 A 42 y.

o man, injure in MVC, suffers a closed head injury, multiple palpable left rib fractures, and
bilateral femur fractures. He is intubated oro-tacheally without difficulty. Initially, his ventilators are
easily assisted with a bag-valve device. It becomes more difficult to ventilate the patient over the
next 5 minutes, and his hemoglobin oxygen saturation level decrease from 98% to 89%. The most
appropriate next steps is to:
o Obtain CXR
o Decrease tidal volume
o Auscultate the patient’s chest *
o Increase rate of assisted ventilations
o Perform needle decompression of the left chest
 A 17 y.o helmeted motorcyclist is struck roadside by and automobile at an intersection. He is
unconscious at the scene with blood pressure 140/90 mmHg, heart rate 90 bpm, and respiratory
rate 22 bpm. His respirations are sonorous and deep. His CGS score is 6. Immobilization of entire
patient may include the use of all the following, EXCEPT:
o Air splints
o Bolstering devices
o A long spine board
o A scoop-style stretcher *
o A semi rigid cervical collar
 The driver of single car crash is orotracheally intubated in the field by prehospital personnel after
the identify a close head injury and determine that the patient is unstable to protect his airway. In
the emergency department, the patient demonstrates decorticate posturing bilaterally, he is being
ventilated with bag-valve device, but his breath sound are absent in the left hemithorax. His blood
pressure is 160/88 mmHg, heart rate is 70 bpm, and pulse oxymeter display a hemoglobin oxygen
saturation of 96%. The next step in assessing and managing this patient should be to
o Determine the arterial blood gases
o Obtain a lateral cervical spine x-ray
o Assess placement of the endotracheal tube *
o Perform needle decompression of the left chest
o Insert a thoracotomy tube in the left hemothorax
 An 8 y.o boy fall 4,5 meters (15 feet) from a tree and is brought to the emergency department by his
family. His vital signs are normal, but he complains of left upper quadran pain. An abdominal CT scan
reveals a moderately severe laceration of the spleen. The recieving institution does not have 24-
hour-a-day operating room capabilities. The most appropriate management of this patient would be
to
o Type and cross match the blood *
o Request consultation of pediatrician
o Transfer patient to a trauma center **
o Admit patient to the intensive care unit
o Prepare the patient for surgery the next day
 A 24 y.o. man sustains multiple fractured ribs bilaterally as a result of being crushed in a press at a
plywood factory. Examination in the emergency department reveals a flail segment of patient’s
thorax. Primary resuscitation includes high flow oxygen administration via a non-rebreathing mask,
and initiation of ringer’s lactate solution. The patient exhibits progressive confusion, cyanosis, and
tachypnea. Management at this time should consist of
o Intravenous sedation **
o External stabilization of chest wall
o Increasing the F102 in the inspired gas
o Intercostal nerve blocks for pain relief
o Endotracheal intubation and mechanical intubation *
 A crossable, lateral x-ray of cervical spine
o Must precede endotracheal intubation
o Exclude serious cervical spine injury
o Is an essential part of primary survey
o Is not necessary for unconscious patient with penetrating cervical injuries
o Is unacceptable unless 7 cervical vertebrae and the C7-T1 relationship are visualized *
 Regarding shock in the child, which of the following is FALSE?
o Vital signs are age-related
o Children have greater physiologic reserves than do adults *
o Tachycardia is the primary physiologic response to hypervolemia
o The absolute volume of blood loss required to produce shock is the same as in adults
o An initial fluid bolus for resuscitation should approximate 20 ml/Kg of Ringer’s lactate
 A 42 y.o. man is trapped from the waist down beneath his overturned tractor for several hours
before medical assistance arrives. He awakes and alert until just before arriving in the emergency
department. He is now unconscious and responds only to painful stimuli by moaning. His pupils are
3 mm in diameter and symmetrically reactive to light. Prehospital personnel indicate that they heve
not seen the patient move either his lover extremities. On examination in the emergency
department, no movement of his lower extremities is detected, even in response to painful stimuli.
The most likely cause for this finding is
o An epidural hematoma
o A pelvic fracture *
o Central cord syndrome
o Intracerebral hemorrhage
o Bilateral compartment syndrome
 During resuscitation, which one of the following is the most reliable as a guide to volume
replacement?
o Pulse rate
o Hematocrit
o Blood pressure
o Urinary output *
 o Jugular venous pressure
 A teen-aged bicycle rider is hit by a truck travelling at high rate of speed. In the emergency
department, she is actively bleeding from open fracture of her legs, and has abrasions on her chest
and abdominal wall. Her blood pressure is 80/50 mmHg, heart rate is 140 bpm, respiratory rate 8
bpm and GCS score is 6. The first step in managing this patient is to
o Obtain a lateral cervical spine x-ray
o Insert a central venous pressure line
o Administer 2 liters of crystalloid solution
o Perform endotracheal intubation and ventilation *
o Apply the PASG and inflate the leg compartments
 During an altercation, a 32 y.o. man sustains a gunshot wound to the right upper hemothorax, above
the nipple line with an exit wound posteriorly above the scapula on the right. He is transported by
ambulance to a community hospital. He is endotracheally intubated, closed tube thorachostomy is
performed, and 2 liters of Ringer’s lactate solutions are infused through 2 large calibers IVs. His
blood pressure now is 60/0 mmHg, heart rate is 160 bpm, and respiratory rate is 14 bpm (ventilated
with 100% O2). The most appropriate next step in managing this patient is:
o Celiotomy
o Diagnostic peritoneal lavage
o Arterial blood gas determination
o Administer packed red blood cells *
o Chest x-ray to confirm tube placement
 A 23 y.o. man is brought immediately to the emergency department from 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 unconscious and has no detectable blood
pressure. Optimal immediate management is to
o Perform diagnostic peritoneal lavage
o Initiate infusion of packed red blood cells *
o Insert a nasogastric tube and urinary catheter
o Transfer the patient to the operating room while initiating fluid therapy **
o Initiate fluid therapy to return his blood pressure to normotensive
 A 30 y.o. man sustains a severely comminuted, open distal right femur fractures in a motorcycles
crash. The wound is actively bleeding. Normal sensation is present over the lateral aspect of the foot
but decreased over the medial foot and great toe. Normal motion of the foot is observed. Dorsalis
pedis and posterior tibial pulses are easily palpable on the left but only by Doppler ont he right.
Immediate effirts to improves circulation to injured extremity should involve
o Immediate angiography
o Tamponade the wound with pressure dressing
o Wound exploration and removal of bony fragments
o Realignment of the fracture with traction splint
o Fasciotomy of all four compartments in the lower extremity *
 To establish a diagnosis of shock
 o Systolic blood pressure must be below 90 mm Hg
o The presence of closed head injury should be excluded
o Acidosis should be present by arterial blood gas analysis
o The patient must fail to respond to intra venous fluid infusion
o Clinical evidence of inadequate organ perfusion must be present *
 The response to catecholamine in an injured, hypovolemic pregnant woman can be expected to
result in
o Placental abruption
o Fetal hypoxia and distress *
o Fetal/maternal dysrhythmia
o Improves uterine blood flow
o Increased maternal renal blood flow
 All of the following signs on the chest x-ray of a blunt injury victim may suggest aortic rupture
EXCEPT
o Mediastinal emphysema*
o Presence of pleural cap
o Obliteration of aortic knob
o Deviation of trachea to right
o Depression of left main stem bronchus
 A young woman sustains a severe head injury as the result of a MVC. In the emergency department,
her GCS score is 6. Her blood pressure is 140/90 mm Hg and her heart rate is 80 bpm. She is
intubated and is being mechanically ventilated. Her pupils are 3 mm in size and equally reactive to
light. There is no apparent injury. The most important principle to follow in the early management
of head injury is to
o Administer an osmotic diuretic
o Prevent secondary brain injury *
o Aggressively treat systemic hypertension
o Reduce metabolic requirement of brains
o Distinguish between intracranial hematoma and cerebral edema
 An electrician is electrocuted by a downed power line after a thunderstorm. He apparently made
contact with the wire at the level of the right mid-thigh. In the emergency department, his vital signs
are normal and no dysrhythmia is noted on ECG. On examination, there is and exit wound on the
bottom of the right foot. His urine is positive for bloody by dip stick but no RBC are seen
microscopically. Initial management should include
o Immediate angiography
o Aggressive fluid infusion *
o Intravenous pyelography
o Debridement of necrotic muscle
o Admission to intensive care unit for observation
 A 24 y.o. woman passenger in an automobile strike the wind screen with her face during head-on
collision. In the emergency department, she is talking and has marked facial edema and crepitus.
The highest priority should be given to
o Lateral, c-spine x-ray
o Upper airway protection *
o Carotid pulse assessment
o Management of blood loss
o Determination of associated injured
 A 22 y.o man is brought to the hospital after crashing his motorcycle into a telephone pole. He is
unconscious and in profound shock. He has no open wounds or obvious fractures. The cause of his
shock is MOST LIKELY caused by
o A subdural hematoma
o An epidural hematoma *
o A transected lumbar spinal cord
o A transected cervical spinal cord
o Hemorrhage into the chest or abdomen
 A 8 years old girl is an unrestrained passenger in a vehicle struck from behind. In the emergency
department, her blood pressure is 80/60 mmHg, heart rate 80 bpm, and respiratory rate 16 bpm.
Her GCS score is 14. She complains that her legs feel “funny and won’t move right,” however, her
spine x-rays do not show a fracture or dislocation. A spinal cord injury in this child
o Is most likely a central cord syndrome
o Must be diagnosed by magnetic resonance imaging
o Can be excluded by obtaining a CT of entire spine
o May exists in the absence of objective findings on the x-ray studies *
o Is unlikely because of the incomplete calcification of vertebral bodies
 A 25 years old woman is brought to the emergency department after a MVC. She was initially lucid
ad the scene and then developed a dilated pupil and contralateral extremity weakness. In the
emergency department, she is unconscious and has a GCS of 6. The initial management step for this
patient should be to
o Obtain a CT scan of head
o Administer decadron 20 mg IV
o Perform endotracheal intubation *
o Initiate an IV line and administer mannitol 1 gr/Kg
o Perform and emergency linar hole on the side of dilated pupil
 An 18 years old, helmeted motorcyclist is brought by ambulance to the emergency department
following a high speed crash. Prehospital personnel report that he was thrown 15 meters (50 feet)
of his bfice. He has a history of hypotension prior to arrival in the emergency department, but now is
awake, alert, and conversational. Which of the following statements is TRUE?
o Cerebral perfusion is intact
o Intravascular volume status is normal
 o The patient has sensitive vasomotor reflexes
o Intraabdominal visceral injuries are unlikely
o The patient probably has an acute epidural hematoma *
 Early central venous pressure monitoring during fluid resuscitation in the emergency department
has the greatest utility in a
o Patient with a splenic laceration
o Patient with an inhalation injury
o 6 years old child with a pelvic trauma
o Patient with a severe cardiac contusion
o 24 years old man with a massive hemothorax *
 A young man sustains a gunshot wound to the abdomen and is brought promptly to the emergency
department by prehospital personnel. His skin is cool and diaphoretic, and he is confused. His pulse
is thready and his femoral pulse is only weakly palpable. The definitive treatment in managing this
patient is to
o Administer O-negative blood
o Apply external warming devices
o Control internal hemorrhage operatively *
o Apply pneumatic antishock garment
o Infuse large volume of intravenous crystalloid solution
 Cardiac tamponade after trauma
o Is seldom life-threatening
o Can be excluded by an upright, AP chest x-ray
o Can be confused with a tensio pneumothorax *
o Causes a fall in systolic pressure of >15 mmHg expiration
o Most commonly occurs after blunt injury to the anterior chest wall
 Which of the following statements regarding injury to the ventral venous system in children is TRUE?
o Children suffer spinal cord injury without c-ray abnormality more commonly than adults *
o An infant with a traumatic brain injury may become hypotensive from cerebral edema
o Initial therapy for child with traumatic brain injury includes the administration of
methylprednisolone intravenously
o Children have more focal mass lesions as a result of brain injust when compared to adults
o Young children are less tolerant of expanding intracranial mass lesions than adults
 Which of the following statement is FALSE concerning Rh isoimmunization in the pregnant trauma
patient?
o It occurs in blunt or penetrating abdominal trauma
o Minor degrees of fetomaternal hemorrhage produce it
o A negative Kleihauer-Betke test exclude RH isoimmunization
o This is not a problem in the traumatized Rh-positive pregnant patient
o Initiation of RH immunoglobulin therapy does not required proof of fetomaternal
hemorrhage *
 Twenty seven patients are seriously injured in and aircraft accident at a local airport. The basic triage
should be to
o Treat the most severely injured patient first
o Establish a field triage directed by a doctor
o Rapidly transport all patients to the nearest appropriate hospital
o Treat the greatest number patients in the shortest period of time
o Produce a great number of survivors based on available resources *
 Which one of the following statements regarding patients with thoracic spine injuries is TRUE?
o Log-rolling may be destabiliing fracture from T-12 to L-1
o Adequare immobilization can be accomplished ith the scoop stretcher
o Spinal cord injury below T-10 usually spares bowel and bladder function *
o Hyperflexion fractures in the upper thoracic spine are inherently unstable
o These patient rerely present with spinal shock in associatin with cord injury
 Which one of the following physical findings suggest a cause of hypotension other than spinal cord
injury
o Priapism
o Bradycardia *
o Diaphragmatic breathing
o Presence of deep tendon reflexes
o Ability to flexes forearms but inability to extend them
 Immediate chest tube insertion is indicated for which of the following conditions
o Pneumothorax
o Pneumomediastium
o Massive hemothorax *
o Diaphragmatic rupture
o Subcutaneous emphysema
 Contraindication to nasogastric intubation is the presence of a
o Gastric perforation
o Diaphragmatic rupture
o Open depressed skull fracture
o Fracture of cervical spine
o Fracture of the cribiform plate *
 Absence of breath sound and dullness to percussion over the left hemothorax are findings best
explained by
o Left hemothorax *
o Cardiac contusion
o Left simple pneumothorax
o Left diaphragmatic rupture
o Right tension pneumothorax
 A 5 years old boy is struck by an automobile and brought to the emergency department. He is
lethargic, bit withdraws purposely from painful stimuli. His blood pressure is 90 mm Hg systolic,
heart rate 140 bpm, and his respiratory rate 36 bpm. The preferred route of venous access on this
patient is
o Percutaneous femoral vein canulation
o Cut down of saphenous vein at the ankle
o Intraosseus catheter placement in the proximal tibia
o Percutaneous peripheral veins in the upper extremities *
o Central venous access via the subclavian or internal jugular vein
 Which one of the following is the recommended method for initially treating frostbite
o Vasodilators
o Anticoagulant
o Warm (40°C) water *
o Padding and elevation
o Topical application of silvasulphadiazine
 The primary indication for transferring a patient to a higher lever trauma center is
o Unavailability of a surgeon or operating room staff
o Multiple system injuries, include severe head injury
o Resource limitations as determined by the transferring doctor *
o Resource limitations as determined by hospital administration
o Widened mediastinum on chest X-ray following blunt thoracic trauma
 A 30 y.o. man is struck by a car travelling at 56 kph (35 mph). He has obvious fractures at the left
tibia near the knee, pain in the pelvic area, and severe dyspnea. His heart rate is 180 bpm, and his
respiratory rate is 48 bpm with no breath sound in the left chest. A tension pneumothorax is
relieved by immediate needle decompression and tube thoracostomy. Subsequently, his heart rate
decreases to 140 bpm, his respiratory rate decreased to 36 bpm, and his blood pressure is 80/50
mm Hg. Warmed Ringer lactate is administered intravenously. The next priority should be to:
o Perform a urethrogram and cystogram
o Perform external fixation of pelvis *
o Obtain abdominal and pelvic CT scans
o Perform arterial embolization of pelvic vessels
o Perform diagnostic peritoneal lavage or abdominal ultrasound.
 A young man sustains a ritle wound to the mid-abdomen. He is brought promptly to the emergency
department by prehospital personnel. His skin is cool and diaphoretic, his systolic blood pressure is
58 mm Hg. Warmed crystalloid fluids are initiated without improvement in his vital signs. The next,
most appropriate step is to perform
o A celiotomy
o An abdominal CT-scan
o Diagnostic laparoscopy
o Abdominal ultrasonography
 o A diagnostic peritoneal lavage *
 A 32 y.o man is brought to the hospital unconscious with severe facial injuries and noisy respirations
after an automobile collision. In the emergency department, he has no apparent injury to the
anterior aspect of his neck. He suddenly become apneic and attempted ventilation with face mask is
unsuccessful. Examination of his mouth reveals a large hematoma of the pharynx with loss of
normal anatomic landmarks. Initial management of his airway should consist of
o Inserting orophrayngeal airway
o Inserting nasopharyngeal airway
o Performing a surgical cricothyroidotomy *
o Performing fiberoptic guided nasotracheal intubation
o Performing orotracheal intubation after obtaining a lateral c-spine x-ray