Practice

Question 1

Question:1 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 2 liters of crystalloid solution 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. His breath sounds are decreased in the left hemithorax, and after initial IV fluid resuscitation, a closed tube thoracostomy is performed for decreased left 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

Answer 1

reexamine the chest.

Question 2

Question:2 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

Answer 2

complete spine x-ray series.

Question 3

Question:3 The principle of balanced resuscitation is:

Answer 3

Permissive hypotension and early plasma infusion

Question 4

Question:4 In managing the head-injured patient, the most important initial step is to

Answer 4

secure the airway.

Question 5

Question:5 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?

His pulse pressure will be widened.
His urinary output will be at the lower limits of normal.
He will have tachycardia, but no change in his systolic blood pressure.
His systolic blood pressure will be decreased with a narrowed pulse pressure.
His systolic blood pressure will be maintained with an elevated diastolic pressure.

Answer 5

His systolic blood pressure will be decreased with a narrowed pulse pressure.

Question 6

Question:6 The physiologic hypervolemia of pregnancy has clinical significance in the management of the severely injured, gravid woman by

Answer 6

increasing the volume of blood loss to produce maternal hypotension.

Question 7

Question:7 The best assessment of fluid resuscitation of the burn patient is

Answer 7

adequate urinary output.

Question 8

Question:8 The diagnosis of shock must include

Answer 8

evidence of inadequate organ perfusion.

Question 9

Question:9 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

Answer 9

direct pressure on the wound.

Question 10

Question:10 For the patient with severe traumatic brain injury, profound hypocarbia should be avoided to prevent

Answer 10

cerebral vasoconstriction with diminished perfusion.

Question 11

Question:11 A 25-year-old man is brought to a hospital with a general surgeon after being involved in a motor vehicle crash. Computed tomography 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

Answer 11

exploratory laparotomy.

Question 12

Question:12 Which one of the following statements regarding abdominal trauma in the pregnant patient is TRUE?

Answer 12

Leakage of amniotic fluid is an indication for hospital admission.

Question 13

Question:13 The first maneuver to improve oxygenation after chest injury is

Answer 13

administer supplemental oxygen.

Question 14

Question:14 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 painful stimuli. He does not follow commands, but he does moan periodically. His right arm is deformed and does not respond to painful stimulus; however, his left hand reaches purposefully toward the painful stimulus. Both legs are stiffly extended. His GCS Score is

Answer 14

9

Question 15

Question:15 A 20-year-old woman, at 32 weeks gestation, is stabbed in the upper right chest. In the emergency department, her blood pressure is 80/60 mm Hg. She is gasping for breath, extremely anxious, and yelling for help. Breath sounds are diminished in the right chest. The most appropriate first step is to

Answer 15

perform needle decompression of the right chest.

Question 16

Question:16 Which one of the following findings in an adult is most likely to require immediate management during the primary survey?

Distended abdomen.
Glasgow Coma Scale Score of 11.
Temperature of 36.5°C (97.8°F).
Deforming of the right thigh.
Respiratory rate of 40 breaths per minute.

Answer 16

Respiratory rate of 40 breaths per minute.

Question 17

Question:17 The most important, immediate step in the management of an open pneumothorax is

Answer 17

placement of an occlusive dressing over the wound.

Question 18

Question:18 The following are contraindications for tetanus toxoid administration

Answer 18

History of neurological reaction or severe hypersensitivity to the product.

Question 19

Question:19 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?

Answer 19

Breath sounds.

Question 20

Question:20 Bronchial intubation of the right or left mainstem bronchus can easily occur during infant endotracheal intubation because

Answer 20

the trachea is relatively short.

Question 21

Question:21 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, and 2 liters of crystalloid solution are infused through 2 large-caliber IVs. 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). 1500cc of blood has drained from the right chest. The most appropriate next step in managing this patient is to

Answer 21

urgently transfer the patient to the operating room.

Question 22

Question:22 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

Answer 22

attempt orotracheal intubation using 2 people and inline stabilization of the cervical spine.

Question 23

Question:23 A patient is brought to the emergency department after a motor vehicle crash. He is conscious and there is no obvious external trauma. He arrives at the hospital completely immobilized on a long spine board. 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?

Vasoactive medications have no role in this patient’s management.
The hypotension should be managed with volume resuscitation alone.
Flexion and extension views of the c-spine should be performed early.
Abdominal visceral injuries can be excluded as a cause of hypotension.
Flaccidity of the lower extremities and loss of deep tendon reflexes are expected.

Answer 23

Flaccidity of the lower extremities and loss of deep tendon reflexes are expected.

Question 24

Question:24 Which one of the following is the most effective method for initially treating frostbite?

Answer 24

Moist heat.

Question 25

Question:25 A 32-year-old man’s right leg is trapped beneath his overturned car for nearly 2 hours before he is extricated. On arrival in the emergency department, his right lower extremity is cool, mottled, insensate, and motionless. Despite normal vital signs, pulses cannot be palpated below the femoral vessel 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?

Answer 25

Perform right lower extremity fasciotomy.

Question 26

Question:26 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

Answer 26

suction the oropharynx.

Question 27

Question:27 A 22-year-old man sustains a gunshot wound to the left chest and is transported to a small community hospital at which surgical capabilities are not 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

Answer 27

repeat the primary survey and proceed with transfer.

Question 28

Question:28 A 64-year-old man, involved in a high-speed car crash, is resuscitated initially in a small hospital with limited resources. 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 infusing 2 liters of crystalloid solution, 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

Answer 28

call the receiving hospital and speak to the surgeon on call.

Question 29

Question:29 Hemorrhage of 20% of the patient’s blood volume is associated usually with

Answer 29

tachycardia.

Question 30

Question:30 Which one of the following statements concerning intraosseous infusion is TRUE?

Only crystalloid solutions may be safely infused through the needle.
Aspiration of bone marrow confirms appropriate positioning of the needle.
Intraosseous infusion is the preferred route for volume resuscitation in small children.
Intraosseous infusion may be utilized indefinitely.
Swelling in the soft tissues around the intraosseous site is not a reason to discontinue infusion.

Answer 30

Aspiration of bone marrow confirms appropriate positioning of the needle.

Question 31

Question:31 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

Answer 31

avoid hypotension.

Question 32

Question:32 A 33-year-old woman is involved in a head-on motor vehicle crash. It took 30 minutes to extricate her from the car. Upon arrival in the emergency department, her heart rate is 120 beats per minute, BP is 90/70 mm Hg, respiratory rate is 16 breaths per minute, and her GCS Score is 15. Examination reveals bilaterally equal breath sounds, anterior chest wall ecchymosis, and distended neck veins. Her abdomen is flat, soft, and not tender. Her pelvis is stable. Palpable distal pulses are found in all 4 extremities. Of the following, the most likely diagnosis is

Answer 32

cardiac tamponade.

Question 33

Question:33 A hemodynamically normal 10-year-old girl is admitted to the Pediatric Intensive Care Unit (PICU) 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 serum amylase of 200.
A leukocyte count of 14,000.
Extraperitoneal bladder rupture.
Free intraperitoneal air demonstrated on follow-up CT.
A fall in the hemoglobin level from 12 g/ dL to 8 g/ dL over 24 hours.

Answer 33

Free intraperitoneal air demonstrated on follow-up CT.

Question 34

Question:34 A 40-year-old woman restrained driver is transported to the emergency department in full spinal immobilization. She is hemodynamically normal and found to be paraplegic at the level of T10. Neurologic examination also determines that there is loss of pain and temperature sensation with preservation of proprioception and vibration. These findings are consistent with the diagnosis of

Answer 34

anterior cord syndrome.

Question 35

Question:35 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

Answer 35

maintain inline immobilization and establish a definitive airway.

Question 36

Question:36 When applying the Rule of Nines to infants,

Answer 36

the head is proportionally larger in infants than in adults.

Question 37

Question:37 Healthy young male in a motor vehicle crash is brought to the emergency department with 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:

Answer 37

Placement of a pelvic binder

Question 38

Question:38 Which one of the following situations requires Rh immunoglobulin administration to an injured woman?

Negative pregnancy test, Rh negative, and torso trauma.
Positive pregnancy test, Rh positive, and has torso trauma.
Positive pregnancy test, Rh negative, has torso trauma.
Positive pregnancy test, Rh positive, and has an isolated wrist fracture.
Positive pregnancy test, Rh negative, and has an isolated wrist fracture.

Answer 38

Positive pregnancy test, Rh negative, has torso trauma.

Question 39

Question:39 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 emergency department and 15 minutes after the incident, she is awake and alert. Her heart rate is 100 beats per minute, blood pressure 80/60 mm Hg, and respiratory rate 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

Answer 39

prepare for an exploratory thoracotomy.

Question 40

Question:40 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?

A flail chest is probable.
A symptomatic cardiac contusion is expected.
A pulmonary contusion may be present in the absence of rib fractures.
Transection of the thoracic aorta is more likely than in an adult patient.
Rib fractures are commonly found in children with this mechanism of injury.

Answer 40

A pulmonary contusion may be present in the absence of rib fractures.