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Trauma, Shock, and Resuscitation-2
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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?
- Small bowel
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?
- 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
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
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
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.
- Perform ED thoracotomy.
- Call the surgical service.
- Needle decompression.