Traumatic Injuries

Front 1

1. A 5-year-old, 23-kg boy was thrown from a sled while riding it down a steep hill approximately 4 He complains of generalized abdominal pain and is diaphoretic and pale. Bedside ultrasound is no available. Vital signs: heart rate 120/min; respiratory rate 30/min; blood pressure is not measurabl femoral pulse is weakly palpable. After two 20 mL/kg boluses of lactated Ringer solution, his cond unchanged. Your next action is to:

a. Give a third crystalloid fluid bolus.

b. Infuse 230 mL 5% albumin.

c. Perform diagnostic peritoneal lavage.

d. Infuse 460 mL type-specific whole blood or 230 ml O negative packed red blood cells.

e. Infuse 690 mL type-specific whole blood or 345 mL O negative packed red blood cells.

Back 1

Pediatric patients presenting in shock from trauma should receive an initial 20 mL/kg bolus isotonic crystalloid. This may be repeated once, but if no improvement in the hemodynamic status occurs, immediate transfusion with packed red blood cells, 10 ml/kg, should be performed while preparing for emerge surgery.

Front 2

• The most important radiographs used in evaluating an adult trauma patient are:

a. Chest, lateral cervical spine, abdomen.

b. Pelvis, abdomen, lateral and anteroposterior cervical spine.

c. Lateral cervical spine, chest, pelvis.

d. Abdomen, chest, lateral and anteroposterior cervical spine.

e. Abdomen, chest, lateral cervical spine, pelvis

Back 2

The answer is c. Radiographs of the anteroposterior chest, pelvis, and lateral cervical spine are the standard initial radiographs obtained in most patients with significant blunt trauma. A pelvic film can identify pelvic fractures, which can cause massive blood loss. If a patient with blunt injuries has persistent hypotension despite normal chest and pelvic radiographs, the most likely causes of the hypotension are intraperitoneal hemorrhage or cardiac. tamponade.

Front 3

Loss of cerebral autoregulation leads to:

a. Cerebral blood flow which varies with arterial pressure.

b. Compensatory hyperventilation.

c. Drastically decreased intracranial pressure.

d. Epidural hematoma.

e. Profound constriction of cerebral resistance vessels.

Back 3

The answer is a. With the loss of autoregulation, massive cerebral vasodilation occurs. Systemic pressure transmitted to the capillaries, and the outpouring of fluids into the extravascular space can contribute to v edema and thus further increase ICP.

Front 4

4. The Glasgow Coma Scale (GCS) includes:

a Oculomotor response, best verbal response, best motor response, light touch.

b. Eye opening, best motor response.

c. Best verbal response, best motor response, eye opening.

d. Best verbal response, best motor response, oculomotor response.

e. Pupillary response, best verbal response, best motor response.

Back 4

The answer is c. Total GCS Best Motor Response (1-6) Best Verbal Response (1-5)

3-15. The score ranges from 3 (no response) to 15 (best response). There are helpful mnemonics; the letter "E" (for eye) has four straight lines, and Eye Opening has a maximum score of 4. "Verbal" begins with the letter "V," which is also the Roman numeral for "5," and Best Verbal Response has a maximum score of 5. The value of this system is the ability to rapidly quantify a patien's level of consciousness (LOC) with an easily repoduced system. The LOCis the most important factor in the assessment of the head injured patient. This examination is reproducible by all levels of health care providers. The motor response is the most important and reproducible component of the examination. Severe injury is defined as a score of 8 or less persisting for at least 6 hours. Moderate injury is defined as a score of 9-12. A patient with a score of 8 or below (in the setting of head trauma) should be intubated for airway protection.

Front 5

Choose the true statement about initial management of the patient with possible spinal injury:

a. In patients with suspected cervical spine injury, immobilization with a properly applied rigid cervical collar is not sufficent to protect the patient from further injury.

b. Because obtaining adequate views of the spine is necessary for complete examination, the physician rather than the radiologic technician should be available to carefully move the patient's neck in order to optimize the examination.

c. Patients walking at the scene of an accident or arriving in the ED under their own power are not at risk for cervical spine or cord injuries.

d. The absenee of an anal reflex is synonymous with a complete transection of the lumbar cord.

e. MAST garments should not be used in patients with a lumbar or low thoracic spinal injury because of the displacement caused by compartment inflation.

Back 5

The answer is a. No cervical collar completely immobilizes the cervical spine, especially at the level of C1-C2.

They are of greater value when used in conjunction with a spinal board, sandbagging, and tape. Patients with a suspected cervical spine injury who are awake and have normal lateral x-rays of the cervical spine or at least no evidence of an unstable injury may be supervised by the physician and position themselves for additional vies, but under no circumstance should the physician actively move the patient's neck or force the motion beyond the limits of pain. Ambulation at the trauma scene does not exclude a C-spine injury. Spinal cord integrity includes the presence of the anal reflex. Absence of this reflex implies severe cord injury or transection at any level.

Front 6

6. Choose the correct statement concerning cervical spine injury:

a. The most common mechanism for cervical spine injuries is falls.

b. Fractures of the odontoid are rare in children aged 8 years and younger.

c. Pseudosubluxation is rare in children.

d. The older the patient, the lower the fracture.

e. Management of nerve root injuries includes methylprednisolone.

Back 6

The answer is d. Pediatric cervical spine injuries differ from adult injuries because of a child's proportionately larger head, the presence of epiphyseal plates, and greater ligamentous laxity. Odontoid fractures are less common in adults (10%), but are the most common pediatric cervical fracture (up to 8 years of age). Most pediatric odontoid fractures occur at the epiphyseal plate. Physiologic ligamentous laxity results in pseudosubluxation of C2 on C3 and C3 on C4 (40% of children younger than 7 years have this finding). Those older than 12 years tend to have lower anatomical cervical injuries. Approximately 40% of patients with a cervical spine fracture have associated neurologic injury. Treatment of cord injuries may include methy/prednisolone 30 mg/kg loading dose, followed by 5.4 mg/kg/h for 23 hours.

Front 7

7. In a patient with penetrating neck trauma, you should:

2. Control bleeding with direct pressure and avoid blind clamping of vessels.

b. Not attempt rapid sequence intubation, as these patients invariably require a surgical airway.

c. Recognize Zone Il injuries as occurring between the angle of the mandible and the thyroid cartilage.

d. Order fiberoptic esophagoscopy, which if negative excludes a significant esophageal injury,

e. Order a Gastrografin swallow, which if negative excludes a significant esophageal injury.

Back 7

The answer is a. Up to 25% of patients with esophageal injuries have negative Gastrografin studies. A barium upper GI series may improve sensitivity. Fiberoptic esophagoscopy has up to a 20% false-negative rate. Posterior triangle injuries may include subclavian vessel and vertebral artery lacerations; thus, subclavian venous access should be avoided. Complications of penetrating injuries to the posterior triangle includes hemothorax and tension pneumothorax. The best initial method to control vascular hemorrhage in the neck is direct pressure. Blind attempts to clamp vessels can result in serious injury to associated structures. The management of neck injuries has been aided by dividing the neck into three zones and the availability of arteriography. Zone III injuries occur above the angle of the mandible and the cricoid. Zone Il injuries occur between the mandible and the cricoid. Zone I injuries occur below the cricoid cartilage and above the clavicle.

Front 8

8. Isolated knee meniscus injuries are most commonly associated with:

An audible pop at the time of injury.

b. Hemarthrosis with fat globules.

c. Delayed onset of pain.

d. A history of "locking" on flexion or extension

e. Positive anterior drawer sign.

Back 8

The answer is a. A joint effusion may develop with a meniscal injury. Hemarthrosis with fat globules indicates a fracture involving marrow. Solitary hemarthrosis may result form skeletal, ligamentous, or cartilaginous injuries. If the cartilage interposes in the intercondylar notch, the joint will lock.

Front 9

9. A 22-year-old woman complains of several days of progressive knee pain after sustaining a twisting injury.

Her knee is stable to valgus and varus stress and you find no laxity and no soft end point on anterior drawer testing. There is, however, an effusion and tenderness of the medial joint line and anterior joint space. She probably has:

a. An anterior cruciate ligament tear.

b. A posterior cruciate ligament tear.

c. Chondromalacia patella.

d. Osteochondritis dessicans.

e. A medial meniscal tear.

Back 9

The answer is e. Valgus stress tests the medial collateral ligament, while the anterior drawer test is for assessing integrity of the anterior cruciate ligament. Meniscal injuries are typically caused by twisting injuries, and sometimes cause effusions. Chondromalacia patella is an overuse syndrome of the articular cartilage of the patella.

Osteochondritis dessicans is a rare condition of unknown etiology commonly found in adolescents where the articular cartilage and subchondral bone become separated from the underlying bone.

Front 10

A workman falls from a height of 10 ft and lands on his feet. He complains of severe left foot pain and has diffuse swelling. You know that:

a. The most commonly fractured tarsal bone is the talus.

b. Bohler's angle should normally be 20 degrees or less.

c. An abnormal Bohler angle indicates a talus fracture.

d. Avascular necrosis is a complication of a talar fracture.

e. Lisfranc's fracture is treated with a weight-bearing cast.

Back 10

The answer is d. Bohler's angle, normally 20-40 degrees, determines the presence of depression in calcaneal fractures. The calcaneus is the most frequently fractured tarsal bone. The mechanism of injury is usually compression. Associated injuries with a calcaneus fracture are injuries to the lumbar spine, pelvis, hip, and knee.

Often, the only radiographic signs are the disruption of the trabecular pattern and an abnormal Bohler's angle the angle formed by the axis of the subtalar joint and the superior surface of the tuberosity). Talar fractures are uncommon, although they are the second most common foot fracture. Because the blood supply to the talus is poor, avascular necrosis of the bone may result. Fracture/dislocations of the tarsal-metatarsal joint (Lisfranc's joint) are uncommon. A fracture through the base of the second metatarsal is almost pathognomonic of a disrupted joint.

Front 11

1. Using the Young classification system, acetabular fractures are associated with which type of pelvi

a. Type I.

b. Type II.

c. Type I.

d. Type IV.

e. Type V.

Back 11

The answer is d. Pelvic fractures are divided into four anatomic types. Type IV fractures constitute approximately 20% of pelvic fractures and involve the acetabulum. The mechanism of injury is a force applied to the flexed hip.

Type I fractures are stable pelvic fractures with no break in the pelvic ring, for example, a transverse sacral fracture.

Type II fractures have a single break in the pelvic ring, such as a vertical fracture of the ileum parallel to the sacroiliac (SI) joint. Both type I and type II are stable fractures. Type III fractures (double break in the pelvic ring) are severe, unstable, and are associated with concomitant injuries. A Malgaigne fracture is a fracture of the ilium and a symphyseal dislocation.