Pre-Test: Trauma and Shock

Question 1

A teenage boy falls from his bicycle and is run over by a truck. On arrival in the ER, he is awake, alert, and is frightened but in no distress. CXR = air-fluid level in the left lower lung field and NGT coils upward into the left chest. Which of the following is the next best step in his mgmt?

a. Placement of left chest tube
b. Thoracotomy
c. Laparotomy
d. Esophagogastroscopy
e. Diagnostic peritoneal lavage

Answer 1

c. Laparotomy

Pt has acute diaphragmatic rupture –> immediate laparotomy –> examine of intra-abdominal solid and hollow viscera for associated injuries and for exposure of diaphragm to repair

CXR findings + NGT entering it after blunt trauma = diagnostic of diaphragmatic rupture with gastric herniation into chest

Question 2

A 65 y/o man falls and fractures the 3rd, 4th, and 5th ribs in the left anterolateral chest. CXR is otherwise normal. Which of the following would be the most appropriate next step in his mgmt?

a. Admission to the hospital and treatment with oral analgesia
b. Tube thoracostomy
c. Placement of epidural for pain mgmt
d. Surgical fixation of ribs

Answer 2

c. Placement of epidural for pain mgmt

Pts with lower rib fractures may have associated abdominal injuries –> undergo proper eval (U/S, CT, or peritoneal lavage)

Epidural catheters, continuous narcotic infusions, patient-controlled analgesia = most effective methods for ensuring pain control in hospitalized pts with rib fractures

• Pts with minor fractures –> go home with oral analgesia
• Tube thoracostomy –> pneumothorax
• Surgical fixation –> not needed, ribs heal spontaneously

Question 3

A 36 y/o man who was hit by a car presents to the ER with hypotension. On exam, he has tenderness and ruising over his left lateral chest below the nipple. An U/S exam is performed and reveals free fluid in the abdomen. What is the most likely organ to have been injured in this pt?

a. Liver
b. Kidney
c. Spleen
d. Intestine
e. Pancreas

Answer 3

c. Spleen

Most likely organ to be damaged in blunt abdominal trauma (then liver)

Question 4

A 52 y/o man is pinned against a loading dock. The patient has a fractured femur, a pelvic fracture, a tender abdomen, and no pulses in the R foot with minimal tissue damage to the R leg. Angiography discloses a popliteal artery injury with obstruction. At surgery, the popliteal vein is also transected. His BP is 85/60 mm Hg. Which of the following is the best mgmt strategy for his vascular injuries?

a. Repair of popliteal vein with simple closure
b. Repair of popliteal vein with saphenous vein patch
c. Ligation of popliteal vein

Answer 4

c. Ligation of popliteal vein

Ligation rather than venous repair is treatment of choice in hemodynamically unstable pts

Question 5

A 27 y/o man sustains a single gunshot wound to the left thigh. In the ER, he is noted to have a large hematoma of his medial thigh. He complains of paresthesias in his left foot. On exam, there are weak pulses palpable distal to the injury and the patient is unable to move his foot. Which of the following is the most appropriate initial mgmt of this pt?

a. Angiography
b. Immediate exploration and repair in the OR
c. Fasciotomy of the anterior compartment of the calf
d. Observation for resolution of spasm
e. Local wound exploration at the bedside

Answer 5

b. Immediate exploration and repair in the OR

Mandated for acute arterial insufficiency in the presence of neurologic symptoms

Exploration is indicated in the presence of “hard signs”:

• Expanding hematoma
• Pulsatile bleeding
• Audible bruit
• Palpable thrill
• Absent distal pulses/distal ischemia

Question 6

A 25 y/o woman arrives in the ER following an automobile accident. She is acutely dyspneic with a RR of 60 bpm. Breath sounds are markedly diminished on the R side. Which of the following is the best first step in the mgmt of this pt?

a. Take CXR
b. Draw blood for ABG
c. Decompress R pleural space
d. Perform pericardiocentesis
e. Administer IV fluids

Answer 6

c. Decompress R pleural space

Tension pneumothorax = life-threatening problem requiring immediate tx

Produces characteristic x-ray findings: ipsilateral lung collapse, mediastinal and trachel shift, compression of contralateral lung

Question 7

A 17 y/o adolescent boy is stabbed in the L seventh intercostal space, midaxillary line. He presents to the ER with a HR of 86 bpm, BP 125/74, O2 sat = 98%.

Breath sounds are equal bilaterally. Which of the following is the most appropriate next step in his workup?

a. Local exploration of the wound
b. L tube thoracostomy
c. Diagnostic laparoscopy
d. CT scan of the abdomen
e. Echo

Answer 7

c. Diagnostic laparoscopy

Diaphragmatic or abdominal injuries should be suspected in patients with penetrating injury below the nipples.

• CT scan has low sensitivity for diagnosing abdominal injuries in setting of penetrating trauma.
• Local wound exploration is contraindicated in penetrating trauma to chest, given risk of creating a pneumothorax

Question 8

Your hospital is conducting an ongoing research study involving the hormonal response to trauma. Blood is drawn regularly for various studies. Which of the following values are likely to be seen after a healthy 36 y/o man is hit by a bus and sustains a ruptured spleen and a lacerated small bowel?

a. Increased secretion of insulin
b. Increased secretion of vasopressin (ADH)
c. Decreased secretion of glucagon
d. Decreased secretion of aldosterone

Answer 8

a. Increased secretion of insulin

Though the immediate release of catecholamines causes a transient drop in insulin levels, shortly thereafter, there is a significant rise in plasma insulin levels in injured humans. Because of increased peripheral insulin resistance in conjunction with increased insulin production, the overall net effect after severe injury is hyperglycemia.

Question 9

You evaluate an 18 y/o man who sustained a R-sided cervical laceration during a gang fight. Your intern suggests nonoperative mgmt and observation. Which of the following is a relative, rather than an absolute, indication for neck exploration?

a. Expanding hematoma
b. Dysphagia
c. Dysphonia
d. Pneumothorax
e. Hemoptysis

Answer 9

d. Pneumothorax

Acute signs of airway distress (stridor, hoarseness, dysphonia), visceral injury (subq air, hemoptysis, dysphagia), hemorrhage (expanding hematoma) and neurologic symptoms referable to carotid injury (stroke or AMS), require formal neck exploration.

Pneumothorax would mandate chest tube first.

Question 10

Following blunt abdominal trauma, a 12 y/o girl develops upper abdominal pain, N/V. An upper GI series reveals a total obstruction of the duodenum with a coiled spring appearance in the 2nd and 3rd portions. In the absence of other suspected injuries, which of the following is the most appropriate mgmt of this pt?

a. Gastrojejunostomy
b. NG suction and observation
c. Duodenal resection
d. TPN to increase the size of retroperitoneal fat pad
e. Duodenojejunostomy

Answer 10

b. NG tube and suction

Duodenal hematomas result from blunt abdominal trauma, and they should be managed initially with observation in pts not undergoing laparotomy to r/o other associated injuries

Upper GI series is almost always diagnostic

Majority of duodenal hematomas resolve spontaneously

Question 11

A 45 y/o man presents after a high-speed MVC. He has a seatbelt sign across his neck and chest with an ecchymosis over his L neck. He is hemodynamically stable and neurologically intact. A CT angiogram shows a left carotid dissection. In the absence of other significant injuries, what is the next step in his mgmt?

a. Antiplatelet therapy
b. Systemic anticoagulation with heparin
c. Neck exploration and L carotid artery repair
d. Angiography and L carotid artery stenting

Answer 11

b. Blunt carotid artery injuries should be treated with full systemic anticoagulation in the absence to any contraindications to prevent stroke.

While surgery/stenting have all been used to treat carotid injruies, none are the standard of care in the neurologically intact patient without any hard signs (e.g. expanding hematoma, bruit, thrill, active bleeding)

Question 12

A 28 y/o man is brought to the ER for a severe head injury after a fall. He was intubated in the field for his decreased level of consciousness. He is tachycardic and hypotensive. On exam, he is noted to have an obvious skull fracture and his R pupil is dilated. Which of the following is the most appropriate method for initially reducing his ICP?

a. Elevation of the head of the bed
b. Lasix infusion
c. Mannitol infusion
d. IV dexamethasone
e. Hyperventilation

Answer 12

e. Hyperventilation

Emergency measures to reduce ICP include hyperventilation, mannitol infusion, and elevation of the head of the bed (reverse Trendelenburg).

However, in the face of inadequate volume resuscitation, all others may exacerbate patient’s hypotension.

Question 13

A 31 y/o man is brought to the ER following an automobile accident in which his chest struck the steering wheel. Exam reveals stable vital signs and no evidence of respiratory distress, but the patient exhibits multiple palpable rib fractures and paradoxical movement of the R side of the chest. CXR shows no evidence of pneumothorax or hemothorax. Which of the following is the most appropriate initlal mgmt of this pt?

a. Intubation, mechanical ventilation, PEEP
b. Stabilization of the chest wall with sandbags
c. Immediate operative stabilization
d. Pain control, chest physiotherapy, close observation

Answer 13

e. Mgmt of flail chest consists of adequate analgesia, chest physiotherapy, mechnical ventilation if respiratory compromise develops.

Question 14

A 75 y/o man with hx CAD, HTN, DM undergoes a R hemicolectomy for colon cancer. On POD2, he complains of SOB and chest pain. He becomes hypotensive with depressed mental status and is immediately transferred to the ICU. After intubation and placement on mechanical ventilation, an echo confirms cardiogenic shock. A central venous catheter is placed that demonstrates a CVP of 18 mm Hg. Which of the following is the most appropriate initial mgmt strategy?

a. Additional L fluid bolus
b. Inotropic support
c. Mechanical circulatory support with intra-aortic balloon pump (IABP)
d. Cardiac cath
e. Heart transplant

Answer 14

b. Inotropic support

Cardiogenic shock = circulatory pump failure –> substantial reduction in CO –> tissue hypoxia

Acute MI = most common cause of cardiogenic shock

Inotropic support indicated when profound cardiac dysfunction exists to improve cardiac contractility and CO –> dobutamine and dopamine = commonly used inotropes

Question 15

A 22 y/o man is examined following a MVA. He has a R knee dislocation which is reduced in the ER. He has palpable pedal pulses and is neurologically intact. Which of the following is an appropriate next step in his workup and mgmt?

a. Measurement of ABI
b. Angiography of the R lower extremity
c. Prophylactic below-knee 4-compartment fasciotomies
d. Surgical exploration of R popliteal artery

Answer 15

a. Measurement of ABI

If <0.9… perform CTA

Question 16

A 34 y/o prostitute with a hx of long-term IV drug use is admitted with a 48 hr hx of pain in her L arm. She is tachycardic to 130 and her systolic BP is 80 mm Hg. Physical exam is remarkable for crepitus surrounding needle track marks in the antecubital space with a serous exudate. What is the appropriate next step?

a. Tx with penicillin G and close observation
b. MRI of arm
c. CT scan of arm
d. Surgical exploration and debridement

Answer 16

d. Surgical exploration and debridement

Crepitus in a soft tissue infection implies anaerobic metabolism –> dead tissue –> surgical infection.

Necrotizing fasciitis is associated with high rates of morbidity and mortality –> prompt surgical exploration is mandatory

Question 17

A 36 y/o man sustains a gunshot wound to the left buttock. He is hemodynamically stable. There is no exit wound, and an x-ray of the abdomen shows the bullet to be located in the RLQ. Which of the following is most appropriate in the mgmt of his suspected rectal injury?

a. Barium studies of the colon and rectum
b. Barium studies of the bullet track
c. CT scan of the abdomen and pelvis
d. Angiography
e. Sigmoidoscopy in the ER

Answer 17

c. A CT scan should be routinely requested for suspected rectal performation.

The use of water-soluble rectal contrast (Gastrografin) is helpful when reconstructing a bullet trajectory. THe use of barium is C/I because its spillage in the peritoneal cavity mixed with feces would increase the likelihood of subsequent intra-abdominal abscesses.

Question 18

A 27 y/o man presents to the ER after a high-speed MVC with chest pain and marked respiratory distress. On exam, he is hypotensive with distended neck veins and absence of breath sounds in the L chest. Which of the following is the proper initial tx?

a. Intubation
b. CXR
c. Pericardiocentesis
d. Chest decompression with a needle

Answer 18

d. Chest decompression with a needle

Pt has tension pneumothorax caused by blunt trauma from MVC, which should be treated with emergent needle decompression

Hypotension and distended neck veins are also seen in cardiac tamponade, but breath sounds are usually symmetric

Question 19

A 25 y/o man is brought to the ED after falling 20 ft from a ladder. He was placed on backboard for spinal stabilization. IV access was obtained en route, and he received infusion of crystalloids. The patient is comatose on arrival. His BP is 92/45, pulse 127/min and respirations are 6/min. Pulse ox 86% on 100% oxygen nonrebreather facemask.

Eval shows superficial facial lacerations, a depressed temporal skull fracture, and forearm fracture. There are no periorbital or periauricular hematomas, and there is no significant neck edema. Which of the following is the most appropriate next step in mgmt?

a. Nasotracheal intubation
b. Needle cricothyroidotomy
c. Orotracheal intubation
d. Surgical tracheostomy

Answer 19

c. orotracheal intubation

**Preferred unless significant facial trauma present**

This patient is hypopneic and hypoxic and rqeuires emergency airway access

Nasotracheal intubation is a blind procedure that is contraindicated in apneic/hypopneic patients. It is also contraindicated if the patient has a basilar skull fracture.

Question 20

A 25 y/o previously healthy man is brought to the ER after falling from a tree. The pt did not lose consciousness but started experiencing left-sided chest and abdominal pain. He also has left shoulder pain. BP is 113/71 mm Hg and pulse is 116/min. Exam shows bruising on L chest wall. Pt reports sharp L chest pain with deep inspiration but has equal breath sounds on both sides. There is tenderness of the L costal margin and LUQ of abdomen with guarding. Bowel sounds +. ROM of L shoulder normal. Hgb 11.8 g/dL and single view CXR normal. FAST shows no significant free intraperitoneal fluid. Which of the following is the most appropriate next step in mgmt of this pt?

a. Obtain CT scan of abdomen with contrast
b. Monitor w/ serial exams
c. Perform urgent ex lap

Answer 20

a. Obtain CT scan of abdomen with contrast

Pt with BAT, L-sided abdominal pain, and anemia most likely has a splenic injury. The evaluation and mgmt of SI due to BAT depend on pt’s hemodynamic status and response to IV fluids:

Pts who are hemodynamically stable (e.g. systolic BP > 90) and alert should undergo FAST. Those with NORMAL (negative) FAST but high risk features such as anemia or guarding –> subsequent CT scan of abdomen

Stable pts with AMS often proceed directly to CT imaging.

Question 21

A 12 y/o boy is brought to the ER after being involved in an MVC. He is in no distress and is admitted for observation. The pt develops tachypnea and tachycardia 2 hours after admission. Temp is 98, BP 110/66, pulse 110/min, respirations 22/min.

Exam shows bruises on the R side of the chest, and palpation of the chest wall elicits diffuse tenderness but no evidence of rib fractures. Breath sounds are decreased on the R side. ABG on 6 L oxygen are as follows: pH 7.4, PaO2 = 60, PaCO2 = 32.

CXR reveals a patchy irregular alveolar infiltrated of the R middle and lower lobes. Which of the following is the most likely dx?

a. ARDS
b. Aspiration pneumonia
c. Flail chest
d. Hemothorax
e. Pneumothorax
f. Pulmonary contusion

Answer 21

f. Pulmonary contusion

Parenchymal bruising of the lung, resulting in intra-alveolar hemorrhage and edema

Clinical manifestations usually develop in the first 24 hrs after blunt thoracic injury; tachypnea, tachycardia, hypoxia = characteristic*

ARDS is a common complication of PC. However, ARDS usually manifests 24-48 hrs after trauma and demonstrates b/l, patchy alveolar infiltrates on CXR.

Question 22

A 48 y/o man sustains a gunshot wound to the R upper thigh just distal to the inguinal crease. He is immediately brought to the ER. Peripheral pulses are palpable in the foot, but the foot is pale, cool, and hypesthetic. The motor exam is normal. Which of the following statements is the most appropriate next step in the pt’s mgmt?

a. Pt should be taken to OR immediately to evaluate for significant arterial injury
b. Neurosurgical consult should be obtained and somatosensory evoked potential monitoring performed
c. Fasciotomy should be performed prophylactically in the ER
d. Duplex exam should be obtained to r/o venous injury

Answer 22

a. Pt should be taken to OR immediately to evaluate for significant arterial injury

The presence of ischemic changes following vascular trauma is an indication for emergency exploration and repair. Nonsurgical mgmt of arterial trauma when distal pulses are palpable may lead to delayed seuelae of embolization, occlusion, 2ndary hemorrhage, false aneurysm, traumatic AV fistula.

The presence of palpable pulses does not reliably exclude significant arterial injury.

Question 23

The victim of a MVC who was in shock is delivered to your trauma center by a rural ambulance service. On exam, his BP is 80/60 mm Hg and he has an unstable pelvis. X-rays reveal a pelvic fracture. CXR normal. FAST exam shows free fluid near the spleen. There are no major extremity deformities noted. A pelvic binder is placed. Which of the following statements is the best next step in the mgmt of this pt?

a. CT of chest
b. CT of abdomen and pelvis
c. Ex lap with pelvic packing

Answer 23

c. Ex lap with pelvic packing

Pt is in hemorrhagic shock from an unstable pelvic fracture and probable splenic injury

In hemodynamically unstable pt, choices for obtaining hemostasis include angiography with embolization or ex lap with pelvic packing

CT is not indicated in the unstable pt

Question 24

A radio transmission is received in your trauma unit stating that a victim of MVC is en route to your ER with no vital signs. The ambulance is 3 minutes away. As you formulate your plan, which of the following situations would constitute an indication for ER thoracotomy?

a. Massive hemothorax following blunt trauma to the chest
b. Blunt trauma to multiple organ systems with obtainable vita signs in the field, but none on arrival in the ER
c. Rapidly deteriorating pt with cardiac tamponade from penetrating thoracic trauma
d. Penetrating thoracic trauma and no signs of life in the field

Answer 24

c. Rapidly deteriorating pt with cardiac tamponade from penetrating thoracic trauma

Question 25

A 22 y/o man sustains a gunshot wound to the abdomen. At exploration, an apparently solitary distal small-bowel injury is treated with resection and primary anastomosis. On POD7, small-bowel fluid drains through operative incision. The fascia remains intact. The fistula output is 300 mL/day and there is no evidence of intra-abdominal sepsis. Which of the following is the most appropriate tx strategy?

a. Early reoperation to close the fistula tract.
b. Broad spec abx
c. TPN
d. Loperamide to inhibit gut motility

Answer 25

c. TPN

In the absence of sepsis, pts with enterocutaneous fistulas should be treated initially nonoperatively with bowel rest, TPN, and correction of electrolyte abnormalities. Most enterocutaneous fistulas result from trauma sustained during surgical procedures. Irradiated, obstructed, and inflamed intestine is prone to fistulization. Complications of fistulas include fluid and electrolyte depletion, skin necrosis, and malnutrition.

Question 26

A 26 y/o man complains of pelvic pain after a motorcycle collision. Physical and radiologic examinations confirm a pelvic fracture. Urologic workup reveals a normal urethrogram and an extraperitoneal bladder injury. Which of the following is the most appropriate tx for his bladder injury?

a. Immediate surgical exploration and repair
b. Placement of permanent suprapubic tube
c. Catheter drainage followed by definitive repair after 2 weeks
d. Catheter drainage for 2 weeks followed by repeat imaging
e. B/l nephrostomy tubes

Answer 26

d. Catheter drainage for 2 weeks followed by repeat imaging

Mgmt of bladder injuries is dependent on its location and concomitant injuries

Extraperitoneal bladder injuries can be treated with initial catheter drainage followed by repeat imaging to confirm healing. Surgical repair for extraperitoneal bladder injuries is indicated at the time of internal fixation of the pelvis to prevent infection of the hardware.

Ex lap is indicated if there is an injury to or avulsion of the bladder neck. intraperitoneal bladder injuries are repaired surgically.

Question 27

A 27 y/o worker falls about 30 ft from a scaffold. At the scene, he complains of inability to move his lower extremities. On arrival in the ER, he has a HR of 45 bpm, and BP of 78/39. His extremities are warm and pink. His BP improves with 1 L of crystalloid. A central venous catheter is placed for further resuscitation and his CVP is 2 mm Hg. Which of the following is the best initial tx strategy for improving his BP?

a. Immediate celiotomy
b. Fluid resuscitation with crystalloids
c. Administration of O- blood
d. Administration of peripheral vasoconstrictor
e. Administration of IV corticosteroids

Answer 27

b. Fluid resuscitation with crystalloids

Pt is in neurogenic shock 2/2 spinal cord injury. In pts with cervical or thoracic injuries, loss of sympathetic regulation results in loss of vasomotor tone and hypotension. They are warm and pink, as opposed to pts who are hypovolemic, who are cold and clammy.

B/c of loss of reflexive tachycardic response to hypotension, pts are usually also bradycardic.

Tx = fluid resuscitation initially and vasoconstrictors after intravascular volume has been restored. CVP is used to assess RV function and systemic fluid status. Normal CVP is 2-6 mm Hg. The pt in this scenario has a low CVP suggestive intravascular volume depletion. Therefore, the pt requires further fluid resuscitation.

Question 28

A 21 y/o woman sustains a stab wound to the middle of the chest. Upon arrival to the ER, she has equal breath sounds, BP of 85/46, distended neck veins, and pulsus paradoxus. Which of the following is the most appropriate mgmt of this patient?

a. Emergent intubation and mechnical ventilation in the ER
b. Emergent pericardiocentesis in the ER
c. Emergent thoracotomy in the ER
d. Emergent pericardiocentesis or subxiphoid pericardial drainage after anesthetic induction in the OR
e. Emergent pericardiocentesis or subxiphoid pericardial drainage under local anesthesia in the OR

Answer 28

e. Emergent pericardiocentesis or subxiphoid pericardial drainage under local anesthesia in the OR

Question 29

Following a head-on MVC, a 21 y/o unrestrained passenger presents to the ER with dyspnea and respiratory distress. She is intubated and exam reveals subcutaneous emphysema and decreased breath sounds. CXR reveals cervical emphysema, pneumomediastinum, and R-sided pneumothorax. What is the most likely dx?

a. Tension pneumothorax
b. Open pneumothorax
c. Tracheobronchial injury
d. Esophageal injury
e. Pulmonary contusion

Answer 29

c. Tracheobronchial injury

Question 30

What is the proper intervention for the following:

a. Laryngeal obstruction
b. Open pneumothorax
c. Flail chest
d. Tension pneumothorax
e. Pericardial tamponade

Answer 30

a. Laryngeal obstruction: Cricothyroidotomy
b. Open pneumothorax: Occlusive dressing
c. Flail chest: Endotracheal intubation / analgesics / supportive
d. Tension pneumothorax: Tube thoracostomy
e. Pericardial tamponade: Subxiphoid window

Question 31

A 23 y/o man was extricated from his vehicle following a MVC in which he was the unrestrained driver. The pt was found unresponsive at the scene and intubated by paramedics. He received 2.5 L normal saline over 20 min en route to the ED. His medical hx is not known. At the ED, BP is 70/30 and pulse is 120/min. The pt responds to strong vocal and tactile stimuli by opening his eyes. PERRLA. There are multiple bruises over the anterior chest and upper abdomen. Neck veins are flat, trachea is midline, and extremities are cold. The abdomen is mildly distended. Cardiac monitoring shows sinus tachycardia. Which of the following is the most likely to be seen in this pt?

a. Diastolic collapse with elevated RVP
b. Dilated LV with apical hypokinesis
c. IVC engorgement
d. RV dilation and hypokinesis
e. Small LV cavity with EF of 75%

Answer 31

e. Small LV cavity with EF of 75%

This patient has blunt thoracic and abdominal trauma and is most likely in hypovolemic shock due to massive internal hemorrhage. Loss of intravascular volume leads to a decrease in venous return to the R atrium (decreased preload) and a consequent decrease in CO and systemic BP. In an effort to maintain adequate CO and organ perfusion, the sympathetic nervous system is activated, resulting in peripheral vasoconstriction (increase in systemic vascular resistance) and increase in HR. The LV, decreased in size due to low filling volume also compensates by increasing EF.

These responses create typical clinical presentation of hypovolemic shock, which includes hypotension, tachycardia, cold extremities, poor organ perfusion (somnolence, unresponsiveness), and hypovolemia (flat neck veins)