Trauma Management: Principles and Practices, Exams of Nursing

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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

• ANSWERS-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
• ANSWERS-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 E. 4ml/kg/percent body burn/24 hours

• ANSWERS-A. Adequate urinary output A 36-year-old woman is beaten about the head and face and is brought to the local community hospital in full spinal immobilization. Her BP is 13088, HR 70/minutes, and RR 18/minute. Pulse oximetry indicated 98% while she was given 100% O2 via a non rebreather mask. Her airway is clear. She has marked swellings on her face and several lacerations of her scalp that are not actively bleeding. She does not respond to verbal stimuli, but localizes to painful stiumuli and opens her eyes. She moves all extremities equally. The remainder of her physical exam is normal. There is no neurosurgeon at the local hospital. After ensuring the patient airway, the most appropriate course of action is to: A. Admit the patient to the hospital for observation B. Obtain x-ray of her facial bones prior to transfer C. Obtain complete x-ray evaluation of the cervical spine D. Transfer the patient to a neurosurgeon without performing a CT-sca
  • ANSWERS-D. Transfer the patient to a neurosurgeon without performing a CT-scan For the trauma patient with cerebral edema, hypercarbia should be avoided to prevent: A. metabolic acidosis B. Respiratory acidosis C. Cerebral vasodilatation D. Neurogenic pulmonary edema E. Reciprocal high level of PaCO
  • ANSWERS-C. Cerebral vasodilatation A 29 y/o male is brought to the ED after being involved in a motor vehicular collision when his car struck a bridge abutment. He is intoxicated, has GCS 13 and complains of abdominal pain.

His BP was 80mmHg systolic by palpation on admission, but rapidly increased to 110/70 with the administration of IV fluid. His heart rate is 120/minute. The chest x-ray show loss of aortic know, widening of mediastinum, no rib fracture and no hemopneumothorax. Contrast angiography: A. Is not indicated B. Should be performed after CT scan of the chest C. Is positive ofr aortic rupture in 80% of similar cases D. Is not necessary if the CT-scan of the chest is normal E. Should be performed after DPL

• ANSWERS-D. Is not necessary if the CT-scan of the chest is normal Important screening x-rays to obtain in the multiple system trauma patient are: A. Skull, chest and abdomen B. Chest, abdomen and pelvis C. Skull cervical spine and pelvis D. Cervical spine, chest and pelvis E. Cervical spine, chest and abdomen
• ANSWERS-D. Cervical spine, chest and pelvis All of the following statement regarding pulse oxymetry are true EXCEPT A. excessive surrounding room light can interfere with the accuracy of the reading B. Significant levels of dysfunctional hemoglobin can affect the accuracy of the reading C. It provides a continuous measurement of the partial pressure of oxygen D. It is dependent on differential light absorption by oxygenated and deoxygenated hemoglobin E. It provides a continuous, non-invasiv measurement of pulse rate that is updated with each HR
• ANSWERS-C. It provides a continuous measurement of the partial pressure of oxygen

Bronchial intubation at the right or left mainstem bronchus can easily occuring during infant endotracheal intubation because A. The trachea is relatively short B. The distance from the lips to the larynx is relatively short C. The use of tubes without cuffs allow the tube to slip easily D. The mainstem bronchi are less angulated in their relation to the trachea E. Do litte friction exist between endotracheal tube and the wall of the trachea.

• ANSWERS-A. The trachea is relatively short A 52 y/o woman sustaining 50% total body surface burns in an explosion. She has burns around the chest and both upper arms. Adequate resuscitation is initiated. She is nasotracheally intubated and is being mechanically ventilated. Her CarboxyHb level is 10%. Her arterial blood gas reveals PaO2 of 40mmHg, PaCo2 of 60mmHg and pH of 7,25. Appropriate immediate management at the time is to A. Ensure adequate tissue perfusion B. Increase the rate of fluid resuscitation C. Add PEEP D. Reassess for the presence of pneumothorax E. Administer IV narcotics in small amounts
• ANSWERS-?A. Ensure adequate tissue perfusion All of the following suggest urethral injury EXCEPT 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 – ANSWERS-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

• ANSWERS-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
• ANSWERS-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.

• ANSWERS-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
• ANSWERS-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
• ANSWERS-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.

• ANSWERS-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
• ANSWERS-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
• ANSWERS-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
• ANSWERS-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

• ANSWERS-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
• ANSWERS-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
• ANSWERS-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
• ANSWERS-

Which one of the following brain stem reflexes is not assessed when assessing for brain death? A. Dolls eyes B. Oculovestibular reflex C. Gag reflex D. Argyll Robertson pupil - ANSWERS- What is the simplest way to open the airway in an unconscious patient? A. Pull out the tongue B. Tilt head and lift chin C. Lift neck from behind D. Jaw thrust - ANSWERS- What is the approximate time the brain can be anoxic before developing irreversible damage? A. 10 min B. 5 min C. 2 min D. 20 min - ANSWERS- You are treating a truama patient and attempt a definitive airway by intubation. However, the vocal cords are not visible. What tool would be the most valuable for achieving successful intubation? A. Gum elastic bougie B. Lateral cervical spine x-ray C. Nasopharyngeal airway D. Oxygen E. Laryngeal mask airway - ANSWERS-A. Gum elastic bougie

A 79 year old female is involved in a motor vehicle crash and presents to the ED. She is on Coumadin and a beta blocker. Which of the following statements is true concerning her management? A. The risk of subdural hemorrhage is decreased B. Absence of tachycardia indicates that the patient is hemodynamically normal C. Non-operative management of abdominal injuries is more likely to be successful in older adults than in younger patients D. Vigorous fluid resuscitation may be associated with cardiorespiratory failure D. epinephrine should be infused immediately for hypotension - ANSWERS-D. Vigorous fluid resuscitation may be associated with cardiorespiratory failure The most common acid base disturbance encountered in injured pediatric patients is caused by: A. Hemorrhage B. Changes in ventilation C. Renal failure D. Injudicious bicarbonate administration E. Insufficient sodium chloride administration - ANSWERS-B. Changes in ventilation? A 17 year old female is brought to the ED following a 2 meter fall onto concrete. She is unresponsive and found to have a RR of 32, BP 90/60 and HR 68. The first step in treatment is: A. Adminstering vasopressors B. Establishing IV access for drug-assisted intubation C. Seeking the cause of her decreased level of consciousness D. Applying oxygen and maintaining airway E. Excluding hemorrhage as a cause of shock - ANSWERS-D. Applying oxygen and maintaining airway A 25 year old male is brought to the ED following a bar fight. He has altered consciousness, open his eyes on command, moans without forming discernible words, and localizes to painful stimuli. Which one of the following statements concerning this patient is true?

A. Hyperoxia should be avoided B. CT scanning is an important part of neurological assessment C. Mandatory intubation to protect his airway is required D. His GCS suggest severe head injury E. His level of consciousness can be solely attributed to elevated blood alcohol. - ANSWERS-B. CT scanning is an important part of neurological assessment Han har GCS på 10-11, således passer det ikke med svaralternativ D som tilsvarer GCS <9. Ettersom GCS er >8 passer heller ikke svaralternativ C. E er feil da det ikke kan gi så lav GCS Which one of the following statements regarding genitourinary injuries is true? A. Urethral injuries are associated with pelvic fractures B. All patients with microscopic hematuria require evaluation of genitourinary tract 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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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, < posterior - ANSWERS-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. Abdominal x-ray B. Abdominal ultrasound C. DPL D. Frequent abdominal examination C. CT of abdomen and pelvis - ANSWERS-C. CT of abdomen and pelvis The most important consequence of inadequate organ perfusion is: A. Vasodilatation B. Multiple organ failure C. Decreased base deficit D. Acute glomerulonephritis E. Increased cellular ATP production - ANSWERS-B. Multiple organ failure A 23 year old construction worker is brought toe the ED after falling more than 9 meters from scaffolding. He is complaining bitterly of lower abdominal and lower limb pain, and has obvious deformity of both lower legs with bilateral open tibial fractures. Which one of the following statement concerning this patient is true? A. Pelvic injury can be ruled out based on the mechanism of injury B. Blood loss from the lower limb is most likely cause of his hypotension C. Spinal cord injury is the most likely cause of his hypotension D. X-ray of the chest and pelvis are important adjuncts in his assessment E. Aortic injury is the most likely cause of his tachycardia. - ANSWERS-D. X-ray of the chest and pelvis are important adjuncts in his assessment

A 82 year old male falls down five stairs and presents to the ED. All following statements are true statements regarding his condition compared to a younger patient with similar mechanism, except: A. He is more likely to have had a contracted circulatory volume prior to his injury B. His risk of cervical spine injury is increased due to degeneration, stenosis and loss of disk compressibility C. His risk of occult fractures is increased D. His risk of bleeding may be increased E. Intracranial hemorrhage will become symptomatic more quickly - ANSWERS-E. Intracranial hemorrhage will become symptomatic more quickly A 25 year old female in the third trimester of pregnancy is brought to the ED following a high speed motor vehicle crash. She is conscious and immobilized on a long spine board. Her RR is 24 bpm, HR is 120bpm, and BP is 70/50mmHg. The lab results show a PaCO2 of 40mmHg. Which one of the following statements concerning this patient is true? A. Fetal assessment should take priority B. Log-rolling the patient to the right will decompress the vena cava C. Rh-immunoglobulin therapy should be immediately administered D. Vasopressors should be given to the patient E. The patient has likely impending respiratory failure. - ANSWERS-E. The patient has likely impending respiratory failure. Minute ventilation increases primarily due to an increase in tidal volume. Hypocapnia (PaCO2 of 30 mm Hg) is therefore common in late pregnancy. A PaCO2 of 35 to 40 mm Hg may indicate impending respiratory failure during pregnancy. Lateral cervical spine film: A. Must be performed in the primary survey B. Can exclude any significant spinal injury C. Are indicated in all trauma patients

D. Should be combined with clinical exam, AP and odontoid, or CT E. Require the following films: oblique views, AP, odontoid and flexion extention views prior to spinal clearance in trauma patients - ANSWERS-D. Should be combined with clinical exam, AP and odontoid, or CT A 30 year old male is stabbed in the right chest. On arrival in the ED, he is very short of breath. His HR is 120bpm, BP is 80/50. His neck veins are flat. On auscultation of the chest, there is diminshed air entry on the right side, and there is dullness posteriorly on percussion. These findings are most consistent with: A. Hemothorax B. pericardial tamponade C. Tension pneumothorax D. Hypovolemia from the liver injury E. Spinal cord injury - ANSWERS-A. Hemothorax A specific aspect of the treatment of thermal injury is: A. Chemical burn require the immediate removal of clothing B. Patients who sustain thermal injury are at lower risk for hypothermia C. Patients with circumferential truncal burns need prompt fasciotomies D. Electrical burn are associated with extensive skin necrosis (from entry point to exit) E. The parkland formula should be used to determine adequacy of resucitation. - ANSWERS-A. Chemical burn require the immediate removal of clothing 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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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. - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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. - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 E. Bronchoscopy to exclude tracheobronchial injury - ANSWERS-C. Monitoried i.v analgesia. Ikke påvist pneumo eller hemothorax, derfor ikke thoraxdren. Troponiner gir ingen tilleggsinformasjon utover hva EKG kan gi. Pasienter med stump skade mot hjertet med diagnostisert med konduksjonsabnormalitet (unormalt EKG) er i riskosonen for å få arrytmier og skal overvåkes i 24 timer med EKG. Pasienter UTEN EKG-forandringer behøver ikke videre monitorering. A 15 year old male present following a motorcycle crash. INitial examinations reveals normal vital signs. There is a large bruise over his epigastrium that extends to the left flank. He has no other apparent injuries. A CT-scan of the abdomen demonstrate a ruptured spleen surrounded by a large hematoma and fluid in the pelvis. The next step in the patients management is: A. Splenic artery embolization B. Pneumococcal vaccine C. Urgent laparotomy D. Surgical consult E. Transfer to a pediatrician - ANSWERS-D. Surgical consult

Hemodynamisk stabil, ingen fri luft. A 30 year old male present with a stab wound to the abdomen BP is 85/60, HR 130, RR 26 and GCS 14. Neck veins are flat and chest examination is clear with bilateral breath sounds. Optimal resusciation should include: A. Transfusion of FFP and platelts B. 500ml of hypertonic saline and transfusion of pRBCs C. Resuscitation with crystalloid and pRBC until base excess is normal D. Fluid resuscitation and angioembolization E. Preparation for laparotomy while initiating fluid resuscitation - ANSWERS-E. Preparation for laparotomy while initiating fluid resuscitation Initial resuscitation in adult patient should: A. Be with 1-2L of crystalloid, monitorin the patients response B. Use crystalloid to normalize BP C. Use permissive hypotension in patients with head injury D. Be with a non blood colloid solution E. Be a minimum of 2L Crystalloid in all trauma patient prior to adminstering blood - ANSWERS- A. Be with 1-2L of crystalloid, monitoring the patients response Compared with adults, children have: A. A longer, wide, funnel shaped airway B. A less pliable, calcified skeleton C. Lower incidence of bony injury with neurogenic shock D. A relatively smaller head and larger jaw E. Anterior displacement of C5 and C6 - ANSWERS-B. A less pliable, calcified skeleton A 30 year old male presents after a motor vehicle crash. Vital signs are RR 18, HR 88, BP 130/72, GCS 13. Laparotomy is indicated when

A. There is distinct seat belt sign over the abdomen B. The CT-scan demonstrates a grade 4 hepatic injury C. There is evidence of extraperitoneal bladder injury D. CT demonstrates retroperitoneal air E. The abdomen is distended with localized right upper quadrant tenderness. - ANSWERS-D. CT demonstrates retroperitoneal air Indikasjoner for laparotomi: Blunt abdominal trauma with hypotension, with a positive FAST or clinical evidence of intraperitoneal bleeding, or without another source of bleeding

• Hypotension with an abdominal wound that penetrates the anterior fascia
• Gunshot wounds that traverse the peritoneal cavity
• Evisceration
• Bleeding from the stomach, rectum, or genitourinary tract following penetrating trauma
• Peritonitis
• Free air, retroperitoneal air, or rupture of the hemidiaphragm
• Contrast-enhanced CT that demonstrates ruptured gastrointestinal tract, intraperitoneal bladder injury, renal pedicle injury, or severe visceral parenchymal injury after blunt or penetrating trauma A 20 year old male is brought to the hospital approximately 30 minutes after being stabbed in the chest. There is 3cm wound just medial to the left nipple. His BP is 70/33 and HR is 140. Neck and arm veins are distended. Breath sounds are normal. Heart sounds are diminshed, iv access has been established and warm crystalloid is infusing. The next most important aspect of immediate management is: A. CT scan of the chest B. 12 lead ECG C. Left tube thoracostomy D. Begin infusion of RBCs

E. FAST exam - ANSWERS-E. FAST exam For å se etter tamponade? Normale resp.lyder bilateralt taler mot trykkpneumothorax. EKG vil ikke gi noe 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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-D. Ensuring adequate oxygenation and ventilation