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563. Which one of the following statements regarding trauma epidemiology is INCORRECT?

(A) Alcohol is associated with 40 percent of motor vehicle accidents (MVAs)

(B) In the elderly, fractured hips are the most common injury sustained during a fall

(C) If involved in a motorcycle accident, you are 35 times more likely to die than if you are involved in an automobile accident

(D) Most trauma victims in the United States are transported to trauma centers for resuscitation

(E) Within the United States, trauma is the leading cause of death up to the age of 45 years

564. A 45-year-old male unrestrained driver is brought to the ED with cervical spine precautions by an EMT unit after a high-speed MVA. He has a Glasgow Coma Scale (GCS) score of 6 and no obvious signs of trauma. His shallow respirations are being inadequately assisted with a bag-valve mask. Radial pulse is thready, and the extremities are cool. Which of the following should be performed before rapid sequence intubation (RSI)?

(A) A brief neurologic examination including a check of rectal tone

(B) An immediate chin lift to clear the airway from any obstruction

(C) A full set of vital signs

(D) A lateral cervical spine x-ray

(E) Four quick tidal volume breaths with 100 percent oxygen using a bag-valve mask device

565. A 28-year-old male sustains a gunshot wound to the back, just medial to the left scapula. Field blood pressure is 98/p, pulse is 101, and respiratory rate is 38. En route to the ED, he received high-flow oxygen and 1 L normal saline. He is agitated and diaphoretic on arrival. You are unable to hear heart sounds because of ambient noise, but the neck veins appear normal. Blood pressure starts to decrease and respiratory status worsens over the next few minutes, but he is still conscious and oriented. Given that all of the following interventions are available, what is the MOST appropriate next step?

(A) Emergent bedside cardiac ultrasound

(B) Emergent thoracotomy

(C) Immediate needle decompression of the left chest

(D) Immediate blood transfusion

(E) Immediate chest x-ray

566. Which of the following statements is TRUE regarding pediatric trauma?

(A) Trauma is the leading cause of death in children younger than 1 year

(B) Because of their smaller body surface area, hypothermia is less common in children than in adults

(C) Head injury is the most frequent cause of death

(D) Initial assessment and management of an injured child differs from that of an adult

(E) Alcohol use is a factor in most trauma cases associated with MVAs

567. Which of the following statements is INCORRECT regarding the child's airway?

(A) Children are dependent on diaphragmatic excursion for breathing in order to generate adequate tidal volume

(B) In children older than 4 years, the narrowest portion of the trachea is no longer subglottic

(C) The location of the infant's larynx is more cephalad than the location of the adult's larynx

(D) Cricothyrotomy is contraindicated in small children

(E) The correct endotracheal tube size for a 4-year-old child is 5.0

568. A 6-month-old child falls and hits his head. Which of the following signs would be the MOST indicative of serious neurological injury?

(A) The parent states the child was pale and sweaty for a few minutes after the fall

(B) A single post-fall episode of emesis

(C) Lethargy immediately after the head injury

(D) Hypotension

(E) A single grand mal seizure immediately after the fall

569. Which of the following statements is INCORRECT regarding pediatric spinal cord injury?

(A) Because of a child's large head, the fulcrum of cervical motion lies at C4-5

(B) Widening of the prevertebral soft tissue of 8 mm or more anterior to C2 is abnormal

(C) In most cases, pseudosubluxation resolves if x-rays are repeated with the child in the sniffing position

(D) More than 50 percent of children with SCIWORA (spinal cord injury without radiographic abnormality) have a delayed onset of paralysis

(E) A normal spine series can be found in up to two-thirds of children with spinal cord injury

570. Which of the following is TRUE regarding geriatric patients?

(A) They fall less frequently than younger people because they are more cautious about their balance

(B) They are likely to sustain multiple orthopedic fractures after a fall

(C) They are more likely to die from an MVA than from any other traumatic injury

(D) The increased incidence in violent crimes in the United States has spared the elderly

(E) Alcohol is less likely to be associated with a fatal assault than it is for a younger person

571. Which of the following statements would be MOST CORRECT regarding evaluation of a head and neck CT of a 75-year-old male after a fall?

(A) Epidural hematomas occur more frequently in the elderly than in young adults

(B) There should be 25 to 30 percent more brain atrophy in the normal 75-year-old male than in a 30-year-old male

(C) Subdural hematomas occur less frequently in the elderly than in young adults

(D) Increased "dead space" within the skull may delay symptoms of intracranial bleeds

(E) Compared with young adults, elderly patients have an increased incidence of cervical spine injuries

572. An 83-year-old female fell while walking to the bathroom. She complains of severe pain and will not tolerate any movement of the left leg. The leg is externally rotated and shortened. Which of the following is the MOST likely location for the fracture?

(A) Intertrochanteric

(B) Transcervical

(C) Subcapital

(D) Subtrochanteric

(E) Acetabular

573. A 15-year-old male is brought to the ED after being assaulted to the head with a lead pipe. He opens his eyes briefly to deep painful stimuli, mumbles incomprehensible sounds, and withdraws to painful stimuli. What is his initial GCS?

574. While in the CT scanner, the patient described in question 573 develops anisocoria. Which of the following statements is INCORRECT regarding uncal herniation?

(A) Compression of cranial nerve III along the edge of the tentorium incisura causes pupillary dilation

(B) Constriction of parasympathetic fibers on the surface of cranial nerve III causes unopposed sympathetic dilation of the pupil

(C) With further compression of cranial nerve III, full oculomotor paralysis develops, causing the eye to deviate inferiorly and medially

(D) Uncal herniation can compress the corticospinal tract, leading to contralateral hemiplegia

(E) An emergency burr hole should be placed on the same side as the dilated pupil in the majority of cases

575. A 42-year-old female has a GCS of 6 after an MVA. Which of the following statements is TRUE regarding her care?

(A) If hypotension is allowed to occur, the mortality risk is more than doubled

(B) The most critical determinant of outcome in severely head-injured patients is ICP

(C) The patient should be hyperventilated to a pCO2 of less than 25 mm Hg

(D) Hypotension in the severely brain-injured patient is usually due to the primary brain injury

(E) CT of the abdomen and head should be performed immediately in a hypotensive, severely head-injured patient

576. A 13-year-old male is involved in a water ski boat accident. Which of the following would NOT be indicative of a basilar skull fracture?

(A) Generalized bruising on the face, most notably around the eyes

(B) Bluish, dull tympanic membrane on the left side

(C) A small retroauricular ecchymosis on the left side

(D) Left-sided facial droop

(E) Medial deviation of the left eye

577. Which of the following patients does NOT require immediate neurosurgical evaluation?

(A) A 24-year-old male with a GCS score of 13 and a linear fracture of the temporal bone diagnosed by skull x-ray at an outside hospital

(B) A comatose 38-year-old female with a depressed linear skull fracture

(C) A 42-year-old male with a basilar skull fracture diagnosed by bony windows on head CT

(D) A 19-year-old female with a scalp laceration and clear discharge from the right ear after an unhelmeted fall while rollerblading

(E) A 58-year-old female with a GCS score of 4 and a negative head CT

578. A homeless, alcoholic male is brought to the ED with a mildly altered level of consciousness. Although there is no history or external signs of trauma, a head CT is obtained and it shows a large collection of blood, with slight midline shift. Which of the following statements is TRUE regarding this patient's most likely diagnosis?

(A) It is usually caused by tearing of the middle meningeal artery

(B) The patient should show signs of elevated intracranial pressure immediately after the injury

(C) Brain atrophy associated with alcoholism makes him less susceptible to this type of bleed

(D) Immediate surgery may not be necessary

(E) Morbidity and mortality are much lower than for other intracerebral bleeds

579. A 36-year-old female comes to the ED complaining of headache and nausea. She had a negative head CT 5 days earlier after a brief lapse of consciousness after an MVA. She is amnestic to the event. Which of the following statements is FALSE?

(A) The mortality rate for patients with head injury and a negative head CT approaches zero

(B) Retrograde and antegrade amnesia is common with this type of injury

(C) The patient is not at risk for significant injuries because she is 5 days out from the initial trauma and relatively asymptomatic

(D) The patient may have alterations in thinking, sleeping, or concentration abilities

(E) A new sensitivity to alcohol is normal and will probably resolve within a few weeks

580. A young female presents to the ED with a GCS score of 6 after being "t-boned" by a large pickup truck on her side of the vehicle. Initial head CT is negative for bleed. Pupils were initially normal and reactive to light but are now bilaterally dilated and sluggish. Which one of the following therapies would be LEAST beneficial for this patient?

(A) 1 L normal saline bolus

(B) Intubation and hyperventilation to keep the pCO2 less than 25 mm Hg

(C) Mannitol 1 g/kg intravenous bolus

(D) Elevation of the head of the bed to 30 degrees

(E) Furosemide 0.3 to 0.5 mg/kg intravenously

581. Which of the following statements regarding spinal injury is TRUE?

(A) Twenty percent of patients deteriorate neuro-logically in the ED

(B) In a neurologically normal patient, the absence of pain or tenderness along the spine excludes spine injury

(C) Approximately 75 percent of spinal injuries occur in the cervical region

(D) Approximately 25 percent of all head-injured patients have associated spinal injuries

(E) If appropriate precautions are maintained, evaluation of the spine may be safely deferred until after intubation is performed

582. Which of the following statements is INCORRECT regarding spinal shock?

(A) Distal areflexia can persist for hours to weeks

(B) After reflexes return, the patient develops spastic paralysis

(C) Fluid resuscitation alone is generally insufficient to treat hypotension

(D) Vasomotor instability leads to hypotension and cool, moist skin

(E) Paradoxical bradycardia can coexist with hypotension

583. A 76-year-old male with severe osteoarthritis falls head first onto the cement. On ED arrival, he is confused and answers "yes" to all questions. You notice that he is not moving the upper extremities or legs. All of the following are characteristic for this type of cord syndrome EXCEPT

(A) the legs are typically weaker than the arms

(B) the hands are weaker than the proximal arm muscles

(C) prognosis is better for this syndrome than for other cord syndromes

(D) vascular compromise in the pattern of the anterior spinal artery is the cause

(E) the bladder is occasionally affected

584. Which of the following statements is INCORRECT regarding cervical spine injuries?

(A) The Jefferson fracture is due to a vertical compression injury

(B) Hangman's fracture is a bilateral fracture through the pedicles of C2

(C) A flexion teardrop fracture leaves the posterior ligaments intact

(D) A unilateral facet dislocation is diagnosed when there is anterior dislocation of 25 to 33 percent of one vertebral body on the next vertebra

(E) Bilateral interfacetal dislocation is an unstable cervical injury with total ligamentous disruption

585. A 26-year-old intoxicated male driver is involved in a high-speed MVA. Which of the following findings on cervical spine x-ray would NOT be suggestive of serious injury?

(A) An 8-mm prevertebral soft tissue swelling at C4

(B) A 4-mm anterior subluxation of C5 on C6

(C) Fanning of the cervical spinous processes

(D) A predental space of 3 mm

(E) An 18-degree change in angulation of the cervical column

586. Which of the following patients with penetrating neck trauma is MOST likely to require immediate surgical exploration?

(A) An 18-year-old asymptomatic male with a stab wound to zone II of the neck that penetrates the platysma

(B) A 12-year-old female with a BB gunshot wound to zone II of the neck who complains of a minor voice change and occasional nonproductive cough

(C) A 43-year-old female with a glass shard laceration to zone III of the neck with minimal associated bleeding

(D) A 21-year-old male with a zone I, II, and III neck laceration from a pocket knife associated with significant hemorrhage that is well controlled with a pressure dressing

(E) A 33-year-old female with a gunshot wound to zone I of the neck and anisocoria

587. Which of the following is the LEAST appropriate management of a patient with a spinal cord injury?

(A) Immobilization with a long spine board, semirigid cervical collar and bolstering devices

(B) Low-dose vasopressors to treat neurogenic shock

(C) Atropine to treat bradycardia

(D) Methylprednisolone 30 mg intravenous bolus and then 5.4 mg/kg/h for 23 h if administered within the first 12 h of injury

(E) Transfer to a definitive-care facility once cardiovascular stability has been achieved

588. Which of the following statements is TRUE regarding chest trauma?

(A) Thoracic injury is the cause of death in 25 percent of all trauma patients

(B) Most deaths from chest trauma occur before ED arrival

(C) Mortality is greater than 50 percent for patients who present with a blood pressure less than

80 systolic or who require intubation on arrival

(D) Twenty-five percent of blunt chest trauma patients are candidates for emergent thoracotomy

(E) Forty-five percent of penetrating chest trauma patients are candidates for emergent thoracotomy

589. A 24-year-old unrestrained male driver is involved in a high-speed MVA. GCS score is 10, and he has severe chest wall contusions and mild hemoptysis. He is intubated for respiratory distress. Within a few minutes of intubation, he suffers a cardiac arrest. Which of the following therapeutic measures would be LEAST likely to have an immediate life-saving effect?

(A) Decrease the ventilatory rate

(B) Needle decompression of the chest

(C) Pull back the endotracheal tube

(D) One liter crystalloid fluid bolus

(E) Immediate Trendelenburg position, left lateral side down

590. Which of the following patients is NOT a candidate for emergent ED thoracotomy?

(A) A 12-year-old male with a stab wound to the left axilla who loses pulses on ED arrival

(B) A 29-year-old male with a gunshot wound to the left upper quadrant, with a distending abdomen and a precipitous decrease in GCS score to 3

(C) A 42-year-old male involved in an MVA, initially alert, who arrives to the ED with pulseless electrical activity after a 6-min transport time

(D) A 36-year-old female with a stab wound to zone I of the neck who becomes altered and loses radial pulses 4 min before ED arrival

(E) An 18-year-old male who fell 12 feet from a tree, was alert in the field, but is now altered, bradycardic, hypotensive, and has a distended abdomen

591. Which of the following statements is INCORRECT regarding flail chest?

(A) The main cause of morbidity and mortality is hypoxia secondary to the patient's inability to generate adequate negative intrathoracic pressure

(B) Flail chest is characterized by paradoxical movement of the involved portion of the chest wall during respiration

(C) It may not be apparent immediately after the injury

(D) Initial therapy is aimed at immediate pain relief, generous pulmonary toilet, and fluid restriction to prevent fluid overload

(E) Prophylactic intubation decreases mortality in minimally symptomatic patients with large pulmonary contusions

592. After a moderate-speed MVA, a 32-year-old male restrained driver has a normal upright anteroposterior chest x-ray but a 2-mm pneumothorax on CT. Which of the following is the BEST indication for placement of a thoracostomy tube?

(A) One or more rib fractures

(B) Need for intubation and mechanical ventilation

(C) Pulmonary contusion

(D) Cardiac contusion

593. Hamman's sign MOST likely suggests which of the following conditions?

(A) Pneumothorax

(B) Pneumomediastinum

(C) Pericarditis

(D) Pleurisy

(E) Pericardial tamponade

594. Which of the following is the LEAST reliable sign of Beck's triad in a patient with pericardial tamponade?

(A) Distended neck veins

(B) Tracheal deviation

(C) Tachycardia

(D) Hypotension

(E) Muffled heart tones

595. Which of the following statements is CORRECT regarding needle pericardiocentesis for diagnosis and treatment of penetrating cardiac injury?

(A) The false negative rate is high

(B) Most of the pericardial blood can usually be removed

(C) If successful, surgery is rarely needed

(D) Rapid aspiration of 20 mL of blood without moving the needle usually indicates successful needle placement

(E) ECG monitoring is more accurate if attached to a plastic catheter

596. Which area of the heart is MOST commonly injured in a myocardial contusion?

(A) Right ventricle

(B) Right atrium

(C) Left ventricle

(D) Left atrium

(E) Interventricular septum

597. Which of the following is the MOST common valvular injury in a patient who survives transport to the ED after blunt cardiac trauma?

(A) Papillary muscle or chordae tendineae of mitral valve

(B) Mitral valve leaflets

(C) Aortic valve

(D) Pulmonic valve

(E) Tricuspid valve

598. What is the MOST likely abnormality that would be seen on chest x-ray in a patient with traumatic rupture of the aorta after blunt injury?

(A) Superior mediastinal widening

(B) Obscuration of the aortic knob

(C) Deviation of esophagus to the left

(D) Fracture of the first or second rib

(E) Apical cap

599. Physical findings suggestive of traumatic rupture of the aorta include all of the following EXCEPT

(A) flail chest

(B) systolic murmur over the back

(C) lower extremity hypertension

(D) difference in pulse amplitudes between the upper and lower extremities

(E) hoarseness without laryngeal injury

600. Which of the following statements is TRUE regarding blunt tracheobronchial injuries?

(A) Blunt cervical tracheal injuries usually occur proximal to the tracheal cartilage

(B) Most lower tracheobronchial injuries occur 5 cm or more from the carina

(C) Common signs and symptoms include dyspnea, hemoptysis, subcutaneous emphysema, Hamman's sign, and sternal tenderness

(D) Injuries to the major bronchi are usually caused by elevated intraabdominal pressure

(E) Concurrent esophageal injuries occur in fewer than 5 percent of cases

601. Approximately how much blood is contained in an acute pericardial tamponade after penetrating cardiac injury?

602. In which of the following cases would a diagnostic peritoneal lavage (DPL) be the MOST useful?

(A) Blunt abdominal trauma with hypotension and free intraperitoneal fluid on ultrasound

(B) Multiple trauma with spinal cord injury and normal abdominal examination

(C) An alert patient involved in a high-speed vehicle collision with no abdominal findings

(D) Gunshot wound (GSW) to the mid-abdomen with intraabdominal bullet fragments

(E) Penetrating abdominal injury with diffuse abdominal tenderness and rebound tenderness

603. Which of the following is an indication for surgery in a patient with blunt kidney injury?

(A) Hematuria with more than 100 red blood cells (RBC)/high-power field (HPF) on an unspun urinalysis

(B) Severe flank pain unrelieved by analgesics

(C) Unexplained hypertension

(D) Flank hematoma

(E) Laceration through Gerota's fascia

604. Which of the following would NOT be considered a positive DPL in a patient with blunt abdominal trauma?

(A) > 20 mL gross blood aspirated upon catheter entry

(B) RBC count in lavage fluid 200,000 cells/^L

(C) WBC count in lavage fluid 100 cells/^L

(D) Amylase level in lavage fluid 500 U/100 mL

(E) Vegetable matter seen in lavage fluid

608. What is the MOST commonly injured structure in the genitourinary (GU) tract?

(A) Bladder

(B) Kidney

(C) Ureter

(D) Urethra

609. A young female presents to the ED with flank pain and abdominal tenderness after a high-speed MVA. Abdominal CT shows a non-enhancing kidney. Which of the following is the MOST likely diagnosis?

(A) Renal artery thrombosis

(B) Ureteral disruption

(C) Renal laceration

(D) Renal pelvis rupture

(E) Renal contusion with large subcapsular hematoma

605. Which of the following statements regarding diaphragmatic injury after blunt abdominal trauma is MOST correct?

(A) Diaphragmatic herniation is usually apparent on initial upright chest x-ray

(B) The right side of the diaphragm is more commonly injured than the left

(C) CT and DPL are almost never helpful in diagnosis

(D) The diagnosis is usually made immediately

(E) Difficulty in passing a nasogastric tube suggests herniation of abdominal viscera into the chest

606. A 25-year-old male driver is brought to the ED by ambulance after a high-speed head-on collision. Physical examination is remarkable for a blood pressure of 70/P, heart rate of 140, abdominal tenderness, and a prominent hematoma across the mid-abdomen. Which of the following organs is MOST likely to be injured?

(B) Spleen

(C) Kidney

(E) Bladder

607. Which one of the following is NOT associated with penile rupture?

(A) Blood at the urethral meatus

(B) Penile pain

(C) Penile swelling

(D) Penile discoloration

(E) Priapism

610. All of the following statements regarding bladder injuries are TRUE EXCEPT

(A) the bony pelvis protects the bladder in adults

(B) penetrating injuries are more common than blunt injuries

(C) surgical repair is usually indicated after intraperitoneal ruptures

(D) extraperitoneal ruptures are usually treated with catheter drainage alone

(E) contusions rarely require surgical treatment

611. Which of the following is LEAST appropriate in the initial management of a patient with a pelvic fracture and ongoing hemorrhage?

(A) Placement of an external fixator device

(B) Crystalloid infusion

(C) Blood transfusion

(D) Angiography and vessel embolization

(E) Laparotomy

612. Which of the following blunt traumatic injuries would be MOST likely to result in a positive DPL?

(A) Renal pedicle injury

(B) Small bowel mesenteric tear

(C) Subcapsular splenic rupture

(D) Ureteral transection

(E) Duodenal hematoma

613. In examining a patient with blunt pelvic injury after a 20-foot fall, you find blood at the urethral meatus and a normal prostate examination. What is the MOST appropriate next step to evaluate for the cause of the urethral blood?

(A) Cystogram

(B) Intravenous pyelogram (IVP)

(C) CT with intravenous and oral contrast

(D) Foley catheter

(E) Retrograde urethrogram

614. Which of the following statements regarding wound ballistics is CORRECT?

(A) Tissue surrounding a bullet track should be excised to prevent wound necrosis

(B) Military bullets are more damaging than civilian bullets of the same size

(C) Bullets frequently tumble in flight

(D) Bullets frequently tumble in tissue

(E) Bullets of the same caliber have the same wounding potential

615. All of the following are considered passive injury countermeasures EXCEPT

(A) motorcycle helmets

(B) automobile airbags

(C) building sprinkler systems

(D) spring-loaded lawnmower shutoff switches

(E) spring-loaded circular saw blade covers

616. Which of the following statements regarding injury control is CORRECT?

(A) Educational programs are almost always valuable in changing behavior

(B) Enactment of mandatory use laws rarely affects behavior

(C) States that have repealed mandatory motorcyclist helmet laws have seen little or no increase in fatality rates

(D) Driver education has been more successful than motor vehicle engineering in reducing death rates from vehicle crashes

(E) Mandatory-use laws are difficult to enact

617. Which of the following neurological findings would MOST likely result from a nerve injury caused by a mid-shaft humerus fracture?

(A) Weakness in wrist extension

(B) Decreased sensation over the dorsum of the little finger

(C) Decreased sensation to the palmar index finger

(D) Weakness in wrist flexion

(E) Weakness in index finger abduction

618. Which of the following statements regarding scapular fractures is CORRECT?

(A) They are most common in elderly women

(B) The most common mechanism of injury is a rotational torso movement

(C) Associated injuries rarely occur

(D) Common associated injuries involve the ribs and lungs

(E) Open reduction and internal fixation is usually required

619. Which is the MOST frequently injured solid organ after penetrating trauma?

(B) Spleen

(C) Pancreas

(D) Kidney

(E) Diaphragm

620. Which of the following statements regarding pancreatic injuries is CORRECT?

(A) Penetrating injuries are more common than blunt injuries

(B) The serum amylase is almost always elevated

(C) DPL is highly sensitive

(D) Complications are infrequent and of little consequence

(E) Concomitant injuries are rare

621. Which of the following urinalysis results would be an indication for IVP or abdominal CT in an adult after blunt abdominal or flank trauma?

(D) Gross hematuria

(E) Dipstick positive for blood

622. An adult patient has abdominal pain, tenderness, and a lap-belt hematoma after a vehicle crash. Which of the following is the LEAST likely to be injured?

(A) Spleen

(C) Small intestine

(D) Ureter

623. Which of the following knee injuries is MOST likely to be associated with vascular trauma?

(A) Tibial plateau fracture

(B) Femoral condyle fracture

(C) Anterior dislocation

(D) Posterior dislocation

(E) Lateral dislocation

624. A fracture at which of the following sites is MOST likely to be associated with a disruption of the midfoot?

(A) Base of the second metatarsal

(B) Calcaneus

(C) Base of the fifth metatarsal

(D) Navicular

(E) Cuboid

625. Regarding Achilles tendon rupture, all of the following are TRUE EXCEPT

(A) Thompson's test is usually positive

(B) a palpable tendon defect is usually present

(C) active plantar flexion excludes the diagnosis

(D) patients frequently report hearing a snap at the time of injury

(E) this injury usually occurs in middle-aged men

626. What compartment pressure indicates the need for fasciotomy in a patient with suspected compartment syndrome?

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