TRAUMA

Question 1

During your assessment of an unresponsive 21-year-old male with a suspected spinal injury, you test for a Babinski reflex. A Babinski reflex is present if:

Answer 1

The big toe turns upward when a blunt object is stroked along the sole of the foot.

Question 2

The MOST significant complication associated with an open-book pelvic fracture is:

Answer 2

An increase in pelvic volume with more internal blood loss than pelvic fractures caused by lateral compression.

Question 3

Assessment of an injured man reveals that he opens his eyes when the paramedic speaks to him and pulls his arm away when it is palpated. He knows his name, but cannot remember what happened and does not know what day it is. He should be assigned a Glasgow Coma Scale (GCS) score of:

Answer 3

11

Question 4

Which of the following assessment findings should alert the paramedic that a patient with a closed lower extremity fracture is developing compartment syndrome?

Answer 4

The pain is greater than one would expect for the injury

Question 5

A 34-year-old construction worker fell approximately 25 feet and landed on his head; he was not wearing a safety helmet. He is semiconscious and has slow, irregular breathing. Further assessment reveals that his teeth are clenched and he is bleeding from the nose. As your partner manually stabilizes his head, you should:

Answer 5

Assist his ventilations with a bag-valve-mask and high-flow oxygen.

Question 6

Which of the following factors would reduce the blood’s natural ability to clot, thus worsening internal or external bleeding?

Answer 6

Hypothermia

Question 7

Which of the following signs would indicate a severe pericardial tamponade?

Answer 7

A drop in the blood pressure of greater than 10 mm Hg during inhalation

Question 8

Most chemical burn injuries are treated with

Answer 8

Water

Question 9

A patient struck the steering wheel when his vehicle crashed into a tree. Assessment reveals respiratory distress, diminished breath sounds to the left lower hemithorax, a scaphoid abdomen, and jugular venous distention. This clinical presentation is MOST consistent with a:

Answer 9

Ruptured diaphragm

Question 10

During your assessment of a patient with a closed head injury, you note the presence of a pinkish fluid draining from the nose. This is MOST indicative of:

Answer 10

A cribriform plate fracture

Bleeding or other fluid drainage from the nose following head trauma is indicative of a fracture of the cribriform plate. The cribriform plate, an extension of the ethmoid bone, is essentially the floor of the cranial vault. When a fracture to this plate occurs, cerebrospinal fluid (CSF) may leak into the sinuses and drain from the nose (cerebrospinal rhinorrhea).

Question 11

If an unrestrained driver strikes a utility pole while traveling at 70 MPH:

Answer 11

His body will strike the interior of the vehicle while moving at 70 MPH.

Question 12

What not to do to a patient with a large avulsion injury

Answer 12

Clean the wound with a betadine solution

Question 13

You and your partner are standing by at a community softball tournament when you witness the collapse of a 39-year-old male immediately after he was struck in the chest by a softball. You quickly assess him and determine that he is apneic and pulseless. This patient’s cardiac arrest was MOST likely caused by:

Answer 13

A cardiac dsyrhythmia

Question 14

Which of the following is a criterion for transporting an adult patient to a trauma center capable of providing the highest level of care?

Answer 14

Two proximal long bone fractures

Question 15

A 41-year-old man has a large open wound to his upper thigh that is bleeding profusely. You should immediately:

Answer 15

Find his femoral artery with your finger and compress it against a solid structure.

Massive hemorrhage control begins with your finger! If the wound is large, locate the artery proximal to the wound and push it against a solid structure, such as the femur. After gaining digital control of the bleeding, apply a tourniquet proximal to the wound. After all massive hemorrhage has been controlled, treat the patient for shock (ie, oxygen, thermal management).

Question 16

After completing an assessment of a patient with a blunt chest injury, the paramedic tells her partner that she suspects a pericardial tamponade. Which of the following did the paramedic MOST likely encounter during her assessment?

Answer 16

Chest wall crepitation

Question 17

You are assessing a patient with an injury to the left midshaft femur. Which of the following is the LEAST reliable indicator of an underlying fracture?

Answer 17

Ecchymosis and swelling

Question 18

Which of the following injuries would MOST likely result from a motorcycle striking a fixed object?

Answer 18

Femur fractures and head injury

Question 19

A 22-year-old man had a strong acid chemical splashed into both of his eyes. He is conscious and alert, is experiencing intense pain, and states that he is wearing contact lenses. Treatment should include:

Answer 19

Removing the contact lenses and beginning irrigation of both eyes.

Question 20

A woman was involved in a motor vehicle crash and is still in her car. She is conscious, but restless, and is breathing rapidly. There is a large volume of blood coming from her groin area. You should:

Answer 20

Apply direct pressure to the wound

Question 21

A 19-year-old male was ejected from his vehicle when it struck a tree head-on. The patient is found lying in a prone position on the road. After log-rolling him to a supine position, your partner, who is manually stabilizing the patient’s head, opens his airway with the jaw-thrust maneuver. The patient is unresponsive; has copious amounts of blood and large debris in his mouth; and has slow, irregular respirations. You should:

Answer 21

Remove the large visible debris from his mouth with a finger sweep.

Question 22

You are treating a patient with penetrating chest trauma. His initial vital signs revealed a blood pressure of 100/60 mm Hg, a pulse of 120 beats/min, and respirations of 28 breaths/min. Which of the following repeat vital signs is MOST suggestive of a pericardial tamponade?

Answer 22

BP of 90/70, pulse rate of 128

Because of blood accumulation within the pericardial sac, cardiac contraction is restricted, which causes a drop in the systolic blood pressure. For the same reason, complete relaxation is inhibited, which causes an increase in the diastolic blood pressure. The difference between the systolic and diastolic pressures is called the pulse pressure, which becomes narrowed with a pericardial tamponade.

Question 23

Which of the following parameters yields the lowest cerebral perfusion pressure?

Answer 23

BP, 105/60 mm Hg; intracranial pressure, 20 mm Hg

Question 24

A 30-year-old unrestrained woman struck the steering wheel when her car hit a tree while traveling at 40 miles per hour. She reports pain to the midsternal area, which is point tender to palpation. Her blood pressure is 100/60 mm Hg, pulse is 118 beats/min and irregular, and respirations are 26 breaths/min and shallow. The remainder of your assessment is unremarkable. You should suspect:

Answer 24

Myocardial contusion

Question 25

A 22-year-old male experienced blunt abdominal trauma. He is conscious and alert, but appears anxious. His blood pressure is 100/62 mm Hg, his pulse is 118 beats/min, and his respirations are 22 breaths/min. Further assessment reveals that his radial pulses are easily palpable. What is the MOST appropriate IV fluid regimen for this patient?

Answer 25

25 mL/hr

At present, fluid boluses are not indicated. Set the IV flow rate at 25 mL/hr, which will keep the vein open (KVO) in case his condition deteriorates to a point where volume replacement is warranted.

Question 26

You are caring for a patient with an open fracture of the forearm in which the bone is protruding from the wound. The MOST appropriate care for this type of injury includes:

Answer 26

Brushing away any obvious debris on the skin surface before applying a dressing.

Question 27

A deep partial-thickness burn is characterized by:

Answer 27

Edema, blister formation, and decreased sensation around the burn.

Question 28

Which of the following injuries would pose the MOST immediate threat to a patient’s life?

Answer 28

Laryngeal fracture

Question 29

You are assessing an adult patient with a head injury. He opens his eyes only when you speak to him, and when you ask him his name, he replies slowly by saying “No thank you.” When you apply a painful stimulus by pinching his arm, he pulls his arm away from you. What is this patient’s Glasgow Coma scale score?

Answer 29

10

He opens his eyes only when you speak to him; under the “eye opening” component of the GCS, this equates to a score of 3. Using inappropriate words - stating “No thank you” when you ask him his name - equates to a score of 3 under the “verbal response” component of the GCS. Withdrawal from pain (ie, pulling his arm away when a painful stimulus is applied) equates to a score of 4 under the “motor response” component of the GCS.

Question 30

In which of the following traumatic injuries would you MOST likely encounter pulsus paradoxus?

Answer 30

Pericardial tamponade

Question 31

A 40-year-old man fell approximately 20 feet from the roof of his house and landed on his feet. On the basis of the mechanism of injury, you should suspect injuries to the:

Answer 31

Calcaneus (heels of feet), hips, and lumbar spine

A typical pattern of injury is often observed when an adult falls and lands on his or her feet. As a result of axial loading, the patient frequently sustains injury to the calcaneus (heels of the feet) as the initial point of impact. The force then travels upward, causing injury to the hips. The force can be severe enough to result in injury to the relatively unprotected lumbar spine.

Question 32

You are caring for a 44-year-old female who experienced a closed head injury. She is responsive only to pain, has a respiratory rate of 8 breaths/min and irregular, a pulse of 120 beats/min and weak, and a blood pressure of 80/50 mm Hg. Which of the following statements regarding this patient is MOST correct?

Answer 32

You should intubate the patient and give IV fluid boluses to maintain a systolic blood pressure of at least 90 mm Hg.

Question 33

Which of the following statements regarding compression injuries of the chest is correct?

Answer 33

Injury tolerance to compression decreases as velocity increases.

Question 34

A 72-year-old female slipped on a throw rug and fell, landing on her left hip. She is conscious and alert and in severe pain. Her left knee is flexed and she has a strong pedal pulse. Further assessment reveals no other obvious injuries and her vital signs are stable. The MOST appropriate method for splinting this patient’s hip involves:

Answer 34

Padding beneath the knee, placing her onto a scoop stretcher, padding around her hip, and securing her to the scoop stretcher.

Question 35

A 44-year-old male was struck across the face with a steel pipe during an assault. Your assessment reveals marked swelling and ecchymosis to his midfacial area. He has nasal discharge, blurred vision, and is unable to follow your finger above the midline with his left eye. These clinical findings are MOST indicative of an:

Answer 35

Orbital skull fracture

Question 36

The ratio of red blood cells to plasma is called:

Answer 36

The hematocrit

Question 37

A 39-year-old 120-pound woman sustained partial- and full-thickness burns to her head, face, and anterior chest. She is tachypneic, tachycardic, and hypotensive. When caring for her, you should:

Answer 37

Suspect that she has internal hemorrhage from an occult injury.

If the burn patient has signs of shock in the field, you should suspect internal hemorrhage from an occult injury. This patient has burns that cover 18% of her body surface area (anterior chest: 9%, head and face: 9%).

Question 38

When assessing the pupils of a patient with a severe closed head injury, you note that they are bilaterally dilated and nonreactive. What does this specifically indicate?

Answer 38

Pressure on the oculomotor nerve.

The oculomotor nerve (cranial nerve III) arises from the midbrain and exits the brain to each eye. It controls the upper eyelid muscle, which raises the eyelid; the extraocular muscle, which moves the eye inward; and the pupillary muscle, which constricts the pupil. Damage to or pressure on this nerve will cause the pupils to dilate and fail to constrict when light is shone into them.

Question 39

A 19-year-old male fell during a basketball game and landed directly on his right elbow when his arm was flexed. He is in moderate pain. Your assessment reveals obvious deformity to the elbow. You are unable to feel a radial pulse, and his forearm is cool and pale. You should:

Answer 39

Splint the injury in the position found and transport without delay.

Question 40

A 17-year-old female was ejected from her car during a motor vehicle crash. You find her in a supine position lying motionless. She is conscious, but confused, and her skin is warm and dry. Her blood pressure is 76/50 mm Hg, her pulse rate is 54 beats/min, and her respiratory rate is 26 breaths/min. You should treat this patient for:

Answer 40

Neurogenic shock

Taking into consideration the mechanism of injury, the fact that the patient is motionless (likely from a spinal injury), and the absence of tachycardia, pallor, and diaphoresis, neurogenic shock should be suspected.

Question 41

Mastoid bruising and cerebrospinal otorrhea following diffuse impact to the head are MOST indicative of:

Answer 41

A basilar skull fracture

Mastoid bruising - battle sign

cerebrospinal otorrhea - CSP leakage from ears

Question 42

Which of the following vehicle impacts will create the greatest amount of kinetic energy?

Answer 42

150 lb pt traveling at 60 MPH

Question 43

Using the adult Rule of Nines, the anterior thorax accounts for what percent of the total body surface area?

Answer 43

9

Question 44

Which of the following factors or conditions would MOST likely impair hemostasis and increase the risk of complications from blunt trauma?

Answer 44

Liver disease

Hemostasis is the body’s natural response to an injury. The hemostatic process involves vasoconstriction, formation of a platelet plug, coagulation, and the growth of fibrous tissue that permanently seals the damaged blood vessel. Numerous factors or conditions can interfere with the blood’s ability to clot (the clotting cascade), thereby impairing the process of hemostasis.

Question 45

A 39-year-old man, who weighs approximately 160 pounds, was trapped inside his burning house and sustained full-thickness burns to approximately 40% of his body. On the basis of the Parkland formula, how much IV crystalloid solution should he receive within the first hour?

Answer 45

730 mL

The Parkland formula, which is used to determine how much IV crystalloid fluid a severely burned patient should receive within the first 24 hours following the burn, is calculated as follows: 4 mL × patient’s weight in kilograms × percentage of body surface area (BSA) burned. On the basis of this formula, a 160-lb (73 kg [160 ÷ 2.2 = 73]) should receive 11,680 mL of IV crystalloid fluid within the first 24 hours following the burn: 4 mL × 73 (kg) × 40 (% BSA burned) = 11,680 mL. The Parkland formula further states that half of the 24-hour fluid amount should be given within the first 8 hours following the burn. Therefore, the calculation continues as follows: 11,680 mL (24-hour fluid amount) ÷ 2 = 5,840 mL (8-hour fluid amount). Thus, if 5,840 mL is to be delivered over 8 hours, the patient should receive 730 mL of IV crystalloid per hour, as follows: 5,840 mL ÷ 8 = 730 mL.

Question 46

A middle-aged male experienced partial-thickness splash burns to 36% of his body surface area. The burns are all located above his waist. What parts of his body have been burned?

Answer 46

Anterior torso and both arms

Question 47

Which of the following is an abnormal physiologic process that occurs at the capillary level during shock?

Answer 47

Precapillary sphincter relaxation in response to lactic acid buildup

Question 48

Following a spinal injury, your patient experiences a loss of proprioception. This means that:

Answer 48

The patient is unaware of one body part in relation to another.

Question 49

Which of the following is considered an early sign of shock?

Answer 49

Increased rate of respirations

Question 50

Which of the following organs would produce the MOST severe blood loss following trauma to the abdomen?

Answer 50

Liver

Question 51

You are assessing a trauma patient and suspect that he is experiencing hemorrhagic shock. Which of the following assessment findings would support this suspicion?

Answer 51

Narrowing pulse pressure

Question 52

Which of the following spinal cord injuries classically presents with weakness of the upper and lower extremities on the ipsilateral side and loss of pain and temperature sensation on the contralateral side?

Answer 52

Brown-Sequard syndrome

Brown-Séquard syndrome is caused by partial transection (hemitransection) of the spinal cord, typically from intervertebral disk rupture or an unstable vertebral fragment that puts pressure on the spinal cord. Classically, pressure on half of the spinal cord causes extremity weakness on the ipsilateral (same) side as the cord injury, and loss of pain and temperature sensation on the contralateral (opposite) side.

Question 53

Which of the following should be your MOST immediate priority when caring for a patient with a closed femur fracture?

Answer 53

Manually stabilize the leg

Question 54

A construction worker fell approximately 30 feet and landed on a concrete surface. He is responsive to pain only; has rapid, shallow respirations; and has a slow, weak pulse. As your partner maintains manual stabilization of his head and assists his ventilations, you perform a rapid head-to-toe assessment. The patient has a closed deformity to his right femur, numerous abrasions, an open deformity to his right humerus, and deformity in the area of the fifth thoracic vertebra. His blood pressure is 74/50 mm Hg. What is the MOST likely pathophysiology of this patient’s clinical presentation?

Answer 54

Relative hypovolemia due to impaired adrenergic function

Question 55

Following blunt force trauma to the anterior chest, a man presents with difficulty breathing, engorged jugular veins, absent breath sounds over the left side of the chest, and hypotension. Which of the following BEST describes the pathophysiology of this patient’s injury?

Answer 55

Increased pressure in the pleural space is compressing the great vessels

Question 56

A 170-pound male experienced partial- and full-thickness burns to 45% of his body surface area. Transport to the closest appropriate facility will take longer than an hour, so medical control has ordered you to begin IV fluid therapy based on the Parkland formula. According to this formula, how much IV fluid should the patient receive per hour?

Answer 56

870 mL

Question 57

You should be MOST suspicious that your patient has experienced a cardiac tamponade if he or she presents with:

Answer 57

Hypotension, jugular venous distention, and normal lung sounds.

Normal lung sounds rules out pneumothorax

Question 58

A 30-year-old man has a closed head injury and is unresponsive. His left pupil is dilated and he has extensor posturing. His BP is 180/100 mm Hg, his pulse rate is 50 beats/min, and his respirations are 8 breaths/min and irregular. Treatment for him should include:

Answer 58

Intubation with ventilations aimed at maintaining an ETCO2 of 30 to 35 mm Hg.

The patient has a severe traumatic brain injury (TBI) with a classic Cushing’s triad presentation (ie, hypertension, bradycardia, irregular breathing). There is also evidence of cerebral herniation (ie, unresponsive, asymmetric pupils, extensor [decerebrate] posturing). His airway should be secured with an ET tube, after a period of preoxygenation with a bag-valve mask device. The Brain Trauma Foundation (BTF) recommends hyperventilation (20 breaths/min in adults) if signs of cerebral herniation are present. Optimally, you should ventilate the patient to maintain an ETCO2 between 30 and 35 mm Hg. In such brain-injured patients, brief periods of hyperventilation may be beneficial.

Question 59

Assessment of a patient with blunt chest trauma reveals labored breathing, tachycardia, pallor, diaphoresis, collapsed jugular veins, and absent breath sounds over the right hemithorax. You should:

Answer 59

Support ventilations, treat for shock, and prepare for transport.

Question 60

Which of the following signs is LEAST suggestive of an underlying arterial injury in a patient with a closed extremity fracture?

Answer 60

Disproportionate pain

Question 61

Which of the following statements regarding vehicle airbags is correct?

Answer 61

Most airbag-related deaths are the result of the occupant being too close to the airbag when it deploys.

Question 62

Which of the following assessment findings is LEAST indicative of spinal cord injury?

Answer 62

Posturing

Posturing, decorticate (flexor) or decerebrate (extensor), is a sign of brainstem injury. Remember that the spinal cord must be intact for the extremities to move, either voluntarily or involuntarily.

Question 63

A 66-year-old man tripped on a throw rug and fell on his outstretched left hand. He presents with swelling, ecchymosis, and severe pain to his left shoulder. He is conscious and alert, and denies striking his head or losing consciousness. His blood pressure is 148/88 mm Hg, pulse is 76 beats/min and strong, and respirations are 20 breaths/min and adequate. Pulse, sensory, and motor functions are grossly intact in all of his extremities. The MOST appropriate treatment for this patient includes:

Answer 63

Premedicating with fentanyl or ketamine and splinting his shoulder in a comfortable position.

Because your patient is hemodynamically stable, you should consider administering analgesia prior to splinting.

Question 64

The baroreceptors in the aortic arch and carotid sinuses are extremely sensitive to:

Answer 64

Changes in arterial perfusion pressure

Question 65

A 51-year-old male experienced partial thickness burns to his face, chest, and arms while trying to ignite a brush pile using gasoline. Upon arriving at the scene, the patient is found sitting on the ground in a safe area. He is conscious and alert and complains of intense pain. He is still wearing his shirt, but there are areas of smoldering fabric that have adhered to his skin. You should:

Answer 65

Remove the part of his shirt that is not adhered to the skin and apply water to the adhered fabric to ensure the burning process has stopped.

Question 66

A 65-year-old woman remains in asystole after 20 minutes of attempted resuscitation, including high-quality CPR, adequate airway management, appropriate drug therapy, and assessment for potentially reversible causes. The patient’s husband and son are present and have observed your resuscitative efforts. At this point, it would be MOST appropriate to:

Answer 66

Explain the situation to her husband and son and recommend cessation of resuscitative efforts.

Question 67

A hiker fell approximately 25 feet and is semiconscious. There is obvious deformity to his thoracic spine and he has a large laceration on his forehead. His BP is 60/40 mm Hg, pulse is 50 beats/min, and respirations are 26 breaths/min. His face and chest are pale and diaphoretic, but his abdomen and lower extremities are pink, warm, and dry. Which of the following BEST describes the pathophysiology of these findings?

Answer 67

Loss of nervous system control over the systemic vasculature

Question 68

You are assessing a 21-year-old male who was stabbed in the left anterior chest. His blood pressure is 84/58 mm Hg, pulse rate is 118 beats/min and weak, and respirations are 28 breaths/min and shallow. Further assessment reveals that he is profusely diaphoretic, has engorged jugular veins, and bilaterally equal breath sounds. What additional clinical finding is MOST consistent with this patient’s injury?

Answer 68

Electrical alternans

Question 69

Which of the following requires immediate removal of an ambulance from service?

Answer 69

brake fade

Question 70

A 30-year-old man has an obvious head injury. You are unable to locate any other injuries during your rapid assessment. He has a blood pressure of 84/62 mm Hg, a weak pulse rate of 124 beats/min, and respirations of 28 breaths/min. Which of the following represents the MOST appropriate treatment for this patient?

Answer 70

High-flow oxygen and a 10 to 20 mL/kg bolus of normal saline

Question 71

A trauma patient has signs of shock, but no external signs of injury. Which of the following should you suspect?

Answer 71

Intraabdominal hemorrhage

Question 72

Which of the following parameters yields the lowest cerebral perfusion pressure?

Answer 72

BP, 105/60 mm Hg; intracranial pressure, 20 mm Hg

Question 73

Which of the following sets of vital signs is MOST indicative of neurogenic shock?

Answer 73

BP, 70/50 mm Hg; pulse rate, 56 beats/min; respirations, 24 breaths/min

Question 74

A 44-year-old male was near a building when it exploded. He presents with widespread burns, hemoptysis, and blunt head trauma with signs of increased intracranial pressure. This patient MOST likely experienced his head injury during the ___________ phase of the explosion.

Answer 74

Tertiary

Question 75

A semiconscious young female has just been extricated from her wrecked vehicle. Her airway is patent, her respirations are rapid and shallow, and her pulse is rapid and weak. She has bilaterally closed femur fractures; an open humerus fracture with active bleeding; a rigid, distended abdomen; and a large hematoma to her forehead. The closest trauma center is 25 miles away. What interventions should you perform at the scene?

Answer 75

Bleeding control, ventilatory assistance with a bag-valve-mask and 100% oxygen, and full spinal precautions

Question 76

Common clinical signs of a hemothorax include all of the following, EXCEPT:

Answer 76

Mediastinal shift

Question 77

In an otherwise healthy 70-kg adult, hypotension is typically noted after he or she has lost ____________ of his or her blood volume.

Answer 77

More than 1500 mL

Question 78

After being struck in the head with a baseball bat, a 9-year-old boy immediately loses consciousness. On your arrival, he is conscious but confused. Shortly into your assessment, he becomes unresponsive. Which of the following injuries has this child MOST likely sustained?

Answer 78

Epidural hemorrhage

Question 79

Common signs of a maxillofacial fracture include all of the following, EXCEPT:

Answer 79

Asymmetric pupils.