Trauma/Emergencies Practice Questions

Q: A 35-year-old male is brought into the emergency department for a trauma emergency. The emergency medical services states that the patient was wounded with a knife on his upper left thigh near the inguinal ligament. Upon examination in the trauma bay, the patient is awake and alert. His physical exam and FAST exam is normal other than the knife wound. Large bore intravenous lines are inserted into the patient for access and fluids are being administered. Pressure on the knife wound is being held by one of the physicians with adequate control of the bleeding, but the physician notices the blood was previously extravasating in a pulsatile manner. His vitals are BP 100/50, HR 110, T 97.8, RR 22. What is the next best step for this patient?

Emergent surgery. ***Emergent surgery*** - The pulsatile bleeding from a thigh wound near the inguinal ligament is highly suggestive of a major arterial injury, such as to the **femoral artery**. - Given the potential for rapid blood loss and hemodynamic instability, **emergent surgical exploration and repair** are necessary to control the bleeding and prevent further compromise. *CT lower extremities* - While CT angiography could further delineate vascular injury, the presence of **active pulsatile bleeding** necessitates immediate surgical intervention rather than delaying for imaging. - Delaying surgery for imaging risks **exsanguination** and worsening patient outcomes, especially with a blood pressure of **100/50 mmHg** and a heart rate of **110 bpm**, indicating early shock. *Radiograph lower extremities* - A radiograph would primarily visualize bone structures and foreign bodies but would not provide adequate information regarding the **vascular injury** and active bleeding. - It would not change the urgent need for **surgical exploration** to address the pulsatile hemorrhage. *Coagulation studies and blood typing/crossmatch* - These are important preparatory steps for major surgery involving significant blood loss, but they should be carried out **concurrently with preparations for emergent surgery**, not instead of it. - Delaying surgery to await these results would be inappropriate when facing **active arterial bleeding**. *Tourniquet of proximal lower extremity* - While a tourniquet can be used for temporary hemorrhage control, especially in an uncontrolled external hemorrhage, the current bleeding is being controlled by **direct pressure**. - Applying a tourniquet could cause **ischemic damage** to the extremity if applied for too long, and for a deep stab wound, direct compression is often effective until surgical control can be achieved.

Q: A 59-year-old man comes to the physician for evaluation of progressively worsening back pain that began about 2 months ago. It started as a dull pain that has now developed into a constant throbbing pain that makes falling asleep difficult. Ibuprofen and acetaminophen do not provide relief. The patient has not had any bowel incontinence, limb weakness, or paresthesias. He has metastatic prostate cancer with known metastasis to the sacrum and left ilium, but has had minimal pain related to these sites. He underwent bilateral orchiectomy two years ago, complicated by urinary incontinence. He currently takes no medications. Vital signs are within normal limits. There is midline tenderness to palpation over the lower lumbar spine. MRI scan of the spine shows a new sclerotic lesion at the L5 vertebral body. Which of the following is the most appropriate next step in management?

Local radiation. ***Local radiation*** - The patient has a new **sclerotic lesion at L5** causing severe, unremitting pain, which is characteristic of **metastatic prostate cancer** to the bone. - **Local radiation therapy** is highly effective for localized bone pain due to metastases, providing significant pain relief and preventing further bone destruction. *Prostatectomy* - **Prostatectomy** is a treatment for localized prostate cancer and would not address existing **metastatic bone disease** causing spinal pain. - The patient has already undergone bilateral orchiectomy, which achieves **androgen deprivation**, making prostatectomy for pain management inappropriate. *Flutamide* - **Flutamide** is an **anti-androgen** used in hormone-sensitive prostate cancer, but the patient has already had an orchiectomy, indicating he is likely on maximum androgen deprivation. - In cases of progression after initial androgen deprivation, **second-line hormonal therapies** or chemotherapy would be considered, but **local radiation** is more targeted for immediate pain relief from a specific bone lesion. *Spinal surgery* - **Spinal surgery** is typically reserved for cases of **spinal cord compression**, neurological deficits (e.g., limb weakness, incontinence), or spinal instability. - Since the patient has no signs of **spinal cord compression** or neurological deficits, surgical intervention is not the most appropriate initial step for pain management from a bone lesion. *Denosumab* - **Denosumab** is a **RANK ligand inhibitor** used to prevent skeletal-related events (SREs) and manage bone pain in metastatic cancer. - While it helps in overall bone health and pain over time, **local radiation** offers more rapid and direct pain relief for a specific, painful metastatic lesion.

Q: A 23-year-old woman presents to the emergency department after being found unresponsive by her friends. The patient is an IV drug user and her friends came over and found her passed out in her room. The patient presented to the emergency department 2 days ago after being involved in a bar fight where she broke her nose and had it treated and packed with gauze. Her temperature is 99.3°F (37.4°C), blood pressure is 90/48 mmHg, pulse is 150/min, respirations are 24/min, and oxygen saturation is 97% on room air. Physical exam is notable for an obtunded woman with nasal packing and EKG tags from her last hospital stay, as well as a purpuric rash on her arms and legs. Her arms have track marks on them and blisters. Which of the following is the best next step in management?

Removal of nasal packing. ***Removal of nasal packing*** - This patient presents with classic **toxic shock syndrome (TSS)** caused by nasal packing following her nasal fracture repair 2 days ago. - Key diagnostic features include: **purpuric rash** (diffuse macular erythroderma with petechiae), hypotension (90/48 mmHg), tachycardia (150/min), fever, and altered mental status. - TSS is caused by **Staphylococcus aureus** toxin production, with nasal packing being a well-known risk factor. - **Immediate removal of the nasal packing** (the source of infection) is the critical first step, followed by fluid resuscitation and empiric anti-staphylococcal antibiotics. *Urine toxicology screen and empiric naloxone* - While the patient is an IV drug user, opioid overdose does **not** explain the **purpuric rash**, which is the key diagnostic finding. - Opioid overdose typically presents with **respiratory depression** (low respiratory rate), not tachypnea (24/min) with normal oxygen saturation. - The clinical picture is dominated by TSS, not drug toxicity. *Nafcillin* - While **nafcillin** (anti-staphylococcal antibiotic) will be needed for TSS treatment, the **first step** is removal of the source (nasal packing). - Source control takes precedence over antibiotics in foreign body-associated infections. *Vancomycin* - Similar to nafcillin, **vancomycin** is appropriate for empiric TSS coverage (especially for MRSA), but must come **after** removal of nasal packing. - Antibiotics without source control will not adequately treat TSS. *Norepinephrine* - While the patient is hypotensive and may eventually require vasopressor support, the **immediate priority** is removing the infectious source. - TSS-induced shock should be managed with aggressive fluid resuscitation first, and vasopressors are added if fluid resuscitation fails.

Q: A 43-year-old man is brought to the emergency department 30 minutes after falling from the roof of a construction site. He reports abdominal and right-sided flank pain. His temperature is 37.1°C (98.8°F), pulse is 114/min, and blood pressure is 100/68 mm Hg. Physical examination shows numerous ecchymoses over the trunk and flanks and a tender right abdomen without a palpable mass. Focused assessment with sonography for trauma (FAST) shows no intraperitoneal fluid collections. His hemoglobin concentration is 7.6 g/dL. The most likely cause of his presentation is injury to which of the following organs?

Kidney. ***Kidney*** - The patient's presentation with **flank pain**, **ecchymoses over the flank**, and **hypotension** following a fall from height is highly suggestive of **renal injury**. The absence of intraperitoneal fluid on FAST scan further supports an injury to a retroperitoneal organ like the kidney. - The **significantly decreased hemoglobin (7.6 g/dL)** indicates substantial blood loss, which is consistent with the vascular nature of the kidney and potential for severe hemorrhage following trauma. *Liver* - While liver injury can cause **hypotension** and **abdominal pain** after trauma, the primary pain would typically be in the **right upper quadrant**, not specifically the flank. - Liver injuries often result in **intraperitoneal fluid collections** (hemoperitoneum), which were explicitly absent on the FAST scan in this patient. *Stomach* - Stomach injuries typically result from penetrating trauma or severe blunt force, leading to **peritonitis** and potential **gastric content leakage**, which would cause diffuse abdominal pain and potentially peritonitis signs. - It is an **intraperitoneal organ**, and injury might be seen on a FAST scan as free fluid, which is not present here. *Small bowel* - Small bowel injuries typically present with **diffuse abdominal pain**, **peritoneal signs**, and can lead to **sepsis** due to contamination. - These injuries often cause **intraperitoneal fluid** or air, neither of which is reported. *Spleen* - Splenic injuries typically cause **left upper quadrant pain** and can lead to significant **intraperitoneal bleeding**, which would be detected by a FAST scan. - The patient's symptoms are localized to the **right side** and flank, making splenic injury less likely.

Q: A 45-year-old male is brought into the emergency room by emergency medical services due to a stab wound in the chest. The wound is located superior and medial to the left nipple. Upon entry, the patient appears alert and is conversational, but soon becomes confused and loses consciousness. The patient's blood pressure is 80/40 mmHg, pulse 110/min, respirations 26/min, and temperature 97.0 deg F (36.1 deg C). On exam, the patient has distended neck veins with distant heart sounds. What is the next best step to increase this patient's survival?

Pericardiocentesis. ***Pericardiocentesis*** - The patient's presentation with **hypotension**, **tachycardia**, **distended neck veins**, and **distant heart sounds** after a chest stab wound is classic for **cardiac tamponade** (Beck's triad). - **Pericardiocentesis** is the immediate life-saving procedure to drain the pericardial fluid and relieve pressure on the heart, improving cardiac output. - In penetrating trauma, this serves as a **bridge to definitive surgical management** (thoracotomy or sternotomy). *Heparin* - **Heparin** is an anticoagulant and would worsen the situation by increasing bleeding into the pericardial space due to the stab wound. - It is contraindicated in active bleeding and traumatic injury. *Intravenous fluids* - While **IV fluid resuscitation is recommended** in cardiac tamponade to maintain preload and support cardiac output, fluids alone **do not address the underlying mechanical obstruction**. - The primary issue is **extrinsic compression of the heart** requiring drainage, not hypovolemia alone. - Fluids are supportive but not definitive—**pericardiocentesis is the life-saving intervention**. *Aspirin* - **Aspirin** is an antiplatelet agent and would increase the risk of bleeding, exacerbating the patient's condition. - It is used for conditions like myocardial infarction or stroke prevention, not for acute traumatic bleeding. *Intravenous colloids* - Similar to crystalloid fluids, **colloids** may provide temporary hemodynamic support but do not relieve the mechanical compression of the heart. - They are supportive measures that **do not substitute for definitive pericardial drainage**.

Q: A 13-year-old boy is brought to the emergency room 30 minutes after being hit in the face with a baseball at high velocity. Examination shows left periorbital swelling, posterior displacement of the left globe, and tenderness to palpation over the left infraorbital rim. There is limited left upward gaze and normal horizontal eye movement. Further evaluation is most likely to show which of the following as a result of this patient's trauma?

Clouding of maxillary sinus. ***Clouding of maxillary sinus*** - This patient's symptoms (periorbital swelling, globe displacement, infraorbital rim tenderness, limited upward gaze) are strongly suggestive of an **orbital floor (blowout) fracture**. The orbital floor is the roof of the **maxillary sinus**, so a fracture often causes blood to leak into the sinus, leading to **clouding on imaging**. - Limited upward gaze is a classic sign due to **entrapment of the inferior rectus muscle** or its surrounding soft tissues in the fracture site. *Cerebrospinal fluid leak* - A CSF leak is associated with fractures involving the **skull base**, particularly the **cribriform plate** or **petrous bone**, which is not directly indicated by these symptoms. - While possible with severe facial trauma, it's less direct consequence of the localized orbital floor fracture described. *Pneumatization of frontal sinus* - **Pneumatization** refers to the development of air cells within a bone, a normal physiological process, not an acute traumatic finding. - The frontal sinus is located superior to the orbit, and while it can be involved in trauma, the described symptoms point specifically to the **orbital floor** and infraorbital region. *Injury to lacrimal duct system* - Injury to the lacrimal duct system typically presents with **epiphora** (excessive tearing) or dacryocystitis. - This type of injury is more common with trauma to the **medial canthus** or nasal area, not primarily the infraorbital rim. *Disruption of medial canthal ligament* - Disruption of the medial canthal ligament would lead to a widened space between the eyelids (telecanthus) and often involve the **lacrimal drainage system**. - This is typically associated with fractures of the **naso-orbital-ethmoid complex**, which is distinct from the orbital floor fracture described.

Q: A 55-year-old man presents to the emergency department with a concern of having sprayed a chemical in his eye. He states he was working on his car when his car battery sprayed a chemical on his face and eye. He states his eye is currently burning. His temperature is 99.0°F (37.2°C), blood pressure is 129/94 mmHg, pulse is 85/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for a teary and red left eye. Which of the following is the most appropriate next step in management?

Irrigation. ***Irrigation*** - Immediate and copious **irrigation** is the most crucial step in managing a chemical eye injury to dilute and remove the corrosive substance, preventing further ocular damage. - Delaying irrigation can lead to irreversible damage, especially with **acid burns** from battery acid (sulfuric acid). *Visual acuity test* - While important, assessing **visual acuity** should occur *after* initial irrigation to prioritize minimizing chemical exposure and preserving ocular health. - Performing it before irrigation delays critical treatment, potentially worsening the prognosis. *Slit lamp exam* - A **slit lamp exam** is essential for evaluating the extent of ocular damage but should only be performed *after* adequate irrigation has been completed. - It provides detailed information on corneal and conjunctival integrity but is not the immediate priority in an acute chemical exposure. *CT orbits* - A **CT scan of the orbits** is not indicated for a chemical eye injury unless there is suspicion of a **globe rupture** or **orbital fracture**, which are not suggested by the patient's presentation. - This imaging study would unnecessarily delay vital treatment for the chemical burn. *Surgical debridement* - **Surgical debridement** is reserved for severe cases of chemical burns with significant tissue necrosis or foreign bodies that cannot be removed by irrigation. - It is not the initial management step and would be considered much later, if at all, based on the severity of the injury after initial stabilization.

Question 1

A 35-year-old male is brought into the emergency department for a trauma emergency. The emergency medical services states that the patient was wounded with a knife on his upper left thigh near the inguinal ligament. Upon examination in the trauma bay, the patient is awake and alert. His physical exam and FAST exam is normal other than the knife wound. Large bore intravenous lines are inserted into the patient for access and fluids are being administered. Pressure on the knife wound is being held by one of the physicians with adequate control of the bleeding, but the physician notices the blood was previously extravasating in a pulsatile manner. His vitals are BP 100/50, HR 110, T 97.8, RR 22. What is the next best step for this patient?

Accepted Answer

Emergent surgery

Answer

CT lower extremities

Answer

Radiograph lower extremities

Answer

Coagulation studies and blood typing/crossmatch

Answer

Tourniquet of proximal lower extremity

Question 2

A 59-year-old man comes to the physician for evaluation of progressively worsening back pain that began about 2 months ago. It started as a dull pain that has now developed into a constant throbbing pain that makes falling asleep difficult. Ibuprofen and acetaminophen do not provide relief. The patient has not had any bowel incontinence, limb weakness, or paresthesias. He has metastatic prostate cancer with known metastasis to the sacrum and left ilium, but has had minimal pain related to these sites. He underwent bilateral orchiectomy two years ago, complicated by urinary incontinence. He currently takes no medications. Vital signs are within normal limits. There is midline tenderness to palpation over the lower lumbar spine. MRI scan of the spine shows a new sclerotic lesion at the L5 vertebral body. Which of the following is the most appropriate next step in management?

Accepted Answer

Local radiation

Answer

Prostatectomy

Answer

Flutamide

Answer

Spinal surgery

Answer

Denosumab

Question 3

A 23-year-old woman presents to the emergency department after being found unresponsive by her friends. The patient is an IV drug user and her friends came over and found her passed out in her room. The patient presented to the emergency department 2 days ago after being involved in a bar fight where she broke her nose and had it treated and packed with gauze. Her temperature is 99.3°F (37.4°C), blood pressure is 90/48 mmHg, pulse is 150/min, respirations are 24/min, and oxygen saturation is 97% on room air. Physical exam is notable for an obtunded woman with nasal packing and EKG tags from her last hospital stay, as well as a purpuric rash on her arms and legs. Her arms have track marks on them and blisters. Which of the following is the best next step in management?

Accepted Answer

Removal of nasal packing

Answer

Urine toxicology screen and empiric naloxone

Answer

Nafcillin

Answer

Vancomycin

Answer

Norepinephrine

Question 4

A 43-year-old man is brought to the emergency department 30 minutes after falling from the roof of a construction site. He reports abdominal and right-sided flank pain. His temperature is 37.1°C (98.8°F), pulse is 114/min, and blood pressure is 100/68 mm Hg. Physical examination shows numerous ecchymoses over the trunk and flanks and a tender right abdomen without a palpable mass. Focused assessment with sonography for trauma (FAST) shows no intraperitoneal fluid collections. His hemoglobin concentration is 7.6 g/dL. The most likely cause of his presentation is injury to which of the following organs?

Accepted Answer

Kidney

Answer

Liver

Answer

Stomach

Answer

Small bowel

Answer

Spleen

Question 5

A 45-year-old male is brought into the emergency room by emergency medical services due to a stab wound in the chest. The wound is located superior and medial to the left nipple. Upon entry, the patient appears alert and is conversational, but soon becomes confused and loses consciousness. The patient's blood pressure is 80/40 mmHg, pulse 110/min, respirations 26/min, and temperature 97.0 deg F (36.1 deg C). On exam, the patient has distended neck veins with distant heart sounds. What is the next best step to increase this patient's survival?

Accepted Answer

Pericardiocentesis

Answer

Heparin

Answer

Intravenous fluids

Answer

Aspirin

Answer

Intravenous colloids

Question 6

A 13-year-old boy is brought to the emergency room 30 minutes after being hit in the face with a baseball at high velocity. Examination shows left periorbital swelling, posterior displacement of the left globe, and tenderness to palpation over the left infraorbital rim. There is limited left upward gaze and normal horizontal eye movement. Further evaluation is most likely to show which of the following as a result of this patient's trauma?

Accepted Answer

Clouding of maxillary sinus

Answer

Cerebrospinal fluid leak

Answer

Pneumatization of frontal sinus

Answer

Injury to lacrimal duct system

Answer

Disruption of medial canthal ligament

Question 7

A 32-year-old woman presents to the office with complaints of intense anal pain every time she has a bowel movement. The pain has been present for the past 4 weeks, and it is dull and throbbing in nature. It is associated with mild bright red bleeding from the rectum that is aggravated during defecation. She has no relevant past medical history. When asked about her sexual history, she reports practicing anal intercourse. The vital signs include heart rate 98/min, respiratory rate 16/min, temperature 37.6°C (99.7°F), and blood pressure 110/66 mm Hg. On physical examination, the anal sphincter tone is markedly increased, and it's impossible to introduce the finger due to severe pain. What is the most likely diagnosis?

Accepted Answer

Local anal trauma

Answer

Rectal prolapse and paradoxical contraction of the puborectalis muscle

Answer

Inflammatory bowel disease

Answer

Anorectal abscess

Answer

Hemorrhoidal disease

Question 8

A 55-year-old man presents to the emergency department with a concern of having sprayed a chemical in his eye. He states he was working on his car when his car battery sprayed a chemical on his face and eye. He states his eye is currently burning. His temperature is 99.0°F (37.2°C), blood pressure is 129/94 mmHg, pulse is 85/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for a teary and red left eye. Which of the following is the most appropriate next step in management?

Accepted Answer

Irrigation

Answer

Visual acuity test

Answer

Slit lamp exam

Answer

CT orbits

Answer

Surgical debridement

Question 9

A 35-year-old woman is brought to the emergency department 45 minutes after being rescued from a house fire. On arrival, she appears confused and has shortness of breath. The patient is 165 cm (5 ft 5 in) tall and weighs 55 kg (121 lb); BMI is 20 kg/m2. Her pulse is 125/min, respirations are 29/min, and blood pressure is 105/65 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Examination shows second and third-degree burns over the anterior surfaces of the chest and abdomen, and the anterior surface of the upper extremities. There is black debris in the mouth and nose. There are coarse breath sounds over the lung bases. Cardiac examination shows no murmurs, rubs, or gallop. Femoral and pedal pulses are palpable bilaterally. Which of the following is the most appropriate fluid regimen for this patient according to the Parkland formula?

Accepted Answer

Administer 6 liters of intravenous crystalloids over the next 24 hours

Answer

Administer 4 liters of intravenous colloids over the next 8 hours

Answer

Administer 5 liters of intravenous colloids over the next 6 hours

Answer

Administer 5 liters of intravenous crystalloids over the next 6 hours

Answer

Administer 8 liters of intravenous colloids over the next 12 hours

Question 10

A 25-year-old male presents to his primary care physician for pain in his knee. The patient was in a wrestling match when his legs were grabbed from behind and he was taken to the floor. The patient states that the moment this impact happened, he felt a snapping and sudden pain in his knee. When the match ended and he stood back up, his knee felt unstable. Minutes later, his knee was swollen and painful. Since then, the patient claims that he has felt unstable bearing weight on the leg. The patient has no significant past medical history, and is currently taking a multivitamin and protein supplements. On physical exam you note a tender right knee, with erythema and an effusion. Which of the following is the most likely physical exam finding in this patient?

Accepted Answer

Anterior translation of the tibia relative to the femur

Answer

Laxity to valgus stress

Answer

Clicking and locking of the joint with motion

Answer

Laxity to varus stress

Answer

Posterior translation of the tibia relative to the femur

Trauma/Emergencies — MCQs

Trauma/Emergencies — MCQs

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