Trauma

Question 1

Cricothyroidotomy

A. Should not be performed in children younger than 12 years
B. Should only be performed in patients who are not good candidates for a tracheostomy
C. Requires the use of an endotracheal tube smaller than 4 mm in diameter
D. Is preferable to the use of percutaneous transtracheal ventilation

Answer 1

A. Should not be performed in children younger than 12 years

Question 2

Which of the following is NOT a sign of tension pneumothorax?

A. Tracheal deviation
B. Decreased breath sounds
C. Respiratory distress with hypertension
D. Distended neck veins

Answer 2

C. Respiratory distress with hypertension

Question 3

Which of the following is a cause of cardiogenic shock in a trauma patient

A. Hemothorax
B. Penetrating injury to the aorta
C. Air embolism
D. Iatrogenic increased afterload due to pressors

Answer 3

C. Air embolism

Question 4

A trauma patient arrives following a stab wound to the left chest with systolic blood pressure (SBP) 85 mm Hg, which improves slightly with intravenous (IV) fluid resuscitation. Chest X-ray demonstrates clear lung fields. What is the most appropriate next step?

A. Computed tomography (CT) scan of the chest
B. Pelvic X-ray
C. Focused abdominal sonography for trauma (FAST) examination
D. Tube thoracostomy of the left chest

Answer 4

C. Focused abdominal sonography for trauma (FAST) examination

Question 5

Primary repair of the trachea should be carried out with

A. Wire suture
B. Absorbable monofilament suture
C. Nonabsorbable monofilament suture
D. Absorbable braided suture

Answer 5

B. Absorbable monofilament suture

Question 6

In which patient is emergency department thoracotomy contraindicated?

A. Motor vehicle accident victim, cardiac tamponade seen on ultrasound, SBP decreasing to 50 mm Hg.
B. Motor vehicle accident victim, became asystolic during transport with 5 minutes of cardiopulmonary resusci-tation (CPR) with no signs of life.
C. Patient with chest stab wound, SBP decreasing to 50 mm Hg.
D. Patient with chest stab wound, became asystolic during transport with 20 minutes of CPR with no signs of life.

Answer 6

D. Patient with chest stab wound, became asystolic during transport with 20 minutes of CPR with no signs of life.

Question 7

A patient with spontaneous eye opening, who is confused and localizes pain has a Glasgow Coma Score (GCS) of

A. 9
B. 11
C. 13
D. 15

Answer 7

C. 13

Question 8

Neck injuries

A. Less than 15% penetrating injuries require neck exploration, a majority can be managed conservatively.
B. Divided into three zones, with zone I above the angle o the mandible, zone II between the thoracic outlet and angle of mandible, and zone III inferior to the clavicles.
C. All patients with neck injury should receive computed tomography angiogram (CTA) to the neck.
D. Patients with dysphagia, hoarseness, hematoma, venous bleeding, hemoptysis, or subcutaneous emphysema should undergo neck exploration.

Answer 8

A. Less than 15% penetrating injuries require neck exploration, a majority can be managed conservatively.

Question 9

Appropriate surgical management of a through-and-through gunshot wound to the lung with minimal bleeding and some air leak is

A. Chest tube only
B. Oversewing entrance and exit wounds to decrease the air leak
C. Pulmonary tractotomy with a stapler and oversewing of vessels or bronchi
D. Wedge resection of the injured lung

Answer 9

C. Pulmonary tractotomy with a stapler and oversewing of vessels or bronchi

Question 10

What is true regarding the evaluation of blunt abdominal trauma?

A. Patients with abdominal wall rigidity and negative abdominal CT should undergo diagnostic peritoneal lavage (DPL) to rule out small bowel injury.
B. If FAST examination is negative in a hemodynamically unstable patient then DPL is indicated to rule out abdominal bleeding.
C. FAST examination cannot detect intraperitoneal fluid in the total volume is <1000 mL.
D. Bowel injury can be ruled out in hemodynamically stable patients with abdominal CT scanning.

Answer 10

B. If FAST examination is negative in a hemodynamically unstable patient then DPL is indicated to rule out abdominal bleeding.

Question 11

After an automobile accident, a 30-year-old woman is discovered to have a posterior pelvic fracture. Hypotension and tachycardia respond marginally to volume replacement. Once it is evident that her major problem is free intraperitoneal bleeding and a pelvic hematoma in association with the fracture, appropriate management would be

A. Application of medical antishock trousers with inflation of the extremity and abdominal sections.
B. Arterial embolization of the pelvic vessels.
C. Celiotomy and ligation of the internal iliac arteries bilaterally.
D. Celiotomy and pelvic packing.
E. External fixation application to stabilize the pelvis.

Answer 11

D. Celiotomy and pelvic packing.

Question 12

Which is true of vascular injuries of the extremities?A. In the absence of hard signs of vascular injury, if the diference between SBP in an injured limb is within 15% of the uninjured limb, no urther evaluation is needed.
B. Occult profunda femoris injuries can result in compartment syndrome and limb loss.
C. All patients with significant hematoma should be surgically explored.
D. Vascular injury repair should be performed prior to realignment of bony fractures or dislocations.

Answer 12

B. Occult profunda femoris injuries can result in compartment syndrome and limb loss.

Question 13

Which of the following statements about blunt carotid injuries is true?

A. Magnetic resonance imaging is the diagnostic modality of choice in patients at risk.
B. Approximately 50% of patients have a delayed diagnosis.
C. The mechanism of injury is usually cervical flexion and rotation.
D. Such injuries are always treated operatively when identified.

Answer 13

B. Approximately 50% of patients have a delayed diagnosis.

Question 14

Massive transfusion protocols

A. Should include transfusion of plasma and platelets in addition to packed RBCs
B. Should only be initiated after blood typing, but crossmatch is not needed
C. Should be initiated in patients with tachycardia despite administration of 3.5 L of crystalloid fluids
D. Should include testing for coagulopathies, present in 5% of patients requiring massive transfusion

Answer 14

A. Should include transfusion of plasma and platelets in addition to packed RBCs

Question 15

The most appropriate treatment for a duodenal hematoma that occurs from blunt trauma is
A. Exploratory laparotomy and bypass of the duodenum.
B. Exploratory laparotomy and evacuation of the hematoma.
C. Exploratory laparotomy to rule out associated injuries.
D. Observation.

Answer 15

D. Observation.

Question 16

Damage control surgery (DCS)

A. Limits enteric spillage by rapid repair of partial small bowel injuries with whipstitch, and complete transection with a GIA stapling device.
B. Aims to control surgical bleeding and identify injuries that can be managed conservatively or with inter-ventional radiology.
C. Is indicated when patients develop intraoperative refractory hypothermia, serum pH >7.6, or refrac-tory coagulopathy.
D. Abdominal wall should be closed with penetrating towel clips.

Answer 16

A. Limits enteric spillage by rapid repair of partial small bowel injuries with whipstitch, and complete transection with a GIA stapling device.

Question 17

Therapy for increased intracranial pressure (ICP) in a patient with a closed head injury is instituted when the ICP is greater than

A. 10
B. 20
C. 30
D. 40

Answer 17

B. 20

Question 18

Cerebral perfusion pressure (CPP)

A. Equals the SBP minus ICP
B. Should be targeted to be greater than 100 mm Hg
C. Is lowered with sedation, osmotic diuresis, paralysis, ventricular drainage, and barbiturate coma
D. Can be increased by lowering ICP and avoiding hypotension

Answer 18

D. Can be increased by lowering ICP and avoiding hypotension

Question 19

An 18-year-old man is admitted to the ED shortly after being involved in an automobile accident. He is in a coma (GCS = 7). His pulse is barely palpable at a rate of 140 beats per minute, and BP is 60/0. Breathing is rapid and shallow, aerating both lung fields. His abdomen is moderately distended with no audible peristalsis. There are closed fractures of the right forearm and the left lower leg. After rapid IV administration of 2 L of lactated Ringer solution in the upper extremities, his pulse is 130 and BP 70/0. The next immediate step should be to

A. Obtain cross-table lateral X-rays of the cervical spine.
B. Obtain head and abdominal CT scans.
C. Obtain supine and lateral decubitus X-rays of the abdomen.
D. Obtain an arch aortogram.
E. Explore the abdomen.

Answer 19

E. Explore the abdomen.

Question 20

A 36-year-old patient arrives in the trauma bay with a stab wound to the left chest. After placement of a left thoracostomy tube and fluid resuscitation, his breathing is stable with BP 160/74 mm Hg and heart rate of 110 beats per minute. CT scanning reveals a descending thoracic pseudoaneurysm and no intracranial or intra-abdominal injury. What is the most appropriate next step?

A. Open repair with partial left heart bypass
B. Endovascular repair with stent
C. Esmolol drip
D. Admission to SICU with repeat C in 24 hours

Answer 20

C. Esmolol drip

Question 21

A patient with penetrating injury to the chest should undergo thoracotomy if

A. There is more than 500 mL of blood which drains from the chest tube when placed.
B. There is more than 200 mL/h of blood for 3 hours from the chest tube.
C. There is an air leak that persists for >48 hours.
D. There is documented lung injury on CT scan.

Answer 21

B. There is more than 200 mL/h of blood for 3 hours from the chest tube.

Question 22

After sustaining a gunshot wound to the right upper quadrant of the abdomen, the patient has no signs of peritonitis. Her vital signs are stable, and CT scan shows a grade III liver injury. What is the next step in management?

A. Exploratory laparotomy with control of hepatic parenchymal hemorrhage.
B. Admission to SICU with serial complete blood count.
C. Admission to SICU with repeat CT in 24 hours.
D. Hepatic angiography.

Answer 22

B. Admission to SICU with serial complete blood count.

Question 23

A 25-year-old man has multiple intra-abdominal injuries after a gunshot wound. Celiotomy reveals multiple inju-ries to small and large bowel and major bleeding from the liver. After repair of the bowel injuries, the abdomen is closed with towel clips, leaving a large pack in the injured liver. Within 12 hours, there is massive abdominal swelling with edema fluid, and intra-abdominal pressure exceeds 35 mm Hg. The immediate step in managing this problem is to

A. Administer albumin intercavernously
B. Give an IV diuretic
C. Limit IV fluid administration
D. Open the incision to decompress the abdomen

Answer 23

D. Open the incision to decompress the abdomen

Question 24

Which of the following statements is correct regarding traumatic spleen injury?

A. An elevation in WBC to 20,000/mm3 and platelets to 300,000/mm3 on postoperative day 7 is a common benign finding in postsplenectomy patients.
B. Delayed rebleeding or rupture will typically occur within 48 hours o injury.
C. Common complications after splenectomy include subdiaphragmatic abscess, pancreatic tail injury, and gastric perforation.
D. Postsplenectomy vaccines against encapsulated bacteria is optimally administered preoperatively or immediately postoperative.

Answer 24

C. Common complications after splenectomy include subdiaphragmatic abscess, pancreatic tail injury, and gastric perforation.

Question 25

The most appropriate treatment for a duodenal hematoma that occurs from blunt trauma is
A. Exploratory laparotomy and bypass of the duodenum.
B. Exploratory laparotomy and evacuation of the hematoma.
C. Exploratory laparotomy to rule out associated injuries.
D. Observation.

Answer 25

D. Observation

Question 26

A 19-year-old man fell of his skateboard, reporting blunt injury to his upper abdomen. Abdominal CT and magnetic resonance cholangiopancreatography (MRCP) confirmed he suffered transection of the main pancreatic duct at the middle of the pancreatic body. Which of the following would be the most appropriate next step in management?

A. Nonoperative treatment
B. Endoscopic retrograde cholangiopancreatography (ERCP) with stenting of pancreatic duct
C. Distal pancreatectomy with splenic preservation
D. Primary repair of pancreatic duct with closed suction drainage

Answer 26

C. Distal pancreatectomy with splenic preservation

Question 27

The most appropriate treatment for a gunshot wound to the hepatic flexure of the colon that cannot be repaired primarily is

A. End colostomy and mucous fistula.
B. Loop colostomy.
C. Exteriorized repair.
D. Resection of the right colon with ileocolostomy.

Answer 27

D. Resection of the right colon with ileocolostomy.

Question 28

Which of the following statements is FALSE regarding traumatic genitourinary injury?

A. If exploratory laparotomy is performed for trauma, all blunt and penetrating wounds to the kidneys should be explored.
B. Renal vascular injuries are common after penetrating trauma, and can be deceptively tamponaded by surrounding fascia.
C. Success of renal artery repair after blunt trauma is slim, but can be attempted if injury occurred within 5 hours or patient does not have any reserve renal function (solitary kidney or bilateral injury).
D. Suspected ureteral injuries in patients with penetrating trauma or pelvic fractures can be evaluated intra-operatively with methylene blue or indigo carmine administered intravenously.
E. Bladder injuries with extraperitoneal extravasation can be managed with Foley decompression for 2 weeks.

Answer 28

A. If exploratory laparotomy is performed for trauma, all blunt and penetrating wounds to the kidneys should be explored.

Question 29

At what pressure is operative decompression of a compartment mandatory?
A. 15 mm Hg
B. 25 mm Hg
C. 35 mm Hg
D. 45 mm Hg

Answer 29

D. 45 mm Hg

Question 30

Which is true regarding trauma in geriatric patients?

A. Admission GCS score after severe head injury is a good predictor o outcome.
B. Rib fractures are associated with pulmonary contusion in 35% of patients, and complicated by pneumonia in 10 to 30% of patients.
C. Approximately 10% of patients older than 65 years will sustain a rib fracture from a fall <6 ft.
D. Chronologic age older than 65 years is associated with higher morbidity and mortality after trauma.

Answer 30

B. Rib fractures are associated with pulmonary contusion in 35% of patients, and complicated by pneumonia in 10 to 30% of patients.