The Quizzes about Trauma, Shock, and Resuscitation – Part 2 (20 test)

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Trauma, Shock, and Resuscitation-2

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Question 1

A 22-year-old man presents to the ED after being ejected from his vehicle following a high-speed motor vehicle collision. Upon arrival, his BP is 85/55 mm Hg and HR is 141 beats per Two large-bore IVs are placed in the antecubital veins and lactated Ringer solution is being administered. After 3 L of crystalloid fluid, the patient’s BP is 83/57 mm Hg. Which of the following statements is most appropriate regarding man- agement of a hypotensive trauma patient who fails to respond to initial volume resuscitation?

A	It is important to wait for fully cross-matched blood prior to transfusion.
B	Whole blood should be used rather than packed red blood cells (RBCs).
C	Blood transfusion should begin after 4 L of crystalloid infusion.
D	Type O blood that is Rh-negative should be transfused.
E	Type O blood that is Rh-positive should be transfused.

Question 1 Explanation:

The decision to begin blood transfusion in a trauma patient is based on the initial response to crystalloid volume resuscitation. Blood products should be administered if vital signs transiently improve or remain unstable despite resuscitation with 2 to 3 L of crystalloid fluid. However, if there is obvious major blood loss and the patient is unstable, blood transfusion should be started concomitantly with crystalloid administration. The main purpose in transfusing blood is to restore the oxygen-carrying capacity of the intravascular volume. Fully cross-matched blood is preferable (eg, type B, Rh-negative, antibody negative); however, this process may take more than 1 hour, which is inappropriate for the unstable trauma patient. Type-specific blood148 Emergency Medicine (eg, type A, Rh negative, unknown antibody) can be provided by most blood banks within 30 minutes. This blood is compatible with ABO and Rh blood types, but may be incompatible with other antibodies. If typespecific blood is unavailable, type O packed cells are indicated for patients who are unstable. Men should be administered type O, Rh-positive blood. To reduce sensitization and future complications, type O, Rh-negative blood is reserved for women of childbearing age. (a) Fully cross-matched blood may take greater than 1 hour to prepare, which is inappropriate for an unstable patient. (b) Whole blood is rarely used by blood centers and was replaced by blood components, such as packed RBCs. Whole blood is not used because the extra plasma can contribute to transfusion associated circulatory overload, a potentially dangerous complication. (c) Blood transfusion should not be delayed in the unstable patient. As dictated in ATLS, if the individual does not respond to 2 to 3 L of crystalloid, blood transfusion should commence. (d) For life-threatening blood loss, type O, Rh-negative blood is reserved for women of childbearing age. This reduces complications of Rh incompatibility in future pregnancies. However, if type O, Rh-negative blood is unavailable, type O, Rh-positive blood should be administered to women.

Question 2

A 24-year-old man is brought into the ED by paramedics after being run over by a His systolic BP is 90 mm Hg by palpation, HR is 121 beats per minute, RR is 28 breaths per minute, and oxygen saturation is 100% on non-rebreather. The airway is patent and breath sounds are equal bilat- erally. You establish large-bore access and fluids are running wide open. Secondary survey reveals an unstable pelvis upon movement with lateral to medial force. Bedside focused abdominal sonography for trauma (FAST) is negative for intraperitoneal fluid. Which of the following is the most appropriate immediate next step in management?

A	Bilateral chest tubes
B	Application of external fixator
C	Application of pelvic binding apparatus
D	Venographic embolization
E	Angiographic embolization

Question 2 Explanation:

This patient is hemodynamically unstable with a pelvic fracture. The retroperitoneum can accommodate up to 4 L of blood after severe pelvic trauma. A few options are useful in managing hemorrhage from an unstable pelvic fracture. However, the initial and simplest modality to use in a patient in shock from a pelvis fracture is placement of a pelvic binding garment. This device can be applied easily and rapidly and is typically effective in tamponading bleeding and stabilizing the pelvis. (a) Bilateral chest tubes would be appropriate if there was evidence for a pneumo- or hemothorax. This patient has bilaterally equal breath sounds. (b) Although external fixation is an effective method to stabilize the pelvis, it may delay management of a trauma patient. Because a pelvic binding apparatus is quick and simple, it is preferred. (d) The source of retroperitoneal bleeding with pelvic fractures is typically the venous plexus or smaller veins. However, venography is not useful in managing these patients; even when venous bleeding is localized, embolization is ineffective because of the extensive anastomoses and valveless collateral flow. (e) In contrast, arteriography is a major diagnostic and therapeutic modality for the patient with severe pelvic hemorrhage from arterial sources. Angiography is indicated whenTrauma, Shock, and Resuscitation Answers 149 hypovolemia persists in a patient with a major pelvic fracture, despite control of hemorrhage from other sources. Since angiography typically takes place in the angiography suite, patients should have a pelvic binding device applied, prior to being transferred to angiography.

Question 3

A 32-year-old man is brought to the ED by paramedics after a diving accident. The lifeguard on duty accompanies the patient and states that he dove head first into the shallow end of the pool and did not On examination, the patient is speaking but cannot move his arms or legs and cannot feel pain below his clavicle. He is able to feel light touch and posi- tion of his four extremities. A cervical spine radiograph does not reveal a fracture. Which of the following is the most likely diagnosis?

A	Spinal cord injury without radiographic abnormality (SCIWORA)
B	Central cord syndrome
C	Anterior cord syndrome
D	Cauda equina syndrome
E	Brown-Séquard syndrome

Question 3 Explanation:

Anterior cord syndrome results from cervical flexion injuries (eg, diving in shallow water) that cause cord contusion or protrusion of a bony fragment or herniated intervertebral disk into the spinal canal. It may also occur from vascular pathology, such as laceration or thrombosis of the anterior spinal artery. The syndrome is characterized by different degrees of paralysis and loss of pain and temperature sensation below the level of injury. Its hallmark is the preservation of the posterior columns, maintaining position, touch, and vibratory sensation. SCIWORA (a) is reserved for the pediatric population because the spinal cord is less elastic than the bony spine and ligaments. The diagnosis is associated with paresthesias and generalized weakness. This syndrome is coming under scrutiny since the advent of the magnetic resonance imaging (MRI) where spinal cord lesions are being identified in patients who otherwise had normal CT scans. Central cord syndrome (b) is often seen in patients with degenerative arthritis of the cervical vertebrae, whose necks are subjected to forced hyperextension. This is seen typically in 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. Cauda equina injury (d) 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. Brown-Séquard syndrome (e) results in ipsi-lateral loss of motor strength, vibratory sensation, and proprioception, and contralateral loss of pain and temperature sensation. Syndrome Neurologic Deficits Anterior cord B/L paralysis below lesion, loss of pain and temperature, and preservation of proprioception and vibratory function Central cord Lower extremity paralysis > upper extremity paralysis, some loss of pain and temperature with upper > lower Brown-Séquard Ipsilateral: paresis, loss of proprioception, and vibratory sensation Contralateral: loss of pain and temperature Cauda equina Variable motor and sensory loss in lower extremities, bowel/ bladder dy

Question 4

A 22-year-old man is brought to the ED 20 minutes after a head-on motor vehicle collision in which he was the unrestrained On arrival, he is alert and coherent but appears short of breath. His HR is 117 beats per minute, BP is 80/60 mm Hg, and oxygen saturation is 97% on a non- rebreather. Examination reveals bruising over the central portion of his chest. His neck veins are not distended. Breath sounds are present on the left but absent on the right. Following administration of 2 L of lactated Ringer solution, his systolic BP remains at 80 mm Hg. Which of the follow- ing is the most appropriate next step in management?

A	Sedate, paralyze, and intubate.
B	Perform a needle thoracostomy.
C	Perform a DPL.
D	Perform a FAST examination.
E	Perform a pericardiocentesis.

Question 4 Explanation:

The treatment of a tension PTX involves immediate reduction in the intrapleural pressure on the affected side of the thoracic cavity. The simplest and quickest way to establish this is by inserting a 14-gauge catheter into the thoracic cavity in the second intercostal space in the midclavicular line. After this procedure, a chest tube should be inserted as definitive management. Needle thoracostomy is necessary when a patient’s vital signs are unstable; otherwise, direct insertion of a chest tube is adequate for suspicion of a hemo- or pneumothorax. A tension PTX is a life-threatening emergency caused by air entering the pleural space that is not able to escape secondary to the creation of a one-way valve. This increased pressure causes the ipsilateral lung to collapse, shifting the mediastinum away from the injured lung, compromising vena caval blood return to the heart. The severely altered preload results in reduced stroke volume, increased cardiac output, and hypotension. (a) Airway is the first component addressed in the ABCs; however, the patient is breathing on his own and does not require intubation. (c and d) If the BP does not elevate with insertion of a chest tube, the next area to focus on is an intra-abdominal injury, which can be assessed either by a DPL or FAST examination. (e) A pericardiocentesis is indicated in the stable trauma patient when there is suspicion for cardiac tamponade, which may present with tachycardia and Beck triad: hypotension, JVD, and muffled heart sounds.

Question 5

An 87-year-old man is brought to the ED on a long board and in a cervical collar after falling down a flight of He denies losing con- sciousness. On arrival, his vital signs include an HR of 99 beats per minute, BP of 160/90 mm Hg, and RR of 16 breaths per minute. He is alert and speaking in full sentences. Breath sounds are equal bilaterally. Despite an obvious right arm fracture, his radial pulses are 2+ and symmetric. When examining his cervical spine, he denies tenderness to palpation and you do not feel any bony deformities. Which of the following is a true statement?

A	Epidural hematomas are very common in the elderly age population.
B	Cerebral atrophy in the elderly population provides protection against subdural hematomas.
C	Increased elasticity of their lungs allows elderly patients to recover from thoracic trauma more quickly than younger patients.
D	The most common cervical spine fracture in this age group is a wedge fracture of the sixth cervical vertebra.
E	Despite lack of cervical spine tenderness, imaging of his cervical spine is warranted.

Question 5 Explanation:

The Canadian C-spine rule for radiography in alert and stable patients following blunt head or neck trauma identified age greater than 65 years as a high risk factor for C-spine injury, even among those with stable vital signs and a GCS score of 15. Therefore, C-spine imaging in all such elderly patients is warranted. (a) It is thought that elderly patients experience a much lower incidence of epidural hematomas than the general population because of a relatively denser fibrous bond between the dura mater and the inner table of the skull in older individuals. (b) There is, however, a high incidence of subdural hematomas in elderly patients. As the brain mass decreases in size with age, there is greater stretching and tension of the bridging veins that pass from the brain to the dural sinuses. (c) In the elderly, diminished elasticity of the lungs can lead to a reduction in pulmonary compliance and in the ability to cough effectively, resulting in an increased risk for nosocomial gram-negative pneumonia. Geriatric patients are thus more susceptible to the development of hypoxia and respiratory infections following trauma.Trauma, Shock, and Resuscitation Answers 151 (d) The most common cervical spine fractures in this age group are upper cervical, particularly fractures of the odontoid, not lower C6 fractures

Question 6

A 45-year-old man is brought into the ED after a head-on motor vehicle His BP is 85/45 mm Hg and HR is 130 beats per minute. He is speaking coherently. His breath sounds are equal bilaterally. After 2 L of fluid resuscitation, his BP is 80/40 mm Hg. A FAST examination reveals fluid in Morison pouch. Which of the following organs is most likely to be injured in blunt abdominal trauma?

A	Liver
B	Spleen
C	Kidney
D	Small bowel
E	Bladder

Question 6 Explanation:

Blunt trauma is the most common mechanism of injury seen in the United States. The forces exerted on the abdomen put all of the organs at risk for injury. Motor vehicle collisions with another vehicle or with pedestrians are the major causes of blunt abdominal trauma. The spleen is the organ most often injured, and in approximately 66% of these cases, it is the only damaged intraperitoneal organ. The liver (a) is the second most commonly injured intra-abdominal organ, third is the kidney (c), fourth is the small bowel (d), and fifth is the bladder (e).

Question 7

A 47-year-old man is brought into the ED after falling 20 ft from a His HR is 110 beats per minute, BP is 110/80 mm Hg, RR is 20 breaths per minute, and oxygen saturation is 100% on face mask. He is able to answer your questions without difficulty. His chest is clear with bilateral breath sounds, abdomen is nontender, pelvis is stable, and the FAST examination is negative. You note a large scrotal hematoma and blood at the urethral meatus. Which of the following is the most appropriate next step in management?

A	Scrotal ultrasound
B	Scrotal ultrasound Kidney-ureter-bladder (KUB) radiograph
C	IV pyelogram
D	Retrograde cystogram
E	Retrograde urethrogram

Question 7 Explanation:

Urethral injuries make up approximately 10% of genitourinary trauma. Anterior urethral injuries are most often attributed to falls with straddle injuries or a blunt force to the perineum. Approximately 95% of posterior urethral injuries are secondary to pelvic fractures. Signs and symptoms of urethral injury include perineal pain, inability to void, gross hematuria, blood at the urethral meatus, perineal or scrotal swelling or ecchymosis, and an absent, highriding, or boggy prostate. A retrograde urethrogram is the study of choice when there is suspicion of a urethral injury. This procedure is performed by inserting an 8F urinary catheter 2 cm into the meatus and inflating the catheter balloon with 2-cc saline to create a seal. Then, 30 cc of radiopaque contrast is administered and a radiograph is obtained looking for extravasation of contrast from the urethra. (a) A scrotal ultrasound may be necessary later on to evaluate for testicular injury, but it is not used to evaluate urethral injury. (b) A KUB is not useful to evaluate the urethra. Prior to CT scanning, it was commonly used to evaluate for kidney stones. (c) An IV pyelogram is an alternative to CT scanning for evaluating the kidney and ureter. (d) A retrograde cystogram is a useful study to evaluate the bladder for injury

Question 8

A 17-year-old man presents to the ED after getting hit in the right eye with a tennis ball during a tennis On arrival to the ED, you note periorbital swelling and ecchymosis. The patient’s visual acuity is 20/20. When you are testing his extraocular muscles, you note that his right eye cannot look superiorly but his left eye can. He also describes pain in his right eye when attempting to look upward. Which of the following is the most likely diagnosis?

A	Zygomatic arch fracture
B	Zygomatic arch fracture
C	Retrobulbar hematoma
D	Ruptured globe
E	Mandible fracture with entrapment of the pterygoid

Question 8 Explanation:

Orbital floor fractures typically occur when a blunt object with a radius of curvature less than 5 cm (eg, often a fist or ball smaller than a softball) strikes the orbit. The blunt force causes an increase in intraorbital pressure causing a fracture along the weakest part of the orbit, usually the inferior or sometimes medial wall. Patients usually complain of pain that is greatest with upward152 Emergency Medicine eye movement. They may have impaired ocular motility or diplopia if the inferior rectus muscle becomes entrapped. They may also present with infraorbital hypoesthesia because of compression of the infraorbital nerve. Generally, the patient has normal visual acuity unless there is an associated ocular injury. A classic radiographic finding is the “teardrop sign,” which represents herniated orbital fat and muscle in the roof of the maxillary sinus. There may also be an air-fluid level in the maxillary sinus as a result of bleeding into it. Patients usually do well and recover completely in mild to moderate fractures. (a) Zygomatic arch fractures usually present with periauricular depression and point tenderness and may be complicated by trismus secondary to impingement of the coronoid process of the mandible on the arch during mouth opening. (c) A retrobulbar hematoma occurs secondary to blunt orbital trauma and typically causes exophthalmos. Patients usually present with periorbital edema, ecchymosis, a decrease in visual acuity, and an afferent papillary defect in the involved eye. (d) Open globe injuries typically result from penetrating trauma to the eye. Patients may present with leakage of aqueous humor, a teardrop-shaped pupil, or prolapse of choroid through the wound. (e) Patients with mandible fractures present with pain and decreased range of motion of the jaw, malocclusion or pain with teeth clenching, and inability to fully open the mouth.

Question 9

A 24-year-old man is brought to the ED after being shot once in the On arrival, his BP is 100/60 mm Hg, HR is 115 beats per minute, and RR is 22 breaths per minute. His airway is patent and you hear breath sounds bilaterally. On abdominal examination, you note a single bullet entry wound approximately 1 cm to the right of the umbilicus. During the log roll, you see a single bullet exit wound approximately 3 cm to the right of the lumbar spine. His GCS score is 15. The patient’s BP is now 85/65 mm Hg and HR is 125 beats per minute after 2 L of fluid. Which of the following is the most appropriate next step in management?

A	Probe the entry wound to see if it violates the peritoneum.
B	Perform a FAST examination.
C	Perform a DPL
D	Take the patient directly to the CT scanner.
E	Take the patient directly to the OR.

Question 9 Explanation:

An important concern with anterior abdominal GSW is to determine whether the missile traversed the peritoneal cavity. Patients with transabdominal GSWs nearly all have intra-abdominal injuries requiring surgery. Most of the time, this can be determined by approximating the trajectory. Therefore, a hole in both the anterior and posterior abdomen highly suggests a transabdominal trajectory. If there are a single or odd number of holes, a plain film may help estimate the trajectory. In cases of tangential or multiple GSWs, it may be impossible to determine trajectory with any certainty. In a patient with evidence of peritoneal penetration, a missile tract that clearly enters the abdominal cavity, or has a positive diagnostic study (eg, DPL, FAST, CT) in a tangential wound, he or she should undergo exploratory laparotomy. The standard algorithm for penetrating abdominal trauma recommends that any patient with unstable vital signs be taken directly to the OR to undergo an exploratory laparotomy. If their vital signs are stable, they should undergo further diagnostic studies, such as a FAST examination, DPL, or CT scan. a) In general, penetrating abdominal wounds should not be probed. This may worsen the injury and disrupt hemostasis, resulting in uncontrolled hemorrhage. Instead, gently separate the skin edges to see if the base of the wound can be visualized. (b, c, and d) In the setting of penetrating abdominal trauma, further diagnostic tests should only occur if the patient has stable vital signs. Otherwise, patients should go directly to the OR to undergo exploratory laparotomy

Question 10

A 55-year-old woman presents to the ED stating that her nose has been bleeding profusely for the last 3 After 25 minutes of bilateral pressure on her nasal septum, there is still profuse bleeding. You place anterior nasal packing bilaterally, but bleeding still persists. The patient is starting to get anxious. Her BP is 110/70 mm Hg, HR is 80 beats per minute, RR is 18 breaths per minute, and oxygen saturation is 98%. Laboratory results reveal a white blood cell (WBC) count of 9000, hematocrit (HCT) 34%, platelets of 225,000, and international normalized ratio (INR) 1.1. Under direct visualization, you note the bleeding originating from the pos- terior aspect of her septum. Which of the following is the most appropriate management?

A	Place posterior nasal packing, start antibiotics, and admit the patient to a moni- tored hospital bed.
B	Place the patient supine and wait for spontaneous resolution of the bleeding.
C	Keep pressure on her nasal septum, and administer fresh frozen plasma (FFP) and platelets.
D	Place posterior nasal packing, and discharge the patient home with follow-up in 24 hours.
E	Apply silver nitrate to the nasal mucosa until the bleeding stops.

Question 10 Explanation:

Posterior epistaxis is identified when posterior bleeding occurs with a properly placed anterior nasal packing. Posterior packing is mandated using either a commercially available balloon or a standard Foley catheter inserted into the posterior nares and inflated with water. Patients with posterior nasal packs should be admitted to a monitored bed. In addition to cardiac dysrhythmias, myocardial infarctions, cerebrovascular accidents, and aspiration have been reported in these patients. Antibiotics are often started to prevent sinusitis and toxic shock syndrome from obstruction of the nasal packing. (b) Placing the patient supine increases risk of aspiration and has no benefit to stopping epistaxis. (c) If the patient had an elevated INR or was thrombocytopenic, then FFP and platelets should be administered. (d) Patients with posterior nasal packing require admission. (e) Silver nitrate is a therapy for anterior epistaxis. It has no role in posterior epistaxis

Question 11

Paramedics bring a 44-year-old man to the He was found in the middle of the street after being struck by a car. His systolic BP is 70 mm Hg; a diastolic BP cannot be obtained. The heart rate is 125 beats per minute, and oxygen saturation is 89% on room air. The patient’s eyes are closed. You ask the patient his name and he doesn’t respond. There is no response when you ask him to move his limbs. You notice that his left foot is severely deformed and there is a large laceration to his right arm. Which of the fol- lowing is the most appropriate next step in management?

A	Prepare for emergent orotracheal intubation.
B	Begin aggressive fluid resuscitation and administer morphine for pain
C	Apply a tourniquet just above his left foot and begin fluid resuscitation.
D	Apply pressure to the laceration, splint the left foot, and order a radiograph.
E	Administer packed RBCs and bring him to the CT scanner for a pan-scan.

Question 11 Explanation:

Patients often present to the ED with life-threatening conditions that require rapid and simultaneous evaluation and treatment. The fundamentals of emergency medicine begin with the ABCs. Airway assessment and management have priority over all other aspects of resuscitation in the critically ill or injured patient. Moreover, airway management is not simply the passage of a tube through the trachea. It involves a series of actions ranging from repositioning a patient’s head and neck, suctioning secretions in the posterior pharynx to supplying supplemental oxygen or performing an emergent cricothyrotomy. Whatever the intervention, it is important to know when and how to manage an airway. There are many reasons for definitive airway management with an orotracheal tube, the obvious being in patients who are not breathing. However, there are instances that require definitive management even when a patient is spontaneously breathing. Any patient who is at risk of losing the ability to protect their airway should be considered for intubation. This includes intoxicated patients, the poisoned patient, worsening hypoxia, those with evolving laryngeal edema or hematoma near the trachea, and patients with significant head injuries. Once the airway is addressed, it is appropriate to move onto the next critical component of the ABCs. (b) The patient will certainly require volume resuscitation and pain control, but airway management takes priority. (c and d) It is important not to get distracted by other injuries in a critical patient who requires definitive airway management as first priority. (e) Although the patient will require a blood transfusion, the airway must be addressed first.

Question 12

A 17-year-old adolescent boy is found unconscious in a swimming He is brought into the ED by paramedics already intubated. In the ED, the patient is unresponsive with spontaneous abdominal breathing at a rate of 16 breaths per minute, BP 80/50 mm Hg, and HR 49 beats per minute. In addition to hypoxemia, what condition must be considered earliest in the management of this patient?

A	Cervical spine injury
B	Electrolyte imbalance
C	Metabolic acidosis
D	Severe atelectasis
E	Toxic ingestion

Question 12 Explanation:

Diving injuries must always be suspected in near-drowning patients. This patient presents with abdominal breathing and spontaneous respirations. This pattern provides an important clue to a cervical spine injury. The diaphragm is innervated by the phrenic nerve that originates from the spinal cord at the C3-C4 level, whereas the intercostal muscles of the rib cage are supplied by nerves that originate in the thoracic spine. Therefore, abdominal breathing in the absence of thoracic breathing indicates an injury below C4. His bradycardia in the presence of hypotension is suspicious for neurogenic hypotension, which is caused by loss of vasomotor tone and lack of reflex tachycardia from the disruption of autonomic ganglia. However, this is a diagnosis of exclusion and should only be made once all other forms of shock are ruled out. It is important to maintain C-spine immobilization to prevent further progression of an injury. (b) Electrolyte abnormalities are typically not a concern in neardrowning injuries. (c) Any patient with hypoxia and hypoperfusion generally also has a metabolic acidosis. Treating the underlying pathology will also treat the acidosis. (d) All near-drowning cases (fresh or saltwater) involve the loss of surfactant and subsequent atelectasis with a high potential for hypoxia. (e) Although a toxic ingestion should always be considered, there are no specific indications for it in this patient.

Question 13

A 22-year-old man is brought to the ED after sustaining a single gun- shot wound (GSW) to his right On arrival, his HR is 105 beats per minute and BP is 115/75 mm Hg. You note a large hematoma of his medial thigh. The patient complains of numbness in his right foot. On extremity examination, the right foot is pale and you cannot palpate a distal pulse but can locate the dorsalis pedis by Doppler. In addition, the patient cannot move the foot. Which of the following is the most appropriate next step in management?

A	Angiography
B	Exploration and repair in the OR
C	Fasciotomy to treat compartment syndrome
D	Wound exploration
E	CT scan of the right extremity

Question 13 Explanation:

Clinical manifestations of penetrating arterial injury of the extremity are generally divided into “hard signs” and “soft signs.” Hard signs include pulsatile bleeding, expanding hematoma, palpable thrill or audible bruit, and evidence of distal ischemia (eg, pain, pallor, pulselessness, paralysis, paresthesia, poikilothermia). Soft signs include diminished ankle-brachial indices, asymmetrically absent orTrauma, Shock, and Resuscitation Answers 155 weak distal pulse, history of moderate hemorrhage or wound close to a major artery, and a peripheral nerve deficit. Emergent surgery is generally necessary when there are hard signs of vascular injury. Although the management of penetrating extremity injury is evolving, whenever there is evidence of distal ischemia, the patient should be taken to the OR for exploration and repair. When severe ischemia is present, the repair must be completed within 6 to 8 hours to prevent irreversible muscle ischemia and loss of limb function. In the presence of hard signs without evidence of ischemia, some surgeons may prefer to first perform angiography to better define the injury. (a) Angiography is a frequently used modality in penetrating extremity trauma and is the study of choice with some injuries that present with hard signs. However, when there is evidence of limb ischemia, the patient should undergo exploration and repair immediately. (c) Fasciotomy is the treatment for compartment syndrome. Although compartment syndrome can occur with blunt and penetrating extremity trauma, it is more common in crush injuries or fractures with marked swelling. It may be required, but should be performed in conjunction with and after the establishment of arterial blood flow. (d) Local wound exploration is not recommended because it may disrupt hemostasis and cause a worsening of the hemorrhage. (e) CT scanning is not appropriate in the setting of limb ischemia.

Question 14

A 67-year-old woman is brought to the ED after being struck by a cyclist while crossing the On arrival to the ED, her eyes remain closed to stimuli, she makes no verbal sounds, and withdraws only to pain- ful stimuli. You assign her a GCS of 6. Her BP is 175/90 mm Hg and HR is 75 beats per minute. As you open her eye lids, you notice that her right pupil is 8 mm and nonreactive and her left is 4 mm and minimally reactive. Which of the following is the most common manifestation of increasing intracranial pressure (ICP) causing brain herniation?

A	Change in level of consciousness
B	Ipsilateral pupillary dilation
C	Contralateral pupillary dilation
D	Significantly elevated BP
E	Hemiparesis

Question 14 Explanation:

Cerebral herniation occurs when increased ICP overwhelms the natural compensatory capacities of the central nervous system (CNS). Increased ICP may be the result of posttraumatic brain swelling, edema formation, traumatic mass lesion expansion, or any combination of the three. When increasing ICP cannot be controlled, the intracranial contents will shift and herniate through the cranial foramen. Herniation can occur within minutes or up to days after a traumatic brain injury. Once the signs of herniation are present, mortality approaches 100% without rapid reversal or temporizing measures. Uncal herniation is the most common clinically significant form of traumatic herniation and is often associated with traumatic extracranial bleeding. The classic signs and symptoms are caused by compression of the ipsilateral uncus of the temporal lobe. This causes compression of cranial nerve III leading to anisocoria, ptosis, impaired extraocular movements, and a sluggish pupillary light reflex. As herniation progresses, compression of the ipsilateral oculomotor nerve eventually causes ipsilateral pupillary dilation and nonreactivity.156 Emergency Medicine (a) An altered level of consciousness is the hallmark of brain insult from any cause and results from an interruption of the RAS or a global event that affects both cortices. (c) Contralateral dilation is a late manifestation in brain herniation. (d) Progressive hypertension associated with bradycardia and diminished respiratory effort is described as Cushing reflex and is a late manifestation of herniation. (e) Contralateral hemiparesis develops as herniation progresses

Question 15

A 34-year-old man is brought to the ED after being shot in the right side of his The patient is awake and speaking. Breath sounds are diminished on the right. There is no bony crepitus or tracheal deviation. His BP is 95/65 mm Hg, HR is 121 beats per minute, and RR is 23 breaths per minute. Supine chest radiograph reveals a hazy appearance over the entire right lung field. You place a 36F chest tube into the right thoracic cavity and note 1200 cc of blood in the chest tube drainage system. Which of the following is an indication for thoracotomy?

A	500 cc of initial chest tube drainage of blood
B	1200 cc of initial chest tube drainage of blood
C	Persistent bleeding from the chest tube at a rate of 50 cc/h
D	Chest radiograph with greater than 50% lung field whiteout
E	Evidence of a pneumothorax (PTX)

Question 15 Explanation:

A hemothorax is the accumulation of blood in the pleural space after blunt or penetrating chest trauma. It can lead to hypovolemic shock and can significantly reduce vital capacity if it is not recognized. It is associated with a PTX approximately 25% of the time. Hemorrhage from injured lung parenchyma is the most common cause of hemothorax, but this tends to be self-limiting unless there is a major laceration to the parenchyma. Specific vessels are less often the source of bleeding. A hemothorax is treated with chest thoracostomy (chest tube) that is generally placed in the fourth or fifth intercostal space at the anterior or midaxillary line, over the superior portion of the rib. The tube should be directed superior and posterior to allow it to drain blood from the dependent portions of the chest. In an isolated PTX, the tube is positioned anteriorly to allow it to suction air. Once the tube is inserted, it is important to closely monitor blood output. Indications for thoracotomy include • Initial chest tube drainage of 1000 to 1500 cc of blood (a and b). • 200 cc/h of persistent drainage (c). • Patient remains hypotensive despite adequate blood replacement, and other sites of blood loss have been ruled out. • Patient decompensates after initial response to resuscitation. • Increasing hemothorax seen on chest x-ray studies.

Question 16

A 32-year-old woman is brought to the ED by paramedics after being involved in a motor vehicle The patient was the front-seat pas- senger of the car and was not wearing a seat belt. In the ED, the patient is speaking and complains of abdominal pain. Her breath sounds are equal bilaterally. You note a distended abdomen. A FAST examination is positive for fluid in the left upper quadrant (LUQ). Her BP is 90/70 mm Hg and HR is 120 beats per minute. You administer 2 L of crystalloid solution. Her repeat BP is 80/60 mm Hg. Which of the following is the most appropriate next step in management?

A	Administer a vasoconstrictor, such as epinephrine.
B	Administer another 2 L of crystalloid.
C	Administer type O, Rh-negative blood.
D	Bring patient to the CT scanner for an emergent scan.
E	Perform another FAST examination to see if the fluid is increasing.

Question 16 Explanation:

This question addresses the “C,” circulation, in the ABCs. Initial fluid resuscitation usually begins with crystalloid fluids such as 0.9% normal saline or Ringer lactate. In general, if the patient remains hemodynamically unstable after 40 cc/kg of crystalloid administration (approximately 2-3 L), a blood transfusion should be started. Fully cross-matched blood is preferable; however, this is generally not available in the early resuscitation period. Therefore, type-specific blood (type O, Rh-negative or type O, Rh-positive) is a safe alternative and is usually ready within 5 to 15 minutes. Type O, Rh-negative blood isTrauma, Shock, and Resuscitation Answers 157 typically reserved for women in their childbearing years to prevent Rh sensitization. Type O, Rh-positive blood can be given to all men and women beyond their childbearing years. (a) The patient’s underlying cause of hypotension is hypovolemia secondary to hemorrhage. Therefore, to treat her hypotension you should treat the underlying cause. She requires fluid resuscitation with blood and eventually may be taken to the OR to stop the bleeding. Epinephrine is used if the patient is in cardiopulmonary arrest and no longer has a pulse. However, the underlying cause, hypovolemia, must be corrected. (b) The best resuscitation fluid is blood. ATLS guidelines suggest starting resuscitation with crystalloid solution and adding blood if there is no response after a 40 cc/kg bolus of crystalloid fluid. (d) The patient is too unstable to be transferred for a CT scan. If the patient’s BP normalizes, the trauma team may elect for a CT scan. If the patient remains hypotensive despite resuscitation, definitive measures need to take place, such as an exploratory laparotomy to stop the hemorrhage. (e) Once the FAST examination is positive, repeating it will not add valuable information. If the patient remains hypotensive, definitive management is a priority.

Question 17

A 27-year-old pregnant woman, in her third trimester, is brought to the ED after being involved in a low-speed motor vehicle The patient was wearing a seat belt in the back seat of a car that was struck in the front by another car. Her BP is 120/70 mm Hg and HR is 107 beats per minute. Her airway is patent, breath sounds equal bilaterally, and skin is warm with 2+ pulses. FAST examination is negative for free fluid. Evalu- ation of the fetus reveals appropriate fetal HR and fetal movement. Repeat maternal BP is 120/75 mm Hg. Which of the following is the most appro- priate next step in management?

A	Perform an immediate cesarean section in the OR.
B	Perform an immediate cesarean section in the ED.
C	CT scan of the abdomen and pelvis to rule out occult injury.
D	Discharge the patient if laboratory testing is normal.
E	Monitor the patient and fetus for a minimum of 4 hours.

Question 17 Explanation:

Trauma occurs in up to 7% of all pregnancies and is the leading cause of maternal death. It is important to focus the primary examination on the patient and evaluate the fetus in the secondary examination. The ABCs are followed in usual fashion. Once the patient is deemed stable, the fetus should be evaluated. Fetal evaluation focuses on the fetal HR and fetal movement. Minor trauma to the patient does not rule out injury to the fetus. Therefore, it is important to monitor the fetus. Cardiotocographic (cardiofetal heartbeat, tocouterine contractions, graphy-measuring) observation of the viable fetus is recommended for a minimum of 4 hours to detect any intrauterine pathology. The minimum should be extended to 24 hours if, at any time during the first 4 hours, there are more than three uterine contractions per hour, persistent uterine tenderness, a non-reassuring fetal monitor strip, vaginal bleeding, rupture of the membranes, or any serious maternal injury is present. (a) Cesarean section in the OR may take place if the patient is stable, but the fetus is unstable and greater than 24 weeks’ gestation. This decision should be made by the obstetrician. (b) Cesarean section in the ED, or perimortem cesarean section, is performed if uterine size exceeds the umbilicus, fetal heart tones are present, and maternal decompensation is acute. (c) Radiation from CT scanning in the setting of pregnancy is a158 Emergency Medicine concern. Shielding of the uterus in head and chest scans allows for an acceptable radiation exposure level. Abdominal and pelvic CT scanning incurs greater radiation exposure, and the risks and benefits of these studies should be discussed with the patient. Other diagnostic procedures can be used in the setting of blunt abdominal trauma, such as ultrasound, DPL, and MRI. (d) Minor trauma does not exempt the fetus from injury and direct impact is not necessary for fetoplacental pathology to occur. The mother with no obvious abdominal injury or even normal laboratory values still requires monitoring.

Question 18

A 61-year-old man presents to the ED with low back pain after slipping on an icy sidewalk He states that the pain started on the left side of his lower back and now involves the right and radiates down both legs. He also noticed difficulty urinating since last night. On neurologic examination, he cannot plantar flex his feet. Rectal examination reveals diminished rectal tone. He has a medical history of chronic hypertension and underwent a “vessel surgery” many years earlier. Which of the following is the best diagnosis?

A	Abdominal aortic aneurysm (AAA)
B	Disk herniation
C	Spinal stenosis
D	Cauda equina syndrome
E	Osteomyelitis

Question 18 Explanation:

Cauda equina syndrome is an injury to the lumbar, sacral, and coccygeal nerve roots, causing peripheral nerve injury that can lead to permanent neurologic defects if not recognized and corrected rapidly. Because of the central location of the disk herniation, symptoms are often bilateral and involve leg pain, saddle anesthesia, and impaired bowel and bladder function (retention or incontinence). On examination, patients may exhibit loss of rectal tone and display other motor and sensory losses in the lower extremities. Patients with suspected cauda equina syndrome require an urgent CT scan or MRI. (a) AAA can present with low back pain and rarely a neurologic deficit if they get large enough and impinge a nerve root. AAA should always be considered in patients over 50 years with hypertension and low back pain. A bedside ultrasound can usually identify large abdominal aortic aneurysms. If there is still concern for an AAA, a CT scan can rule the diagnosis out. (b) Disk herniation can result in peripheral nerve root compression and irritation leading to sensory and motor deficits. Patients, however, should not exhibit altered bowel and bladder function, or have decreased rectal tone. If so, the condition is likely cauda equina syndrome and is a neurologic emergency. (c) Spinal stenosis is narrowing of the spinal canal, which may cause spinal cord compression that typically is worse with back extension and relieved with flexion. (e) Osteomyelitis is an infection of the bone that typically presents with fever.

Question 19

Paramedics bring a 55-year-old woman to the ED after she was struck by a motor vehicle traveling at 30 miles/h. Her BP is 165/95 mm Hg, HR is 105 beats per minute, and RR is 20 breaths per Upon arrival, she does not open her eyes, is verbal but not making any sense, and withdraws to painful stimuli. You assign her a GCS score of 8. As you prepare to intu- bate the patient, a colleague notices that her left pupil has become dilated compared to the right. Which of the following has the quickest effect to reduce ICP?

A	Cranial decompression
B	Cranial decompression Dexamethasone
C	Furosemide
D	Hyperventilation
E	Mannitol

Question 19 Explanation:

A unilateral dilated pupil in the setting of head trauma is an indicator of increased ICP. If ICP is not lowered immediately, the patient has little chance of survival. Hyperventilation to produce an arterial PCO2 of 30 to 35 mm Hg will temporarily reduce ICP by promoting cerebral vasoconstriction and subsequentTrauma, Shock, and Resuscitation Answers 159 reduction in cerebral blood flow. The onset of action is within 30 seconds. In most patients, hyperventilation lowers the ICP by 25%. PCO2 should not fall below 25 mm Hg because this may cause profound vasoconstriction and ischemia in normal and injured areas of the brain. Hyperventilation is a temporary maneuver and should only be used for a brief period of time during the acute resuscitation and only in patients demonstrating neurologic deterioration. (a) ED cranial decompression (burr hole) should only be performed under extreme circumstances when all other attempts at reducing ICP have failed. (b) There is no evidence that steroids lower ICP and are not recommended in head trauma. (c) Furosemide has no role in acute traumatic brain injury. (e) Mannitol is the best osmotic agent to reduce ICP. Its onset is within 30 minutes and lasts up to 6 to 8 hours. Mannitol has the additional benefit of expanding volume, initially reducing hypotension, and improving the blood’s oxygen-carrying capacity

Question 20

A car pulls up to your ED and drops off a 19-year-old man who was shot in the The man tells you his name and complains of right-sided chest pain and difficulty breathing. On primary survey, his airway is patent and his oropharynx has no blood or displaced teeth. He is breathing at 32 beats per minute with retractions and an oxygen saturation of 88% on 15 L of oxygen. There is a bullet wound to his right mid-chest with another wound in his back. His trachea is deviated to the left. On auscultation, he has diminished breath sounds on the right side. Which of the following is the most appropriate next step in management?

A	Stat portable chest x-ray.
B	Intubation.
C	Perform ED thoracotomy.
D	Call the surgical service.
E	Needle decompression.

Question 20 Explanation:

This patient has a tension pneumothorax. Secondary to the gunshot, air has entered the pleural space, secondary to the gunshot, and caused the right lung to collapse. This air cannot escape and pressure continues to increase, pushing the right lung into the mediastinum, causing the trachea to shift to the left. If this process is not corrected, venous return and cardiac output can be compromised and the patient will die. Classic symptoms of tension pneumothorax include dyspnea, tachypnea, tracheal deviation to the uninjured side, absent breath sounds on the injured side, and hypotension. Treatment of a tension pneumothorax is immediate needle decompression using a large 14- or 16-gauge IV catheter inserted into the pleural space (ie, second intercostals space in the midclavicular line). Air should come out of the catheter and the patient’s clinical condition should improve. A tube thoracostomy should be performed after the needle decompression. (a) Tension pneumothorax is a clinical diagnosis and, if suspected, should be treated immediately, without waiting for a chest x-ray. While intubation (b) is generally helpful for patients in respiratory distress, it can be dangerous in the setting of a tension pneumothorax. Positive-pressure ventilation worsens the tension pneumothorax leading to further cardiovascular compromise. This patient will likely require surgical management and the surgical team (d) should be called; however, needle decompression and tube thoracostomy are core emergency medicine skills and should be performed immediately by the emergency physician. ED thoracotomy160 Emergency Medicine (c) is indicated in penetrating trauma patients who have witnessed loss of pulse in the field or in the ED.

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1. A 22-year-old man presents to the ED after being ejected from his vehicle following a high-speed motor vehicle collision. Upon arrival, his BP is 85/55 mm Hg and HR is 141 beats per Two large-bore IVs are placed in the antecubital veins and lactated Ringer solution is being administered. After 3 L of crystalloid fluid, the patient’s BP is 83/57 mm Hg. Which of the following statements is most appropriate regarding man- agement of a hypotensive trauma patient who fails to respond to initial volume resuscitation?

It is important to wait for fully cross-matched blood prior to transfusion.
Whole blood should be used rather than packed red blood cells (RBCs).
Blood transfusion should begin after 4 L of crystalloid infusion.
Type O blood that is Rh-negative should be transfused.
Type O blood that is Rh-positive should be transfused.

2. A 24-year-old man is brought into the ED by paramedics after being run over by a His systolic BP is 90 mm Hg by palpation, HR is 121 beats per minute, RR is 28 breaths per minute, and oxygen saturation is 100% on non-rebreather. The airway is patent and breath sounds are equal bilat- erally. You establish large-bore access and fluids are running wide open. Secondary survey reveals an unstable pelvis upon movement with lateral to medial force. Bedside focused abdominal sonography for trauma (FAST) is negative for intraperitoneal fluid. Which of the following is the most appropriate immediate next step in management?

Bilateral chest tubes
Application of external fixator
Application of pelvic binding apparatus
Venographic embolization
Angiographic embolization

3. A 32-year-old man is brought to the ED by paramedics after a diving accident. The lifeguard on duty accompanies the patient and states that he dove head first into the shallow end of the pool and did not On examination, the patient is speaking but cannot move his arms or legs and cannot feel pain below his clavicle. He is able to feel light touch and posi- tion of his four extremities. A cervical spine radiograph does not reveal a fracture. Which of the following is the most likely diagnosis?

Spinal cord injury without radiographic abnormality (SCIWORA)
Central cord syndrome
Anterior cord syndrome
Cauda equina syndrome
Brown-Séquard syndrome

4. A 22-year-old man is brought to the ED 20 minutes after a head-on motor vehicle collision in which he was the unrestrained On arrival, he is alert and coherent but appears short of breath. His HR is 117 beats per minute, BP is 80/60 mm Hg, and oxygen saturation is 97% on a non- rebreather. Examination reveals bruising over the central portion of his chest. His neck veins are not distended. Breath sounds are present on the left but absent on the right. Following administration of 2 L of lactated Ringer solution, his systolic BP remains at 80 mm Hg. Which of the follow- ing is the most appropriate next step in management?

Sedate, paralyze, and intubate.
Perform a needle thoracostomy.
Perform a DPL.
Perform a FAST examination.
Perform a pericardiocentesis.

5. An 87-year-old man is brought to the ED on a long board and in a cervical collar after falling down a flight of He denies losing con- sciousness. On arrival, his vital signs include an HR of 99 beats per minute, BP of 160/90 mm Hg, and RR of 16 breaths per minute. He is alert and speaking in full sentences. Breath sounds are equal bilaterally. Despite an obvious right arm fracture, his radial pulses are 2+ and symmetric. When examining his cervical spine, he denies tenderness to palpation and you do not feel any bony deformities. Which of the following is a true statement?

Epidural hematomas are very common in the elderly age population.
Cerebral atrophy in the elderly population provides protection against subdural hematomas.
Increased elasticity of their lungs allows elderly patients to recover from thoracic trauma more quickly than younger patients.
The most common cervical spine fracture in this age group is a wedge fracture of the sixth cervical vertebra.
Despite lack of cervical spine tenderness, imaging of his cervical spine is warranted.

6. A 45-year-old man is brought into the ED after a head-on motor vehicle His BP is 85/45 mm Hg and HR is 130 beats per minute. He is speaking coherently. His breath sounds are equal bilaterally. After 2 L of fluid resuscitation, his BP is 80/40 mm Hg. A FAST examination reveals fluid in Morison pouch. Which of the following organs is most likely to be injured in blunt abdominal trauma?

Liver
Spleen
Kidney
Small bowel
Bladder

7. A 47-year-old man is brought into the ED after falling 20 ft from a His HR is 110 beats per minute, BP is 110/80 mm Hg, RR is 20 breaths per minute, and oxygen saturation is 100% on face mask. He is able to answer your questions without difficulty. His chest is clear with bilateral breath sounds, abdomen is nontender, pelvis is stable, and the FAST examination is negative. You note a large scrotal hematoma and blood at the urethral meatus. Which of the following is the most appropriate next step in management?

Scrotal ultrasound
Kidney-ureter-bladder (KUB) radiograph
IV pyelogram
Retrograde cystogram
Retrograde urethrogram

8. A 17-year-old man presents to the ED after getting hit in the right eye with a tennis ball during a tennis On arrival to the ED, you note periorbital swelling and ecchymosis. The patient’s visual acuity is 20/20. When you are testing his extraocular muscles, you note that his right eye cannot look superiorly but his left eye can. He also describes pain in his right eye when attempting to look upward. Which of the following is the most likely diagnosis?

Zygomatic arch fracture
Orbital floor fracture
Retrobulbar hematoma
Ruptured globe
Mandible fracture with entrapment of the pterygoid

9. A 24-year-old man is brought to the ED after being shot once in the On arrival, his BP is 100/60 mm Hg, HR is 115 beats per minute, and RR is 22 breaths per minute. His airway is patent and you hear breath sounds bilaterally. On abdominal examination, you note a single bullet entry wound approximately 1 cm to the right of the umbilicus. During the log roll, you see a single bullet exit wound approximately 3 cm to the right of the lumbar spine. His GCS score is 15. The patient’s BP is now 85/65 mm Hg and HR is 125 beats per minute after 2 L of fluid. Which of the following is the most appropriate next step in management?

Probe the entry wound to see if it violates the peritoneum.
Perform a FAST examination.
Perform a DPL.
Take the patient directly to the CT scanner.
Take the patient directly to the OR.

10. A 55-year-old woman presents to the ED stating that her nose has been bleeding profusely for the last 3 After 25 minutes of bilateral pressure on her nasal septum, there is still profuse bleeding. You place anterior nasal packing bilaterally, but bleeding still persists. The patient is starting to get anxious. Her BP is 110/70 mm Hg, HR is 80 beats per minute, RR is 18 breaths per minute, and oxygen saturation is 98%. Laboratory results reveal a white blood cell (WBC) count of 9000, hematocrit (HCT) 34%, platelets of 225,000, and international normalized ratio (INR) 1.1. Under direct visualization, you note the bleeding originating from the pos- terior aspect of her septum. Which of the following is the most appropriate management?

Place posterior nasal packing, start antibiotics, and admit the patient to a moni- tored hospital bed.
Place the patient supine and wait for spontaneous resolution of the bleeding.
Keep pressure on her nasal septum, and administer fresh frozen plasma (FFP) and platelets.
Place posterior nasal packing, and discharge the patient home with follow-up in 24 hours.
Apply silver nitrate to the nasal mucosa until the bleeding stops.

11. Paramedics bring a 44-year-old man to the He was found in the middle of the street after being struck by a car. His systolic BP is 70 mm Hg; a diastolic BP cannot be obtained. The heart rate is 125 beats per minute, and oxygen saturation is 89% on room air. The patient’s eyes are closed. You ask the patient his name and he doesn’t respond. There is no response when you ask him to move his limbs. You notice that his left foot is severely deformed and there is a large laceration to his right arm. Which of the fol- lowing is the most appropriate next step in management?

Prepare for emergent orotracheal intubation.
Begin aggressive fluid resuscitation and administer morphine for pain.
Apply a tourniquet just above his left foot and begin fluid resuscitation.
Apply pressure to the laceration, splint the left foot, and order a radiograph.
Administer packed RBCs and bring him to the CT scanner for a pan-scan.

12. A 17-year-old adolescent boy is found unconscious in a swimming He is brought into the ED by paramedics already intubated. In the ED, the patient is unresponsive with spontaneous abdominal breathing at a rate of 16 breaths per minute, BP 80/50 mm Hg, and HR 49 beats per minute. In addition to hypoxemia, what condition must be considered earliest in the management of this patient?

Cervical spine injury
Electrolyte imbalance
Metabolic acidosis
Severe atelectasis
Toxic ingestion

13. A 22-year-old man is brought to the ED after sustaining a single gun- shot wound (GSW) to his right On arrival, his HR is 105 beats per minute and BP is 115/75 mm Hg. You note a large hematoma of his medial thigh. The patient complains of numbness in his right foot. On extremity examination, the right foot is pale and you cannot palpate a distal pulse but can locate the dorsalis pedis by Doppler. In addition, the patient cannot move the foot. Which of the following is the most appropriate next step in management?

Angiography
Exploration and repair in the OR
Fasciotomy to treat compartment syndrome
Wound exploration
CT scan of the right extremity

14. A 67-year-old woman is brought to the ED after being struck by a cyclist while crossing the On arrival to the ED, her eyes remain closed to stimuli, she makes no verbal sounds, and withdraws only to pain- ful stimuli. You assign her a GCS of 6. Her BP is 175/90 mm Hg and HR is 75 beats per minute. As you open her eye lids, you notice that her right pupil is 8 mm and nonreactive and her left is 4 mm and minimally reactive. Which of the following is the most common manifestation of increasing intracranial pressure (ICP) causing brain herniation?

Change in level of consciousness
Ipsilateral pupillary dilation
Contralateral pupillary dilation
Significantly elevated BP
Hemiparesis

15. A 34-year-old man is brought to the ED after being shot in the right side of his The patient is awake and speaking. Breath sounds are diminished on the right. There is no bony crepitus or tracheal deviation. His BP is 95/65 mm Hg, HR is 121 beats per minute, and RR is 23 breaths per minute. Supine chest radiograph reveals a hazy appearance over the entire right lung field. You place a 36F chest tube into the right thoracic cavity and note 1200 cc of blood in the chest tube drainage system. Which of the following is an indication for thoracotomy?

500 cc of initial chest tube drainage of blood
1200 cc of initial chest tube drainage of blood
Persistent bleeding from the chest tube at a rate of 50 cc/h
Chest radiograph with greater than 50% lung field whiteout
Evidence of a pneumothorax (PTX)

16. A 32-year-old woman is brought to the ED by paramedics after being involved in a motor vehicle The patient was the front-seat pas- senger of the car and was not wearing a seat belt. In the ED, the patient is speaking and complains of abdominal pain. Her breath sounds are equal bilaterally. You note a distended abdomen. A FAST examination is positive for fluid in the left upper quadrant (LUQ). Her BP is 90/70 mm Hg and HR is 120 beats per minute. You administer 2 L of crystalloid solution. Her repeat BP is 80/60 mm Hg. Which of the following is the most appropriate next step in management?

Administer a vasoconstrictor, such as epinephrine.
Administer another 2 L of crystalloid.
Administer type O, Rh-negative blood.
Bring patient to the CT scanner for an emergent scan.
Perform another FAST examination to see if the fluid is increasing.

17. A 27-year-old pregnant woman, in her third trimester, is brought to the ED after being involved in a low-speed motor vehicle The patient was wearing a seat belt in the back seat of a car that was struck in the front by another car. Her BP is 120/70 mm Hg and HR is 107 beats per minute. Her airway is patent, breath sounds equal bilaterally, and skin is warm with 2+ pulses. FAST examination is negative for free fluid. Evalu- ation of the fetus reveals appropriate fetal HR and fetal movement. Repeat maternal BP is 120/75 mm Hg. Which of the following is the most appro- priate next step in management?

Perform an immediate cesarean section in the OR.
Perform an immediate cesarean section in the ED.
CT scan of the abdomen and pelvis to rule out occult injury.
Discharge the patient if laboratory testing is normal.
Monitor the patient and fetus for a minimum of 4 hours.

18. A 61-year-old man presents to the ED with low back pain after slipping on an icy sidewalk He states that the pain started on the left side of his lower back and now involves the right and radiates down both legs. He also noticed difficulty urinating since last night. On neurologic examination, he cannot plantar flex his feet. Rectal examination reveals diminished rectal tone. He has a medical history of chronic hypertension and underwent a “vessel surgery” many years earlier. Which of the following is the best diagnosis?

Abdominal aortic aneurysm (AAA)
Disk herniation
Spinal stenosis
Cauda equina syndrome
Osteomyelitis

19. Paramedics bring a 55-year-old woman to the ED after she was struck by a motor vehicle traveling at 30 miles/h. Her BP is 165/95 mm Hg, HR is 105 beats per minute, and RR is 20 breaths per Upon arrival, she does not open her eyes, is verbal but not making any sense, and withdraws to painful stimuli. You assign her a GCS score of 8. As you prepare to intu- bate the patient, a colleague notices that her left pupil has become dilated compared to the right. Which of the following has the quickest effect to reduce ICP?

Cranial decompression
Dexamethasone
Furosemide
Hyperventilation
Mannitol

20. A car pulls up to your ED and drops off a 19-year-old man who was shot in the The man tells you his name and complains of right-sided chest pain and difficulty breathing. On primary survey, his airway is patent and his oropharynx has no blood or displaced teeth. He is breathing at 32 beats per minute with retractions and an oxygen saturation of 88% on 15 L of oxygen. There is a bullet wound to his right mid-chest with another wound in his back. His trachea is deviated to the left. On auscultation, he has diminished breath sounds on the right side. Which of the following is the most appropriate next step in management?

Stat portable chest x-ray.
Intubation.
Perform ED thoracotomy.
Call the surgical service.
Needle decompression.

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