ATLS TEST 1 LATEST EXAM 2024 ADVANCED TRAUMA LIFE SUPPORT TEST 1 LATEST, Exams of Nursing

Download ATLS TEST 1 LATEST EXAM 2024 ADVANCED TRAUMA LIFE SUPPORT TEST 1 LATEST and more Exams Nursing in PDF only on Docsity! ATLS PRE TEST QUESTIONS AND CORRECT ANSWERS QUESTIONS AND ANSWERS| GRADED A+ Which of the following physical findings suggest a cause of hypotension other than spinal cord injury? A. Prispism B. Bradycardia C. Diaphragmatic breathing D. Presence of deep tendon reflexes E. Ability to flex forearms but not extend them -ANSWER- D. Presence of deep tendon reflexes. Spinal shock refers to loss of muscle toe (flaccidty) and loss of reflexes. The primary indication for transferring A patient to a higher level trauma center is: A. Unavailibility of surgeon or operating staff B. Multiple system injuries, including severe head injury C. Resource limitations as determined by the transferring doctor D. Resource limitations as determined by the hospital administration E. Widened mediastinum on chest x-ray following blunt trauma -ANSWER- C. Resource limitations as determined by the transferring doctor (MÅ SJEKKES) A young man sustains a rifle wound to the mid-abdomen. He is brought promptly to the ED by prehospital personnel. His skin is cool and diaphoretic, and his systolic blood pressure is 58mmHg. Warmed crystalloid fluids are initiated without improvement in his vital signs. The next, most appropriate, step is to perform: A. a laparotomy B. An abdominal CT-scan C. Diagnostic laparoscopy D. Abdominal ultrasonography E. A diagnostic peritoneal lavage -ANSWER- A. Laparotomy because of hemodynamic abnormality A 42-year-old man is trapped from the waist down beneath his overturned tractor for several hours before medical assistance arrives. He is awake and alert until just before arriving in the ED. He is now unconscious and responds only to painful stimuli by moaning. His pupils are 3mm in diameter and symmetrically reactive to light. Prehospital personnel indicate that they have not seen the patient move either of his lower extremities. On examination in the ED, no movement of his lower extremities are detected, even in response to painful stimuli. The most likely cause for this finding is: A. An epidural hematoma B. A pelvic fracture C. Central cord syndrome D. Intracerebral hemorrhage E. Bilateral compartment syndrome -ANSWER- MÅ SJEKKES A 6-year-o boy is struck by an automobile and brought to the ED. He is lethargic, but withdraws purposefully from painful stimuli. His blood pressure is 90mmHg systolic, heart rate 140 beats per minute and his respiratory rate is 36 breaths per minute. The preferred route of venous access in this patient is: A. Percutaneous femoral vein cannulation B. Cutdown on the saphenous vein at the ankle C. Intraosseous catheter placement in the proximal tibia D. Percutaneous peripheral veins in the upper extremities E. Central venous access via the subclavian or internal jugular vein -ANSWER- D. Percutaneous peripheral veins in the upper extremities A young man sustains a gunshot wound to the abdomen and is brought promptly to the ED by prehospital personnel. His skin is cool and diaphoretic, and he is confused. His pulse is thready and his femoral pulse is only weakly palpable. The definitive treatment in managing this patient is to: A. Administer O-negative blood B. Apply external warming devices C. Control internal hemorrhage operatively D. Apply a pneumatic antishock garment (PASG) E. Infuse large volumes of intravenous crystalloid solutions. -ANSWER- C. Control internal hemorrhage operatively Regarding shock in the child, which of the following is FALSE? A. Vital signs are age-related B. Children have greater physiologic reserves than do adults C. Tachycardia is the primary physiologic response to hypovolemia D. The absolute volume of blood loss required to produce shock is the same as in adults E. An initial fluid bolus for resuscitation should approximate 20ml/kg Ringers Lactate -ANSWER- D. The absolute volume of blood loss required to produce shock is the same as in adults C. A short spine board D. Cervical traction tongs E. Pneumatic antishock garment -ANSWER- B. A long spine board During an altercation, a 36-year-old man sustains a gunshot wound above the nipple line on the right, with an exit wound posteriorly above the scapula on the right. He is transported by ambulance to a community hospital. He is endotracheally intubated, close tube thoracostomy is performed, and 2 liters Ringers lactate solution are infused via 2 large-caliber IV´s. His blood pressure now is 60/0mmHg, heart rate is 160 beats per minute, and respiratory rate is 14 breaths per minute (ventilated with 100% O2). The most appropriate next step in managin this patient is: A. Laparotomy B. Diagnostic peritoneal lavage C. Arterial blood gas determination D. Administer packed red blood cells E. Chest X-ray to confirm tube placement -ANSWER- E. Chest X-ray to confirm tube placement Abscence of breath sounds and dullness to percussion over the left hemithorax are findings best explained by: A. Left hemothorax B. Cardiac contusion C. Left simple pneumothorax D. Left diaphragmatic rupture E. Right tension pneumothorax -ANSWER- A. Left hemothorax A 23-year-old man is brought immediately to the ED from the hospitals parking lot where he was shot in the lower abdomen. Examination reveals a single bullet wound. He is breathing and has a thready pulse. However, he is unconsious and has no detectable blood pressure. Optimale immediate management is to: A. Perform a diagnostic peritoneal lavage B. Initiate infusion of packed red blood cells C. Insert a nasogastric tube and urinary catheter D. Transfer the patient to the operating room, while initiating fluid therapy E. Initiate fluid therapy to return his blood pressure to normotensive -ANSWER- D. Transfer the patient to the operating room, while initiating fluid therapy A teen-aged bicycle rider is hit by a truck traveling at high speed. In the ED, she is actively bleeding from open fractures of her legs, and has abrasions on her chest and abdominal wall. Her blood pressure is 80/50 mmHg, heart rate is 140 beats per minute, respiratory rate is 8 breaths per minute, and GCS score is 6. The first step in managing this patient is to: A. Obtain a lateral cervical spine x-ray B. Insert av central venous pressure line C. Adminster 2 liters of crystalloid solution D. Perform endotracheal intubation and ventilation E. Apply a pneumatic antishock garment (PASG) and inflate the leg compartments. -ANSWER- D. Perform endotracheal intubation and ventilation An 8-year-old boy falls 4,5 meters (15 feet) from a tree and is brought to the ED by his family. His vital signs are normal, but he complains of left upper quadrant pain. An abdominal CT-scan reveals a moderately severe laceration of the spleen. The receiving institution does not have 24-hour-a-day operating room capabilities. The most appropriate management of this patient would be to A. Type and crossmatch for blood B. Request consultation of a pediatrician C. Transfer the patient to a trauma center D. Admit the patient to the intensive care unit E. Prepare the patient for surgery the next day -ANSWER- D. Admit the patient to the intensive care unit Which of the following statements regarding injury to the central nervous system in children is TRUE? A. Children suffer spinal cord injury without x-ray abnormality more commonly than adults. B. An infant with a traumatic brain injury may become hypotensive from cerebral edema C. Initial therapy for the child with traumatic brain injury includes the administration of methylprednisolone intravenously D. Children have more focal mass lesions as a result for traumatic brain injury when compared to adults. E. Young children are less tolerant of expanding intracranial mass lesions than adults -ANSWER- A. Children suffer spinal cord injury without x-ray abnormality more commonly than adults. A 17-year-old helmeted motorcyclist is struck broadside by an automobile at an intersection. He is unconscious at the scene with a blood pressure of 140/90mmHg, heart rate of 90 beats per minute, and respiratory rate of 22 breaths per minute. His respirations are sonorous and deep. His GCS score is 6. Immobilization of the entire patient may include the use of all the following EXCEPT: A. Air splints B. Bolstering devices C. A long spine board D. A scoop-style stretcher E. A semi-rigid cervical collar -ANSWER- A. Air splints Twenty-seven patients are seriously injured in an aircraft accident at a local airport. The basic principle of triage should be to: A. Treat the most severely injured patients first B. Establish a field triage area directed by a doctor C. Rapidly transport all patients to the nearest appropriate hospital D. Treat the greatest number of patients in the shortest period of time E. Produce the greatest number of survivors based on available resources - ANSWER- E. Produce the greatest number of survivors based on available resources An electrician is eletrocuted by a downed power line after a thunderstorm. He apparently made contact with the wire at the level of the right mid thigh. In the ED, his vital signs are normal and no dysrythmia is noted on ECG. On examination, there is an exit wound on the bottom of the right foot. His urine is positive for blood by dipstick but not RBCs are seen microscopically. Initial management should include: A. Immediate angiography B. Aggressive fluid infusion C. Intravenous pyelography D. Debridement of necrotic muscle E. Admission to the ICU for observation -ANSWER- B. Aggressive fluid infusion - suspected rhabdomyolyse A young woman sustains a severe head injury as the result of a motor vehicular crash. In the ED, her GCS is 6. Her blood pressure is 140/90 mmHg and her heart rate 80 beats per minute. She is intubated and is being mechanically ventilated. Her pupils are 3mm in size and equally reactive to light. There is no other apparent injury. The most important principle to follow in early management of her head injury is to: A. Administer an osmotic diuretic B. Prevent secondary brain injury C. Agressively treat systemic hypertension Which of the following statements is FALSE concerning Rh-isoimmunization in the pregnant trauma patient? A. It occurs in blunt or penetrating abdominal trauma B. Minor degrees of fetomaternal hemorrhage produce it C. A negative Kleihauer-Betke test excludes Rh-Isoimmunzation D. This is not a problem in the traumatized Rh-positive pregnant patient E. Initiation of Rh-immunoglobulin therapy does not require proof of fetomaternal hemorrhage -ANSWER- C. A negative Kleihauer-Betke test excludes Rh- Isoimmunzation All of the following signs on the chest x-ray of a blunt injury victim may suggest aortic rupture EXCEPT: A. Mediastinal emphysema B. Presence of a "pleural cap" C. Obliteration of the aortic knob D. Deviation of the trachea to the right E. Depression of the left mainstem bronchus -ANSWER- A. Mediastinal emphysema Early central venous pressure monitoring during fluid resusciation in the ED has the greatest utility in a: A. Patient with a splenic laceration B. Patient with a inhalation injury C. 6 year-old child with a pelvic fracture D. Patient with a severe cardiac contusion E. 24-year-old man with a massive hemothorax -ANSWER- D. Patient with a severe cardiac contusion A cross-table lateral x-ray of the cervical spine: A. must precede endotracheal intubation B. excludes serious cervical spine injury C. Is an essential part of the primary survey D. Is not necessary for unconscious patients with penetrating cervical injuries E. Is unacceptable unless 7 cervical vertebrae and the C-7 to T-1 relationship are visualized. -ANSWER- E. Is unacceptable unless 7 cervical vertebrae and the C-7 to T-1 relationship are visualized. A 24-year old man sustains multiple fractured ribs bilaterally as a result of being crushed in a press at a plywood factory. Examination in the ED reveals a flail segment of the patients thorax. Primary resuscitation includes high-flow oxygen administration via a nonrebreathing mask, and initiation of Ringers lactate solution. The patient exhibits progressive confusion, cyanosis and tachypnea. Management at this time should consist of: A. Intravenous sedation B. External stabilization of the chest wall C. Increasing the FIO2 in the inspired gas D. Intercostal nerve blocks for pain relief E. Endotracheal intubation and mechanical ventilation. -ANSWER- E. Endotracheal intubation and mechanical ventilation Which of the following statements regarding patients with thoracic spine injuries is TRUE? A. Log-rolling may be destabilizing to fractures from T12 to L1 B. Adequate immobilization can be accomplished with the scoop stretcher C. Spinal cord injury below T10 usually spares bowel and bladder function D. Hyperflexion fractures in the upper thoracic spine are inherently unstable E. These patients rarely present with neurogenic shock in association with cord injury. -ANSWER- A. Log-rolling may be destabilizing to fractures from T12 to L1 During resuscitation, which one of the following is the most reliable as a guide to volume replacement? A. Heart rate B. Hematocrit C. Blood pressure D. Urinary output E. Jugular venous pressure -ANSWER- D. Urinary out A 24-year-old woman passenger in an automobile strikes the wind screen with her face during a head-on collision. In the ED, she is talking and has marked facial edema and crepitus. The highest priority should be given to: A. Lateral c-spine x-ray B. Upper airway protection C. Carotid pulse assessment D. Management of blod loss E. Determination of associated injuries -ANSWER- B. Upper airway protection The driver of a single car crash is orotracheally intubated in the field by prehospital personnel after they identify a closed head injury and determine that the patient is unable to protect his airway. In the ED, the patient demonstrate decorticate posturing bilaterally. He is being ventilated with a bag-valve device, but his breath sounds are absent in the left hemithorax. His blood pressure is 160/80mmHg, heart rate is 70 beats per minute, and the pulse oximeter displays a hemoglobin oxygen saturation of 96%. The next step in assessing and managing this patient should be to: A. Determine the arterial blood gases B. Obtain a lateral cervical spine x-ray C. Assess placement of the endotracheal tube D. Perform needle decompression of the left chest E. Insert a thoracostomy in the left hemithorax. -ANSWER- C. Assess placement of the endotracheal tube The response to catecholamines in an injured, hypovolemic pregnant woman can be expected to result in: A. Placental abruption B. Fetal hypoxia and distress C. Fetal/maternal dysrhytmia D. Improved uterine blood flow E. Increased maternal renal blood flow -ANSWER- B. Fetal hypoxia and distress A 22-year-old man sustains a gunshot wound to the left chest and is transported to a small community hospital at which surgical capabilites are not available. In the ED, a chest tube is inserted and 700ml of blood is evacuted. The trauma center accepts the patient in transfer. Just before the patient is placed in an ambulance for transfer, his blood pressure decreases to 80/68mmHg and his heart rate increases to 136 beats per minute. The next step should be to: A. Clamp the chest tube B. Cancel the patients transfer C. Perform an ED thoracotomy D. Repeat the primary survey and proceed with transfer E. Delay the transfer until the referring doctor can contact a thoracic surgeon. - ANSWER- D. Repeat the primary survey and proceed with transfer A young woman sustains a severe head injury as the result of a motor vehicular crash. In the ED, her GCS is 6. Her blood pressure is 140/90 mmHg and her heart rate 80 beats per minute. She is intubated and is being mechanically ventilated. Her pupils are 3mm in size and equally reactive to light. There is no other apparent injury. The most important principle to follow in early management of her head injury is to: A. Avoid hypotension C. Carbon deposits in the mouth or nose and carbonaceous sputum D. Hoarseness E. Face or neck burns -ANSWER- B. Carboxyhemoglobin level >4% (grensen er 10%) A 32-year-old man right leg is trapped beneath his overturned car for nearly 2 hours before he is extricated. On arrival in the ED, his right lower extremity is cool, mottled, insensate, and motionless. Despite normal vital signs, pulses cannot be palpated inferior to the femoral artery, and the muscles of the lower extremity are firm and hard. During initial management of this patient, which of the following is most likely to improve chances for limb salvage? A. Apply skeletal traction B. Administering anticoagulant drugs C. Adminstering thrombolytic therapy D. Perform right lower extremity fasciotomy E. Immediately transferring the patient to a trauma center. -ANSWER- D. Perform right lower extremity fasciotomy A patient arrives in the ED after being beaten about the head and face with a wooden club. He is comatose and has a palpable depressed skull fracture. His face is swollen and ecchymotic. He has gurgling respirations and vomitus on his face and clothing. The most appropriate step after providing supplemental oxygen and elevating his jaw is to: A. Request a CT-scan B. Insert a gastric tube C. Suction of the oropharynx D. Obtain a lateral cervical spine x-ray E. Ventilate the patient with a bag-mask -ANSWER- C. Suction of the oropharynx A 64-year-old man, involved in a high-speed car crash, is resuscitated initially in a small hospital with limited resources. He has a closed head injury with a GCS score of 13. He has a widened mediastinum on chest x-ray with fractures of left ribs 2 through 4 but no pneumothorax. After infusing 2 liters of crystalloid solution, his blood pressure is 100/74, heart rate is 110 beats per minute, and respiratory rate is 18 breaths per minute. He has gross hematuria and a pelvic fracture. You decide to transfer this patient to a facility capable of providing a higher level of care. The facility is 128km (80 miles) away. Before transfer, you should first: A. Intubate the patient B. Perform diagnostic peritoneal lavage C. Apply the pneumatic antishock garment D. Call the receiving hospital and speak to the surgeon on call E. Discuss the advisability of transfer with the patients family. -ANSWER- D. Call the receiving hospital and speak to the surgeon on call During the third trimester of pregnancy, all of the following changes occur normally, EXCEPT a: A. Decrease in PaCO2 B. Decrease in the leukocyte count C. Reduce gastric emptying rate D. Diminished residual lung volume E. Diminished pelvic ligament tension -ANSWER- B. Decrease in the leukocyte count In managing the head-injury patient, the most important initial step is to: A. Secure the airway B. Obtain c-spine film C. Support the circulation D. Control scalp hemorrhage E. Determine GCS score -ANSWER- A. Secure the airway The first maneuver to improve oxygenation after chest injury is: A. Intubate the patient B. Assess arterial blood gases C. Administer supplemental oxygen D. Ascertain the need for a chest tube E. Obtain a chest x-ray -ANSWER- C. Administer supplemental oxygen A 25-year-old man, injured in a motor vehicular crash, is admitted to the ED. His pupils react sluggishly and his eyes open to painful stimuli only. He does not follow commands, but he does moan periodically. His right arm is deformed and does not respond to painful stimulus; however, his left hand reaches purposefully toward the painful stimulus. Both legs are stiffly extended. His GCS score is: A. 7 B. 8 C. 9 D. 10 E. 11 -ANSWER- 9 A 20-year-old woman, at 32 weeks gestation, is stabbed in the upper right chest. In the ED, her blood pressure is 80/60mmHg. She is gasping for breath, extremely anxious, and yelling for help. Breath sounds are diminished in the right chest. The most appropriate first step is to: A. perform tracheal intubation B. Insert an oropharyngeal airway C. Perform needle decompression of the right chest D. Manually displace the gravid uterus to the left side of the abdomen E. Initiate 2 large-caliber peripheral IV lines and crystalloid infusion -ANSWER- C. Perform needle decompression of the right chest Which one of the following findings in an adult should prompt immediate management during primary survey? A. Distended abdomen B. GCS of 11 C. Temperature of 36,5 D. Heart rate of 120 beats per minute E. Respiratory rate of 40 breaths per minute -ANSWER- E. Respiratory rate of 40 breaths per minute A trauma patient present to your emergency department with inspiratory stridor and a suspected C-spine injury. Oxygen saturation is 88% on high-flow oxygen via a nonrebreathing mask. The most appropriate next step is to: A. Apply cervical traction B. Perform immediate tracheostomy C. Insert bilateral thoracostomy tubes D. Maintain 100% oxygen and obtain immediate c-spine x-rays E. Maintain inline immobilization and establish a definitive airway -ANSWER- E. Maintain inline immobilization and establish a definitive airway When apply the Rule of Nines to infants, A. It is not reliable B. The body is proportionally larger in infants than in adults C. The head is proportionally larger in infants than in adults D. The legs are proportionally larger in infants than in adults E. The arms are proportionally larger in infants than in adults -ANSWER- C. The head is proportionally larger in infants than in adults A 60-year-old man sustains a stab wound to the right posterior flank. Witnesses state the weapon was a small knife. His heart rate is 90 beats per minute, blood C. Hypotension D. Tachycardia E. Blood transfusion requirement -ANSWER- D. Tachycardia Which of the follow statements concerning intraosseous infusion is TRUE? A. Only crystalloid solutions may be safely infused through the needle B. Aspiration of bone marrow confirms appropriate positioning of the needle C. Intraosseous infusion is the preferred route for volume resuscitation in small children D. Intraosseous infusion may be utilized indefinitely E. Swelling in the soft tissues around the intraosseous site is not a reason to discontinue infusion. -ANSWER- B. Aspiration of bone marrow confirms appropriate positioning of the needle The most important, immediate step in the management of an open pneumothorax is: A. endotracheal intubation B. Operation to close the wound C. Placing a chest tube through the chest wound D. Placement of an occlusive dressing over the wound E. Initiation of 2 large-caliber IVs with crystalloid solution -ANSWER- D. Placement of an occlusive dressing over the wound Which one of the following situations requires Rh immunoglobulin administration to an injured woman? A. Negative pregnancy test, Rh negative, and torso trauma B. Positive pregnancy test, Rh positive, and has torso trauma C. Positive pregnancy test, Rh negative, and has torso trauma D. Positive pregnancy test, Rh positive, and has an isolated wrist fracture E. Positive pregnancy test, Rh negative, and has an isolated wrist fracture - ANSWER- C. Positive pregnancy test, Rh negative, and has torso trauma A 22-year-old man is hypotensive and tachycardic after a shotgun wound to the left shoulder. His BP is initially 80/40mmHg. After 2 liters of crystalloid solution his blood pressure increases to 122/84mmHg. His heart rate is now 100 beats per minute and his respiratory rate is 28 breaths per minute. His breath sounds are decreased in the left hemithorax, and after initial IV fluid resusciation, a closed tube thoracostomy is performed for decreased left breath sound with the return of small amount of blood and no air leak. After chest tube insertion, the most appropriate next step is to: A. Reexamine the chest B. Perform an aortogram C. Obtain a CT-scan of the chest D. Obtain arterial blood gas analyses E. Perform transesophageal echocardiography -ANSWER- A. Reexamine the chest A construction worker falls two stories from a building and sustain bilateral calcaneal fractures. In the ED, he is alert, vital signs are normal, and he is complaining of severe pain in both heels and his lower back. Lower extremity pulses are strong and there is no deformity. The suspected diagnosis is most likely to be confirmed by: A. Angiography B. Compartment pressures C. Retrograde urethrogram D. Doppler-ultrasound studies E. Complete spine x-ray series -ANSWER- E. Complete spine x-ray series A 22-year-old female athlete is stabbed in her left chest at the third interspace in the anterior axillary line. On admission to the ED and 15 minutes after the incident, she is awake and alert. Her heart rate is 100 beats per minute, BP 80/60mmHg, and respiratory rate is 20 breaths per minute. A chest x-ray reveals a large left hemithorax. A left chest tube is placed with an immediate return of 1600ml of blood. The next management step for this patient is: A. perform a thoracoscopy B. Perform an arch aortogram C. Insert a second left chest tube D. Prepare for an exploratory thoracotomy E. Perform a chest CT -ANSWER- D. Prepare for an exploratory thoracotomy A 56-year-old man is thrown violently against the steering wheel of his truck during a motor vehicle crash. On arrival in the ED he is diaphoretic and complaining of chest pain. His BP is 60/40mmHg and his respiratory rate is 40 breaths per minute. Which of the following best differentiates cardiac tamponade from tension pneumothorax as the cause of his hypotension? A. Tachycardia B. Pulse volume C. Breath sounds D. Pulse pressure E. Jugular venous pressure -ANSWER- C. Breath sounds All of the following are true of the Mallampati classification EXCEPT: A. Class IV is the easiest intubation, while Class 1 is the most difficult B. It helps assess for difficult intubations C. It is part of the LEMON assessment D. It comprises a visual assessment of the distance from the tongue base to the roof of the mouth, and therefore the amount of space there is to work E. A poor Mallampati score is associated with a higher incidens of obstructive sleep apnea. -ANSWER- A. Class IV is the easiest intubation, while Class 1 is the most difficult A 23-year-old man sustains three stab wounds to the upper right chest during an altercation and is brought by ambulance to a hospital that has full surgical capabilities. His wounds are all above the nipple. He is endotracheally intubates, closed tube thoracostomy is performed, and 2 liters of crystalloid solution are infused through 2 large-caliber IVs. His BP i 60/0mmHg, heart rate is 160 beats per minute, and respiratory rate is 14 breaths per minute (ventilated with 100% O2). 1500ml of blood has drained from the right chest. The most appropriate next step in managing this patient is to: A. Perform FAST B. Obtain a CT of the chest C. Perform angiography D. Urgently transfer the patient to the operating room E. Immediately transfer the patient to a trauma center. -ANSWER- D. Urgently transfer the patient to the operating room Which of the following signs is LEAST reliable for diagnosing esophageal intubation? A. Symmetrical chest movement B. End-tidal CO2 presence by colorimetry C. Bilateral breath sounds D. Oxygen saturation > 92% E. ETT above carina on chest x-ray -ANSWER- E. ETT above carina on chest x- ray Which one of the following signs necessitates a definitive airway in severe trauma patients? A. Facial lacerations B. Repeated vomiting C. Severe maxillofacial fractures D. Sternal fracture A 28 year old male is brought to the ED. He was involved in a fight in which he was beaten with a wooden stick. His chest shows multiple severe bruises. His airway is clear, RR is 22, HR is 126 and systolic BP is 90mmHg. Which one of the following should be performed during the primary survey? A. GCS B. Cervical spine x-ray C. TT-administration D. Blood alcohol level E. Rectal exam -ANSWER- A. GCS Which one of the following statements is true regarding access in pediatric resuscitation? A. Intraosseous access should only be considered after five percutaneous attempts B. Cut down at the ankle is a preferred initial access technique C. Blood transfusion can be delievered through an intraosseous access D. Internal jugular cannulation is the next preferred opinion when percutaneous venous access fails E. Intraosseous cannulation should be first choice for access -ANSWER- C. Blood transfusion can be delievered through an intraosseous access Regarding shock in the child, which of the following is FALSE? A. Vital signs are age-related B. Children have greater physiologic reserves than do adults C. Tachycardia is the primary physiologic response to hypervolemia D. The absolute volume of blood loss required to produce shock is the same as in adults E. An initial fluid bolus for resuscitation should approximate 20ml/kg of Ringers lactate -ANSWER- D. The absolute volume of blood loss required to produce shock is the same as in adults A young man sustain a gunshot wound to the abdomen and is brought promptly to the ED by prehospital personnel. His skin is cool and diaphoretic, and he is confused. His pulse is thready and his femoral pulse is only weakly palpable. The definitive treatment in managing this patient is to A. Administer 0.neg blood B. Apply external warming devices C. Control internal hemorraghe operatively D. Apply pneumatic anti shock garment E. Infuse large volumes of IV crystalloid solution -ANSWER- C. Control internal hemorraghe operatively A four-year-old girl, weighing approximately 20kg is admitted in shock after an automobile crash. The initialt fluid challenge or bolus should consist of Ringers lactate solution in the volume of A. 200ml B. 400ml C. 440ml D. 600ml E. 880ml -ANSWER- B. 400ml (20ml/kg) All of the following are considered minimal precautions for the prevention of the spread of communicable diseases during resuscitation, EXCEPT: A. goggles B. Face mask C. Water-impervious gown D. Water-impervious leggings E. Needle-impenetrable sterile gloves -ANSWER- E. Needle-impenetrable sterile gloves 30-year-old woman fell down four stair landing on concrete. Unconscious for 5 minutes after the fall, full consciousness during 10 minute transport to hospital, GCS 15, complaint is a slight headache, 30 minute later she is unresponsive with GCS 6 and left pupil is large. -ANSWER- Epidural hematoma A young male fallen from height with obvious flail chest. ABG shows pH 7,47. What is the cause of this abnormality? -ANSWER- Pulmonary contusion Cushings triad which occurs in cases of increased intracranial pressure? - ANSWER- Bradycardia with irregular respirations and isolated increase in SYSTOLIC BLOOD PRESSURE In comparison with young adults, elderly patients exhibit which of the following regarding brain injuries? A. Increased cerebral blood flow B. Less stretching of the bridging veins C. Less subdural hematomas D. Less brain contusions E. Less mobility with angular acceleration and deceleration -ANSWER- D. Less brain contusions Which of the following will be missed by DPL? -ANSWER- Subcapsular hematoma of the spleen (becauase it is a retroperitoneal organ) Burn victim, core temperature is 34C. Whats next? A. Escharotomy B. Rewarm C. Oxygen mask D... E.. -ANSWER- C. Oxygen mask Which of the following is NORMAL in pregnancy? A. increased residual lung volume B. Decreased plasma volume C. Decreased total RBC mass D. Widened symphysis pubis E. -ANSWER- D. Widened symphysis pubis A 34-year-old man is brought to the ED after being pinned to the wall of building by a cement truck. He is in obvious shock, and has deformities and marked swelling of both thighs. Although no open wound are present, his shock: A. Cannot be explained without concomitant pelvic fracture B. Signifies a loss of approximately 15% C. Is consistent with blood loss from bilateral femoral fracture D. Will likely be reversed if appropriate traction splint are applied E. Cannot be explained by his observed injuries unless a major arterial injury exist -ANSWER- C. Is consistent with blood loss from bilateral femoral fracture Prior to passage of urinary catheter in a man, it is essential to: A. Examine the abdomen B. Determine pelvic stability C. Examine the rectum and perineum D. Perform a retrograde urethrogram E. Know the history and mechanism of injury -ANSWER- C. Examine the rectum and perineum The best guide for adequate fluid resuscitation of the burn patient is: A. Adequate urinary output B. Reversal of systemic acidosis C. Normalization of the heart rate D. A normal central venous pressure A. scrotal hematoma B. Blood in rectal lumen C. Blod in external urethral meatus D. High riding prostate on rectal exam E. Absence of a palpable prostate on rectal exam -ANSWER- E. Absence of a palpable prostate on rectal exam Which one of the following is recommended method for threating frostbite? A. Moist heat B. Early amputation C. Padding and elevation D. Vasodilators and heparin E. Topical application of silversulphadiazine -ANSWER- A. Moist heat A 32-year-old mans right leg is trapped beneath his overturned car for nearly two hours before he is extricated. On arrival in the ED, both lower extremities are cool, mottled, insensate and motionless. Despite normal vital signs, pulses cannot be palpated below the femoral vessels and the muscles of the lower extremities are firm and hard. During the initial management of this patient, which of the followin is most likely to improve chances for limb salvage? A. Apply skeletal traction B. Administering anticoagulant drugs C. Administering trombolytic thearpy D. Performing lower extremity fasciotomies E. Immediately transfer the patient to a trauma care -ANSWER- D. Performing lower extremity fasciotomies A 26 y/o seat belted driver is brought to the ED after a car crash. Primary survey reveals no evidence of serious injury except for diffuse, mild abdominal tenderness. Bowel sounds are hypoactive and liver dullness is questionable. Abdominal films reveal free air. The patient should A. Undergo peritoneal lavage B. Undergo promp celiotomy C. Have a contrast x-ray of her GI-tract D. Be carefully observed for further evidence of intraabdominal injury E. Be suspected of having a ruptured diaphragm and accompanying pneumothorax. -ANSWER- B. Undergo promp celiotomy The least likely cause of a depressed level of consiousness in the multisystem injured patient is: A. shock B. Head injury C. Hyperglycemia D. Impaired oxygenation E. Alcohol and other drugs -ANSWER- C. Hyperglycemia Which one of the following statements concerning massive hemothorax is true? A. It is usually caused by blunt thoracic trauma B. It is commonly confused with pneumothorax C. The diagnosis should be confirmed by upright, plain chest x-ray prior to treatment D. The initial draining of 1000ml of blood after chest tube insertion requires immediate thoracotomy E. The condition should be suspected in situations with shock and unilateral absent breath sounds -ANSWER- E. The condition should be suspected in situations with shock and unilateral absent breath sounds During primary and secondary survey, the patient injured by blunt trauma should be completely immobilized until A. The neurologic exam has been completed B. The patient is transferred to definitive care C. The patient is able to indicate that he has no neck pain D. A spinal fracture has been excluded by x-ray E. The patient complains of potential pressure sores due to the spine board. - ANSWER- D. A spinal fracture has been excluded by x-ray Cervical spine injury A. Is excluded by a normal neurologic exam B. Is not present if the patient has normal range of motion C. Can be detected safely by careful flexion and extension of the neck D. Can be excluded by a crosstable lateral x-ray of the c-spine E. May be first manifested by neurologic deficit after movement of the neck - ANSWER- E. May be first manifested by neurologic deficit after movement of the neck An 18 y/o man is brought to the ED after smashing his motorcycle into a tree. He is conscious and alert, but paralyzed in both legs and arms. His skin is pale and cold. He complains of thirst and difficulty in breathing. His airway is clear. His BP is 60/40 and his pulse is 140 bpm. Breath sounds are full and equal bilaterally. He should A. Undergo exploratory celiotomy B. Be treated for neurogenic shock C. Be treated for hypovolemic shock D. Undergo immediate nasotracheal intubation E. be placed in cervical traction tongs before any other treatment is instituted - ANSWER- C. Be treated for hypovolemic shock The principle of balanced resuscitation is: A) Permissive hypotension and early plasma infusion B) Equal amounts of crystalloid and colloids C) Simultaneous management of breathing and circulation D) Maintenance of a normal acid base balance E) Achieving a pulse rate <90 -ANSWER- A) Permissive hypotension and early plasma infusion Healthy young male in a motor vehicle crash is brought to the emergency department with a blood pressure of 84/60, pulse 123, GCS 10. The patient moans when his pelvis is palpated. After initiating fluid resuscitation, the next step in management is: A) Placement of a pelvic binder B) Transfer to a trauma center C) Pelvic x-ray D) Insert urinary catheter E) Repeat examination of pelvis -ANSWER- A) Placement of a pelvic binder 22 year old male fall from 2m, large right pneumothorax. Chest tube placed, connected to drainage. Control x-ray shows pneumothorax, third x-ray reveals pneumothorax -ANSWER- Tracheobronchal injury Which one of the following is not a feature of neurogenic shock? A. Increased venous capaitance B. Decreased systemic vascular resistance C. Increased cardiac output D. Warm skin -ANSWER- C. Increased cardiac output Tension pneumothorax can be caused by: A. Flail chest B. Cardiac tamponade C. Clamping of a chest tube D. All of the above -ANSWER- C. Patient presenting with gross hematuria and shock will have a major renal injury as the source of hemorrhage D. Intraperitoneal bladder injuries are usually managed definitively with a urinary catether E. Urinary catheters should be placed in all patients with pelvic fractures during the primary survey -ANSWER- A. Urethral injuries are associated with pelvic fractures B er feil - det er pasienter med makroskopisk hematuri og/eller pas. med mikroskopisk hematuri og sjokk som det er aktuelt å gjøre CT av. C kan være riktig, men kan ikke si det sikkert at det er nyrene som er blødningskilden. D er feil - ekstraperitoneal blæreskade behandles med kateter, og E er feil da man først må undersøke for uretraskade Cardiac tamponade: A. Requires surgical intervention B. Is defintively managed by needle pericardiocentesis C. Is easily diagnosed by discovery of Becks triad in the ED D. Is indicated by Kussmaul breathing E. Is most common with blunt thoracic trauma and anterior rib fractures - ANSWER- A. Requires surgical intervention A 6 month old infant, being held in her mothers arms, is ejected on impact from a vehicle that is struck head on by an oncoming car traveling at 65kph. The infant arrives in the ED with multiple facial injuries, is lethargic, and is in severe respiratoy distress. Respiratory support is not effective using a bag mask device, and her oxygen saturation is falling. Repeated attempts at orotracheal intubation are unsuccessful. the most appropriate procedure to perform next is: A. perform needle cricothyroidotomy with jet insufflation B. Administer heliox and racemic epinephrine C. Perform nasotracheal intubation D. Perform surgical cricothyroidotomy E. Repeat orotracheal intubation -ANSWER- A. perform needle cricothyroidotomy with jet insufflation Which one of the following injuries is adressed in the secondary survey? A. Bilateral femur fractures with obvious deformity B. Open fracture with bleeding C. Mid thigh amputation D. Unstable pelvic fracture E. Forearm fracture -ANSWER- E. Forearm fracture A 22 year old male present following a motorcycle crash. He complains of the inability to move his legs. His BP is 80/50, HR 70, RR 18 and GCS 15. Oxygen saturation is 99% on 21 nasal prongs. Chest x-ray, pelvic x-ray and FAST are normal. Extremities are normal. His management should be: A: 2L of iv . crystalloid and two units of pRBCs B. 2L of iv crystalloid and vasopressors if BP does not respond C. 2L of iv. crystalloid, mannitol and iv steroids D. Vasopressors and laparotomy E. 1 unit of albumin and compression stockings -ANSWER- B. 2L of iv crystalloid and vasopressors if BP does not respond A 35 year old female sustains multiple injuries in a motor vehicle crash and is transported to a small hospital in full spinal protection. She has a GCS of 4 and is being mechanically ventilaed. I.v access is established and warmed crystalloid is infused. She remains hemodynamically normal and full spinal protection is maintained. Preparations are made to transfer her to another facility for definitive neurosurgical care. Prior to transport, which of the following tents or treatments is mandatory? A. FAST exam B. Lateral cervical spine xray C. Chest x-ray D. Administration of methylprednisolon E. CT of abdomen -ANSWER- C. Chest x-ray A 22 year old male is assaulted in a bar. A semi-rigid cervical collar is applied and he is immobilized on a spine board. On initial examination, his vital signs are normal, and his GCS is 15. Which of the following is an indication for CT in this patient with possible minor traumatic brain injury? A. Blood alcohol concentration of 0,16% B. Presence of an isolated 10cm scalp laceration C. Presence of a mandibular fracture D. Presence of hemotympanum E. History of assault -ANSWER- D. Presence of hemotympanum Which one of the following statement is true? A. Hypotonic fluids should be used to limit brain edema in patients with severe head injury B. Elevated intracranial pressure will not affect cerebral perfusion C. CSF cannot be displaced from cranial vault D. Cerebral blood flow is increased when PaCO2 is below 30mmHg --> below 50mmHg E. Autoregulation of cerebral blood flow normally occurs between cerebral perfusion pressure of 50 to 150mmHg -ANSWER- D. Cerebral blood flow is increased when PaCO2 is below 30mmHg --> below 50mmHg A 40 year old obese patient with GCS of 8 requries a CT scan. Before transfer to the scanner, you should: A. give more sedative drugs B. Insert a defintive airway C. Insert a multilumen esophageal airway D. Request a lateral cervical spine film E. insert a nasogastric tube -ANSWER- B. Insert a defintive airway A 30 year old male is brought toe the hospital after falling 6 meters. Inspection reveals an obvious flail chest on the right. The patient is tachypneic. Breath sounds are present and symmetrical. There is no significant hyperresonance or dullness. Arterial blood gas obtained while the patient recieves oxygen by face mask are: PaO2 of 45mmHg (6Kpa), PaCO2 of 28mmHg (3,7 Kpa) and pH of 7,47. The component of injury that most likely responsible for abnormalities in this patients blood gas is: A. Hypoventilation B. Pulmonary contusion C. Hypovolemia D. Small pneumothorax E. Flail chest -ANSWER- B. Pulmonary contusion A 14 year old female is brought to the ED after falling from a horse. She is immobilized on a long spine board with a hard collar and blocks. Cervical spine x- ray: A. Will show cervical spine injury in more than 20% of these patients B. Will exclude cervical spine injury if no abnormalities are found on the x-rays C. Are not needed if she is awake, alert, neurologically normal, and has no neck pain or midline tenderness D. Should be performed before adressing potential breating or circulatory problems E. May show atlanto-occipital dislocation if the Powers ratio is <1 --> 1:noraml, >1 anterior, <1 posterior -ANSWER- C. Are not needed if she is awake, alert, neurologically normal, and has no neck pain or midline tenderness The most specific test to evaluate for injuries of solid abdominal organ is: A 15 year old male is brought to the ED after being involved in a motor vehicle crash. He is unconscious and was intubated at the scene by emergency personnel. Upon arrival at the ED, the patients oxygen saturation is 92%, HR is 96 bpm and BP is 150/85 Breath sounds are decreased on the left side of the thorax. The next step is: A. Immediate needle crycothyroidotomy B. Reassess the position of the endotracheal tube C. Chest tube insertion D. Immediate needle thoracentesis E. Obtain a chest x-ray -ANSWER- B. Reassess the position of the endotracheal tube The first priory in management of a long bone fracture is: A. Reduction of pain B. Prevention of infection in case of an open fracture C. Prevention of further soft tissue injury D. Improve long term function E. Control of hemorrhage -ANSWER- E. Control of hemorrhage A 30 year old female is brought to the ED after being injured in a motor vehicle crash. Her initialt BP is 90/60mmHg, and her HR is 122bpm. She responds to rapid infusion of 1L crystalloid solution with a rise in her BP to 118/88 and decrease in her HR to 90bpm. Her pressure suddenly decreased to 96/66. The least likely cause of her hemodynamic change is: A. Ongoing blood loss B. Blunt cardiac injury C. Traumatic brain injury D. Inadequate resuscitation. E. Tension pneumothorax -ANSWER- C. Traumatic brain injury Limb-threatening extremity injuries: A. Require a torniquet B. Should be defintively managed by application of a traction split. C. Are rarely present without an open wound D. Are characterized by the presence of ischemic or crushed tissue. E. Indicate a different order or priorities for the patients initial assessment and resuscitation. -ANSWER- B. Should be defintively managed by application of a traction split. A 29 year old female arrives in the ED after being involved in a motor vehicle crash. She is 30 weeks pregnant. She was restrained with a lap and shoulder belt, and an airbag deployed. Which one of the following statement best decribes the risk of injury? A. Deployment of the airbag increased the risk of fetal loss B. The risk of premature fetal delivery and death is reduced by the use of restraints C. The use of seatbelts is associated with increased risk of maternal death. D. The mechanism of injury suggest the need for emergency ceasarean section due to the risk of impending abruptio placentae E. The deployment of the airbag increases the risk of maternal abdominal injury - ANSWER- B. The risk of premature fetal delivery and death is reduced by the use of restraints Supraglottic airway devices: A. Are equivalent to endotracheal intubation B. Require neck extension for proper placement C. Are preferable to endotracheal intubation in a patient who cannot lie flat D. Are of value as part of a difficult or failed intubation plan E. Provide one form of definitive airway -ANSWER- D. Are of value as part of a difficult or failed intubation plan A 25 year old male is brought to the hospital after sustaining partial and full thickness burns involving 60% of his body surface area. His right arm and hand are severely burned. There are obvious full thickness burns of the entire right hand and a circumferential burn of the right arm. Pulses are absent at the right right wrist and are not detected by doppler examination. The first step in management of the right upper extremity should be: A. Fasciotomy B. Angiography C. Escharatomy D. Heparinization E. Tangential excision -ANSWER- C. Escharatomy Hypertension following a headinjury: A. Should be treated to reduce intracranial pressure B: Indicates pre-existing hypertension C. May indicate imminent herniation from critically high intracranial pressure D. Mandates prompt administration of mannitol E. Should prompt burr hole drainage of potentialt subdural hematomas. - ANSWER- C. May indicate imminent herniation from critically high intracranial pressure Initial treatment of frostbite injuries involves: A. application of dry heat B. Debridement of hemorrhagic blisters C. Early amputation to prevent septic complications D Rapid rewarming of the body part in circulation warm water E. Massage of the affected area -ANSWER- D Rapid rewarming of the body part in circulation warm water Signs and symptoms of airway compromise include all of the following, EXCEPT: A. change in voice B. Stridor C. Tachypnea D. Dyspnea and agitation E. Decreased pulse pressure -ANSWER- E. Decreased pulse pressure Which one of the following statements is true regarding a pregnant patient who presents following blunt trauma? A. Early gastric decompression is important B A Hb level of 10g/dl indicates recent blood loss C. The CVP response to volume resuscitation is blunted in pregant patients D. A lap belt is the best form of restraint due to the size of the gravid uterus E. A PaCO2 of 40mmHg provides reassurance about the adequacy of respiratory function -ANSWER- A. Early gastric decompression is important Hb kan være lav av andre grunner, CVP-responen på væske er lik som hos ikke- gravide, lap+shoulder belt er beste form for restraint, og hypocapnia er vanlig i graviditeten slik at normalverdi kan indikere resp.svikt. A 70 year old suffers blunt chest traume after bein struck by a car. On presentation, his GCS is 15, BP is 145/90, HR is 72. RR is 24 and O2-sat on 5L is 91%. Chest x- ray demonstrates multiple right sided rib fractures. ECG demonstrates normal sinus rythm with no conduction abnormalities. Management should include: A. Placement of a 22Fr right sided chest tube B. Serial troponins and cardiac monitoring C. Monitoried i.v analgesia D. Thoracic splinting, taping and immobilization informasjon. Thoracostomy ikke indisert da det ikke er mistenkt pneumo/hemothorax. CT uaktuelt pga hemodynamisk ustabil A 47 year old house painter is brought to the hospital after falling 6 meters from a ladder and landing straddled on a fence. Examination of his perineum reveals extensive ecchymosis. There is blood in the external urethreal meatus. The initial diagnostic study for evaluation of the urinary tract in this patient should be: A. Cystoscopy B. Cystography C. IV pyelography D. CT scan E. Retrograde urethrography -ANSWER- E. Retrograde urethrography Neurogenic shock has all of the following classic characteristics except which one: A. Hypotension B. Vasodilatation C. Bradycardia D. Neurologic deficit E. Narrowed pulse pressure -ANSWER- E. Narrowed pulse pressure Which one of the following should be performed first in any patient whose injuries may include multiple closed extremity fractures? A. A thorough assessment of four limb perfusion B. Maneuvers to prevent necrosis of the skin C. Extremity compartment syndrome release D. Ensuring adequate oxygenation and ventilation E. Evaluation for occult crush syndrome -ANSWER- D. Ensuring adequate oxygenation and ventilation Patients with a GSC of less than usually require intubation. -ANSWER- 8 The "A" in ABCD stands for . -ANSWER- Airway maintenance with CERVICAL SPINE PROTECTION You should assume that any patient in a multisystem trauma with an altered level of consciousness or blunt injury above the clavicle has what type of injury? -ANSWER- Cervical spine injury Flail chest is invariably accompanied by which can interfere with blood oxygenation. -ANSWER- pulmonary contusion - do NOT over fluid resuscitate these patients! Hypotension is caused by until proven otherwise. -ANSWER- hypovolemia When you don't have/can't get a blood pressure, what are three things to look for when evaluating perfusion. -ANSWER- 1. Level of consciousness (brain perfusion), 2. Skin color (ashen face/grey extremities) 3. Pulse (bilateral femoral - thready/tachy) Elderly patients have a limited ability to to compensate for blood loss. - ANSWER- increase heart rate Resuscitation fluids should be warmed 39 degrees Celsius (102.2 F). Can you use a microwave to do this? -ANSWER- YES - for CRYSTALLOID ONLY (but NOT for blood products). Urinary catheters are good for assessing renal perfusion and volume status. List 5 signs of urethral injury that might prevent you from inserting one. -ANSWER- Blood at urethral meatus, perineal ecchymosis, blood in scrotum, high-riding/non-palpable prostate, pelvic fracture Which arm should you NOT put a pulse-ox on? -ANSWER- The arm with a blood pressure cuff on it Name two anatomical things that can interfere with doing a FAST scan. -ANSWER- Obesity & intraluminal bowel gas When should radiographs be obtained? -ANSWER- During the SECONDARY survey. How do you get an ample patient history? -ANSWER- A=Allergies, M=Medications, P=PMH/Pregnancy, L=Last meal, E=Events/Environment of injury Why might you want a Bair Hugger for a patient who smells of alcohol? -ANSWER- Vasodilation can lead to hypothermia What things are you looking for when you do a DRE in a trauma? -ANSWER- Blood, high-riding prostate (in males), and sphincter tone What should you do for every female patient? -ANSWER- Pregnancy test (females of childbearing age) Adult patients should maintain UOP of at least mL/kg/hr. Kids should have at least mL/kg/hr. -ANSWER- Adults 0.5 mL/kg/hr, Kids 1.0 ml/kg/hr Preventing hypercarbia is critical in patients who have sustained a injury. - ANSWER- head What two places would you LOOK at a patient if you suspect hypoxemia? -ANSWER- Lips and fingernail beds Patients may be abusive and belligerent because of , so don't just assume it's due to drugs, alcohol, or the fact that they are just inherently a jerk. -ANSWER- hypoxia Can a patient breathe on their own after complete cervical cord transection? -ANSWER- Yes, if the phrenic nerves (C3-C5) are spared. This will result in "abdominal" breathing. The intercostal muscles will be paralyzed though. Can you use an OPA (Guedel) in a conscious patient? -ANSWER- No, it could make them vomit. An NPA (trumpet) would be okay. Bougies are typically inserted blindly, how do you know you are in the trachea and not the esophagus? -ANSWER- You can feel the "clicks" as the distal tip rubs against the cartilaginous tracheal rings, or it will deviate right or left when entering either bronchus (usually at 50 cm). What do you NOT want to hear if you ascultate a patient after placement of an ET tube? -ANSWER- Borborygmi - rumbling or gurgling noises suggesting esophageal insertion. What is the RSI dose for etomidate? -ANSWER- 0.3 mg/kg (usually 20 mg) What is the RSI dose for sux? -ANSWER- 1-2 mg/kg (usually 100 mg) How does etomidate affect blood pressure? -ANSWER- It doesn't - at least it SHOULDN'T have any significant effect on BP. Ketamine will increase BP, and propofol and thiopental will both drop BP. A RSI dose of sux usually lasts about minutes. -ANSWER- 5 What hypnotic/sedative/induction agent do you NOT want to use for a severely burned patient? -ANSWER- SUX - patients with severe burns, crush injuries, hyperkalemia, or chronic paralytic/neuromuscular diseases should NOT get sux because of hyperkalemia risk. Oxygen should flow at 15L for needle cricothyroidotomy, and have a Y-connector for insufflation if possible. What size needle do you use for adults? Kids? -ANSWER- Adults 12-14 gauge, kids 16-18 gauge Cricoid cartilage is the only circumferential support for the upper trachea in kids, therefore surgical cricothyroidotomy is not recommended in kids under the age of . - ANSWER- 12 In a "normal" patient without significant chest wall injury or lung disease, needle cricothyroidotomy can provide adequate oxygenation for approximately minutes. - ANSWER- 30-45 How much blood volume is lost with Class II Hemorrhage? -ANSWER- 15-30% (750- 1500 mL in a 70 kg adult) How do you treat a Class II Hemorrhage? -ANSWER- Usually just crystalloid resuscitation Subtle CNS changes such as anxiety, fright, and hostility would be expected in a patient with a Class Hemorrhage. -ANSWER- II How much blood volume is lost with Class III Hemorrhage? -ANSWER- 30-40% (2000 mL in a 70 kg adult) A patient with inadequate perfusion, marked tachycardia and tachypnea, significant mental status change, and a measurable fall in systolic blood pressure likely has a Class Hemorrhage. -ANSWER- III or IV - These patients almost always require a blood transfusion, which depends on their response to initial fluid resuscitation. The first priority is stopping the hemorrhage. Loss of more than _ % of blood volume results in loss of consciousness. -ANSWER- 50 How much blood volume is lost with Class IV Hemorrhage? -ANSWER- More than 40%. Unless very aggressive measures are taken the patient will die within minutes. A Class Hemorrhage represents the smallest volume of blood loss that is consistently associated wiht a drop in systolic blood pressure. -ANSWER- III Up to mL of blood loss is commonly associated with femur fractures. - ANSWER- 1500 Unexplained hypotension or cardiac dysrhythmias (usually bradycardia from excessive vagal stimulation) are often caused by , especially in children. -ANSWER- gastric distention How much crystalloid should you give an adult for an initial fluid resuscitation bolus? For kids? -ANSWER- Adults: 2 liters, Kids: 20 mL/kg (may repeat and give as much as 60 mL/kg but with high reserve in kids, if they're in shock they should get blood sooner rather than later. Each mL of blood loss whould be replaced with mL of crystalloid, thus allowing for replacement of plasma volume lost into interstitial and intracellular spaces. -ANSWER- 3 Blood on the floor x four more is a mnemonic for occult blood loss where? -ANSWER- Chest, pelvis, retroperitoneum, and thigh For children UNDER 1 year of age, UOP should be mL/kg/hr. -ANSWER- 2 Would patients in EARLY hypovolemic shock be acidodic or alkalotic? -ANSWER- Alkalotic - respiratory alkalosis from tachypnea ... followed later by mild metabolic acidosis in the early phase of shock. "Rapid responders" whose vital signs return to normal (and stay there) after fluid resuscitation likely have/had a Class Hemorrhage. -ANSWER- I or II "Transient responders" are associated with Class Hemorrhage. -ANSWER- II or III What differential diagnoses should you always consider for "non-responders" following fluid resuscitation? -ANSWER- NON-HEMORRHAGIC causes, e.g. tension pneumothorax, tamponade, blunt cardiac injury, MI, acute gastric distention, neurogenic shock... Most patients receiving blood transfusions need calcium replacement. -ANSWER- don't How should you position the patient before placing a subclavian or IJ line? -ANSWER- SUPINE, head down 15 degrees to distend neck veins and prevent embolism, only turn head away if C-SPINE HAS BEEN CLEARED FIRST. How long can you keep an IO line in? -ANSWER- Intraosseous infusion should be limited to emergency resuscitation and shoudl be discontinued as soon as other venous access is obtained. Where do you want to make an incision for a saphenous vein cutdown and how long should your incision be? -ANSWER- The saphenous vein can be accessed approximately 1 cm anterior and 1 cm superior to the medial malleolus. Make a 2.5 cm transverse incision through the skin and SQ tissue, careful not to injure the vessel. A patient arrives to the trauma bay intubated and there are absent breath sounds over the left hemithorax, where should you place your decompression needle? -ANSWER- This may NOT be a pneumothorax, for intubated patients always suspect a right main- stem before attempting needle decompression. Where would you insert a large caliber needle to decompress a tension pnuemothorax? -ANSWER- Into the 2nd intercostal space in the midclavicular line of the affected hemithorax. For an open pneumothorax, (sucking chest wound) air passes preferentially through the chest wall defect (least resistance) if the diameter of the defect is at least the diameter of the trachea. -ANSWER- 2/3 Flail chest results from multiple rib fractures - by definition this would be or more ribs, fractured in or more places. -ANSWER- 2 or more ribs fractured in 2 or more places Both tension pneumothorax and massive hemothorax are associated with decreased breath sounds on auscultation, so you can tell which it is by . -ANSWER- Percussion - hyperresonant with pnuemo, dull with hemothorax. If a patient doesn't have JVD, does this mean they don't have a tension pneumo or tamponade? -ANSWER- No, they might have a massive internal hemorrhage and be hypovolemic. By definition, how much blood is in the chest cavity to call it a "massive hemothorax"? - ANSWER- 1500 mL or 1/3 or more of the patient's total blood volume. (Some also define it as continued blood loss of 200 mL/hr for 2-4 hours- but ATLS does NOT use this rate for any mandatory treatment decisions). What size chest tube might you use to evacuate a massive hemothorax? -ANSWER- #38 French - inserted at the 4th or 5th intercostal space, just anterior to the midaxillary line. What is Kussmaul's sign? -ANSWER- A rise in venous pressure with inspiration while breathing spontaneously, and is a true paradoxical venous pressure abnormality associated with cardiac tamponade. How well do CPR compressions work on someone with a penetrating chest injury and hypovolemia? -ANSWER- "Closed heart massage for cardiac arrest or PEA is INEFFECTIVE in patients with hypovolemia." Patients with PENETRATING thoracic injuries who arrive pulseless, but with myocardial electrial activity, may be candidates for an ED thoacotomy. Are patients with PEA who have sustained blunt thoracic injuries candidates for an ED thoracotomy? -ANSWER- NO - Only PEA with PENETRATING thoracic injuries should get an ED thoracotomy. An ED thoracotomy can allow you to do what? -ANSWER- Evacuate pericardial blood, direcly control hemorrhage, cardiac massage, cross-clamp the descending aorta to slow blood loss below the diaphragm and increase perfusion to the heart and brain. For a patient with a traumatic simple pneumothorax, what should you do BEFORE you start positive pressure ventilation or take them to surgery for a GA? -ANSWER- CHEST TUBE - positive pressure ventilation can turn a simple pneumo into a tension pneumo, so put in a chest tube first. Anterior/posterior forces causes book pelvic fractures, and lateral forces cause book fractures. -ANSWER- AP = Open Book, LATERAL = Closed Book What are some indications for laparotomy in patients with penetrating abdominal wounds? -ANSWER- Unstable, GSW, peritoneal irritation, fascial penetration What percentage of stab wounds to the anterior abdomen do NOT penetrate the peritoneum? -ANSWER- 25-33% Does an early normal serum amylase level exclude major pancreatic trauma? - ANSWER- NO Do you need to operate on anyone with an isolated soild organ injury? -ANSWER- No - not if they remain hemodynamically stable (Of all patients who are initially thought to havea ISOLATED solid organ injury, <5% will have hollow viscus injury as well). Which is LESS likely to have a life-threating hemorrhage - an open book or closed book pelvic fracture? -ANSWER- Closed book - the pelvic volume is compressed, so not as much room for blood. Which are more common, open or closed book pelvic fracturs? -ANSWER- CLOSED BOOK - 60-70% (Open book 15-20%, vertical shear 5-15%) If a patient with a pelvic fracture is positive for intraperitoneal gross blood, a ex-lap is warranted. What is your next move if that same patient is NEGATIVE for gross intraperitoneal blood? -ANSWER- Angiography What do you need to do BEFORE you do a DPL? (Other than getting stuff together and surgically prepping, etc...) -ANSWER- DECOMPRESS BLADDER, DECOMPRESS STOMACH What is "adequate" fluid return when getting DPL fluid back? -ANSWER- 30% A blown pupil in a patient with a traumatic injury is caused by compression of which nerve? -ANSWER- Superficial parasympathetic fibers of the CN III (occulomotor). What is a "normal" ICP in the resting state? -ANSWER- 10mm Hg (Pressures >20, particularly if sustained, are associated with poor outcomes). The Monro-Kellie Doctrine describes compensatory mechanisms inside the calvarium to stabilize pressure - what are the 2 main/first ones? -ANSWER- Venous Blood & CSF (decreased in equal volumes, when this is exhausted, herniation can occur and brain perfusion will likely be inadequate). Patients with a GCS of 3-8 meet the accepted definition of "coma" or "severe brain injury." What are the GCS scores for "minor" and "moderate" brain injury? -ANSWER- Minor = 13-15, Moderate = 8-12 When calculating GCS and there is right/left assymetry in the motor response - which one do you use? -ANSWER- The "BEST" response. (Better predictor than worst response) What signs might you see if a patient has a basillar skull fracture? -ANSWER- PERIORBITAL ECCHYMOSIS (raccoon eyes), RETROAURICULAR ECCHYMOSIS (Battle sign), and otorrhea/rhinorrhea. What do you need to know about the GCS? -ANSWER- EVERYTHING - Know it COLD! What things might require a person with MINOR brain injury get admitted? -ANSWER- Abnormal CT (or no scan available), penetrating head injury, prolonged LOC, worsening LOC, moderate to severe HA, significant drug/alcohol intoxication, skull fx, oto/rhinorrhea, nobody at home to watch, GCS stays <15, focal neuro deficits. What would you want to do if a patient with a minor brain injury fails to reach a GCS of 15 within 2 hour post injury, had LOC >5 min, are older than 65, emesis x 2, or had retrograde amnesia >30 minutes? -ANSWER- CT scan - Everything but the 30 min amnesia makes them HIGH risk for neurosurgical intervention (as would a basillar skull fx). What 2 things do you need to do first for everyone with a MODERATE brain injury (according to ATLS algorithm)? -ANSWER- CT scan, admit to faciolity capable of definitive neurosurgical care (Moderate = GCS 9-12) High levels of CO2 will cause cerebral vasculature to . -ANSWER- Dilate (to increase blood flow) - so you might want to HYPERventilate people with brain injuries. Ideally, you want to wait to perform a GCS on a person with SEVERE brain injury until what? -ANSWER- BP is normalized A FAST scan, DPL, or ex-lap should take priority over a CT scan if you can't get the brain injured patient's BP up to mm Hg. -ANSWER- 100 If a patient has a systolic over 100 with evidence of intracranial mass (blown pupil, unequal motor exam) THEN a CT would take first priority. A midline shift of greater than often indicates the need for neurosurgical evacuation of the mass/blood. -ANSWER- 5mm Your patient has a dilated pupil and you want to give mannitol on the way to the CT scanner or OR. What is the correct dose? -ANSWER- 0.25-1.0 g/kg via rapid bolus A cast cutter should be removed to remove a trauma victim's helmet if there is evidence of a c-spine injury or if . -ANSWER- the patient experiences pain or paresthesias during an initial attempt to remove the helmet. What are the signs of neurogenic shock? -ANSWER- Vasodilation of lower extremity blood vessels - resulting in pooling of blood and hypotension. This loss of sympathetic tone may cause bradycardia or inhibit the tachycardic response to hypovolemia. How do you treat neurogenic shock? -ANSWER- Judicious use of pressors and MODERATE fluid resuscitation. Too much fluid may result in overload and pulmonary edema. What is the most common type of C1 fracture? -ANSWER- Burst fractures (Jefferson fracture) What's the difference between types I, II, and III odontoid process fractures? - ANSWER- I=tip of odontoid, II=fx at base, III=base of odontoid and extends obliquely into body of axis. (Odontoid process = dens). What are the indications for c-spine radiographs in a trauma patient? Which x-ray views should be obtained? -ANSWER- Midline neck pain, tenderness on palpation, neurological deficits related to c-spine injuries, altered LOC or intoxication. 1) Lateral, 2) AP, 3) Open mouth odontoid view With the proper views of the c-spine, and a qualified radiologist - what is the sensitivity for finding unstable cervical spine injuries? -ANSWER- >97% (CT with 3mm slices >99%). Ten percent of all patients with a c-spine fracture have what? -ANSWER- A second, noncontiguous vertebral column fracture. (So scan the rest of their spine). Attempts to align the spine for the purpose of immobilization on the backboard are not recommended if they . -ANSWER- cause pain Can you clear a c-spine without films? -ANSWER- Yes, if they are awake, alert, sober, neurological normal, have NO pain, and can flex, extend, and move their head to both sides without pain - you don't need films. Should a quadriplegic or paraplegic patient be put on a hard board? -ANSWER- Not for more than 2 hours - get them off ASAP. What's a big difference in a physical finding between hypovolemic and neurogenic shock? -ANSWER- Hypovolemic = usually TACHY, Neurogenic = usually BRADY Partial or total loss of respiratory function may be seen in a patient with a cervical spine injury above . -ANSWER- C6 What are you thinking if a child has broken ribs? -ANSWER- MASSIVE force and highly likely organ damage (since their ribs are very pliable, a huge amount of force is required to break them, there is often underlying organ damage WITHOUT broken ribs). How should you insert a Guedel in a kid? -ANSWER- Use tongue blade depressor and insert gently without turning - otherwise there is great risk for trauma and resultant hemorrhage. NOT the 180 degree spin trick. The normal systolic BP in kids can be estimated by what? -ANSWER- 90 mm Hg + (age x 2) How do you estimate a child's total circulating volume? -ANSWER- 80 mL/kg When shock in a child is suspected, how much fluid do you give them? -ANSWER- 20 mL/kg warm crystalloid May need to repeat up to 3 times (60 mL/kg) then consider blood products. Optimal UOP for infants is mL/kg/hr. -ANSWER- 2 (1.5 for younger kids, and 1.0 for older kids). How much warmed crystalloid should be used for a DPL in kids? -ANSWER- 10 mL/kg (up to 1000 mL) What would you see in an infant that would make you suspect very severe brain injury despite normal LOC? -ANSWER- Bulging fontanelles - these allow tolerance for expanding masses/swelling... What is a possible mistake about a blood pressure of 120/80 in a 87 year old man? - ANSWER- Assuming that normal blood pressure = normovolemia. Many geriatric patients have uncontrolled hypertension, and if their normal systolic is 180, then 120/80 is relative HYPOtension for them. How well do geriatric patients do with non-operative management of abdominal injuries compared to younger people? -ANSWER- Not as well - the risks of non-operative management are often worse than the risks of surgery. Why would geriatric patients be MORE susceptible to head bleeds when there is increased space around a shrinking brain to protect them from contusion? -ANSWER- Atrophic brains = stretching of the parasagittal bridging veins, making them more prone to rupture upon impact. Plasma volume increases during pregnancy, what happens to hematocrit? -ANSWER- Decreases - dilution by plasma (31-35% is normal in pregnancy) What would you think of a WBC of 15,000 in a pregnant woman? -ANSWER- Normal, it can go up to 25,000 during labor! What should you always assume about a pregnant patient's stomach? -ANSWER- That it is always full. (Gastric emptying time increases during pregnancy). Early NG tube placement recommended. A PaCO2 of 35 to 40 in a pregnant patient may indicate what? -ANSWER- Impending respiratory failure. It is usually around 30 due to hyperventilation due to increased levels of progesterone. True or False: All Rh negative pregnant trauma patients should get Rhogam? - ANSWER- True, unless the injury is remote from the uterus (distal extremity injury only). This therapy should be initiated within 72 hours of injury. When worn correctly, seatbelts reduce fatalities by %. -ANSWER- 65-70%, with a 10-fold reduction in serious injury. A 22-year-old man is hypotensive and tachycardic after a shotgun wound to the left shoulder. His blood pressure is initially 80/40 mm Hg. After initial fluid resuscitation his blood pressure increases to 122/84 mm Hg. His heart rate is now 100 beats per minute and his respiratory rate is 28 breaths per minute. A tube thoracostomy is performed for decreased left chest breath sounds with the return of a small amount of blood and no air leak. After chest tube insertion, the most appropriate next step is: re-examine the chest A construction worker falls two stories from a building and sustains bilateral calcaneal fractures. In the emergency department, he is alert, vital signs are normal, and he is complaining of severe pain in both heels and his lower back. Lower extremity pulses are strong and there is no other deformity. The suspected diagnosis is most likely to be confirmed by: complete spine x-ray series What is true regarding the initial resuscitation of a trauma patient? Evidence of improved perfusion after fluid resuscitation could include improvement in Glasgow Coma Scale score on reevaluation In managing a patient with a severe traumatic brain injury, the most important initial step is to: secure the airway A previously healthy, 70-kg (154-pound) man suffers an estimated acute blood loss of 2 liters. What applies to this patient? An ABG would demonstrate a base deficit between -6 and -10 mEq/L. The physiological hypervolemia of pregnancy has clinical significance in the management of the severely injured, gravid woman by: increasing the volume of blood loss to produce maternal hypotension. The best assessment of fluid resuscitation of the adult burn patient is: urinary output of 0.5 mL/kg/hr The diagnosis of shock must include: evidence of inadequate organ perfusion A 7-year-old boy is brought to the emergency department by his parents several minutes after he fell through a window. He is bleeding profusely from a 6-cm wound of his medial right thigh. Immediate management of the wound should consist of: direct pressure on the wound For the patient with severe traumatic brain injury, profound hypocarbia should be avoided to prevent: cerebral vasoconstriction with diminished perfusion After being involved in a motor vehicle crash, a 25-year-old man is brought to a hospital that has surgery capabilities available.. Computed tomography of the chest and abdomen shows an aortic injury and splenic laceration with free abdominal fluid. His blood pressure falls to 70 mm Hg after CT. The next step is: perform an exploratory laparotomy What statements regarding abdominal trauma in the pregnant patient is TRUE? Leakage of amniotic fluid is an indication for hospital admission. The first maneuver to improve oxygenation after chest injury is: administer supplemental oxygen A 25-year-old man, injured in a motor vehicular crash, is admitted to the emergency department. His pupils react sluggishly and his eyes open to pressure. A 22-year-old man sustains a gunshot wound to the left chest and is transported to a small community hospital no surgical capabilities are available. In the emergency department, a chest tube is inserted and 700 mL of blood is evacuated. The trauma center accepts the patient in transfer. Just before the patient is placed in the ambulance for transfer, his blood pressure decreases to 80/68 mm Hg and his heart rate increases to 136 beats per minute. The next step should be to: repeat the primary survey and proceed with transfer A 64-year-old man involved in a high-speed car crash, is resuscitated initially in a small hospital without surgical capabilities. He has a closed head injury with a GCS score of 13. He has a widened mediastinum on chest x-ray with fractures of left ribs 2 through 4, but no pneumothorax. After initiating fluid resuscitation, his blood pressure is 110/74 mm Hg, heart rate is 100 beats per minute, and respiratory rate is 18 breaths per minute. He has gross hematuria and a pelvic fracture. You decide to transfer this patient to a facility capable of providing a higher level of care. The facility is 128 km (80 miles) away. Before transfer, you should first: call the receiving hospital and speak to the surgeon on call Hemorrhage of 20% of the patient's blood volume is associated usually with tachycardia What statement concerning intraosseous infusion is TRUE? Aspiration of bone marrow confirms appropriate positioning of the needle. A young woman sustains a severe head injury as the result of a motor vehicle crash. In the emergency department, her GCS is 6. Her blood pressure is 140/90 mm Hg and her heart rate is 80 beats per minute. She is intubated and mechanically ventilated. Her pupils are 3 mm in size and equally reactive to light. There is no other apparent injury. The most important principle to follow in the early management of her head injury is to avoid hypotension A 33-year-old woman is involved in a head-on motor vehicle crash. It took 30 minutes to extricate her from the car. Upon arrival in the emergency department, her heart rate is 120 beats per minute, BP is 90/70 mm Hg, respiratory rate is 16 breaths per minute, and her GCS score is 15. Examination reveals bilaterally equal breath sounds, anterior chest wall ecchymosis, and distended neck veins. Her abdomen is flat, soft, and not tender. Her pelvis is stable. Palpable distal pulses are found in all 4 extremities. Of the following, the most likely diagnosis is: cardiac tamponade A hemodynamically normal 10-year-old girl is hospitalized for observation after a Grade III (moderately severe) splenic injury has been confirmed by computed tomography (CT). What mandates prompt celiotomy (laparotomy)? development of peritonitis on physical exam A 40-year-old woman who was a restrained driver in a motor vehicle crash is evaluated in the emergency department. She is hemodynamically normal and found to be paraplegic at the level of T10. What precaution should be taken during evaluation and management? Log rolling using 4 people is a safe approach to restrict spinal motion when moving her. A trauma patient presents to your emergency department with inspiratory stridor and a suspected c-spine injury. Oxygen saturation is 88% on high-flow oxygen via a nonrebreathing mask. The most appropriate next step is to: restrict cervical motion and establish a definitive airway When applying the Rule of Nines to infants The head is proportionally larger in infants than in adults A healthy young male is brought to the emergency department following a motor vehicle crash. His vital signs are a blood pressure of 84/60, pulse 123, GCS 10. The patient moans when his pelvis is palpated. After initiating fluid resuscitation, the next step in management is: placement of a pelvic binder What situations requires Rh immunoglobulin administration to an injured woman? positive pregnancy test, Rh negative, and has torso trauma A 22-year-old female athlete is stabbed in her left chest at the third interspace in the anterior axillary line. On admission to the emergency department and 15 minutes after the incident, she is awake and alert. Her heart rate is 100 beats per minute, blood pressure 80/60 mm Hg, and respiratory rate 20 breaths per minute. A chest x-ray reveals a large left hemothorax. A left chest tube is placed with an immediate return of 1600 mL of blood. The next management step for this patient is: prepare for an exploratory thoracotomy A 6-year-old boy walking across the street is struck by the front bumper of a sports utility vehicle traveling at 32 kph (20 mph). What's true about this patient? A pulmonary contusion may be present in the absence of rib fractures. Adjuncts used during the primary survey ECG Pulse ox CO2 monitoringV Ventilatory rate ABGs Foleys (UOP) Gastric catheter FAST or eFAST DPL Urinary output is sensitive for Patient's volume status and renal perfusion "Golden hour" The time from injury to definitive care, during which treatment of shock and traumatic injuries should occur because survival potential is best; also called the Golden Period. Leading cause of trauma deaths worldwide MVCs Trimodal death distribution 1st: seconds to minutes of injury (apnea) 2nd: minutes to several hours (EDH, SDH, liver lac, pelvic fractures, spleen ruptures) 3rd: several days to weeks after injury (sepsis and multi-organ failure) Recognize the dynamic status of the airway Recognize the injuries that can result in progressive airway loss Frequently reassess the patient for signs of deterioration of the airway In a trauma patient with hypotension, what are the two most important causes to consider in order of importance? Tension pneumothorax Hemorrhage What is the best way to manage rapid external blood loss? Direct manual pressure on the wound What are the major areas of internal hemorrhage? Chest Abdomen Retroperitoneum Pelvis Long bones How should fluids be administered in trauma patients with shock? Warm IVFs If unresponsive to initial IVF, give blood transfusion immediately What are the uses for ETCO2? Detect ROSC Confirm ET intubation Help avoid hypoventilation and hyperventilation You'd like to insert a foley catheter for a trauma patient but you notice urethras injury. What test should be performed prior to the insertion of a urinary catheter? Retrograde urethrogram DDX for blood in gastric aspirate in a trauma patient Swallowed blood Traumatic gastric tube placement UGI injury What's a C/I to NGT insertion? Fracture of the cribriform/midface fracture (insert OG instead) What injuries are at high risk of compartment syndrome in trauma patients? Long bones Crush injuries Circumferential thermal burns Prolonged ischemia to the limb What's normal UOP? Adult: 0.5 ml/kg/hr Child: 1-2 ml/kg/hr MIST for obtaining info from EMS Mechanism and time of injury Injuries found and suspected Symptoms and signs Treatment initiated Retroperitoneal organs Abdominal aorta IVC Duodeum Pancreas Kidneys Ureters Posterior aspects of ascending/descending colon Bladder Rectum Reproductive organs What's the most frequently injured abdominal organ in blunt trauma? Followed by? Spleen (40-55%) Liver (35-45%) Small bowel (5-10%) Which patients should you consider transferring, and what tests should be performed prior to transfer? The patients whose injuries exceed your ability to care for them, either sue to specialize needs, or resource availably. Only perform testing that enables the referring physician to resuscitate, stabilize, and ensure the safer transfer of the patient What's a pulse oximetry measure? Oxygen saturation by relative absorption of light by oxyhemoglobin and deoxyhemoglobin Gastric catheter placement can induce vomiting Be prepared to logroll Ensure suction is immediately available Special populations that may have physiological responses that do not follow expected patterns Children Pregnant females Elderly Obese individuals Athletes Why is info about mechanism of injury so important? The patient's condition is greatly influenced by MOI. It can enhance the understanding of the patient's condition and anticipated injuries Possible adjuncts to secondary survey X-rays of spine and extremities CT scans of head, chest, abdomen, spine Contrast urography and angiography TEE Bronchoscopy Esophagoscopy