Question:1 A 22-year-old man is hypotensive and tachycardic

after a shotgun wound to the left shoulder. His blood pressure is

initially 80/40 mm Hg. After 2 liters of crystalloid solution his blood
pressure increases to 122/84 mm Hg. His heart rate is now 100
beats per minute and his respiratory rate is 28 breaths per minute.
His breath sounds are decreased in the left hemithorax, and after
initial IV fluid resuscitation, a closed tube thoracostomy is
performed for decreased left breath sounds with the return of a
small amount of blood and no air leak. After chest tube insertion,
the most appropriate next step is
A) reexamine the chest.
B) perform an aortogram.
C) obtain a CT scan of the chest.
D) obtain arterial blood gas analyses
E) perform transesophageal echocardiography.

Question:2 A construction worker falls two stories from a building

and sustains bilateral calcaneal fractures. In the emergency
department, he is alert, vital signs are normal, and he is
complaining of severe pain in both heels and his lower back.
Lower extremity pulses are strong and there is no other deformity.
The suspected diagnosis is most likely to be confirmed by
A) angiography.
B) compartment pressures
C) retrograde urethrogram
D) Doppler-ultrasound studies.
E) complete spine x-ray series.

Question:3 The principle of balanced resuscitation is:

A) Permissive hypotension and early plasma infusion
B) Equal amounts of crystalloid and colloids
C) Simultaneous management of breathing and circulation
D) Maintenance of a normal acid base balance
E) Achieving a pulse rate <90

Question:4 In managing the head-injured patient, the most

important initial step is to
A) secure the airway.
B) obtain c-spine film.
C) support the circulation.
D) control scalp hemorrhage.
E) determine the GCS Score.

Question:5 A previously healthy, 70-kg (154-pound) man suffers

an estimated acute blood loss of 2 liters. Which one of the
following statements applies to this patient?
A) His pulse pressure will be widened.
B) His urinary output will be at the lower limits of normal.
 He will have tachycardia, but no change in his systolic
C)
blood pressure.
His systolic blood pressure will be decreased with a
D)
narrowed pulse pressure.
His systolic blood pressure will be maintained with an
E)
elevated diastolic pressure.

Question:6 The physiologic hypervolemia of pregnancy has

clinical significance in the management of the severely injured,
gravid woman by
A) reducing the need for blood transfusion.
B) increasing the risk of pulmonary edema.
C) complicating the mangement of closed head injury.
reducing the volume of crystalloid required for
D)
resuscitation.
increasing the volume of blood loss to produce maternal
E)
hypotension.

Question:7 The best assessment of fluid resuscitation of the burn

patient is
A) adequate urinary output.
B) reversal of systemic acidosis.
C) normalization of the heart rate.
D) a normal central venous pressure.
E) 4 mL/kg/percent body burn/ 24 hours.

Question:8 The diagnosis of shock must include

A) hypoxemia.
B) acidosis.
C) hypotension.
D) increased vascular resistance.
E) evidence of inadequate organ perfusion.

Question:9 A 7-year-old boy is brought to the emergency

department by his parents several minutes after he fell through a
window. He is bleeding profusely from a 6-cm wound of his medial
right thigh. Immediate management of the wound should consist of
A) application of a tourniquet.
B) direct pressure on the wound.
C) packing the wound with gauze.
D) direct pressure on the femoral artery at the groin.
E) debridement of devitalized tissue.

Question:10 For the patient with severe traumatic brain injury,

profound hypocarbia should be avoided to prevent
A) respiratory acidosis.
B) metabolic acidosis.
C) cerebral vasoconstriction with diminished perfusion.
D) neurogenic pulmonary edema.
E) shift of the oxyhemoglobin dissociation curve.

Question:11 A 25-year-old man is brought to a hospital with a

general surgeon after being involved in a motor vehicle crash.
Computed tomography shows an aortic injury and splenic
laceration with free abdominal fluid. His blood pressure falls to 70
mm Hg after CT. The next step is
A) contrast angiography.
B) transfer to a higher level trauma center.
C) exploratory laparotomy.
D) infuse additional crystalloids.
E) transesophageal echocardiography.

Question:12 Which one of the following statements regarding

abdominal trauma in the pregnant patient is TRUE?
A) The fetus is in jeopardy only with major abdominal trauma.
Leakage of amniotic fluid is an indication for hospital
B)
admission.
Indications for peritoneal lavage are different from those in
C)
the nonpregnant patient.
Penetration of an abdominal hollow viscus is more
D)
common in late than in early pregnancy.
The secondary survey follows a pattern from that of the
E)
nonpregnant patient.

Question:13 The first maneuver to improve oxygenation after

chest injury is
A) intubate the patient.
B) assess arterial blood gases.
C) administer supplemental oxygen.
D) ascertain the need for a chest tube.
E) obtain a chest x-ray.

Question:14 A 25-year-old man, injured in a motor vehicular

crash, is admitted to the emergency department. His pupils react
sluggishly and his eyes open to painful stimuli. He does not follow
commands, but he does moan periodically. His right arm is
deformed and does not respond to painful stimulus; however, his
left hand reaches purposefully toward the painful stimulus. Both
legs are stiffly extended. His GCS Score is
A) 2
B) 4
C) 6
D) 9
E) 12

Question:15 A 20-year-old woman, at 32 weeks gestation, is

stabbed in the upper right chest. In the emergency department,
her blood pressure is 80/60 mm Hg. She is gasping for breath,
extremely anxious, and yelling for help. Breath sounds are
diminished in the right chest. The most appropriate first step is to
A) perform tracheal intubation.
B) insert an oropharyngeal airway.
C) perform needle decompression of the right chest.
manually displace the gravid uterus to the left side of the
D)
abdomen.
initiate 2, large-caliber peripheral IV lines and crystalloid
E)
infusion.

Question:16 Which one of the following findings in an adult is

most likely to require immediate management during the primary
survey?
A) Distended abdomen.
B) Glasgow Coma Scale Score of 11.
C) Temperature of 36.5°C (97.8°F).
D) Deforming of the right thigh.
E) Respiratory rate of 40 breaths per minute.

Question:17 The most important, immediate step in the

management of an open pneumothorax is
A) endotracheal intubation.
B) operation to close the wound.
C) placing a chest tube through the chest wound.
D) placement of an occlusive dressing over the wound.
E) initiation of 2, large-caliber IVs with crystalloid solution.

Question:18 The following are contraindications for tetanus

toxoid administration
History of neurological reaction or severe hypersensitivity
A)
to the product.
B) Local side effects.
C) Muscular spasms.
D) Pregnancy.
E) All of the above.

Question:19 A 56-year-old man is thrown violently against the

steering wheel of his truck during a motor vehicle crash. On arrival
in the emergency department he is diaphoretic and complaining of
chest pain. His blood pressure is 60/40 mm Hg and his respiratory
rate is 40 breaths per minute. Which of the following best
differentiates cardiac tamponade from tension pneumothorax as
the cause of his hypotension?
A) Tachycardia.
B) Pulse volume.
C) Breath sounds.
D) Pulse pressure.
E) Jugular venous pressure.
Question:20 Bronchial intubation of the right or left mainstem
bronchus can easily occur during infant endotracheal intubation
because
A) the trachea is relatively short.
B) the distance from the lips to the larynx is relatively short.
the use of tubes without cuffs allows the tube to slip
C)
distally.
the mainstream bronchi are less angulated in their relation
D)
to the trachea.
so little friction exists between the endotracheal tube and
E)
the wall of the trachea.

Question:21 A 23-year-old man sustains 4 stab wounds to the

upper right chest during an altercation and is brought by
ambulance to a hospital that has full surgical capabilities. His
wounds are all above the nipple. He is endotracheally intubated,
closed tube thoracostomy is performed, and 2 liters of crystalloid
solution are infused through 2 large-caliber IVs. His blood
pressure now is 60/0 mm Hg, heart rate is 160 beats per minute,
and respiratory rate is 14 breaths per minute (ventilated with 100%
O2). 1500cc of blood has drained from the right chest. The most
appropriate next step in managing this patient is to
A) perform FAST.
B) obtain a CT of the chest.
C) perform an angiography.
D) urgently transfer the patient to the operating room.
E) immediately transfer the patient to a trauma center.

Question:22 A 39-year-old man is admitted to the emergency

department after an automobile collision. He is cyanotic, has
insufficient respiratory effort, and has a GCS Score of 6. His full
beard makes it difficult to fit the oxygen facemask to his face. The
most appropriate next step is to
A) perform a surgical cricothyroidotomy.
B) attempt nasotracheal intubation.
ventilate him with a bag-mask device until c-spine injury
C)
can be excluded.
attempt orotracheal intubation using 2 people and inline
D)
stabilization of the cervical spine.
ventilate the patient with a bag-mask device until his beard
E)
can be shaved for better mask fit.

Question:23 A patient is brought to the emergency department

after a motor vehicle crash. He is conscious and there is no
obvious external trauma. He arrives at the hospital completely
immobilized on a long spine board. His blood pressure is 60/40
mm Hg and his heart rate is 70 beats per minute. His skin is warm.
Which one of the following statements is TRUE?
Vasoactive medications have no role in this patient's
A)
management.
The hypotension should be managed with volume
B)
resuscitation alone.
Flexion and extension views of the c-spine should be
C)
performed early.
 Abdominal visceral injuries can be excluded as a cause of
D)
hypotension.
Flaccidity of the lower extremities and loss of deep tendon
E)
reflexes are expected.

Question:24 Which one of the following is the most effective

method for initially treating frostbite?
A) Moist heat.
B) Early amputation.
C) Padding and elevation.
D) Vasodilators and heparin.
E) Topical application of silver sulfadiazine.

Question:25 A 32-year-old man's right leg is trapped beneath his

overturned car for nearly 2 hours before he is extricated. On
arrival in the emergency department, his right lower extremity is
cool, mottled, insensate, and motionless. Despite normal vital
signs, pulses cannot be palpated below the femoral vessel and the
muscles of the lower extremity are firm and hard. During the
management of this patient, which of the following is most likely to
improve the chances for limb salvage?
A) Applying skeletal traction.
B) Administering anticoagulant drugs.
C) Administering thrombolytic therapy.
D) Perform right lower extremity fasciotomy.
E) Transferring the patient to the trauma center 120 km away.

Question:26 A patient arrives in the emergency department after

being beaten about the head and face with a wooden club. He is
comatose and has a palpable depressed skull fracture. His face is
swollen and ecchymotic. He has gurgling respirations and vomitus
on his face and clothing. The most appropriate step after providing
supplemental oxygen and elevating his jaw is to
A) request a CT scan.
B) insert a gastric tube.
C) suction the oropharynx.
D) obtain a lateral cervical spine x-ray.
E) ventilate the patient with a bag-mask.

Question:27 A 22-year-old man sustains a gunshot wound to the

left chest and is transported to a small community hospital at
which surgical capabilities are not available. In the emergency
department, a chest tube is inserted and 700 mL of blood is
evacuated. The trauma center accepts the patient in transfer. Just
before the patient is placed in the ambulance for transfer, his
blood pressure decreases to 80/68 mm Hg and his heart rate
increases to 136 beats per minute. The next step should be to
A) clamp the chest tube.
B) cancel the patient's transfer.
C) perform an emergency department thoracotomy.
D) repeat the primary survey and proceed with transfer.
 delay the transfer until the referring doctor can contact a
E)
thoracic surgeon.

Question:28 A 64-year-old man, involved in a high-speed car

crash, is resuscitated initially in a small hospital with limited
resources. He has a closed head injury with a GCS Score of 13.
He has a widened mediastinum on chest x-ray with fractures of left
ribs 2 through 4, but no pneumothorax. After infusing 2 liters of
crystalloid solution, his blood pressure is 110/74 mm Hg, heart
rate is 100 beats per minute, and respiratory rate is 18 breaths per
minute. He has gross hematuria and a pelvic fracture. You decide
to transfer this patient to a facility capable of providing a higher
level of care. The facility is 128 km (80 miles) away. Before
transfer, you should first
A) intubate the patient.
B) perform diagnostic peritoneal lavage or FAST.
C) insert a left chest tube.
call the receiving hospital and speak to the surgeon on
D)
call.
E) discuss the advisability of transfer with the patient's family.

Question:29 Hemorrhage of 20% of the patient's blood volume is

associated usually with
A) oliguria.
B) confusion.
C) hypotension.
D) tachycardia.
E) blood transfusion requirement.

Question:30 Which one of the following statements concerning

intraosseous infusion is TRUE?
Only crystalloid solutions may be safely infused through
A)
the needle.
Aspiration of bone marrow confirms appropriate
B)
positioning of the needle.
Intraosseous infusion is the preferred route for volume
C)
resuscitation in small children.
D) Intraosseous infusion may be utilized indefinitely.
Swelling in the soft tissues around the intraosseous site is
E)
not a reason to discontinue infusion.

Question:31 A young woman sustains a severe head injury as

the result of a motor vehicle crash. In the emergency department,
her GCS is 6. Her blood pressure is 140/90 mm Hg and her heart
rate is 80 beats per minute. She is intubated and mechanically
ventilated. Her pupils are 3 mm in size and equally reactive to
light. There is no other apparent injury. The most important
principle to follow in the early management of her head injury is to
A) avoid hypotension.
B) administer an osmotic diuretic.
C) aggressively treat systemic hypertension.
D) reduce metabolic requirements of the brain.
 distinguish between intracranial hematoma and cerebral
E)
edema.

Question:32 A 33-year-old woman is involved in a head-on motor

vehicle crash. It took 30 minutes to extricate her from the car.
Upon arrival in the emergency department, her heart rate is 120
beats per minute, BP is 90/70 mm Hg, respiratory rate is 16
breaths per minute, and her GCS Score is 15. Examination
reveals bilaterally equal breath sounds, anterior chest wall
ecchymosis, and distended neck veins. Her abdomen is flat, soft,
and not tender. Her pelvis is stable. Palpable distal pulses are
found in all 4 extremities. Of the following, the most likely
diagnosis is
A) hemorrhagic shock.
B) cardiac tamponade.
C) massive hemothorax.
D) tension pneumothorax.
E) diaphragmatic rupture.

Question:33 A hemodynamically normal 10-year-old girl is

admitted to the Pediatric Intensive Care Unit (PICU) for
observation after a Grade III (moderately severe) splenic injury
has been confirmed by computed tomography (CT). Which of the
following mandates prompt celiotomy (laparotomy)?
A) A serum amylase of 200.
B) A leukocyte count of 14,000.
C) Extraperitoneal bladder rupture.
D) Free intraperitoneal air demonstrated on follow-up CT.
A fall in the hemoglobin level from 12 g/ dL to 8 g/ dL over
E)
24 hours.

Question:34 A 40-year-old woman restrained driver is

transported to the emergency department in full spinal
immobilization. She is hemodynamically normal and found to be
paraplegic at the level of T10. Neurologic examination also
determines that there is loss of pain and temperature sensation
with preservation of proprioception and vibration. These findings
are consistent with the diagnosis of
A) central cord syndrome.
B) spinal shock syndrome.
C) anterior cord syndrome.
D) complete cord syndrome.
E) Brown-Sequard's syndrome.

Question:35 A trauma patient presents to your emergency

department with inspiratory stridor and a suspected c-spine injury.
Oxygen saturation is 88% on high-flow oxygen via a
nonrebreathing mask. The most appropriate next step is to
A) apply cervical traction.
B) perform immediate tracheostomy.
C) insert bilateral thoracostomy tubes.
maintain 100% oxygen and obtain immediate c-spine x-
D)
rays.
 maintain inline immobilization and establish a definitive
E)
airway.

Question:36 When applying the Rule of Nines to infants,

A) it is not reliable.
B) the body is proportionally larger in infants than in adults.
C) the head is proportionally larger in infants than in adults.
D) the legs are proportionally larger in infants than in adults.
E) the arms are proportionally larger in infants than in adults.

Question:37 Healthy young male in a motor vehicle crash is

brought to the emergency department with a blood pressure of
84/60, pulse 123, GCS 10. The patient moans when his pelvis is
palpated. After initiating fluid resuscitation, the next step in
management is:
A) Placement of a pelvic binder
B) Transfer to a trauma center
C) Pelvic x-ray
D) Insert urinary catheter
E) Repeat examination of pelvis

Question:38 Which one of the following situations requires Rh

immunoglobulin administration to an injured woman?
A) Negative pregnancy test, Rh negative, and torso trauma.
Positive pregnancy test, Rh positive, and has torso
B)
trauma.
C) Positive pregnancy test, Rh negative, has torso trauma.
Positive pregnancy test, Rh positive, and has an isolated
D)
wrist fracture.
Positive pregnancy test, Rh negative, and has an isolated
E)
wrist fracture.

Question:39 A 22-year-old female athlete is stabbed in her left

chest at the third interspace in the anterior axillary line. On
admission to the emergency department and 15 minutes after the
incident, she is awake and alert. Her heart rate is 100 beats per
minute, blood pressure 80/60 mm Hg, and respiratory rate 20
breaths per minute. A chest x-ray reveals a large left hemothorax.
A left chest tube is placed with an immediate return of 1600 mL of
blood. The next management step for this patient is
A) perform a thoracoscopy.
B) perform an arch aortogram.
C) insert a second left chest tube.
D) prepare for an exploratory thoracotomy.
E) perform an chest CT.

Question:40 A 6-year-old boy walking across the street is struck

by the front bumper of a sports utility vehicle traveling at 32 kph
(20 mph). Which one of the following statements is TRUE?
A) A flail chest is probable.
B) A symptomatic cardiac contusion is expected.
 A pulmonary contusion may be present in the absence of
C)
rib fractures.
Transection of the thoracic aorta is more likely than in an
D)
adult patient.
Rib fractures are commonly found in children with this
E)
mechanism of injury.