, Question 1
A patient with severe traumatic brain injury (TBI) has an intracranial pressure
(ICP) of 25 mmHg and cerebral perfusion pressure (CPP) of 55 mmHg.
According to the latest Brain Trauma Foundation guidelines, which
intervention is most appropriate to optimize CPP while minimizing secondary
injury?
A. Hyperventilation to a PaCO2 of 25-30 mmHg
B. Mannitol 1 g/kg IV bolus
C. Norepinephrine infusion to maintain CPP > 60 mmHg
D. Therapeutic hypothermia to 33°C
Correct Answer: C - Norepinephrine infusion to maintain CPP >
60 mmHg
RATIONALE
The BTF guidelines recommend maintaining CPP between 60-70
mmHg; norepinephrine is first-line to augment MAP without
increasing ICP. Hyperventilation is only a temporizing measure for
herniation and can cause ischemia. Mannitol is used for ICP elevation
but may worsen CPP if not volume-resuscitated. Hypothermia is not
recommended for routine ICP management due to lack of outcome
benefit.
Question 2
Which of the following best describes the concept of 'damage control
resuscitation' in the management of hemorrhagic shock?
A. Immediate transfusion of packed red blood cells to a hemoglobin >10
g/dL
B. Early administration of crystalloids to restore blood pressure, followed
by blood products
C. Balanced resuscitation with limited crystalloids, early blood products
in 1:1:1 ratio, and permissive hypotension
D. Aggressive fluid resuscitation to maintain systolic blood pressure
Page 2
, >110 mmHg until surgical control
Correct Answer: C - Balanced resuscitation with limited
crystalloids, early blood products in 1:1:1 ratio, and permissive
hypotension
RATIONALE
Damage control resuscitation emphasizes minimal crystalloid, early
balanced blood products (1:1:1 PRBC:FFP:platelets), and permissive
hypotension (target SBP 80-90 mmHg) until hemorrhage control.
Large-volume crystalloid worsens coagulopathy and acidosis.
Immediate transfusion to a high hemoglobin target is not supported;
permissive hypotension is contraindicated in TBI.
Question 3
A trauma patient develops oliguria, elevated bladder pressure of 22 mmHg, and
peak airway pressures of 45 cm H2O. Which of the following is the most
appropriate next step in management?
A. Immediate decompressive laparotomy
B. Paracentesis to drain ascites
C. Neuromuscular blockade and optimization of sedation
D. Initiation of continuous renal replacement therapy
Correct Answer: C - Neuromuscular blockade and optimization
of sedation
RATIONALE
This represents intra-abdominal hypertension (IAH) with impending
abdominal compartment syndrome (ACS). Medical management
includes sedation, analgesia, and neuromuscular blockade to reduce
abdominal wall compliance. Decompressive laparotomy is indicated
for frank ACS (e.g., bladder pressure >20 mmHg with new organ
dysfunction refractory to medical therapy). Paracentesis and CRRT are
not first-line for IAH.
Page 3
, Question 4
In a trauma patient with suspected aortic injury, which imaging modality is the
gold standard for diagnosis and characterization?
A. Chest X-ray
B. Transthoracic echocardiography
C. CT angiography (CTA)
D. Magnetic resonance angiography (MRA)
Correct Answer: C - CT angiography (CTA)
RATIONALE
CT angiography is the gold standard for diagnosing traumatic aortic
injury, with high sensitivity and specificity. It provides detailed
anatomic information for surgical or endovascular planning. Chest
X-ray is only a screening tool. TTE is limited for aortic arch
evaluation. MRA is time-consuming and less available in
emergencies.
Question 5
A patient with a pelvic fracture and hemodynamic instability undergoes a CT
scan showing a 'blush' of contrast extravasation. According to current
guidelines, what is the most appropriate next step?
A. Immediate transfer to operating room for preperitoneal packing
B. Angioembolization
C. Application of a pelvic binder and observation
D. Exploratory laparotomy
Correct Answer: B - Angioembolization
Page 4
A patient with severe traumatic brain injury (TBI) has an intracranial pressure
(ICP) of 25 mmHg and cerebral perfusion pressure (CPP) of 55 mmHg.
According to the latest Brain Trauma Foundation guidelines, which
intervention is most appropriate to optimize CPP while minimizing secondary
injury?
A. Hyperventilation to a PaCO2 of 25-30 mmHg
B. Mannitol 1 g/kg IV bolus
C. Norepinephrine infusion to maintain CPP > 60 mmHg
D. Therapeutic hypothermia to 33°C
Correct Answer: C - Norepinephrine infusion to maintain CPP >
60 mmHg
RATIONALE
The BTF guidelines recommend maintaining CPP between 60-70
mmHg; norepinephrine is first-line to augment MAP without
increasing ICP. Hyperventilation is only a temporizing measure for
herniation and can cause ischemia. Mannitol is used for ICP elevation
but may worsen CPP if not volume-resuscitated. Hypothermia is not
recommended for routine ICP management due to lack of outcome
benefit.
Question 2
Which of the following best describes the concept of 'damage control
resuscitation' in the management of hemorrhagic shock?
A. Immediate transfusion of packed red blood cells to a hemoglobin >10
g/dL
B. Early administration of crystalloids to restore blood pressure, followed
by blood products
C. Balanced resuscitation with limited crystalloids, early blood products
in 1:1:1 ratio, and permissive hypotension
D. Aggressive fluid resuscitation to maintain systolic blood pressure
Page 2
, >110 mmHg until surgical control
Correct Answer: C - Balanced resuscitation with limited
crystalloids, early blood products in 1:1:1 ratio, and permissive
hypotension
RATIONALE
Damage control resuscitation emphasizes minimal crystalloid, early
balanced blood products (1:1:1 PRBC:FFP:platelets), and permissive
hypotension (target SBP 80-90 mmHg) until hemorrhage control.
Large-volume crystalloid worsens coagulopathy and acidosis.
Immediate transfusion to a high hemoglobin target is not supported;
permissive hypotension is contraindicated in TBI.
Question 3
A trauma patient develops oliguria, elevated bladder pressure of 22 mmHg, and
peak airway pressures of 45 cm H2O. Which of the following is the most
appropriate next step in management?
A. Immediate decompressive laparotomy
B. Paracentesis to drain ascites
C. Neuromuscular blockade and optimization of sedation
D. Initiation of continuous renal replacement therapy
Correct Answer: C - Neuromuscular blockade and optimization
of sedation
RATIONALE
This represents intra-abdominal hypertension (IAH) with impending
abdominal compartment syndrome (ACS). Medical management
includes sedation, analgesia, and neuromuscular blockade to reduce
abdominal wall compliance. Decompressive laparotomy is indicated
for frank ACS (e.g., bladder pressure >20 mmHg with new organ
dysfunction refractory to medical therapy). Paracentesis and CRRT are
not first-line for IAH.
Page 3
, Question 4
In a trauma patient with suspected aortic injury, which imaging modality is the
gold standard for diagnosis and characterization?
A. Chest X-ray
B. Transthoracic echocardiography
C. CT angiography (CTA)
D. Magnetic resonance angiography (MRA)
Correct Answer: C - CT angiography (CTA)
RATIONALE
CT angiography is the gold standard for diagnosing traumatic aortic
injury, with high sensitivity and specificity. It provides detailed
anatomic information for surgical or endovascular planning. Chest
X-ray is only a screening tool. TTE is limited for aortic arch
evaluation. MRA is time-consuming and less available in
emergencies.
Question 5
A patient with a pelvic fracture and hemodynamic instability undergoes a CT
scan showing a 'blush' of contrast extravasation. According to current
guidelines, what is the most appropriate next step?
A. Immediate transfer to operating room for preperitoneal packing
B. Angioembolization
C. Application of a pelvic binder and observation
D. Exploratory laparotomy
Correct Answer: B - Angioembolization
Page 4
