall injury
these are signs and symptoms of an open pneumothorax. sterile occlusive dressing large enough to overlap the wound’s edges and tap it securely on 3 sides
Causes of Pulseless Electrical Activity
hypovolemia, hypokalemia, hyperkalemia, hypoglycemia, hypothermia, toxins, cardiac tamponade, tension pneumothorax, thrombosis
Massive hemothorax is suggested when a patient is in shock and has decreased breath sounds or dullness to percussion on one side of the chest with collapsed neck veins
chest tube at the fifth intercostal space at the midaxillary line and you get a return of 1500mL or 1/3 or more of the patient’s blood in the chest, that indicated the need for urgent thoracotomy. persistent need for blood is an indication for a thoracotomy. color of the blood is a poor indicator of the necessity for thoracotomy.
muffled heart sounds, hypotension, and distended necks veins may not always be present in cardiac tamponade. Kussmaul’s sign (rise in venous pressure with inspiration when breathing spontaneously) is a true paradoxical venous pressure abnormality that is associated with tamponade
The presence of hyperresonance on percussion indicated tension pneumothorax whereas presence of bilateral breath sounds is cardiac tamponade. FAST can identify cardiac tamponade. if FAST is unavailable, use echo or pericardial window. definitive treatment is surgery so thoracotomy or sternotomy.
potentially life threatening injuries that should be identified on secondary survey
simple pneumothorax, hemothorax, flail chest, pulmonary contusion, blunt cardiac injury, traumatic aortic disruption, traumatic diaphragmatic injury, esophageal rupture
pulmonary contusion can occur with rib fractures and flail chest (two or more adjacent ribs fractured in two or more places).
initial treatment includes humidified oxygen, adequate ventilation, and cautious fluid resuscitation. definitive treatment includes pain control, adequate oxygenation
Blunt cardiac injury can present with hypotension, dysrhythmias, EKG changes, premature ventricular contractions, unexplained sinus tachycardia, AFib, bundle branch block, elevated central venous pressure without any obvious cause may indicate right ventricular dysfunction secondary to contusion.
cardiac troponins can be diagnostic in an MI but have little role in diagnosing blunt cardiac injury. patients with a blunt injury to the heart diagnosed by conduction abnormalities are at increased risk for sudden dysrhythmias and need to be monitored for 24 hours.
Traumatic aortic disruption- most survive if they have an incomplete laceration near the ligmentum arteriosum. commonly caused by vehicle collision or fall from a great height. have a high index of suspicion if history has decelerating force.
Look for widened mediastinum on chest xray, obliteration of the aortic knob, deviation of the trachea to the right, depression of the L mainstem bronchus, elevation of R mainstem bronchus, deviation of the esophagus to the right, left hemothorax, presence of the pleural or apical cap, fractures of the first or second rib or scapula, widened paraspinal interface, widened paratracheal stripe.
In a traumatic aortic rupture, heart rate and blood pressure control can decrease the likelihood of rupture.
definitive treatment is surgery.
Diaphragmatic injury-displaced bowel, stomach, and nasogastric tube on left side.
The appearance of peritoneal lavage fluid in the chest tube also confirms diagnosis
esophageal injury- clinical picture is a patient with a left pneumothorax or hemothorax without a rib fracture who has received a severe blow to the lower sternum or epigastrum and is in pain or shock out of proportion to the apparent injury
presence of mediastinal air also suggests diagnosis and definitive treatment is direct repair of the injury.
injuries to the retroperitoneal structures are difficult to recognize because they occur deep within the abdomen and may not initially present with signs or symptoms of peritonitis.
the retroperitoneal space is NOT sampled by DPL or FAST
physical exam findings suggestive of a pelvic fracture include:
ruptured urethra, scrotal hematoma or blood at the urethral meatus, discrepancy in limb length and rotational deformity of a leg w/o obvious fracture. use pelvic binder that is centered at the greater trochanters rather than over the iliac crests.
signs of urethral injury include:
blood at the uretheral meatus, ecchymosis or hematoma of the scrotum and perineum. Palpation of the prostate gland is NOT a reliable sign of urethral injury.
a retrograde urethorgram is mandatory when the patient is unable to void, requires a pelvic binder, or has blood at the meatus, scrotal hematoma, or perineal ecchymosis. confirm an intact urethra before inserting a urinary catheter.
DPL: Aspiration of gastrointestinal contents, vegetable fibers, or bile through the lavage mandate laparotomy. Aspiration of 10cc or more of blood in hemodynamically abnormal patients requires laporotomy.
performed rapidly, invasive procedure
sensitive for detecting intraperitoneal hemorrhage
low specificity
requires gastric and urinary decompression
not repeatable
a positive DPL is an indication for laparotomy
contraindications include previous abdominal operations, morbid obesity, advanced cirrhosis, pre-existing coagulopathy.
FAST
noninvas and can be done rapidly
repeatable
does not assess retroperitoneal structures.
obesity can degrade images obtained by FAST
indications for a laparotomy:
Blunt abdominal trauma with hypotension, positive FAST
hypotension with an abdominal wound that penetrates anterior fascia
gunshot wounds that traverse the peritoneal cavity
evisceration
bleeding from stomach, rectum, or GU tract
peritonitis
free air of hemidiaphragm
contrast CT showing rupture GI tract, bladder injury
Aspiration of gastrointestinal contents, vegetable fibers, or bile through the lavage mandate laparotomy. Aspiration of 10cc or more of blood in hemodynamically abnormal patients requires laparotomy.
Diaphragm injuries
elevation or blurring of the hemidiaphragm, hemothorax, an abnormal gas shadow that obscures the hemidiaphragm, or a gastric tube in the chest
Duodenal injuries- a bloody gastric aspirate or retroperitoneal air on abdominal CT or radiograph should raise suspicion
classically seen in unrestrained drives involved in frontal-impact MVC and patients who sustain direct blows to the abdomen from bicycle handlebars.
Any early normal serum amylase level or an elevated amylase level does not conclude pancreas injury
uncal herination
ipsilateral pupillary dilation associated w/contralateral hemiparesis and loss of pupillary response to light
ICP
normal is 10. > 22 has poor outcomes. increased ICP decreases cerebral perfusion pressure. monroe kellie doctrine states that total volume of intracranial contents must remain constant because cranium is a rigid container incapable of expanding.
CPP= MAP -ICP
a MAP of 50-150 is autoregulated to maintain a constant cerebral blood flow.
GCS of 8 or less= severe brain injury
GCS of 9-12= moderate
GCS of 13-15= mild
Indications for CT scanning
GCS < 15 at 2 hours after injury suspected open or depressed skull fracture any sign of basilar skull fracture emesis more than 2 episodes age > 65
anticoagulant use
LOC > 5 minutes
amnesia before impact
Goals of treatment of brain injury
systolic BP > 100
temp 36-38
Glucose 80-180
Hgb > 7
PaCO2 35-45
ICP 5-15
pulse ox > 95
NA 135-145
TBI treatment
IV fluids & hypertonic saline (do not give hypotonic fluids or glucose containing fluids because this can harm the injured brain)
Avoid hyponatremia
reversal of anticoagulants
Hyperventilation to keep PaCO2 at 35-temporizing measure
Mannitol-do not give to patients with hypotension
reversal agents:
aspirin/plavix: platelets
warfarin: FFP, vitamin K, Prothrombin Complex
Heparin or LMWH: Protamine Sulfate
Direct thrombin inhibitors: Idarucizumab
Rivaroxaban: N/A
Neurogenic shock
loss of vasomotor tone and sympathetic innervation to the heart. Injury T6 and above can cause impairment of the sympathetic pathways. We get hypotension and bradycardia.
Neurogenic shock is not reversed with fluid resuscitation alone. Vasopressors may be required.
spinal shock refers to the loss of muscle tone (flaccid) and reflexes immediately after injury
Central cord syndrome
loss of function in upper extremities > lower extremities occurring after a hyperextension injury, forward fall resulting in facial impact.
Anterior Cord Syndrome
injury to the motor and sensory pathways in the anterior part of cord. paraplegia and bilateral loss of pain and temp. However, position, vibration, and deep pressure sense are preserved (sensations from dorsal columns). commonly due to cord ischemia
Brown-Sequard Syndrome
results from hemisection of the spinal cord. Ipsilateral motor loss and loss of position sense and contralateral loss of pain and temp
Atlanto Occipital Dislocation
this is commonly seen in shaken baby syndrome due to severe traumatic flexion and distraction. Most patients with this injury die of brainstem destruction and apnea or have profound neurological impairments.
Jefferson Fracture
Burst fracture of C1 due to axial loading, which occurs when a large load falls vertically on the head in a relatively neutral position. Disruption of anterior and posterior rings of C1
Fracture best seen on an open mouth view of the C1-C2 region on CT
Hangman Fracture
this involves the posterior elements of C2, the pars interarticularis and this type of fracture is caused by an extension type injury
Chance Fracture
transverse fractures through the vertebral body seen after MVC where patient was restrained by only an improperly placed lap belt.
Chance fractures can be associated with retroperitoneal and abdominal visceral injuries. these are unstable and require internal fixation
NEXUS
Neurological deficit
ethanol intoxication
distracting injury
unable to provide history
spinal tenderness midline
Signs of blood loss in a child
progressive weakening of peripheral pulses, narrowing pulse pressure less than 20, skin mottling (clammy skin), cool extremities compared with torso skin, decrease in level of consciousness with dulled response to pain.
often times tachycardia may be the only sign of shock in a kid
hypotension in child
systolic BP for kid is 90 + twice the child’s age in years. hypotension represents a state of decompensated shock and can indicated blood loss of > 45%.
Assessed first in trauma patient
Airway
(*)Degree of burn that is characterized by bone involvement
Fourth
Complications of head trauma
Intracerebral hematoma
Extradural hematoma
Brain abscess
Most common cause of laryngotracheal stenosis
Trauma
Intervention that can help prevent development of acute renal failure
Infusion of normal saline
A 26-year-old male is resuscitated with blood transfusion after a motor vehicle collision that was complicated by a fractured pelvis. A few hours later, the patient becomes febrile, hypotensive with a normal CVP, and oliguric. Upon examination, the patient is found to be bleeding from the NG tube and IV sites. Which of the following is the most likely diagnosis?
A. Hemorrhagic shock
B. Acute adrenal insufficiency
C. Fat embolism syndrome
D. Transfusion reaction
D. Transfusion reaction
Skin antiseptic
-Ethanol 70% is an effective skin antiseptic
-Acetic acid can be used to treat Gram- skin infections
-Salicylic acid is used to treat certain skin yeast infections
Class IV hemorrhage indicates what % blood loss
55%
How does shivering affect body temperature
Increases body temperature
Class III hemorrhage indicates what % of blood loss
35%
Management of a stable patient with kidney contusion
Observation
Associated with hypovolemic shock
-Inadequate tissue perfusion with resultant tissue hypoxia
-Blood shunting to vital organs
-Decreased circulating blood volume and decreased venous return
-Low cardiac output
-Loss of less than 20% of the blood volume is usually without symptom except for mild tachycardia
-Patients become orthostatic with losses between 20 and 40%
-Shock is evidenced by tachycardia, hypotension, oliguria, flat neck veins
The most effective method of monitoring the success of resuscitation during CPR?
Reactivity of pupils to light
Used to ensure correct placement of endotracheal tube
-Ultrasound
-Bilateral breath sounds
-Sustained end-tidal CO2
Total body surface area involved in a burn in an adult to the anterior chest and abdomen
18%
What is often caused by carotid massage?
Bradycardia
Step in a patient diagnosed with tension pneumothorax
- Needle decompression/ thoracotomy
- Chest tube
True statements regarding diaphragmatic injuries
-Blunt diaphragmatic injuries are usually associated with skeletal trauma
-Penetrating diaphragmatic injuries may be missed
-Repair of traumatic diaphragmatic injuries usually does not require prosthetic material
First priority in the treatment of an unconscious patient
Checking the pulse
A patient involved in a road accident is brought to the emergency department in an unconscious state. On arrival, her vitals show a temperature of 96.4 degrees Fahrenheit, a respiration rate of 24 breaths per minute, a heart rate of 140 beats per minute, and a blood pressure of 80/40 mm Hg. She is cold, shivering, and perspiring profusely. She has bilateral reactive pupils but she does not respond to pain. On physical examination, she has no obvious sign of external bleeding. Which of the following cannot be the cause of hypotension in this patient?
A. Pelvic fracture
B. Fracture of femur
C. Intracranial hemorrhage
D. Hemothorax
C. Intracranial hemorrhage
A patient suffered a slash to his right neck. The wound is over the mid-portion of the sternocleidomastoid. There is a large hematoma and brisk bleeding when uncovered. He is stable. What is the next step in management?
A. Get an angiogram
B. Close the wound in the ER
C. Take him to the operating room
D. CT scan to evaluate neck structure
C. Take him to the OR
After abdominal injury, which of the following urinalysis findings would be an indication for further testing?
A. 0-5 casts/HPF
B. 5-10 WBC/HPF
C. 10-20 RBC/HPF
D. Gross hematuria
D. Gross hematuria
A laceration of the neck superficial to the deep cervical fascia along the sternocleidomastoid muscle at its midpoint would cause bleeding from which structure?
External jugular vein
Clinical features associated with tension pneumothorax
Unilateral decrease in breath sounds
Hyperresonance
Respiratory distress
Tachycardia
Tracheal shift
Desatruation
Decreased breath sounds
Decreased compliance
Asymmetric chest movement
NOT hypertension, audible bronchial sounds
Not recommended as a mode of ventilation for a patient with a diaphragmatic hernia
A. Bag and mask
B. LMA
C. Endotracheal intubation
D. Jet ventilation
A. Bag and mask
What is the next step in the assessment of a traumatic patient after airway is established?
Breathing
Blood group that is considered a universal donor
O
A provider is examining a patient who sustained a severe traumatic head injury. He documents no Doll’s eyes. What does this signify?
Brainstem injury
Which of the following is the least preferred method of administering IV fluids?
A. Cubital veins
B. Cephalic veins
C. Subclavian veins
D. Saphenous vein
Subclavian veins
Dermatome level for nipple sensation
Dermatome level for umbilicus
T4
T10
At which temperature would a hypothermic patient stop shivering?
88 degrees F
What is the energy recommendation for the first defibrillation in an adult (*)
300 J
Pharmacologic effects of Morphine
Behavioral changes
Analgesia
Respiratory depression
NOT diarrhea
A patient with which condition should be triaged to receive medical attention first?
A. Choking
B. Dizziness
C. Leg cramp
D. Vomiting
A. Choking
For pediatric patients, what volume of fluid resuscitation should be given initially in the setting of shock?
A. 750 mL of saline uniformly
B. 1 liter of saline
C. 20 mL/kg of 0.45% NaCl with 5% glucose
D. 10 to 20 mL/kg of Ringers lactate
D. 10 to 20 mL/kg of Ringers lactate
A patient is found unconscious after a fire in his bedroom. He is found to have severe burns around his face. What is the first aspect of treatment?
A. Tetanus toxoid
B. Cover the wound
C. Airway
D. Obtain blood work
C. Airway
Basilar skull fracture
PE: raccoon eyes, battle sign, CSF ottorrhea (rhinorrhea), loculated pneumoencephalocele
Bone MC involved = Temporal
A patient with von Willebrand disease is bleeding after sustaining a knife wound. Which of the following is most appropriate for the treatment of this patient?
A. Vitamin K
B. Cryoprecipitate
C. Protamine
D. DDAVP
D. DDAVP
What is the total body surface area involved in a burn to both lower extremities?
36%
Which injury is most common in rear end motor vehicle accidents?
A. Cervical fractures
B. Hypextension-hyperflexion neck injuries
C. Forearm fractures
D. Rotational neck injuries
B. Hypextension-hyperflexion neck injuries
What is true about an unrestrained pregnant driver?
A. She is at increased risk of placenta previa
B. She is at increased risk of placental abruption
C. At 33 weeks, her fetus is well protected by an amniotic fluid cushion and thus the pregnancy is not at risk
D. If the mother’s vital signs are stable, complications are unlikely
B. She is at increased risk of placental abruption
In adults, an aspirated foreign body is most likely to get stuck in the:
A. Left main bronchus
B. Carina
C. Right main bronchus
D. Esophagus
C. Right main bronchus
Skin finding characteristic of second-degree burns
Blisters
Which is true regarding cervical spine fractures?
A. Seen most commonly in elderly females
B. Athletic activities are the most common cause
C. Falls are the most common cause
D. Methylprednisolone should not be used in associated spinal cord injury in the first 48 hours
D. Methylprednisolone should not be used in associated spinal cord injury in the first 48 hours
In which patients can an oropharyngeal airway be used?
Non-gag reflex
If a trauma patient has clear fluid draining from the nose the provider should do which of the following?
A. Tilt the head back
B. Apply pressure
C. Collect the fluid
D. Insert nasal tampons
C. Collect the fluid
What is the estimated time a person’s brain can be anoxic from cardiopulmonary failure and not develop permanent brain damage?
A. 10 minutes
B. 5 minutes
C. 2 minutes
D. 20 minutes
B. 5 minutes
The laryngeal mask airway is contraindicated in patients with what condition?
A. Spine injury
B. Head trauma
C. Giving birth
D. Propensity to aspirate
D. Propensity to aspirate
A patient sustains blunt trauma to the back and left leg. Vital signs in the emergency department show temperature 36 degrees C, BP 120/80 mm Hg, heart rate 92, respirations 19, GCS 15. There is bilateral lower extremity paraplegia, T12 sensory level, and decreased rectal tone. Hemoglobin is 14.2 and the same in one hour. Which of the following tests is best for diagnosing an intraperitoneal bleed?
A. Abdominal ultrasound
B. Laparotomy
C. KUB
D. Diagnostic peritoneal lavage
A. Abdominal ultrasound
Why is tracheostomy generally not performed at the first cartilage ring
A. The trachea is too narrow
B. A high chance of subglottic stenosis
C. A high chance of tracheo-innominate artery fistula
D. Inability to access the area
B. A high chance of subglottic stenosis
What does a carotid pulse indicate?
A. A functioning pump for blood flow
B. The circulating blood volume is reaching end organs
C. Diastolic blood pressure
D. None of the above
B. The circulating blood volume is reaching end organs
Which of the following generally causes hemorrhage associated with pelvic fractures?
A. Obturator artery injury
B. Superior gluteal artery
C. Lateral sacral artery injury
D. Venous bleeding
D. Venous bleeding
Hemothorax facts
-Must have at least 500 cc of blood to make a diagnosis on chest x-rayin an adult
-Incomplete evacuation of hemothorax can lead to empyema
-Initial treatment of hemothorax is always a chest tube
In a 66 year old intubated, comatose patient, what is one of the most important information that one needs to obtain?
A. Organ donation status
B. Power of attorney
C. Lawyer
D. Driver’s license
B. Power of attorney
A patient is hit by a car and has severe injuries to his extremities. He is immediately brought to the emergency room by EMS. Evaluation reveals that he has multiple organ injuries. He has an open, gaping wound which measures 2 x 2 centimeters, just below the right knee. The leg appears dislocated and ecchymotic. However, pulses are present in the distal extremity. He does not complain of any paresthesias. X-ray reveals that there is a fracture of the tibia. The trauma team is called. As their arrival is awaited, which of the following should NOT be done to help manage this patient?
A. Obtain culture and close wound using a sterile technique
B. Don’t reduce the dislocation
C. Give tetanus toxoid/booster shot
D. Give antibiotics
A. Obtain culture and close wound using a sterile technique
During resuscitation, your intubated patient’s intravenous fluid infiltrates. You know that you may deliver the following drugs via the endotracheal tube:
Lidocaine
Atropine
Naloxone
Epinephrine
Prior to tracheobronchial suctioning, the patient should receive:
A. 5cc normal saline lavage
B. Be placed on NPO status
C. 100% oxygen prior to suctioning
D. Versed 1 mg/mL
C. 100% oxygen prior to suctioning
In a patient with a pneumothorax following a stab wound, the chest tube is best inserted at which level?
Between the 4th and 5th intercostal spaces, just anterior to the mid axillary line
Indications for a CT scan of the head in trauma patients
-Glasgow coma scale score of less than 14
-Evidence of basilar skull fracture
-Amnesia lasting more than 30 minutes
Most common Emergency Medical Services pediatric calls
-Seizures
-Respiratory problems
-Trauma
Treatments utilized in a patient with head trauma and raised intracranial pressure
-Elevation of the head
-Sedation
-Use of diuretics
NOT fluid restriction
How deep should the provider depress the patient’s sternum during CPR in adults?
2 to 3 inches
First parameter to change in patient’s with hypovolemic shock?
A. Systolic blood pressure
B. Pulse rate
C. Respiratory rate
D. Skin vasoconstriction
B. Pulse rate
A 34-year-old with severe head trauma and elevated intracranial pressures is intubated. Which of the following should be the target for mechanical ventilation?
Set PaCO2 between 30-35
A young motorcycle driver is thrown against a concrete bridge and sustains severe trauma about the face, with marked deformity and bleeding. Which of the following statements regarding this scenario is TRUE?
A. Cervical spine evaluation takes precedence over facial injuries
B. LeFort fractures rarely cause severe hemorrhage
C. Nasotracheal intubation must be done urgently to prevent airway obstruction
D. Plain radiographs are preferred to CT in emergencies
A. Cervical spine evaluation takes precedence over facial injuries
Which US industry has the highest accidental death rate?
A. Construction
B. Agriculture
C. Manufacturing
D. Transportation
B. Agriculture
Subdural hematoma facts
Etiology: tearing of bridging veins
-Most common in elderly individuals who fall
-Hematoma should be evacuated surgically
-Prognosis is much better for chronic subdurals than acute cases
-More common than epidural hematomas
NOT often associated with skull fractures
An 8-year old child is brought to the ER after being struck by a car while crossing the street. He is not alert and required immediate intubation at the scene by EMS. His GCS is 8 T. He appears to have a significant laceration of his scalp on the left side but there are no skeletal fractures. The initial chest x-ray revealed a right sided pneumothorax and a chest tube was inserted. His hematocrit is 23.5 and hemoglobin is 7.6. The next thing you would do is:
A. CT head
B. CT abdomen
C. Repeat blood work
D. Observe patient
B. CT abdomen
Class I hemorrhage indicates what percentage of blood loss?
10%
Which is not a clinical component of the Glasgow Coma Score?
A. Eye movement
B. Sensation
C. Verbal response
D. Extremity movement
B. Sensation
How should epinephrine should be injected for treatment of anaphylaxis?
Intramuscularly (IM) into vastus lateralis
How would a patient with a change in mental status would be triaged using the simple triage and rapid treatment (START)?
A. Delayed
B. Immediate
C. Minor
D. Critical
B. Immediate
Appropriate site for insertion of a subclavian line
-One centimeter inferior to the junctions of the middle and medial third of the clavicle
-One fingerbreadth lateral to the angle of the clavicle
-Inferior to the clavicle @ deltopectoral groove, lateral to the midclavicular line
In head trauma, the majority of patients with post-traumatic CSF otorrhea:
A. Need surgery
B. Should be started on antibiotics
C. Heal spontaneously
D. Develop meningitis
C. Heal spontaneously
Uncal herniation
PE: Biot breathing, dilated and fixed pupil (out and down)
Nerves affected: 3rd, 4th, parasympathetic input
Laryngeal mask is usually seated over the which structure?
A. Tonsils
B. Esophagus
C. Vallecula
D. Pyriform fossa
D. Pyriform fossa
Patterns of injury seen in spinal cord trauma
-Central cord syndrome
-Anterior cord syndrome
-Brown-Sequard syndrome
Should be avoided in patient with suspected nasal fracture
Nasal intubation
What is the best way to evaluate a cardiac contusion?
A. CT scan of the chest
B. Echocardiogram
C. ECG monitoring x 24 hours
D. Cardiac enzymes
C. ECG monitoring x 24 hours
Cerebral contusions
May happen opposite to the point of impact
An 18-year-old is thrown off his motorbike on a slippery road. At the scene, what is the first priority in the management of this patient?
A. Assess vital signs
B. Stabilize cervical spine
C. Assess airway
D. Start IV fluids
C. Assess airway
Normal adult respiratory rate
12-20 breaths per minute
Scapular fracture
-Usually requires a tremendous force to fracture
-May be uneasily visible on plain xray
-Treatment requires prolonged immobilization
-Usually associated with other chest injuries
A patient suffers a stab wound to the chest. In the emergency room, he is found to have an 80 percent pneumothorax with a midline shift of the trachea to the contralateral chest. There is evidence of circulatory and respiratory dysfunction. What is the next step in the management of this patient?
A. Endotracheal tube
B. Fluid bolus
C. Epinephrine
D. 20 gauge needle
D. 20 gauge needle
Flail chest
Mediastinum is pulled toward affected side during expiration
Epidural hematoma
MC due to injury of Middle meningeal artery
Temporoparietal = area that has most epidural hematomas from trauma
-Can be intracranial or intraspinal (may follow LP)
-Often associated with skull fractures
7-year-old girl is found at the bottom of a swimming pool. Initially she was in full arrest but after 5 minutes she showed sinus tachycardia but no respiratory effort. Intubation was done in the field and cervical collar placed. After transport to the emergency department she was unresponsive with a blood pressure of 100/60 mmHg, pulse 105, temperature 34.3C, and oxygen saturation 100%. The pupils were 3 mm and sluggishly responsive to light. There is no response to pain. The lungs show wheezing on the left and coarse breath sounds bilaterally. The monitor shows sinus tachycardia. There is no rectal tone. Which of the following should be the next step in management?
A. Cervical spine films and CT of the head B. Portable chest radiograph
C. Arterial blood gas
D. Right and left decubitus chest radiographs
A. Cervical spine films and CT of the head
Position patient should be transported in when patient complains of neck pain and is 32 weeks pregnant
Supine on a backboard with her right hip elevated
Air embolism
PE: murmur, petechiae, desaturation
Tx: turn patient on left side in Trendelenburg position
Fat embolism
MCC = bone fx
Clinical presentation
-Fever
-Petechial hemorrhage
-Desaturation
-Hypotension
-Altered mental status
Cauda equina syndrome
-Bilateral sciatica
-Bowel dysfunction
-Saddle sensory changes
At what point should hyper oxygenation be administered when performing tracheal suctioning on a mechanically ventilated patient?
A. Before the procedure
B. After the procedure
C. Before and after the procedure
D. During the procedure
C. Before and after the procedure
Nerve to muscle relationship
C5 – Deltoid
C6 – Wrist extension
C7 – Elbow extension
Most common cause of kidney injuries
Motor vehicle accidents
Crystalloid solutions
Ringer’s lactate
Dextrose 5%
D5W plus 1/2 NS
NOT albumin
Indication for emergency thoracotomy
A. Pulmonary contusion
B. Flail chest
C. Hemothorax with initial blood loss of 700 cc
D. Lung collapse with an air leak
D. Lung collapse with an air leak
Studies used for a patient with widened mediastinum after injury
CT scan
Upper endoscopy
Transesophageal ultrasound
Pericardial tamponade
Muffled heart sounds
JVD
Equalization of cardiac chamber pressure
NOT hypertension
Blood groups facts
-ABO compatibility is a must for renal transplant
-Febrile reactions may be due to bacterial contamination
-Citrate toxicity can cause hypocalcemia
Which statement is most accurate regarding a chest tube connected to a water seal drainage system?
A. Bubbles in the water indicate that the chest tube is no longer needed
B. The water level should fall slightly with each spontaneous inspiration
C. The drainage system should be kept below the level of chest tube insertion
D. The chest tube should be clamped at all times when the patient is ambulatory
C. The drainage system should be kept below the level of chest tube insertion
Confirmatory test that is a reliable indicator of brain death
A. Apnea test with a pCO2 less than 40 B. Electromyography
C. 4-vessel cerebral angiography
D. CT scan of the brain
C. 4-vessel cerebral angiography
MC spine problem seen in patient’s with Down syndrome
Atlanto-axial instability
As a result of burn trauma, fluid shifts can cause hematocrit levels to
A. Rise
B. Fall
C. Remain unchanged while hemoglobin levels drop
D. Rise initially then fall dramatically
A. Rise
A 17-year-old male is hit on the head with a baseball bat. He withdraws and opens his eyes in response to deep painful stimuli. He also mumbles incomprehensibly. What is his Glasgow coma scale score?
8
Hypoxia
PE: cyanosis
Can be rapidly measured with pulse ox
After placement of a chest tube for a traumatic pneumothorax, subcutaneous emphysema is observed. After checking the drainage and chest tube site, what else should be done?
-Increase level of suction
-Insert second chest tube
-Adjust chest tube
Do NOT flush tube with saline
Which of the following injuries is most critical?
A. Fractured femur
B. Fractured pelvis
C. Fractured humerus
D. Fractured fibula
B. Fractured pelvis
A patient on a mechanical ventilator is fighting the machine, and has elevated peak airway pressures. What medication should be used?
A. Benzodiazepines
B. Vecuronium
C. Barbiturates
D. Baclofen
B. Vecuronium
What is the primary goal in the initial resuscitation of a cardiac arrest?
A. Renal perfusion
B. Limb perfusion
C. Myocardial perfusion
D. Brain perfusion
D. Brain perfusion
During an MVA, what is most likely injury to occur after knees strike the dashboard
A. Fractured femur
B. Fractured humerus
C. Lacerated spleen
D. None of the above
A. Fractured femur
Reason epinephrine is added to local anesthetics
Prolongs its action
Used to treat high ICP
Control BG
Hyperventilation (pCO2 30-35)
Elevate head of bed
Mannitol (osmotic diuretic)
Furosemide (loop diur.)
Earliest symptom of local anesthetic toxicity
Tongue and circumoral numbness
A 18-year-old male sustains a right femur fracture and a cerebral concussion in a motor vehicle accident. His initial blood pressure is 75/50 mmHg with a pulse of 90 beats per minute. After giving him 2 liters of Ringer lactate he stabilizes, but the blood pressure falls when he is seen in the ER. Which of the following would be the cause of suspected hypotension in this patient?
A. Subdural hematoma
B. Undiagnosed facial fracture
C. Ruptured spleen
D. 10% pneumothorax
C. Ruptured spleen
An unrestrained driver involved in a high speed MVA is transported by paramedics with c-spine precautions. GCS score is 7, but there is no obvious trauma. Respirations are shallow, and BVM is not providing adequate ventilation. Extremities are cool, and the pulses are thready. Prior to rapid sequence intubation, what should be done?
A. Brief neurologic examination
B. Immediate chin lift and jaw thrust maneuver
C. Assess all vital signs
D. Administer 4-5 quick tidal volume breaths with an FIO2 of 100% using a bag mask ventilatory device
D. Administer 4-5 quick tidal volume breaths with an FIO2 of 100% using a bag mask ventilatory device
Which of the following is indicative of a kidney injury?
A. Ascites
B. Flank tenderness
C. Hematuria
D. Hematemesis
C. Hematuria
Can occur during massive blood transfusions
-Dilutional thrombocytopenia
-Hypocalcemia
-Coagulation abnormalities
NOT hypokalemia
Which of the following most likely will result in a favorable outcome in pediatric drowning?
A. Spontaneous circulation established in the ER
B. Core temperature in the ER <33ºC C. Return of spontaneous circulation at the scene of the drowning
D. Reactive pupils at the scene of the drowning
C. Return of spontaneous circulation at the scene of the drowning
Underlying pathophysiology of a decrease in urine output
Compromised organ perfusion
Which of the following clinical signs is the most worrisome in a patient whom elevation of ICP is a concern?
A. Tachycardia
B. Asymmetric pupils
C. Hypothermia
D. Decreased blood pressure
B. Asymmetric pupils
Battle sign
(Mastoid ecchymosis)
Etiology: fracture of middle cranial fossa of skull
Posterior auricular = artery that causes the bruising
A patient is on mechanical ventilator and his arterial blood gas reveals a PCO2 of 38 and a pH of 7.41. What is the appropriate next step?
A. Increase oxygen
B. Observe
C. Increase rate
D. Increase tidal volume
B. Observe
A trauma patient is receiving fluids at 150 cc/hr. He received two units of blood because his initial hemoglobin was 7.3 g. After 4 hours, his urine output is 7 cc/hr and his central venous pressure is 3 cm of water. What is the next step in his management?
A. Start furosemide drip
B. Start dopamine at renal dose
C. Administer 500 cc of NS bolus over 1 hour
D. Decrease the rate of fluid administration
C. Administer 500 cc of NS bolus over 1 hour
A patient is placed on a heating blanket for hypothermia. It is most important to monitor which of the following?
A. Vital signs
B. Neurologic status
C. Sensory deficits
D. Oxygenation
A. Vital signs
Principle that most closely aligns with the oath, “Do no harm.”
Nonmaleficence
Carbon monoxide poisoning
PE: cherry red skin
Hypersensitivity is most commonly reported after use of which type of suture?
A. Nylon
B. Stainless steel wire
C. Chromic catgut
D. Silk
C. Chromic catgut
A patient suffers a gunshot wound to the abdomen. She is stable and only complains of mild pain at the site. On examination, she has mild rebound tenderness. Her WBC count is 10, hematocrit is 31, and hemoglobin is 13.2. What is the next step in the management of this patient?
A. Surgery
B. Abdominal CT
C. Abdominal Ultrasound
D. Rectal exam
B. Abdominal CT
First step taken to minimize thermal burn injury
Remove source of heat
Best assessment of fluid resuscitation of adult burn patient
A. Urine output of 0.5 mL/kg/hr
B. Normalization of BP
C. Normalization of HR
D. Measuring a normal central venous pressure
E. Providing 4mL/kg/% body burned/24 hours crystalloid fluid
A. urine output of 0.5 mL/kg/hr
Facts concerning spine trauma
-5% patients with brain injury have a spine injury
-25% patients with spine injury have a brain injury
-33% of patients with upper c-spine injuries die at the scene
Which of the following local anesthetics has the longest duration of action?
A. Procaine (Novocaine)
B. Bupivacaine (Marcaine)
C. Mepivacaine (Carbocaine)
D. Lidocaine (Xylocaine)
B. Bupivacaine (Marcaine)
When the cephalic vein cut down is done in the deltopectoral groove, the vein is usually found between the….
Deltoid and pectoralis muscles
What is the most important factor in preventing accidental pool drowning?
A. Pool covers
B. Fences around pools
C. Swimming lessons
D. Parental supervision
D. Parental supervision
Characteristics of early hemorrhagic shock
Cold skin
Slow capillary refill
Confusion
NOT bradycardia
A patient is thrown out of a car. He is hemodynamically stable, asymptomatic, and the only finding is a right sided pneumothorax. What is the best treatment for this man?
A. Aspiration of pneumothorax
B. Monitor pneumothorax
C. CT scan
D. Placement of chest tube
D. Placement of chest tube
Important landmark for location of second rib
Sternal angle
Contributes to a low score on the Glasgow coma scale
Paralysis
Low blood sugar
Use of narcotics
Pericardiocentesis is done by needle insertion through which of the intercostal spaces?
Fifth intercostal space
After a femur fracture, which of the following is LEAST likely?
A. Severe pain
B. Expanding hematoma
C. Severe nerve injury
D. Absent distal pulses
C. Severe nerve injury
Which of the following is no longer indicated for routine treatment of shock patients?
A. Cervical spine stabilization
B. Pneumatic anti-shock garment (PASG)
C. Endotracheal intubation
D. Oxygen
B. Pneumatic anti-shock garment (PASG)
A 13 year old boy fell while riding his bicycle and hit his head. He was unconscious for 4 or 5 minutes. He vomited twice. He has no memory of the event or a headache. His exam is entirely normal. Glasgow coma score is 15. Select the next step in management.
A. Discharge home with concussion instructions
B. CT of the head
C. Skull films
D. Admit for observation
B. CT of the head
Cerebral edema treatment
Mannitol
Head up position
Hyperventilation
Sellick maneuver
Minimizes the chances of regurgitation during intubation
Which of the following is predominantly an iatrogenic complication?
A. Venous air embolism
B. Deep venous thrombosis (DVT)
C. Venous thromboembolism
D. None of the above
A. Venous air embolism
Normal capillary refill time
2 seconds
Which of the following cannot be administered via endotracheal (ET) tube?
A. Atropine
B. Atenolol
C. Epinephrine
D. Lidocaine
B. Atenolol
Can be added to lidocaine to reduce the burning sensation when administered
Sodium bicarbonate
Nerve + sensory relationships
C6 – Thumb
C7 – Middle finger
C8 – Little finger
True regarding the initial resuscitation of a trauma patient
Evidence of improved perfusion after fluid resuscitation could include improvement of GCS on reevaluation
For the patient with severe traumatic brain injury, profound hypocarbia should be avoided to prevent:
cerebral vasoconstriction with diminished perfusion
After being involved in a motor vehicle crash, a 25-year-old man is brought to a hospital that has surgery capabilities available.. Computed tomography of the chest and abdomen shows an aortic injury and splenic laceration with free abdominal fluid. His blood pressure falls to 70 mm Hg after CT. The next step is:
perform an exploratory laparotomy
Which one of the following statements regarding abdominal trauma in the pregnant patient is TRUE?
A. The fetus is in jeopardy only with major abdominal trauma.
B. Leakage of amniotic fluid is an indication for hospital admission.
C. Indications for peritoneal lavage are different from those in the nonpregnant patient.
D. With penetrating trauma, injury to the mother’s abdominal hollow viscus is more common in late than in early pregnancy.
E. The secondary survey follows a different pattern from that of the nonpregnant patient.
B. 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?
A. distended abdomen
B. Glasgow Coma Scale score of 11
C. temperature of 36.5°C (97.8°F)
D. deforming of the right thigh
E. Respiratory rate of 40 breaths per minute
E. Respiratory rate of 40 breaths per minute
The most important, immediate step in the management of an open pneumothorax is:
A. endotracheal intubation
B. operation to close the wound
C. placing a chest tube through the chest wound
D. placement of an occlusive dressing over the wound
E. initiation of 2, large-caliber IVs with crystalloid solutionE.
D. placement of an occlusive dressing over the wound
The following are contraindications for tetanus toxoid administration:
A. history of neurological reaction or severe hypersensitivity to the product
B. local side effects
C. muscular spasms
D. pregnancy
E. all of the above
A. history of neurological reaction or severe hypersensitivity to the product
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?
A. Tachycardia
B. pulse volume
C. breath sounds
D. pulse pressure
E. jugular venous pressure
C. breath sounds
Bronchial intubation of the right or left mainstem bronchus can easily occur during infant endotracheal intubation because:
A. The trachea is relatively short.
B. The distance from the lips to the larynx is relatively short.
C. The use of cuffed endotracehal tubes eliminates this issue.
D. The mainstem bronchi are less angulated in their relation to the trachea.
E. So little friction exists between the endotracheal tube and the wall of the trachea.
A. The trachea is relatively short.
Which one of the following is the most effective method for initially treating frostbite?
A. moist heat
B. early amputation
C. padding and elevation
D. vasodilators and heparin
E. topical application of silver sulfadiazine
A. moist heat
Which one of the following statements concerning intraosseous infusion is TRUE?A. Only crystalloid solutions may be safely infused through the needle.
B. Aspiration of bone marrow confirms appropriate positioning of the needle.
C. Intraosseous infusion is the preferred route for volume resuscitation in small children.
D. Intraosseous infusion may be utilized indefinitely.
E. Swelling in the soft tissues around the intraosseous site is not a reason to discontinue infusion.
B. Aspiration of bone marrow confirms appropriate positioning of the needle.
A young woman sustains a severe head injury as the result of a motor vehicle crash. In the emergency department, her GCS is 6. Her blood pressure is 140/90 mm Hg and her heart rate is 80 beats per minute. She is intubated and mechanically ventilated. Her pupils are 3 mm in size and equally reactive to light. There is no other apparent injury. The most important principle to follow in the early management of her head injury is to:
A. avoid hypotension
B. administer an osmotic diuretic
C. aggressively treat systemic hypertension
D. reduce metabolic requirements of the brain
E. distinguish between intracranial hematoma and cerebral edema
A. avoid hypotension
A hemodynamically normal 10-year-old girl is hospitalized for observation after a Grade III (moderately severe) splenic injury has been confirmed by computed tomography (CT). Which of the following mandates prompt celiotomy (laparotomy)?
A. a serum amylase of 200
B. a leukocyte count of 14,000
C. evidence of retroperitoneal hematoma on CT scan
D. development of peritonitis on physical exam
E. a fall in the hemoglobin level from 12 g/dL to 8 g/dL over 24 hours
D. development of peritonitis on physical exam
A patient presents to the emergency room after a motor vehicle accident with hypotension, tachycardia, and abdominal distension. What is the most likely diagnosis?
A. Closed head injury
B. Splenic injury
C. Pneumothorax
D. Neurogenic shock
B. Splenic injury
Considered a mechanically stable cervical spine injury
-Clay shoveler’s fracture
-Simple wedge fracture not involving posterior elements
-Unilateral facet dislocation
NOT flexion teardrop fracture
In most adults, the spinal cord terminates at what vertebrae?
L1
Which is the best diagnostic test of nonpenetrating renal injuries?
A. KUB
B. IVP
C. CT
D. Laparoscopy
C. CT
Which arterial blood gas finding is most suggestive of acute respiratory failure?
A. PCO2= 50, PO2= 80
B. PCO2 =40, PO2=60
C. PCO2=60, PO2= 50
D. PCO2= 30, PO2=70
C. PCO2=60, PO2= 50
Trio of hypertension, bradycardia and tachypnea
Cushing’s Triad
During neck trauma, which cervical disc is most likely to herniate?Mark one answer:
A. C1-C2
B. C3-C4
C. C5-C6
D. C6-C7
D. C6-C7
Which of the following patients with head trauma does not require admission?
A. An individual with alcohol intoxication
B. An individual with a Glasgow coma score < 9
C. An individual with the presence of rhinorrhea
D. An individual who cannot sleep
D. An individual who cannot sleep
What is the most appropriate study for a patient who suffered a fall and presents with acute cervical radiculopathy?
A. Cervical CT
B. Cervical MRI
C. Lateral C-spine radiograph
D. Myelogram
B. Cervical MRI
What is the most common traumatic intracranial mass lesion?
A. Epidural hematoma
B. Gliocytoma
C. Subdural hematoma
D. Subarachnoid hemorrhage
C. Subdural hematoma
To prevent a surgical infection when is the best time to administer an antibiotic?
A. 2-24 hrs before surgery
B. 1 hr before surgery
C. After the incision is made
D. During the procedure
B. 1 hr before surgery
In which situation should a femoral traction splint NOT be used?
A. Hip dislocation
B. Femur fracture
C. Ankle fracture
D. Tibia fracture
A. Hip dislocation
Minimal score on the Glasgow coma scale
3
A stab wound at the left 5th intercostal space, 8 cm from the midline would most likely damage which of the following?
A. Spleen
B. Apex of the heart
C. Left lung
D. Left kidney
B. Apex of heart
A trauma patient is rapidly intubated and capnograph is hooked up to the outflow line. After five breaths the capnography tracings falls off. What is the next step in the management?
A. Increased FIO2
B. Hyperventilate patient
C. Immediately remove the endotracheal tube and reintubate
D. Add CO2 to the system
C. Immediately remove the endotracheal tube and reintubate
A 28-year-old male was involved in a motor vehicle accident. He is stable. When he is asked to sit up, the umbilicus moves up toward the neck area. What type of injury can this indicate?
A. Rectus hematoma
B. Diastasis recti
C. T6-T10 spinal cord injury
D. Muscle spasms
C. T6-T10 spinal cord injury
Where would one attempt a second IV start if the first is unsuccessful?
A. In the same location as the first attempt
B. In a more proximal location
C. In a more distal location
D. None of the above
C. In a more distal location
Foot drop is caused by which of the following?
A. Common peroneal nerve lesion B. Superficial peroneal nerve lesion C. Sciatic nerve
D. Femoral nerve
A. Common peroneal nerve lesion
A 22-year-old man sustains a gunshot wound to the abdomen and presents with shock. He requires multiple units of packed red blood cells during resuscitation. Later he complains of numbness around his mouth. Physical exam reveals carpopedal spasm and a positive Chvostek sign. An electrocardiogram demonstrates a prolonged QT interval. Which of the following is the most appropriate treatment?
A. IV bicarbonate
B. IV furosemide
C. IV calcium
D. IV insulin
C. IV calcium
Symptoms associated with spinal shock
-Flaccidity
-Loss of anal sphincter tone or fecal incontinence
-Priapism
A patient injures his left arm and is found to have a transected nerve. Which is true about this injury?
A. Nerves tend to recover and grow at a rate of 1 mm/day
B. The growing ends of the nerve can be located by EMG studies
C. All cut nerves should be immediately resutured
D. The neuromuscular junction end plates start to degenerate 2-3 weeks after the nerve is transected
A. Nerves tend to recover and grow at a rate of 1 mm/day
Causes of heme-positive urine
Ingestion of blackberries, beets
or phenolphthalein
Which of the following patients is most likely going to have a difficult intubation?
A. A patient with a previous tracheostomy
B. A patient with COPD
C. An obese patient
D. A patient with a huge goiter
D. A patient with a huge goiter
37-year-old man is struck on the side of the head but is conscious and talkative after the injury. No evidence of skull fracture. Several days later, he becomes increasingly lethargic, somewhat confused, and unable to move his right side. Which type of event has most likely occurred?
A. Subdural hematoma
B. Epidural hematoma
C. Carotid dissection
D. Brain contusion
A. Subdural hematoma
An investigational drug is being tried on health volunteers for its safety and pharmacokinetic properties. Which of the following stages in the drug development process does this scenario most closely describe?
A. Phase I
B. Phase II
C. Phase III
D. Phase IV
A. Phase I
What intravenous fluid is to be given with blood products?
A. Normal saline
B. Ringers lactate
C. 5% dextrose in water
D. Half normal saline with 20 mEq/L of KCl
A. Normal saline
Increases ICP after head trauma
Meningitis
Intracerebral bleed
Cerebral edema
Neurogenic pulmonary edema
Treatment
-Oxygenation
-Reduce ICP
-High PO2
A female is transported to the emergency department after a motor vehicle accident with trauma to the left leg and back. Vital signs show temperature=37.1ºC, BP= 125/75 mm Hg, HR= 94, R=20. GCS is 15. There is paraplegia, T12 sensory level, and decreased rectal tone. Hemoglobin is normal and stable at 1 hour. Which of the following should be done to assess for intraperitoneal bleeding?
A. Diagnostic peritoneal lavage
B. CT of the abdomen
C. Abdominal ultrasound
D. Flat plate of the abdomen
C. Abdominal ultrasound
True statement regarding head trauma in elderly
A larger subdural space in the skull requires more blood accumulation for brain compression, which often will delay presentation of symtoms
What can cause unintentional airway closure in a mechanically ventilated pediatric patient?
A. The Sellick maneuver
B. CPR
C. Hyperextension of the neck
D. None of the above
C. Hyperextension of the neck
Blunt trauma to abdomen
-Result in rupture of hollow viscus
-Can cause hematoma in the duodenum
-May cause stress ulcers
Which of the following is the best indicator of adequate shock resuscitation?
A. Blood pressure
B. Serum bicarbonate
C. Skin capillary refill
D. Urine output
D. Urine output
Which of the following statements is true regarding emergent pericardiocentesis?
A. Complication rate for blind approach is 50 percent
B. Echocardiogram is the procedure of choice
C. Subxyphoid approach increases risk of injury to the heart
D. Liver laceration is not a potential complication
B. Echocardiogram is the procedure of choice
Following a minor motor vehicle accident, a patient is experiencing pain and stiffness in her neck. Upon physical exam, she is able to rotate her neck greater than 55 degrees and denies paresthesias in the extremities. Which of the following is the next best step for this patient?
A. Exercise therapy
B. NSAIDs and rest
C. Neck x-rays
D. Narcotics
B. NSAIDs and rest
Which of the following is the most reliable predictor of poor outcome for drowning victims?
A. Submersion time more than 10 minutes
B. Glasgow coma scale less than 10
C. Lack of spontaneous cardiac rhythm for 15 minutes
D. Need for CPR at the scene
A. Submersion time more than 10 minutes
A patient admitted with mild hypothermia is at risk to develop:
A. Atrial fibrillation
B. Ventricular tachycardia
C. Heart failure
D. Loss of their extremity
A. Atrial fibrillation
Which is a sign of increasing intracranial pressure (ICP)?
A. Barotrauma reflex
B. Babinski reflex
C. Cushing reflex
None of the above
C. Cushing reflex
Clinical presentation of cardiogenic shock
-Hypotension
-Clammy skin
-Tachycardia
-Confusion
A patient is involved in a MVA and suffers multiorgan trauma. He is brought to the ER by EMS and found to be hypotensive with bradycardia and his abdomen is not distended. He is disoriented and confused. He has a GCS of 9; his legs are warm and the pulses thready. His CVP is 9, his HR is 42, and his BP is 80/40. What is the most likely cause of his shock state?
A. Closed head injury
B. Ongoing intra-abdominal hemorrhage
C. Pneumothorax
D. Neurogenic shock
D. Neurogenic shock
Which component of the Glasgow coma scale is most predictive of brain injury severity?
A. Eye component
B. Motor component
C. Verbal component
D. None of the above
B. Motor component
What is the best test to diagnose a pneumothorax?
A. Chest x-ray
B. CT
C. Ultrasound
D. Clinical
A. Chest x-ray
A patient is involved in a motor vehicle accident. He is brought into the ER and found to have a broken femur. His blood work reveals an hemoglobin of eight and an Hct of 28. It is decided to transfuse him with three units of blood. Soon after the blood is started, he develops a fever and becomes hypotensive. In a patient suspected of having a hemolytic transfusion reaction, one should do which of the following?A
A. Inserting a foley catheter
B. Fluid restriction
C. 0.1N HCL to reverse the alkalosis D. Fluids and mannitol
D. Fluids and mannitol
Concurrent injuries occur in which percentage of thoracic spine injuries?
A. 6%
B. 10%
C. 21%
D. 30%
B. 10%
Head trauma in children
-Brain doubles in size in first 6 months of life and achieves 80% of adult size at 2 years of age
-Subarachnoid space is smaller and offers less protection to the brain because there is less buoyancy and momentum is more likely to cause parenchymal structural damage
-Cerebral blood flow increases to nearly twice adult levels by age 5, then decreases, placing children at greater risk of cerebral hypoxia and edema
-Children have a better outcome than adults who suffer brain injuries
An adult with a widened mediastinum might have which of the following?
Aortic dissection
Signs and symptoms of cardiac tamponade may be listed as:
A. Virchow’s Triad
B. Brudzinski’s signs
C. Phalen’s signs
D. Beck’s Triad
D. Beck’s Triad – hypotension, muffled heart sounds, JVD
Pulsus parodoxus: larger than normal drop of SBP during inspiration
A patient with their neck flexed would have which vertebrae as most prominent?
A. C5
B. C6
C. C7
D. T1
C. C7
What is the most common reason for the chest not to rise with each breath during CPR?
A. Air is being delivered to the stomach
B. The breaths are being given at too rapidly
C. The airway is not clear
D. The trachea has collapsed
C. The airway is not clear
Which is the preferred site for arterial sampling?
A. Carotid artery
B. Ulnar artery
C. Tibial artery
D. Radial artery
D. Radial artery
Neuromuscular blocking agent works by depolarization
Succinylcholine
Which of the following is of no benefit for a patient who has just aspirated during induction of anesthesia?
A. Nasogastric tube placement and suction
B. Bronchoscopy
C. Corticosteroids
D. Hydration
C. Corticosteroids
A healthy 24-year-old is involved in a motor vehicle accident. He loses consciousness but regains it within a few hours and appears normal to friends. He later presents to the emergency room very lethargic, weak, and with a dilated pupil on the left side. The patient most likely has which of the following conditions?
A. Acute subdural hematoma
B. Subarachnoid hemorrhage
C. Acute epidural hematoma
D. Intra-cerebral hemorrhage
C. Acute epidural hematoma
What is the MOST sensitive test used to make a diagnosis of skull fracture?
A. Physical exam
B. Head CT
C. Skull radiographs
D. MRI
B. Head CT
The most common complication after nasotracheal intubation is:
A. Epistaxis
B. Nasal congestion
C. Infection
D. Aspiration
A. Epistaxis
True about depressed skull fractures
Any bone fragment displaced > 1 cm inward should be elevated surgically
During CPR, the highest amount of blood flow is observed with which technique?
High impulse CPR at 100-120 compressions per min
What is the main bleeding source in a subdural hematoma?
A. Capillary
B. Venous
C. Arterial
D. Mix type
B. Venous
Central venous pressure is reflective of:
Pressure of blood returning to the heart
Why does the ACLS protocol recommend epinephrine?
A. Increases muscular blood flow
B. Dilates the bronchioles
C. Enhances myocardial contractility D. Raises the systolic blood pressure
C. Enhances myocardial contractility
What occurs in patients developing a central herniation of the brain?
A. One sided paralysis
B. Pupillary constriction
C. Bilateral deterioration of functioning
D. Lower extremity paralysis
C. Bilateral deterioration of functioning
Blood containing HIV that is spilled on the floor can be disinfected with which of the following?
A. Benzene
B. Sodium hypochlorite
C. Iodine
D. Penicillin
B. Sodium hypochlorite
What is the most likely place for an over advanced endotracheal (ET) tube to enter?
A. Stomach
B. Right mainstem bronchus
C. Soft palate
D. Left mainstem bronchus
B. Right mainstem bronchus
For flail chest to occur…
3 or more anterior and posterior rib fractures need to be present
In comparison to the vocal cords, where is the laryngeal mask airway usually placed?
A. Superior
B. Inferior
C. Adjacent
D. Flush
A. Superior
A patient is involved in a MVA. He suffers a left femur fracture with head trauma. He is resuscitated at the scene and stabilized. Upon transfer to the ER, his blood pressure gradually decreases and then suddenly drops to 60/40. He has a splint on the left leg. What is the most likely cause of his decreased blood pressure?
A. Head trauma
B. Abdominal organ rupture
C. Rib fracture
D. Cardiac contusion
B. Abdominal organ rupture
In a patient with head trauma, what indicates rising intracranial pressure (ICP)?
Pupillary dilation
Wide pulse pressure
Rising BP
In which of the following clinical contexts is an urgent, post-traumatic head CT NOT necessary?
A. Individual with seizures
B. Individual with a progressive headache
C. Individual with an unreliable history
D. Individual with a Glasgow coma scale score of 15
D. Individual with a Glasgow coma scale score of 15
Which of the following is CORRECT about visceral pain?
A. Always superficial
B. Difficulty to localize
C. Only seen in peritonitis
D. Is rarely referred
B. Difficulty to localize
Emergency decompression of the brain with a subdural hematoma should be evacuated if there is a midline shift of what amount?
A. 1 mm
B. 2 mm
C. 5 mm
D. 10 mm
C. 5 mm
To relieve a right tension pneumothorax, where should the needle should be placed?
A. 4th intercostal space left of the mediastinum
B. 2nd intercostal space left of the mediastinum
C. 4th intercostal space right of the mediastinum
D. 2nd intercostal space right of the mediastinum
D. 2nd intercostal space right of the mediastinum
A patient has been in a major MVA and is comatose. He has a high level of alcohol and is hypothermic. Which of the following test can stand alone in certifying the patient as brain dead?
A. Apnea test
B. Absence of oculocephalic and oculovestibular reflexes
C. Absence of blood flow on cerebral angiogram after warming
D. EEG
C. Absence of blood flow on cerebral angiogram after warming
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:
Select one:
a.
reexamine the chest
b.
perform an aortogram
c.
obtain a CT scan of the chest
d.
obtain arterial blood gas analyses
e.
perform transesophageal echocardiography
A) Reexamine the chest
A construction worker falls two stories from a building and sustains bilateral calcaneal fractures. In the emergency department, he is alert, vital signs are normal, and he is complaining of severe pain in both heels and his lower back. Lower extremity pulses are strong and there is no other deformity. The suspected diagnosis is most likely to be confirmed by:
Select one:
a.
angiography
b.
compartment pressures
c.
retrograde urethrogram
d.
Doppler ultrasound studies
e.
complete spine x-ray series
e) Complete spine x-ray series
Which of the following is true regarding the initial resuscitation of a trauma patient?
Select one:
a.
A patient that presents with a torso gunshot wound and is hypotensive should receive crystalloid fluid resuscitation until the blood pressure is normal
b.
Evidence of improved perfusion after fluid resuscitation could include improvement in Glasgow coma scale score on reevaluation
c.
Massive transfusion is defined as transfusion of more than >10 of packed red blood cells and plasma in 24 hours
d.
When tranexamic acid is administered by pre-hospital providers a second dose is required within 24 hours
e.
Fluid resuscitation is far more important than bleeding control in trauma patients
b.
Evidence of improved perfusion after fluid resuscitation could include improvement in Glasgow coma scale score on reevaluation
In managing a patient with a severe traumatic brain injury, the most important initial step is to:
Select one:
a.
Secure the airway
b.
obtain a c-spine film
c.
support the circulation
d.
control scalp hemorrhage
e.
determine the GCS score
Feedback
Your answer is corr
a.
Secure the airway
A previously healthy, 70-kg (154-pound) man suffers an estimated acute blood loss of 2 liters.
Which one of the following statements applies to this patient?
Select one:
a.
His pulse pressure will be widened.
b.
His urinary output will be at the lower limits of normal.
c.
He will have tachycardia, but no change in his systolic blood pressure.
d.
An ABG would demonstrate a base deficit between -6 and -10 mEq/L
e.
His systolic blood pressure will be maintained with an elevated diastolic pressure.
d.
An ABG would demonstrate a base deficit between -6 and -10 mEq/L
The physiologic hypervolemia of pregnancy has clinical significance in the management of the severely injured, gravid woman by:
Select one:
a.
reducing the need for blood transfusion
b.
resulting in an elevated hematocrit
c.
complicating the management of closed head injury
d.
reducing the volume of crystalloid required for resuscitation
e.
increasing the volume of blood loss to produce maternal hypotension
e.
increasing the volume of blood loss to produce maternal hypotension
The best assessment of fluid resuscitation of the adult burn patient is:
Select one:
a.
Urine output of 0.5 mL/kg/hr
b.
normalization of blood pressure
c.
normalization of the heart rate
d.
measuring a normal central venous pressure
e.
providing 4 mL/kg/percent body burn/24 hours of crystalloid fluid
a.
Urine output of 0.5 mL/kg/hr
The diagnosis of shock must include:
Select one:
a.
hypoxemia
b.
acidosis
c.
hypotension
d.
increased vascular resistance
e.
evidence of inadequate organ perfusion
e.
evidence of inadequate organ perfusion
A 7-year-old boy is brought to the emergency department by his parents several minutes after he fell through a window. He is bleeding profusely from a 6-cm wound of his medial right thigh. Immediate management of the wound should consist of:
Select one:
a.
application of a tourniquet
b.
direct pressure on the wound
c.
packing the wound with gauze
d.
direct pressure on the femoral artery at the groin
e.
debridement of devitalized tissue
b.
direct pressure on the wound
For the patient with severe traumatic brain injury, profound hypocarbia should be avoided to prevent:
Select one:
a.
respiratory acidosis
b.
metabolic acidosis
c.
cerebral vasoconstriction with diminished perfusion
d.
neurogenic pulmonary edema
e.
shift of the oxyhemoglobin dissociation curve
c.
cerebral vasoconstriction with diminished perfusion
After being involved in a motor vehicle crash, a 25-year-old man is brought to a hospital that has surgery capabilities available.. Computed tomography of the chest and abdomen shows an aortic injury and splenic laceration with free abdominal fluid. His blood pressure falls to 70 mm Hg after CT. The next step is:
Select one:
a.
obtain contrast angiography
b.
transfer to a higher level trauma center
c.
perform an exploratory laparotomy
d.
infuse additional crystalloid fluids
e.
Obtain transesophageal echocardiography
c.
perform an exploratory laparotomy
Which one of the following statements regarding abdominal trauma in the pregnant patient is TRUE?
Select one:
a.
The fetus is in jeopardy only with major maternal abdominal trauma.
b.
Leakage of amniotic fluid is an indication for hospital admission.
c.
Indications for peritoneal lavage are different from those in the nonpregnant patient.
d.
With penetrating trauma, injury to the mother’s abdominal hollow viscus is more common in late than in early pregnancy.
e.
The secondary survey follows a different pattern from that of the nonpregnant patient.
b.
Leakage of amniotic fluid is an indication for hospital admission.
The first maneuver to improve oxygenation after chest injury is to:
Select one:
a.
intubate the patient
b.
assess arterial blood gases
c.
administer supplemental oxygen
d.
ascertain the need for a chest tube
e.
obtain a chest x-ray
c.
administer supplemental oxygen
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:
Select one:
a: 2
b: 4
c: 6
d: 9
e: 12
d: 9
Which one of the following findings in an adult is most likely to require immediate management during the primary survey?
Select one:
a.
distended abdomen
b.
Glasgow Coma Scale score of 11
c.
temperature of 36.5°C (97.8°F)
d.
deformity of the right thigh
e.
respiratory rate of 40 breaths per minute
e.
respiratory rate of 40 breaths per minute
A 20-year-old woman that is 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:
Select one:
a.
perform tracheal intubation
b.
insert an oropharyngeal airway
c.
perform needle or finger decompression of the right chest
d.
manually displace the gravid uterus to the left side of the abdomen
e.
initiate 2, large-caliber peripheral IV lines and crystalloid infusion
c.
perform needle or finger decompression of the right chest
An important, immediate step in the management of an open pneumothorax is:
Select one:
a.
endotracheal intubation
b.
operation to close the wound
c.
placing a chest tube through the chest wound
d.
placement of an occlusive dressing over the wound secured on three sides
e.
initiation of 2, large-caliber IVs and infusing crystalloid solution
d.
placement of an occlusive dressing over the wound secured on three sides
Which of the following is a contraindication for tetanus toxoid administration?
Select one:
a.
history of neurological reaction or severe hypersensitivity to the product
b.
Local side effects
c.
muscular spasms
d.
pregnancy
e.
all of the above
a.
history of neurological reaction or severe hypersensitivity to the product
A 56-year-old man is thrown violently against the steering wheel of his truck during a motor vehicle crash. On arrival to 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?
Select one:
a.
tachycardia
b.
pulse volume
c.
breath sounds
d.
pulse pressure
e.
jugular venous pressure
c.
breath sounds
Bronchial intubation of the right or left mainstem bronchus can easily occur during infant endotracheal intubation because:
Select one:
a.
The trachea is relatively short.
b.
The distance from the lips to the larynx is relatively short.
c.
The use of cuffed endotracheal tubes eliminates this issue.
d.
The mainstem bronchi are less angulated in their relation to the trachea.
e.
So little friction exists between the endotracheal tube and the wall of the trachea.
a.
The trachea is relatively short.
A 23-year-old man sustains 4 stab wounds to the upper right chest during an altercation and is brought by ambulance to a hospital that has full surgical capabilities. His wounds are all above the nipple. He is endotracheally intubated, closed tube thoracostomy is performed, fluid resuscitation is initiated through 2 large-caliber IVs. FAST exam does not reveal intraabdominal injuries. His blood pressure now is 60/0 mm Hg, heart rate is 160 beats per minute, and respiratory rate is 14 breaths per minute (ventilated with 100% O2). 1500 mL of blood has drained from the right chest. The most appropriate next step in managing this patient is to
Select one:
a.
perform diagnostic peritoneal lavage
b.
obtain a CT of the chest
c.
perform an angiography
d.
urgently transfer the patient to the operating room
e.
immediately transfer the patient to a trauma center
d.
urgently transfer the patient to the operating room
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
Select one:
a.
perform a surgical cricothyroidotomy
b.
attempt nasotracheal intubation
c.
ventilate him with a bag-mask device until c-spine injury can be excluded
d.
restrict cervical motion and attempt orotracheal intubation using 2 people
e.
ventilate the patient with a bag-mask device until his beard can be shaved for better mask fit
a.
perform a surgical cricothyroidotomy
b.
attempt nasotracheal intubation
c.
ventilate him with a bag-mask device until c-spine injury can be excluded
d.
restrict cervical motion and attempt orotracheal intubation using 2 people
e.
ventilate the patient with a bag-mask device until his beard can be shaved for better mask fit
d.
restrict cervical motion and attempt orotracheal intubation using 2 people
A patient is brought to the emergency department after a motor vehicle crash. He is conscious and there is no obvious external trauma. His blood pressure is 60/40 mm Hg and his heart rate is 70 beats per minute. His skin is warm. Which one of the following statements is TRUE?
Select one:
a.
Vasoactive medications have no role in this patient’s management.
b.
The hypotension should be managed with volume resuscitation alone.
c.
Flexion and extension views of the c-spine should be performed early.
d.
Abdominal visceral injuries can be excluded as a cause of hypotension.
e.
Flaccidity of the lower extremities and loss of deep tendon reflexes are expected.
e.
Flaccidity of the lower extremities and loss of deep tendon reflexes are expected
Which one of the following is the most effective method for initially treating frostbite?
Select one:
a.
moist heat
b.
early amputation
c.
padding and elevation
d.
vasodilators and heparin
e.
topical application of silver sulfadiazine
a.
moist heat
A 32-year-old man’s right leg is trapped beneath his overturned car for nearly 2 hours before he is extricated. On arrival to the emergency department, his right lower extremity is cool, mottled, insensate, and motionless. Despite normal vital signs, a pulse cannot be palpated below the right femoral artery and the muscles of the lower extremity are firm and hard. During the management of this patient, which of the following is most likely to improve the chances for limb salvage?
Select one:
a.
applying skeletal traction
b.
administering anticoagulant drugs
c.
administering thrombolytic therapy
d.
surgical consultation for right lower extremity fasciotomy
e.
transferring the patient to the trauma center 120 km away
d.
surgical consultation for right lower extremity fasciotomy
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:
Select one:
a.
request a CT scan
b.
insert a gastric tube
c.
suction the oropharynx
d.
obtain a lateral cervical spine x-ray
e.
ventilate the patient with a bag-mask
c.
suction the oropharynx
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:
Select one:
a.
clamp the chest tube
b.
cancel the patient’s transfer
c.
perform an emergency department thoracotomy
d.
repeat the primary survey and proceed with transfer
e.
delay the transfer until the referring doctor can contact a thoracic surgeon
d.
repeat the primary survey and proceed with transfer
A 64-year-old man involved in a high-speed car crash, is resuscitated initially in a small hospital without surgical capabilities. He has a closed head injury with a GCS score of 13. He has a widened mediastinum on chest x-ray with fractures of left ribs 2 through 4, but no pneumothorax. After initiating fluid resuscitation, his blood pressure is 110/74 mm Hg, heart rate is 100 beats per minute, and respiratory rate is 18 breaths per minute. He has gross hematuria and a pelvic fracture. You decide to transfer this patient to a facility capable of providing a higher level of care. The facility is 128 km (80 miles) away. Before transfer, you should first:
Select one:
a.
intubate the patient
b.
perform diagnostic peritoneal lavage or FAST
c.
insert a left chest tube
d.
call the receiving hospital and speak to the surgeon on call
e.
discuss the advisability of transfer with the patient’s family
d.
call the receiving hospital and speak to the surgeon on call
Hemorrhage of 20% of the patient’s blood volume is associated usually with:
Select one:
a.
oliguria
b.
confusion
c.
hypotension
d.
tachycardia
e.
blood transfusion requirement
d.
tachycardia
Which one of the following statements concerning intraosseous infusion is TRUE?
Select one:
a.
Only crystalloid solutions may be safely infused through the needle.
b.
Aspiration of bone marrow confirms appropriate positioning of the needle.
c.
Intraosseous infusion is the preferred route for volume resuscitation in small children.
d.
Intraosseous infusion may be utilized indefinitely.
e.
Swelling in the soft tissues around the intraosseous site is not a reason to discontinue infusion.
b.
Aspiration of bone marrow confirms appropriate positioning of the needle.
A young female sustains a severe head injury as the result of a motor vehicle crash. In the emergency department, her GCS is 6, 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:
Select one:
a.
avoid hypotension
b.
administer an osmotic diuretic
c.
aggressively treat systemic hypertension
d.
reduce metabolic requirements of the brain
e.
distinguish between intracranial hematoma and cerebral edema
a.
avoid hypotension
A 33-year-old female 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:
Select one:
a.
hemorrhagic shock
b.
cardiac tamponade
c.
massive hemothorax
d.
tension pneumothorax
e.
diaphragmatic rupture
b.
cardiac tamponade
A hemodynamically normal 10-year-old girl is hospitalized for observation after a Grade III (moderately severe) splenic injury has been confirmed by computed tomography (CT). Which of the following mandates prompt celiotomy (laparotomy)?
Select one:
a.
a serum amylase of 200
b.
a leukocyte count of 14,000
c.
evidence of retroperitoneal hematoma on CT scan
d.
development of peritonitis on physical exam
e.
a fall in the hemoglobin level from 12 g/dL to 8 g/dL over 24 hours
d.
development of peritonitis on physical exam
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?
Select one:
a.
Neurogenic shock is likely to develop
b.
Imaging of her complete spine is required prior to transfer to a trauma center
c.
Given the injury level knee extension would be expected
d.
log rolling using 4 people is a safe approach to limit spinal motion when moving her
e.
Presence of bulbocarvenous reflex indicates a better prognosis
d.
log rolling using 4 people is a safe approach to limit spinal motion when moving her
A trauma patient presents to your emergency department with inspiratory stridor and a suspected c- spine injury. Oxygen saturation is 88% on high-flow oxygen via a nonrebreathing mask. The most appropriate next step is to:
Select one:
a.
apply cervical traction
b.
perform immediate tracheostomy
c.
insert bilateral thoracostomy tubes
d.
maintain 100% oxygen and obtain immediate c-spine x-rays
e.
restrict cervical motion and establish a definitive airway
e.
restrict cervical motion and establish a definitive airway
When applying the Rule of Nines to infants:
Select one:
a.
It is not reliable.
b.
The body is proportionally larger in infants than in adults.
c.
The head is proportionally larger in infants than in adults.
d.
The legs are proportionally larger in infants than in adults.
e.
The arms are proportionally larger in infants than in adults.
c.
The head is proportionally larger in infants than in adults.
A healthy young male is brought to the emergency department following a motor vehicle crash. His vital signs are a blood pressure of 84/60, pulse 123, GCS 10. The patient moans when his pelvis is palpated. After initiating fluid resuscitation, the next step in management is:
Select one:
a.
placement of a pelvic binder
b.
transfer to a trauma center
c.
pelvic x-ray
d.
insert urinary catheter
e.
repeat examination of pelvis
a.
placement of a pelvic binder
Which situation requires Rh immunoglobulin administration to an injured female?
Select one:
a.
negative pregnancy test, Rh negative, and has torso trauma
b.
positive pregnancy test, Rh positive, and has torso trauma
c.
positive pregnancy test, Rh negative, and has torso trauma
d.
positive pregnancy test, Rh positive, and has an isolated wrist fracture
e.
positive pregnancy test, Rh negative, and has an isolated wrist fracture
c.
positive pregnancy test, Rh negative, and has torso trauma
A 22-year-old female athlete is stabbed in her left chest at the third interspace in the anterior axillary line. On admission to the ED and 15 minutes after the incident, she is awake and alert. Her heart rate is 100 beats per minute, blood pressure is 80/60 mm Hg, and respiratory rate is 20 breaths per minute. A chest x-ray reveals a large left hemothorax. A left chest tube is placed with an immediate return of 1600 mL of blood. The next management step for this patient is to:
Select one:
a.
perform a thoracoscopy
b.
perform an arch aortogram
c.
insert a second left chest tube
d.
prepare for an exploratory thoracotomy
e.
perform a chest CT
d.
prepare for an exploratory thoracotomy
A 6-year-old boy walking across the street is struck by the front bumper of a sports utility vehicle traveling at 32 kph (20 mph). Which one of the following statements is TRUE about this patient?
Select one:
a.
A flail chest is probable.
b.
A symptomatic blunt cardiac injury is expected.
c.
A pulmonary contusion may be present in the absence of rib fractures.
d.
Transection of the thoracic aorta is more likely than in an adult patient.
e.
Rib fractures are commonly found in children with this mechanism of injury.
c.
A pulmonary contusion may be present in the absence of rib fractures
What is the primary goal of treating TBI? How is this done?
After managing ABCDEs of TBI what MUST be identified if present? How is this done?
Which brain lobes do the following hold:
1. anterior fossa:
2. middle fossa:
3. posterior fossa:
What are the 3 layers of the meninges?
dura mater, arachnoid mater, pia mater
What does the dura mater adhere firmly to?
the skull. it is tough and fibrous
dura mater.
these sinuses provide major venous drainage from the brain.
What are the arteries that lie between the skull and the dura mater (epidural space)?
What is the most commonly injured meningeal artery and where is it located?
middle meningeal artery.
Located over the temporal fossa
T/F: the arachnoid mater is fused to the dura mater?
FALSE: not attached. This produces a potential space for a subdural hematoma
In a subdural hematoma, what is the cause?
injury to bridging veins that extend from brain surface to the sinuses within the dura.
_______ fills the space between the arachnoid and pia mater?
CSF. this cushions the brain and spinal cord.
The ____ and _____ contain the reticular activating system which is responsible for ____.
midbrain and upper pons
state of alertness
What important function resides in the medulla?
What divides the brain into supratentorial and infratentorial compartments?
tentorium cerebelli. (tent over cerebellum)
What is the physiology behind a blown pupil?
What is the tentorial notch/hiatus
this is where the midbrain passes through into the infratentorial compartment.
what part of the brain most commonly herniates through the tentorial notch?
Uncus (medial part of temporal lobe)
does weakness occur on the same or opposite side of the uncal herniation?
a rigid, non expandable container.
What is the equation for CPP (cerebral perfusion pressure)?
in TBI, Every effort should be made to reduce ______, while normalizing ____, ___, and _____.
ICP
MAP, oxygenation, intravascular volume
What GCS ranges for the following classes:
1. Minor
2. Moderate
3. Severe
What nerve palsy may occur with basilar skull fracture?
A GCS of ___ is accepted definition of coma?
How do you assess a GCS of someone with asymmetric responses?
Use the best possible because this will be the best predictor of outcome
Basilar fractures of the skull usually require what type of imaging?
this requires CT with bone-window setting.
What are the typical clinical signs of basilar skull fractures?
hematoma. linear skull fracture increases likelihood of intracranial hematoma by about 400x
What mechanism is common with diffuse axonal injury and what is the likely outcome?
temporal
middle meningeal artery
What is the classic presentation of a epidural hematoma?
a lucid interval between time of injury and neurologic a deterioration.
What are more common brain injury: epidural or subdural?
Subdural hematoma occur from tear of _________.
bridging vessels of the cerebral cortex
20-30%
frontal or temporal
intracerebral hematoma.
What is the imaging protocol for a patient with cerebral contusion?
get CT at presentation. then get another within 24 hours to assess for coalesced hematoma.
What factors would require a CT in minor brain injury?
How long after discharge should patient with mild brain injury be observed by friend?
What type of brain injury requires serial GCS?
What imaging is done in all patient with moderate brain injury?
What factor of ABCDE must be monitored closely in moderate brain injury?
What should immediately follow the secondary survey in major/severe brain injury?
CT.
REMEMBER: CT should never delay patient transfer
When assessing ABCDE of severe brain injury, when does DPL or FAST come before neuro exam?
Spinal cord injury has what result in blood pressure?
hypotension. This may also occur in terminal brain injury with medullary failure
What needs to be cleared before Doll’s eye testing is conducted?
What tests should be performed before sedation?
What type of fluids should be used?
hypertonic (ringers lactate or normal saline). NO GLUCOSE.
What electrolyte abnormality is associated with brain edema and must be monitored?
What are the physiologic consequences of PaCO2 >45?
PaCO2 <30?
f PaCO2 >45 = vasodilation = inc ICP
PaCO2 <30 (hyperventilation) = constriction = ischemia
What is the preferred PaCO2 in brain injury?
If ICP is rapidly increasing, what can be done while preparing for craniotomy?
hyperventilation. NOTE: this must be monitored closely and is only done very short periods at a time
Does hypertonic saline lower ICP in hypovolemia?
Does mannitol lower ICP in hypovolemia?
After administration of mannitol what should be monitored closely?
ICP! mannitol has a substantial rebound effect on ICP
What is the role of muscle relaxants (vecuronium or succinylcholine) in seizures with TBI?
What meningeal tear would a CSF leakage of a head laceration indicate?
What is the treatment of any intracranial mass lesion?
Must be evacuated by neurosurgeon. transfer if not available.
What clinical signs are the criteria for brain death?
GCS of 3, nonreactive pupil, absent brainstem reflexes, no spontaneous ventilatory effort
Which vertebrae is most susceptible to injury?
Cervical.
NOTE: in peds this accounts for only 1% of vertebral injury
When a dislocation-fracture of the vertebrae occurs, almost always the result is _____.
T/F: the thoracolumbar junction is extremely strong and rarely incurs injury?
At what levels do the spinal cord begin and end?
begins at foramen magnum at terminal end of the medulla oblongata and end at L1
What function does the dorsal column have? What tests can be done to assess function?
What function does the spinothalamic tract have? what tests can be done to assess function?
pain and temperature to opposite side of body
TESTS: pinprick and light touch
What function does the corticospinal tract have? what tests can be done to assess function?
Motor power on same side of body
TESTS: voluntary muscle contract or involuntary response to pain
What type of gastric tube should be placed when cribiform plate fx or mid face fracture is present?
orogastric.
nasopharyngeal intrumentation is potentially dangerous
When fluids must be administered what is the best route, and which type of catheter is best?
What anatomical change is common in the third trimester of pregnancy?
widening of the symphasis pubis
What pulmonary complication is common with blunt trauma and PaCO2 <35?
All EXCEPT pulmonary contusion
What is the initial bolus for fluid resuscitation when a small child is in shock?
What are the chest tube blood volume output parameters that would require a thoracotomy?
How can one determine the appropriate tube depth for pediatric intubation?
ETT tube size x 3
Ex: 4.0 ETT would be properly positioned at 12 cm from the gums
For a patient who is not breathing what intervention is indicated?
What should be used when vocal chords cannot be visualized on direct laryngoscopy?
gum elastic bougie. in place when you feel clicks. can be inserted blindly beyond epiglottis
what is the most common life threatening injury in children?
What is the most common acid-base disturbance in the injury child and what is it caused by?
Respiratory acidosis caused by hypoventilation.
LMA, or intubating LMA, or needle cricothyroidotomy.
-needle-jet insufflation is an appropriate temporizing technique for oxygenation but does not provide adequate ventilation.
NOTE: surgical cric is RARELY indicated for infants an small children. usually it is an adoption when the cricothyroid membrane is easily palpable around the age of 12.
A local area of frost bite should be rewarmed with what temperature and in what waY?
40C (104F)
should be done in whirlpool. not dry heat.
What is the main utility of ECG during resuscitation?
detecting rhythm abnormalities
What does PaCO2 of 35-40 mmHg indicate in late pregnancy?
Other than maternal death, what is the leading cause of fetal death? Symptoms?
What type of monitoring should be initiated in fetus of gestation age >20 wks
What are the two extra precautions during primary survey of pregnant woman?
T/F? Diaphragmatic breathing in a patient who is unconscious is not a sign of C-Spine injury
FALSE. diaphragmatic breathing=c-spine injury
What is used to evaluate a suspected urethral injury? What is used to evaluate a bladder rupture?
retrograde urethrogram
cystogram
What are the abdominal structures that may not be detected on DPL?
duodenum, ascending/descending colon, rectum, biliary tract, and pancreas
What hold urine output be maintained at after a crush injury to prevent kidney injury?
Is operation ever indicated in first hour after injury of multiple injured patient?
yes. especially if class 3 or 4 hemorrhagic shock is present
What class of shock are there NO clinical signs of inadequate organ perfusion?
Class I. <14% blood volume loss. (<750mL)
Why do chest injuries have a high priority in the multiply injured person?
What is the physiology behind neurogenic shock?
What is another name for Central Venous Pressure? When is it elevated?
What would be expected on ABG abnormalities for pulmonary contusion?
t/f vomitus in the posterior oropharynx suggests esophageal intubation.
t/f: major head injury rarely causes shock by itself
What are the vital signs to be expected when ICP increases?
decreased respirations and HR, increased systolic and pulse pressure
Urethral injury should be suspected in the presence of what three things?
1. blood at the meatus
2. perineal ecchymosis
3. high riding or non-palpable prostate
What test is used to confirm the integrity of the urethra before a catheter is inserted?
What physical exam is essential before passing a urethral catheter
examine the rectum and perineum
What is the best guide for adequate fluid resuscitation in a burn patient?
For a patient bleed profusely from a wound not he medial thigh where should pressure be applied?
What is one characteristic shared by all SURVIVORS of traumatic aortic disruption?
What does x ray showing widened mediastinum and obliteration of the aortic knob suggest?
What is the sensitivity and specificity of CT in aortic disruption?
What three X-ray views are most important for a person with multiple trauma?
Pulse oximetry provides information about _____ and ____ but does not provide information about ____
1. O2 sat
2. peripheral perfusion
3. adequacy of ventilation
An 18-year-old man is brought to the hospital after smashing his motorcycle into a tree. He is conscious us and alert, but paralyzed in both arms and legs. His skin is pale and cold. He complains of thirst and difficulty in breathing. His airway is clear. His blood pressure is 60/40 and his pulse rate is 140 beats per minute. Breath sounds are full and equal bilaterally. He should be treated for what first?
What is the most important principle in the early management of someone with TBI and increasing ICP?
prepare for exploratory thoracotomy
What are the symptoms with anterior crod syndrome?
What are the symptoms of central cord syndrome?
What are the symptoms of Brown-Sequard syndrome?
What is the primary concern in flail chest?
pulmonary contusion resulting in hypoxia
prevention of hypo perfusion and hypoxia are most important for optimal outcome in _____.
T/F: bony injury in pediatrics is more common than in adults?
Compare the specificity and sensitivity of DPL and CT in blunt abdominal trauma.
DPL- high sens (98), low spec
CT – high sens (92-98), high spec (95)
A 23-year-old man is brought immediately to the ED from the hospitals parking lot where he was shot in the lower abdomen. Examination reveals a single bullet wound. He is breathing and has a thready pulse. However, he is unconsious and has no detectable blood pressure. Optimale immediate management is to:
A. Perform a FAST
B. Initiate infusion of packed red blood cells
C. Insert a nasogastric tube and urinary catheter
D. Transfer the patient to the operating room, while initiating fluid therapy
E. Initiate fluid therapy to return his blood pressure to normotensive
D. Transfer the patient to the operating room, while initiating fluid therapy
A 22 year old male present following a motorcycle crash. He complains of the inability to move his legs. His BP is 80/50, HR 70, RR 18 and GCS 15. Oxygen saturation is 99% on 21 nasal prongs. Chest x-ray, pelvic x-ray and FAST are normal. Extremities are normal. His management should be:
A: 1L of iv . crystalloid and two units of pRBCs
B. 1L of iv. crystalloid, mannitol and iv steroids
C. 1 unit of albumin and compression stockings
D. Vasopressors and laparotomy
E. 1 L of cystalloid and vasopressors if blood pressure does not respond
E. 1 L of cystalloid and vasopressors if blood pressure does not respond
Which of the following is MOST RELIABLE to confirm endotracheal intubation?
a. presence of breath sounds bilaterally
b. absence of borborygmi in the epigatrium on ascultation
c. presence of CO2 in exhaled air via capnography
d. appearance of fog in the endotracheal tube
e. chest xray with endotracheal tube tip appearing above the carina
e. chest xray with endotracheal tube tip appearing above the carina
A 6 month old infant, being held in her mothers arms, is ejected on impact from a vehicle that is struck head on by an oncoming car traveling at 64kph. The infant arrives in the ED with multiple facial injuries, is lethargic, and is in severe respiratoy distress. Respiratory support is not effective using a bag mask device, and her oxygen saturation is falling. Repeated attempts at orotracheal intubation are unsuccessful. the most appropriate procedure to perform next is:
A.Administer heliox and racemic epinephrine
B. Perform nasotracheal intubation
C.Perform surgical cricothyroidotomy
D.Repeat orotracheal intubation
E. Perform needle cricothyroidotomy with jet insufflation
E. Perform needle cricothyroidotomy with jet insufflation
A 28 year olf male is brought to the ED. He was involved in a fight, during which he was beaten with a wooden stick. His chest shows multiple severe bruises. His arway is clear, resp rate is 22, hear rate 126, and systolic blood pressure is 90 mmHG. Which of the following should be performed during the primary survey
a. glasgow coma
b. tetanus status
c. cervical spine xray
d. blood alcohol level
e. rectal exam
an 18yo male is brought to the emergency department after being dumped by a large wave while surfing. He landed head first on the firm beach sand. His vital signs are blood pressure 85/60 mmHg, heart rate 60, and respiratory rate 18; he is unable to move his lower extremities. He appears calm and asks if he will ever walk again. The most appropriate next step is to:
a. reassure patient that he will walk again
b. proceed to a more detailed neuro exam
c. obtain c spin xrays
d. begin infusion of vasopressors
e. begin bolus of warm IV crystalloid
e. begin bolus of warm IV crystalloid
Whic one of the following statements is true regarding access in pediatric resuscitation?
a. intraosseous access should be considered only after 5 percutaneous attempts
b. cutdown at teh ankle is the preferred initial access technique
c. internal jugular cannulation is the next preferred option when percutaneous venous access fails
d. intraosseous cannulation should be the first choice
e. blood transfusion can be delivered through intraosseous access
e. blood transfusion can be delivered through intraosseous access
a 35 year old female ustains multiple linjuries in a MVA and is transported to a small hospital. She has a GCS of V2E2M2. Spinal motion restrictions are in place. ET is performed, IV and wamred fluids are administered. She remains hemodynamically normal, and preparations are made to transfer to another facility for definitive neuro care. Which of the following tests or treatment should occur before transport?
a. ct abdomen and chest
b. chest xray
c. lateral cervical spine xray
d. admin of methlyprednisolone
e. transfusion of 2 units packed RBCs
A 22 year old male sustains a shotgun wound to the left shoulder and chest at close range. His BP is 80/40mmHg and his HR is 130bpm. Fluid resusciation is initiated, his BP increases to 122/84, and HR decreases to 100bpm. He is tachypneic with RR of 28. On physical examination, his breath sounds are decreased at the left upper chest with dullness on percussion. A tube thoracostomy is inserted in the fifth intercostal space with the return of 200ml of blood and no air leak. The most appropriate next step is to:
a. measure blood pressure again
b. begin transfuse O negative blood
c. wait until the chest xray is completed
d. obtain a CT scan of the chest and abdomen
e. repeat the physical exam of the chest
e. repeat the physical exam of the chest
A 22 yo male is brought to the ED after being assaulted in a bar. On intial exam, his vital signs are normal and his Glasgow Coma scale is V5E4M6. A definite indication for a head CT is
a. prescence of hemotympanum
b. complains of headache
c. prescense of 10cm scapl laceration
d. prescence of mandibular fracture
e. history of assault
a 23 yo construction worker is brought to the ED after falling more than 9 meters from scaffolding. He is reported to have landed on his feet and then been unable to bear weight. His vital signs are heart 140, blood pressure 96/60 mmHg, resp rate 36. He is complaining of lower abdbominal and lower limb pain, and has obvious deformity of both lower legs with bilateral open tibial fractures. WHich one of the following statements concerning this patient is true?
a. pelvic injury can be ruled out, based on the MOI
b. blood loss from the lower limbs is the most likely cause of his tachycardia
c. xrays of the patient chest and pevlic are important adjuncts in the inital assessment
d. spinal cord injury is the most likely cause of hypotension
e. aortic injury is likely
c. xrays of the patient chest and pevlic are important adjuncts in the inital assessment
25 yo female in the third trimester of preganacy is brought to the ED following a high speed MVA. She is conscious, and her vital signs are RR 16, HR 120, BP 70/50. The laboratory results show a PaCO2 of 50mmHg/5.3kPa (normal range 35-45). Which one of the following statments concerning this patient is true?
a. fetal assessment should take priority
b. logrolling the patient to the right will decompress the vena cava
c. Rh immuno therapy sshould be immediately adminstered
d. normal PaCO2 is concerning for impending RR
e. vasopressors should be given to the patient
d. normal PaCO2 is concerning for impending RR
a 30 year old male is stabbed in the right chest. on arrival in the ED he is very short of breath. His heart rate is 120, and blood pressure is 80/50 mmHg. His neck veins are flat. On auscultation of the chest, there is diminished air entry on the right side and on percussion there is dullness posteriorly. These findings are most consistent with
a. tension pneumothorax
b. pericardial tamponade
c. hypovolemia from liver injury
d. massive hemothorax
e. spinal cord injury
which one of the following is true regarding burns?
a. alkali chemica burns should be neutralized with a dilute acid rather than irrigated with warm water
b. patients who sustain thermal burns are at a lower risk for hypothermia
c. initial treatment of partial thickness thermal burns should include antibiotic cream and cold compress
d. an electrical burn with only a small external injury associated with a clenched hand indicates deep ST injury
e. The parkland formula should be used to determine adequacy of resuscitation
A 15 year old is brought to the ED after being involved in a MVA. He was intubated by emergency medical personnal with subsequent bilateral breath sounds per their report. Upon arrival to the ED the patients O2 saat is 92%, heart 96, and blood pressure 150/85. Breath sounds are decreased in the left side of the thorax. The next step is
a. immediate needle cricothyroidotomy
b. immediate needle thoracentesis
c. chest tube insertion
d. reassess the position of the endotracheal tube
e. obtain a chest CT
d. reassess the position of the endotracheal tube
Which one of the following statements is true regrading patients with severe traumatic brain injuries
a. Dextrose is the IV fluid of choice
b. prescence of hypoxia and hypotension significantly increase the risk of mortality
c. Benzodiazepines are the medications of choice for sedation
d. In a unresponsive patient, mannitol should be the first line therapy to treat increased ICP
b. prescence of hypoxia and hypotension significantly increase the risk of mortality
Which of the following patient require imaging…..?
a. 28 yo who fell from a 3 meter balcony and sustained a fracture. The patient does not have spine pain, motor or sensory deficits and has an otherwise normal PE.
b. 40 yo patient who sustained a severe closed head injury and has a GCS of 8 V2M3E3
c. 6month old who fell from the couch to the carpted floor and has a GCS of 15
d. 10 yo who was hit in the head with a bat and has a right frontal hematoma without history of LOC and does not have neck pain or tenderness
e. 30 yp man who after a MVA, briefly LOC but was ambulating at teh scene and does not have neck or back pain
b. 40 yo patient who sustained a severe closed head injury and has a GCS of 8 V2M3E3
A 30 year old male is brought toe the hospital after falling 6 meters. Inspection reveals an obvious flail chest on the right. Breath sounds on the right are slightly increased. Twelve hours later, the patient is in severe respiratory distress. Arterial blood gas obtained while the patient recieves oxygen by face mask are: pH of 7,47, PaO2 of 45mmHg (6Kpa), PaCO2 of 28mmHg (3,7 Kpa). The component of injury that most likely responsible for abnormalities in this patients blood gas is:
a. pain
b. hypovolemia
c. PTX
d. pulmonary contusion
e. chest wall instability
A 82 year old male falls down five stairs and presents to the ED. Which of the following statements IS NOT CORRECT:
A. He is more likely to have had a contracted circulatory volume prior to his injury
B. His risk of cervical spine injury is increased due to degeneration, stenosis and loss of disk compressibility
c. Internal hemorrhage will become symptomatic more quickly
d. His risk of occult fractures is increased
e. His risk of bleeding may be increased
c. Internal hemorrhage will become symptomatic more quickly
A 14 year old female is brought to the ED after falling from a horse. Cervical spinal motion is restricted wit ha hard collar and cervical blocks and she is immobilized on a long spine board. Which of the following IS TRUE REGARDING Cervical spine x-ray:
A. More than 20% of these patients will have cervical spine injury
B. Cervical spine injury is excluded if no abnormalities are found on lateral cervical spine xray
C. Are not needed if she is awake, alert, neurologically normal, and has no neck pain or midline tenderness
D. Should be performed before adressing potential breating or circulatory problems
E. She should reamin on teh long spine board until imaging excluded injuries
A patient is brought to the hospital with no surgical capabilities following head trauma. He is intubated due to compromised mental status. His BP on arrival is 155/82, heart rate 100. Shortly after arrival his BP is found to be 220/120 with a heart rate of 53. Which of the following is TRUE regarding this patient’s condition?
a. The bradycardia is a sign of neurogenic shock
b. The change in BP and HR may indicate imminent herniations from critically high ICP
c. The change in BP is reflective of worsening pre existing HTN
d. The change in vital signs should prompt burr hole drainage of potential subdural hematoms
b. The change in BP and HR may indicate imminent herniations from critically high ICP
b. rapid rewarming of body part
Which of the following statements is TRUE regarding a pregnant patient who presents following blunt trauma?
a. fetal distress may be an early sign of maternal blood loss
b. a hemoglobin level of 10 indicates blood loss
c. cardiac output will be decreased due to decreased circulating plasma volume
d. wearing lap belt only is the best form of restraint due to the size of the gravid uterus
e. normal PaCO2 provides reassurance about the adequacy of the resp function
a. fetal distress may be an early sign of maternal blood loss
A 30 year old female is brought to the ED after being injured in a motor vehicle crash. Her initialt BP is 90/60mmHg, and her HR is 122bpm. She responds to rapid infusion of 1L crystalloid solution with a rise in her BP to 118/88 and decrease in her HR to 90bpm. Her pressure suddenly decreased to 96/66. The least likely cause of her hemodynamic change is:
A. Ongoing blood loss
B. Blunt cardiac injury
C. Traumatic brain injury
D. Inadequate resuscitation.
E. Tension pneumothorax
Limb threatening extremity injuries
a. require a tourniquet
b. are characterized by the presence of ischemic or crushed tissue
c. should be definitively managed by application of traction splint
d. are rarely present without an open wound
e. indicated a different order of priorities for the patient’s initial assessment and resuscitation
b. are characterized by the presence of ischemic or crushed tissue
A 29 year old female arrives in the ED after being involved in a motor vehicle crash. She is 30 weeks pregnant. She was restrained with a lap and shoulder belt, and an airbag deployed. Which one of the following statement best decribes the risk of injury?
A. Deployment of the airbag increased the risk of fetal loss
B. The risk of premature fetal delivery and death is reduced by the use of restraints
C. The use of seatbelts is associated with increased risk of maternal death.
D. The mechanism of injury suggest the need for emergency ceasarean section due to the risk of impending abruptio placentae
E. The deployment of the airbag increases the risk of maternal abdominal injury
B. The risk of premature fetal delivery and death is reduced by the use of restraints
a 28 year old man is brought in after a MVA. His airway is patent and breath sounds are equal. His GCS is E1V2M1. His BP is 146/82; HR is … . The decision is made to secure his airway. Which of the following is a definitive airway
a. LMA
b. oral airway
c. cuffed ET
d. LTA
e. needle cricothyroidotomy
A 70 year old suffers blunt chest trauma after being struck by a car. On presentation, his GCS is 15, BP is 145/90, HR is 72. RR is 24 and O2-sat on 5L is 91%. Chest x-ray demonstrates multiple right sided rib fractures. CT abdomen and pelvis is normal. ECG demonstrates normal sinus rythm with no conduction abnormalities. Management should include:
A. Placement of a 22Fr right sided chest tube
B. Serial troponins and cardiac monitoring
C. Monitoried i.v analgesia
D. Thoracic splinting, taping and immobilization
E. Bronchoscopy to exclude tracheobronchial injury
A 15 year old male present following a motorcycle crash. INitial examinations reveals normal vital signs. There is a large bruise over his epigastrium that extends to the left flank. He has no other apparent injuries. A CT-scan of the abdomen demonstrate a ruptured spleen surrounded by a large hematoma and fluid in the pelvis. The next step in the patients management is:
A. Splenic artery embolization
B. Pneumococcal vaccine
C. Urgent laparotomy
D. Surgical consult
E. Transfer to a pediatrician
30 year old male present with a stab wound to the abdomen. BP is 60/34, HR 130, RR 25 and GCS 13 E3V4M6. Neck veins are flat and chest examination is clear with bilateral breath sounds. Optimal resuscitation should include:
A. Transfusion of FFP and platelets
B. 500ml of hypertonic saline and transfusion of pRBCs
C. Resuscitation with crystalloid and pRBC until base excess is normal
D. Fluid resuscitation and angioembolization
E. Preparation for laparotomy while initiating fluid resuscitation
E. Preparation for laparotomy while initiating fluid resuscitation
Which of the following statement are true regarding crystalloid fluid resuscitation of a patient with penetrating torso trauma?
a. It can produce dilutional coagulopathy
b. It is the fluid of choice for the patient presenting in Class IV hemorrhagic shock
c. It should be infused until a normal BP is achieved
d. Hypotonic fluids are preferred
e. Crystalloid fluids are the only fluids that should be given through an intraosseous needle
a. It can produce dilutional coagulopathy
A 25 year old male is brought to the ED of a trauma center following a bar fight. He has altered consciousness, open his eyes on command, moans without forming discernible words, and localizes to painful stimuli. Which one of the following statements concerning this patient is true?
A. He requies immediate intubation to protect his airway
B. The GCS score suggests a severe traumatic brain injury
C. His level of consciousness can be attributed to alcohol
D. CT scanning is an important part of the neuro assessment
E. Hyperoxia should be avoided
D. CT scanning is an important part of the neuro assessment
Which one of the following statements regarding patients with genitourinary trauma is true?
a. Hematuria is present in all patients with significant genitourniary injury
b. injuries to the urethra are more common in females than in males
c. evaluation of injuries to the urethra always require a CT scan
d. blunt renal injuries should always have surgical intervention
e. hypotension can be caused by renal injury