The Quizzes about Trauma, Shock, and Resuscitation – Part 1 (20 test)

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Question 1

A 58-year-old woman is brought to the emergency department (ED) by emergency medical service (EMS) after slipping on a patch of ice while walking to work and hitting her head on the cement Bystanders acknowledged that the patient was unconscious for approximately 1 minute. On arrival, her vital signs are blood pressure (BP) 155/75 mm Hg, heart rate (HR) 89 beats per minute, respiratory rate (RR) 18 breaths per minute, and pulse oxygenation 98% on room air. She has a 5-cm laceration to the back of her head that is actively bleeding. You ask the patient what hap- pened but she cannot remember. You inform her that she is in the hospital as a result of a fall. Over the next 10 minutes she asks you repeatedly what happened and where she is. You do not find any focal neurologic deficits. As you bring the patient to the CT scanner, she vomits once. CT results show a normal brain scan. Which of the following is the most likely diag-

nosis?

A	Cerebral concussion
B	Diffuse axonal injury
C	Cerebral contusion
D	Posttraumatic epilepsy
E	Trauma-induced Alzheimer disease

Question 1 Explanation:

The patient sustained a cerebral concussion. This is caused by a head injury leading to a brief loss of neurologic function. These individuals are often amnestic to the event and frequently ask the same questions over and over again (perseverations). Headache with or without vomiting is generally present; however, there are no focal neurologic findings on examination. Loss of consciousness results from impairment of the reticular activating system (RAS). Patients show rapid clinical improvement. CT scan is normal. Diffuse axonal injury (b) is caused by microscopic shearing of brain nerve fibers. Patients typically present unconscious and remain in a coma for a prolonged period of time. Although the CT scan does not show a mass lesion, patients have over a 33% mortality rate. The clinical features of a cerebral contusion (c) are similar to those of a concussion except that neurologic dysfunction is more profound and prolonged and focal deficits may be present if contusions occur in the sensorimotor area. These injuries occur when the brain impacts the skull. The lesion is typically seen on CT scan. Posttraumatic epilepsy (d) is associated with intracranial hematomas and depressed skull fractures. The seizures generally occur within the first week of the head injury. Some scientists believe that head trauma predisposes to Alzheimer disease (e); however, this would take years to develop

Question 2

A 41-year-old man, the restrained driver in a high-speed motor vehicle collision, is brought to the ED by The patient is breathing without difficulty with bilateral and equal breaths sounds. He has strong pulses peripherally indicating a BP of at least 90 mm Hg. The HR is 121 beats per minute. His Glasgow coma scale (GCS) is 14. A secondary survey reveals chest wall bruising. You suspect a cardiac injury. Which of the fol- lowing locations most commonly involve cardiac contusions?

A	Right atrium
B	Right ventricle
C	Left atrium
D	Left ventricle
E	Septum

Question 2 Explanation:

Blunt cardiac injuries usually result from high-speed vehicular collisions in which the chest wall strikes the steering wheel. Although they are all associated with potentially fatal complications, they should be viewed clinically as a continuous spectrum of myocardial damage: concussion (no permanent cell damage), contusion (permanent cell damage), infarction (cell death), tamponade (bleeding into the pericardium), and rupture (exsanguination). The mechanism of injury in a cardiac contusion involves a high-speed deceleration, which causes the heart to move forward, forcibly striking the sternum. In addition, the direct134 Emergency Medicine force of hitting an object (eg, the steering wheel) also can damage the heart. The right ventricle is most commonly injured because it is the most anterior aspect of the heart and is closest to the sternum.

Question 3

A 25-year-old man is brought into the trauma resuscitation room after his motorcycle is struck by another EMS reports that the patient was found 20 ft away from his motorcycle, which was badly damaged. His vital signs include a BP of 90/60 mm Hg, HR 115 beats per minute, RR 22 breaths per minute, and pulse oxygenation of 100% on facemask. Which of the following is the smallest amount of blood loss that produces a decrease in the systolic BP in adults?

A	Loss of 5% of blood volume
B	Loss of 10% of blood volume
C	Loss of 15% to 30% of blood volume
D	Loss of 30% to 40% of blood volume
E	Loss of greater than 40% of blood volume

Question 3 Explanation:

Hypovolemia secondary to hemorrhage is the most common cause of shock in the trauma patient. The earliest signs of hemorrhagic shock are tachycardia and cutaneous vasoconstriction. The amount of blood loss present can be estimated based on the individual’s initial clinical presentation. Class I hemorrhage (a and b) is characterized by 0% to 15% blood loss (0-750 mL). This stage exhibits minimal clinical signs and symptoms. The patient is normotensive with a slightly elevated HR (> 100). Class II hemorrhage (c) is characterized by 15% to 30% blood loss (750-1500 mL). This stage exhibits tachycardia (HR > 100) with a narrow pulse pressure, delayed capillary refill, mild anxiety, tachypnea, and a slight decrease in urine output. Class III hemorrhage is characterized by 30% to 40% blood loss (1500-2000 mL). This stage exhibits tachypnea, tachycardia (HR > 120), decrease in systolic BP, delayed capillary refill, decreased urine output, and a change in mental status. Class IV hemorrhage (e) is characterized by blood loss greater than 40% (> 2 L). This stage exhibits obvious shock, tachycardia (HR > 140), decreased systolic BP, extremely narrow pulse pressure, scant urine output, delayed capillary refill, confusion, and lethargy.

Question 4

You are notified by the EMS dispatcher that there is a multiple-car collision on the local highway with many He states that there are two people dead at the scene, one person is critically injured and hypoten- sive, and three people have significant injuries but with stable vital signs. Which of the following is the leading cause of death and disability in trauma victims?

A	Abdominal injury
B	Thoracic injury
C	Back injury
D	Cervical injury
E	Head injury

Question 4 Explanation:

Trauma is the leading cause of death between the ages of 1 and 44 years. Many of these injuries are treatable mainly because the patients are young and otherwise healthy. The primary role of the emergency physician is to assess, resuscitate, and stabilize the trauma patient by priority. There are three peak times for trauma deaths. The first, classified as immediate death, is the period with the greatest number of fatalities. This occurs within seconds to minutes of the injury and these patients generally die at the scene. The cause is most commonly because of massive head injury, followed by high cervical spine injury with spinal cord disruption, cardiac and great vessel rupture, and airway obstruction. The second peak period, classified as early death, occurs within minutes to a few hours of injury. This is the period called the “golden hour” where intervention is critical and significantly reduces the morbidity and mortality rate in these patients. Death in these patients is generally secondary to subdural and epidural hematomas. Other causes of death in this group include ruptured spleen, lacerated liver, hypovolemicTrauma, Shock, and Resuscitation Answers 135 shock, fracture of pelvis or multiple long bones, hemopneumothorax, tension pneumothorax, cardiac tamponade, and aortic dissection or rupture. The third peak period, classified as delayed death, occurs days to weeks following the initial injury. Death in these patients is usually a result of multisystem organ failure and sepsis.

Question 5

Paramedics bring a 17-year-old high school football player to the ED on a backboard and with a cervical During a football game, the patient “speared” another player with his helmet and subsequently expe- rienced severe neck pain. He denies paresthesias and is able to move all of his extremities. A cervical spine CT scan reveals multiple fractures of the first cervical vertebra. Which of the following best describes this fracture?

A	Odontoid fracture
B	Hangman’s fracture
C	Jefferson fracture
D	Clay shoveler’s fracture
E	Teardrop fracture

Question 5 Explanation:

Spearing—hitting another player with the crown of the helmet—generates an axial loading force that is transmitted through the occipital condyles to the superior articular surfaces of the lateral masses of the first cervical vertebra (C1). This fracture is commonly referred to as a Jefferson fracture. It is considered an unstable fracture and is associated with C2 fractures 40% of the time. On plain radiograph, it is best seen on the open-mouth odontoid view as the lateral masses are shifted laterally. It is associated with diving accidents and in this scenario, “spearing” in a football game, which places an increased axial load to the cervical spine. Proper cervical spine precautions should remain in place throughout his management in the ED. (a) Odontoid fractures occur when there is a fracture through the odontoid process of the C2 vertebra. (b) A hangman’s fracture, or traumatic spondylolysis of C2, occurs when the cervicocranium is thrown into extreme hyperextension secondary to abrupt deceleration (eg, head-on, high-speed motor vehicle collisions). (d) Clay shoveler’s fracture occurs secondary to cervical hyperextension or direct trauma to the posterior neck, resulting in an avulsion fracture of the spinous process (eg, assault with blunt object to back of neck). (e) A teardrop fracture occurs from severe hyperflexion of the cervical spine and is commonly seen after diving accidents. This injury disrupts all of the cervical ligaments, facet joints, and causes a triangular fracture of a portion of the vertebral body. It is associated with anterior cord syndrome.

Question 6

A 20-year-old man presents to the ED with multiple stab wounds to his His BP is 85/50 mm Hg and HR is 123 beats per minute. Two large-bore IVs (intravenous) are established and running wide open. On examination, the patient is mumbling incomprehensibly, has good air entry on lung examination, and you notice jugular venous distension (JVD). As you are listening to his heart, the nurse calls out that the patient has lost his pulse and that she cannot get a BP reading. Which of the following is the most appropriate next step in management?

A	Atropine
B	Epinephrine
C	Bilateral chest tubes
D	ED thoracotomy
E	Pericardiocentesis

Question 6 Explanation:

The vignette describes a traumatic arrest after penetrating chest trauma. The most likely cause is cardiac tamponade, which occurs in approximately 2% of anterior penetrating chest traumas. Clinically, patients present with hypotension, JVD, and muffled heart sounds. These three signs are called Beck triad. In addition, tachycardia is often present. JVD may not be present if there is marked hypovolemia. The most effective method for relieving acute pericardial tamponade in the trauma setting is thoracotomy and incision of the pericardium with removal of blood from the pericardial sac. The indications136 Emergency Medicine to perform an ED thoracotomy generally include blunt or penetrating trauma patients who lose their vital signs in transport to or in the ED. Patients with penetrating wounds have a significantly better chance of surviving with thoracotomy; also patients with stab wounds are more likely to do better than GSWs. (a and b) The role of advanced cardiac life support (ACLS) drugs in traumatic arrest is unclear. However, patients in traumatic arrest typically require surgical, rather than medical intervention. (c) Chest tube placement will not treat pericardial tamponade. If the patient had evidence of a tension PTX, chest tubes are the treatment of choice. (e) Pericardiocentesis may or may not be effective in acute traumatic tamponade because the pericardium is usually distended by clotted blood rather than by free blood. Pericardiocentesis is indicated for patients with suspected cardiac tamponade who have measurable vital signs that are stable.

Question 7

A 22-year-old man calls the ED from a local bar stating that he was punched in the face 10 minutes ago and is holding his front incisor tooth in his He wants to know what the best way is to preserve the tooth. Which of the following is the most appropriate advice to give the caller?

A	Place the tooth in a napkin and bring it to the ED.
B	Place the tooth in a glass of water and bring it to the ED.
C	Place the tooth in a glass of beer and bring it to the ED.
D	Pour some water over the tooth and place it immediately back into the socket.
E	Place the tooth in a glass of milk and bring it to the ED.

Question 7 Explanation:

The patient has an avulsed tooth, which is a dental emergency. When a tooth is missing from a patient, the possibility of aspiration or entrapment in soft tissues should be considered. Avulsed permanent teeth require prompt intervention. The best environment for an avulsed tooth is its socket. Replantation is most successful if the tooth is returned to its socket within 30 minutes of the avulsion. A 1% chance of successful replantation is lost for every minute that the tooth is outside of its socket. The tooth should only be handled by the crown, so as not to disrupt the root. If the patient cannot replant the tooth, he or she should keep the tooth under his or her tongue or in the buccal pouch so that it is bathed in saliva. If that cannot be achieved, then the tooth can be placed in a cup of milk (e) or in saline. The best transport solution is Hank solution, which is a buffered chemical solution. However, it is typically unavailable in this setting. (a) The worst situation is to transport the tooth in a dry medium. (b and c) Water and beer are less than ideal. Saliva, milk, or saline are better solutions.

Question 8

A 19-year-old man is brought into the trauma room by EMS after a head-on cycling The patient was not wearing a helmet. Upon presentation his BP is 125/75 mm Hg, HR is 105 beats per minute, RR is 19 breaths per minute, and oxygen saturation is 100% on mask. His eyes are closed but open to command. He can move his arms and legs on com- mand. When you ask him questions, he is disoriented but able to converse. What is this patient’s GCS score?

A	11
B	12
C	13
D	14
E	15

Question 8 Explanation:

The GCS score, as seen below, may be used as a tool for classifying head injury and is an objective method for following a patient’s neurologic status. The GCS assesses a person’s eye, verbal, and motor responsiveness. Although the GCS was originally developed to assess head trauma at 6 hours postinjury, it is commonly used in the acute presentation. This patient received a score of 3 forTrauma, Shock, and Resuscitation Answers 137 109. The answer is a. (Rosen, p 415.) Since most people are right-handed and hold the offending instrument in their right hand, the LUQ is most commonly injured in stab wounds. However, the liver occupies the most space in the abdomen and therefore is the most common organ injured. (b) The small bowel is the second most commonly injured organ in stab wounds and is the most common organ injured in projectile penetrating abdominal trauma (eg, GSW). The stomach, colon, and spleen (c, d, and e) are less commonly injured than the liver and small bowel in penetrating abdominal trauma. 110. The answer is d. (Rosen, pp 387-388.) Simple rib fractures are the most common form of significant chest injury. Ribs usually break at the eye opening to verbal command, 4 for disorientation, but conversant, and 6 for obeying verbal commands. Eye opening Spontaneous 4 To verbal command 3 To pain 2 None 1 Verbal Oriented 5 responsiveness Confused 4 Inappropriate words 3 Incomprehensible sounds 2 None 1 Motor response Obeys 6 Localized 5 Withdraws (pain) 4 Flexion (pain) 3 Extension (pain) 2 None 1 A Glasgow Coma Scale Total: ________ (Reproduced, with permission, from Stone CK, Humphries RL, eds. The multiply injured patient. In: Current Diagnosis & Treatment: Emergency Medicine. 6th ed. New York, NY: McGraw-Hill, 2008: Figure 10-2.)

Question 9

An 18-year-old man presents to the ED after getting stabbed in his His HR is 140 beats per minute and BP is 90/40 mm Hg. He is yelling that he is in pain. Two large-bore IVs are inserted into his antecu- bital fossa and fluids are running wide open. After 2 L of fluids, his BP does not improve. Which of the following is the most common organ injured in stab wounds?

A	Liver
B	Small bowel
C	Stomach
D	Colon
E	Spleen

Question 9 Explanation:

Since most people are right-handed and hold the offending instrument in their right hand, the LUQ is most commonly injured in stab wounds. However, the liver occupies the most space in the abdomen and therefore is the most common organ injured. (b) The small bowel is the second most commonly injured organ in stab wounds and is the most common organ injured in projectile penetrating abdominal trauma (eg, GSW). The stomach, colon, and spleen (c, d, and e) are less commonly injured than the liver and small bowel in penetrating abdominal trauma.

Question 10

A 61-year-old man presents to the ED with chest wall pain after a motor vehicle He is speaking full sentences, breath sounds are equal bilat- erally, and his extremities are well-perfused. His BP is 150/75 mm Hg, HR is 92 beats per minute, and oxygen saturation is 97% on room air. Chest radi- ography reveals fractures of the seventh and eighth ribs of the right antero- lateral chest. He has no other identifiable injuries. Which of the following is the most appropriate treatment for this patient’s rib fractures?

A	Apply adhesive tape on the chest wall perpendicular to the rib fractures.
B	Insert a chest tube into the right thorax.
C	Bring the patient to the OR for surgical fixation.
D	Analgesia and incentive spirometry.
E	Observation.

Question 10 Explanation:

Simple rib fractures are the most common form of significant chest injury. Ribs usually break at the point of impact or at the posterior angle, which is structurally the weakest area. The fourth through ninth ribs are most commonly involved. Rib fractures occur more commonly in adults than in children owing to the relative inelasticity of the adult chest wall compared to the more compliant chest wall of children. The presence of two or more rib fractures at any level is associated with a higher incidence of internal injuries. The treatment of patients with simple acute rib fractures includes adequate pain relief and maintenance of pulmonary function. Oral pain medications are usually sufficient for young and healthy patients. Older patients may require better analgesia with opioids, but care must be taken to avoid over sedation. Continuing daily activities and deep breathing are important to ensure ventilation and prevent atelectasis. If there is a question about the patient’s ability to cough, breathe deeply, and maintain activity, particularly if two or more ribs are fractured, it is preferable to admit the patient to the hospital for aggressive pulmonary care. (a) Attempts to relieve pain by immobilization or splinting should not be used. Although they may decrease pain, they also promote hypoventilation leading to atelectasis and pneumonia. (b) A chest tube is indicated only if a PTX or hemothorax is suspected. (c) Rib fractures heal spontaneously and do not require surgical fixation. (e) The main concern in treating rib fractures is preventing complications, such as atelectasis and pneumonia. Therefore, it is important that the patient have adequate analgesia.

Question 11

A 27-year-old man brought to the ED by paramedics after a motor vehicle His RR is 45 breaths per minute, oxygen saturation is 89%, HR is 112 beats per minute, and BP is 115/75 mm Hg. You auscultate his chest and hear decreased breath sounds on the left. Which of the fol- lowing is the most appropriate next step in management?

A	Order a stat chest radiograph.
B	Perform a pericardiocentesis.
C	Perform a diagnostic peritoneal lavage (DPL).
D	Perform an ED thoracotomy.
E	Perform a tube thoracostomy.

Question 11 Explanation:

A PTX can be divided into three classifications: simple, communicating, and tension. A PTX is considered simple when there is no communication with the atmosphere or any shift of the mediastinum or hemidiaphragm resulting from the accumulation of air within the pleural cavity. A communicating PTX is associated with a defect in the chest wall and is sometimes referred to as a “sucking chest wound.” A tension PTX occurs when air enters the pleural cavity on inspiration, but cannot exit, which leads to compression of the vena cava and subsequent decreased cardiac output and hypotension. The progressive accumulation of air under pressure in the pleural cavity may lead to a shift of the mediastinum to the contralateral hemithorax. Patients with a traumatic PTX typically present with shortness of breath, chest pain, and tachypnea. The physical examination may reveal decreased or absent breath sounds over the involved side, as well as subcutaneous emphysema. Any patient with respiratory symptoms in the setting of a PTX should be treated with a tube thoracostomy (chest tube). The preferred site for insertion is the fourth or fifth intercostal space at the anterior or midaxillary line. The tube should be positioned posteriorly and toward the apex so that it can effectively remove both air and fluid. (a) A chest radiograph may be helpful in diagnosing a PTX; however, the patient is unstable in the setting of blunt trauma and intervention should not wait for a chest radiograph. If the patient was stable, a chest radiograph could be used to confirm the presence of a PTX prior to chest tube insertion. (b) A pericardiocentesis is a procedure used to remove fluid from the pericardial sac, such as in the case of pericardial tamponade. It is more likely to occur after a penetrating trauma to the chest rather than a blunt trauma. (c) A DPL is used to diagnose fluid in the peritoneum. Although this may be necessary for this patient, it is important to follow the ABCs of resuscitation. In this patient, airway and breathing need to be addressed first. (d) ED thoracotomy is used in select circumstances, such as in blunt or penetrating trauma patients who lose their vital signs in transport to or in the ED.

Question 12

A 29-year-old man is brought to the ED by EMS after being stabbed in the left side of his His BP is 120/80 mm Hg, HR is 105 beats per minute, RR is 16 breaths per minute, and oxygen saturation is 98% on room air. On the secondary survey, you note motor weakness of his left lower extremity and the loss of pain sensation in the right lower extremity. Which of the following is the most likely diagnosis?

A	Spinal shock
B	Central cord syndrome
C	Anterior cord syndrome
D	Brown-Séquard syndrome
E	Cauda equina syndrome

Question 12 Explanation:

Brown-Séquard syndrome or hemisection of the spinal cord typically results from penetrating trauma, such as a gunshot or knife wound. Patients with this lesion have ipsilateral motor paralysis and contralateral loss of pain and temperature distal to the level of the injury. This syndrome has the best prognosis for recovery of all of the incomplete spinal cord lesions. (a) Spinal shock is a clinical syndrome characterized by the bilateral loss of neurologic function and autonomic tone below the level of a spinal cord lesion. Patients typically exhibit flaccid paralysis with loss of sensory input, deep tendon reflexes, and urinary bladder tone. Also, they are usually bradycardic, hypotensive, and hypothermic. Spinal shock generally lasts less than 24 hours, but may last several days. (b) Central cord syndrome is often seen in patients with degenerative arthritis of the cervical vertebrae, whose necks are subjected to forced hyperextension (eg, a forward fall onto the face in an elderly person). Patients often have greater sensorimotor neurologic deficits in the upper extremities compared to the lower extremities. (c) Anterior cord syndrome results in variable degrees of motor paralysis and absent pain sensation below the level of the lesion. Its hallmark is preservation of vibratory sensation and proprioception because of an intact dorsal column. (e) Cauda equina injury causes peripheral nerve injury rather than direct spinal cord damage. Its presentation may include variable motor and sensory loss in the lower extremities, sciatica, bowel and bladder dysfunction, and saddle anesthesia.

Question 13

A 33-year-old man, who was drinking heavily at a bar, presents to the ED after getting into a A bystander tells paramedics that the patient was punched and kicked multiple times and sustained multiple blows to his head with a stool. In the ED, his BP is 150/75 mm Hg, HR is 90 beats per minute, RR is 13 breaths per minute, and oxygen saturation is 100% on non-rebreather. On examination, he opens his eyes to pain and his pupils are equal and reactive. There is a laceration on the right side of his head. He withdraws his arm to pain but otherwise does not move. You ask him questions, but he just moans. Which of the following is the most appropri- ate next step in management?

A	Prepare for intubation.
B	Suture repair of head laceration.
C	Administer mannitol.
D	Bilateral burr holes.
E	Neurosurgical intervention.

Question 13 Explanation:

Head injury severity is assessed on the mechanism of injury and on the initial neurologic examination. Although the GCS is currently used in multiple settings, it was initially developed for the clinical evaluation of hemodynamically stable, adequately (Reproduced, with permission, from McPhee SJ, Lingappa VR, Ganong WF. Nervous system disorders. In: Lange Pathophysiology of Disease. 5th ed. New York, NY: McGraw-Hill, 2006: Figure 7-20.) Impaired proprioception, vibration, two-point discrimination, and joint and position sensation Loss of all sensation Impaired pain and temperature sensationTrauma, Shock, and Resuscitation Answers 141 oxygenated trauma patients with isolated head trauma. A score of 14 to 15 is associated with minor head injury, 9 to 13 indicates moderate, and 8 or less is associated with severe head injury. His GCS score is 8 (2 points for eye opening to pain, 2 points for mumbling speech, 4 points for withdrawing from pain). He is classified with a severe head injury. The overall mortality of severe head injury is almost 40%. It is recommended to intubate patients with a GCS score of 8 or less for airway protection. These patients are at risk for increased ICP and herniation, which can lead to rapid respiratory decline. All patients with severe traumatic brain injury require an emergent CT scan and should be admitted to the intensive care unit in a hospital with neurosurgical capabilities. (b) Repairing his laceration is not a priority and can take place after diagnosing and stabilizing injuries that are more serious. If there is an active scalp bleed, staples can be rapidly placed to limit bleeding until definitive repair can take place. (c) Mannitol is an osmotic agent that is used to reduce ICP. It is administered if there are signs of impending or actual herniation (eg, fixed and dilated pupil). (d) Bilateral ED trephination (burr holes) is rarely, if ever, performed and is considered if definitive neurosurgical care is not available. (e) Although this individual may require neurosurgical intervention (eg, if there is any evidence of intracranial hemorrhage or declining neurologic status, indicating increased ICP), priority is given to his airway.

Question 14

A 74-year-old man presents to the ED after being involved in a motor vehicle He states he was wearing his seat belt in the driver’s seat when a car hit him from behind. He thinks his chest hit the steering wheel and now complains of pain with breathing. His RR is 20 breaths per minute, oxygen saturation is 98% on room air, BP is 145/75 mm Hg, and HR is 90 beats per minute. On examination, you notice paradoxical respirations. Which of the following best describes a flail chest?

A	One rib with three fracture sites
B	Two adjacent ribs, each with two fracture sites
C	Three adjacent ribs, each with two fracture sites
D	One fractured right-sided rib and one fractured left-sided rib
E	Two fractured right-sided ribs and two fractured left-sided ribs

Question 14 Explanation:

Flail chest results when three or more adjacent ribs are fractured at two points, allowing a freely moving segment of the chest wall to move in a paradoxical motion. It is one of the most commonly overlooked injuries resulting from blunt chest trauma. The paradoxical motion of the chest wall is the hallmark of this condition, with the flail segment paradoxically moving inward with inspiration and outward with expiration.

Question 15

A 29-year-old man presents to the ED after being stabbed in his The patient is speaking in full sentences. His breath sounds are equal bilat- erally. His BP is 130/75 mm Hg, HR is 95 beats per minute, RR is 16 breaths per minute, and oxygen saturation is 99% on room air. The stab wound is located between the angle of the mandible and the cricoid cartilage and violates the platysma. There is blood oozing from the site although there is no expanding hematoma. Which of the following is the most appropriate next step in management?

A	Explore the wound and blind clamp any bleeding site.
B	Probe the wound looking for injured vessels.
C	Apply direct pressure and bring the patient immediately to the OR to explore the zone I injury.
D	Apply direct pressure and bring the patient immediately to the OR to explore the zone II injury.
E	Apply direct pressure and bring the patient immediately to the OR to explore the zone III injury.

Question 15 Explanation:

Owing to its lack of bony protection, the neck is especially vulnerable to severe, life-threatening injuries. Neck trauma is caused by three major mechanisms, including penetrating, blunt, and strangulation, which can affect the airway, digestive tract, vascular, and neurologic systems. The neck is divided into three zones, as seen in the picture below. Zone I extends superiorly from the sternal notch and clavicles to the cricoid cartilage. Injuries to this region can affect both neck and mediastinal structures. Zone II is the area between the cricoid142 Emergency Medicine cartilage and the angle of the mandible. Zone III extends from the angle of the mandible to the base of the skull. Zones I and III injuries typically pose a greater challenge to manage than zone II injuries because zones I and III are much less exposed than zone II. Generally, zone II injuries are taken directly to the operating room for surgical exploration. Injuries in zones I and III may be taken to the operating room or managed conservatively using a combination of angiography, bronchoscopy, esophagoscopy, and CT scanning. Airway management is always given priority in trauma patients, particularly when neck structures are involved because of the potential for rapid airway compromise. Active bleeding sites or wounds with blood clots should not be probed because massive hemorrhage can occur. Bleeding should be controlled by direct pressure. Blind clamping should be avoided because of the high concentration of neurovascular structures in the neck. (a) Blind clamping should be avoided because of the high concentration of neurovascular structures in the neck. (b) Active bleeding sites or wounds (Reproduced, with permission, from Doherty GM, Way LW. Current Surgical Diagnosis & Treatment. New York, NY: McGraw-Hill, 2006: 210.)Trauma, Shock, and Resuscitation Answers 143 with blood clots should not be probed because massive hemorrhage can occur. Bleeding should be controlled by direct pressure. (c and e) The injury is in zone II of the neck.

Question 16

A 45-year-old man is brought to the ED after a head-on motor vehicle colli- Paramedics at the scene tell you that the front end of the car is smashed. The patient’s BP is 130/80 mm Hg, HR is 100 beats per minute, RR is 15 breaths per minute, and oxygen saturation is 98% on room air. Radiographs of the cervical spine reveal bilateral fractures of the C2 vertebra. The patient’s neurologic exami- nation is unremarkable. Which of the following best describes this fracture?

A	Colles fracture
B	Boxer’s fracture
C	Jefferson fracture
D	Hangman’s fracture
E	Clay shoveler’s fracture

Question 16 Explanation:

The hangman’s fracture, or traumatic spondylolysis of C2, occurs when the head is thrown into extreme hyperextension because of abrupt deceleration, resulting in bilateral fractures of the pedicles. The name “hangman’s fracture” was derived from judicial hangings, where the knot of the noose was placed under the chin which caused extreme hyperextension of the head on the neck, resulting in a fracture at C2. However, many hangings resulted in death from strangulation rather than spinal cord damage. Today, the most common cause of a hangman’s fracture is the result of head-on automobile collisions. (a) Colles fracture is the most common wrist fracture seen in adults. It is a transverse fracture of the distal radial metaphysis, which is dorsally displaced and angulated. These fractures usually occur from a fall on an outstretched hand. (b) A boxer’s fracture is a fracture of the neck of the fifth metacarpal. It is one of the most common fractures of the hand and usually occurs from a direct impact to the hand (eg, a punch with a closed fist). (c) A fracture of C1 is called a Jefferson fracture, which is typically produced by a vertical compression force. (e) Clay shoveler’s fracture occurs secondary to cervical hyperextension or direct trauma to the posterior neck, resulting in an avulsion fracture of the spinous process.

Question 17

A 71-year-old man is found lying on the ground one story below the balcony of his Paramedics bring the patient into the ED. He is cool to touch with a core body temperature of 96°F. His HR is 119 beats per minute and BP is 90/70 mm Hg. His eyes are closed, but they open when you call his name. His limbs move to stimuli, and he answers your questions but is confused. On examination, you note clear fluid dripping from his left ear canal and an area of ecchymosis around the mastoid bone. Which of the following is the most likely diagnosis?

A	Le Fort fracture
B	Basilar skull fracture
C	Otitis interna
D	Otitis externa
E	Tripod fracture

Question 17 Explanation:

The skull base comprises the floors of the anterior, middle, and posterior cranial fossae. Fractures in this region typically do not have localized symptoms. However, indirect signs of injury may include visible evidence of bleeding from the fracture into surrounding soft tissue. Ecchymosis around the mastoid bone is often described as Battle sign and periorbital ecchymosis is often described as “raccoon eyes.” The most common basilar skull fracture involves the petrous portion of the temporal bone, the external auditory canal, and the tympanic membrane. It is commonly associated with a torn dura leading to cerebrospinal fluid (CSF) otorrhea or rhinorrhea. Other signs and symptoms of a basilar skull fracture include hemotympanum (eg, blood in the tympanic cavity of the middle ear), vertigo, decreased hearing or deafness, and seventh nerve palsy. Periorbital and mastoid ecchymosis develop144 Emergency Medicine gradually over hours after an injury and are often absent in the ED. If clear or pink fluid is seen from the nose or ear and a CSF leak is suspected, the fluid can be placed on filter paper and a “halo” or double ring may appear. This is a simple but nonsensitive test to confirm a CSF leak. Evidence of open communication, such as a CSF leak, mandates neurosurgical consultation and admission. (a) Le Fort factures typically result from high-energy facial trauma and are classified according to their location. A Le Fort I involves a transverse fracture just above the teeth at the level of the nasal fossa, and allows movement of the alveolar ridge and hard palate. A Le Fort II is a pyramidal fracture with its apex just above the bridge of the nose and extending laterally and inferiorly through the infraorbital rims allowing movement of the maxilla, nose, and infraorbital rims. A Le Fort III represents complete craniofacial disruption and involves fractures of the zygoma, infraorbital rims, and maxilla. It is rare for these fractures to occur in isolation; they usually occur in combination. (c and d) Otitis interna and externa are inflammation of the inner ear and outer ear, respectively, and are not relevant in acute trauma. (e) Tripod fractures typically occur from blunt force applied to the lateral face causing fractures of zygomatic arch, the lateral orbital rim, the inferior orbital rim, and the anterior and lateral walls of the maxillary sinus. These fractures present clinically with asymmetrical facial flattening, edema, and ecchymosis.

Question 18

A 34-year-old construction worker is brought to the ED by EMS after falling 30 ft from a His vital signs are HR 124 beats per minute, BP 80/40 mm Hg, and oxygen saturation 93% on 100% oxygen. He has obvious head trauma with a scalp laceration overlying a skull fracture on his occiput. He does not speak when asked his name, his respirations are poor, and you hear gurgling with each attempted breath. Auscultation of the chest reveals diminished breath sounds on the right. There is no JVD or anterior chest wall crepitus. His pelvis is unstable with movement laterally to medially and you note blood at the urethral meatus. His right leg is grossly deformed at the knee and there is an obvious fracture of his left arm. Which of the following is the most appropriate next step in management?

A	Insert a 32F chest tube into the right thoracic cavity.
B	Perform a DPL to rule out intra-abdominal hemorrhage.
C	Create two Burr holes into the cranial vault to treat a potential epidural hematoma.
D	Immediately reduce the extremity injuries and place in a splint until the patient is stabilized.
E	Plan for endotracheal intubation of the airway with in-line stabilization of the cervical spine.

Question 18 Explanation:

Based on the principles of advanced trauma life support (ATLS), injured patients are assessed and treated in a fashion that establishes priorities based on their presenting vital signs, mental status, and injury mechanism. The approach to trauma care consists of a primary survey, rapid resuscitation, and a more thorough secondary survey followed by diagnostic testing. The goal of the primary survey is to quickly identify and treat immediately life-threatening injuries. The assessment of the ABCDEs (airway, breathing, circulation, neurologic disability, exposure) is a model that should be followed in all patients. Airway patency is first evaluated by listening for vocalizations, asking the patient to speak, and looking in the patient’s mouth for signs of obstruction. Breathing is assessed by observing for symmetric rise and fall of the chest and listening for bilateral breath sounds over the anterior chest and axillae. The chest should be palpated for subcutaneous air and bony crepitus. Circulatory function is assessed by notingTrauma, Shock, and Resuscitation Answers 145 the patient’s mental status, skin color and temperature, and pulses. The patient’s neurologic status is assessed by noting level of consciousness and gross motor function. An initial GCS should be calculated in the ED. Last, the patient is completely undressed to evaluate for otherwise hidden bruises, lacerations, impaled foreign bodies, and open fractures. The secondary head-to-toe survey is undertaken only after the primary survey is complete, life-threatening injuries are addressed, and the patient is resuscitated and stabilized. (a) This patient will require a chest tube for presumed hemo- or pneumothorax demonstrated by decreased breath sounds and oxygen saturation of 93%. However, the airway should first be secured. (b) A DPL or FAST examination is used to screen the abdomen for hemoperitoneum. However, airway and breathing take priority in this patient. (c) Bilateral ED trephination (burr holes) is rarely, if ever, performed and should only be considered in the case of severe neurologic impairment and definitive neurosurgical care is not available. (d) Extremity injuries are typically not life threatening and are assessed after the airway, breathing, and circulation are evaluated

Question 19

A 20-year-old man was found on the ground next to his car after it hit a tree on the side of the Bystanders state that the man got out of his car after the collision but collapsed within a few minutes. Paramedics sub- sequently found the man unconscious on the side of the road. In the ED, his BP is 175/90 mm Hg, HR is 65 beats per minute, temperature is 99.2°F, RR is 12 breaths per minute, and oxygen saturation is 97% on room air. Physical examination reveals a right-sided fixed and dilated pupil. A head CT is shown below. Which of the following is the most likely diagnosis?

A	Epidural hematoma
B	Subdural hematoma
C	Subarachnoid hemorrhage (SAH)
D	Intracerebral hematoma
E	Cerebral contusion

Question 19 Explanation:

Epidural hematomas are the result of blood collecting in the potential space between the skull and the dura mater. Most epidural hematomas result from blunt trauma to the temporal or temporoparietal area with an associated skull fracture and middle meningeal artery disruption. The classic history of an epidural hematoma is a lucid period following immediate loss of consciousness after significant blunt head trauma. However, this clinical pattern occurs in a minority of cases. Most patients either never lose consciousness or never regain consciousness after the injury. On CT scan, epidural hematomas appear lenticular or biconvex (football shaped), typically in the temporal region. The high-pressure arterial bleeding of an epidural hematoma can lead to herniation within hours after injury. Therefore, early recognition and evacuation are important to increase survival. Bilateral ED trephination (burr holes) is rarely, if ever, performed and should only be considered if definitive neurosurgical care is not available. (b) Subdural hematomas appear as hyperdense, crescent-shaped lesions that cross suture lines. They result from a collection of blood below the dura and over the brain. To differentiate the CT finding from146 Emergency Medicine an epidural hematoma, think about the high pressure created by the arterial tear of an epidural that causes the hematoma to expand inward. In contrast, the low-pressure venous bleed of a subdural hematoma layers along the calvarium. (c) Traumatic SAH is probably the most common CT abnormality in patients with moderate to severe traumatic brain injury. (d and e) Intracerebral hematomas and contusions occur secondary to traumatic tearing of intracerebral blood vessels. Contusions most commonly occur in the frontal, temporal, and occipital lobes. They may occur either at the site of the blunt trauma or on the opposite site of the brain, known as a contrecoup injury. Examples of each are seen above.

Question 20

An 81-year-old woman presents to the ED after tripping over the sidewalk curb and landing on her chin causing a hyperextension of her She was placed in a cervical collar by paramedics. On examination, she has no sensorimotor function of her upper extremities. She cannot wiggle her toes, has 1/5 motor function of her quadriceps, and only patchy lower extremity sensation. Rectal examination reveals decreased rectal tone. Which of the following is the most likely diagnosis?

A	Central cord syndrome
B	Anterior cord syndrome
C	Brown-Séquard syndrome
D	Transverse myelitis
E	Exacerbation of Parkinson disease

Question 20 Explanation:

Central cord syndrome is often seen in patients with degenerative arthritis of the cervical vertebrae, whose necks are subjected to forced hyperextension. Typically, it is seen in a forward fall onto the face in an elderly person. This causes the ligamentum flavum to buckle into the spinal cord, resulting in a contusion to the central portion of the cord. This injury affects the central gray matter and the most central portions of the pyramidal and spinothalamic tracts. Patients often have greater neurologic deficits in the upper extremities, compared to the lower extremities, since nerve fibers that innervate distal structures are located in the periphery of the spinal cord. In addition, patients with central cord syndrome usually have decreased rectal sphincter tone and patchy, unpredictable sensory deficits. (b) Anterior cord syndrome results in variable degrees of motor paralysis, and loss of temperature and pain sensation below the level of (Courtesy of Adam J. Rosh MD.)Trauma, Shock, and Resuscitation Answers 147 (Reproduced, with permission, from Schwartz DT. Emergency Radiology: Case Studies. New York, NY: McGraw-Hill, 2007: chap V-4, Figure 15.) Arm Trunk Trunk Leg Leg Cervical Thoracic Lumbar Sacral Posterior horn Dorsal column (position, vibration, light touch) Lateral corticospinal tract (motor) Lateral spinothalamic tract (pain, temperature) Arm the lesion. Its hallmark is preservation of vibratory sensation and proprioception because of an intact dorsal column. (c) Brown-Séquard syndrome results in ipsilateral loss of motor strength, vibratory sensation, and proprioception, and contralateral loss of pain and temperature sensation. (d) Transverse myelitis is an inflammatory process that produces complete motor and sensory loss below the level of the lesion. (e) Parkinson disease develops over years and does not result in paralysis.

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1. A 58-year-old woman is brought to the emergency department (ED) by emergency medical service (EMS) after slipping on a patch of ice while walking to work and hitting her head on the cement Bystanders acknowledged that the patient was unconscious for approximately 1 minute. On arrival, her vital signs are blood pressure (BP) 155/75 mm Hg, heart rate (HR) 89 beats per minute, respiratory rate (RR) 18 breaths per minute, and pulse oxygenation 98% on room air. She has a 5-cm laceration to the back of her head that is actively bleeding. You ask the patient what hap- pened but she cannot remember. You inform her that she is in the hospital as a result of a fall. Over the next 10 minutes she asks you repeatedly what happened and where she is. You do not find any focal neurologic deficits. As you bring the patient to the CT scanner, she vomits once. CT results show a normal brain scan. Which of the following is the most likely diag-nosis?

Cerebral concussion
Diffuse axonal injury
Cerebral contusion
Posttraumatic epilepsy
Trauma-induced Alzheimer disease

2. A 41-year-old man, the restrained driver in a high-speed motor vehicle collision, is brought to the ED by The patient is breathing without difficulty with bilateral and equal breaths sounds. He has strong pulses peripherally indicating a BP of at least 90 mm Hg. The HR is 121 beats per minute. His Glasgow coma scale (GCS) is 14. A secondary survey reveals chest wall bruising. You suspect a cardiac injury. Which of the fol- lowing locations most commonly involve cardiac contusions?

Right atrium
Right ventricle
Left atrium
Left ventricle
Septum

3. A 25-year-old man is brought into the trauma resuscitation room after his motorcycle is struck by another EMS reports that the patient was found 20 ft away from his motorcycle, which was badly damaged. His vital signs include a BP of 90/60 mm Hg, HR 115 beats per minute, RR 22 breaths per minute, and pulse oxygenation of 100% on facemask. Which of the following is the smallest amount of blood loss that produces a decrease in the systolic BP in adults?

Loss of 5% of blood volume
Loss of 10% of blood volume
Loss of 15% to 30% of blood volume
Loss of 30% to 40% of blood volume
Loss of greater than 40% of blood volume

4. You are notified by the EMS dispatcher that there is a multiple-car collision on the local highway with many He states that there are two people dead at the scene, one person is critically injured and hypoten- sive, and three people have significant injuries but with stable vital signs. Which of the following is the leading cause of death and disability in trauma victims?

Abdominal injury
Thoracic injury
Back injury
Cervical injury
Head injury

5. Paramedics bring a 17-year-old high school football player to the ED on a backboard and with a cervical During a football game, the patient “speared” another player with his helmet and subsequently expe- rienced severe neck pain. He denies paresthesias and is able to move all of his extremities. A cervical spine CT scan reveals multiple fractures of the first cervical vertebra. Which of the following best describes this fracture?

Odontoid fracture
Hangman’s fracture
Jefferson fracture
Clay shoveler’s fracture
Teardrop fracture

6. A 20-year-old man presents to the ED with multiple stab wounds to his His BP is 85/50 mm Hg and HR is 123 beats per minute. Two large-bore IVs (intravenous) are established and running wide open. On examination, the patient is mumbling incomprehensibly, has good air entry on lung examination, and you notice jugular venous distension (JVD). As you are listening to his heart, the nurse calls out that the patient has lost his pulse and that she cannot get a BP reading. Which of the following is the most appropriate next step in management?

Atropine
Epinephrine
Bilateral chest tubes
ED thoracotomy
Pericardiocentesis

7. A 22-year-old man calls the ED from a local bar stating that he was punched in the face 10 minutes ago and is holding his front incisor tooth in his He wants to know what the best way is to preserve the tooth. Which of the following is the most appropriate advice to give the caller?

Place the tooth in a napkin and bring it to the ED.
Place the tooth in a glass of water and bring it to the ED.
Place the tooth in a glass of beer and bring it to the ED.
Pour some water over the tooth and place it immediately back into the socket.
Place the tooth in a glass of milk and bring it to the ED.

8. A 19-year-old man is brought into the trauma room by EMS after a head-on cycling The patient was not wearing a helmet. Upon presentation his BP is 125/75 mm Hg, HR is 105 beats per minute, RR is 19 breaths per minute, and oxygen saturation is 100% on mask. His eyes are closed but open to command. He can move his arms and legs on com- mand. When you ask him questions, he is disoriented but able to converse. What is this patient’s GCS score?

9. An 18-year-old man presents to the ED after getting stabbed in his His HR is 140 beats per minute and BP is 90/40 mm Hg. He is yelling that he is in pain. Two large-bore IVs are inserted into his antecu- bital fossa and fluids are running wide open. After 2 L of fluids, his BP does not improve. Which of the following is the most common organ injured in stab wounds?

Liver
Small bowel
Stomach
Colon
Spleen

10. A 61-year-old man presents to the ED with chest wall pain after a motor vehicle He is speaking full sentences, breath sounds are equal bilat- erally, and his extremities are well-perfused. His BP is 150/75 mm Hg, HR is 92 beats per minute, and oxygen saturation is 97% on room air. Chest radi- ography reveals fractures of the seventh and eighth ribs of the right antero- lateral chest. He has no other identifiable injuries. Which of the following is the most appropriate treatment for this patient’s rib fractures?

Apply adhesive tape on the chest wall perpendicular to the rib fractures.
Insert a chest tube into the right thorax.
Bring the patient to the OR for surgical fixation.
Analgesia and incentive spirometry.
Observation.

11. A 27-year-old man brought to the ED by paramedics after a motor vehicle His RR is 45 breaths per minute, oxygen saturation is 89%, HR is 112 beats per minute, and BP is 115/75 mm Hg. You auscultate his chest and hear decreased breath sounds on the left. Which of the fol- lowing is the most appropriate next step in management?

Order a stat chest radiograph.
Perform a pericardiocentesis.
Perform a diagnostic peritoneal lavage (DPL).
Perform an ED thoracotomy.
Perform a tube thoracostomy.

12. A 29-year-old man is brought to the ED by EMS after being stabbed in the left side of his His BP is 120/80 mm Hg, HR is 105 beats per minute, RR is 16 breaths per minute, and oxygen saturation is 98% on room air. On the secondary survey, you note motor weakness of his left lower extremity and the loss of pain sensation in the right lower extremity. Which of the following is the most likely diagnosis?

Spinal shock
Central cord syndrome
Anterior cord syndrome
Brown-Séquard syndrome
Cauda equina syndrome

13. A 33-year-old man, who was drinking heavily at a bar, presents to the ED after getting into a A bystander tells paramedics that the patient was punched and kicked multiple times and sustained multiple blows to his head with a stool. In the ED, his BP is 150/75 mm Hg, HR is 90 beats per minute, RR is 13 breaths per minute, and oxygen saturation is 100% on non-rebreather. On examination, he opens his eyes to pain and his pupils are equal and reactive. There is a laceration on the right side of his head. He withdraws his arm to pain but otherwise does not move. You ask him questions, but he just moans. Which of the following is the most appropri- ate next step in management?

Prepare for intubation.
Suture repair of head laceration.
Administer mannitol.
Bilateral burr holes.
Neurosurgical intervention.

14. A 74-year-old man presents to the ED after being involved in a motor vehicle He states he was wearing his seat belt in the driver’s seat when a car hit him from behind. He thinks his chest hit the steering wheel and now complains of pain with breathing. His RR is 20 breaths per minute, oxygen saturation is 98% on room air, BP is 145/75 mm Hg, and HR is 90 beats per minute. On examination, you notice paradoxical respirations. Which of the following best describes a flail chest?

One rib with three fracture sites
Two adjacent ribs, each with two fracture sites
Three adjacent ribs, each with two fracture sites
One fractured right-sided rib and one fractured left-sided rib
Two fractured right-sided ribs and two fractured left-sided ribs

15. A 29-year-old man presents to the ED after being stabbed in his The patient is speaking in full sentences. His breath sounds are equal bilat- erally. His BP is 130/75 mm Hg, HR is 95 beats per minute, RR is 16 breaths per minute, and oxygen saturation is 99% on room air. The stab wound is located between the angle of the mandible and the cricoid cartilage and violates the platysma. There is blood oozing from the site although there is no expanding hematoma. Which of the following is the most appropriate next step in management?

Explore the wound and blind clamp any bleeding site.
Probe the wound looking for injured vessels.
Apply direct pressure and bring the patient immediately to the OR to explore the zone I injury.
Apply direct pressure and bring the patient immediately to the OR to explore the zone II injury.
Apply direct pressure and bring the patient immediately to the OR to explore the zone III injury.

16. A 45-year-old man is brought to the ED after a head-on motor vehicle colli- Paramedics at the scene tell you that the front end of the car is smashed. The patient’s BP is 130/80 mm Hg, HR is 100 beats per minute, RR is 15 breaths per minute, and oxygen saturation is 98% on room air. Radiographs of the cervical spine reveal bilateral fractures of the C2 vertebra. The patient’s neurologic exami- nation is unremarkable. Which of the following best describes this fracture?

Colles fracture
Boxer’s fracture
Jefferson fracture
Hangman’s fracture
Clay shoveler’s fracture

17. A 71-year-old man is found lying on the ground one story below the balcony of his Paramedics bring the patient into the ED. He is cool to touch with a core body temperature of 96°F. His HR is 119 beats per minute and BP is 90/70 mm Hg. His eyes are closed, but they open when you call his name. His limbs move to stimuli, and he answers your questions but is confused. On examination, you note clear fluid dripping from his left ear canal and an area of ecchymosis around the mastoid bone. Which of the following is the most likely diagnosis?

Le Fort fracture
Basilar skull fracture
Otitis interna
Otitis externa
Tripod fracture

18. A 34-year-old construction worker is brought to the ED by EMS after falling 30 ft from a His vital signs are HR 124 beats per minute, BP 80/40 mm Hg, and oxygen saturation 93% on 100% oxygen. He has obvious head trauma with a scalp laceration overlying a skull fracture on his occiput. He does not speak when asked his name, his respirations are poor, and you hear gurgling with each attempted breath. Auscultation of the chest reveals diminished breath sounds on the right. There is no JVD or anterior chest wall crepitus. His pelvis is unstable with movement laterally to medially and you note blood at the urethral meatus. His right leg is grossly deformed at the knee and there is an obvious fracture of his left arm. Which of the following is the most appropriate next step in management?

Insert a 32F chest tube into the right thoracic cavity.
Perform a DPL to rule out intra-abdominal hemorrhage.
Create two Burr holes into the cranial vault to treat a potential epidural hematoma.
Immediately reduce the extremity injuries and place in a splint until the patient is stabilized.
Plan for endotracheal intubation of the airway with in-line stabilization of the cervical spine.

19. A 20-year-old man was found on the ground next to his car after it hit a tree on the side of the Bystanders state that the man got out of his car after the collision but collapsed within a few minutes. Paramedics sub- sequently found the man unconscious on the side of the road. In the ED, his BP is 175/90 mm Hg, HR is 65 beats per minute, temperature is 99.2°F, RR is 12 breaths per minute, and oxygen saturation is 97% on room air. Physical examination reveals a right-sided fixed and dilated pupil. A head CT is shown below. Which of the following is the most likely diagnosis?

(Reproduced, with permission, from Knoop KJ, Stack LB, Storrow AB. Atlas of Emergency Medicine. New York, NY: McGraw-Hill, 2002: 162.)

Epidural hematoma
Subdural hematoma
Subarachnoid hemorrhage (SAH)
Intracerebral hematoma
Cerebral contusion

20. An 81-year-old woman presents to the ED after tripping over the sidewalk curb and landing on her chin causing a hyperextension of her She was placed in a cervical collar by paramedics. On examination, she has no sensorimotor function of her upper extremities. She cannot wiggle her toes, has 1/5 motor function of her quadriceps, and only patchy lower extremity sensation. Rectal examination reveals decreased rectal tone. Which of the following is the most likely diagnosis?

Central cord syndrome
Anterior cord syndrome
Brown-Séquard syndrome
Transverse myelitis
Exacerbation of Parkinson disease

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