Question 1

Difference between tension PTX and pericardial tamponade (for boards)

Accepted Answer

Tension pneumothorax: tracheal deviation, decreased breath sounds, subQ air. Pericardial tamponade: decreased heart sounds. BOTH will have JVD, hypotension, tachycardia

Question 2

How to determine GCS

Accepted Answer

E4 V5 M6; Eyes: 4- Spontaneous, 3- Voice, 2- Pain, 1- None; Voice: 5- Normal, 4- Confused, 3- Words, 2- Sounds, 1- None; Motor: 6- Follows commands, 5- Localizes pain, 4- Withdraws to pain, 3- DeCORticate (arms to CORE; flexed), 2- Decerebrate (extended) posturing, 1- None; GCS < 8 intubate

Question 3

How to determine ACS Class of Hemorrhagic Shock

Accepted Answer

I: Normal vitals (<15% loss, 750cc), II: Tachy, but normal BP with ↓ PP (15-30% loss, 750-1.5L), III: Hypotension (30-40% loss, 1.5-2L), IV: AMS-confused/lethargic (>40%, >2L)

Question 4

Vital sign changes with brain herniation

Accepted Answer

Cushing's reflex (2/2 inc ICP): hypertension, bradycardia, irregular respirations

Question 5

Compare subfalcine, uncal and tonsillar herniation

Accepted Answer

Subfalcine: most common, frontal lobe under falx, ssx abnormal gait; Uncal: temporal lobe under cerebellar tentorium, ssx CN3 palsy (blown pupil, down and out), ipsilateral hemiparesis, coma; Tonsillar: rare, brainstem herniation, coma and death

Question 6

Traumatic injuries CT can commonly miss

Accepted Answer

Diaphragmatic injury, pancreas injury, basilar skull fracture, hollow viscus injuries

Question 7

Classification of LeFort fractures

Accepted Answer

Midface fx resulting in detachment of maxilla from skull, all the fractures involve pterygoid plate; Dx with CT; LeFort I: palate mobile (fx below nose); LeFort II: palate + nose mobile (inferior orbits); LeFort III: entire face is mobile (zygoma bone), ± CSF rhinorrhea. IV: a III that involves the frontal bone

Question 8

SSx, Dx and Tx of mandibular fractures

Accepted Answer

SSx: malocclusion, trismus, lower lip paresthesias; BODY = most common; Dx: CT or panorex; Tx: manage non-condylar fx as open fx with empiric PCN/Clinda, ENT/OMFS consult

Question 9

SSx, Dx and Tx of orbital fractures

Accepted Answer

SSx: diplopia, proptosis, limited EOM, ↓ visual acuity; check for infraorbital paresthesia, inhibited upward gaze, diplopia, globe injury; Dx: CT orbit; Tx: consult ophtho/ENT, decongestants, abx (Augmentin) for sinus involvement

Question 10

Which facial bone fx has the lowest rate of infection?

Accepted Answer

Zygomatic

Question 11

Dx and Tx of nasal septal hematomas

Accepted Answer

Dx: dark red mass/hematoma associated with nasal fx/trauma; Tx: MUST incise & pack (NO needle) to prevent saddle nose deformity/pressure necrosis

Question 12

Classification of neck zones

Accepted Answer

Zone I: sternum/clavicles to cricoid cartilage; Zone II: cricoid to angle of mandible, (most common site of injury); Zone III: angle of mandible to base of skull

Question 13

Management of penetrating neck injury

Accepted Answer

Intubate early, straight to OR if unstable vitals or HARD signs of vascular injury ("HARD BRUIT": Hypotension (shock), Arterial bleeding, Rapidly expanding hematoma, Deficit [pulse/neuro], Bruit/thrill), airway obstruction; Soft signs: CT angio, possible scope/exploration if stable

Question 14

Possible complications of blunt neck injury

Accepted Answer

Pseudoaneurysm, carotid artery dissection, tracheal injury; Dx: CT angio, if unstable, intubate/ENT consult; blunt neck trauma + neuro findings = carotid artery dissection until proven otherwise

Question 15

SSx, Dx and Tx of traumatic aortic dissection

Accepted Answer

SSx: consider when- high speed deceleration, chest pain/back pain, new murmur, pulse deficits BUT exam often unremarkable; Dx: stable- CXR (look for mediastinal widening but 1/3 are normal, obscured aortic knob, L apical pleural cap, R tracheal deviation, ↓ L bronchus/↑ R bronchus, loss of AP window, R displaced NGT), VERY stable- get CTA; if (+) dispo to OR on beta blocker for BP control; aortic isthmus = most common location; most die in the field

Question 16

Dx and Tx of flail chest

Accepted Answer

Dx: ≥3 adjacent rib fractures at 2 different points; leads to paradoxical chest motion with respirations; Association: pulmonary contusion; Tx: early intubation, ± chest tube

Question 17

Appropriate imaging to eval for sternal fracture

Accepted Answer

Must get lateral CXR; consider CT if high suspicion and XR (-)

Question 18

Identify high risk rib fractures

Accepted Answer

1-2: associated with vascular and bronchial injuries; 9-11: associated with liver and spleen lacerations; 4-9: most common location; multiple ribs: associated with underlying lung contusion

Question 19

Indications for OR thoracostomy with hemothorax

Accepted Answer

Unstable vitals, initial chest tube output >1.5L (20cc/kg) OR >200/hr over 3-4hr (3cc/kg), persistent bleeding >7cc/kg/hr, persistent air leak

Question 20

Management of traumatic pneumothorax

Accepted Answer

Small: O2, repeat CXR; Large: chest tube; **Pearl: if intubating with ptx, do chest tube first to prevent tension ptx**

Question 21

Indications for ED thoracotomy

Accepted Answer

Penetrating traumatic cardiac arrest: field arrest with initial vitals, ED arrest, SBP <50 after IVF; Blunt trauma: ED arrest; Other: suspected air embolism

Question 22

General approach to traumatic abdominal injury

Accepted Answer

OR (penetrating): unstable vitals, peritonitis w/ (+) FAST, evisceration, or transabdominal GSW; STABLE- get CT, DO NOT send unstable patient to CT; Tx: blood for shock even if normal initial H/H

Question 23

Most common injury sites for abdominal GSW and stab wound

Accepted Answer

GSW: small bowel; SW: Liver (Blunt abdominal trauma: spleen > liver)

Question 24

SSx, Dx and Tx of diaphragmatic injuries

Accepted Answer

Both sides are injured equally, but historically L>R for blunt (more common) & penetrating; consider with any injury nipple to navel; frequently missed/delayed dx; SSx: SOB, chest/abd pain, n/v, Kehr sign (referred L shoulder pain); Dx: CXR with coiled NGT in chest = pathognomonic, blurred hemidiaphragm, air/fluid level in chest; CXR & CT miss 50%; Definitive Dx and Tx: laparoscopy/otomy in OR

Question 25

Abdominal pain 2/2 bike handlebar injury

Accepted Answer

Duodenal/pancreas injury

Question 26

Abdominal pain after lap belt injury

Accepted Answer

Small bowel injury. Part of the "seat belt syndrome" which includes: 1. Transverse abdominal wall contusion 2. Chance fracture 3. Abdominal visceral trauma (e.g. small bowel injury).

Question 27

What volume of fluid/bleeding is required for positive FAST?

Accepted Answer

250ml

Question 28

What traumatic injuries would NOT be identified on FAST?

Accepted Answer

Poor sensitivity for solid-organ injury, hollow viscus injury, and retroperitoneal injury

Question 29

When is DPL considered positive?

Accepted Answer

Use if unstable + no US or equivocal FAST; (+) DPL if (Rule of 10's)- 10 mL initial gross blood/bile/feces; if no gross contents, infuse 1000cc and then aspirate: (+)DPL if >10,000 RBCs (penetrating) or >100,000 RBCs (blunt)

Question 30

How to Dx retroperitoneal injuries

Accepted Answer

CT with IV contrast, FAST will be negative

Question 31

SSx, Dx and Tx of scrotal/testicular injuries

Accepted Answer

SSx: straddle injury, hematuria, scrotal ecchymosis/hematoma/ttp; Dx: doppler US; Tx: urology consult

Question 32

Time limit to reimplant amputated penis

Accepted Answer

8-12 hr max

Question 33

SSx, Dx and Tx of bladder/urethral Injuries

Accepted Answer

SSx red flags: pelvic fx, gross hematuria, blood at meatus, urinary retention, high prostate, perineal bruising, females may have vaginal bleeding; Dx: NO FOLEY, RUG first to eval for urethral injury, CT cystogram for bladder injury, urology consult; Tx: partial urethral lacs typically treated with Foley, complete urethral lacs require surgery

Question 34

Interpretation of RUG for possible urethral injuries

Accepted Answer

Anterior Urethral Injury: distal to UG diaphragm, usually external signs of trauma, RUG: small extravasation with bladder filling; Posterior Urethral Injury: proximal to UG diaphragm, usually normal external exam, RUG large extravasation into pelvis

Question 35

SSx, Dx and Tx of bladder rupture

Accepted Answer

SSx red flags: pelvic fx, gross hematuria (most common); Dx: retrograde cystogram; Tx: Intraperitoneal (contrast posterior to bladder) → OR (non-emergent), Extraperitoneal (flame pattern) → Foley (no OR)

Question 36

SSx, Dx and Tx of renal injuries

Accepted Answer

SSx: blunt trauma causes 90% renal injuries, gross hematuria (microscopic hematuria is rare for significant injury); Dx: CT with IV contrast; Tx: all ureteral injuries go to OR, most blunt renal injuries are nonoperative; Renal injury is rarely in isolation - look for other injuries

Question 37

Management of severe head trauma

Accepted Answer

Intubate with GCS ≤ 8; remove c-collar + hold inline cervical stabilization for intubation; hyperventilation → cerebral vasoconstriction → ↓ ICP

Question 38

What are the NEXUS Criteria and what are they used for?

Accepted Answer

Used to clear c-spine; DOES NOT include "cervical PAIN": cervical ttp, pain that distracts, AMS, intoxication, neuro deficits

Question 39

How to read C-spine XR?

Accepted Answer

Lateral: Ant/Post spinal line & spinal laminar lines should be smooth; normal prevertebral space- 6mm at C2 & 22mm at C6; Open mouth: C1 and C2 lateral edges should align, look at odontoid for fx

Question 40

Identify unstable C-spine injuries

Accepted Answer

"Jefferson Bit Off A Hangman's Thumb"; Jefferson fx (C1 burst fracture 2/2 axial load), Bilateral facet joint dislocation (2/2 hyperflexion), Odontoid fx (Type I - tip [stable fx]; Type II - neck [most common and unstable]; Type III - body [unstable] ), Atlantoaxial dislocation (C1/C2 dislocation), Hangman's fx (bilateral C2 pedicle fracture 2/2 hyperextension), Teardrop fx (anterior & inferior vertebral body fx with interspinous ligament rupture, 2/2 flexion > extension)

Question 41

Identify landmarks for anterior, middle and posterior spinal column (Denis model)

Accepted Answer

Classification for thoracolumbar fx; Ant column: anterior half of vertebral body; Middle column: posterior half of vertebral body; Post column: posterior to vertebral body; > 2 columns = unstable

Question 42

Most common location of spinal fractures

Accepted Answer

T11-L2 (50%). **Spinal fractures often occur in multiples**

Question 43

Describe wedge, burst and Chance fractures

Accepted Answer

Wedge: compression of anterior column; Burst: crush with multiple fragments involving anterior & middle columns; Chance: fracture through all columns, associated with lap belt injuries

Question 44

Identify spinal cord syndromes: Central Cord, Anterior Cord, Brown-Séquard

Accepted Answer

Central cord: 2/2 hyperextension, usually elderly person hitting chin, sensory (cape distribution) & motor deficit, UE > LE; Anterior cord: 2/2 hyperflexion, bilateral motor paralysis, loss of pain/temp, intact vibration & proprioception; Brown-Séquard: penetrating trauma to 1/2 spinal cord, ipsilateral loss of motor, vibration & proprioception, contralateral loss of pain/temp

Question 45

Identify landmarks for dermatomes: C6/7/8, T4, T10, L1, L4/L5/S1, S3-5

Accepted Answer

C6- 1st dorsal web space; C7- middle finger; C8- pinky finger; T4- nipple; T10- umbilicus; L1- inguinal ligament; L4- patella; L5- big toe; S1- 5th toe; S3-5- anus

Question 46

What are the clinical findings in Neurogenic Shock?

Accepted Answer

Loss of vasomotor & sympathetic tone; Classic features: hypotension (vasodilation), bradycardia (unopposed vagal tone), poikilothermia (peripheral vasodilation, "warm shock"); Rx: IVF, pressors, Atropine

Question 47

What is spinal shock?

Accepted Answer

Not true shock, more of a spinal "stun" 2/2 no circulatory involvement; SSx: areflexia & flaccid paralysis (all transient), relative bradycardia; first reflex to return is bulbocavernosus

Question 48

Indication for perimortem C-section

Accepted Answer

gestation ≥ 24 weeks + loss of maternal vital signs; best if delivery performed ≤ 5 minutes after arrest; does not worsen maternal outcome

Question 49

What population is at highest risk for intimate partner violence?

Accepted Answer

Pregnant women

Question 50

Differential for serious complications in pregnant trauma?

Accepted Answer

Placental abruption, maternofetal hemorrhage, uterine rupture, preterm labor

Question 51

Review blast injury Types I-IV

Accepted Answer

1°: blast shock wave (hollow viscus injury; TM rupture = most common blast injury, blast lung), 2°: projectiles from explosion (penetrating trauma, amputations, lacs); 3°: blunt trauma from explosion (crush injuries, blunt trauma); 4°: environmental contamination (burns, inhalation injury, smoke, radiation, etc.)

Question 52

Review concerning specialized blast-related injuries

Accepted Answer

TM rupture: most common injury, CXR if (+) to look for blast lung; Blast Lung: pulmonary barotrauma, most common cause of death, Dx: CXR (patchy opacities in butterfly pattern); Others: delayed intra abdominal injuries, compartment syndrome

Question 53

Immediate and delayed possible complications with myocardial contusion

Accepted Answer

Immediate: arrhythmia (sinus tach most common); Delayed: pericardial effusion (most common complication 2 weeks out), MI/CHF, valvular injuries (aortic valve + AR most common), ventricular wall rupture (rare; most common cause of death in non penetrating cardiac injuries); Sternal fx = most common associated fx. Screen with ekg not troponin

Question 54

What is the most common cause of in-hospital death following near-hanging?

Accepted Answer

Pulmonary edema

Question 55

What criteria require transfer of a patient to a trauma center?

Accepted Answer

Abnormal vitals, GCS < 14, penetrating trauma, severe blunt injuries (flail chest, multiple long bone fx), pelvic or skull fx, neurological deficits, high mechanism MVC or ped vs auto, elderly or kids, anticoagulant use, pregnant > 20wks

Question 56

Potential complication of not repairing a galeal laceration?

Accepted Answer

Loss of the frontalis muscle function

Question 57

Dx and Tx: Patient presents 2 days after a femur fracture w/ AMS, hypotension, hypoxia and petechiae.

Accepted Answer

Fat embolism to the lungs. Supportive care. Aggressively intubate because of the development of ARDS and AMS. High risk for DIC. There is no specific treatment.

Question 58

What type of brain bleed is associated with basilar skull fractures?

Accepted Answer

Epidural hematoma. Temporal bone is most fractured bone in the base of the skull. Middle meningeal artery runs along the temporal bone.

Question 59

Fat protruding through an eyelid laceration makes you suspicious for what?

Accepted Answer

Globe injury. Eyelids do not have fat therefore the presence of fat is concerning for deeper injury.

Question 60

When should tourniquets be applied prehospital per ACEP practice guidelines?

Accepted Answer

Tourniquets should be used in the setting of significant extremity hemorrhage if direct pressure is not sufficient or impractical

Question 61

What injury should you expect in pediatric trauma patient with paralysis on scene that resolves on arrival to ED and how do you manage it?

Accepted Answer

Injury: SCIWORA - spinal cord injury without radiographic abnormalities. Dx: MRI of spine. Tx: Spine Immobilization for 12 weeks.

Question 62

What location of a dog bite is a candidate for primary closure?

Accepted Answer

Facial laceration (close approximation is appropriate and does not lead to increased infection rates).

Question 63

SSx, Dx and Tx of patella tendon rupture

Accepted Answer

SSx: inability to extend knee, superior patellar displacement, tenderness inferior to patella; Dx: patella alta on XR; Tx: place in knee immobilizer and referral to orthopedics.

Question 64

How do you manage a high pressure injury (paint gun into finger)?

Accepted Answer

Splinting, IV antibiotics, admission and immediate surgical consultation (most important as needs debridement).

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