What is the highest priority during the Primary Survey of a trauma patient according to ATLS guidelines? A. Breathing and Ventilation B. Circulation with Hemorrhage Control C. Airway maintenance with restriction of cervical spine motion D. Disability (Neurologic Evaluation) Correct Answer: C Explanation: The ATLS protocol follows the ABCDE sequence. Establishing and maintaining a patent airway while protecting the cervical spine is the first and most critical step, as airway obstruction can lead to death faster than other injuries.During the initial assessment ("10-second assessment"), asking the patient "What happened?" primarily assesses which component? A. Airway patency and Level of Consciousness B. Breathing adequacy only C. Circulatory status only D. Exposure needs Correct Answer: A Explanation: An appropriate verbal response indicates a patent airway (able to speak), sufficient ventilation (air movement for speech), and an adequate level of consciousness (able to understand and respond), covering A, B, and D aspects initially. Failure suggests issues requiring immediate assessment in these areas.When should the Secondary Survey (head-to-toe evaluation) begin? A. Immediately upon patient arrival B. Only after all diagnostic tests are completed C. After the Primary Survey (ABCDEs) is completed, resuscitation is underway, and vital functions are improving D. After the patient has been transferred to definitive care Correct Answer: C Explanation: The Secondary Survey is a detailed assessment performed onlyafter life-threatening injuries identified in the Primary Survey have been addressed and the patient is stabilizing.Which adjunct is most useful for the rapid detection of intra-abdominal hemorrhage in a hypotensive blunt trauma patient during the Primary Survey? A. Diagnostic Peritoneal Lavage (DPL) B. Computed Tomography (CT) scan C. Focused Assessment with Sonography for Trauma (FAST) D. Plain abdominal X-ray Correct Answer: C Explanation: FAST is a rapid, noninvasive bedside tool used during the primary survey adjuncts to detect hemoperitoneum (and pericardial effusion). CT scans require patient transport and stability, while DPL is more invasive and less commonly used now.In a mass casualty incident (MCE), how does the principle of triage change compared to a multiple casualty incident (MCI)? A. Treat the most severely injured patients first, regardless of resources. B. Focus shifts to doing the greatest good for the greatest number of people, potentially delaying care for critically injured patients with low survival probability. C. All patients receive the same level of immediate care. D. Treatment priorities are based solely on arrival time. Correct Answer: B Explanation: In an MCE, resources are overwhelmed. Triage prioritizes patients with the highest chance of survival requiring the least expenditure of limited time, personnel, and supplies, to maximize the number of survivors.What is the primary reason for completely undressing the trauma patient during the "E" (Exposure/Environmental Control) phase of the Primary Survey? A. To assess skin temperature accurately B. To facilitate a thorough examination and identify all injuries C. To prepare the patient for surgery D. To apply monitoring devices Correct Answer: B Explanation: Complete exposure is necessary to perform a thorough visual inspection and palpation to identify potentially missed injuries over the entire body surface. Preventing hypothermia is doneafter exposure and examination.Which finding is the earliest measurable circulatory sign of shock in most adults? A. Decreased systolic blood pressure B. Decreased urine output C. Tachycardia D. Altered level of consciousness Correct Answer: C Explanation: Tachycardia is often the earliest compensatory mechanism and measurable sign in response to volume loss. Significant hypotension and altered mental status occur later, often after >30% blood volume loss.What is the primary purpose of applying a cervical collar during the initial assessment? A. To treat a confirmed cervical spine fracture B. To restrict cervical spine motion until injury can be excluded C. To provide comfort to the patient D. To facilitate airway management Correct Answer: B Explanation: A cervical spine injury is assumed in patients with multisystem trauma, especially with altered consciousness or blunt injury above the clavicles. The collar restricts motion to prevent potential secondary spinal cord injury until imaging and/or clinical examination clears the C-spine.Which information is represented by the "M" in the AMPLE history? A. Mechanism of injury B. Medications currently used C. Major illnesses D. Meals (last meal) Correct Answer: B Explanation: The AMPLE mnemonic stands for Allergies, Medications, Past illnesses/Pregnancy, Last meal, Events/Environment related to the injury.What is a critical aspect of hospital preparation before the arrival of a trauma patient notified by prehospital providers?A. Completing all patient registration paperwork B. Ensuring the waiting room is clear C. Mobilizing the trauma team and ensuring necessary equipment and resources (e.g., warmed fluids, airway cart) are ready D. Pre-ordering meals for the trauma team Correct Answer: C Explanation: Effective prehospital notification allows the receiving hospital to activate the trauma team and prepare the resuscitation bay with essential personnel, equipment (airway, IV access, monitoring), and resources (warmed fluids, blood availability protocols) to expedite care upon patient arrival.
Which of the following patients most definitively requires establishment of a definitive airway? A. A conscious patient with GCS 14 complaining of neck pain B. An unconscious patient with a GCS score of 7 C. A patient with isolated rib fractures and normal oxygen saturation D. An anxious patient with a respiratory rate of 24 Correct Answer: B Explanation: A GCS score of 8 or less is a strong indication for a definitive airway due to the high risk of airway compromise, loss of protective reflexes, and the need for controlled ventilation, especially with TBI.What does the "L" in the LEMON assessment for difficult airway stand for? A. Laryngeal height B. Look externally C. Listen for stridor D. Large tongue Correct Answer: B Explanation: The LEMON mnemonic assesses potential airway difficulty: Look externally (facial trauma, small mandible, etc.), Evaluate 3-3-2 rule, Mallampati score, Obstruction, Neck mobility.Which airway adjunct is contraindicated in a patient with a suspected basilar skull fracture? A. Oropharyngeal airway (OPA) B. Nasopharyngeal airway (NPA) C. Laryngeal Mask Airway (LMA) D. Endotracheal tube (ETT) via oral route Correct Answer: B Explanation: In patients with suspected cribriform plate fracture (often associated with basilar skull fractures), inserting an NPA carries the risk of intracranial passage. OPAs, LMAs, and oral ETTs do not pose this specific risk.What is the most reliable method for confirming correct endotracheal tube placement immediately after insertion?A. Auscultation of bilateral breath sounds B. Observation of chest rise C. Detection of end-tidal CO2 (capnography) D. Chest X-ray Correct Answer: C Explanation: While chest rise and auscultation are important clinical signs, end-tidal CO2 detection (qualitative or quantitative/waveform) is the most reliable immediate confirmation that the tube is in the trachea (airway) rather than the esophagus. Chest X-ray confirms depth but is not immediate.In which situation is a surgical cricothyroidotomy the indicated procedure for establishing an airway? A. As the primary airway choice in all trauma patients B. Inability to intubate the trachea orally or nasally C. Presence of a simple pneumothorax D. GCS score of 9 Correct Answer: B Explanation: A surgical airway (cricothyroidotomy is preferred emergently) is indicated when definitive airway is required but cannot be achieved via endotracheal intubation due to factors like massive facial trauma, laryngeal fracture, or anatomical obstruction.What is the primary goal of oxygen administration in the initial management of a trauma patient? A. To decrease respiratory rate B. To prevent hypercarbia C. To maximize oxygen saturation and oxygen delivery to tissues D. To facilitate suctioning Correct Answer: C Explanation: The primary goal is to prevent or correct hypoxia by ensuring maximal oxygen saturation of hemoglobin, thereby optimizing oxygen delivery to vital organs and tissues vulnerable to secondary injury from ischemia.What is the appropriate first step in managing a conscious patient with potential airway compromise due to facial burns and soot in the mouth? A. Observe closely and wait for stridor to develop B. Administer nebulized bronchodilators C. Perform early endotracheal intubation D. Obtain an urgent chest X-ray Correct Answer: C Explanation: Signs suggestive of inhalation injury and potential for massive edema (facial burns, burns inside mouth, soot, hoarseness) warrant early, often preemptive, intubation before airway edema progresses and makes intubation difficult or impossible.The jaw-thrust maneuver is preferred over the chin-lift maneuver in trauma patients because: A. It provides better visualization for intubation B. It is easier to perform with one person C. It can be used even if the patient is vomiting D. It minimizes movement of the cervical spine Correct Answer: D Explanation: Both maneuvers open the airway, but the jaw-thrust achieves this by lifting the mandible forward without tilting the head back, thus minimizing potentially harmful movement of an unstable cervical spine.Needle cricothyroidotomy provides: A. A definitive airway for long-term ventilation B. Temporary oxygenation but inadequate ventilation C. Both adequate oxygenation and ventilation D. A route for suctioning secretions Correct Answer: B Explanation: Needle cricothyroidotomy allows for oxygen insufflation (oxygenation) via transtracheal jet ventilation but does not permit effective exhalation, leading to CO2 retention (inadequate ventilation). It is a temporary, life-saving measure until a definitive airway is established.Which finding during auscultation most strongly suggests inadequate ventilation on one side of the chest? A. Wheezing B. Crackles C. Decreased or absent breath sounds D. Rhonchi Correct Answer: C Explanation: Decreased or absent breath sounds indicate poor air entry into that side of the chest, suggesting conditions like pneumothorax, hemothorax, or mainstem intubation blocking ventilation.
Which parameter is the LEAST reliable indicator of tissue perfusion in the early stages of shock? A. Level of consciousness B. Skin color and temperature C. Systolic blood pressure D. Urine output Correct Answer: C Explanation: Compensatory mechanisms (tachycardia, vasoconstriction) can maintain systolic blood pressure until significant volume loss (>30%) occurs. Changes in heart rate, skin perfusion, mental status, and later urine output are earlier indicators of inadequate tissue perfusion.A patient involved in a high-speed MVC has a BP of 85/50 mmHg, HR 130 bpm, RR 28, cool pale skin, and confusion. What is the estimated percentage of blood volume loss (Class of Hemorrhage)? A. <15% (Class I) B. 15-30% (Class II) C. 31-40% (Class III) D. >40% (Class IV) Correct Answer: C Explanation: The combination of significant tachycardia, tachypnea, hypotension (SBP <90 mmHg), altered mental status, and poor skin perfusion corresponds to Class III hemorrhage.What is the appropriate initial fluid resuscitation bolus for an adult trauma patient in suspected hemorrhagic shock? A. 500 mL of 5% Dextrose in water (D5W) B. 1 liter of warmed isotonic crystalloid (e.g., Lactated Ringer's or Normal Saline) C. 2 units of packed red blood cells (pRBCs) D. 500 mL of hypertonic saline Correct Answer: B Explanation: The initial management involves rapid infusion of 1 liter (adult) or 20 mL/kg (child) of warmed isotonic crystalloid solution. Blood products are considered based on initial response and evidence of ongoing hemorrhage. Hypotonic (D5W) and hypertonic solutions are generally not used for initial bolus resuscitation in trauma.A patient responds transiently to the initial fluid bolus, with vital signs improving but then deteriorating again. What is the most likely implication? A. The patient has neurogenic shock B. The patient has ongoing hemorrhage requiring blood transfusion and likely surgical intervention C. The patient was over-resuscitated D. The initial diagnosis of shock was incorrect Correct Answer: B Explanation: A transient response indicates significant initial blood loss (likely Class II or III) and suggests ongoing bleeding. These patients typically require blood products and urgent intervention (surgery or angioembolization) to control the hemorrhage.What is the primary goal of fluid resuscitation in hemorrhagic shock? A. To normalize blood pressure rapidly B. To restore adequate organ perfusion and tissue oxygenation C. To dilute toxins in the bloodstream D. To increase urine output above 100 mL/hr Correct Answer: B Explanation: The fundamental goal is not just to raise blood pressure, but to restore adequate blood flow (perfusion) and oxygen delivery to vital organs and tissues, reversing the shock state.Which type of shock is characterized by hypotension WITHOUT tachycardia (or even bradycardia)? A. Hemorrhagic shock B. Cardiogenic shock C. Obstructive shock D. Neurogenic shock Correct Answer: D Explanation: Neurogenic shock results from loss of sympathetic tone due to spinal cord injury (typically T6 or above), leading to vasodilation and pooling of blood, causing hypotension. The disruption of sympathetic pathways to the heart prevents the typical compensatory tachycardia.In managing hemorrhagic shock, when should vasopressors be considered? A. As the first-line treatment for hypotension B. Only after fluid resuscitation has failed and hemorrhage is controlled, or in neurogenic shock C. Whenever systolic blood pressure drops below 100 mmHg D. Concurrently with the initial crystalloid bolus Correct Answer: B Explanation: Vasopressors are generally contraindicated as first-line therapy in hemorrhagic shock because they worsen tissue perfusion by causing vasoconstriction without restoring volume. Their use may be considered cautiously after volume resuscitation if hypotension persists despite hemorrhage control, or specifically in neurogenic shock to counteract vasodilation.What is the target urine output for adequate resuscitation in an adult trauma patient? A. 0.1 mL/kg/hr B. 0.5 mL/kg/hr C. 1.5 mL/kg/hr D. 2.0 mL/kg/hr Correct Answer: B Explanation: Urine output is a sensitive indicator of renal perfusion. A target of 0.5 mL/kg/hr in adults (1 mL/kg/hr in children, 2 mL/kg/hr in infants <1 yr) generally signifies adequate resuscitation and end-organ perfusion.Massive transfusion protocol (MTP) is typically considered when a patient is anticipated to require: A. More than 2 units of pRBCs in 24 hours B. Any amount of plasma transfusion C. More than 10 units of pRBCs in 24 hours, or >4 units in 1 hour D. Only crystalloid resuscitation Correct Answer: C Explanation: While definitions vary slightly, MTP is generally initiated for patients expected to need large volumes of blood products rapidly, often defined as >10 units pRBCs/24 hrs or >4 units/1 hr, to allow for balanced resuscitation with plasma and platelets alongside pRBCs.Why is aggressive fluid resuscitation potentially harmful before definitive hemorrhage control is achieved, especially in penetrating trauma?A. It can cause hypernatremia B. It dilutes clotting factors and can disrupt forming clots, worsening hemorrhage C. It always leads to pulmonary edema D. It significantly increases the risk of infection Correct Answer: B Explanation: Rapidly restoring normal or high blood pressure before bleeding is stopped can "pop the clot," increase hemorrhage, and worsen outcomes through hemodilution of clotting factors and platelets. This has led to concepts like permissive hypotension or balanced resuscitation until definitive control is achieved.
Which condition is NOT considered an immediately life-threatening thoracic injury identified during the Primary Survey? A. Tension pneumothorax B. Massive hemothorax C. Pulmonary contusion D. Cardiac tamponade Correct Answer: C Explanation: Airway obstruction, tension pneumothorax, open pneumothorax, massive hemothorax, cardiac tamponade, and tracheobronchial injury are immediately life-threatening and addressed in the primary survey. Pulmonary contusion is a potentially lethal injury identified and managed during the secondary survey.A patient presents with respiratory distress, hypotension, distended neck veins, absent breath sounds on the left, and tracheal deviation to the right. What is the most appropriate immediate action? A. Obtain an urgent chest X-ray B. Perform endotracheal intubation C. Perform immediate needle or finger decompression of the left chest D. Insert a left-sided chest tube Correct Answer: C Explanation: These are classic signs of tension pneumothorax, a clinical diagnosis requiring immediate decompression to relieve pressure on the mediastinum and improve venous return/cardiac output. Waiting for X-ray is contraindicated. Chest tube insertion follows decompression.What is the initial management for an open pneumothorax (sucking chest wound)? A. Immediate endotracheal intubation B. Closing the wound completely with an occlusive dressing taped on four sides C. Applying a sterile occlusive dressing taped securely on three sides D. Inserting a chest tube directly through the wound Correct Answer: C Explanation: An open pneumothorax is initially managed by placing a sterile dressing large enough to cover the wound and taping it on three sides. This creates a flutter-valve effect, allowing air to escape during exhalation but preventing air entry during inhalation. A chest tube is placed later (remote from the wound).Massive hemothorax is initially defined as the rapid accumulation of how much blood in the chest cavity? A. > 500 mL B. > 1000 mL C. > 1500 mL D. > 2000 mL Correct Answer: C Explanation: Massive hemothorax is defined as >1500 mL of blood initially drained via chest tube, or ongoing bleeding >200 mL/hr for 2-4 hours. It often requires thoracotomy for definitive hemorrhage control.Beck's triad, associated with cardiac tamponade, consists of: A. Hypertension, bradycardia, irregular respirations B. Hypotension, muffled heart sounds, distended neck veins C. Hypotension, tachycardia, absent breath sounds D. Hypertension, muffled heart sounds, tracheal deviation Correct Answer: B Explanation: Beck's triad includes hypotension (due to decreased cardiac output), muffled heart sounds (due to fluid in the pericardial sac), and distended neck veins (due to impaired cardiac filling). However, these signs are not always present, especially in hypovolemic patients.What diagnostic tool is most readily available and accurate for diagnosing cardiac tamponade in the emergency department? A. Chest X-ray B. Electrocardiogram (ECG) C. Focused Assessment with Sonography for Trauma (FAST) exam D. Pericardiocentesis Correct Answer: C Explanation: The FAST exam specifically includes views of the pericardial sac and is highly effective for rapidly detecting pericardial fluid suggestive of tamponade at the bedside. Pericardiocentesis is primarily therapeutic and potentially diagnostic, but carries risks.A flail chest occurs when: A. A single rib is fractured in one place B. The sternum is fractured C. A segment of the chest wall loses bony continuity with the rest of the thoracic cage D. There is only a pulmonary contusion without rib fractures Correct Answer: C Explanation: Flail chest results from multiple fractures (≥2 ribs fractured in ≥2 places) or costochondral separation, creating a segment that moves paradoxically with respiration, impairing ventilation.Which injury should be suspected in a patient with a severe deceleration mechanism (e.g., high-speed MVC, fall from height) and a widened mediastinum on chest X-ray? A. Simple pneumothorax B. Pulmonary contusion C. Traumatic aortic disruption D. Flail chest Correct Answer: C Explanation: A widened mediastinum is a key radiographic finding suggesting potential traumatic aortic disruption, a highly lethal injury often occurring near the ligamentum arteriosum due to shear forces in deceleration trauma.What is the significance of subcutaneous emphysema in a trauma patient? A. It always requires surgical intervention B. It indicates the presence of an open fracture C. It suggests injury to an air-containing structure (e.g., lung, trachea, esophagus) D. It is a definitive sign of tension pneumothorax Correct Answer: C Explanation: Subcutaneous emphysema (air under the skin, causing crepitus) indicates that air has escaped from the airway, lungs, or rarely the esophagus into the surrounding soft tissues, pointing to an underlying injury that needs identification and treatment.What is the primary reason for the high mortality associated with tracheobronchial tree injuries? A. Associated vascular injuries B. Difficulty in surgical repair C. Rapid development of complete airway obstruction or tension pneumothorax D. Frequent association with esophageal tears Correct Answer: C Explanation: Disruption of the major airways leads to massive air leaks, inability to ventilate, rapid airway obstruction from blood or tissue, and often tension pneumothorax, making these injuries highly lethal if not managed immediately and effectively, often requiring advanced airway techniques or surgery.
Which organ is most frequently injured in blunt abdominal trauma? A. Liver B. Spleen C. Small bowel D. Kidney Correct Answer: B Explanation: The spleen is the most commonly injured organ in blunt abdominal trauma (40-55% incidence), followed closely by the liver (35-45%).A patient presents with a seatbelt sign (bruising across the lower abdomen) after an MVC. This finding increases suspicion for injury to which structure? A. Spleen B. Liver C. Hollow viscus (e.g., small bowel, colon) D. Kidney Correct Answer: C Explanation: The compression force from a lap belt, especially if worn too high, is associated with an increased risk of injury to the underlying hollow organs, particularly the small bowel and colon, as well as Chance fractures of the lumbar spine.Which diagnostic modality is contraindicated if an unstable pelvic fracture is suspected? A. FAST exam B. Manual manipulation or "rocking" of the pelvis C. AP Pelvic X-ray D. CT scan of the pelvis Correct Answer: B Explanation: Manually stressing an unstable pelvis can dislodge clots and worsen potentially life-threatening hemorrhage. Pelvic stability should be assessed gently only once, if at all. Imaging (X-ray, CT) and application of a pelvic binder are the preferred methods for evaluation and initial stabilization.What is the primary purpose of applying a pelvic binder or sheet in a patient with a suspected unstable pelvic fracture and hypotension? A. To reduce the fracture definitively B. To provide pain relief C. To decrease pelvic volume and tamponade bleeding D. To allow for easier patient transport Correct Answer: C Explanation: Unstable pelvic fractures, particularly AP compression ("open book") types, increase the potential pelvic volume. A binder applied correctly at the level of the greater trochanters helps close the pelvic ring, reducing the potential space for hemorrhage and providing a tamponade effect.An indication for urgent laparotomy in a patient with penetrating abdominal trauma is: A. Isolated hematuria B. A single stab wound with no peritoneal signs C. Hemodynamic instability (hypotension) D. Presence of a subcutaneous hematoma Correct Answer: C Explanation: Hypotension in the setting of penetrating abdominal trauma strongly suggests significant intra-abdominal hemorrhage requiring immediate surgical exploration (laparotomy) to control bleeding. Other indications include peritonitis, evisceration, and positive findings on specific diagnostic tests.What is the most sensitive noninvasive test for detecting free intraperitoneal fluid (hemoperitoneum)? A. Plain abdominal X-ray B. Focused Assessment with Sonography for Trauma (FAST) C. Computed Tomography (CT) scan D. Diagnostic Peritoneal Lavage (DPL) Correct Answer: B Explanation: FAST is highly sensitive for detecting free fluid (usually blood) in the peritoneal cavity, particularly in the dependent areas (hepatorenal, splenorenal, pelvic pouches). CT is also sensitive but requires patient stability and transport. DPL is invasive.Injuries to which retroperitoneal structure are notoriously difficult to diagnose early with physical examination, FAST, or DPL? A. Spleen B. Liver C. Pancreas D. Kidney Correct Answer: C Explanation: Pancreatic and duodenal injuries, located deep in the retroperitoneum, often do not cause early peritoneal signs and are poorly visualized on FAST or sampled by DPL. CT with contrast is often required, but findings may be subtle initially.A patient with a gunshot wound traversing the peritoneal cavity requires: A. Serial abdominal examinations B. A FAST exam C. An urgent CT scan D. An exploratory laparotomy Correct Answer: D Explanation: Gunshot wounds that traverse the peritoneal cavity have a very high likelihood (>90%) of causing significant intra-abdominal injury and generally mandate exploratory laparotomy for diagnosis and treatment.What is the significance of finding blood at the urethral meatus in a male trauma patient? A. It indicates a definite bladder rupture B. It strongly suggests a urethral injury, and a urinary catheter should not be inserted until a retrograde urethrogram is performed C. It is a normal finding after blunt trauma D. It requires immediate surgical exploration Correct Answer: B Explanation: Blood at the meatus, scrotal hematoma, or a high-riding prostate are signs of potential urethral injury. Blindly inserting a Foley catheter can worsen the injury. A retrograde urethrogram (RUG) is required first to assess urethral integrity.Nonoperative management of blunt splenic or hepatic injury is appropriate primarily in patients who: A. Are hemodynamically unstable B. Have associated hollow viscus injuries C. Are hemodynamically stable D. Have penetrating trauma Correct Answer: C Explanation: Nonoperative management is the standard of care for many blunt solid organ (liver, spleen, kidney) injuriesonly if the patient is hemodynamically stable and remains stable, and typically requires CT scanning for diagnosis/grading and intensive monitoring capabilities.
What is the primary goal in the management of traumatic brain injury (TBI)? A. To reverse the primary brain injury B. To prevent or minimize secondary brain injury C. To rapidly decrease intracranial pressure (ICP) with hyperventilation D. To administer high-dose steroids Correct Answer: B Explanation: The initial (primary) injury is irreversible. Management focuses on preventing secondary injury caused by factors like hypoxia, hypotension, increased ICP, seizures, and metabolic derangements, which worsen the initial damage.Which component of the Glasgow Coma Scale (GCS) is considered the most reliable predictor of outcome in TBI? A. Eye opening response B. Verbal response C. Motor response D. Pupillary response Correct Answer: C Explanation: While the total GCS score is used for classification and tracking, the motor component has been shown to have the strongest correlation with patient outcome after TBI.A "blown pupil" (fixed and dilated pupil) in a patient with head trauma typically indicates compression of which cranial nerve? A. Optic nerve (CN II) B. Oculomotor nerve (CN III) C. Trochlear nerve (CN IV) D. Abducens nerve (CN VI) Correct Answer: B Explanation: The oculomotor nerve (CN III) carries parasympathetic fibers responsible for pupillary constriction. These fibers run superficially and are vulnerable to compression, often during uncal (transtentorial) herniation, leading to unopposed sympathetic dilation.According to the Monro-Kellie doctrine, an increase in the volume of one intracranial component (e.g., hematoma) must be compensated by: A. Expansion of the skull B. A decrease in the volume of other components (CSF and/or venous blood) C. An increase in cerebral blood flow D. An increase in CSF production Correct Answer: B Explanation: The doctrine states that the rigid skull contains a fixed total volume of brain, CSF, and blood. If one component increases (e.g., hematoma), ICP will rise unless there is a compensatory decrease in the volume of CSF and/or venous blood.Which condition is the most critical systemic factor to prevent in order to minimize secondary brain injury? A. Hyperglycemia B. Hypotension (SBP < 100 mmHg in adults 50-69 yrs; <110 mmHg in 15-49 or >70yrs) C. Mild hyponatremia D. Fever Correct Answer: B Explanation: Hypotension significantly reduces cerebral perfusion pressure (CPP = MAP - ICP) and is strongly associated with worse outcomes after TBI. Maintaining adequate MAP is a cornerstone of TBI management to prevent secondary ischemic injury. Hypoxia is equally critical to avoid.An epidural hematoma is most commonly caused by injury to which vessel? A. Bridging veins B. Middle meningeal artery C. Sagittal sinus D. Internal carotid artery Correct Answer: B Explanation: Epidural hematomas typically result from arterial bleeding, most often from a tear in the middle meningeal artery, frequently associated with a temporal bone fracture. They collect in the potential space between the dura and the skull.Which type of intracranial hematoma typically conforms to the contours of the brain surface on CT scan? A. Epidural hematoma B. Subdural hematoma C. Intracerebral hematoma D. Subarachnoid hemorrhage Correct Answer: B Explanation: Subdural hematomas result from tearing of bridging veins and collect in the potential space between the dura and arachnoid mater. They typically spread out over the surface of the brain, assuming a crescent shape that follows the brain's contour. Epidural hematomas are typically lenticular (lens-shaped).What is the immediate management priority for a patient presenting with signs of acute uncal herniation (e.g., unilaterally dilated pupil, contralateral hemiparesis)? A. Administer high-dose steroids B. Perform emergent CT scan C. Initiate measures to reduce ICP (e.g., mannitol, brief controlled hyperventilation) and arrange urgent neurosurgical consultation D. Place an ICP monitor Correct Answer: C Explanation: Acute herniation is a neurosurgical emergency. While definitive treatment is surgical evacuation of the mass lesion, immediate medical management focuses on reducing ICP through osmotic agents (mannitol if euvolemic), temporary hyperventilation (if signs of herniation), and ensuring optimal oxygenation and blood pressure, alongside urgent neurosurgical consultation.Prophylactic hyperventilation (PaCO2 < 25 mmHg) in severe TBI patients is generally: A. Recommended for all patients B. Beneficial only in the first 24 hours C. Not recommended due to risk of cerebral ischemia D. Indicated only if ICP is normal Correct Answer: C Explanation: While brief hyperventilation can acutely lower ICP, prolonged or aggressive hyperventilation (PaCO2 < 25-30 mmHg) causes excessive vasoconstriction, potentially leading to cerebral ischemia and worse outcomes. It is reserved for acute, temporary management of refractory intracranial hypertension or signs of herniation.What is the significance of Battle's sign (retroauricular ecchymosis) or raccoon eyes (periorbital ecchymosis)? A. They indicate direct orbital trauma only B. They are signs suggestive of a basilar skull fracture C. They are definitive proof of an epidural hematoma D. They mandate immediate anticoagulation reversal Correct Answer: B Explanation: These clinical signs result from bleeding that tracks along fracture lines in the base of the skull, indicating a basilar skull fracture, even if not immediately visible on plain X-rays.
What percentage of patients with a cervical spine fracture have a second, non-contiguous vertebral column fracture? A. <1% B. 2% C. Up to 10% D. 25% Correct Answer: C Explanation: The ATLS manual states that up to 10% of patients with a C-spine fracture will have another fracture elsewhere in the vertebral column, necessitating imaging of the entire spine if one fracture is identified.Neurogenic shock is characterized by: A. Hypertension and tachycardia B. Hypotension and tachycardia C. Hypotension and bradycardia (or absence of tachycardia) D. Hypertension and bradycardia Correct Answer: C Explanation: Loss of sympathetic tone from high spinal cord injury causes vasodilation (hypotension) and loss of sympathetic cardiac stimulation (bradycardia or inability to become tachycardic).Spinal shock refers to: A. Hypotension due to spinal cord injury B. The flaccidity and loss of reflexes that occur immediately after spinal cord injury C. A psychological reaction to spinal injury D. Hemorrhagic shock associated with spinal fractures Correct Answer: B Explanation: Spinal shock is a transient physiological state following spinal cord injury characterized by the loss of spinal reflexes, motor function (flaccidity), and sensation below the level of the injury. It is distinct from neurogenic shock (which involves hemodynamic changes).Which spinal cord tract is responsible for transmitting pain and temperature sensation? A. Corticospinal tract B. Dorsal columns C. Spinothalamic tract D. Spinocerebellar tract Correct Answer: C Explanation: The spinothalamic tracts, located anterolaterally in the cord, transmit pain and temperature sensation from the contralateral side of the body. Dorsal columns carry proprioception/vibration; corticospinal tracts carry motor function.A patient presents with loss of motor function and pain/temperature sensation bilaterally below the level of injury, but preserves proprioception and vibration sense. This pattern suggests which spinal cord syndrome? A. Central cord syndrome B. Anterior cord syndrome C. Brown-Séquard syndrome D. Complete cord transection Correct Answer: B Explanation: Anterior cord syndrome typically involves damage to the anterior 2/3rds of the cord (corticospinal and spinothalamic tracts) often due to cord ischemia, sparing the posterior dorsal columns (proprioception/vibration).According to the NEXUS low-risk criteria, cervical spine radiography is NOT required if which of the following is present? A. Posterior midline cervical spine tenderness B. Evidence of intoxication C. Altered level of alertness D. Absence of all five criteria (No tenderness, No intoxication, Normal alertness, No focal neuro deficit, No distracting injury) Correct Answer: D Explanation: The NEXUS criteria identify patients at very low risk of clinically significant C-spine injury who do not require imaging. Ifall five criteria are met (i.e., none of the risk factors are present), the C-spine can potentially be cleared clinically.What is the most common level for cervical spine fractures in adults? A. C1-C2 B. C3-C4 C. C5-C6 D. C7-T1 Correct Answer: C Explanation: The C5-C6 level represents the area of greatest flexion and extension in the adult cervical spine, making it the most common site for fractures and subluxations.A Jefferson fracture involves a burst fracture of which vertebra? A. Atlas (C1) B. Axis (C2) C. C5 D. C7 Correct Answer: A Explanation: A Jefferson fracture is a burst fracture of the ring of C1 (atlas), typically caused by axial loading, resulting in fractures of the anterior and posterior arches.The primary reason long spine boards should be removed as soon as safely possible is: A. They are uncomfortable for the patient B. They interfere with radiographic imaging C. They increase the risk of pressure ulcer formation D. They are difficult to clean Correct Answer: C Explanation: While uncomfortable, the main clinical concern with prolonged immobilization on a hard spine board is the development of pressure sores (decubitus ulcers) over bony prominences (occiput, sacrum, heels). Respiratory compromise can also occur.High-dose methylprednisolone administration for acute spinal cord injury is: A. The standard of care for all patients B. Proven to significantly improve long-term neurological outcome C. Recommended only for penetrating injuries D. No longer recommended as a standard treatment or guideline by major neurosurgical/spine organizations due to lack of clear benefit and potential complications Correct Answer: D Explanation: Based on re-evaluation of the evidence from the NASCIS trials and concerns about complications (e.g., infection, GI bleed), major guidelines no longer recommend high-dose steroids as a standard of care or treatment guideline for acute spinal cord injury. Its use may be considered a treatmentoption in select cases after discussion of risks/benefits.
What is the most immediate life-threatening complication of major musculoskeletal trauma? A. Compartment syndrome B. Nerve injury C. Hemorrhage D. Fat embolism Correct Answer: C Explanation: While compartment syndrome, nerve injury, and fat embolism are serious complications, massive hemorrhage (external or internal) associated with fractures (especially pelvic or bilateral femur fractures) or major vascular injury poses the most immediate threat to life.Which fracture is most commonly associated with significant blood loss (up to 1500 mL or more)? A. Tibial shaft fracture B. Humeral shaft fracture C. Pelvic fracture D. Clavicle fracture Correct Answer: C Explanation: Unstable pelvic ring fractures can disrupt the large pelvic venous plexus and arteries, leading to massive retroperitoneal hemorrhage, often exceeding several liters. Femur fractures are next, potentially causing 1-1.5L loss.Compartment syndrome is caused by: A. Direct nerve transection B. Increased pressure within a closed musculofascial space, impairing perfusion C. Arterial occlusion due to thrombosis D. Systemic infection spreading to the muscle Correct Answer: B Explanation: Compartment syndrome occurs when swelling or bleeding increases pressure within a non-expansile fascial compartment to a level that compromises capillary blood flow to muscles and nerves, leading to ischemia and necrosis if not relieved by fasciotomy.Which sign or symptom is considered the earliest and most reliable indicator of compartment syndrome? A. Loss of distal pulses B. Motor paralysis C. Pain out of proportion to the apparent injury, especially with passive stretch of the muscles in the compartment D. Pallor of the extremity Correct Answer: C Explanation: Severe pain, often described as out of proportion to the injury and exacerbated by passive muscle stretch, is the hallmark early symptom. Paresthesias occur next. Loss of pulses and paralysis are late, ominous signs indicating irreversible damage.What is the definitive treatment for established compartment syndrome? A. Elevation of the limb B. Application of ice packs C. Narcotic analgesia D. Fasciotomy Correct Answer: D Explanation: Fasciotomy, the surgical incision of the overlying fascia, is the only definitive treatment to relieve the elevated pressure within the compartment and restore perfusion.An open fracture is defined as: A. Any fracture associated with significant soft tissue swelling B. A fracture where the bone ends are visible on X-ray C. A fracture associated with a break in the overlying skin and soft tissues, creating communication between the fracture and the external environment D. A fracture involving a joint surface Correct Answer: C Explanation: An open (or compound) fracture involves communication between the fracture site and the outside environment through a traumatic wound, posing a significant risk of contamination and infection.What is the most critical initial step in managing an open fracture? A. Immediate surgical fixation B. Application of a cast C. Administration of intravenous antibiotics and sterile dressing application D. Obtaining multiple X-ray views Correct Answer: C Explanation: Preventing infection is paramount. Initial management includes prompt administration of IV antibiotics (within 3 hours), tetanus prophylaxis, removal of gross contamination, covering the wound with a sterile dressing, and splinting. Surgical debridement follows.A posterior hip dislocation typically presents with the limb in what position? A. Extended, abducted, and externally rotated B. Flexed, adducted, and internally rotated C. Extended, adducted, and internally rotated D. Flexed, abducted, and externally rotated Correct Answer: B Explanation: This is the classic position for a posterior hip dislocation, the most common type (>85%). Anterior dislocations present with abduction and external rotation.A knee dislocation, even if spontaneously reduced upon presentation, carries a high risk of injury to which structure? A. Femoral nerve B. Popliteal artery C. Patellar tendon D. Medial collateral ligament only Correct Answer: B Explanation: The popliteal artery is relatively fixed behind the knee joint and is vulnerable to traction injury or transection during a knee dislocation. Vascular injury occurs in up to 40% of cases and requires urgent assessment (ABI, +/- angiography) and treatment to prevent limb loss. Peroneal nerve injury is also common.The primary purpose of applying a traction splint to a mid-shaft femur fracture is to: A. Provide definitive fixation B. Reduce pain, muscle spasm, and potential bleeding by realigning the fracture fragments C. Allow the patient to bear weight D. Prevent compartment syndrome Correct Answer: B Explanation: Traction splints provide temporary immobilization by applying longitudinal traction to counteract muscle spasm, which helps align the fracture, reduce pain, decrease further soft-tissue injury, and minimize bleeding into the thigh.
What is the most immediate priority in managing a patient with extensive burns? A. Calculating the burn surface area B. Stopping the burning process C. Administering pain medication D. Applying topical antibiotics Correct Answer: B Explanation: The first step is always to stop the burning process by removing the patient from the source, extinguishing flames, and removing smoldering or chemical-soaked clothing, while preventing hypothermia.Which finding most strongly suggests the presence of an inhalation injury in a burn patient? A. Burns to the extremities B. History of being burned in an enclosed space, associated with facial burns or soot in the nares/mouth C. Presence of partial-thickness burns only D. A normal initial chest X-ray Correct Answer: B Explanation: While hypoxia or CO poisoning can occur without direct airway burns, suspicion for inhalation injury (damage from heat/smoke/chemicals) is highest when the burn occurs in an enclosed space. Clinical signs like facial burns, singed nasal hairs, soot, hoarseness, or carbonaceous sputum further increase this suspicion.According to the updated ABLS guidelines, what is the recommended starting rate for intravenous fluid resuscitation in an adult with major thermal burns (excluding electrical)? A. 1 mL/kg/%TBSA B. 2 mL/kg/%TBSA C. 3 mL/kg/%TBSA D. 4 mL/kg/%TBSA Correct Answer: B Explanation: The current consensus guideline starts resuscitation at 2 mL of Lactated Ringer's x body weight (kg) x % Total Body Surface Area (TBSA) burned (second- and third-degree only). This is a starting point, and the rate must be titrated based on urine output.How should the first half of the calculated 24-hour resuscitation fluid volume be administered? A. Evenly over the first 24 hours B. Over the first 4 hours C. Over the first 8 hours from the time of injury D. As a single rapid bolus upon arrival Correct Answer: C Explanation: The formula calculates the total 24-hour volume. Half of this volume is given in the first 8 hourspost-injury , and the remaining half is given over the subsequent 16 hours. The rate is then adjusted based on physiological response (primarily urine output).What is the most reliable indicator of adequate fluid resuscitation in a burn patient? A. Blood pressure B. Heart rate C. Urine output D. Hematocrit Correct Answer: C Explanation: Urine output is the most sensitive indicator of end-organ (renal) perfusion and adequacy of volume resuscitation in burn shock. Target rates are 0.5 mL/kg/hr for adults and 1 mL/kg/hr for children (<30 kg).Which type of burn commonly causes deep tissue damage that is disproportionately greater than the surface injury suggests? A. Scald burns B. Superficial partial-thickness burns C. Chemical burns (acid) D. Electrical burns Correct Answer: D Explanation: Electrical current travels through the body along paths of least resistance (nerves, blood vessels), causing extensive deep muscle damage and potential cardiac or neurological injury, often with minimal overlying skin findings apart from entry/exit sites.What is the immediate management for a circumferential full-thickness burn to an extremity causing impaired distal circulation? A. Elevation of the limb only B. Application of a pressure dressing C. Escharotomy D. Administration of anticoagulants Correct Answer: C Explanation: A circumferential full-thickness burn acts like a tourniquet as edema develops beneath the inelastic eschar, compromising distal circulation. Escharotomy (surgical incision through the eschar) is required to relieve the pressure.Carbon monoxide (CO) poisoning primarily causes tissue hypoxia by: A. Directly damaging alveolar membranes B. Causing intense bronchospasm C. Binding to hemoglobin with high affinity, reducing oxygen carrying capacity and shifting the O2-dissociation curve D. Inducing methemoglobinemia Correct Answer: C Explanation: CO binds to hemoglobin ~240 times more avidly than oxygen, forming carboxyhemoglobin (HbCO). This reduces the amount of hemoglobin available to carry oxygen and shifts the oxyhemoglobin dissociation curve to the left, impairing oxygen release to tissues.What is the initial treatment for suspected carbon monoxide poisoning? A. Intravenous sodium bicarbonate B. Administration of 100% high-flow oxygen C. Hyperbaric oxygen therapy D. Methylene blue Correct Answer: B Explanation: Administering 100% oxygen significantly reduces the half-life of HbCO (from ~4 hours on room air to ~40-60 minutes), rapidly displacing CO from hemoglobin. Hyperbaric oxygen is reserved for severe cases.Systemic hypothermia in a trauma patient is defined as a core body temperature below: A. 37.0°C (98.6°F) B. 36.0°C (96.8°F) C. 35.0°C (95.0°F) D. 34.0°C (93.2°F) Correct Answer: B Explanation: While mild hypothermia traditionally starts at <35°C, in the context of trauma, hypothermia is often defined as <36°C due to its significant adverse impact on coagulation and outcomes in injured patients.
Compared to adults, children have: A. Lower body surface area to mass ratio B. More pliable bones and stronger ligaments C. Lower metabolic rate D. Less physiologic reserve Correct Answer: B Explanation: Children's skeletons are less ossified, making bones more pliable (prone to greenstick/torus fractures) and ligaments relatively stronger (making physeal injuries more common than ligament tears). They have ahigher BSA:mass ratio (prone to hypothermia),higher metabolic rate, and oftengreater initial physiologic reserve (masking shock).The most common cause of preventable death after injury in geriatric patients is: A. Hemorrhage B. Failure to recognize and manage complications related to co-morbidities C. Airway obstruction D. Over-resuscitation leading to heart failure Correct Answer: B Explanation: While hemorrhage is critical, geriatric patients often succumb to complications because their decreased physiologic reserve makes them less tolerant of injury stress, and co-morbidities (cardiac, pulmonary, renal disease) and medications complicate management and recovery. Failure to account for these factors is key.During pregnancy, physiological changes include: A. Decreased plasma volume and increased hematocrit B. Increased functional residual capacity (FRC) C. Decreased heart rate and decreased cardiac output D. Increased plasma volume, decreased hematocrit (physiological anemia), and increased cardiac output Correct Answer: D Explanation: Pregnancy involves significant increases in plasma volume (more than RBCs, causing hemodilution), increased cardiac output, increased heart rate, anddecreased FRC due to diaphragmatic elevation.What is the most important initial step in ensuring fetal well-being after maternal trauma? A. Performing an immediate fetal ultrasound B. Administering tocolytics to prevent preterm labor C. Ensuring optimal resuscitation and stabilization of the mother D. Placing internal fetal monitors Correct Answer: C Explanation: The fetus is entirely dependent on the mother. Optimal maternal resuscitation (ensuring oxygenation and perfusion) is the single most important factor in ensuring fetal survival and well-being. Fetal assessment follows maternal stabilization.When transferring a critically injured patient to a higher level of care, who holds the ultimate responsibility for the patient until arrival at the receiving facility? A. The transporting personnel (e.g., paramedics) B. The receiving physician C. The referring physician D. The hospital administrator Correct Answer: C Explanation: The referring physician is responsible for ensuring the patient is stabilized as much as possible, selecting the appropriate receiving facility and mode of transport, communicating with the receiving physician, ensuring appropriate care continues en route, and documenting the transfer process. Responsibility transfers only upon arrival and acceptance by the receiving physician.The primary purpose of using the ABC-SBAR format during interhospital transfer communication is to: A. Bill for the transfer services B. Ensure complete and standardized transmission of critical patient information C. Satisfy legal requirements only D. Provide a script for the transport crew Correct Answer: B Explanation: SBAR (Situation, Background, Assessment, Recommendation) - adapted here to ABC-SBAR to fit the ATLS structure - provides a standardized framework to ensure clear, concise, and complete communication of vital patient information between referring and receiving physicians/teams, minimizing errors and delays.In which situation is Diagnostic Peritoneal Lavage (DPL) still considered most useful? A. In all hemodynamically stable blunt trauma patients B. In evaluating penetrating back injuries C. In hemodynamically unstable blunt trauma patients when FAST or CT is unavailable or indeterminate D. As a routine screening tool for pediatric trauma Correct Answer: C Explanation: With the advent and widespread use of FAST and CT, DPL use has declined significantly. Its primary remaining role is in resource-limited settings or for hemodynamically unstable patients with equivocal FAST/unavailable CT to rapidly rule out significant hemoperitoneum.Regarding ocular trauma, what is the immediate priority if an open globe injury is suspected? A. Measure intraocular pressure B. Apply a pressure patch C. Protect the eye with a rigid shield and obtain urgent ophthalmology consultation D. Instill fluorescein dye Correct Answer: C Explanation: If an open globe is suspected, further examination (pressure measurement, dye) or pressure application must be avoided as they can extrude intraocular contents. The priority is to protect the eye from further injury with a shield and seek immediate specialist consultation for surgical repair.The most effective method for cooling a patient with exertional heat stroke is: A. Administering intravenous cold saline B. Applying ice packs to the groin and axillae only C. Fanning the patient vigorously D. Immersion in cold or ice water Correct Answer: D Explanation: Immersion in ice/cold water provides the most rapid and effective cooling through conduction and is the treatment of choice for exertional heat stroke, especially in young, healthy individuals, if feasible. Other methods like evaporative cooling (water spray + fan) are alternatives.In a mass casualty incident, a patient tagged as "Expectant" (e.g., Black or Blue tag) typically: A. Receives the highest priority for immediate surgical intervention B. Has minor injuries and can wait for treatment C. Has injuries considered unsurvivable given the available resources and receives palliative care initially D. Is deceased upon initial assessment Correct Answer: C Explanation: The "Expectant" category is unique to mass casualty triage. It designates patients with catastrophic injuries who are unlikely to survive even with maximal care under the current resource constraints. They receive comfort measures while resources are directed towards saving those with a higher chance of survival (Red and Yellow categories). Deceased patients are tagged separately (e.g., Black).
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