Trauma and shock

Question 1

a teenage boy falls from his bicycle and is run over by a truck. on arrival in the ED, he is awake and laert and appears frightened but in no distress. the CXR suggests an air-fluid level in the LLL field and the NGT seems to coil upward into the L chest. which of the following is the next best step in his management?

a. placement of a L chest tube
b. thoracotomy
c. laparotomy
d. esophagogastroscopy
e. diagnostic peritoneal lavage

Answer 1

C
diaphragmatic rupture

• -> immediate laparotomy & diaphragmatic repair
  1) examination of abdomen for associated injuries
  2) possible incarceration fo hernia (esp. w/ negative thoracic pressure)

dx = hx of abdominal trauma, air fluid level in LL chest, NGT entering into chest wall.

Question 2

10yo boy was the backseat belted passenger in a high speed MVA. on presentation to the ED, he is awake, alert and hemodynamically stable. he is complaining of abdominal pain and has an ecchymosis on his anterior abdominal wall where the seatbelt was located. which of the following is the best next step in his management?

a. discharge him home w/out any other workup
b. discharge him home if his amylase level is normal
c. discharge him home if his abdominal plain films are negative for the presence of free air.
d. discharge him home if an abdominal CT is negative
e. observe him regardless of negative test results.

Answer 2

E
“seatbelt sign” —> concerns for enteric / mesenteric injury

Complications
- worsening abdominal pain, fevers, signs of sepsis

Dx

• CT - free air, thickening of SB wall / mesentery; free fluid in the absence of solid organ injury
• WBC > 500, high amylase, bile/bacteria/food fibers.

Question 3

65yo man who smokes cigarettes and has COPD falls and fractures the 3rd, 4th, and 5th ribs in the L anterolateral chest. CXR is otherwise normal. which of the following would be the most appropriate next step in his management?

a. strapping the chest with adhesive tape
b. admission to the hospital and treatment with oral analgesia.
c. tube thoracostomy
d. placement of an epidural for pain management
e. surgical fixation of the fractured ribs

Answer 3

D. don’t fix ribs

to observe that this doesn’t cause further insult to COPD = atelectasis, pneumonia, respiratory fiailure

1) Eval = US, CT, peritoneal lavage
2) Pain management = epidural catheter (MAJOR), oral meds (MINOR)

Question 4

36yo man who was hit by a car presents to the ED with hypotension. On exam, he has tenderness and bruising over his L lateral chest below the nipple. an US exmaination is performed and reveals free fluid in the abdomen. what is the most likely organ to have been injured in this pt?
a. liver
b kidney
c. spleen
d. intestine
e. pancreas

Answer 4

C

= most likely to be damaged in blunt abdominal trauma

Dx = abd US / FAST

Question 5

52yo man is pinned against a loading dock. the pt has a fractured femur, a pelvic fracture, a tender abdomen, and no pulses in the R foot with minimal tissue damage to the R leg. angiography discloses a popliteal artery injury with obstruction. at surgery, the popliteal vien is also transected. his BP is 85/60. which of the following is the best management strategy for his vascular injuries?

a. repair of the popliteal vein with simple closure
b. repair of the popliteal vein with saphenous vein patch
c. repair of the popliteal vein with a synthetic interposition graft
d. ligation of the popliteal vein
e. amputation of the R Le above the knee.

Answer 5

D

hemodynamically unstable ==> Ligate the vein

hemodynamically stable ==> ?venous repair - proximal veins should be repaired to avoid chornic venous insufficiency

Question 6

27yo man sustains a single gunshot wound to the L thigh. in the ED, he is noted to have a large hematoma of his medial thigh. he complains of paresthesias in his L foot. on exam, there are weak pulses palpable distal to the injury and the pt is unable to move his foot. which of the following is the most appropriate initial management of this pt?

a. angiography
b. immediate exploration and repair in the OR
c. fasciotomy of the anterior compartment of the calf
d. observation for resolution of spasm
e. local wound exploration at the bedside

Answer 6

B

large hematoma –>

diffdx:

• compartment syndrome = nerve damage, arterial damage.
• acute arterial insufficiency = hematoma, pulsatile bleeding, audible bruit, palpable thrill, absent distal pulses / distal ischemia

Question 7

25yo woman arrives in the ED following an automobile accident. she is acutely dyspneic with a RR of 60. breath sounds are markedly diminished on the R side. which of the following is the best first step in the management of this pt?

a. take a CXR
b. draw arterial blood for blood gas determination
c. decompress the R pleural space
d. perform pericardiocentesis
e. administer IV fluids

Answer 7

C

tension pneumothorax –> best first step = decompress

Question 8

17yo adolescent boy is stabbed in the L 7th intercostal space, midaxillary line. he presents to the ED with a HR of 86, BP 125/74, and O2 sat of 98%. breath sounds are equal b/l. which of the following is the most appropriate next step in his workup?

a. local exploration of the wound
b. L tube thoracostomy
c. diagnostic laparoscopy
d. CT scan of the abdomen
e. Echocardiography

Answer 8

C

lung/spleen –> exploration of the thorax or abdomen

local wound exploration can lead to pneumothorax

Question 9

your hospital is conducting an ongoing research study involving the hormonal response to trauma. blood is drawn regularly (with IRB approval) for various studies. which of the following values are likely to be seen after a healthy 36yo man is hit by a bus and sustains a ruptured spleen and a lacerated small bowel?

a. increased secretion of insulin
b. increased secretion of thyroxine
c. decreased secretion of vasopressin (ADH)
d. decreased secretion of glucagon
e. decreased secretion of aldosterone

Answer 9

A

increased insulin (b/c increased glucose from cortisol), aldosterone; ADH (b/c hypovelemic), catecholamines, glucagon

decreased

Question 10

18yo man who sustained a R sided cervical laceration during a gang fight. your intern suggests nonoperative management and observation. which of the following is a relative, rather than an absolute, indication for neck exploration?

a. expanding hematoma
b. dysphagia
c. dysphonia
d. pneumothorax
e. hemoptysis

Answer 10

D. pneomotorax doesn’t necessarily mean something in the throat (more the thorax)

hematoma - from carotid
dysphonia - pressure on trachea
dysphagia = pressure on esophagus
hemoptysis - damage to esophagus –> bleeding into GI system

Question 11

following blunt abdominal trauma, 12yo girl develops upper abdominal pain, N&V. an upper GI series reveals a total obstruction of the duodenum with a coiled spring appearance in the 2nd & 3rd portions. in the absence of other suspected injuries, which of the following is the most appropriate management of this pt?

a. gastroejejunostomy
b. NG suction & observation
c. duodenal resection
d. TPN to increase the size of the retroperitoneal fat pad
e. duodenojejunostomy

Answer 11

B

1) NGT & fluids = see if it will go away
2) ex-lap = if after 2 weeks of persistent sxs

Question 12

45yo man presents after a high speed MVA. he has a seatbelt sign across his neck and chest with an ecchyosis over his L neck. he is hemodynamically stable and neurologically intact. CTA shows a L carotid dissection. in the absence of other significant injuries, what is the next step in his management?

a. antiplatelet therapy
b. systemic anticoagulation with heparin
c. neck exploration and L carotid artery repair
d. neck exploration & L intra-extracranial bypass
e. angiography & L carotid artery stenting

Answer 12

B

carotid dissection or type B aortic dissection = lifetime anticoagulation

Question 13

18yo man was assaulted and sustained significant head and facial trauma. which of the following is the most common initial manifestation of increased intracranial pressure?

a. change in level of consciousness
b. ipsilateral (side of hemorrhage) pupillary dilation
c. contralateral pupillary dilation
d. hemiparesis
e. HTN

Answer 13

A

Closed head injuries

1) change in mental status / level of consciousness
2) cushing triad = hypotension, bradycardia, irregular respiration
3) laterlizing signs –> focal intracranial lesion

Question 14

28yo man is brought to the ER for a severe heard injury after a fall. he was intubated in the field for his decreased level of consciousness. he is tachycardic and hypotensive. on exam, he is noted to have an obvious skull fracture and his R pupil is dilated. which of the following is the most appropriate method for initially reducing his ICP?

a. elevation of the head of the bed
b. saline-furosemide (lasix) infusion
c. mannitol infusion
d. IV dexamethasone (Decadron)
e. hyperventilation

Answer 14

E. hyperventilation, mannitol

steroids - reduce edema
hyperosmotic solution - 3% saline

Question 15

45yo man was an unhelmeted motorcyclist involved in a high speed collision. he was ejected from the motorcycle and was noted to be apneic at the scene. after being intubated, he was brought to the Er, where he is noted to have a L dilated pupil that responds only sluggishly. what is the pathophysiology of his dilated pupil?

a. infection within the cavernous sinus
b. herniation of the uncal process of the temporal lobe
c. laceration of the corpus callosum by the falx cerebri
d. occult damage to the superior cervical ganglion
e. cerebellar hypoxia

Answer 15

B

pressing on the CN3 - ipsilateral compression of nerve & its parasympathetic fibers

Question 16

31yo man is brought to the ED following an automobile accident in which his chest struck the steering wheel. exam reveals stable vital signs and no evidence of respiratory distress, but the pt exhibits multiple rib fractures and paradoxical movement of the R side of the chest. CXR shows no evidence of pneumothorax or hemothorax. which of the following is the most appropriate initial management of this pt?

a. intubation, mechanical ventilation and PEEP
b. stabilization fo the chest wall with sandbags
c. stabilization with towel clips
d. immediate operative stabilization
e. pain control, chest physiolotherapy, and close observation

Answer 16

E

“flail chest”

even for flail chest - don’t fix the ribs (unless doing a thoracotomy for another reason)
- mechanical ventilation if needed.

Question 17

30 yo man is stabbed in the arm. there is no evidence of vascular injury, but he cannot flex his 3 radial digits. which of the following structures has he most likely injured?

a. flexor policis longus & flexor digitus medius tendons
b. radial nerve
c. median nerve
d. thenar and digital nerves at the wrist
e. ulnar nerve

Answer 17

C

median nerve.

no such thing as flexor digitus medius

Question 18

following a 2h firefighting episode, a 36yo fireman begins complaining of a throbbing HA, nausea, dizziness, and visual disturbances. he is taken to the ED, where his carboboxyhemoglobin level is found to be 31%. which of the following is the most appropriate next step in his treatment?

a. begin an immediate exchange transfusion
b. transfer to pt to a hyperbaric O2 chamber
c. begin bicarbonate infusion & give 250mg acetazolamide (diamox) IV
d. administer 100% O2 by mask
e. perform flexible bronchoscopy with further therapy determined by findings

Answer 18

D. breathing in the CO from the fire

unlikely to be inhalational injury b/c likely had protective equipment on.

Question 19

75yo man with a hx of coronary artery disease, HTn, and DM undergoes a R hemocolectomy for colon cancer. on POD2, he complains of SOB and chest pain. he becomes hypotensive with depressed mental status and is immediately transferred to the ICU . after intubation and placement on mechanical ventilation, an echo confirms cardiogenic shock. a central venous catheter is placed that demonstrates a central venous pressure of 18mmHg. which following is the appropriate initial management strategy?

a. additional liter fluid bolus
b. inotropic support
c. mechanical circulatory support with intra-aortic balloon pump (IABP)
d. cardiac catheterization
e. heart transplant

Answer 19

B. give pressors

probably from an MI

CVP = 5

1) supplemental O2
2) limit fluids - b/c already fluid overloaded
3) pressors (dopamine) (dobutamine - increased HR, minimal increased BP)
4) mechanical circulatory support - intra-aortic balloom pump (decreased afterload; increased diastolic perfusion pressure)

Question 20

18yo man climbs up a utility pole to retrieve his younger brother’s kite. an electrical spark jumps from the wire to his metal belt buckle and burns his abdominal wall, knocking him to ground. which of the following should guide your treatment of this pt?

a. injuries are generally more superficial than those from thermal burns
b. IV fluid replacement is based on percentage of body surface area burned.
c. electric burns often result in a transient traumatic optic neuropathy
d. evaluation for fracture of the other extremities and visceral injury is indicated
e. cardiac conduction abnormalities are unlikely.

Answer 20

D

thermal burn –> IV fluid replacement
TX = debridement , skin grafting, amputation of extremities

electrical burn –> more internal, esp. cardiac
- myonecrosis w/ myoglobinuria, renal damage
- cardiac / respiratory arrest
- compartment syndrome
- cataract development
TX = debridement , skin grafting, amputation of extremities, AND fasciotomy

Question 21

22yo man is examined following a MVA. he has a R knee dislocation which is reduced in hte ED. he has palpable pedal pulses and is neurologically intact. which of the following is an appropriate next step in his workup and management?

a. measurement of ankle brachial indices
b. angiography of the R LE
c. prophylactic below knee 4 compartment fasciotomies
d. surgical exploration of the R popliteal artery
e. observation with serial pulse checks.

Answer 21

A

complications of knee dislocations
- popliteal artery transection ==> but he has palpable pulses
- popliteal artery injuries
DX –> ankle-brachial index< 0.9; CTA
- compartment syndrome d/t ischemia-reperfusion injury

Question 22

23yo previously healthy man presents to the ED after sustaining a single gunshot wound to the L chest. the entrance wound is 3cm inferior to the nipple and the exit wound is just below the scapula. a chest tube is placed that drains 400mL of blood and continues to drain 50-75mL/h during the initial resuscitation. initial BP of 70/0mmHg has responded to a 2L crystalloid and is now 100/70. abdominal examination is unremarkable. CXR reveals a reexpanded lung and no free air under the diaphragm. which of the following is the best next step in his management?

a. admission and observation
b. peritoneal lavage
c. exploratory thoracotomy
d. exploratory celiotomy
e. local wound exploration

Answer 22

D

Complications of gunshot wounds to the lower chest (below T4)
- intra-abdoinal injury ==> abdominal exploration

• less likely pulmonary injury ==> b/c most parenchymal lung injuries will stop bleeding & heal spontaneously with tube thoracostomy (no need for exploratory thoracotomy)

Question 23

a pt is brought to the Ed after a MVA. he is unconscious and has a deep scalp laceration and one dilated pupil. his HR is 120, BP 80/40, and RR is 35. despite rapid administration of 2L normal saline, the pt’s vital signs do not change significantly. which of the following is the most appropriate next step in the w/up of his hypotension?

a. neurosurgical consultation for emergent ventriculostomy to manage his ICP.
b. neurosurgical consultation for emergent craniotomy for suspected subdurral hematoma
c. emergent burr hole drainage at the bedside for suspected epidural hematoma
d. administration of mannitol and hyperventilation to treat his elevated ICP
e. abdominal US (focused assessment with sonography in trauma [FAST]).

Answer 23

E

image first !

nothing else on exam that would necesarily say increased ICP.

usually due to hypovolemia

Question 24

25yo man is involved in a gang shoot-out and sustains an abdominal gunshot wound from a .22 pistol. at laparotomy, it is discovered that the L transverse colon has incurred a through and through injury with minimal fecal soilage of the peritoneum. which of the following is the most appropriate management of the pt?

a. a colostomy should be performed regardless of the pt’s hemodynamic status to decrease the risk of an intraabdominal infection.
b. primary repair should be performed, but only in the absence of hemodynamic instability
c. primary repair should be performed with placement of an intra-abdominal drain next to the repair
d. primary repair should be performed and IV antibiotics administered for 14d.
e. the pt should undergo a 2-stage procedure with resection of the injured portion and reanastomosis 48h later when clinically stabilized.

Answer 24

B

no evidence that abx > 24h in the setting of immediate repair or placement of a drain reduces postoperative infectious complicaitons

Question 25

34yo prostitute with a hx of long term IVDU is admitted with a 48h hx of pain in her L arm. she is tachycardic to 130 and her SBP is 80. physical exam is remarkable for crepitus surroundig needle-track marks in the antecubital space with a serous exudate. the plain xray of the arm shows . which of the following is the most appropriate next step in her management

a. treatment with penicillin G and close observation
b. MRI of the arm
c. CT scan of the arm
d. surgical exploration and debridement
e. hyperbaric O2 therapy

Answer 25

D

necrotizing faciitis = anaerobics

Question 26

47yo man is extricated from an automobile after a MVA. he is hypotensive with a systolic BP of 80. the pt has a steering wheel bruise on the anterior chest. his EKG shows some premature ventricular complexes, and his cardiac isoenzymes are elevated. which of the following is the best next test for evaluation for a blunt cardiac injury?

a. measurement of serial creatinine phosphokinase and creatinine kinase (including the myocardial band) levels
b. thallium stress test
c. echocardiography
d. single photon emission CT (SPECT)
e. multiple acquisition scans (MUGA)

Answer 26

C

1) EKG - ~100% of pts who develop cardiac complications display EKG abnormalities in first 24h
2) ECHO
- -> for ventricular wall motion and ejecction fraction after blunt chest trauma
- meant for hemodynamically unstble pts

cardiac enzymes aren’t specific enough to tell us what is actually wrong and what to do to fix it.

Question 27

70yo man presents to the ER with several fractures and ruptured spleen after falling 20ft. which of the following will occur in response to the injury?

a. decreased liver gluconeogenesis
b. inhibition of skeletal muscle breakdown by IL-1 and TNF
c. decreased urinary nitrogen loss
d. hepatic synthesis of acute phase reactants
e. decreased glutamine consumption by fibrolasts, lymphocytes, and intestinal epithelial cells

Answer 27

D

injury & sepsis –> accelerated protein breakdown with increased urinary nitrogen loss & peripheral release of amino acids.

Question 28

29yo man sustained a gunshot wound tot he RUQ. he is taken to the OR and after management of his liver injury is found to have a complete transection of the common bile duct with significant tissue loss. which of the following is the optimal surgical management of this pt’s injury?

a. choledochoduodenostomy
b. loop choledochoduodenostomy
c. primary end-to-end anastomosis of the transected bile duct
d. roux-en-Y choledochoduodenostomy
e. bridging of the injury with of a T tube

Answer 28

D

complete transection of the CBD

• Unstable pt ==> place T tube on either end of the open CBD & staging the repair
• Stable pt + transected CBD + loss ot tissue ==> biliary enteric bypass (Roux-en-y choledochoduodenostomy or Rou-en-Y limb of jejunum)

Question 29

36yo man sustains a gunshot wound to the L buttock. he is hemodynamically stable. there is no exit wound, and an xray of the abdomen shows the bullet to be located in the RLQ. which of the following is the most appropriate in the management of his suspected rectal injury?

a. barium studies of the colon & rectum
b. barium studies of the bullet track
c. CT scan of the abdomen and pelvis
d. angiography
e. sigmoidoscopy in the ER

Answer 29

C. CT scan + water-soluble contrast –> the bullet hasn’t yet exited.

rectal injury = if use sigmoidoscopy - can perforate

can’t use barium d/t risk of intra-abdominal abscess with spillage into abdomen

Question 30

27yo man presents to the ED after a high speed motor vehicle collision with chest pain and marked respiratory distress. on exam, he is hypotensive with distended neck veins and absence of breath sounds in the L chest. which of the following is the proper initial treatment?

a. intubation
b. CXR
c. pericardiocentesis
d. chest decompression with a needle
e. emergent thoracotomy

Answer 30

D. pneumothorax

distended neck veins diffdx:

• pulmonary embolism, constrictive pericarditis and a failing right side of the heart,
• pericardial effusion, restrictive cardiomyopathy or ventricular tachycardia.

tx = emergent needle decomperssion

Question 31

48yo man sustains a gunshot wound to the R upper thigh, just distal to the inguinal crease. he is immediately brought to the ED. peripheral pulses are palpable in the foot, but the foot is pale, cool, and hypesthetic. the motor examination is normal. which of the following statements is the most appropriate next step in the pt’s management

a. pt should be taken to the OR immediately to evaluate for a significant arterial injury
b. a neurosurgical consult should be obtained and somatosensory evoked potential monitoring performed
c. a fasciotomy should be performed prophylactically in the ED
d. a duplex exam should be obtaned to rule out a venous injury
e. the pt should be observed for at least 6h then reexamined for changes in the physical exam.

Answer 31

A

concerns about arterial insufficiency of the femoral artery –> ischemic changes after vascular trauma.

indications for fasciotomy:

• ischemic period > 6h
• combined arterial & major venous injury
• prolonged period of hypotesion
• massive associated soft tissue trauma
• massive edema

Question 32

62yo woman is seen after 3d of fever, abdominal pain, nausea & anorexia. she has not urinated for 24h. she has a hx of previous abdominal surgery for IBD. her BP is 85/64 and her pulse is 136. her response to the physiologic state includes which of the following.

a. increase in Na and water excretion
b. increase in renal perfusion
c. decrease in cortisol levels
d. hyperkalemia
e. hypoglycemia

Answer 32

D

septic shock after UTI.
- volume retention: decreased Na, H2O excretion; increased cortisol & glucose levels; decreased renal perfusion

Question 33

20yo man presents after being punched in the R eye and assaulted to the head. on a facial CT scan, he is noted to have a blowout fracture of the R orbital floor. which of the following findings mandates immediate surgical intervention?

a. a fracture 25% of the orbital floor
b. 1mm of enophthalmos
c. periorbital ecchymosis
d. inability to move the R eye upward
e. traumatic optic neuropathy

Answer 33

D

nerve or muscle damage = extraocular muscle entrapment

sxs = periorbital ecchymoses, pain, diplopia
==> inability to move eye upward == superior rectus

tx = surgical release

Question 34

33yo woman is seen in the ED with severe rectal bleeding. she has a hx of ulcerative colitis. her BP is 78/56, pulse 144, and she is pale and clammy. which of the following responses is likely to occur after administration of Ringer lactate solution?

a. increase in serum lactate concentration
b. impairment of liver fx
c. improvement of hemodynamics by alleviating the deficit in the interstitial fluid compartment
d. increase in metabolic acidosis
e. increase in the need for blood transfusion

Answer 34

C

hypovolemia

lactated ringers –> metabolized to bicarbonate in the liver –> increase in alkalosis levels

volume restitution, improved liver function, decreased lactate levels

Question 35

18yo HS football player is kicked in the L flank. 3h later he develops hematuria. his VS are stable. a CT scan demonstrates a grade II renal injury based on the urologic injury scale of the american association for he surgery of trauma. which of the following is the most appropriate treatment of this pt?

a. resumption of normal daily activity excluding sports
b. exploration and suture of the laceration
c. exploration and wedge resection of the L kidney
d. nephrostomy
e. strict bed rest with serial Hgb levels

Answer 35

E

Grade I - return to normal activities w/out sports
Grade II - gross hematuria

Question 36

32yo man is in a high speed motorcycle collision and presents with an obvious pelvic fracture. on exam, he has a scrotal hematoma and blood at his urethral meatus. which of the following is the most appropriate next step in his management?

a. placement of a foley catheter
b. cystoscopy
c. CT of the pelvis
d. retrograde urethrogram
e. nephrostomy tube placement

Answer 36

D

urethral injury
sxs = blood at urethral meatus, crtoal hematoma, free-floating prostate on rectal exam
dx = retrograde urethrogram to assess for anatomic disturbance before placing foley
+ urethral disruption –> place suprapubic catheter

Question 37

17yo adolescent boy sustains a small caliber gunshot wound to the mid-epigastrium with no obvious exit wound. his abdomen is very tender. he is taken to the OR and the bullet appears to have tracked through the stomach, distal pancreas, and spleen. the duct appears to have been injured. which of the following is the best strategy for the management of this pt’s pancreatic injury

a. drainage alone
b. roux-en-y pancreaticojejunostomy
c. pancreaticoduodenectomy
d. frey procedure
e. distal pancreatectomy

Answer 37

E

removal of damaged parts of the pancreas

if to the left of the mesenteric vessels –> distal pancreatectomy

Question 38

22yo woman who is 4mo pregnant presents after an MVA complaining of abdominal pain and R leg pain. she has an obvious deformity of her R femur. she is hemodynamically stable. which of the best next step in her management?

a. observation with serial abdominal exams
b. diagnostic peritoneal lavage
c. plain film of the abdomen with a lead apron as a shield
d. FAST examination of the abdomen
e. MRI of the abdomen

Answer 38

D

ultrasound

Question 39

the victim of an MVA who is in shock is transfered to your trauma center by a rural ambulance service. on exam, his BP is 80/60 and he has an unstable pelvis. xrays reveal a pelvic fracture. CXR is normal. FAST exam shows free fluid near the spleen. there are no major extremity deformities noted. A pelvic binder is placed. which of the following statements is the best next step in the management of the pt?

a. CT of the chest
b. CT of the abdomen and pelvis
c. angiography
d. diagnostic peritoneal lavage
e. exploratory laparotomy with pelvic packing

Answer 39

E

indications for ex - lap in pt with blood loss

• shock (+/- free fluid around spleen), hemodynamically unstable
• positive FAST scan
• unstable pelvic fracture

temporizing measures
- pelvic binder

Question 40

radio transmission is received in your trauma unit stating that a victim of a MVA is en route to your ED with no vital signs. the ambulance is 3 min away. as you formulate your plan, which of the following situations would constitute an indication for ER thoracotomy?

a. massive hemothorax following blunt trauma to the chest
b. blunt trauma to multiple organ systems with obtainable vital signs int he field, but non on arrival in the ER
c. rapidly deteriorating patient with cardiac tamponade from penetrating thoracic trauma
d. penetrating thoracic trauma and no signs of life in the field
e. penetrating abdominal trauma and no signs of life in the field

Answer 40

C
thoracotomy in the ER = surgical incision into chest wall

indications

• release cardiac tamponade in deteriorating pts with penetrating thoracic trauma –> creating subxiphooid pericardial window
• allow cross-clamping of the descending aorta in pts with intra-abdominal bleeding (LAST RESORT)
• allow efffective internal cardiac massage in pts who arrive w/ faint/absent pulses and distant heart sounds (LAST RESORT)

Contraindications to emergency thoracotomy

• those with no vital signs in the field - pulse, pupillary rxn, spontaneous respiration
• blunt trauma to multiple organ systems & absent vital signs on arrival to the ER

Question 41

22yo man sustains a gunshot wound to the abdomen. at exploration, an apparently solitary distal small bowel injury is treated with resection and primary anastomosis. on POD7, small bowel fluid drains through the operative incision. the fascia remains intact. the fistula output is 300mL/day and there is no evidence of intra-abdominal sepsis. which of the following is the most appropriate treatment strategy?

a. early reoperation to close the fistula tract
b. broad-spectrum antibiotics
c. total parenteral nutrition
d. somatostatin to lower fistula output
e. loperamide to inhibit gut motility

Answer 41

C

to slow the fluid output and allow it to heal –> if open up again, concerns for infection
(if no sepsis)

distal SB fistula –> usually low output (300cc) - let heal

Question 42

26yo man complains of pelvic pain after a motorcycle collision. physical and radiologic examinations confirm a pelvic fracture. urologic workup reveals a normal urethrogram and an extraperitoneal bladder injury. which of the following is the most appropriate treatment for his bladder injury?

a. immediate surgical exploration and repair
b. placement of a permanent suprapubic tube
c. catheter drainage followed by definitive repair after 2w
d. catheter drainage for 2w followed by repeat imaging
e. bilateral nephrostomy tubes

Answer 42

D

“simple injury” without involvement of other structures / bladder neck

let it heal and see what happens

Question 43

pt’s cxr shows midline airway, rib fractures near sternum in ribs 4, 5, 6, 7, normal heart, flattened diaphragm with large inspiratory volume. L diaphram seems to have a defect in the membrane just superior to the gastric bubble. contrast study does not show extravasation of fluid from bowels. goes from one end of transverse colon, through splenic flexure (which is above the level of the R hemidiaphragm), down to rectum.
he was hospitalized after a car collision 2d ago in which he suffered blunt trauma to the abdomen. he sustained several L rib fractures, but he is hemodynamically stable. which of the following is the appropriate step in the pt’s management?
a. observation and serial abdominal exams
b. immediate L posterolateral thoracotomy and repair of the injury
c. immediate exploratory laparotomy and repair of the injury
d. delayed L posterolateral thoractomy and repair of the injury
e. delayed exploratory laparotomy and repair of the injury

Answer 43

D

1) stabilize pt
2) ACUTE diaphragmatic repair via abdomen –> also r/ut associated intra-abdominal injuries
3) CHRONIC diaphragmatic repair via thorax / abdomen

complications
- herniation / bowel strangulation

Question 44

56yo woman sustains blunt abdominal trauma from an assault. her BP is 107/56 and her pulse is 92. she complains of abdominal pain. she undergoes CT of the abdomen and pelvis, which demonstrates a splenic injury. which of the following would preclude an attempt at nonoperative management of the pt?

a. presence of a subcapsular hematoma involving >25% of the spleen
b. presence of a subcapsular hematoma involving >50% of the spleen
c. evidence of a blush on CT scan
d. RBC 120,000 on diagnostic peritoneal lavage
e. peritoneal signs on abdominal examination

Answer 44

E

if they’re symptomatic - concerns about perforation.

if splenic hematoma - these can resolve

Question 45

49yo man was the unrestrained driver in a MVA. he decelerated rapidly in order to avoid hitting another ar and swerved into a ditch. he complains of chest pain. which of the following findings on CXR would be the most suspicious for an aortic injury?

a. multiple right sided rib fractures
b. a L pulmonary contusion
c. a L pneumothorax
d. widening of the mediastinum > 8cm
e. pneumomediastinum

Answer 45

D

a. multiple right sided rib fractures
b. a L pulmonary contusion - from rib fractures
c. a L pneumothorax - pleural injury
e. pneumomediastinum- tracheobronchial disruption

Question 46

29yo woman was hit by a car while crossing the street. she is hemodynamically unstable with a HR of 124, SBP of 82/45. US machine is broken and therefore a diagnostic peritoneal lavage (DPL) is performed. which of the following findings on DPL is an indication for exploratory laparotomy in this pt?

a. aspiration of 5cc of gross blood initially
b. > 50,000 RBCs
c. > 100,000 RBCs
d. > 100 WBCs
e. > 250 WBCs

Answer 46

C
>10CC blood
>100,000 RBCs
> 500 WBCs

Question 47

27yo construction worker falls about 30ft from a scaffold. at the scene, he complains of inability to move his lower extremities. on arrival in the ED, he has a HR of 45 and BP of 78/39. his extremities are warm and pink. his BP improves with 1L of crystalloid. a central venous catheter is placed for further resuscitaiton and his CVP is 2mmHg. which of the following is the best initial treatment strategy for improving his BP.

a. immediate celiotomy
b. fluid resuscitation with crystalloids
c. administration of O-negative blood
d. administration of peripheral vasoconstrictor
e. administration of IV corticosteroids

Answer 47

B. can give up to 2L

fluid down. still seems to be perfusing

==> neurogenic shock due to spinal cord injury

? unable to move legs –> concerns that have transected spinal cord - bleeding into spine?
but celiotomy would look at abdomen

Question 48

22yo an undergeos an exploratory laparotomy after a gunshot wound to the abdomen. the pt has multiple injuries, including a significant liver laceration, multiple small bowel and colon injuries and an injury to the infrahepatic vena cava. the pt receives 35U of pRBCs, 15L of crystalloid, 12U of FFP, and 12 packs of platelets. the p’s abdomen is packed closed and he is taken to the ICU for further resuscitation. which of the following warrants a decompressive laparotomy?

a. increased peak airway pressure
b. increased CO
c. decreased SVR
d. decreased plasma renin and aldosterone
e. increased cerebral perfusion pressure

Answer 48

A –> inability to expand the lungs due to expansion of the abdominal volume upward?

presumably, of the abdomen - for hypovolemic shock
decreased CO, decreased PCWP, decreased CVP, increased SVR
increased plasma renin and aldosterone

CO = HR * SV

Question 49

10yo girl is the unrestrained backseat passenger in a high speed MVA. she is intubated in the field for unresponsiveness and on presentation to the ED, her HR is 160, BP is 60/35. She weighs 40kg. which of teh following is the most appropriate recommendation for her fluid resuscitation?

a. bolus 1L of NS initially
b. bolus 1L of 5% albumin initially
c. transfuse 300cc of pRBCs initially
d. bolus 600cc of NS initially. transfuse if no response
e. bolus 600cc of NS initially followed by a repeat bolus. transfuse if no response.

Answer 49

E

unresponsive - likely has lost 30% TBW. If give 1L –> giving 250mL into intravascular space.
RESUSCITATION ==> 20ml/kg –> 800mL bolus

TBW = 30kg * 0.5 (female) = 15L

15L*0.3 = 4.5L

Question 50

21yo woman sustains a stab wound to the middle of the chest. upon arrival to the ER, she has equal breath sounds, BP of 85/46, distended neck veins, and pulsus paradoxus. which of the following is the most appropriate management of this pt?

a. emergent intubation and mechanical ventilation in the ER
b. emergent pericardiocentesis in the ER
c. emergent thoracotomy in the ER
d. emergent pericardiocentesis or subxiphoid pericardial drainage after anaesthesia induction in the OR
e. emergent pericardiocentesis or subxiphoid pericardial drainage under local anaesthesia in the OR

Answer 50

E

cardiac tamponade

shouldn’t wait for anaesthetic induction –> go straight to local BEFORE anaesthetic induction

Question 51

58yo man presents to the ED after falling 10ft from a ladder. exam reveals stable vital signs, no evidence of respiratory distress, and multiple R sided rib fractures. CXR shows a hemothorax on the R side and a R tube thoracostomy is performed in the ED. Appprox 700mL is immediately drained with placement of the thoracostomy tube. over the next 4h, he continues to drain 300mL/h after the original evacuation. which fo the following is the definiitve treatment for this pt?

a. platelets
b. FFP
c. 2nd tube thoracostomy
d. thoracotomy in the OR
e. thoracotomy in the ER

Answer 51

D

likely blood draining from the rib fracutres. but you aren’t going to fix the ribs

his physiology and blood transfusion requirements –> go to the OR

Question 52

65yo woman is involved in a MVA and sustains multiple L sided rib fractures. upon presentation to the ED, her vital signs are stable and she is in no respiratory distress. CXR reveals fractures of ribs 4-7 on teh L side without evidence of hemothorax or pneumothorax. she is admitted for observation and a few H later, she develops shortness of breath. a repeat CXR demonstrates a well-defined infiltrate in her L lung. what is hte most likely diagnosis?

a. pulmonary contusion
b. pulmonary embolus
c. pneumonia
d. MI
e. cardiac tamponade

Answer 52

A

hx of trauma + what looks like pneumonia on 1 side ==> PULMONARY CONTUSION

Question 53

Following a head-on MVA, a 21yo unrestrained passenger presents to the ED with dyspnea and respiratory distress. she is intubated and exam reveals subcutaneous emphysema and decreased breath sounds. CXR reveals cervical emphysema, pneumomediastinum, and a R sided pneumothorax. what is the most likely diagnosis?

a. tension pneumothorax
b. open pneumothorax
c. tracheobronchial injury
d. esophageal injury
e. pulmonary contusion

Answer 53

C

air under the skin, air in the neck

Question 54

an intoxicated 22yo man is a restrained driver in a high speed MVA. exam reveals normal VS, but the rest of the exam is unreliable secondary to the pt’s intoxicated state from alcohol. which of the following sole findings on a CT scan of teh abdomen and pelvis mandates an exploratory laparotomy?

a. free fluid in the pelvis
b. pelvic fracture
c. liver hematoma
d. splenic hematoma
e. renal hematoma

Answer 54

A

–> perforation

Question 55

23yo man arrives in the ER after a MVA. exam reveals an unstable pelvis and blood at the urethral meatus. which of the following studies would most accurately identify a urethral injury?

a. CT scan of the pelvis
b. IV pyelogram
c. stress cystogram
d. antegrade urethrogram
e. retrograde urethrogram

Answer 55

E. urethral injury –> “blood at urethral meatus”

any potential bladder / urethral injury

1) retrograde urethrogram
2) Foley

Question 56

18yo woman is transported to your trauma unit after sustaining a side-impact collision on her side of the car. she is hypotensive and in respiratory distress and has distended neck veins. for each immediately life-threatening injury of the chest, select the proper intervention. 
a. endotracheal intubation
b. cricothyroidotomy
c. subxiphoid window
d. tube thoracostomy
e. occlusive dressing
==> laryngeal obstruction

Answer 56

B

needs help immediately

sxs = cough / mild dyspnea –> stridor / hypoxic cardiac arrest

0) EMERGENCY - cricothyroidotomy –> for proximal obstruction / severe maxillofacial trauma
1) STABLE - fiberoptic endoscopy - determine cause & remove it
2) UNSTABLE - endotracheal intubation

Question 57

18yo woman is transported to your trauma unit after sustaining a side-impact collision on her side of the car. she is hypotensive and in respiratory distress and has distended neck veins. for each immediately life-threatening injury of the chest, select the proper intervention. 
a. endotracheal intubation
b. cricothyroidotomy
c. subxiphoid window
d. tube thoracostomy
e. occlusive dressing
==> open pneumothorax

Answer 57

E

if open pneumothorax, the body will “breathe” through this instead of the airway –> can’t get air into alveoli.

Question 58

18yo woman is transported to your trauma unit after sustaining a side-impact collision on her side of the car. she is hypotensive and in respiratory distress and has distended neck veins. for each immediately life-threatening injury of the chest, select the proper intervention. 
a. endotracheal intubation
b. cricothyroidotomy
c. subxiphoid window
d. tube thoracostomy
e. occlusive dressing
==>flail chest

Answer 58

A

observation, pain management, and intubation if they can’t breathe

intubate if in respiratory distress

Question 59

18yo woman is transported to your trauma unit after sustaining a side-impact collision on her side of the car. she is hypotensive and in respiratory distress and has distended neck veins. for each immediately life-threatening injury of the chest, select the proper intervention. 
a. endotracheal intubation
b. cricothyroidotomy
c. subxiphoid window
d. tube thoracostomy
e. occlusive dressing
==>tension pneumothorax

Answer 59

D

chest tube –> to decompress & relieve pneumothorax

Question 60

18yo woman is transported to your trauma unit after sustaining a side-impact collision on her side of the car. she is hypotensive and in respiratory distress and has distended neck veins. for each immediately life-threatening injury of the chest, select the proper intervention. 
a. endotracheal intubation
b. cricothyroidotomy
c. subxiphoid window
d. tube thoracostomy
e. occlusive dressing
==>pericardial tamponade

Answer 60

C

due to blunt force trauma to the chest wall

==> subxiphoid, supradiaphragmatic incision and creation of a pericardial window