Trauma

Question 1

You are called to treat a patient who has burns to the anterior abdomen and the anterior aspects of both arms. Using the Rule of Nines, what percentage of the body surface area do these burns account for?

A) 0.09
B) 0.18
C) 0.27
D) 0.36

Answer 1

Answer: B

The anterior abdomen accounts for 9% of the body surface area (the anterior trunk [chest and abdomen] accounts for 18% of the body surface area). The entire arm accounts for 9%; therefore, the anterior arm accounts for 4.5%. Both anterior arms and the anterior abdomen account for 18% of the body surface area.

Question 2

When performing a rapid assessment on a young male who fell approximately 25 feet, you should assess the chest for:

A) distention and rigidity.
B) distention and crepitus.
C) distention and lung sounds.
D) symmetry and tenderness.

Answer 2

Answer: D

When assessing the chest of a trauma patient during the rapid assessment, you should note any deformities, contusions, abrasions, penetrating injuries, burns, tenderness, lacerations, and swelling or symmetry of the chest wall. Further assessment should include auscultation of breath sounds (apices and bases) and heart tones. Crepitus should not be intentionally elicited; it is a coincidental finding. Although bleeding may be occurring in the chest, the ribcage prevents the chest from becoming distended. Distention is commonly seen in patients with intraabdominal bleeding.

Question 3

During transport of a patient with a closed head injury, which of the following signs is MOST important to monitor?

A) Mental status
B) Blood pressure
C) Respiratory rate
D) Pupillary reaction

Answer 3

Answer: A

Changes in the patient’s mental status after a closed head injury may be subtle; therefore, it is critical to continuously monitor the patient’s level of consciousness throughout transport. BP, respiratory rate, and pupillary reaction are clearly important parameters to monitor; however, changes in mental status are often the earliest indicator of clinical deterioration.

Question 4

A 21-year-old man sustained a large laceration to the left groin area when the chainsaw he was using to cut wood slipped. Bright red blood is spurting from the wound, which he is attempting to control without success. You should:

A) assess the status of his airway and breathing.
B) apply an icepack to the wound and elevate his leg.
C) give high-flow oxygen by nonrebreathing mask.
D) apply a multitrauma dressing to the wound

Answer 4

Answer: D

Profuse bleeding must be controlled immediately. In this scenario, the patient is attempting to control the bleeding himself; the fact that he is doing this indicates that his airway is not compromised. Therefore, you should apply direct pressure to the wound with a multitrauma or other bulky dressing. After you have controlled the bleeding, apply high-flow oxygen and continue your assessment. Applying icepacks to the wound and elevating his leg would simply waste time; the quickest and most effective means of controlling external bleeding is the use of direct pressure.

Question 5

When struck by an automobile, a typical sequence of events in the adult includes turning:

A) toward the vehicle and being thrown onto the hood.
B) toward the vehicle and being propelled away from the car.
C) away from the vehicle and being thrown onto the hood.
D) away from the vehicle and being propelled away from the car.

Answer 5

Answer: C

Typically, when an adult is struck by an automobile, the initial instinct is to turn away from the car. The initial point of impact is generally to the lateral or posterior aspect of the body. The patient is then thrown onto the hood or windshield and then propelled away from the automobile. By contrast, children typically turn toward the vehicle, and the initial point of impact depends on the child’s height and the height of the bumper at the time of impact.

Question 6

Which of the following patients is MOST in need of rapid extrication from an automobile after a crash?

A) 16-year-old girl with tachycardia and abrasions to her arms
B) 28-year-old man with a unilateral femur fracture and confusion
C) 40-year-old man with an open head injury and partial decapitation
D) 56-year-old woman with a Colles fracture and severe emotional upset

Answer 6

Answer: B

The patient with confusion would be the best candidate for a rapid extrication. Any altered mental status after trauma should be assumed to be the result of a head injury, cerebral hypoxia, or both. Open head injury and partial decapitation are injuries that are clearly not compatible with life; therefore, rapid extrication of this patient would be a low priority. Rapid extrication is performed by applying a cervical collar to the patient and quickly removing him or her from an automobile onto a long backboard.

Question 7

Your first priority in caring for a patient with a swollen, painful, and deformed forearm is to:

A) align the deformity.
B) assess distal pulses.
C) immobilize the injury.
D) prevent further injury.

Answer 7

Answer: D

As with any patient, preventing further harm or injury is your initial priority of patient care. In a patient with a swollen, painful deformity, the injury should be manually stabilized until completely immobilized. Distal perfusion, sensory, and motor functions should be assessed before and after immobilization.

Question 8

While assessing a patient with a painful deformity to the left humerus, you should:

A) check range of motion in the elbow.
B) manipulate the injury to elicit crepitus.
C) check range of motion in the shoulder.
D) assess the pulse at the radial artery.

Answer 8

Answer: D

As with any extremity injury, you should assess the pulse that is most distal to the injury. If it is present, you will know that the entire extremity is being perfused. In the patient with a painful deformity of the humerus, the pulse most distal is the radial pulse. Crepitus, a grating sound heard when broken bone ends rub together, is often noted as a coincidental finding while assessing an extremity fracture; however, you should never manipulate an extremity injury for the expressed purpose of eliciting this sign. Splint the joints above and below the injured bone; in this case, the shoulder and elbow. Do not check range of motion in an obviously injured extremity.

Question 9

Initial treatment for a patient with a large open wound to the leg includes:

A) assessing a pedal pulse.
B) splinting the entire extremity.
C) cleaning the wound with peroxide.
D) applying a dry, sterile dressing.

Answer 9

Answer: D

Initial treatment for any soft-tissue injury includes controlling external bleeding. The most effective method of doing this is to apply direct pressure to the wound with a dry, sterile dressing. Assessment of distal perfusion, sensory, and motor functions is performed after you have controlled the bleeding. In most cases, open wounds are not irrigated in the prehospital setting. Splinting an extremity that has an open wound may be considered, but only after controlling any bleeding.

Question 10

Which of the following sets of vital signs is MOST suggestive of increased intracranial pressure in a patient with a closed head injury?

A) BP, 80/40 mm Hg; pulse, 68 beats/min and weak; respirations, 20 breaths/min and irregular
B) BP, 90/60 mm Hg; pulse, 130 beats/min and weak; respirations, 34 breaths/min and irregular
C) BP, 180/88 mm Hg; pulse, 64 beats/min and bounding; respirations, 40 breaths/min and irregular
D) BP, 174/80 mm Hg; pulse, 120 beats/min and thready; respirations, 30 breaths/min and irregular

Answer 10

Answer: C

As intracranial pressure (ICP) increases, the body attempts to shunt more blood to the brain by increasing mean arterial pressure (MAP); clinically, this manifests as hypertension. As a reflex response to an increase in BP, the heart rate decreases. Hypoxia of, or injury to, the brain stem can result in a variety of abnormal breathing patterns (slow and irregular or rapid and irregular). Clinical findings of hypertension, bradycardia, and abnormal respirations (Cushing triad) are a classic sign of increased ICP. Hypotension and bradycardia may be seen in patients with neurogenic shock. Hypotension and tachycardia is classically seen in patients with decompensated hypovolemic or septic shock. Hypertension and tachycardia may be seen in patients with congestive heart failure or a hypertensive crisis.

Question 11

While assessing an elderly woman who fell, you note crepitus and pain in the pelvis. The patient has no other visible injuries. She is conscious but very restless, and her skin is warm and dry. Her blood pressure is 78/48 mm Hg and her heart rate is 62 beats/min. She has a history of hypertension and takes Tenormin. Which of the following would MOST likely explain her clinical presentation?

A) The patient has most likely sustained a severe head injury
B) The patient has sustained a spinal injury and is in neurogenic shock
C) Beta blockers often blunt the normal physiologic response to shock
D) Elderly patients generally do not respond to shock with tachycardia

Answer 11

Answer: C

This patient is in hypovolemic shock because of the pelvic fracture. Beta-blocking medications (atenolol [Tenormin], metoprolol [Lopressor], propranolol [Inderal], or esmolol [Brevibloc]) inhibit sympathetic nervous system discharge, thereby reducing the amount of epinephrine and norepinephrine that is secreted. These catecholamines are responsible for the classic signs of shock (ie, tachycardia, pallor, diaphoresis). Although the patient’s ability to compensate for shock diminishes with age, one cannot say that elderly patients do not respond to shock with tachycardia. The patient’s vital signs are not consistent with a severe head injury, which typically presents with hypertension and bradycardia. Neurogenic shock cannot be ruled out, although the mechanism of injury and your clinical findings (unstable pelvis) do not suggest this.

Question 12

A 22-year-old construction worker fell approximately 25 ft and landed on his head. Your primary assessment reveals that the patient is unresponsive with rapid, irregular respirations, and is bleeding from the nose. As your partner manually stabilizes the patient’s head and opens his airway, you should:

A) insert a supraglottic airway to prevent aspiration.
B) look behind the ears for signs of a basilar skull fracture.
C) apply a nonrebreathing mask at a flow rate of 15 L/min.
D) insert an airway adjunct and begin assisting his ventilations.

Answer 12

Answer: D

After opening an unresponsive patient’s airway, you must ensure that there are no secretions or debris in the patient’s mouth. Use suction as needed. If the airway is clear, insert a simple airway adjunct (in this case, an oral airway; nasal airways are contraindicated in patients with a head injury) and evaluate breathing adequacy. Rapid, irregular, respirations will likely not provide adequate minute volume; therefore, you should assist the patient’s ventilations with a bag-mask device attached to high-flow oxygen. More advanced airway techniques (supraglottic airways and multilumen airways) can be considered, but not before ensuring adequate ventilation and oxygenation with more basic means. Furthermore, supraglottic airway devices (ie, King LT, CobraPLA, LMA) do not prevent aspiration. Assessing the patient for signs of a basilar skull fracture should occur during your rapid head-to-toe assessment of the patient, after you have addressed any problems with the ABCs.

Question 13

Management of a patient with partial-thickness burns to 27% of her body and stable vital signs includes:

A) local cooling with sterile saline or water.
B) pulling clothing from the burned areas.
C) covering the burns with moist dressings.
D) transport to a local community hospital.

Answer 13

Answer: A

Partial-thickness (second-degree) burns are typically very painful because the nerves of the dermis have been partially damaged and are hypersensitive. If the patient is not in shock, provide local cooling by pouring sterile saline or water over the burned areas and then covering them with dry, sterile dressings. Moist, sterile dressings should not be applied to any significant burn, regardless of the depth, because this may increase the risk of infection. Clothing should be cut away from burned areas, not pulled off. Patients with burns that cover more than 20% of their body surface area should, at a minimum, be transported to a trauma center. Depending on local protocols and the hemodynamic status of the patient, he or she may be transported directly to a burn facility.

Question 14

A 25-year-old man is found semiconscious by his wife. The patient was struck in the side of the head while playing baseball the day before and had been complaining of a headache ever since. You should be MOST suspicious that this patient has a/an:

A) cerebral contusion.
B) moderate concussion.
C) subdural hemorrhage.
D) epidural hemorrhage.

Answer 14

Answer: C

A subdural hemorrhage is usually caused by injury to a vein within the cranium and can be an elusive injury. The patient may or may not lose consciousness immediately after the injury; however, as the vein continues to slowly bleed, intracranial pressure increases and the patient’s condition deteriorates. Deterioration can occur as long as 24 to 48 hours after the injury. An epidural hemorrhage typically causes rapid deterioration in the patient’s condition because it is usually the result of an arterial hemorrhage. Patients with a cerebral concussion may lose consciousness immediately after the injury; however, their condition usually improves over time. A cerebral contusion cannot be ruled out; however, you should err on the side of caution and assume the worst case scenario, an intracranial hemorrhage.

Question 15

An unrestrained woman struck the steering wheel after her car hit a utility pole. She complains of 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. Based on this information, you should suspect:

A) a flail chest.
B) an esophageal injury.
C) a myocardial contusion.
D) a pericardial tamponade.

Answer 15

Answer: C

The mechanism and location of the injury, and the irregularity of the patient’s pulse, suggests a myocardial contusion. Patients with this type of injury can experience all of the same negative effects associated with an acute myocardial infarction, including cardiogenic shock, arrhythmias, and cardiac arrest.

Question 16

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

A) increases in arterial carbon dioxide.
B) changes in arterial perfusion pressure.
C) fluctuations in the level of arterial oxygen.
D) changes in the rate and contractility of the heart.

Answer 16

Answer: B

Baroreceptors also are known as pressure receptors. They are located within the carotid arteries and aortic arch and are extremely sensitive to changes in arterial perfusion pressure (blood pressure). When the baroreceptors sense a drop in blood pressure, they send signals by the sympathetic nervous system, which results in the release of catecholamines (epinephrine and norepinephrine) that constrict the vasculature and increases heart rate and myocardial contractility to maintain arterial perfusion pressure. Chemoreceptors sense the levels of oxygen and carbon dioxide in the blood, as well as the pH of the cerebrospinal fluid, and send messages to the respiratory centers in the brainstem to adjust respiratory rate and depth accordingly.

Question 17

The initial injury sustained by a person from an explosion usually is caused by:

A) flying projectiles.
B) the pressure wave.
C) being thrown into a structure.
D) widespread burns to the body.

Answer 17

Answer: B

The blast from an explosion causes a wave of pressure. This wave causes the initial injury to the patient, usually in the form of barotrauma, which can rupture hollow organs and the tympanic membrane (eardrum). Secondary injuries occur when the patient is struck by flying debris, and tertiary injuries result from the patient being thrown into fixed structures or other hard surfaces. Burns can occur during any phase of an explosion.

Question 18

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

A) Liver
B) Spleen
C) Kidney
D) Stomach

Answer 18

Answer: A

Relative to the other solid organs (spleen and kidneys), the liver is a very large, highly vascular organ that produces several clotting factors, including fibrinogen and prothrombin. In addition, the blood within the liver parenchyma does not clot and a significant portion of the blood volume is in the liver at any given time. Because of these factors, lacerations of the liver cause profuse internal bleeding and can result in death from exsanguination very quickly. The stomach is a hollow organ; when hollow organs rupture or are lacerated, they spill their contents into the abdominal cavity, resulting in peritonitis.

Question 19

Which of the following clinical signs is often present in patients with a significant head injury and increased intracranial pressure?

A) Projectile vomiting
B) Eupneic respirations
C) Pupillary constriction
D) Kussmaul respirations

Answer 19

Answer: A

Signs and symptoms of a significant head injury with increased intracranial pressure (ICP) include unequal or nonreactive pupils, projectile vomiting, and grossly abnormal breathing patterns (ie, Cheyne-Stokes breathing, central neurogenic hyperventilation, Biot [ataxic] breathing), among others. Eupneic respirations are normal respirations, and Kussmaul respirations (deep, rapid breathing with an acetone breath odor) are seen in patients with diabetic ketoacidosis.

Question 20

When assessing a patient who experienced severe chest trauma, which of the following findings is MOST indicative of a tension pneumothorax?

A) Difficulty breathing
B) Mediastinal shift
C) Flat jugular veins
D) Chest wall bruising

Answer 20

Answer: B

A tension pneumothorax occurs when a lung perforation acts as a one-way valve by allowing air to enter the pleural space, but preventing it from escaping. As a result of pleural tension, the affected lung collapses. As pleural tension increases further, pressure shifts across the mediastinum (the space between the lungs), causing it to shift to the opposite side. Any number of chest injuries can cause difficulty breathing and chest wall bruising, including rib fractures and flail chest. Flat jugular veins are a sign of a massive hemothorax; in a tension pneumothorax, the jugular veins are typically distended.

Question 21

During your rapid assessment of a man who sustained blunt trauma to the anterior chest, you note the presence of paradoxical movement to the left hemithorax. You should:

A) tape the chest wall circumferentially to minimize pain.
B) place an IV bag over the injured area to provide stabilization.
C) ventilate the patient with a manually triggered device.
D) have your partner stabilize the chest wall with a bulky dressing.

Answer 21

Answer: D

Paradoxical chest wall movement is a classic sign of a flail chest. Once discovered, you should instruct your partner to immediately stabilize the flail segment. This may be accomplished initially with hand stabilization, but should be stabilized with a bulky dressing as soon as possible. You should then continue with your rapid assessment of the patient. Circumferentially taping the chest wall may impair breathing and should be avoided. Heavy objects, such as sandbags or IV bags, should not be placed over a flail segment; they may push the section of fractured ribs further into the chest cavity and injure a lung or impair breathing. Manually triggered ventilation devices should not be used in patients with thoracic trauma because they may cause barotrauma and further pulmonary injury.

Question 22

In which of the following situations would external bleeding be the MOST difficult to control?

A) Carotid artery laceration; BP of 108/58 mm Hg
B) Brachial artery laceration; BP of 60/40 mm Hg
C) Femoral artery laceration; BP of 160/90 mm Hg
D) Popliteal artery laceration; BP of 120/78 mm Hg

Answer 22

Answer: C

The severity of external bleeding and the ease or difficulty in controlling it are largely related to the type and size of the injured vessel and the pressure exerted on that vessel (BP). The larger the blood vessel and the higher the BP, the more difficult the bleeding is to control. Of the choices listed, a femoral artery laceration with a BP of 160/90 mm Hg presents the greatest challenge when attempting to control the external bleeding. Furthermore, it is extremely difficult, if not impossible, to apply a tourniquet proximal to the groin, which is where the femoral artery is located.

Question 23

During your assessment of a patient who fell, you note the absence of sensation and movement below the umbilicus. What area of the spinal cord is MOST likely injured?

A) C3
B) C5
C) T4
D) T10

Answer 23

Answer: D

The umbilicus is at the level of the 10th thoracic vertebra (T10). The clavicles are at the level of the fifth cervical vertebra (C5), and the nipple line is at the level of the fourth thoracic vertebra (T4). By noting where the deficit is, you can approximate the area of the spinal cord injury.

Question 24

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?

A) Anterior torso and both arms
B) Chest, neck, and both arms
C) Chest, head, and one arm
D) Abdomen and one arm

Answer 24

Answer: A

According to the adult Rule of Nines, the head (including the face and neck) represents 9% of the total body surface area (TBSA), the anterior torso (chest and abdomen) represents 18% of the TBSA, and each entire upper extremity represents 9% of the TBSA. Given that all of the patient’s burns are located above the waist, the only combination in this question that equals 36% is the anterior torso (18%) and both arms (18%). The chest is one-half of the torso; therefore, it represents 9% of the TBSA. The abdomen is also one-half of the torso; therefore, it also represents 9% of the TBSA. Burns to the abdomen and one arm would equal 18% of the TBSA. Burns to the chest, head, and one arm would equal 27% of the TBSA. Burns to the chest, neck, and both arms would equal ± 30% of the TBSA.

Question 25

You are treating a patient who sustained severe trauma to the chest after his car collided head-on with a tree. The patient’s initial BP is 100/60 mm Hg with 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?

A) BP 80/40 mm Hg, pulse 130 beats/min
B) BP 90/70 mm Hg, pulse 126 beats/min
C) BP 104/70 mm Hg, pulse 100 beats/min
D) BP 160/90 mm Hg, pulse 112 beats/min

Answer 25

Answer: B

Because of blood accumulation within the pericardial sac, cardiac contraction is restricted, which causes a drop in the systolic pressure, and full relaxation of the cardiac muscle is inhibited, causing an increase in the diastolic pressure. The difference between the systolic and diastolic pressures is called the pulse pressure, which becomes narrowed with a pericardial tamponade. A BP of 90/70 mm Hg has a pulse pressure of only 20 mm Hg, which is less than any of the other values listed.

Question 26

After controlling external bleeding from a large laceration, you obtain a 32-year-old man’s vital signs and note a BP of 112/70 mm Hg and a heart rate of 116 beats/min. The patient is conscious and alert, but diaphoretic. Which of the following is the MOST appropriate IV therapy for this patient?

A) Two large-bore IV lines and a 2-L bolus of lactated Ringer solution
B) Two large-bore IV lines and repeated 20 mL/kg normal saline boluses
C) At least one large-bore IV and fluid boluses as needed to maintain radial pulses
D) At least one large-bore IV and 20 mL/kg fluid boluses to increase his BP

Answer 26

Answer: C

The patient’s BP is stable at this point and he is conscious and alert. He is, however, experiencing other signs of shock (tachycardia, diaphoresis). At least one large-bore IV (14- or 16-gauge catheter) should be started, and he should be given IV fluid boluses as needed to maintain adequate perfusion (normal mental status and radial pulses). Increasing his BP with fluids may cause him to start bleeding again; this is especially true for patients with internal bleeding, which you cannot control. Remember, the goal of IV therapy for the patient in shock is NOT to increase the BP, but to maintain adequate perfusion; mental status and the presence of peripheral pulses are excellent indicators of perfusion. If his condition deteriorates, a second large-bore IV should be started.

Question 27

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

A) Traumatic asphyxia
B) Massive hemothorax
C) Pericardial tamponade
D) Tension pneumothorax

Answer 27

Answer: C

Pulsus paradoxus is defined as a 10 to 15 mm Hg drop in the systolic blood pressure during inhalation, and is seen in patients with severe asthma, decompensated chronic obstructive pulmonary disease, and as a later sign in pericardial tamponade. In pericardial tamponade, the heart already is restricted from contracting because of blood in the pericardial sac, and when the lungs enlarge during inhalation, even more pressure is placed on the heart and literally stops it until the patient exhales. You can assess for pulsus paradoxus by palpating the radial pulse and noting that it markedly weakens (or even disappears) when the patient inhales and returns when the patient exhales.

Question 28

When securing a patient with a suspected spinal injury to a long backboard, it is important to:

A) secure the legs to the backboard first to prevent the patient from sliding.
B) secure the patient’s head first in case the patient has a cervical fracture.
C) apply devices, such as sandbags, for lateral stabilization of the head.
D) secure the patient’s torso as your partner manually stabilizes the head.

Answer 28

Answer: D

When securing a patient to a long backboard, short backboard, or a vest-style immobilization device, you must secure the patient’s torso before securing the head. If the head is secured first, it can be inadvertently manipulated as you secure the torso. Your partner must maintain constant manual stabilization of the patient’s head until the patient is fully immobilized. Sandbags should not be used as lateral immobilization for the head. If you must turn the immobilized patient onto his or her side (in case of vomiting), the weight of the sandbag forces the head from a neutral alignment and potentially complicates an existing spinal injury.

Question 29

During your rapid assessment of a patient with a gunshot wound, you discover an open wound to the right anterior chest. You should:

A) place a gloved hand or non-porous dressing over the wound.
B) immediately reevaluate the patency of the patient’s airway.
C) stop your assessment and prepare for immediate transport.
D) make a mental note of the injury and continue your assessment.

Answer 29

Answer: A

An open pneumothorax (sucking chest wound) must be sealed immediately on discovery so that air is not sucked into the wound, resulting in inadequate ventilation of the affected lung. Place a gloved hand or non-porous (occlusive) dressing over the wound; your partner can do this as you continue with your assessment. Remember, however, that once you have sealed a sucking chest wound, you must closely monitor the patient for signs of a developing tension pneumothorax. Assessing airway patency is a continual process during your assessment of a patient with serious trauma.

Question 30

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

A) Chest and abdominal trauma
B) Tibia, fibula, and pelvic fractures
C) Femur fractures and c-spine injury
D) Thoracic spine and femur fractures

Answer 30

Answer: C

When a motorcycle strikes a fixed object, the operator is ejected, striking his or her legs on the handlebars, which fractures one or both of the femurs. The operator then typically strikes the ground or object head first. Although a helmet clearly reduces the risk of a severe head injury, it does not prevent a cervical spine (c-spine) injury. Noting the mechanism of injury is a critical part of your assessment because it enables you to predict the type and severity of the patient’s injuries.

Question 31

Which of the following assessment findings is an obvious indicator of a severed spinal cord?

A) Paralysis
B) Priapism
C) Posturing
D) Paresthesia

Answer 31

Answer: A

A severed spinal cord (transection) results in total paralysis distal to the area of the transection. Priapism, posturing, and paresthesia indicate spinal cord injury; however, because motor activity is associated with these findings, the spinal cord is intact, at least to some degree.

Question 32

The average ratio of red blood cells to plasma in the adult is:

A) 35%.
B) 45%.
C) 55%.
D) 65%.

Answer 32

Answer: B

The average ratio of red blood cells to plasma, called the hematocrit, is 45% in the adult. This means that 45% of the total blood volume is composed of red blood cells and 55% is composed of plasma. There is some variation between males and females, however. A low hematocrit indicates whole blood loss, whereas an increased hematocrit indicates plasma loss, such as what may be seen with significant burns.

Question 33

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?

A) 570 mL
B) 650 mL
C) 730 mL
D) 815 mL

Answer 33

Answer: C

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]) patient 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 34

After a motorcycle accident, a 40-year-old woman has deformity to the fifth and sixth thoracic vertebrae, a BP of 80/50 mm Hg, and a heart rate of 74 beats/min. Her vital signs are MOST likely the result of:

A) impairment of the sympathetic nervous system.
B) damage to the parasympathetic nervous system.
C) spinal fracture with associated myocardial damage.
D) posterior pressure on the heart from spinal cord swelling.

Answer 34

Answer: A

Hypotension and a normal or slow heart rate, especially with accompanying trauma to the spine, is indicative of neurogenic (spinal) shock. Because the sympathetic nerves originate from the thoracic spine, injury to this area may impair the sympathetic pathways and inhibit the release of catecholamines (epinephrine and norepinephrine). These catecholamines result in the typical tachycardia, diaphoresis, and pallor seen in other types of shock (ie, hypovolemic, septic, anaphylactic). The mechanism of injury does not suggest myocardial damage.

Question 35

During your rapid assessment of a man with severe anterior chest trauma, you note that his jugular veins are flat, breath sounds are absent over the right hemithorax, and he is coughing up bright red blood. You should:

A) request a paramedic unit to perform a needle decompression of his chest.
B) aggressively manage his airway, treat for shock, and prepare for transport.
C) apply the pneumatic antishock garment, give high-flow oxygen, and transport.
D) immediately start two large-bore IV lines, assist his ventilations, and transport.

Answer 35

Answer: B

Your patient has signs of a massive hemothorax. His jugular veins are flat; breath sounds are absent on one side of the chest (hemithorax); and he is coughing up blood (hemoptysis). Patients with this type of injury require prompt surgical intervention; therefore, you must prepare for immediate transport to a trauma center. Aggressively manage his airway, ensure adequate ventilation and oxygenation, keep him warm, and transport without delay. Time consuming procedures, such as IV therapy, should be performed while you are en route to the hospital, not at the scene. Needle decompression, a skill that can only be performed by a paramedic, is indicated for patients with a tension pneumothorax, not a massive hemothorax. The PASG is contraindicated in any injury above the pelvis. Application of the PASG in patients with intrathoracic bleeding would likely only worsen the bleeding.

Question 36

A 21-year-old man has a large laceration to his wrist with profuse bleeding. You apply direct pressure to the wound with a sterile dressing, but it continues to bleed profusely. You should:

A) apply a pressure dressing and ice.
B) apply a proximal tourniquet at once.
C) elevate the extremity and start an IV line.
D) apply pressure to the brachial artery.

Answer 36

Answer: B

In most cases, external bleeding can be controlled with direct pressure; however, if a wound continues to bleed profusely despite direct pressure, you should apply a tourniquet proximal to the wound. Any profuse external bleeding must be stopped immediately or the patient will die. Evidence has shown that locating a proximal pressure point and applying enough pressure to it to control external bleeding is often difficult and time-consuming. Furthermore, elevation of the extremity has also been shown to be a less effective method of controlling severe external bleeding than was once thought. Only after controlling all external bleeding should you consider IV therapy.

Question 37

The diaphoresis seen in patients with shock is the result of:

A) peripheral vasoconstriction.
B) shunting of blood from the skin.
C) increased secretion by the sweat glands.
D) decreased peripheral vascular resistance.

Answer 37

Answer: C

Patients in shock are diaphoretic because sympathetic nervous system stimulation causes increased secretions of sweat. Peripheral vasoconstriction results in shunting of blood to the central organs and gives the skin a pale appearance and cool or cold temperature because of a markedly diminished peripheral blood flow.

Question 38

You respond to the scene of a local knife-throwing contest for an injured person. On your arrival, you find a man with a large knife impaled in the center of his chest, in between the nipples. Assessment reveals that he is unresponsive, apneic, and pulseless. You should:

A) stabilize the knife in place and provide rapid transport to the hospital.
B) stabilize the knife in place, begin CPR, and provide rapid transport to the hospital.
C) remove the knife, apply the AED pads, and provide rapid transport to the hospital.
D) remove the knife, control bleeding, begin CPR, and provide rapid transport to the hospital.

Answer 38

Answer: D

There are two situations in which you should remove an impaled object: if the object is causing ventilatory compromise or impairing your ability to manage the patient’s airway, or if an object is impaled in a location that interferes with your ability to perform CPR. In this patient, the knife is impaled in the center of the chest, in between the nipples (precordium). This is the area where chest compressions are performed. You must remove the knife, control any external bleeding, begin CPR, and rapidly transport the patient to the hospital. The AED is generally not indicated for patients with traumatic cardiac arrest.

Question 39

The pneumatic antishock garment (PASG) may be useful for patients with:

A) pelvic instability and significant hypotension.
B) open abdominal trauma with severe bleeding.
C) blunt chest trauma with signs of hypoperfusion.
D) bilateral femur fractures with congestive heart failure.

Answer 39

Answer: A

Most EMS systems no longer carry the PASG on their ambulances. However, the PASG may be useful for patients with unstable pelvic fractures and signs of shock (ie, hypotension, weak or absent peripheral pulses), but only as a stabilization device. The PASG may also be useful in stabilizing bilateral femur fractures. Newer devices are on the market, such as the SAM sling pelvic binder, and are much easier and quicker to apply. The PASG is contraindicated for any injury above the last rib, which includes open abdominal trauma. The PASG is absolutely contraindicated in any patient with pulmonary edema, such as a patient with congestive heart failure. Follow your local protocols regarding the use of the PASG.

Question 40

Immediate care for a severely burned patient includes:

A) ensuring a patent airway.
B) moving the patient to safety.
C) stopping the burning process.
D) applying dressings to the burns.

Answer 40

Answer: B

Before taking care of any patient, you must ensure that you, your partner, and the patient are in a place of safety. Once safety is ensured, assessment and management of the patient can begin. In the case of a burn patient, you must first make sure that the burning process has stopped and then tend to the airway.

Question 41

A construction worker fell approximately 12 ft and sustained an open fracture of the femur. On inspection, you note that the distal femur is protruding through the skin. The MOST appropriate care for this patient’s injury includes:

A) applying a traction splint to the extremity and covering the wound.
B) providing manual traction to the extremity until the fracture is reduced.
C) immobilizing the extremity in a flexed position and transporting the patient.
D) covering the wound with a sterile dressing and immobilizing the extremity.

Answer 41

Answer: D

The fracture should be covered with a sterile dressing and stabilized in the position found. A traction splint should not be applied to an injury that occurs near the knee, especially if the fracture is open and the femur is protruding through the skin. Any action that could cause the femur to retract back into the thigh significantly increases the risk of infection.

Question 42

Which of the following represents the MOST appropriate technique for performing a rapid extrication from an automobile?

A) Apply an extrication collar, secure the patient to a short backboard, and quickly move the patient from the vehicle to a long backboard
B) Apply a vest-style extrication device and slide the patient onto a long backboard in the same position in which he or she was found
C) Apply an extrication collar, maintain manual stabilization of the head, rotate the patient onto a long backboard, and remove the patient from the vehicle
D) Maintain manual stabilization of the head without using an extrication collar, grasp the patient’s clothing, and remove the patient from the vehicle

Answer 42

Answer: C

Rapid extrication is performed on patients who are clinically unstable and is performed by placing an extrication collar on the patient and rotating the patient onto a long backboard for removal from the automobile. Use of a short spine board or vest-style immobilization device takes too much time to apply and is not practical for clinically unstable patients. If the patient or the AEMT’s life is in imminent danger, the patient is literally grabbed and dragged from the car, while providing as much spinal protection as possible (emergency move).

Question 43

Which of the following is a sign of a severe pericardial tamponade?

A) Marked decrease in pulse strength during inhalation
B) A rise in the systolic BP and a fall in the diastolic BP
C) Flat jugular veins when seated at a 45-degree angle
D) A marked decrease in the systolic BP during exhalation

Answer 43

Answer: A

Pulsus paradoxus, also called a paradoxical pulse, may be observed in patients with a severe pericardial tamponade. Pulsus paradoxus exists when the systolic BP drops by more than 10 to 15 mm Hg during inhalation or if a marked decrease in pulse strength is noted during inhalation. In some cases, the pulse may not be palpable at all during inhalation. This occurs because mechanical function of the heart, which is already impaired because of blood in the pericardial sac, is further impaired by lung inflation. Additional signs include a narrowing pulse pressure (falling systolic BP and rising diastolic BP); muffled or distant heart tones; and jugular venous distention (Beck triad).

Question 44

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

A) Fall from a height of 10 to 15 feet
B) Respiratory rate of 24 breaths/min
C) Two proximal long bone fractures
D) GCS that is equal to or less than 14

Answer 44

Answer: C

According to the 2011 Guidelines for Field Triage of Injured Patients, published by the Centers for Disease Control and Prevention (CDC), the AEMT should use certain predefined criteria when determining the most appropriate transport destination for the injured patient; these criteria are based on physiologic findings, anatomic findings, mechanism of injury, and special patient considerations. According to the guidelines, two or more proximal long bone fracture is an anatomic criterion for preferential transport to the highest level of care within the defined trauma system. A Glasgow Coma Scale (GCS) score that is equal to or less than 13 or a respiratory rate less than 10 breaths/min or greater than 29 breaths/min are physiologic criteria for transport to the highest level of trauma care. If an adult falls from greater than 20 feet, but does not meet any of the physiologic or anatomic criteria, he or she should be transported to a trauma center; depending on the defined trauma system, this need not be the highest level trauma center. If the patient does not meet any of the predefined criteria for transport to the highest level of trauma care, the AEMT should use his or her judgment or follow local protocol.

Question 45

A woman was ejected from her car after it struck a tree. You find her in a supine position lying motionless, conscious, and confused. Her BP is 80/40 mm Hg, her heart rate is 58 beats/min, and her respirations are 28 breaths/min. You should be MOST suspicious for:

A) neurogenic shock.
B) hypovolemic shock.
C) a severe head injury.
D) intraabdominal bleeding.

Answer 45

Answer: A

Taking into consideration the mechanism of injury and the fact that the patient is motionless (likely from a spinal injury) and is not tachycardic, neurogenic shock should be suspected. Neurogenic shock, referred to as spinal shock when it occurs because of a spinal injury, occurs when injury to the spinal cord interrupts the pathways that send messages to the sympathetic nervous system, thereby inhibiting the release of catecholamines (epinephrine and norepinephrine) that result in the classic signs of shock (ie, tachycardia, diaphoresis, pallor). Although the patient’s low BP is consistent with shock, her slow heart rate is not. By contrast, hypotension is not consistent with a closed head injury.

Question 46

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

A) Crushed pelvis
B) Cerebral concussion
C) Simple pneumothorax
D) Unilateral femur fracture

Answer 46

Answer: A

A crushed pelvis is often associated with massive internal bleeding because of all the vasculature that runs through the pelvic region. Although unilateral femur fractures sometimes are associated with internal blood loss, the blood loss is not as great as that associated with pelvic injuries. A simple pneumothorax usually does not pose an immediate threat to life unless it is unmanaged and progresses to a tension pneumothorax. Cerebral concussions are rarely life threatening and generally do not result in permanent neurologic deficit.

Question 47

A patient with a closed head injury has a BP of 150/100 and a pulse rate of 70 beats/min. What is his mean arterial pressure (MAP)?

A) 102 mm Hg
B) 117 mm Hg
C) 126 mm Hg
D) 134 mm Hg

Answer 47

Answer: B

Mean arterial pressure (MAP) is the average arterial pressure during a single cardiac cycle. Several formulae can be used to calculate a patient’s MAP. One method is to divide the pulse pressure (difference between the systolic and diastolic BP) by three and then add that number to the patient’s diastolic BP. Therefore, a patient with a BP of 150/100 mm Hg has a MAP of 117 mm Hg, as follows: 150 - 100 = 50 mm Hg (pulse pressure) / 3 = 17 + 100 (diastolic BP) = 116.6 (117 mm Hg). Another method to calculate MAP is as follows: MAP = systolic BP + (diastolic BP × 2) / 3.

Question 48

A 30-year-old man has experienced an obvious head injury. He is conscious, but does not respond appropriately to questions. Your rapid assessment does not reveal any other obvious injuries. His BP is 70/48 mm Hg, pulse is 120 beats/min and weak, and respirations are 24 breaths/min. The MOST appropriate treatment for this patient includes:

A) administering high-flow oxygen and IV fluid boluses.
B) inserting a King airway and hyperventilating the patient.
C) administering high-flow oxygen and restricting IV fluids.
D) elevating the head of the backboard by 15 to 20 degrees.

Answer 48

Answer: A

Patients with isolated head trauma rarely present with signs of shock; therefore, you should suspect hemorrhage from an occult injury. The abdominal cavity is a common source of internal bleeding in patients without gross external signs of trauma. Administer high-flow oxygen and give crystalloid fluid boluses, usually 20 mL/kg, as needed to maintain adequate perfusion. Hypotension in the presence of a severe head injury can be disastrous and is associated with a high mortality rate. The patient in this scenario is conscious and is therefore not a candidate for an advanced airway device (ie, King LT, LMA, CobraPLA). Furthermore, routine hyperventilation of patients with a head injury should be avoided unless signs of brain herniation are observed (unresponsive, unequal or bilaterally fixed and dilated pupils, and decerebrate [extensor] posturing).

Question 49

General care for full-thickness burns includes:

A) applying an antibiotic burn cream.
B) preserving the patient’s body temperature.
C) irrigating the burned areas with sterile saline.
D) covering the burns with moist, sterile dressings.

Answer 49

Answer: B

The skin is a vital organ in maintaining body temperature. Because full-thickness (third-degree) burns destroy all layers of the skin, the patient is prone to, among other things, hypothermia. The AEMT must prevent the loss of body heat in patients with any significant burn, especially full-thickness burns. Although it is acceptable to provide local cooling for superficial (first-degree) and partial-thickness (second-degree) burns, you should NOT apply saline or moist dressings to full-thickness burns; these actions simply increase the risks of hypothermia and infection. All burns, regardless of depth, should be covered with dry, sterile dressings or a dry, sterile burn sheet. Do not apply any ointments or creams to any burn; these will only need to be removed at the hospital and may also increase the risk of infection.

Question 50

A 45-year-old man sustained an isolated stab wound to the upper left thigh during a bar fight. As you approach him, he is conscious and screaming in pain. You can see a large volume of blood in the region of his groin. You should:

A) administer high-flow oxygen.
B) ensure that his airway is patent.
C) control the bleeding immediately.
D) manually stabilize the c-spine.

Answer 50

Answer: C

The fact that the patient is conscious and screaming clearly indicates that he has a patent airway. Your priority must be to control the bleeding that is coming from his groin region; if you do not, he will bleed to death. As you are doing this, your partner can apply oxygen. Spinal immobilization is not indicated because the mechanism of injury does not suggest a spinal injury. Remember, always treat what will kill your patient FIRST.

Question 51

You are assessing a trauma patient who has signs of shock, yet exhibits no external signs of injury. You should suspect:

A) intrathoracic hemorrhage.
B) intracerebral hemorrhage.
C) retroperitoneal hemorrhage.
D) bleeding into the pelvic cavity.

Answer 51

Answer: C

The retroperitoneal space, the part of the abdomen that contains the kidneys and pancreas, is a common location for occult bleeding and may not produce obvious signs of abdominal injury (ie, distention, rigidity, bruising). Therefore, any trauma patient who has signs of shock, yet exhibits no external signs of trauma, should be assumed to be bleeding into the retroperitoneal space until proved otherwise.

Question 52

When administering crystalloid fluids to a patient in severe hypovolemic shock, it is important to remember that:

A) you should give 1 mL for every 3 mL of estimated blood loss.
B) you should limit the total volume of crystalloid in the field to 5 L.
C) crystalloids do not increase the blood’s oxygen-carrying capacity.
D) crystalloids contain proteins and stay in the vascular space longer.

Answer 52

Answer: C

Crystalloid solutions, such as normal saline and lactated Ringer solution, only increase the ability to circulate the red blood cells that are in the vascular space. They do not possess any oxygen-carrying capacity. In the field, their use should not exceed 3 L because they hemodilute the blood and ultimately reduce the oxygen-carrying capacity to near zero. For every 1 mL of estimated blood loss, you should administer 3 mL of crystalloid. After 1 hour of administration, only one-third of crystalloid solutions remain in the vascular space. Colloids, such as whole blood, or synthetic substitutes, such as hespan, dextran, and plasmanate, contain proteins, which are larger molecules and remain in the vascular space longer. They are replaced at a 1:1 ratio for blood loss.

Question 53

A 54-year-old man was stabbed in the abdomen after being involved in an altercation. A 2-inch loop of bowel is protruding from the wound. He is conscious, alert, and talking to you. You should immediately:

A) administer high-flow oxygen.
B) control any bleeding from the wound.
C) apply a moist, sterile dressing to the wound.
D) gently replace the bowel back into the wound.

Answer 53

Answer: B

The patient in this scenario has a patent airway, as evidenced by the fact that he is conscious, alert, and talking to you. Your most immediate priority in this scenario should be to control any bleeding coming from his wound. As you are doing this, your partner can apply oxygen. After controlling all external bleeding, cover the exposed viscera with a moist, sterile dressing and secure that in place with a dry, sterile dressing. Some medical directors advocate placing an occlusive dressing over an abdominal evisceration.

Question 54

Which of the following mechanisms of injury results in stretching or tearing of the spinal cord?

A) Distraction of the neck
B) Hyperflexion of the neck
C) Hyperextension of the neck
D) Lateral impact to the head

Answer 54

Answer: A

Distraction injuries of the neck, such as those that occur during a hanging, are the most likely to result in the stretching or tearing of the spinal cord.

Question 55

Septic shock develops in a 40-year-old man in the hospital after resuscitation after severe trauma. The pathophysiology of septic shock is MOST accurately described as a:

A) bacterial infection that results in massive vasodilation.
B) bacterial infection that results in excessive vasoconstriction.
C) viral infection that results in severe damage to the capillaries.
D) viral or bacterial infection that results in damage to the lungs.

Answer 55

Answer: A

Septic shock (systemic sepsis) is rarely seen in the field after a severe traumatic injury; it is more commonly seen in the hospital, after the patient has been resuscitated. Septic shock is caused by a severe bacterial infection that attacks the blood vessels and impairs their ability to constrict; as a result, widespread vasodilation occurs and the patient develops hypotension. The bacteria also causes the blood vessels to leak, which results in internal fluid loss.

Question 56

A woman was involved in a motor vehicle crash and is still in her car. She is conscious, but confused, and is moaning in pain. You see large amounts of bright red blood coming from the region of her groin. You should:

A) apply high-flow supplemental oxygen.
B) apply direct pressure to the wound.
C) open her airway with the jaw-thrust.
D) immediately extricate her from the car.

Answer 56

Answer: B

Treatment for any patient must focus on what will kill him or her first. The patient in this scenario is conscious, although confused. Her moaning in pain suggests that she has a patent airway. Bright red bleeding from the groin area indicates an injury to the femoral artery. The patient will exsanguinate (bleed to death) if this bleeding is not controlled immediately. After controlling the bleeding, you should apply high-flow oxygen and quickly remove her from her vehicle using the rapid extrication technique. A head-to-toe examination while the patient is still in the vehicle is impractical because you will not be able to assess every part of her body adequately.

Question 57

A 30-year-old man has multiple-system trauma after being struck by a car traveling at a high rate of speed. Which of the following elements of care is MOST critical to his survival?

A) Providing high concentrations of oxygen
B) Minimal on-scene time and rapid transport
C) Immediate use of air medical transport
D) Maintaining perfusion with IV crystalloids

Answer 57

Answer: B

The Golden Period is crucial to the survival of critically injured patients, and dictates that a patient should receive definitive care as soon as possible after their injury. To achieve this goal, no more than 10 minutes should be spent at the scene, and the patient should be transported to a trauma center without delay. EMS personnel are not definitive care providers; instead, they recognize critical injuries, stabilize the patient, and transport to a facility where definitive care can be provided. Time-consuming procedures, such as IV therapy, should be performed en route to the hospital. The decision to use air medical transport is based on a number of factors, including the time of day, your ground transport time, and whether or not the flight crew can truly do more than you can for the patient.

Question 58

The MOST crucial aspect in the management of a patient with extensive full-thickness burns includes:

A) continuously assessing the airway.
B) cooling the burned areas with saline.
C) taking steps to prevent hyperthermia.
D) at least 2 liters of IV crystalloid fluids.

Answer 58

Answer: A

A common cause of death in patients with extensive burns, especially full-thickness burns, is swelling and closure of the airway. You must constantly monitor the patient for signs of this, which include singed nasal hairs, a brassy cough, hoarseness, stridor, and progressive respiratory distress. In addition to monitoring the airway, the patient must be protected from hypothermia. Do not cool full-thickness burns with saline or water; these actions increase the risks of hypothermia and infection. Burn patients are typically not hypotensive in the field unless they have concomitant internal bleeding. Therefore, IV fluid boluses are often not needed. You should, however, establish IV access, preferably in an unburned extremity.

Question 59

Which of the following is the earliest sign of shock?

A) Skin mottling or cyanosis
B) Absence of peripheral pulses
C) Increased rate of respirations
D) Weak carotid and femoral pulses

Answer 59

Answer: C

Early signs of shock include an increase in respirations (tachypnea); restlessness; pallor; and tachycardia. As shock progresses, the patient’s skin often takes on a mottled appearance or may become cyanotic. Other later signs of shock include absent peripheral pulses; weak central (carotid and femoral) pulses; and a declining level of consciousness. Hypotension is a late sign of shock and indicates that the body is no longer able to compensate and perfuse the body. Do not rely on the absence of hypotension to rule out shock of any kind.

Question 60

Which of the following injuries would MOST likely result in obstructive shock?

A) Pelvic fracture
B) Crushed trachea
C) Simple pneumothorax
D) Pericardial tamponade

Answer 60

Answer: D

Obstructive shock results from inadequate circulation of the blood through the cardiovascular system. This type of shock can result from cardiac tamponade, in which excessive blood within the pericardial sac inhibits adequate contractility, thus compromising cardiac output; a tension pneumothorax, in which excessive intrathoracic pressure squeezes the heart and kinks the vena cavae and aorta; and pulmonary embolism, in which a clot obstructs a pulmonary artery, resulting in a significant strain on the right side of the heart that ultimately leads to decreased left ventricular filling and subsequent cardiac output. Simple pneumothoraces are seldom life-threatening, although they can progress to a tension pneumothorax. Pelvic fractures are associated with outright blood loss. A crushed trachea, for obvious reasons, is associated with significant airway compromise.