83 Top TRAUMA and BURNS Multiple Choice Questions and Answers pdf

1. Nasotracheal intubation:
A. Is preferred for the unconscious patient without cervical spine injury.
B. Is preferred for patients with suspected cervical spine injury.
C. Maximizes neck manipulation.
D. Is contraindicated in the patient who is breathing spontaneously.
Answer: B

DISCUSSION: The first principle in the management of any injured patient is to secure an adequate airway. This can be particularly difficult in the presence of facial or laryngeal trauma, or in the unconscious patient with a suspected cervical spine injury. The mechanical removal of oral debris followed by the “chin lift” or “jaw thrust” maneuvers to relieve soft tissue obstruction of the pharynx are the first steps. However, when there is any question regarding the adequacy of the airway, or in the presence of severe head injury, or when the patient is in profound shock, more definitive airway control is required. In most patients this involves oral endotracheal intubation. However, the insertion of an oral endotracheal tube often involves hyperextension of the neck with the potential for aggravating cervical spine ligamentous or bony injury. Nasotracheal intubation is the preferred option for the patient with suspected cervical spine ligamentous or bony injury since the head and neck can be maintained in the neutral position with minimal manipulation. This technique requires a breathing patient, as the passage of air must be heard through the nasotracheal tube prior to its insertion through the larynx into the trachea. Nasotracheal intubation is contraindicated in the presence of mid-face fractures. In this situation, a surgical airway (cricothyroidotomy, tracheostomy, or needle cricothyroidotomy) is the preferred option.

2. Cardiac contusions caused by blunt chest trauma:
A. Are fairly easy to diagnose.
B. Occur in up to 20% to 40% of patients with major blunt thoracic trauma.
C. Do not usually cause right ventricular dysfunction.
D. Demonstrate arrhythmia as the most common complication.
Answer: BD

DISCUSSION: Cardiac contusions are often difficult to diagnose, but have been estimated to occur in 5% of major trauma patients, and up to 20% to 40% of patients with severe blunt chest injury. The difficulty in diagnosing cardiac contusions is that they remain a pathologic diagnosis, confirmed only at autopsy or on direct cardiac examination. The injury may vary from superficial epicardial petechiae to complete transmural damage. Although significant myocardial injuries, such as ventricular rupture, coronary vessel thrombosis, and valvular disruption, have been reported, the most common clinically significant result of cardiac contusion is the occurrence of arrhythmias. Hence, an initial electrocardiogram (ECG) and subsequent continuous cardiac monitoring for at least 24 hours is generally recommended. Alternative methods of diagnosing myocardial contusion include creatine phosphokinase cardiac isoenzymes (CPK-MB), two-dimensional echocardiography, gated ventricular scintigraphic angiography (GVA), radioactive thallous chloride ( 201Tl) uptake, and right ventricular monitoring. Unfortunately, none of these tests is adequately sensitive or specific in the diagnosis of cardiac contusion, and their correlation with the presence of arrhythmias or ECG changes is also imprecise.

3. According to the recommendations of the American College of Surgeons Committee on Trauma, which of the following patients should be transported to a trauma center?
A. Fifty-year-old female who fell 8 feet from a step ladder, with isolated hip fracture and normal vital signs.
B. Fifteen-year-old bicyclist with closed head injury and Glasgow Coma Scale score of 12.
C. Twenty-three-year-old male assault victim with stab wound to the back, normal vital signs, and respiratory distress.
D. Three-year-old infant passenger (restrained) in motor vehicle accident with normal vital signs and no apparent injuries except abdominal wall contusion.
Answer: BCD

DISCUSSION: The American College of Surgeons Committee on Trauma has developed a field triage decision scheme to help identify trauma victims with a significant risk of dying as a result of their injuries. This classification is based on four factors: (1) abnormal physiologic signs, (2) anatomic area of injury, (3) mechanism of injury, and (4) concurrent or co-morbid disease states. Major physiologic abnormalities include a Glasgow Coma Scale score of less than 13, systolic blood pressure less than 90 mm. Hg, respiratory rate less than 10 or greater than 29 per minute, or a Revised Trauma Score of less than 11 or a Pediatric Trauma Score of less than 9. Significant anatomic considerations include penetrating injuries to the torso, head and neck, and proximal extremities, flail chest, combination of trauma with burns to greater than 10% of body surface area, two or more proximal long bone fractures, pelvic fractures, paralysis, or traumatic amputation above the wrist or ankle. Significant mechanisms of injury include a death in the same passenger compartment or ejection from the automobile, high-impact (greater than 5 miles per hour) auto-pedestrian injuries, or a pedestrian thrown or run over. The co-morbid factors include pediatric or elderly (55) patients or known history of insulin-dependent diabetes or cardiac, respiratory, or psychotic disorders. These criteria should serve as guidelines for medical control and the pre-hospital care providers. Such triage guidelines have been shown to produce the triage of only a small fraction (5% to 10%) of all injured patients to Level I or Level II trauma centers.

4. Which of the following statements about head injuries is/are false?
A. The majority of deaths from auto accidents are due to head injuries.
B. Head injury alone often produces shock.
C. A rapid and complete neurologic examination is part of the initial evaluation of the trauma patient.
D. Optimizing arterial oxygenation is part of initial therapy.
Answer: B

DISCUSSION: Head injuries cause the majority of deaths following automobile accidents, with rupture of the thoracic aorta the second most common cause of fatality. Head injury itself rarely produces hypotensive shock. It is only in the terminal phases of brain death that hypotension may be attributable to head injury alone. Therefore, hypotension in trauma patients must be assumed to be secondary to volume depletion or ongoing hemorrhage. An occult site of hemorrhage (chest, abdomen, pelvis, retroperitoneum, or extremities) must be strongly suspected and dealt with accordingly. A rapid and complete neurologic assessment is a crucial part of the initial assessment of all trauma patients. This initial exam gives an excellent indication of injury severity and prognosis. Since the ultimate outcome of a brain injury is dependent on adequate cerebral perfusion and oxygenation, adequate airway control, ventilation, hemorrhage control, volume restitution, and arterial oxygenation are crucial factors in the early management of head injuries.

5. Which of the following statements about maxillofacial trauma is/are false?
A. Asphyxia due to upper airway obstruction is the major cause of death from facial injuries.
B. The mandible is the most common site of facial fracture.
C. The Le Fort II fracture includes a horizontal fracture of the maxilla along with nasal bone fracture.
D. Loss of upward gaze may indicate either an orbital floor or orbital roof fracture.
Answer: B

DISCUSSION: Maxillofacial injuries generally do not cause life-threatening injuries, with the exception of those that occlude the airway. Therefore, the first priority in assessing and managing the patient with maxillofacial trauma is to assess and assure the adequacy of the airway. The face is typically divided into thirds when defining injuries. Injuries to the upper third of the face are often accompanied by ocular or central nervous system complications as well as facial deformities. Fractures of the orbital roof are frequently associated with frontal sinus and nasal ethmoid fractures, and are accompanied by a loss of upward gaze due to involvement of the superior rectus muscle. However, the most common cause of loss of upward gaze is orbital floor injury and associated entrapment of the globe or injury to the inferior rectus muscle. Middle third of facial structures include the maxilla, zygoma, orbits, and nose. The Le Fort classifications of facial fractures are commonly employed to describe these complex fracture lines. In a Le Fort II fracture, the superior fracture line is transverse through the nasal bones or through the articulation of the maxillary and nasal bones with the frontal bones. This is also known as the “pyramidal” fracture of the mid-face. The diagnosis is established by digital manipulation of the anterior maxilla and observation for mobility of the central triangle (the maxilla and nose). The lower third of the face contains a single facial bone, the mandible. After the nasal bones, the mandible is the second most commonly fractured facial bone.

6. What percentage of patients with thoracic trauma require thoracotomy?
A. 10%–15%.
B. 20%–25%.
C. 30%–40%.
D. 45%–50%.
Answer: A

DISCUSSION: Twenty-five per cent of civilian trauma deaths are caused by thoracic trauma, and two thirds of these deaths occur after the patient reaches the hospital. Mortality of hospitalized patients with isolated chest injury ranges from 4% to 8% and increases to 35% when multiple additional organ systems are involved. Despite high mortality, only 10% to 15% of thoracic injuries require thoracotomy. Most injuries are successfully managed by the rather simple life-saving maneuvers of airway control and tube thoracotomy. Unrelenting hemorrhage following either penetrating or blunt thoracic trauma is a primary indication for immediate thoracotomy. An initial thoracic blood loss of greater than 1500 ml. (30% of blood volume) or an ongoing loss of 250 ml. for 3 consecutive hours serves only as a practical guideline. The patient’s hemodynamic status and overall condition should be the most influential factors.

7. The radiographic findings indicating a torn thoracic aorta include:
A. Widened mediastinum.
B. Presence of an apical “pleural cap.”
C. First rib fractures.
D. Tracheal deviation to the right.
E. Left hemothorax.
Answer: ABCDE

DISCUSSION: All of the listed radiographic findings should arouse suspicion of a possible torn thoracic aorta. The most common abnormality noted is a widening of the mediastinal shadow, although only 20% to 40% of patients with a wide mediastinum have aortic injury. In addition to the radiographic signs listed, other findings that may alert the physician to the possibility of an aortic tear include loss of aortic contour, elevation of the left mainstem bronchus, depression of the right mainstem bronchus, shift of the nasogastric tube to the left, and the presence of retrocardiac density. Aortography remains the “gold standard” diagnostic modality and is indicated if aortic injury is suspected on the basis of mechanism of injury and any of these suggested findings.

8. Which of the following statements about diagnostic peritoneal lavage (DPL) is/are false?
A. DPL is the diagnostic procedure of choice for gunshot wounds to the abdomen with no obvious intra-abdominal injuries.
B. The average reported incidence of false-positive DPL in patients with significant pelvic fractures is 20% to 30%.
C. Accuracy rates for DPL have generally been reported between 95% and 97%.
D. DPL has been entirely replaced by computed tomography as the diagnostic procedure of choice following blunt abdominal trauma.
Answer: AD

DISCUSSION: DPL remains the most sensitive and specific indicator of intra-abdominal injury in the trauma patient. The accuracy rates for DPL in several large collective series reveal an overall sensitivity of 95%, specificity of 98% to 99%, and overall accuracy of 97%. As result, DPL remains the mainstay for diagnosis of intraperitoneal injury in the trauma patient; however, not every trauma patient requires DPL. In the awake, alert, and responsive patient with isolated abdominal injuries, the physical examination and history are very helpful in predicting the presence of significant injury. In the patient with lower torso (nipples to pubis) or back or flank gunshot wounds, the incidence of intra-abdominal injury is so high that exploratory laparotomy without further diagnostic modalities is generally advocated. In addition, DPL is generally inaccurate in the diagnosis of retroperitoneal injuries (duodenum, renal, pancreas), and significant retroperitoneal hemorrhage in association with pelvic fractures produces a false-positive DPL rate of up to 30%. Computed tomography (CT) scans have proved extremely valuable in these situations. General recommendations for the use of abdominal CT scans in trauma victims include patients who are hemodynamically stable (normal) with (1) equivocal abdominal examination, (2) closed head injury, (3) spinal cord injury, (4) hematuria, and (5) pelvic fractures with significant bleeding. These five indications are appropriate if the patient is truly hemodynamically stable and the time required to perform CT does not delay any surgical procedures.

9. A 28-year-old male was injured in a motorcycle accident in which he was not wearing a helmet. On admission to the emergency room he was in severe respiratory distress and hypotensive (blood pressure 80/40 mm. Hg), and appeared cyanotic. He was bleeding profusely from the nose and had an obviously open femur fracture with exposed bone. Breath sounds were decreased on the right side of the chest. The initial management priority should be:
A. Control of hemorrhage with anterior and posterior nasal packing.
B. Tube thoracostomy in the right hemithorax.
C. Endotracheal intubation with in-line cervical traction.
D. Obtain intravenous access and begin emergency type O blood transfusions.
E. Obtain cross-table cervical spine film and chest film.
Answer: C

DISCUSSION: Airway remains the first priority in the management of any patient with multiple injuries. Control of the airway in a patient with head, face, and neck injury can be extremely challenging. In the patient presented, the best option given for control of the airway is endotracheal intubation with in-line cervical traction. This requires at least two persons, one to maintain the head in the neutral position and one to insert the endotracheal tube under direct vision. An alternative in this case would be emergency cricothyroidotomy, tracheostomy, or needle-jet insufflation. Nasotracheal intubation is not an option in the presence of a mid-face fracture and a nasal hemorrhage. Clearly, attention must also be directed at assuring adequacy of ventilation (potential right pneumothorax), assessing and treating obvious hemorrhage, determining if there is occult intra-abdominal or thoracic hemorrhage, and determining the patient’s neurologic status. While management of these other issues can occur simultaneously, they do not take priority over securing an adequate airway. In this patient the airway is so tenuous that time should not be spent obtaining a cross-table cervical spine film and chest film prior to definitive control of the airway.

10. True or False?
A. Trauma is second only to congenital heart disease as the leading cause of death in children.
B. Each year in the United States, approximately 50,000 people die from injuries.
C. Motor vehicle accidents (MVAs) involving intoxicated drivers are responsible for 50% of all MVA fatalities.
D. Active prevention strategies (e.g., seat belts, helmets) have not proved effective in reducing injuries and fatalities.
E. Falls and diving accidents comprise approximately 30% to 40% of cervical spine injuries.
Answer: TRUE C; FALSE ABD

DISCUSSION: The statistics on injuries highlight trauma as “the principal public health problem in America today.” Trauma remains the leading cause of death in children and adults up to the age of 44 years, and injuries kill more Americans age 1 to 34 years than all diseases combined. Each year more than 140,000 Americans die of injuries, 50,000 due to motor vehicle accidents. Just over 50% of motor vehicle injuries involve intoxicated drivers. Injury prevention would be the most cost-effective method of dealing with this major social and economic burden. Active injury prevention strategies are those that require active continued cooperation on the part of the individual, such as wearing a helmet when driving a motorcycle or wearing seat belts in automobiles. Passive approaches such as fitting all motor vehicles with driver air bags require little or no individual cooperation and have clearly proved the more effective option, but active prevention strategies have repeatedly been demonstrated to reduce injury fatalities. States with seat belt and child restraining laws show an increase in seat belt use of more than 60% with a concurrent 9% to 12% reduction in occupant fatalities. Motor vehicle accidents are responsible for approximately 60% of spinal cord injuries, falls for 20% to 30%, and diving accidents for an addition 5% to 10%. Spinal cord injury acute care and rehabilitation represent some of the most expensive medical treatment, with an average hospital charge of $50,000 in 1988 for a quadriplegic survivor.

11. Regarding the diagnosis and treatment of cardiac tamponade, which of the following statements is/are true?
A. Accumulation of greater than 250 ml. of blood in the pericardial sac is necessary to impair cardiac output.
B. Beck’s classic triad of signs of cardiac tamponade include distended neck veins, pulsus paradoxicus, and hypotension.
C. Approximately 15% of needle pericardiocenteses give a false-negative result.
D. Cardiopulmonary bypass is required to repair most penetrating cardiac injuries.
Answer: C

DISCUSSION: Cardiac tamponade is most frequently caused by penetrating thoracic injury, but may occasionally be observed following blunt thoracic trauma from cardiac chamber rupture, coronary artery laceration, or ascending dissection of an aortic tear. Accumulation of as little as 150 ml. of blood in the pericardium will sufficiently decrease diastolic filling to produce distended neck veins, cyanosis, and decreased cardiac output. Beck’s classic triad of distended neck veins, muffled heart sounds, and hypotension is present in only one third of patients with tamponade. Pulsus paradoxicus is even less frequently discernible. Immediate temporary treatment consists of pericardiocentesis, which also provides a diagnosis. However, approximately 15% of pericardiocenteses give false-negative results because of a clotted hemopericardium. Therefore, echocardiography prior to needle aspiration is generally advisable if promptly available. In the patient in extremis, emergency thoracotomy with pericardiotomy and cardiac repair should be performed. Most patients with penetrating cardiac wounds do not require cardiopulmonary bypass to repair their injuries.

12. Which of the following statements or descriptions typically characterizes the syndrome of overwhelming postsplenectomy sepsis?
A. A syndrome of fulminant gram-negative bacteremia and septicemia in asplenic individuals, characterized by the presence of as many as 10 6 bacterial organisms per cu. mm. circulating in the bloodstream.
B. A syndrome caused primarily by impaired host ability to mount an effective humoral (immunoglobulin) response to infection.
C. A syndrome that occurs in 5% to 7% of patients following traumatic splenectomy.
D. A syndrome of rapidly appearing septic shock unresponsive to antibiotic therapy, with an average mortality of 50%.
E. The syndrome may be prevented by preserving as little as 15% of splenic mass in adult trauma victims.
Answer: D

DISCUSSION: In 1952 King and Schumaker suggested that children who had undergone splenectomy were at risk for the development of bacterial infections, and the syndrome of overwhelming postsplenectomy sepsis (OPSS) was suggested by Diamond in 1969. The syndrome is unlike fulminating bacteremias and septicemia in individuals with normal splenic function. The onset is sudden, with nausea, vomiting, headache, and confusion leading to coma. The new infecting organism is a gram-positive organism in over half the cases, primarily Streptoccoccus pneumoniae. Blood cultures may occasionally demonstrate up to as many as 10 6 bacterial organisms per cu. mm. circulating in the bloodstream. Disseminated intravascular coagulation is common along with hypoglycemia, electrolyte imbalance, and shock unresponsive to antibiotics and fluid or pharmacologic support. Mortality has generally been reported as high as 50% and even up to 80% for pneumococcal infections. The true incidence of overwhelming postsplenectomy sepsis following a splenectomy from trauma is not well defined. Green and colleagues suggested that the risk of OPSS is 166 times the rate expected for the general population. Eraklis and Filler suggested that the incident rate of mortality from sepsis and OPSS is 78 times greater than that expected for the general population. Despite this increased frequency, overwhelming postsplenectomy sepsis remains a rare event. Singer’s large review of 688 children who had undergone splenectomy for trauma demonstrated only a 1.45% incidence of postsplenectomy sepsis, but a 40% mortality. The occurrence of OPSS appears to be less following splenectomy for trauma when compared with splenectomy for congenital hematologic disorders. Nonetheless, the recognition of the severe nature of this entity has prompted many trauma surgeons to more aggressively attempt splenic salvage. Animal laboratory evidence suggests that at least 50% of the splenic tissue mass must be preserved to prevent overwhelming postsplenectomy sepsis. The immunologic function of the spleen that appears to be most beneficial in preventing OPSS is the spleen’s capacity for clearance of blood-borne particles and the provision of circulating opsins, which assist in cell-mediated immunologic functions.

13. Trauma deaths most commonly occur at three distinct time periods after injury. Which of the following statement(s) is/are true concerning the time pattern of trauma mortality?

a. Only 10% of trauma deaths occur within seconds or minutes of the injury
b. A second mortality peak occurs within hours of injury with deaths in this time period being markedly reduced with the development of trauma and rapid transport systems
c. Death one day to weeks after the injury are almost entirely due to infection and multiple organ failure
d. Late mortality in trauma patients, occurring days to weeks after the injury, has not been affected by better trauma delivery systems
Answer: b

Trauma deaths occur at three traditionally recognized times after injury. About half of all trauma-related deaths occur within seconds or minutes of injury and are related to lacerations of the aorta, heart, brain stem, brain, and spinal cord. Few of these patients are saved by health care systems, regardless of efficiency. The second mortality peak occurs within hours of injury and accounts for about 30% of deaths, half of which are due to hemorrhage and half due to central nervous system injuries. Important reductions in mortality during this period have resulted from the development of trauma and rapid transport systems. Overall, trauma mortality rates have been reduced from about 30% to 2% to 9% where well-organized trauma care systems exist. The third mortality peak includes deaths that occur one day after trauma to weeks later. This mortality rate is usually attributed to infection and multiple organ failure. Ten to 20% of trauma deaths occur during this period. The development of efficient trauma systems, however, has changed the epidemiology of these deaths. During the first week after trauma, refractory intracranial hypertension after severe head injury now accounts for a significant number of these deaths. The incidence of sepsis and multiple organ failure has diminished as the result of aggressive and better early resuscitation and care. Sepsis and multiple organ failure now account for about 5% of overall mortality and only 30% of late mortality where organized trauma systems exist.

14. Which of the following statement(s) is/are true concerning the epidemiology of trauma?

a. Trauma is the leading cause of death of individuals less than 44 years of age
b. Trauma follows only cancer and heart disease as leading causes of productive life lost
c. Motor vehicle accidents are the most common cause of traumatic death in young males of all ethnic groups
d. Young males are the population at highest risk for trauma death
Answer: a, d

Although injury affects all age groups, it is epidemic within the younger population of our society. In the United States, injury is the leading cause of death in individuals less than 44 years and results in 70% of the total hospital admissions. Young males are the highest risk group, not because of physiologic distinctions, but because of their propensity to engage in high-risk activities. Although the three leading causes of traumatic death in all ethnic groups are motor vehicle accidents, homicide, and suicide, for individuals under 35 years of age, the order in which these occur differs. In the African-American population, the leading cause of death in this age group is homicide, while in all other groups it is motor vehicle accidents. Although morbidity and mortality figures are important, another important method of analyzing the toll injury places on a society is in years of productive life lost. Years of productive life lost is used to reflect the amount of productive working time lost due to premature death. Since injury is so prevalent in the younger population, a traumatic death in this age group will result in a large number of years of productive life lost, more so than deaths in the older age groups due to chronic diseases. In fact, years of productive life lost due to injury are approximately 40% higher than those found in cancer or heart disease patients, the second and third leading causes of productive life lost.

15. Which of the following statement(s) is/are true concerning the biomechanics of blunt trauma?

a. A small child and a large adult have a markedly different level of energy transfer in a high speed vehicular collision
b. Shear strain injuries result from rapid acceleration or deceleration
c. Tensile strain results from direct compression of tissues
d. The tolerance of biologic tissue to trauma injury is directly proportional to the elasticity of the organ
Answer: b, c, d

The severity of any injury is directly proportionate to the amount of kinetic energy transferred to the tissues and the properties of that tissue which accept and dissipate the energy. Kinetic energy (KE) is a function of the mass (M) of an object and its
velocity (V):

KE = M x V^2 /2

It is clear from this relationship that changes in velocity alter the kinetic energy transferred more significantly than changes in mass. Therefore, a small child and a large adult, though significantly different in size and weight, are subjected to similar levels of energy transfer in a high-speed vehicular collision, the primary determinant being velocity rather than mass. The tolerance of a biologic tissue to traumatic injury is directly proportional to the elasticity of the organ—that is, its ability to return to its original shape and position. Elasticity is directly affected by the rate of loading, or the rate at which strain is applied to the tissues. Applying the force more rapidly increases the likelihood of exceeding tolerance. Blunt trauma results in two types of forces during impact. First, changes in speed (acceleration or deceleration) create shear strain, and second, deformity changes (stretch or compression) creates tensile strain.

16. The patient described above has also suffered major facial trauma. Which of the following statement(s) is/are true?

a. A frontal bone fracture and injury to the frontal sinus is a common facial injury in a young adult
b. The optic nerve can be injured in a LeFort type II fracture
c. A facial nerve injury may occur with the fracture of the temporal bone
d. Coronal CT scan images can be a useful adjunct to the evaluation of the patient with facial and head injuries
Answer: c, d

A major cause of maxillofacial trauma are motor vehicle accidents. Facial skeletal fractures and soft tissue damage in the frontal, orbital, nasal, zygomatic, maxillary and mandibular regions are included. The frontal bone, which houses the frontal sinuses, is particularly strong due to its arched configuration as well as thick, hard bone. The amount of force necessary to fracture the frontal sinus is two to three times greater than that necessary for other facial bone fractures. Consistent fracture patterns from blows to the maxilla have been classified by LeFort and occur within and along the maxilla at its junction with weaker and aerated bone of the paranasal sinuses and nasal cavity. The classic LeFort fractures are classified as LeFort I, LeFort II and LeFort III and are of increasing complexity and morbidity. The cribriform plate, ethmoidal arteries, optic nerve and internal maxillary artery are all vulnerable to injury with a LeFort III fracture.
Soft tissue injuries of the face are encountered even more often than facial fractures. The facial nerve is the most important underlying structure at risk since blunt or penetrating trauma to the nerve or branches can cause complete or partial ipsilateral facial paralysis. The most common cause of facial nerve injury is fracture of the temporal bone, but injury can occur anywhere from the intracranial to the extracranial facial course of the nerve.
After securing the airway and controlling life-threatening hemorrhage, the secondary survey including the facial area is carried out. The nose is inspected for deformity, pain, mobility, septal hematoma and obstruction. Bleeding should be managed immediately. Leakage of cerebral spinal fluid suggests a cribriform plate or ethmoidal fracture and a presence should warn against insertion of any nasal tubes or packing. Since CT scan is part of the standard management of the head-injured patient, sections of the facial skeleton can be obtained simultaneously, providing information on the extent of facial fractures in addition to the status of the brain. Axial and coronal sections (obtained with the patient’s head hanging with the neck extended) are complimentary and are especially helpful in delineating the cribriform plate and ethmoid roof region, the orbital rims, and the overall vertical facial height.

17. There are a number of options for resuscitative fluids. Which of the following statement(s) is/are true concerning fluids used for resuscitation of shock?

a. Resuscitation with crystalloid requires volume replacement in a ratio of 1:1 to volume lost
b. The literature strongly supports the use of colloid as being superior to crystalloid in the resuscitation of shock
c. Risks of autotransfused blood include disseminated intravascular coagulation and activation of fibrinolysis
d. Hypertonic saline solution results in volume expansion, an increase in left ventricular performance, decreased peripheral resistance, and redistribution of cardiac output to kidneys and viscera
e. The use of perfluorocarbons as an experimental resuscitative fluid has been demonstrated to stimulate the immune system
Answer: c, d

Balanced salt solutions are the most commonly used resuscitative fluids, and their use to restore extracellular volume significantly decreases the transfusion requirement after hemorrhagic shock. Lactated Ringers and normal saline are the most effective crystalloid solutions in common use. Resuscitation with crystalloid require a volume administration ratio of 3:1 to 4:1 over volume lost. Although colloids do not replete the interstitial space, they have a volume-expanding effect somewhat greater than the amount used. Colloids commonly used for volume expansion in hypovolemia include albumen, dextran 70, dextran 40, and hydroxyethyl starch (hetastarch). Significant controversy exists concerning the use of crystalloid versus colloid resuscitation. Although the question has not been resolved, several recent studies have indicated an advantage to crystalloid in resuscitation. A meta-analysis of colloid versus crystalloid resuscitation after hemorrhagic shock has demonstrated a higher mortality rate in the colloid resuscitated patients, partly due to pulmonary complications. Patients who lose more than 25 to 30% of total blood volume will need blood for resuscitation. Type O, Rh-negative (universal donor blood) is immediately available without a cross match. Type-specific blood is available within most blood banks within five to ten minutes of receipt of the blood specimen, while the patient is being resuscitated with balanced salt solutions. Although not cross matched, this blood can be administered safely, and therefore its rapid availability and safety make type-specific blood the blood of choice for resuscitation in trauma. Autotransfusion involves the collection of shed blood and its reinfusion through a filter back into the patient. Autotransfused blood may produce disseminated intravascular coagulation (DIC) and activation of fibrinolysis. In addition, blood collected from the peritoneal cavity after hollow viscus injury, even with cell washing, may lead to bacterial contamination of the autotransfused blood. Hypertonic solutions have been used in the resuscitation of patients after burn, shock, elective vascular surgery and trauma. In addition to volume expansion, hypertonic saline solutions have been shown to increase left ventricular performance, decrease peripheral resistance from arteriolar dilatation, and redistribute cardiac output to the kidneys and viscera. Perfluorocarbons are an experimental resuscitation fluid comprised of large, branched or cyclic aliphatic compounds which have the ability to dissolve and carry oxygen. Although effective in volume resuscitation with improved oxygen delivery and oxygen-carrying capacity, perfluorocarbon infusion has been shown to depress platelet counts, plasma immune globulin levels and depress other aspects of immune function.

18. Hemorrhage initiates a series of compensatory responses. Which of the following statement(s) is/are true concerning the physiologic responses to hemorrhagic shock?

a. An immediate response is an increased sympathetic discharge with resultant reflex tachycardia and vasoconstriction
b. Transcapillary refill is a response serving to restore circulating volume
c. Extracellular fluid becomes increasingly hyperosmolar
d. Adrenergically mediated vasoconstriction is well maintained at the arteriolar and precapillary sphincters
Answer: a, b, c

Hemorrhage initiates both rapid and slower, more sustained compensatory responses. The body responds to maintain hemostasis almost immediately after the onset of hemorrhage. Decreased activation of the arterial baroreceptors, though a decrease in blood pressure or even more subtly, a decrease in pulse pressure, causes an increased sympathetic discharge, resulting in reflex tachycardia and vasoconstriction. Increased adrenergic output with increased secretion of catecholamines also leads to vasoconstriction, increased heart rate, and increased myocardial contractility. Sustained compensatory responses include the release of vasoactive hormones and fluid shifts from the interstitium and the intracellular space. Adrenergically mediated vasoconstriction affects arterial precapillary and postcapillary sphincters and small veins and venules. The decrease in intravascular hydrostatic pressure distal to the precapillary sphincter leads to reabsorption of interstitial fluid into the vascular space and thereby functions to restore circulating volume. This is known as transcapillary refill. The increased release of stress hormones coupled with relative insulin resistance after shock leads to high extracellular glucose concentrations. In addition, products of anaerobic metabolism from hypoperfused cells accumulate in the extracellular compartment, inducing hyperosmolarity. This extracellular hyperosmolarity draws water from the intracellular space, increasing interstitial osmotic pressure, which in turn drives water, sodium and chloride across the capillary endothelium into the vascular space. If the shock state continues, however, the postcapillary sphincter remains in spasm, but the arteriolar and precapillary sphincters cannot maintain the tension, and they become relaxed. As sphincters relax, the capillary hydrostatic pressure increases and sodium, chloride and water move into the interstitium leading to further depletion of intravascular volume.

19. Which of the following steps is/are part of the primary survey in a trauma patient?

a. Insuring adequate ventilatory support
b. Measurement of blood pressure and pulse
c. Neurologic evaluation with the Glasgow Coma Scale
d. Examination of the cervical spine
Answer: a, b, c

The resuscitation team’s first priority is to simultaneously assess the airway, blood pressure and level of consciousness of the patient. The first priority is assessment of the airway. After establishment of an airway, the next priority is to insure adequate ventilatory exchange by rapid auscultation of both lung fields and assessment for mechanical factors that may interfere with breathing. After establishment of an airway, ventilation and appropriate pleural drainage, if necessary, the next priority is the assessment of the patient’s circulatory status. This includes an estimation of blood volume and cardiac function. The initial survey evaluates blood pressure, pulse, and skin perfusion. It is important to emphasize that effective resuscitation from hemorrhagic shock requires both restoration of intravascular volume and control of hemorrhage. The final priority of the primary survey is a brief neurological evaluation using the components of the Glasgow Coma Scale. Although maintaining axial immobilization of the cervical spine is an important early component of all assessments and resuscitation protocols, examination of the cervical spine regardless of injury is part of the secondary survey.

20. Immediate life-threatening injuries that preclude air exchange which can be treated in the field include which of the following?

a. Tension pneumothorax
b. Massive open chest wounds
c. Sucking chest wounds
d. Tracheal disruption
Answer: a, b, c

After establishment of a patent and controlled airway, the next priority is to insure that air exchange is taking place. Immediate life-threatening injuries that preclude air exchange include: tension pneumothorax, massive open chest wounds, sucking chest wounds, and tracheal disruption. There are no maneuvers likely to correct tracheal disruption in the field. Both open chest wounds and sucking chest wounds will respond to endotracheal intubation and positive pressure ventilation. Tension pneumothorax may require field decompression in the rare patient. Field techniques to deal with tension pneumothorax include needle thoracostomy and chest tube thoracostomy.

21. Which of the following statement(s) is/are true concerning the diagnosis of a peripheral vascular injury?

a. The presence of a Doppler signal over an artery in an extremity essentially rules out an arterial injury
b. Doppler examination is a valuable tool in the diagnosis of venous injuries
c. A gunshot wound in the proximity of a major vessel is an absolute indication for arteriography
d. Both the sensitivity and specificity of arteriography of the injured extremity approaches 100%
Answer: d

22. A 22-year-old male is hospitalized with multiple extremity fractures including a comminuted fracture of the femur and multiple rib fractures. Which of the following statement(s) is/are true concerning his hospital course?

a. Low-dose heparin should not be employed during his hospital stay
b. Acute respiratory failure associated with petechiae of the head, torso, and sclerae would suggest a pulmonary embolism
c. Early fracture fixation would decrease the incidence of fat emboli
d. The placement of a Greenfield filter should be avoided due to the risk of lower extremity edema
Answer: c

23. A middle-aged construction worker had a significant fall on the job and presents with obvious high cervical spine injury. Which of the following statement(s) is/are true concerning his diagnosis and management?

a. A paradoxical breathing pattern in which the abdomen protrudes on inhalation may be observed
b. If the patient appears well compensated on initial evaluation, intubation is unlikely to be necessary
c. The presence of hypotension strongly suggests significant blood loss from associated injury
d. The patient’s extremities are likely to appear warm and well perfused despite the presence of hypotension
e. The use of methylprednisolone beginning 24 hours after the injury will be indicated
Answer: a, d

24. Which of the following statement(s) is/are true concerning Emergency Room thoracotomy?

a. Overall survival rates approach 25%
b. Blunt trauma patients without signs of life upon arrival in the Emergency Room are candidates for Emergency Room thoracotomy
c. All patients with penetrating trauma to the chest and the absence of vital signs are candidates for ER thoracotomy
d. None of the above
Answer: d

25. An untreated or an unrecognized compartment syndrome produces nerve and muscle damage and prevents good functional recovery despite the patency of vascular repair. Which of the following factors suggests the need for a fasciotomy?

a. A period of 6 hours or more between injury and restoration of perfusion
b. Combined arterial and venous injuries
c. Postoperative signs of muscle pain or pain on passive stretch
d. Elevated compartment pressures
answer: a, b, c, d

Factors that suggest the need for fasciotomy are as follows:

1. Prolonged period (6 hours or more) between injury and restoration of perfusion
2. Associated crush injury
3. Preoperative calf swelling
4. Combined arterial and venous injuries
5. Extensive venous ligation
6. Postoperative signs or disproportionate muscle pain, pain on passive stretch, or tender and firm muscles
7. Elevated compartment pressures

26. Which of the following statement(s) is/are true concerning the consequences of vascular injuries?

a. Outcome is time-dependent
b. Further injury can take place after restoration of blood flow
c. Acute acidosis, hyperkalemia and myoglobin-induced renal failure can be consequences of severe extremity ischemia
d. Ischemia to peripheral nerves and muscles can be tolerated to up to four hours without permanent injury
Answer: a, b, c, d

27. Which of the following statement(s) is/are true concerning the surgical management of vascular injuries?

a. A direct approach through the site of injury is often effective as the initial step
b. Systemic heparinization must be avoided in patients with multiple injuries
c. Reversed saphenous vein from the same extremity is the first choice as an interposition graft for extensive arterial injuries
d. Venous repair should not be attempted in a hemodynamically unstable patient
Answer: b, d

28. Penetrating injuries to the pancreas and duodenum are uncommon occurring in 4% and 6% of patients, respectively. Which of the following statement(s) is/are true concerning the management of pancreaticoduodenal injuries?

a. The Kocher maneuver is essential for providing exposure for the duodenum
b. A large injury of the duodenum which cannot be closed primarily will always require a pancreaticoduodenectomy
c. Pyloric exclusion involves suture or staple closure of the pylorus, gastrojejunostomy, tube decompression of the duodenum, and placement of a T-tube in the common bile duct
d. Class III injuries of the head of the pancreas should be treated with simple external drainage rather than resection
Answer: a, d

29. A CT scan is performed on this patient. Which of the following statement(s) is/are true concerning the findings on CT scan and the patient’s management?

a. The CT finding that correlates most significantly with intracranial hypertension is compression or obliteration of the basilar cisterns
b. Intracranial pressure monitoring is indicated immediately in any patient with cisternal compression.
c. A brain contusion appears as a very homogeneous high density area in the cerebral cortex
d. Intracerebral hematomas are routinely treated with craniotomy
Answer: a, b

30. Which of the following statement(s) is/are true concerning the management of chest trauma?

a. The majority of injuries to the chest require surgical intervention
b. The posterior lateral thoracotomy is the optimal approach for emergency thoracotomy
c. Either computed tomography or angiography are suitable methods for detecting aortic disruption in a patient with an abnormal chest x-ray
d. Persistent bleeding associated with a penetrating injury to the chest is often due to injury to an artery of the systemic circulation
Answer: d

31. The anterior neck is divided into three zones defined by horizontal planes. Which of the following statement(s) is/are true concerning penetrating injuries to the anterior neck?

a. Penetrating injuries to Zone I carry the highest mortality
b. Injuries to Zone II are the most common and the mortality rate is second only to those of Zone I
c. Exposure of Zone III for detection of injuries to the distal carotid artery and pharynx can be quite difficult
d. All hemodynamically stable patients with penetrating injuries to Zone I should have angiography
e. Most vascular lesions in Zone III are best treated by surgical exploration
Answer: a, c, d

32. Which of the following statement(s) is/are true concerning the definitive management of neck injuries?
a. Patients with evidence of an acute stroke following penetrating injury involving the carotid artery should be managed with arterial ligation
b. Unilateral vertebral artery occlusion usually results in a clear neurologic deficit and therefore revascularization is indicated
c. The combination of esophography and endoscopy improves the accuracy of detecting esophageal injury with penetrating trauma
d. External drainage is an important aspect of the surgical management of an esophageal injury
e. Arterial dissection secondary to blunt trauma is best managed by operative exploration and resection of the dissection
Answer: c, d

33. A 25-year-old male is involved in a motor vehicle accident with a significant head injury. Which of the following statement(s) is/are true concerning his injury and management?

a. A single episode of systolic blood pressure < 90 mm Hg occurring during the early period after injury significantly increases the chances of mortality and morbidity
b. Systemic hypertension should be avoided to reduce the risk of intracranial hemorrhage
c. The patient should be vigorously hyperventilated to reduce PaCO2
d. The patient should be heavily sedated and pharmacologically paralyzed after the initial neurologic examination Answer: a

34. Which of the following statement(s) is/are true concerning the biomechanics of penetrating injuries?
a. Stab wounds are associated with significant cavitation
b. A hollow point bullet is associated with an enlarged area of injury
c. A high velocity gunshot wound creates a vacuum pulling clothing, bacteria, and other debris into the wound
d. The frontal area of impact of a bullet is determined by the caliber of the bullet
Answer: b, c

35. In which of the following clinical situations is peritoneal lavage indicated?
a. A patient with suspected intraabdominal injury who will undergo prolonged general anesthesia for another injury outside the abdomen
b. A patient with a high velocity abdominal gunshot wound
c. A patient with an abdominal knife wound
d. A hemodynamically unstable patient with a high suspicion of intraabdominal hemorrhage e.
A patient with major noncontiguous injuries (i.e., chest and lower extremity) Answer: a, c, e

36. Physiologic responses to hypothermia include:
a. Tachycardia regardless of core temperature
b. Tachypnea regardless of core temperature
c. Pupillary dilatation and loss of cerebral autoregulation at temperatures below 26°C
d. A cardiac rhythm contraindicates cardiopulmonary resuscitation even in the absence of a palpable pulse Answer: c, d

37. Which of the following statement(s) is/are true concerning the injury pattern in patients with blunt versus penetrating injuries?
a. Solid organs are most frequently injured following blunt trauma b. The liver is the most frequently injured organ in both penetrating and blunt trauma
c. Major vascular injuries occur much more commonly in penetrating trauma than with blunt abdominal trauma
d. Injury patterns for blunt abdominal trauma in children are different than adults whereas with penetrating trauma no such difference exists
Answer: a, c, d

38. An 18-year-old male suffers a gunshot wound to the abdomen, resulting in multiple injuries to the small bowel and colon. Which of the following statement(s) is/are true concerning this patient’s perioperative management?
a. A multi-agent antibiotic regimen is indicated
b. Antibiotics should be continued postoperatively for at least 7 days
c. Laparotomy, as a diagnostic test for postoperative sepsis, should be considered
d. The incidence of postoperative wound or intraabdominal infection would be increased in association with a colon injury
Answer: d

39. A middle-aged man is undergoing laparotomy for blunt abdominal trauma. The spleen and liver are both found to be injured. Which of the following statement(s) is/are true concerning the management of these injuries?
a. If the patient has multiple other abdominal injuries and hypotension, splenic salvage should not be attempted
b. The incidence of life-threatening sepsis in the adult following splenectomy is no greater than in the normal population
c. All liver injuries regardless of their depth require external drainage
d. The Pringle maneuver should control all bleeding from hepatic parenchymal vessels e. If concern for a biliary fistula from the liver parenchyma exists, a T-tube should be placed even if the common bile duct is otherwise normal Answer: a

40. Which of the following conclusions can be drawn from prospective randomized studies involving restoration of circulation in the field?
a. Pneumatic anti-shock garment is of benefit only in patients with a field blood pressure less than 50
b. Patients with major vascular injury should not receive intravenous fluid infusion until bleeding can be controlled in the operating room
c. Hypertonic saline, used as resuscitation fluid, provides no benefit to patients
d. Hypertonic saline has been shown to exacerbate bleeding and precipitate coagulopathy Answer: a, b

41. Which of the following statement(s) is/are true concerning hypothermia following traumatic injury?
a. The majority of patients presented to a level I trauma center are hypothermic at some time
b. The initial temperature for trauma-associated hypothermia is associated with no seasonal variation
c. Moderate levels of hypothermia (34°–32°C) has no effect on mortality in the trauma patient
d. The coagulation system is most affected in hypothermic patients who have sustained major trauma
Answer: a, b, d

42. Which of the following statement(s) is/are true concerning injuries to the chest wall?
a. The mortality rate currently associated with sternal fractures is as high as 25–30%
b. The severe ventilatory insufficiency associated with a flail chest is due to the paradoxical motion of the involved segment of chest wall
c. In most cases of an open pneumothorax, or sucking chest wound, surgical closure is necessary
d. Persistent chest tube bleeding at a rate greater than 200 ml/hour for four hours, or greater than 100 ml/hour for eight hours is an indication for thoracotomy for control of hemorrhage
e. A 20% incidence of splenic injury is associated with fractures of ribs 9, 10 and 11 on the left
Answer: c, d, e

43. A 22-year-old male driving a car at a high speed and not wearing a seatbelt, leaves a road and crashes with a full frontal impact into a tree. Which of the following injury patterns may be predictable from this type of motor vehicle accident?

a. Orthopedic injuries involving the knees, femurs, or hips
b. Laceration to the aorta
c. Hyperextension of the neck with cervical spine injury
d. Diaphragmatic rupture due to marked increase in intraabdominal pressure
Answer: a, b, c

44. Which of the following statement(s) is/are correct concerning the pathophysiology of frostbite?

a. Frostbite injury may have two components: initial freeze injury and a reperfusion injury that follows during rewarming
b. The formation of extracellular ice crystals in the tissue begins to occur at -10°C
c. The release of oxygen free radicals and arachidonic acid metabolites aggravates vasoconstriction and platelet and leukocyte aggregation
d. Experimental evidence suggests that a substantial component of severe cold injury may be mediated due to platelet aggregation
Answer: a, c

45. The management of a patient with frostbite includes:

a. Gradual spontaneous warming
b. Emersion of the tissue in a large water bath with a temperature of 40–42°C
c. Immediate initiation of prophylactic antibiotics
d. Systemic anticoagulation with heparin
e. Immediate debridement of necrotic tissue
Answer: b

46. There are a number of injuries associated with common orthopedic injuries. Which of the following diagnosed orthopedic injuries is associated with the injury listed?

a. Sternal fracture—cardiac contusion
b. Posterior dislocation of the knee—popliteal artery thrombosis
c. Pelvic fracture—ruptured bladder or urethral transection
d. Posterior dislocation of hip—-sciatic nerve injury
Answer: a, b, c, d

47. Correct statement(s) concerning cold injury include:

a. Chilblain is a form of local cold injury characterized by pruritic papules, macules, or plaques on the skin associated with repeated exposure to cold temperatures
b. Trenchfoot is a freeze injury of the hands or feet due to chronic exposure to cold, wet conditions below freezing
c. Frost nip is reversible with warming of the tissue and will result in the return of sensation and function with no tissue loss
d. Characteristic large blisters can be seen with all degrees of frostbite
Answer: a, c

48. A 37-year-old man driving an automobile travelling at a rapid speed hits a tree. At arrival to the Trauma Center, aortic disruption is suspected. Which of the following statement(s) is/are true concerning the patient’s diagnosis and management?

a. If undiagnosed, a thoracic aortic disruption is associated with a 50% mortality within the first 24 hours
b. Transesophageal echocardiography is a promising new modality for the diagnosis of aortic injury
c. Repair of aortic disruption is best completed with cardiopulmonary bypass
d. Pharmacologic control of blood pressure with sodium nitroprusside should be used routinely in the preoperative management
Answer: a, b

49. Which of the following statement(s) is/are true concerning endotracheal intubation at the site of injury?

a. Bag valve mask systems are equally as efficient as endotracheal intubation for early management of the trauma patient
b. Paramedic intubation in the field is successful in over 90% of cases
c. Indications for intubation in the field include respiratory distress, significant head injury, severe chest injury and hypovolemic shock
d. If patients clench their teeth violently, endotracheal intubation is impossible without the use of paralytic agents
Answer: b, c

50. Which of the following statement(s) concerning the operative approach to abdominal trauma is/are correct?

a. Pelvic hematomas associated with pelvic fractures should be explored
b. Central retroperitoneal hematomas should be explored after control of other injuries within the peritoneal cavity
c. Stable hematomas in the perinephric space lateral to the midline should be explored to rule out renal injury
d. The initial approach is control of hemorrhage by packing and controlling ongoing contamination from enteric injuries
Answer: b, d

TRAUMA and BURNS  Interview Questions and Answers :-

51. Which of the following statement(s) is/are true concerning trauma involving children?

a. The greater head/body ratio in children compared to adults leads to a higher frequency of head injuries in children
b. Unfused cranial sutures and open fontanels serve as a protective mechanism against intracranial hemorrhage
c. A greater propensity to hypothermia is seen in children
d. A propensity to single organ system injury is seen in the child
Answer: a, c

52. Indications for Cesarean section during laparotomy for trauma include:

a. Maternal shock after 28 weeks gestation
b. Unstable thoracolumbar spinal injury
c. Mechanical limitation for maternal repair
d. Maternal death if estimated gestational age is at least 28 weeks
nswer: b, c, d

53. A 75-year-old man is involved in a motor vehicle accident. Which of the following statement(s) is/are true concerning this patient’s injury and management?

a. Acceptable vital sign parameters are similar across all age groups
b. Hypertonic solutions should not be used for resuscitation due to concerns for fluid overload
c. The patient would be more prone to a subdural hematoma than a younger patient
d. There is no role for inotropic agents in the management of this patient
Answer: c

54. Important physiologic alterations of pregnancy which may alter the injury response include:

a. Increased cardiac output
b. Expanded plasma volume
c. Decreased fibrinogen and clotting factors
d. Partial obstruction of the inferior vena cava
Answer: a, b, d

55. A number of systems have been developed in an effort to allow comparison of trauma injuries and trauma patients among institutions. Which of the following statement(s) is/are true concerning trauma scoring systems?

a. The Revised Trauma Score uses the physiologic parameters of blood pressure, heart rate, and head injury to mathematically assess injury severity
b. The Abbreviated Injury Scale (AIS) is a specific anatomic index
c. The Injury Severity Score (ISS) correlates not only the severity of the injury but adjusts for patient age and comorbid risk factors
d. The Triss System is the most complete system in combining trauma score and anatomic component as well as patient age
Answer: a, b, d

56. Alterations in the immunologic response after a major trauma include:

a. Decreased CD3 and CD4 population
b. Depression of neutrophil antimicrobial functions including chemotaxis and phagocytosis
c. Decreased levels of pro-inflammatory cytokines including tumor necrosis factor, interleukin-1, and interleukin-6
d. Impaired macrophage receptor expression and antigen presentation
Answer: a, b, d

57. Which of the following statement(s) is/are true concerning penetrating injuries to the colon and rectum?

a. A patient with 2 or more additional organs injured, significant fecal spillage, preoperative hypotension, or intraperitoneal hemorrhage exceeding 1 liter should not have a primary repair of a colon injury
b. If rectal injury is documented, a loop colostomy provides adequate decompression.
c. Irrigation of the rectal stump should be avoided to prevent contamination via the site of injury
d. The rectal wall should be repaired in all cases
Answer: a

58. Genitourinary injuries are common with both blunt and penetrating trauma. Which of the following statement(s) is/are true concerning genitourinary trauma injuries?

a. All patients with microscopic hematuria and blunt trauma should be evaluated with an intravenous pyelogram
b. The indications for radiographic assessment of renal injury in the face of blunt trauma is more liberal than penetrating trauma
c. CT scan is the current imaging technique of choice for suspected renal trauma
d. Perinephric hematomas occurring after either penetrating or blunt trauma should not be explored
e. Extraperitoneal bladder ruptures can often be treated nonoperatively using urethral catheter drainage alone
Answer: c, e

59. In children who sustain multiple trauma, 25% have serious intraabdominal injuries. Which of the following statement(s) is/are true concerning blunt abdominal trauma in children?

a. Peritoneal lavage plays an important role in the evaluation of the patient
b. Most pediatric trauma patients will be hemodynamically unstable at the time of admission
c. Splenic salvage can be achieved in 90% to 100% of patients
d. The indications for laparotomy for splenic injury include refractory hypotension or transfusion requirement in excess of 50% of blood volume within the first 24 hours
e. Unlike splenic injury, hepatic injury will frequently require exploratory laparotomy
Answer: c, d

60. Which of the following statement(s) is/are true concerning the diagnosis and management of pelvic fractures secondary to blunt trauma?

a. Most pelvic fractures are apparent on the basis of physical examination
b. An infra-umbilical approach to peritoneal lavage in a patient with a major pelvic fracture may yield a false-positive rate approaching 50%
c. If a large expanding pelvic hematoma is found at surgery, the intraabdominal injury should be dealt with, and the hematoma explored
d. The application of pelvic external fixation may be used as the initial step in control of hemorrhage from pelvic fractures
e. A urethral catheter should be placed immediately in patients with suspected pelvic fracture to allow early peritoneal lavage
Answer: b, d

61. Which of the following statement(s) is/are true concerning the Advanced Trauma Life Support (ATLS) classification system of hemorrhagic shock?

a. Class I shock is equivalent to voluntary blood donation
b. In Class II shock there will be evidence of change in vital signs with tachycardia, tachypnea and a significant decrease in systolic blood pressure
c. Class III hemorrhage can usually be managed by simple administration of crystalloid solution
d. Class IV hemorrhage involves loss of over 40% of blood volume loss and can be classified as life-threatening
Answer: a, d

62. Which of the following statement(s) is/are true concerning traumatic pericardial tamponade?

a. The condition only develops in cases of penetrating trauma
b. Beck’s triad, consisting of muffled heart sounds, decreased pulse pressure, and jugular venous distention can be seen in most patients
c. Two-dimensional echocardiography has replaced diagnostic pericardiocentesis in most hemodynamically stable patients
d. The majority of patients with a small injury to a single chamber of the heart arriving with vital signs at the hospital will die of their injuries
Answer: c

63. The intravenous fluid that a 60 kg., 30-year-old woman with an 80% burn should be given in the first 24 hours following burn injury is:
A. 19.2 liters of 5% glucose in lactated Ringer’s.
B. 14.4 liters of lactated Ringer’s.
C. 9.6 liters of hypertonic salt solution (sodium concentration 200 mEq. per liter).
D. 7.2 liters of 5% albumin solution.
E. 5.5 liters of the pentafraction component of hydroxyethyl starch.
Answer: B

64. Indications for escharotomy of a circumferentially burned right lower limb include all of the following except:
A. Progressively severe deep tissue pain.
B. Coolness of the unburned skin of the toes of the right foot.
C. A pressure of 40 mm. Hg in the anterior compartment of the distal right leg.
D. Edema of the unburned skin of the right foot.
E. Absence of pulsatile flow in the posterior tibial artery.
Answer: BD

65. Which of the following is/are true about inhalation injury in burn patients?
A. A chest x-ray obtained within 24 hours of injury is an accurate means of diagnosis.
B. Its presence characteristically necessitates administration of resuscitation fluids in excess of estimated volume.
C. When moderate or severe, it exerts a comorbid effect that is related to both extent of burn and the age of the patient.
D. It increases the prevalence of bronchopneumonia.
E. Prophylactic high-frequency ventilation reduces the occurrence of pneumonia and the mortality in burn patients with inhalation injury.
Answer: BCDE

66. Adequacy of fluid resuscitation in burn patients is indicated by which of the following?
A. Urine output of 45 ml. per hr. in a 70-kg. 30-year-old man with flame burns involving 55% of the total body surface.
B. Hourly urine output of 7 ml. in a 7-kg. 15-month-old child with burns involving 40% of the total body surface.
C. A pulmonary capillary wedge pressure of 17 to 20 mm. Hg.
D. Hourly output of 40 ml. of port wine–colored urine in an 80-kg. male who has severe high-voltage electric injury of the right arm and left leg.
E. A urinary sodium concentration of 4 mEq. per liter.
Answer: ABC

67. Common electrolyte changes during and after resuscitation in a patient with a burn of 65% of the total body surface include:
A. A serum sodium concentration of 128 mEq. per liter following 48 hours of resuscitation fluid therapy.
B. A serum sodium concentration of 152 mEq. per liter on the fifth postburn day in a 75-kg. male with a 75% burn who has received only calculated maintenance fluids each day following successful resuscitation.
C. A serum potassium concentration of 5.7 mEq. per liter as a consequence of the destruction of red cells and other tissues in a patient with high-voltage electrical injury.
D. Hypokalemia due to the kaliuretic effect of 0.5% silver nitrate soaks.
E. Hypocalcemia with a low ionized calcium level on the third postburn day as a consequence of dilution and hypoalbuminemia.
Answer: ABC

68. The clinical and histologic signs of invasive burn wound infection include which of the following?
A. Focal dark red or dark brown discoloration of the eschar.
B. Delayed separation of the eschar.
C. Conversion of an area of partial-thickness burn to full-thickness necrosis.
D. The presence of micro-organisms in the unburned subcutaneous tissue in a burn wound biopsy specimen.
E. Perineural and perivascular microbial migration through the eschar with proliferation of micro-organisms in the subeschar space.
Answer: ACD

69. The treatment of invasive burn wound infection may include which of the following?
A. Subeschar infusion of half the daily dose of a broad-spectrum penicillin suspended in 1 liter of normal saline.
B. Use of 0.5% silver nitrate soaks for topical therapy.
C. Specific systemic antibiotic therapy.
D. Excision and immediate autografting.
E. Amputation when the infection has extended to involve underlying muscle.
Answer: ACE

70. The treatment of patients with high-voltage electric injury differs from that of patients with conventional thermal injury with respect to the need for:
A. Fasciotomy.
B. Hemodialysis.
C. Amputation.
D. Pulse oximetry.
E. Prehospital cardiopulmonary resuscitation.
Answer: ABCE

71. Therapeutic interventions needed for specific chemical agents include which of the following?
A. Prolonged saline irrigation of eyes injured by concentrated sodium hydroxide using a scleral lens with an irrigating sidearm.
B. Administration of an emetic agent as immediate treatment following lye ingestion.
C. Intra-arterial infusion of calcium gluconate for relief of refractory deep tissue pain due to hydrofluoric acid injury.
D. Use of propylene glycol to remove residual phenol following water lavage.
E. Application of 5% copper sulfate solution soaks to areas of embedded particles of white phosphorus.
Answer: ACD

72. Characteristics of the hypermetabolic response to burn injury include:
A. Elevation of core temperature, skin temperature, and core-to-skin heat transfer.
B. Ambient temperature dependency of metabolic rate.
C. A marked increase of blood flow to the burn wound.
D. A curvilinear relationship to the extent of burn.
E. Oxidation of stored lipid as the major source of metabolic energy.
Answer: ACE

73. A 32-year-old mountain climber who struck his head in a fall lay in the snow overnight before he could be rescued and brought to the hospital. Upon admission he is semicomatose and not shivering, with a pulse rate of 48 beats per minute and a blood pressure of 80/50 mm. Hg. His rectal temperature as measured by a standard thermometer is reported as 34؛ C. All the digits on both feet appear to be frozen. Treatment for this patient should include:
A. Administration of inotropic and chronotropic vasoactive agents.
B. Intra-arterial infusion of vasodilating agents.
C. Infusion of lactated Ringer’s solution warmed to 40؛ C.
D. Immersion in a circulating water bath heated to 40؛ C.
E. Excision of damaged tissue within 48 hours after thawing.
Answer: CD

74. Valid points in the management of burns on special areas include:

a. The large majority of genital burns are best managed by immediate excision and autografting
b. All digits with deep dermal and full-thickness burns should be immobilized with six weeks of axial Kirschner wire fixation
c. Deep thermal burns of the central face are best managed with immediate excision and autografting
d. Burns of the external ear are commonly complicated by acute suppurative chondritis if topical mafenide acetate is not applied
Answer: d

75. The hypermetabolic response seen in patients with large burns, who are successfully resuscitated, is thought to be driven by which of the following factors?

a. Deficient gastrointestinal barrier function
b. Bacterial contamination of the burn wound
c. Evaporative heat loss
d. Changes in hypothalamic function
Answer: a, b, c, d

76. Which of the following statement(s) is/are true concerning inhalation injury?

a. The physiology of these injuries include upper airway obstruction secondary to progressive edema, reactive bronchospasm from aerosolized irritants, and microatelectasis from loss of surfactant and alveolar edema
b. Endotracheal intubation is indicated immediately in all patients with suspected inhalation injury
c. Distal airway injuries are usually caused by heat injury
d. Peak inspiratory pressures of > 40 cm of water are indicated to maintain functional residual capacity
Answer: a

77. Which of the following statement(s) is/are true concerning the initial fluid resuscitation of a burn patient?

a. Rigid adherence to the Modified Brooke formula is advised
b. In general, children require less fluid than that predicted by standard formulae
c. Patients with inhalation injuries require less fluid than predicted by standard formulae
d. Dextrose should not be given as the primary resuscitative fluid for any age group
e. Most resuscitative formulae withhold colloid solutions until 24 hours post-injury
Answer: e

78. Which of the following statement(s) is/are true concerning techniques of burn excision, and temporary and definitive wound closure?

a. Techniques to conserve blood include subeschar injection of dilute epinephrine solution, exsanguination of the extremity and inflation of a pneumatic tourniquet
b. Fresh or cryopreserved human allograft is usually rejected within 2 to 4 weeks
c. A common use for human allograft is as a physiologic cover for selected clean superficial wounds as they epithelialize
d. A donor site can only serve as a single source for autograft
Answer: a, b

79. Which of the following statement(s) is/are true concerning topical antimicrobials in common use in the United States today?

a. Of the common topical antimicrobials, only mafenide acetate is painful upon application
b. The use of 0.5% silver nitrate is associated with trans-eschar leeching of sodium and potassium from the wound
c. Silver sulfadiazine has the best eschar penetration
d. Silver sulfadiazine, mafenide acetate, and 0.5% silver nitrate all have a broad spectrum activity, however, only silver nitrate has anti-fungal activity
Answer: a, b, d

80. The anthropometric changes observed as a patient progresses from infancy to adulthood include which of the following statement(s)?

a. The major anthropometric changes involve the head and torso
b. A decrease in the relative size of the head from 18% to 9% of the body’s surface area occurs
c. The total surface area of the legs increases from 14 to 18%
d. The upper extremities increase to 12% of the body surface area
Answer: b, c

81. Arguments in favor of early wound excision include which of the following statement(s)?

a. Enhanced survival is seen in patients with large burn injuries
b. Hospital stays can be shortened with this technique
c. Early burn excision results in fewer painful dressing changes
d. A decrease in duration and intensity of the hypermetabolic response is observed
Answer: a, b, c, d

82. Which of the following are accepted adjuncts in the management of hypertrophic scar?

a. Local steroid injection
b. Compression garments
c. Topical silicone
d. Release or excision with autografting
e. Topical platelet-derived growth factor
Answer: a, b, c, d

83. Which of the following statement(s) is/are true concerning carbon monoxide and cyanide exposure?

a. A normal oxygen saturation by standard transmission pulse oximetry precludes the possibility of significant carboxyhemoglobinemia
b. Most patients with cyanide exposure require administration of sodium thiosulfate
c. The half-life of carbon monoxide is reduced by a factor of 5 with ventilation with 100% oxygen
d. Even if fire victims are well ventilated with high concentrations of oxygen by emergency response personnel from the time of extrication, carboxyhemoglobin values are frequently greater than 10% on initial evaluation
Answer: c