Trauma weirdness

Question 1

You are responding to a single-vehicle MVI. The driver of the vehicle was unrestrained and impacted the steering wheel with their face, which has notable deformity and crepitus. They are currently GCS=12 with otherwise stable vital signs. There is significant bleeding from their nose which is interfering with their ability to breath, as well as bleeding from both ears. What should you do next?
a. Apply firm pressure to the distal part of the nose to staunch the bleeding. If possible, lean the patient forward to minimize aspiration of blood
b. Apply high-flow oxygen and place the patient supine in full SMR due to the high risk of cervical spine injury.
c. Cover the nose loosely with sterile gauze and position the patient laterally, taking care not to cause undue motion of the neck.
d. Suction the nares and mouth, then place a nasopharyngeal airway to tamponade the bleeding site

Answer 1

c. Cover the nose loosely with sterile gauze and position the patient laterally, taking care not to cause undue motion of the neck.
There is high suspicion for a skull fracture. DO NOT attempt to control epistaxis when a skull fracture is suspected, loose gauze to protect against infection is standard of care. NPA is contraindicated in this patient. Supine positioning is not appropriate due to airway compromise (perhaps appropriate following intubation)

Question 2

You are responding to an explosion at a clandestine drug laboratory. Rescue crews extricate a patient to you with bilateral hearing loss and bleeding from the ears. This is likely the result of a:
a. Primary blast injury
b. Secondary blast injury
c. Tertiary blast injury
d. Miscellaneous blast injury

Answer 2

a. Primary blast injury
Due to the initial pressure wave of the blast. The organs that are most affected are the gas-containing organs like the ears, lungs, and intestines

Question 3

You respond to a 36YOm patient who has fallen 10+ meters at a job site. On arrival, you find them to have multiple injuries, with significant damage to their hard hat. GCS = E2V2M3, HR=56, BP = 78/35, SpO2 = 100% on 15LPM NRB. They do not respond to pain stimuli below the level of their shoulders, and their skin is flushed and warm below this level. What form of shock is MOST likely occuring?
a. hypovolemic shock
b. spinal shock
c. obstructive shock
d. neurogenic shock

Answer 3

d. neurogenic shock
This refers to a disruption of normal sympathetic outflow following a head or spinal injury, leading to adverse vasodilation and hypotension. Spinal shock is not truly a form of hemodynamic shock, it refers to acute loss of function following spinal injury

Question 4

Which of the following forms of shock are typically associated with bradycardia?
* hypovolemic
* neurogenic
* septic
* anaphylactic
* irreversible
* decompensated

Answer 4

neurogenic and irreversible

Question 5

What degree of blood loss is associated with decompensated shock?
a. 10-15%
b. 15-30%
c. 30-40%
d. 40-60%

Answer 5

c. 30-40%
Blood loss up to 30% can normally be compensated for. Decompensation starts to occur at 30-40%. Irreversible shock begins to develop after 40%+ blood loss. Note that these numbers are higher for infants and children, who have more effective compensatory mechanisms

Question 6

Which form of MVC has the highest rate of mortality?
a. Head-on
b. Rear-impact
c. Lateral (T-bone)
d. Rollover

Answer 6

d. Rollover

Question 7

Which of the following is NOT a sign of compensated shock?
a. Decreased LOC
b. Hypotension
c. Narrowed pulse pressure
d. Increased respiratory rate

Answer 7

b. Hypotension
That’s the whole point of it being compensated… Narrowed pulse pressure occurs due to compensatory vasoconstriction, which has a greater effect on DBP than SBP. Increased RR is due to anxiety and need to clear CO2 and correct acidosis. Changes in LOC may be more reliable than changes in BP

Question 8

What is the effect on a vehicle’s kinetic energy if it doubles its speed?
a. 1/2 the energy
b. 2x the energy
c. 4x the energy
d. 8x the energy

Answer 8

c. 4x the energy
KE = 1/2 mv^2. Kinetic energy is proportional to the velocity squared

Question 9

Which of the following is a sign of lower GI bleeding?
a. melena
b. hematochezia
c. coffee-ground emesis
d. hematemesis

Answer 9

b. hematochezia
bright red rectal bleeding is called hematochezia and is a sign of lower GI bleeding. Black, tarry stools are called melena and indicate upper GI bleeding.

Question 10

Injuries to passengeres in an MVI are often attributable to the principle that an object in motion will stay in motion until acted upon by an external force. This principle is known as:
a. Newton’s first law
b. Newton’s second law
c. The law of conservation of energy
d. The law of deceleration

Answer 10

a. Newton’s first law
1st law = law of inertia. 2nd law = force is a product of mass and acceleration

Question 11

Which of the followng is not considered a form of peripheral shock?
a. hypovolemic
b. obstructive
c. septic
d. anaphylactic

Answer 11

b. obstructive
The Weil-Shubin classification seperates shock into central shock (obstructive and cardiogenic) and peripheral (hypovolemic and distributive). Septic and anaphylactic shock are both subtypes of distributive shock

Question 12

Which of the following is NOT a common complication of airbag deployment?
a. Corneal abrasion
b. Blunt trauma to the chest
c. Inhalational injuries
d. Minor corrosive toxic effects

Answer 12

b. Blunt trauma to the chest
This is precisely what airbags avoid!

Question 13

Why is low-dose dopamine recommended for cardiogenic shock, but not high-dose?

Answer 13

• dopamine has a dose-dependent receptor specificity
• at low doses, the effect is primarily Beta-1, causing increased inotropy/chronotropy
• at higher doses, alpha effects become more prominent, and the failing heart may not be able to tolerate the increased SVR

Question 14

A scar which is larger than normal due to excessive collagen deposition, does not grow past the borders of the wound, and that usually occurs in areas of high skin tension on lighter-skinned patients is called a:
a. hypertrophic scar
b. collagenic scar
c. keloid scar
d. pathologic scar

Answer 14

a. hypertrophic scar

Question 15

You are responding to an explosion at a clandestine drug laboratory. Rescue crews extricate a patient to you with dyspnea, vision disturbance, dizziness/vertigo, and focal neurological deficits. The MOST likely cause of their symptoms is:
a. CVA/stroke
b. Arterial gas embolus
c. Epidural hematoma
d. mTBI/concussion

Answer 15

b. Arterial gas embolus
The other pathologies do not explain the dyspnea. AGE is one of the most concerning pulmonary blast injuries

Question 16

You respond to a 22YO stabbing patient, who has multiple wounds to their left flank. On assessment, you find the following; GCS=E3V4M6, HR=135, BP=114/88, skin is pale, cool and clammy, SpO2 = 97% on room air.
Which of the following is true about this patient’s presentation?
a. They are demonstrating signs of compensated shock
b. They are demonstrating signs of decompensated shock
c. They are showing signs of irreversible shock
d. No signs of hemodynamic compromise are present

Answer 16

a. They are demonstrating signs of compensated shock
DLOC, narrowed pulse pressures, tachycardia, and skin findings are all signs of compensated shock. Given the patient’s age, theya re likely very ill but compensating, and you should prepare for rapid decompensation

Question 17

Describe the normal neurologic pathway involved in the body’s response to hypoperfusion (i.e. shock).

Answer 17

• a drop in blood pressure (usually 60-80mmHg SBP) is detected by carotid and aortic baroreceptors
• A signal is sent to the vasomotor center in the brain, triggering sympathetic outflow
• Direct sympathetic outflow causes peripheral vasoconstriction, increasing SVR and BP
• Sympathetic ouflow also causes RAAS activation and adrenal gland stimulation, and the release of epinpehrine and norepinephrine cause further cardiovascular effects

Question 18

A level 1 trauma center is also known as a:
a. Primary trauma center
b. District trauma center
c. Secondary trauma center
d. Tertiary trauma center

Answer 18

d. Tertiary trauma center
level 1 = tertiary, level 2 = district, level 3 = primary

Question 19

You respond to a 22YO stabbing patient, who has multiple wounds to their left flank. On assessment, you find the following; GCS=E3V4M6, HR=135, BP=96/70, skin is pale, cool and clammy, SpO2 = 97% on room air. The patient complains of severe pain.
What should you do next?
a. Apply firm pressure to the flanks to control internal hemorrhage and initiate rapid transport
b. Obtain bilateral IV access and administer a 20mL/kg fluid bolus to resolve hypotension
c. Provide IV analgesia; 0.5-1mcg/kg fentanyl to a maximum of 100mcg per aliquot
d. Position the patient supine, apply high-flow oxygen, and turn up the heat in the patient compartment

Answer 19

d. Position the patient supine, apply high-flow oxygen, and turn up the heat in the patient compartment
This patient is in SHOCK! Keep in mind that hypotension is a LATE finding in young/healthy individuals. External compression of retroperitoneal injuries is unlikely to control bleeding. Treat for shock and initiate transport.

Question 20

Distinguish between SIRS, sepsis, septic shock, and MODS

Answer 20

• SIRS: systemic inflammatory response which may have many different causes, including trauma, burns, or pancreatitis. criteria are 2 or more of hypo/hyperthermia, tachycardia, tahcypnea, and/or leukocytosis/leukopenia
• Sepsis: SIRS + signs of infection
• Spetic Shock: Sepsis + hypotension (SBP less than 90)
• MODS: SIRS/Sepsis + altered end organ function such that hemostasis can’t be maintained without intervention.

Question 21

You are responding to an explosion at a clandestine drug laboratory. Rescue crews extricate a patient to you with an impailed shard of wood that was projected outwards by the explosion. This is an example of a:
a. Primary blast injury
b. Secondary blast injury
c. Tertiary blast injury
d. Miscellaneous blast injury

Answer 21

c. Tertiary blast injury

Question 22

The property of shock waves to shatter objects or cause disruption to tissues is known as:
a. Spalling
b. Pressure
c. Brisance
d. Fragmentation

Answer 22

c. Brisance
spalling occurs when a shock wave passes from a high-density to low density medium, causing the heavier medium to fragment

Question 23

Which of the following is NOT a component of Waddell’s triad?
a. Tibia/knee injury ipsilateral to the impact
b. Sternal and rib fractures ipsilateral to the impact
c. Skull and facial fractures contralateral to the impact
d. Femur/pelvis fractures ipsialteral to the impact

Answer 23

a. Tibia/knee injury ipsilateral to the impact
Waddell’s triad refers to the pediatric injury pattern seen in pedestrian-struck MVCs. Tibia/knee injury is part of the adult pattern of injury. Children, being shorter, receive the initial impact of the bumper to the hip/pelvis region.

Question 24

Select all of the following which influence the degree and types of injuries sustained after a fall from height
* The height of the fall
* The position or orientation of the body
* The presence of drug or alcohol intoxication
* The area over which the impact is distributed
* The surface onto which the person has fallen
* The time of day/night
* The physical condition of the patient

Answer 24

• The height of the fall
• The position or orientation of the body
• The area over which the impact is distributed
• The surface onto which the person has fallen
• The physical condition of the patient

Question 25

Which 2 forms of shock are less likely to be associated with pallor?

Answer 25

neurogenic and septic

Question 26

Which of the following is true about entry and exit wounds?
a. Projectiles typically follow a straight line between entry and exit
b. For every entry wound there will be one exit wound
c. The size of the exit wound depends on the degree of cavitation at the point of exit
d. The entry wound is typically larger, with more ragged edges than the exit wound

Answer 26

c. The size of the exit wound depends on the degree of cavitation at the point of exit
Projectiles frequently travel highly irregular paths through the body and ricochet off internal structures. Some entry wounds will have no exit wounds, while some will have multiple exit wounds due to projectile fragmentation. The exit wound is typically larger.

Question 27

The displacement of tissue from the pathway of a bullet due to low-displacement shockwaves is known as:
a. Cavitation
b. Pathway expansion
c. Permanent cavity formation
d. Missile fragmentation

Answer 27

b. Pathway expansion
This is very simialr to cavitation, but specifically refers to tissue displacement, rather than the formation of a cavity. Much of the damage from pathway expansion does not result in a permanent cavity, rather causing damage through shearing forces

Question 28

Which of the following would most likely be the result of a secondary blast injury?
a. Pulmonary over-pressurization (POP)
b. Femur fracture
c. Burns to the torso
d. Penetrating trauma of the abdomen

Answer 28

b. Femur fracture
*Secondary blast injuries occur due to the patient being thrown and impacting another surface. “a” is more likely due to primary injury, “c” due to miscellaneous injury, and “d” due to tertiary injury *

Question 29

You are called for a patient who complains of abdominal pain and bleeding PR. They state they were in an MVI 2 days previous, but did not seek medical attention, now they are passing bright red blood per rectum. This type of bleeding is known as
a. hematochezia
b. hematuria
c. melena
d. hematemesis

Answer 29

a. hematochezia
bright red rectal bleeding is called hematochezia. Black, tarry stools are called melena and indicate upper GI bleeding.

Question 30

Which form of MVC has the lowest rate of mortality?
a. Head-on
b. Rear-impact
c. Lateral (T-bone)
d. Rollover

Answer 30

b. Rear-impact

Question 31

Which of the following would be a cause of central shock?
a. septicemia
b. exsanguinating hemorrhage
c. ventricular tachycardia
d. spinal cord injury

Answer 31

c. ventricular tachycardia
The Weil-Shubin classification seperates shock into central shock (obstructive and cardiogenic) and peripheral (hypovolemic and distributive). VTach causes cardiogenic shock. Sepsis and neurogenic shock are both forms of distributive shock.

Question 32

Crush syndrome should be considered in any patient who has had an area of the body trapped for:
a. any amount of time
b. greater than 1 hour
c. greater than 4 hours
d. greater than 12 hours

Answer 32

c. greater than 4 hours
seems surprising… would have thought less…

Question 33

Red streaking at the site of a wound is a sign of:
a. lymphangitis
b. phlebitis
c. sepsis
d. erythema

Answer 33

a. lymphangitis

Question 34

List the four phases of an MVI which lead to injuries to the occupant

Answer 34

1. Decelration of the vehicle
2. Deceleration of the occupant
3. Deceleration of the organs
4. Secondary collisions (ex: the unrestrained LUCAS device flying around and smacking you)

Question 35

In young people, a change in blood pressure is an early sign of shock. True/false

Answer 35

FALSE!
Hypotension is a LATE finding in young people

Question 36

Distributive shock generally occurs due to changes in the tone of:
a. capillaries
b. major veins and arteries
c. Small venules and arterioles
d. Major arteries only

Answer 36

c. Small venules and arterioles
these are called capacitance vessels for venules or resistance vessels for arterioles

Question 37

Necrotizing fasciitis following a wound is caused by which organism?
a. Staph aureus
b. Haemophylus influenzae
c. Haemolytic streptococci
d. There is no single causative organism

Answer 37

d. There is no single causative organism
usual culprits are either or both of Staph aureus and/or Haemolytic streptococci

Question 38

You respond to a patient following a fall from height with signs of new paralysis. On arrival you note the following; GCS=14, BP = 78/30, HR=46, SpO2=99% on room air, skin is flushed, warm, and dry. The patient is complaining of severe pain in his neck. Which of the following are appropriate treatment strategies for this patient?
a. The patient likely has a head injury with increasing ICP. Elevate the head by 30-degrees and target low-normal EtCO2 (do not hyperventilate)
b. Provide vagal-blocking agents (atropine) and pressors (low-dose dopamine, norepinephrine, or epinephrine) to adress neurogenic shock
c. Administer phenylephrine in 50-100mcg aliquots to reverse systemic vasodilation without stimulating an unmatched Beta-1 surge
d. Attempt a 1000mL fluid bolus and apply a tight-fitting cervical collar to address neurogenic shock and C-spine injury

Answer 38

b. Provide vagal-blocking agents (atropine) and pressors (low-dose dopamine, norepinephrine, or epinephrine) to adress neurogenic shock
Straight out of Nancy’s; atropine + epi is the way to go

Question 39

Ejection from an MVC increases the chances of mortality by:
a. 50%
b. 100%
c. 500%
d. 2500%

Answer 39

d. 2500%
25x greater chance of dying and 1 in 3 chance of a c-spine injury

Question 40

You are responding to an explosion at a clandestine drug laboratory. Rescue crews extricate a patient to you with respiratory distress from hot gas inhalation. This is an example of a:
a. Primary blast injury
b. Secondary blast injury
c. Tertiary blast injury
d. Miscellaneous blast injury

Answer 40

d. Miscellaneous blast injury
These include injuries that are not directly attributable to the expanding pressure wave. Ex: burns, toxic inhalations, crush injuries from collapsing structures

Question 41

A scar which is larger than normal due to excessive collagen deposition, that grows past the borders of the wound, and that usually occurs on the ears, upper extremities, lower abdomen, and sternum of darker-skinned patients is called:
a. hypertrophic scar
b. collagenic scar
c. keloid scar
d. pathologic scar

Answer 41

c. keloid scar

Question 42

You respond to an industrial site for a worker with an arm entrapped under heavy equipment. The foreman states that they have been trapped for 45 minutes. They patient seems very uncomfortable, but they are alert/oriented and vital signs are unremarkable. The arm appears obviously crushed and mangled. What should your approach be?
a. Initiate IV access and provide up to 2L of crystalloid solution for hemodilution, prepare for hyperkalemia once the crush is released.
b. Initiate IV access, provide up to 2L of crystalloid solution for hemodilution, and administer 1g of calcium chloride as a slow IV push in anticipation of hyperkalemia
c. Prepare for deadly hemorrhage upon release of the crush by applying a tourniquet. Release the crush as soon as possible to limit tissue necrosis
d. Provide IV analgesia and sedation, release the crush once the patient appears comfortable and appropriately sedated.

Answer 42

c. Prepare for deadly hemorrhage upon release of the crush by applying a tourniquet. Release the crush as soon as possible to limit tissue necrosis
Crush syndrome should only be considered in patients where there has been entrapment of more than 4 hours. It’s not the crush itself that releases the toxic cell contents, it’s the slow necrosis and subsequent rupture of the affected cells. In a fresh crush, the emphasis should be on bleeding control and early release to limit tissue destruction