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A 33-year-old man is struck by a car travelling at 56km/h
(35mph). He has obvious fractures of the left tibia near the
knee, pain in the pelvic area, and severe dyspnea. His
heart rate is 182 beats per minute, and his respiratory rate
is 48 breaths per minute with no breath sounds heard in
the left chest. A tension pneumothorax is relieved by
immediate needle decompression and tube thoracostomy.
Subsequently, his heart rate decreases to 144 beats per
minute, his respirartory rate decreases to 36 breaths per
minute and his blood pressure is 81/53 mmHg. Warmed
Ringers lactate is adminstered intravenously. The next
priority should be to:
A. Perform external fixation of the pelvis
B. Obtain abdominal and pelvic CT-scans
C. Perform arterial embolization of the pelvic vessel
D. Perform diagnostic peritoneal lavage or FAST
E. Perform a urethrogram and cystogram - Answer-D.
Perform diagnostic peritoneal lavage or FAST
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A 42-year-old man, injured in a motor vehicle crash,
suffers a closed head injury, multiple palpable left rib
fractures, and bilateral femur fractures. He is intubated
orotracheally without difficulty. Initially, his ventilations are
easily assisted with a bag-mask device. It becomes more
difficult to ventilate the patient over the next 5 minutes,
and his hemoglobin oxygen saturation level decreases
from 98% to 89%. The most appropriate next step is to:
A. Obtain a chest x-ray
B. Decrease the tidal volume
C. Decrease PEEP
D. Increase the rate of assisted ventilations
E. Perform needle decompression of the left chest. -
Answer-A. Obtain a chest x-ray
A 30-year-old man sustains a severely comminuted, open,
distal right femur fracture in a motorcycle crash. The
wound is actively bleeding. Normal sensation is present
over the lateral aspect of the foot but decreased over the
medial foot and great toe. Normal motion of the foot is
observed. Dorsalis pedis and posterior tibial pulses are
easily palpable on the left, but heard only by Doppler on
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the right. Immediate efforts to improve circulation to the
injured extremity should involve:
A. Immediate angiography
B. Tamponade of the wound with a pressure dressing
C. Wound exploration and removal of bony fragments
D. Realignment of the fracture segments with a traction
splint
E. Fasciotomy of all four compartments in the lower
extremity - Answer-B. Tamponade of the wound with a
pressure dressing
An 18-yeard-old, unhelmeted motorcyclist is brought by
ambulance to the ED following a crash. He had decreased
level of consciousness at the scene, but then was alert
and conversational during transportation. Now his GCS is
only 11. Which of the following statements is TRUE?
A. Cerebral perfusion is intact
B. Intravascular volume status is normal
C. The patient is in a postictal state
D. Intra-abdominal visceral injury is unlikely
E. The patient probably has an acute epidural hematoma -
Answer-E. The patient probably has an acute epidural
hematoma
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A previously healthy, 70kg (175 pound) man suffers an
estimated acute blood loss of two liters. Which one of the
following statements apply to this patient?
A. His pulse pressure will be widened
B. His urinary output will be at the lower limits of normal
C. He will have tachycardia, but no change in systolic
blood pressure
D. His systolic blood pressure will be decreased with a
narrowed, pulse pressure
E. His systolic blood pressure will be maintained with an
elevated diastolic pressure. - Answer-E. His systolic blood
pressure will be maintained with an elevated diastolic
pressure.
The physioclogic 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 management of closed head injury
D. Increasing the volume of blood loss to produce
shock/maternal hypotension