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1. An 8-year-old girl is an unrestrained passenger in a vehicle struck


from behind. In the emergency department, her blood pressure is
80/60 mm g, heart rate is 80 beats per minute, and respiratory
rate is !6 breaths per minute. er "#$ score is !%. $he
complains that her legs feel &funny and 'on(t move right)&
ho'ever, her spine *-rays do not sho' a fracture or dislocation. A
spinal cord in+ury in this child
a. is most likely a central cord syndrome.
b. must be diagnosed by magnetic resonance imaging.
c. can be e*cluded by obtaining a #, of the entire spine.
d. may e*ist in the absence of ob+ective -ndings on *-ray
studies.
e. is unlikely because of the incomplete calci-cation of the
vertebral bodies.
2. .egarding shock in the child, 'hich of the follo'ing is /A0$12
a. 3ital signs are age-related.
b. #hildren have greater physiologic reserves than do adults.
c. ,achycardia is the primary physiologic response to
hypovolemia.
d. ,he absolute volume of blood loss re4uired to produce
shock is the same as in adults.
e. An initial 5uid bolus for resuscitation should appro*imate
60 m0/kg of .inger(s lactate.
3. A young man sustains a gunshot 'ound to the abdomen and is
brought promptly to the emergency department by prehospital
personnel. is skin is cool and diaphoretic, and he is confused.
is pulse is thready and his femoral pulse is only 'eakly
palpable. ,he defmitive treatment in managing this patient is to
a. administer 0-negative blood
b. apply e*temal 'arming devices
c. control intemal hemorrhage operatively.
d. apply the pneumatic antishock garment.
e. infuse large volumes of intravenous crystalloid solution.
4. An electrician is electrocuted by a do'ned po'er line after a
thunderstorm. e apparently made contact 'ith the 'ire at the
level of the right mid thigh. In the emergency department, his
vital signs are normal and no dysrhythmia is noted on 1#". 7n
e*amination, there is an e*it 'ound on the bottom of the right
foot. is urine is positive for blood by dip stick but no .8#s are
seen microscopically. Initial management should include
a. immediate angiography.
b. aggressive 5uid infusion.
c. intravenous pyleography.
d. debridement of necrotic muscle.
e. admission to the intensive care unit for observation.
5. A teen-aged bicycle rider is hit by a truck traveling at a high rate
of speed. In the emergency department, she is actively bleeding
from open fractures of her legs, and has abrasions on her chest
and abdominal 'all. er blood pressure is 80/90 mm g, heart
rate is !%0 beats per minute, respiratory rate is 8 breaths per
minute, and "#$ score is 6. ,he -rst step in managing this
patient is to
a. obtain a lateral cervical spine *-ray.
b. insert a central venous pressure line.
c. administer 6 liters of crystalloid solution.
d. perform endotracheal intubation and ventilation.
e. apply the :A$" and in5ate the leg compartments.
6. A 9-year-old boy is struck by an automobile and brought to the
emergency department. e is lethargic, but 'ithdra's
purposefully from painful stimuli. is blood pressure is ;0 mm g
systolic, heart rate is !%0 beats per minute, and his respiratory
rate is <6 breaths per minute. ,he preferred route of venous
access in this patient is
a. percutaneous femoral vein cannulation
b. cutdo'n on the saphenous vein at the ankle.
c. intraosseous catheter placement in the pro*imal tibia.
d. percutaneous peripheral veins in the upper e*tremities.
e. central venous access via the subclavian or interna!
+ugular vein.
7. =hich one of the follo'ing statements is /A0$1 concerning .h
isoimmuni>ation in the pregnant trauma patient2
a. It occurs in blunt or penetrating abdominal trauma.
b. ?inor degrees of fetomaternal hemorrhage produce it.
c. A negative @leihauer-8etke test e*cludes .h
isoimmuni>ation.
d. ,his is not a problem in the traumati>ed .h-positive
pregnant patient.
e. Initiation of .h immunoglobulin therapy does not re4uire
proof of fetomaternal hemorrhage.
8. Absence of breath sounds and dullness to percussion over the
left hemithora* are -ndings best e*plained by
a. left hemothora*.
b. cardiac contusion.
c. left simple pneumothora*.
d. left diaphragmatic rupture.
e. right tension pneumothora*.
9. A 6<-year-old man is brought immediately to the emergency
department from the hospital( s parking lot 'here he 'as shot in
the lo'er abdomen. 1*amination reveals a single bullet 'ound.
e is breathing and has a thready pulse. o'ever, he is
unconscious and has no detectable blood pressure. 7ptimal
immedi(ate management is to
a. perform diagnostic peritoneal lavage.
b. initiate infusion of packed red blood cells.
c. insert a nasogastric tube and urinary catheter.
d. transfer the patient to the operating room, 'hile initiating
5uid therapy.
e. initiate 5uid therapy to return his blood pressure to
normotensive
10. A young 'oman sustains a severe head in+ury as the result of
a motor vehicular crash. In the emergency department, her "#$
score is 6. er blood pressure is !%0/;0 mm g and her heart
rate is 80 beats per minute. $he is intubated and is being
mechanically ventilated. er pupils are < mm in si>e and e4ually
reactive to light. ,here is no other apparent in+ury. ,he most
important principle to follo' in the early management of her
head in+ury is to
a. administer an osmotic diuretic.
b. prevent secondary brain in+ury.
c. aggressively treat systemic hypertension.
d. reduce metabolic re4uirements of the brain.
e. distinguish bet'een intracranial hematoma and cerebral
edema.
11. All of the follo'ing signs on the chest *-ray of a blunt in+ury
victim may suggest aortic rupture 1A#1:,B
a. mediastinal emphysema.
b. presence of a &pleural cap.&
c. obliteration of the aortic knob.
d. deviation of the trachea to the right.
e. depression of the left mainstem bronchus
12. ,'enty-seven patients are seriously in+ured in an aircraft
accident at a local airport. ,he basic principle of triage should be
to
a. treat the most severely in+ured patients -rst.
b. establish a -eld triage area directed by a doctor.
c. rapidly transport all patients to the nearest appropriate
hospital.
d. treat the greatest number of patients in the shortest period
of time.
e. produce the greatest number of survivors based on
available resources.
13. ,he primary indication for transferring a patient to a higher
level trauma center is
a. unavailability of a surgeon or operating room staC.
b. multiple system in+uries, including severe head in+ury.
c. resource limitations as determined by the transferring
doctor.
d. resource limitations as determined by the hospital
administration.
e. 'idened mediastinum on chest *-ray follo'ing blunt
thoracic trauma.
14. Immediate chest tube insertion is indicated for 'hich of the
follo'ing conditions2
a. :neumothora*
b. :neumomediastinum
c. ?assive hemothora*
d. Diaphragmatic rupture
e. $ubcutaneous emphysema
15. During resuscitation, 'hich one of the follo'ing is the most
reliable as a guide to volume replacement2
a. :ulse rate
b. ematocrit
c. 8lood pressure
d. Erinary output
e. Fugular venous pressure
16. =hich one of the follo'ing physical -ndings suggests a cause
of hypotension other than spinal cord in+ury2
a. priapism.
b. bradycardia.
c. diaphragmatic breathing.
d. presence of deep tendon re5e*es.
e. ability to 5e* forearms but inability to e*tend them.
17. A 69-year-old 'oman is brought to the emergency department
after a motor vehicle crash. $he 'as initially lucid at the scene
and then developed a dilated pupil and contralateral e*tremity
'eakness. In t.he emergency department, she is unconscious
and has a "#$ score of 6. ,he initial management step for this
patient should be to
a. obtain a #, scan of the head.
b. administer decadron 60 mg I3.
c. perform endotracheal intubation.
d. initiate an = line and administer ?annitol ! g/kg.
e. perform an emergency linar hole on the side of the dilated
pupil.
18. A <6-year-old man is brought to the hospital unconscious 'ith
severe facial in+uries and noisy respirations after an automobile
collision. In the emergency department, he has no apparent
in+ury to the anterior aspect of his neck. e suddenly becomes
apneic, and attempted ventilation 'ith a face mask is
unsuccessful. 1*amination of his mouth reveals a large
hematoma of the pharyn* 'ith loss of normal anatomic
landmarks. Initial management of his air'ay should consist of
a. inserting an oropharyngeal airvvay.
b. inserting a nasopharyngeal air'ay.
c. performing a surgical cricothyroidotomy.
d. performing -beroptic-guided nasotracheal intubation.
e. performing orotracheal intubation after obtaining a lateral c-
spine *-ray.
19. An !8-year-old, helmeted motorcyclist is brought by
ambulance to the emergency department follo'ing a high-speed
crash. :rehospital persormel report that he 'as thro'n !9 meters
G90 feetH oC his b-ce. e has a history of hypotension prior to
arrival in the emergency department, but is no' a'ake, alert,
and conversational. =hich of the follo'ing statements is ,.E12
a. #erebral per-ision is intacto
b. Intravascular volume status is normal.
c. ,he patient has sensitive vasomotor re5e*es.
d. Intraabdominal visceral in+uries are unlikely.
e. ,he patient probably has an acute epidural hematoma.
20. A crosstable, lateral *-ray of the cervical spine
a. must precede endotracheal intubation.
b. e*cludes serious cervical spine in+ury.
c. is an essential part of the primary survey.
d. is not necessary for unconscious patients 'ith penetrating
cervical in+uries.
e. is unacceptable unless I cervical vertebrae and the #-I to ,-!
relationship are visuali>ed.
21. A 66-year-old man is brought to the hospital after crashing his
motorcycle into a telephone pole. e is unconscious and in
profound shock. e has no open 'ounds or obvious fractures.
,he cause of his shock is ?7$, 0I@10J caused by
a. a subdural hematoma.
b. an epidural hematoma.
c. a transected lumbar spinal cord.
d. a transected cervical spinal cord.
e. hemorrhage into the chest or abdomen.
22. A %6-year-old man is trapped from the 'aist do'n beneath his
overtumed tractor for several hours before medical assistance
arrives. e is a'ake and alert until +ust before arriving in the
emergency department. e is no' unconscious and responds
only to painful stimuli by moaning. is pupils are < mm in
diameter and symmetrically reactive to light. :rehospital
personnel indicate that they have not seen the patient move
either of his lo'er e*tremities. 7n e*amination in the emergency
department, no movement of his lo'er e*tremities is detected,
even in response to painful stimuli. ,he most likely cause for this
-nding is
a. an epidural hematoma.
b. a pelvic fracture.
c. central cord syndrome.
d. intracerebral hemorrhage.
e. G1H bilateral compartment syndrome.
23. A 6%-year-old man sustains multiple fractured ribs bilaterally
as a result of being crushed in a press at a ply'ood factory.
1*amination in the emergency department reveals a 5ail
segment of the patient(s thora*. :rimary resuscitation includes
high-5o' o*ygen administration via a nonrebreathing mask, and
initiation of .inger( s lactate solution. ,he patient e*hibits
progressive confusion, cyanosis, and tachypnea. ?anagement at
this time should consist of
a. intravenous sedation.
b. e*ternal stabili>ation of the chest 'all.
c. increasing the /!06 in the inspired gas.
d. intercostal nerve blocks for pain relief.
e. endotracheal intubation and mechanical ventilation.
24. #ardiac tamponade after trauma
a. is seldom life-threatening.
b. can be e*cluded by an upright, A: chest *-ray.
c. can be confused 'ith a tension pneumothora*.
d. causes a fall in systolic pressure of K !9 mm g 'ith
e*piration.
e. most commonly occurs after blunt in+ury to the anterior chest
'all.
25. #ontraindication to nasogastric intubation is the presence of a
a. gastric perforation.
b. diaphragmatic rupture.
c. open depressed skull fracture.
d. fracture of the cervical spine.
e. fracture of the cribriform plate.
26. =hich one of the follo'ing statements regarding patients 'ith
thoracic spine in+uries is ,.E12
a. 0og-rolling may be destabili>ing to fractures from ,-!6 to 0-!.
b. Ade4uate immobili>ation can be accomplished 'ith the scoop
stretcher.
c. $pinal cord in+ury belo' ,-!0 usually spares bo'el and bladder
function.
d. yper5e*ion fractures in the upper thoracic spine are
inherently unstable.
e. ,hese patients rarely present 'ith spinal shock in association
'ith cord in+ury.
27. =hich of the follo'ing statements regarding in+ury to the
central nervous system in children is ,.E12
a. #hildren suCer spinal cord in+ury 'ithout *-ray abnormality
more commonly than adults.
b. An infant 'ith a traumatic brain in+ury may become
hypotensive from cerebral edema.
c. Initial therapy for the child 'ith traumatic brain in+ury includes
the administration of methylprednisolone intravenously.
d. #hildren have more focal mass lesions as a result of traumatic
brain in+ury 'hen compared to adults .
e. Joung children are less tolerant of e*panding intracranial mass
lesions than adults.
28. An 8-year-old boy falls %.9 meters G!9 feetH from a tree and is
brought to the emergency department by his family. is vital
signs are normal, but he complains of left upper 4uadrant pain.
An abdominal #, scan reveals a moderately severe laceration of
the spleen. ,he receiving institution does not have 6%-hour-a-day
operating room capabilities. ,he most appropriate management
of this patient 'ould be to
a. type and crossmatch for blood.
b. re4uest consultation of a pediatrician.
c. transfer the patient to a trauma center.
d. admit the patient to the intensive care unit.
e. prepare the patient for surgery the ne*t day
29. 1arly central venous pressure monitoring during 5uid
resuscitation in the emergency department has the greatest
utility in a
a. patient 'ith a splenic laceration.
b. patient 'ith an inhalation in+ury.
c. 6-year-old child 'ith a pelvic fracture.
d. patient 'ith a severe cardiac contusion.
e. 6%-year-old man 'ith a massive hemothora*.
30. A !I-year-old helmeted motorcyclist is struck broadside by an
automobile at an intersection. e is unconscious at the scene
'ith a blood pressure of !%0/;0 mm g, heart rate of ;0 beats
per minute, and respiratory rate of 66 breaths per minute. is
respirations are sonorous and deep. is "#$ score is 6.
Immobili>ation of the entire patient may include the use of all the
follo'ing 1A#1:,
a. air splints.
b. bolstering devices.
c. a long spine board.
d. a scoop-style stretcher.
e. a semirigid cervical collar.
31. A 6%-year-old 'oman passenger in an automobile strikes the
'ind screen 'ith her face during a head-on collision. In the
emergency department, she is talking and has marked facial
edema and crepitus. ,he highest priority should be given to
a. lateral, c-spine *-ray.
b. upper air'ay protection.
c. carotid pulse assessment.
d. management of blood loss.
e. determination of associated In+uries.
32. A young man sustains a ritle 'ound to the mid-abdomen. e
is brought promptly to the emergency department by prehospital
personnel. is skin is cool and diaphoretic, and his systolic blood
pressure is 98 mm g. =armed crystalloid 5uids are initiated
'ithout improvement in his vital signs. ,he ne*t, most
appropriate step is to perform
a. a celiotomy.
b. an abdominal #, scan.
c. diagnostic laparoscopy.
d. abdominal ultrasonography.
e. a diagnostic peritoneal lavage.
33. A <0-year-old man sustains a severely comminuted, open
distal right femur fracture in a motorcycle crash. ,he 'ound is
actively bleeding. Lormal sensation is present over the lateral
aspect of the foot but decreased over the medial foot and great
toe. Lormal motion of the foot is observed. Dorsalis pedis and
posterior tibial pulses are easily palpable on the left, but heard
only by Doppler on the right. Immediate eCorts to improve
circulation to the in+ured e*tremity should involve
a. immediate angiography.
b. tamponade of the 'ound 'ith a pressure dressing.
c. 'ound e*ploration and removal of bony fragments.
d. realignment of the fracture segments 'ith a traction splint.
e. fasciotomy of all four compartments in the lo'er e*tremity.
34. =hich one of the follo'ing is the recommended method for
initially treating frostbite2
a. 3asodilators
b. Anticoagulants
c. =arm G%0M#H 'ater
d. :adding and elevation
e. ,opical application of silvasulphadia>ine
35. ,he response to catecholamines in an in+ured, hypovolemic
pregnant 'oman can be e*pected to result in
a. placental abruption.
b. fetal hypo*ia and distress.
c. fetal/maternal dysrhythmia.
d. improved uterine blood 5o'.
e. increased maternal renal blood 5o'.
36. A %6-year-old man, in+ured in a motor vehicle crash, suCers a
closed head in+ury, multiple palpable left rib fractures, and
bilateral femur fractures. e is intubated orotracheally 'ithout
diNculty. Initially, his ventilations are easily assisted 'ith a
bagOvalve device. It becomes more diNcult to ventilate the
patient over the ne*t 9 minutes, and his hemoglobin o*ygen
saturation level decreases from ;8P to8; P . ,he most
appropriate ne*t step is to
a. obtain a chest *-ray.
b. decrease the tidal volume.
c. auscultate the patient(s chest.
d. increase the rate of assisted ventilations.
e. perform needle decompression of the left chest.
37. ,o establish a diagnosis of shock,
a. systolic blood pressure must be belo' ;0 mm g.
b. the presence of a closed head in+ury should be e*cluded.
c. acidosis should be present by arterial blood Qgas analysis.
d. the patient must fail to respond to intravenous 5uid infusion.
e. clinical evidence of inade4uate organ perfusion must be
present
38. A <0-year-old man is struck by a car traveling at 96 kph G<9
mphH. e has obvious fractures of the left tibia near the knee,
pain in the pelvic area, and severe dyspnea. is heart rate is !80
beats per minute, and his respiratory rate is %8 breaths per
minute 'ith no breath sounds heard in the left chest. A tension
pneumothora* is relieved by immediate needle decompression
and tube thoracostomy. $ubse4uently, his heart rate decreases
to !%0 beats per minute, his respiratory rate decreases to <6
breaths per minute, and his blood pressure is 80/90 inm g.
=armed .inger(s lactate is administered intravenously. ,he ne*t
priority should be toB
a. perform a urethrogram and cystogram.
b. perform e*ternal -*ation of the pelvis.
c. obtain abdominal and pelvic #, scans.
d. perform arterial emboli>ation of the pelvic vessels.
e. perform diagnostic peritoneal lavage or abdominal ultrasound.
39. During an altercation, a <6-year-old man sustains a gunshot
'ound to the right upper hemithora*, above the nipple line 'ith
an e*it 'ound posteriorly above the scapula on the right. e is
transported by ambulance to a community hospital. e is
endotracheally intubated, closed tube thoracostomy is
performed, and 6 liters of .inger(s lactate solution are infused
through 6 large-caliber I3s. is blood pressure no' is 60/0 mm
g, heart rate is !60 beats per minute, and respiratory rate is !%
breaths per minute Gventilated 'ith !00P 06H. ,he most
appropriate ne*t step in managing this patient is
a. celiotomy.
b. diagnostic peritoneal lavage.
c. arterial blood gas determination.
d. administer packed red blood cells.
e. chest *-ray to con-rm tube placement.
40. ,he driver of a single car crash is orotracheally intubated in
the -eld by prehospital personnel after they identify a closed
head in+ury and determine that the patient is unable to protect
his air'ay. In the emergency department, the patient
demonstrates decorticate posturing bilaterally. e is being
ventilated 'ith a bag-valve device, but his breath sounds are
absent in the left hemithora*. is blood pressure is !60/88 mm
g, heart rate is I0 beats per minute, and the pulse o*imeter
displays a hemoglobin o*ygen saturation of ;6P . ,he ne*t step
in assessing and managing this patient should be to
a. determine the arterial blood gases.
b. obtain a lateral cervical spine *-ray.
c. assess placement of the endotracheal tube.
d. perform needle decompression of the left chest.
e. insert a thoracostomn the left hemithora*.