‫دورة اﻟﺗﺣﺿﯾر ﻟﻼﻣﺗﺣﺎن اﻟوزاري ﻟﻠطب اﻟﻌﺎم‬

‫‪2018/9‬‬
TRAUMA
 Main Menu
• Subjects: Trauma surgery.
• 45 Questions
• Years 2010-2016

• Average questions/exam ~6-7

Ready..??
1. The first priority during evaluation of a multiply injured
patient who is hypotensive is to:

A. Establish intravenous access

B. Obtain blood for crossmatch
C. Perform a mini-neurologic examination
D. Access the airway
E. Search for occult bleeding

(2.2013)
 TRAUMA…
How does it work?
 TRAUMA…
How does it work?
 ATLS
Advanced Trauma Life Support

• Primary survey
• Secondary Survey
 ATLS-
Advanced Trauma Life Support
Primary Survey
(A,B,C,D,E)

Secondary Survey Operation

Room

• Observation (ICU)
• Discharge
• Operation Room
• Definitive treatment
 ATLS-
Advanced Trauma Life Support
 A

Primary C
Survey

Secondary
Cover (heat) the patient!!!
Survey
Remember the TRAUMA TRIAD OF DEATH : hypothermia, acidosis, coagulopathy
 When to perform CT ??????

CT = stable patient!!
1. The first priority during evaluation of a multiply injured
patient who is hypotensive is to:

primary Survey:
A. Establish intravenous access A…
B. Obtain blood for crossmatch B…
C. Perform a mini-neurologic examination C…
D. Access the airway D…
E. Search for occult bleeding
E…

Secondary Survey
2. A 25-years old woman is brought to the Emergency room after a
rollover motor vehicle crash, she has a femur fracture, her Glasgow
coma scale score is 7, her right pupil is dilated, her systolic blood
pressure is 80 mm Hg, and her heart rate is 120 beats per minute.
Which of the following is the least important initial intervention in the
care of this patient?
primary Survey:
A. Intubation A…
B. CT scan of the head B…
C. Chest x-ray
C…
D. FAST
D…
E. Fluid resuscitation
E…

(03.2015) Secondary Survey

 Airway !!!!!!!
Can he maintain an adequate airway to support acceptable
oxygenation and ventilation ?

This is best achieved by eliciting a verbal response. speaking patients are

typically able to protect their airway.

Signs of compromised airway:

• The inability to speak- indicates severe mental status depression or
some obstruction to air flow through the upper airway.
• noisy breathing.
• severe facial trauma, specifically with oropharyngeal blood or foreign
body
• patient agitation.
• GCS ≤ 8
 A

Primary C
Survey

secondary
Survey
CT = stable patient!!
2. A 25-years old woman is brought to the Emergency room after a
rollover motor vehicle crash, she has a femur fracture, her Glasgow
coma scale score is 7, her right pupil is dilated, her systolic blood
pressure is 80 mm Hg, and her heart rate is 120 beats per minute.
Which of the following is the least important initial intervention in the
care of this patient?
primary Survey:
A. Intubation A…
B. CT scan of the head B…
C. Chest x-ray
C…
D. FAST
D…
E. Fluid resuscitation
E…

Secondary Survey
3. A 20-year-old male is brought to the ER following a fall from 10m.
The patient is unconscious, blood pressure of 100/50 mmhg, pulses
120 beats/min, 6 breath/min. Oxygen saturation of 86% om mask, on
examination-several facial cuts and-condensed temporal fracture are
identified. What is the most effective method to oxygenate this
patient?

A. laryngeal mask
B. nasotracheal intubation
C. needle cricothyroidotomy
D. orotracheal intubation
E. surgical tracheostomy

(2.2016)
 Definitive Airway
Patients require a definitively secured airway:
• Apnea
• Glasgow Coma Scale < 8 or sustained seizure activity.
• Unstable mid-face trauma.
• Airway injuries.
• Large flail segment or respiratory failure.
• High aspiration risk.
• Inability to otherwise maintain an airway or oxygenation.
 Definitive Airway
Immediate airway adjuncts include:
• supplemental oxygen
• Oropharyngeal
• nasopharyngeal airways
• bag valve mask ventilation.

These can be applied quickly to support the failing patient while

preparing to secure a more definitive airway.
 airways
Endo-pharyngeal:
1. Oropharyngeal
2. Nasopharyngeal
3. Laryngeal Mask (LMA)

Endotracheal (definitive airway):

1. orotracheal
2. Nasotracheal
3. Cricothyroidotomy
4. tracheostomy
 Tracheal Vs. pharyngeal airways

1. Protection against aspiration and gastric insufflation

2. More effective ventilation and oxygenation
3. Delivery of anaesthetic and other drugs via the endotracheal
tube (ETT)

The airway of choice for most injured

patients is oral endotracheal intubation
provided using a rapid-sequence technique,
With cricoid pressure applied.
 Contraindications for Endotracheal airway

• Total upper airway obstruction.

• Total loss of facial/oropharyngeal landmarks.
• Inability to open the mouth (eg, scleroderma or surgical
wiring).

• Neck immobility or increased risk of neck (makes intubation

more difficult).
• Anticipated "difficult" airway - unsuccessful intubation may lead
to further difficulties, especially if anaesthetic drugs have been
given
Laryngeal Mask Airway (LMA)

• The LMA does not protect the airway from

aspiration.
• May increase reflux.

• It's use should probably be limited to maintenance of

the airway after a failed attempt at intubation.
 cricothyroidotomy
Intubation is not possible via the oral or nasal route:
• Severe maxillofacial trauma.

• Oedema of throat tissues preventing visualisation of

the cords (eg, angioneurotic oedema, anaphylaxis,
burns, smoke inhalation).
• Severe oropharyngeal/tracheobronchial haemorrhage.
• Foreign body in upper airway.

• Lack of equipment for endotracheal intubation.

• Technical failure of intubation.
3. A 20-year-old male is brought to the ER following a fall from 10m.
The patient is unconscious, blood pressure of 100/50 mmHg, pulses
120 beats/min, 6 breath/min. Oxygen saturation of 86% om mask, on
examination-several facial cuts and-condensed temporal fracture are
identified. What is the most effective method to oxygenate this
patient?

A. laryngeal mask
B. nasotracheal intubation
C. needle cricothyroidotomy
D. orotracheal intubation
E. surgical tracheostomy
4. A 72-year-old man has multiple injuries and an altered sensorium
after a high-speed motor vehicle collision. He is intubated for his
decreased mental status. During intubation, a large amount of gastric
contents are noted in the posterior pharynx and he aspirates. Which of
the following is the appropriate initial treatment?

A. Nasogastric decompression
B. Steroids
C. Prophylactic antibiotics
D. Antacid administration
E. High positive end-expiratory pressure
 Aspiration

Treatment of aspiration is:

1. to clear the airways of debris mechanically.
2. decompress the stomach to prevent further events.
3. provide supportive respiratory care (e.g., bronchodilators,
bronchoscopy, mechanical ventilation) as needed.

• There is no role for corticosteroids or prophylactic antibiotics

because these will serve only to select for bacterial resistance.
• Antibiotics are indicated only if pneumonia develops
• High positive end-expiratory pressure is not required in patients
unless respiratory failure develops.
4. A 72-year-old man has multiple injuries and an altered sensorium
after a high-speed motor vehicle collision. He is intubated for his
decreased mental status. During intubation, a large amount of gastric
contents are noted in the posterior pharynx and he aspirates. Which of
the following is the appropriate initial treatment?

A. Nasogastric decompression
B. Steroids
C. Prophylactic antibiotics
D. Antacid administration
E. High positive end-expiratory pressure
5. A 36-year-old male was found unconscious on scene following a
motor vehicle accident as a driver. He is rushed to the ER with blood
pressure of 70/40 mmHg and 34 breath/min. On physical examination
there is distinct tracheal deviation to the left. Breathing sound are
absent on the right and the right chest is tympanic on percussion.
There is also jugular vein distention. What is the next step in the
management of this patient?

A. bed side cardiac echocardiography

B. chest CT with IV contrast
C. intubation and ventilation
D. decompression of the chest with a needle
E. insertion of two large bore IV and fluid resuscitation
 B…
Breathing/ Ventilation/ Oxygenation

• Pneumothorax (simple/ open/ tension)

• Cardiac Tamponade
• Flail chest
 Tension Pneumothorax
Diagnosis:
• CLINICAL diagnosis - never radiographic diagnosis
– If suspect - TREAT IMMEDIATELY

• Clinical findings
– No pulse, (+) cardiac activity
– Shock unresponsive to fluids
– Severe respiratory distress
– Hard to bag / ventilate patient
– Unilateral decreased breath sounds
– Hyperresonance/ tympany on percussion
– Tracheal deviation away from injury
– JVD (May be absent if hypovolemic)
– Chest or neck crepitus
 Tension Pneumothorax Treatment
Immediate:
needle application
(thoracostomy)
2nd IC space line-
mid clavicular line

Definitive:
Tube thoracostomy
5th IC space line-
mid Axillar line
5. A 36-year-old male was found unconscious on scene following a
motor vehicle accident as a driver. He is rushed to the ER with blood
pressure of 70/40 mmhg and 34 breath/min. On physical examination
there is distinct tracheal deviation to the left. Breathing sound are
absent on the right and the right chest is tympanic on percussion.
There is also jugular vein distention. What is the next step in the
management of this patient?

A. bed side cardiac echocardiography

B. chest CT with IV contrast
C. intubation and ventilation
D. decompression of the chest with a needle
E. insertion of two large bore IV and fluid resuscitation
6. After intubation the most accurate and expedition way to
determine whether the endotracheal is in the trachea?

A. Lung auscultation
B. Stomach auscultation
C. Tube misty
D. End tidal volume
E. Chest wall raising
 ET tube placement
Helpful signs:
• Bilateral breath sounds.
• Rise of chest with each ventilation.
• No gastric distention.
• Chest X-Ray.
• Most in tube.

The gold standard:

ETCO2- End Tidal CO2 (Capnometer)
6. After intubation the most accurate and expedition way to
determine whether the endotracheal is in the trachea?

A. Lung auscultation
B. Stomach auscultation
C. Tube misty
D. End tidal volume
E. Chest wall raising
7. 20 years old man is stapped in the left side of his chest, medial to
the nipple. upon examination his blood pressure is 90/60 mmHg, and
his pulse is 130/min, his jugular venous pulse increases on inspiration,
whereas his peripheral pulse and blood pressure decreases on
inspiration. breath sounds are normal bilaterally. the patient's chest x-
ray film is unremarkable. after receiving 2L of isotonic saline, his blood
pressure remains low, whereas his central venous pressure rises to 32
cm H2O. which of the following is the most appropriate next step in
the managing of this patient?

A. Insert a chest tube into the left pleural cavity

B. Increase parenteral fluids until the blood pressure increases
C. Order an echocardiogram
D. Decrease venous pressure by administering ventilator
E. Decrease venous pressure by administering loop diuretics

(3.2012)
 Cardiac Tamponade
• Blood, clots, or gas accumulates in the pericardium resulting
in slow or rapid compression of the heart.
• Common in penetrating chest trauma
• Diagnosis:
– Beck’s Triad: Hypotension, Distended neck veins, Muffled heart
sounds

-US (FAST /ECHO):

pericardial effusion
+ RV collapse
 Cardiac Tamponade
– Initial Resuscitation
• Volume expansion with crystalloid via two large bore IV
catheters
• Bedside echocardiography for diagnosis

– Pericardiocentesis
• 5-10 cc aspiration of blood may result in dramatic
improvement of clinical condition

– Surgical Repair (Thoracotomy)

• Definitive treatment
7. 20 years old man is stapped in the left side of his chest, medial to
the nipple . upon examination his blood pressure is 90/60 mmHg , and
his pulse is 130/min , his jugular venous pulse increases on inspiration ,
whereas his peripheral pulse and blood pressure decreases on
inspiration . breath sounds are normal bilaterally . the patient's chest
x-ray film is unremarkable . after receiving 2L of isotonic saline , his
blood pressure remains low , whereas his central venous pressure rises
to 32 cm H2O . which of the following is the most appropriate next
step in the managing of this patient ?

A. Insert a chest tube into the left pleural cavity

B. Increase parenteral fluids until the blood pressure increases
C. Order an echocardiogram
D. Decrease venous pressure by administering ventilator
E. Decrease venous pressure by administering loop diuretics

(3.2012)
8. A patient is brought to the ER after a motor vehicle accident. He is
unconscious and has a deep scalp laceration and one dilated pupil. His
heart rate is 120 beats per minute, blood pressure is 80/40 mm Hg, and
respiratory rate is 35 breaths per minute. Despite rapid administration of
2-L normal saline, the patient’s vital signs do not change significantly.
Which of the following is the most appropriate next step in the workup of
his hypotension?

A. Neurosurgical consultation for emergent ventriculostomy to manage his

intracranial pressure
B. Neurosurgical consultation for emergent craniotoymy for suspected
subdural hematoma
C. Emergent burr hole draining at the bedside for suspected epidural
hematoma
D. Administration of mannitol and hyperventilation to treat his elevated
intracranial pressure
E. Abdominal ultrasound (focused assessment with sonography in trauma,
FAST)
 A

Primary C
Survey

secondary
Survey
Cover (heat) the patient!!!
Remember the TRAUMA TRIAD OF DEATH : hypothermia, acidosis, coagulopathy
 Focused Assessment with Sonography
in Trauma (FAST)
(1) the hepatorenal recess
(Morison pouch)

(2) the perisplenic view

(3) the subxiphoid pericardial

window

(4) the suprapubic window

(Douglas pouch).
8. A patient is brought to the ER after a motor vehicle accident. He is
unconscious and has a deep scalp laceration and one dilated pupil. His
heart rate is 120 beats per minute, blood pressure is 80/40 mm Hg, and
respiratory rate is 35 breaths per minute. Despite rapid administration of
2-L normal saline, the patient’s vital signs do not change significantly.
Which of the following is the most appropriate next step in the workup
of his hypotension?

A. Neurosurgical consultation for emergent ventriculostomy to manage his

intracranial pressure
B. Neurosurgical consulation for emergent craniotoymy for suspected
subdural hematoma
C. Emergent burr hole draining at the bedside for suspected epidural
hematoma
D. Administration of mannitol and hyperventilation to treat his elevated
intracranial pressure
E. Abdominal ultrasound (focused assessment with sonography in trauma,
FAST)
9. A 32-year-old woman is a restrained passenger in a high speed
motor vehicle collision. In the emergency room she is found to be
nontachycardic with a systolic blood pressure of 110 mm Hg. Blood is
drawn for determination of the hemoglobin concentration, which is
noted to be 12.2 g/dL. On FAST, a moderate amount of fluid is seen in
the right upper quadrant, between the liver, kidney, and diaphragm.
What is the most appropriate step in management?

A. Laparotomy
B. CT scan of the abdomen and pelvis with intravenous contrast
enhancement
C. Angiography for embolization of the liver laceration
D. Diagnostic peritoneal lavage
E. Observation with serial abdominal examinations
 Focused Assessment with Sonography
in Trauma (FAST)
(1) the hepatorenal recess
(Morison pouch)

(2) the perisplenic view

(3) the subxiphoid pericardial

window

(4) the suprapubic window

(Douglas pouch).
 9. A 32-year-old woman is a restrained passenger in a high speed
motor vehicle collision. In the emergency room she is found to be
nontachycardic with a systolic blood pressure of 110 mm Hg. Blood is
drawn for determination of the hemoglobin concentration, which is
noted to be 12.2 g/dL. On FAST, a moderate amount of fluid is seen in
the right upper quadrant, between the liver, kidney, and diaphragm.
What is the most appropriate step in management?

A. Laparotomy
B. CT scan of the abdomen and pelvis with intravenous contrast
enhancement
C. Angiography for embolization of the liver laceration
D. Diagnostic peritoneal lavage
E. Observation with serial abdominal examinations
10. A 20-year-old male is brought to the ER following a motor vehicle
accident as a driver. Upon arrival his blood pressure 90/60 mmHg,
heart rate of 125 beats/min. After 2 liters of IV fluid his blood pressure
increased to 110/70 mmHg and the pulse is now 90 beats/min. He has
left upper quadrant abdominal tenderness. Ultrasound identifies fluid
at the splenorenal space. What is the next step in the management of
this patient?

A. exploratory laparotomy
B. abdominal CT scan
C. admission to the ICU
D. intubation and ventilation
E. diagnostic laparoscopy

(2.2016)
10. A 20-year-old male is brought to the ER following a motor vehicle
accident as a driver. Upon arrival his blood pressure 90/60 mmhg,
heart rate of 125 beats/min. After 2 liters of IV fluid his blood pressure
increased to 110/70 mmHg and the pulse is now 90 beats/min. He has
left upper quadrant abdominal tenderness. Ultrasound identifies fluid
at the splenorenal space. What is the next step in the management of
this patient?

A. exploratory laparotomy
B. abdominal CT scan
C. admission to the ICU
D. intubation and ventilation
E. diagnostic laparoscopy
11. Young female is injured at a motor vehicle excitant, as seat belted
passenger. She is hemodynamically and respiratory stable and has a
seat belt sign on her abdomen. Her abdomen is soft with mild right
sided tenderness. CT scan demonstrates free air in proximity to
ascending colon. What is the next step?

A. Admission to surgical ward with close monitoring and antibiotics.

B. Exploratory laparotomy/ laparoscopy.
C. Colonoscopy to search for perforation and clip it.
D. Repeat CT scan with rectal margins.
E. Diagnostic peritoneal lavage.
 TRAUMA

Penetrating Blunt
Penetrating or blunt?

Primary survey?
Stable or unstable?

Secondary survey?

Injury?
 Abdominal blunt trauma

• laceration of solid organs usually causing

bleeding, >>>> hemorrhagic shock

• visceral perforation of the GI tract.

 Exploratory
Laparotomy
in blunt trauma:

• peritonitis
• Hollow organ
injury . (free air)
• Hemodynamically
unstable with
suspected
abdominal injury
• Diaphragmatic
rupture
11. Young female is injured at a motor vehicle excitant, as seat belted
passenger. She is hemodynamically and respiratory stable and has a
seat belt sign on her abdomen. Her abdomen is soft with mild right
sided tenderness. CT scan demonstrates free air in proximity to
ascending colon. What is the next step?

A. Admission to surgical ward with close monitoring and antibiotics.

B. Exploratory laparotomy/ laparoscopy.
C. Colonoscopy to search for perforation and clip it.
D. Repeat CT scan with rectal margins.
E. Diagnostic peritoneal lavage.
12. A 32-year-old female is brought to the ER following a motor
vehicle accident as a passenger. She is unconscious with equal pupils
that respond to light. Her blood pressure is 70/40 mmhg, pulse is 115
beats/min and respiratory rate 20/min. The abdomen is distended
with injury signs and peristalsis is absent. Intubation and ventilation
are performed and 2 liters of IV fluid are administered. The blood
pressure is now 80/40 mmhg and the pulse is 118 beats/min What is
the next step in the management of this patient?

A. another 2 liter of IV fluid

B. head CT
C. exploratory laparotomy
D. abdominal CT
E. thoracotomy
 Exploratory
Laparotomy
in blunt trauma:

• peritonitis
• Hollow organ
injury . (free air)
• Hemodynamically
unstable with
suspected
abdominal injury
• Diaphragmatic
rupture
12. A 32-year-old female is brought to the ER following a motor
vehicle accident as a passenger. She is unconscious with equal pupils
that respond to light. Her blood pressure is 70/40 mmhg, pulse is 115
beats/min and respiratory rate 20/min. The abdomen is distended
with injury signs and peristalsis is absent. Intubation and ventilation
are performed and 2 liters of IV fluid are administered. The blood
pressure is now 80/40 mmhg and the pulse is 118 beats/min What is
the next step in the management of this patient?

A. another 2 liter of IV fluid

B. head CT
C. exploratory laparotomy
D. abdominal CT
E. thoracotomy
13. A 36-year-old man who was hit by a car presents to the ER with
hypotension. On examination, he has tenderness and bruising over his
left lateral chest below the nipple. An ultrasound examination is
performed and reveals free fluid in the abdomen. What is the most
likely organ to have been injured in this patient?

A. Liver
B. Kidney
C. Spleen
D. Intestine
E. Pancreas
14. A 48-year-old man is stabbed in the right quadrant. He arrives in
the ED hypotensive and with abdominal tenderness. He is taken
emergently to the OR for laparotomy. At exploration, he is found to
have a 5-cm laceration to the dome of the liver that is no longer
bleeding. No other injuries are found. The next step in managing this
injury would be:

A. Pringle maneuver
B. Pringle maneuver and finger fracture exploration of the injury
C. Exploration of the injury
D. Drain injury area and close the abdomen
E. Close the abdomen and get an angiogram

(02.2013)
 Hepatic injury

• Common both in penetrating and blunt trauma.

• Often first diagnosed on entering the abdomen in the unstable
patient explored for the finding of free fluid on FAST
examination.
• Stable patients with suspected hepatic trauma should undergo
abdominal CT with IV contrast.
 Liver Injury
• Patients who are unstable during emergency department
evaluation and are found to have intra-abdominal fluid require
immediate laparotomy.

• Patients who are stable benefit from a more conservative

approach.
• most injuries to the liver have stopped bleeding by the time of
evaluation, which is usually reflected by the patient’s physiologic
condition.
 Hepatic Injury
Physiologic stability is the major predictor of successful
nonoperative management of hepatic trauma.

evidence that hepatic bleeding has stopped:

• absence of tachycardia, hypotension, metabolic acidosis, and
physical examination evidence of shock,

• This is true independently of injury severity, in that even high-

grade liver injuries should be considered for nonoperative
management
• On patient stabilization, the packs are removed and the hepatic
lacerations evaluated.

• Mild injuries: with little or no ongoing bleeding may be

managed with further compression, topical hemostatic agents,
or suture hepatorrhaphy

• In more severe bleeding- Pringle maneuver.

 Pringle maneuver
• The hepatoduodenal ligament is encircled with a vessel loop or
vascular clamp.
• It occludes hepatic blood flow from the hepatic artery and
portal vein.

• This maneuver helps distinguish hepatic venous bleeding, which

persists from a portal vein, and hepatic artery bleeding that
slows, allowing identification of sources of hemorrhage.

• The hepatic laceration can then be explored and any actively

bleeding vessels controlled with suture ligation.
14. A 48-year-old man is stabbed in the right quadrant. He arrives in
the ED hypotensive and with abdominal tenderness. He is taken
emergently to the OR for laparotomy. At exploration, he is found to
have a 5-cm laceration to the dome of the liver that is no longer
bleeding. No other injuries are found. The next step in managing this
injury would be:

A. Pringle maneuver
B. Pringle maneuver and finger fracture exploration of the injury
C. Exploration of the injury
D. Drain injury area and close the abdomen
E. Close the abdomen and get an angiogram
15. A 20-year-old male is injured a pedestrian in a motor-vehicle
accident. At the ER is fully conscious. BP is 110/70, her rate is 95. Room
saturation is 92%. On Examination there are abrasions on the right
chest and abdomen, deformation of the right arms and normal
peripheral pulses. FAST identifies small amount of abdominal fluid, CT
identifies a stage 4 liver laceration with no active bleeding, and
significant right lung contusion. What is the next step in this patient’s
Management?

A. Positive pressure ventilation

B. Laparotomy
C. Angiographic Embolization of the liver
D. Intensive care observation
E. Surgical repair of arm fracture

(3.2011)
15. A 20-year-old male is injured a pedestrian in a motor-vehicle
accident. At the ER is fully conscious. BP is 110/70, her rate is 95. Room
saturation is 92%. On Examination there are abrasions on the right
chest and abdomen, deformation of the right arms and normal
peripheral pulses. FAST identifies small amount of abdominal fluid, CT
identifies a stage 4 liver laceration with no active bleeding, and
significant right lung contusion. What is the next step in this patient’s
Management?

A. Positive pressure ventilation

B. Laparotomy
C. Angiographic Embolization of the liver
D. Intensive care observation
E. Surgical repair of arm fracture
16. A teenage boy falls from his bicycle and is run over by a truck. On
arrival in the emergency room (ER), he is awake and alert and appears
frightened but in no distress. The chest radiograph suggests an air-fluid
level in the left lower lung field and the nasogastric tube seems to coil
upward into the left chest. Which of the following is the next best step
in his management?

A. Placement of a left chest tube

B. Thoracotomy
C. Laparotomy
D. Esophagogastroscopy
E. Diagnostic peritoneal lavage
 Diaphragmatic rupture
• Can be caused by either blunt trauma or penetrating trauma
• occurs in ~ 4% of patients after blunt abdominal or chest trauma.
• The left-hemidiaphragm is involved 3 times more frequently than the
right, possibly because the liver has a buffering effect

• Diagnosis and treatment are similar regardless of mechanism.

• treated with immediate laparotomy :examination of the intra-abdominal

solid and hollow viscera for associated injuries and for adequate exposure
of the diaphragm to allow secure repair.
• Diaphragmatic repair can be accomplished via the left chest, but
laparotomy is the procedure of choice for acute traumatic rupture for the
stated reasons.
 Diaphragmatic rupture
1. Asymmetry of a hemidiaphragm or changing diaphragmatic level
2. intrathoracic herniation of a hollow viscus (stomach, colon, small bowel)
with or without focal constriction of the viscus at the site of the tear –
Collar sign.
3. visualization of a nasogastric tube above the hemidiaphragm on the left
side
16. A teenage boy falls from his bicycle and is run over by a truck. On
arrival in the emergency room (ER), he is awake and alert and appears
frightened but in no distress. The chest radiograph suggests an air-fluid
level in the left lower lung field and the nasogastric tube seems to coil
upward into the left chest. Which of the following is the next best step
in his management?

A. Placement of a left chest tube

B. Thoracotomy
C. Laparotomy
D. Esophagogastroscopy
E. Diagnostic peritoneal lavage
17. A 36 years old man has a blood pressure of 70/60 mmHg after a
motor vehicle crash. Resuscitation is initiates. Focused Assessment
with Sonography for Trauma (FAST) was positive for fluid in the
abdomen. On examination of the pelvic, fracture-related- crepitus and
an enlarging perianal hematoma are appreciated. The blood pressure
dose not improve with resuscitation. What is the next step?

A. CT of the abdomen and pelvic.

B. Diagnostic peritoneal lavage.
C. Placement of external pelvic fixator.
D. Explorative laparotomy.
E. Pelvic angioemobilization.

(03.2012)
17. A 36 years old man has a blood pressure of 70/60 mmHg after a
motor vehicle crash. Resuscitation is initiates. Focused Assessment
with Sonography for Trauma (FAST) was positive for fluid in the
abdomen. On examination of the pelvic, fracture-related- crepitus and
an enlarging perianal hematoma are appreciated. The blood pressure
dose not improve with resuscitation. What is the next step?

A. CT of the abdomen and pelvic.

B. Diagnostic peritoneal lavage.
C. Placement of external pelvic fixator.
D. Explorative laparotomy.
E. Pelvic angioemobilization.

(03.2012)
 Pelvic trauma
• Stable patient (bp> 100) >> CT

• Unstable then stablized (bp 70-80) >> pelvic binder >> CT/
angiography

• Unstable (bp< 70) >> Operation room

18. While riding his bicycle, a 9-year-old boy loses control and falls.
During the process, his abdomen strikes the handlebar. His parents
bring him to the emergency department because he has vague
midabdominal pain and some bruising of the anterior abdominal wall.
His vital signs are stable, and he has no other visible injuries. Which of
the following is the most likely diagnosis?

A. Ruptured spleen
B. Ruptured liver
C. Ruptured pancreas
D. Hematoma of the rectus muscle
E. Ruptured duodenum

(3.2012)
 Duodenal injuries
• Duodenal injuries identification after a blunt mechanism can be
challenging and therefore require a high index of suspicion to avoid
missed injuries.

• Because of the retroperitoneal location of a significant portion of the

duodenum, physical examination findings may be limited.

• Even full-thickness perforations of the duodenum may not

demonstrate peritoneal signs unless the perforation involves an
intraperitoneal segment.

• Serum amylase is often elevated but is not diagnostic. X-ray films of

the abdomen reveal retroperitoneal air, which is the sine qua non of
duodenal rupture.
• Which symptoms does the patient have?

• Vital signs?

• Abdominal pain? Sharp? Peritonitis?

18. While riding his bicycle, a 9-year-old boy loses control and falls.
During the process, his abdomen strikes the handlebar. His parents
bring him to the emergency department because he has vague
midabdominal pain and some bruising of the anterior abdominal wall.
His vital signs are stable, and he has no other visible injuries. Which of
the following is the most likely diagnosis?

A. Ruptured spleen vital signs are stable

B. Ruptured liver
C. Ruptured pancreas
D. Hematoma of the rectus muscle mmm…
E. Ruptured duodenum
Pancreatic rupture is associated with:

• Also follows blunt trauma

• hypovolemic shock (tear of the gastroduodenal artery).
• High Serum amylase.
• The common bile duct may be avulsed as well.
18. While riding his bicycle, a 9-year-old boy loses control and falls.
During the process, his abdomen strikes the handlebar. His parents
bring him to the emergency department because he has vague
midabdominal pain and some bruising of the anterior abdominal wall.
His vital signs are stable, and he has no other visible injuries. Which of
the following is the most likely diagnosis?

A. Ruptured spleen vital signs are stable

B. Ruptured liver
C. Ruptured pancreas
D. Hematoma of the rectus muscle mmm…
E. Ruptured duodenum

(3.2012)
19. Following blunt abdominal trauma, a 12-year-old girl develops
upper abdominal pain, nausea, and vomiting. An upper gastrointestinal
series reveals a total obstruction of the duodenum with a coiled spring
appearance in the second and third portions. In the absence of other
suspected injuries, which of the following is the most appropriate
management of this patient?

A. Gastrojejunostomy
B. Nasogastric suction and observation
C. Duodenal resection
D. TPN (total parental nutrition) to increase the size of the
retroperitoneal fat pad
E. Duodenojejunostomy

(10.2013)
 Duodenal hematomas
• Present as a proximal bowel obstruction with abdominal pain
and occasionally a palpable right upper quadrant mass.

• typically require no treatment.

• vast majority of duodenal hematomas resolve spontaneously.

• Treatment when they are large and result in a gastric outlet

obstruction:
 Hematomas of the duodenal wall
Treatment:

• Gastric decompression and initiation of total parenteral nutrition.

• reevaluation of gastric emptying with a contrast study after 5 to 7
days.

• If after 2 weeks of upper GI bowel rest the obstruction persists,

exploration is warranted to evaluate for perforation, stricture, or
associated pancreatic injury.

• Duodenal hematomas identified at the time of laparotomy for

another indication require careful evaluation for perforation.
19. Following blunt abdominal trauma, a 12-year-old girl develops
upper abdominal pain, nausea, and vomiting. An upper gastrointestinal
series reveals a total obstruction of the duodenum with a coiled spring
appearance in the second and third portions. In the absence of other
suspected injuries, which of the following is the most appropriate
management of this patient?

A. Gastrojejunostomy
B. Nasogastric suction and observation
C. Duodenal resection
D. TPN (total parental nutrition) to increase the size of the
retroperitoneal fat pad
E. Duodenojejunostomy
20. A 10-year-old boy was the backseat belted passenger in a high-
speed motor vehicle collision. On presentation to the ER, he is awake,
alert, and hemodynamically stable. He is complaining of abdominal
pain and has an ecchymosis on his anterior abdominal wall where the
seatbelt was located. Which of the following is the best next step in his
management?

A. Discharge him home without any other workup

B. Discharge him home if his amylase level is normal
C. Discharge him home if his abdominal plain films are negative for
the presence of free air
D. Discharge him home if an abdominal computed tomography (CT)
scan is negative
E. The boy should be observed regardless of test results
 Seatbelt sign
• suspicion for an enteric or mesenteric injury.

• Observation for: worsening abdominal pain, fevers, or signs of

sepsis, even in the face of negative diagnostic tests.

• Serum amylase levels, plain films of the abdomen, abdominal CT

scans, and DPL all have low sensitivity for small-bowel injuries.
20. A 10-year-old boy was the backseat belted passenger in a high-
speed motor vehicle collision. On presentation to the ER, he is awake,
alert, and hemodynamically stable. He is complaining of abdominal
pain and has an ecchymosis on his anterior abdominal wall where the
seatbelt was located. Which of the following is the best next step in his
management?

A. Discharge him home without any other workup

B. Discharge him home if his amylase level is normal
C. Discharge him home if his abdominal plain films are negative for
the presence of free air
D. Discharge him home if an abdominal computed tomography (CT)
scan is negative
E. The boy should be observed regardless of test results
21. A 58-year-old man presents to the ER after falling 3m from a
ladder. Examination reveals stable vital signs, no evidence of
respiratory distress, and multiple right-sided rib fractures. Chest x ray
shows a hemothorax on the right side and a right tube thoracostomy is
performed in the ER. Approximately 700 mL of blood is immediately
drained with placement of the thoracostomy tube. Over the next 4
hours he continues to drain 300 mL/h after the original evacuation.
Which of the following is the definitive treatment for this patient?

A. Platelets
B. Fresh-frozen plasma
C. Second tube thoracostomy
D. Thoracotomy
E. Observation
 Chest trauma- thoracotomy
There are four main goals of a thoracotomy in the emergency
department:

1. opening of the pericardium to relieve cardiac tamponade.

2. internal cardiac massage
3. cross-clamping of the distal thoracic aorta.
4. management of intra-thoracic bleeding.
 Chest trauma- thoracotomy
immediate thoracotomy is indicated for more than
– 1500 mL of blood drained on chest tube insertion.
– more than 300 mL/hr for 3 hours.

Other indications for immediate thoracotomy

• massive air leak with associated pneumothorax
• drainage of esophageal or gastric contents from the chest
21. A 58-year-old man presents to the ER after falling 3m from a
ladder. Examination reveals stable vital signs, no evidence of
respiratory distress, and multiple right-sided rib fractures. Chest x ray
shows a hemothorax on the right side and a right tube thoracostomy is
performed in the ER. Approximately 700 mL of blood is immediately
drained with placement of the thoracostomy tube. Over the next 4
hours he continues to drain 300 mL/h after the original evacuation.
Which of the following is the definitive treatment for this patient?

A. Platelets
B. Fresh-frozen plasma
C. Second tube thoracostomy
D. Thoracotomy
E. Observation
22 . A 23-year old man sustains blunt chest trauma following a high-
speed motor vehicle accident. He is hemodynimacally stable. Which of
the following conditions is an indication for thoractomy?

A. Undrained hemothorax despite a tube thoracostomy

B. Continuous chest tube drainage of more than 200mL/hr of blood
for 4 hours.
C. Intial chest tube outputs of 1100ML
D. Wide mediastinum
E. Flail chest

(02.2013)
22 . A 23-year old man sustains blunt chest trauma following a high-
speed motor vehicle accident. He is hemodynimacally stable. Which of
the following conditions is an indication for thoractomy?

A. Undrained hemothorax despite a tube thoracostomy

B. Continuous chest tube drainage of more than 200mL/hr of blood
for 4 hours.
C. Intial chest tube outputs of 1100ML
D. Wide mediastinum
E. Flail chest

(02.2013)
23. A 65-year-old man who smokes cigarettes and has chronic
obstructive pulmonary disease falls and fractures the third, fourth, and
fifth ribs in the left anterolateral chest. Chest x-ray is otherwise
normal. Which of the following would be the most appropriate next
step in his management?

A. Strapping the chest with adhesive tape

B. Admission to the hospital and treatment with oral analgesia
C. Tube thoracostomy.
D. Placement of an epidural for pain management
E. Surgical fixation of the fractured ribs
 Rib fractures
• the most common traumatic injury sustained after blunt chest wall
trauma.
• Symptoms include: pain on inspiration and localized point tenderness.
• Diagnosis: Chest X-ray, ribs x ray.

• Contusion of the lung parenchyma and/or injury to the spleen, liver,

diaphragm, or kidney can occur.
• Evaluation ( ultrasound examination, CT scan, or peritoneal lavage).

• Treatment with analgesia and nerve blocks can be helpful

 Ribs fractures
• Epidural catheters, continuous narcotic infusions, and patient-controlled
analgesia are the most effective methods for ensuring pain control in
hospitalized patients with rib fractures.

• elderly patient, multiple rib fractures, demonstrate ventilatory

compromise, or have underlying respiratory problems (COPD or smoking)
are at increased risk for pulmonary complications (atelectasis, pneumonia,
respiratory failure). Require hospitalization and pain management.

• Rib fractures heal spontaneously, without need for surgical fixation.

 Flail chest
• Flail chest may occur with multiple rib fractures.

• this results in an unstable chest wall that develops paradoxical motion

during respiration (e.g., depression during the negative inspiratory phase
and extrusion during the positive expiratory phase).

• often associated with an underlying pulmonary contusion.

• patients require pain relief, stabilization of the chest wall, or even
mechanical ventilation.
23. A 65-year-old man who smokes cigarettes and has chronic
obstructive pulmonary disease falls and fractures the third, fourth, and
fifth ribs in the left anterolateral chest. Chest x-ray is otherwise
normal. Which of the following would be the most appropriate next
step in his management?

A. Strapping the chest with adhesive tape

B. Admission to the hospital and treatment with oral analgesia
C. Tube thoracostomy.
D. Placement of an epidural for pain management
E. Surgical fixation of the fractured ribs

only if pneumothorax is diagnosed

24. A 31-year-old man is brought to the ER following an automobile
accident in which his chest struck the steering wheel. Examination
reveals stable vital signs and no evidence of respiratory distress, but
the patient exhibits multiple palpable rib fractures and paradoxical
movement of the right side of the chest. Chest x-ray shows no
evidence of pneumothorax or hemothorax. Which of the following is
the most appropriate initial management of this patient?

A. Intubation, mechanical ventilation, and positive end-expiratory

pressure
B. Stabilization of the chest wall with sandbags
C. Stabilization with towel clips
D. Immediate operative stabilization
E. Pain control, chest physiotherapy, and close observation
25. A 49 years old man was the restrained driver in a motor vehicle
collision. He decelerated rapidly in order to avoid hitting another car
and swerved into a ditch. He complains of chest pain. Which of the
following finding on chest X-ray would be most suspicious for an aortic
injury?

A. Multiple right-sided rib fractures

B. A left pulmonary contusion
C. A left pneumothorax
D. Widening of the mediastinum greater thean 8 cm
E. Pneumomediastinum
 Traumatic aortic injury
• The cause of blunt aortic injuries is a result of rapid deceleration,
which tears the aortic wall in the vicinity of the ligamentum arteriosum, where
it is fixed to the thorax.

• normal chest x-ray does not rule out a diagnosis of a thoracic great vessel
injury.

If clinical suspicion is high, then further diagnostic workup:

• Aortography
• CT angiography
• transesophageal echocardiography.
 Traumatic aortic injury

findings in X ray include:

– a widened mediastinum
– apical capping (There is a pleural effusion in the rigt lung apex)
– loss of the aortic knob
– deviation of the left mainstem bronchus.
– sternal or scapular fracture
– multiple left-sided rib fractures
– massive left hemothorax
25. A 49 years old man was the restrained driver in a motor
vehicle collision. He decelerated rapidly in order to avoid hitting
another car and swerved into a ditch. He complains of chest
pain. Which of the following finding on chest X-ray would be
most suspicious for an aortic injury?

A. Multiple right-sided rib fractures

B. A left pulmonary contusion
C. A left pneumothorax
D. Widening of the mediastinum greater thean 8 cm
E. Pneumomediastinum
26. A 27-year-old man presents to the ER after a high-speed motor
vehicle collision with chest painand marked respiratory distress. On
physical examination, he is hypotensive with distended neck veinsand
absence of breath sounds in the left chest. Which of the following is
the proper initial treatment?

A. Intubation
B. Chest x-ray
C. Pericardiocentesis
D. Chest decompression with needle
E. Emergent thoracotomy

(03.2012)
 B…
Breathing/ Ventilation/ Oxygenation

• Pneumothorax (simple/ open/ tension)

• Cardiac Tamponade
• Flail chest
 Tension Pneumothorax
Diagnosis:
• CLINICAL diagnosis - never radiographic diagnosis
– If suspect - TREAT IMMEDIATELY

• Clinical findings
– No pulse, (+) cardiac activity
– Shock unresponsive to fluids
– Severe respiratory distress
– Hard to bag / ventilate patient
– Unilateral decreased breath sounds
– Hyperresonance/ tympany on percussion
– Tracheal deviation away from injury
– JVD (May be absent if hypovolemic)
– Chest or neck crepitus
 Tension Pneumothorax
treatment
Immediate:
needle application
(thoracostomy)
2ed IC space line-
mid clavicular line

Definitive:
Tube thoracostomy
5th IC space line-
mid Axillar line
26. A 27-year-old man presents to the ER after a high-speed motor
vehicle collision with chest painand marked respiratory distress. On
physical examination, he is hypotensive with distended neck veinsand
absence of breath sounds in the left chest. Which of the following is
the proper initial treatment?

A. Intubation
B. Chest x-ray
C. Pericardiocentesis
D. Chest decompression with needle
E. Emergent thoracotomy
27. A 24-year-old man is brought into the emergency department
after a fall from a ladder. His breathing is labored and he is cyanotic.
No breath sounds can be heard, even in the right lung field, which is
resonant to percussion. The first step in his management should be

A. Cricothyroidotomy
B. Obtaining a stat chest X-ray
C. Passing an oral endotracheal tube
D. Tube thoracostomy

(10.2010)
27. A 24-year-old man is brought into the emergency department
after a fall from a ladder. His breathing is labored and he is cyanotic.
No breath sounds can be heard, even in the right lung field, which is
resonant to percussion. The first step in his management should be

A. Cricothyroidotomy
B. Obtaining a stat chest X-ray
C. Passing an oral endotracheal tube
D. Tube thoracostomy
28. A 25-year-old woman arrives in the ER following an automobile
accident. She is acutely dyspneic with a respiratory rate of 60 breaths
per minute. Breath sounds are markedly diminished on the right side.
Which of the following is the best first step in the management of this
patient?

A. Take a chest x-ray.

B. Draw arterial blood for blood-gas determination.
C. Decompress the right pleural space.
D. Perform pericardiocentesis
E. Administer intravenous fluids

(10.2013)
28. A 25-year-old woman arrives in the ER following an automobile
accident. She is acutely dyspneic with a respiratory rate of 60 breaths
per minute. Breath sounds are markedly diminished on the right side.
Which of the following is the best first step in the management of this
patient?

A. Take a chest x-ray.

B. Draw arterial blood for blood-gas determination.
C. Decompress the right pleural space.
D. Perform pericardiocentesis
E. Administer intravenous fluids
29. The head and face of 45-year-old man were assaulted with
fists and feet. He arrives at the emergency department with
incomprehensible responses to questions, eyes opening to pain
only, and a flexor response to pain. What is this patient’s
Glasgow Coma Scale (GCS) score?

A. 5
B. 6 2

C. 7
2
D. 8

4
GCS
29. The head and face of 45-year-old man were assaulted with
fists and feet. He arrives at the emergency department with
incomprehensible responses to questions, eyes opening to pain
only, and a flexor response to pain. What is this patient’s
Glasgow Coma Scale (GCS) score?

A. 5
B. 6 2

C. 7
2
D. 8

4
30. A 45-year-old man was an unhelmeted motorcyclist involved in a
high-speed collision. He was ejected from the motorcycle and was
noted to be apneic at the scene. After being intubated, he was brought
to the ER, where he is noted to have a left dilated pupil that responds
only sluggishly. What is the pathophysiology of his dilated pupil?

A. Infection within the cavernous sinus

B. Herniation of the uncal process of the temporal lobe
C. Laceration of the corpus callosum by the falx cerebri
D. Occult damage to the superior cervical ganglion
E. Cerebellar hypoxia

(02.2016/ 02.2014)
 increased intracranial pressure
caused by:
1. added mass of epidural, subdural, and intracranial hematomas
2. cerebral edema which develops around large contusions, from
diffuse vascular injury, and as a result of HIE.

Signs & symptoms:

• Behavior changes
• Decreased consciousness
• Headache
• Lethargy
• Neurological symptoms, including weakness, numbness, eye
movement problems, and double vision
• Seizures
• Vomiting
Cerebral herniation
 Cerebral herniation
Uncal (transtentorial) herniation
• herniation of the medial temporal lobe from the middle into the
posterior fossa, across the tentorial opening.
• This compresses the ipsilateral oculomotor nerve, causing a
fixed and dilated pupil, and collapses the ipsilateral posterior
cerebral artery, causing an infarct in its distribution.
30. A 45-year-old man was an unhelmeted motorcyclist involved in a
high-speed collision. He was ejected from the motorcycle and was
noted to be apneic at the scene. After being intubated, he was brought
to the ER, where he is noted to have a left dilated pupil that responds
only sluggishly. What is the pathophysiology of his dilated pupil?

A. Infection within the cavernous sinus

B. Herniation of the uncal process of the temporal lobe
C. Laceration of the corpus callosum by the falx cerebri
D. Occult damage to the superior cervical ganglion
E. Cerebellar hypoxia
31. An 18-year-old man was assaulted and sustained significant head
and facial trauma. Which of the following is the most common initial
manifestation of increased intracranial pressure?

A. Change in level of consciounsness

B. Ipsilateral (side of hemorrhage) pupillary dilation
C. Contralateral pupillary dilation ????
D. Hemiparesis
E. Hypertension

(03.2010)
 increased intracranial pressure
caused by:
1. added mass of epidural, subdural, and intracranial hematomas
2. cerebral edema which develops around large contusions, from
diffuse vascular injury, and as a result of HIE.

Signs & symptoms:

• Behavior changes
• Decreased consciousness
• Headache
• Lethargy
• Neurological symptoms, including weakness, numbness, eye
movement problems, and double vision
• Seizures
• Vomiting
31. An 18-year-old man was assaulted and sustained significant head
and facial trauma. Which of the following is the most common initial
manifestation of increased intracranial pressure?

A. Change in level of consciousness

B. Ipsilateral (side of hemorrhage) pupillary dilation
C. Contralateral pupillary dilation
D. Hemiparesis
E. Hypertension
32. Which of the following the appropriate method to evaluate
cervical spine in an alert unintoxicated neurologically normal patient
without distracting injuries after a motor vehicle crash?

A. If the patient denies neck pain nothing more is needed

B. Clinical exam to assess midline tenderness and range of motion
C. View spine radiographs
D. CT scan of cervical spine
E. MRI
 Cervical spine clearance
• Patients who have no findings on examination, demonstrate no decreased
level of consciousness, and have no distracting injuries can undergo
clearance of the spine by clinical means alone.

NEXUS Criteria for C-Spine Imaging

(if no one of this exist Cervical spine can by clinically clearanced)
• Focal Neurologic Deficit Present
• Midline Spinal Tenderness Present
• Altered Level of Consciousness Present
• Intoxication Present
• Distracting Injury Present
 Cervical spine clearance

Clinical clearance:
• no bruising or deformity
• no tenderness and a pain
• free range of active movements
32. Which of the following the appropriate method to evaluate
cervical spine in an alert unintoxicated neurologically normal patient
without distracting injuries after a motor vehicle crash?

A. If the patient denies neck pain nothing more is needed

B. Clinical exam to assess midline tenderness and range of motion
C. View spine radiographs
D. CT scan of cervical spine
E. MRI
33. Which is of the following is a cause of cardiogenic shock in a
trauma patient?

A. Hemothorax
B. Penetrating injury to the aorta
C. Air embolism
D. Iatrogenic increased afterlaod due to pressors
33. Which is of the following is a cause of cardiogenic shock in a
trauma patient?

A. Hemothorax
B. Penetrating injury to the aorta
C. Air embolism
D. Iatrogenic increased afterload due to pressors
 Air embolism
Systemic arterial embolism is a potentially lethal complication of
bronchopulmonary venous fistula in trauma patients with blunt chest
trauma or isolated penetrating lung injury on positive pressure
ventilation.
Cardiogenic shock
34. A 30-year-old is brought to the ER following a motor vehicle
accident as a back seat passenger. Her blood pressure is 110/80, pulse
90, RR 12. A change in which of the following is the first sign of
hypovolemia?

A. systemic blood pressure

B. heart rate
C. respiratory rate
D. consciousness level
E. capillary refill
 Hypovolemia
• patient can be in shock before developing hypotension because
this is one of the last findings before complete cardiovascular
collapse.
34. A 30-year-old is brought to the ER following a motor vehicle
accident as a back seat passenger. Her blood pressure is 110/80, pulse
90, RR 12. A change in which of the following is the first sign of
hypovolemia?

A. systemic blood pressure

B. heart rate
C. respiratory rate
D. consciousness level
E. capillary refill
35. Damage control approach was developed in order to avoid lethal
triad. What is included in this triad?

A. renal failure,acidosis, hypo coagulability

B. Hypo coagulability, hypothermia, acidosis
C. thrombocytopenia, hypothermia, acidosis
D. liver failure, hypothermia, acidosis
Cover (heat) the patient!!!
Remember the TRAUMA TRIAD OF DEATH : hypothermia, acidosis, coagulopathy
35. Damage control approach was developed in order to avoid lethal
triad. What is included in this triad?

A. renal failure,acidosis, hypo coagulability

B. Hypo coagulability, hypothermia, acidosis
C. thrombocytopenia, hypothermia, acidosis
D. liver failure, hypothermia, acidosis
36. Abnormalities in all of the following variables have been used to
suggest the need for damage control (or abbreviated) laparotomy in
trauma patients except :

A. Temperature
B. PH
C. Base deficit
D. Prothrombin time
E. Platelet count
37. A 42-year-old man who was in a house fire is transferred to your
burn unit. He has singed nose hairs and facial burns. Direct
laryngoscopy in the emergency room demonstrates pharyngeal edema
and mucosal sloughing. He has 60% total body surface area burns.
Which of the following is the next step in the management of this
patient?

A. Hyperbaric oxygen
B. Intravenous steroids
C. Inhaled steroids
D. Bronchoscopy
E. Intubation

(02.2016)
38. Following a head-on motor vehicle collision, a 21-year-old
unrestrained passenger presents to the ER with dyspnea and
respiratory distress. She is intubated and physical examination reveals
subcutaneous emphysema and decreased breath sounds. Chest x-ray
reveals cervical emphysema, pneumomediastinum, and a right-sided
pneumothorax. What is the most likely diagnosis?

A. Tension pneumothorax
B. Open pneumothorax
C. Tracheobronchial injury
D. Esophageal injury
E. Pulmonary contusions

(02.2016)
39. A victim of blunt abdominal trauma undergoes a partial
hepatectomy. During surgery, he receives twelve units of packed red
blood cells. In the recovery room, he is noted to be bleeding from
intravenous puncture sites and the surgical incision. Which of the
following statements regarding the coagulopathy is most likely true?

A. The patient has an unknown primary bleeding disorder.

B. The coagulopathy is secondary to the partial hepatectomy.
C. The coagulopathy is secondary to dilutional thrombocytopenia and
deficiency of clotting factors from the massive blood transfusion.
D. The treatment is oral vitamin K.
E. The treatment is intravenous vitamin K.

(02.2013)
40. A 32-year-old man is in a high-speed motorcycle collision
and presents with an obvious pelvic fracture. On examination, he
has a scrotal hematoma and blood at his urethral meatus. Which
of the following is the most appropriate next step in his
management?

A. Placement of a Foley catheter

B. Cystoscopy
C. CT of the pelvis
D. Retrograde urethrogram
E. Nephrostomy tube placement
 Traumatic urethral injury

• The classic indication of urethral injury is blood per the urethra or blood
at the urethral meatus following blunt trauma (e.g., pelvic fracture,
straddle injury with perineal impact) or penetratingTrauma.

• Other findings includes: scrotal hematoma, a free-floating prostate on

rectal examination.

• When suspicion of urethral injury exists, retrograde urethrography should

be performed prior to Foley catheter insertion.

• If there is a urethral disruption, a suprapubic catheter should be placed

traumatic urethral injury
40. A 32-year-old man is in a high-speed motorcycle collision
and presents with an obvious pelvic fracture. On examination, he
has a scrotal hematoma and blood at his urethral meatus. Which
of the following is the most appropriate next step in his
management?

A. Placement of a Foley catheter

B. Cystoscopy
C. CT of the pelvis
D. Retrograde urethrogram
E. Nephrostomy tube placement
41. A 29-year-old man sustained a gunshot wound to the right
upper quadrant. He is taken to the operating room and, after
management of a liver injury, is found to have a complete
transection of the common bile duct with significant tissue loss.
Which of the following is the optimal surgical management of
this patient’s injury?

A. Choledochoduodenostomy
B. Loop choledochojejunostomy
C. Primary end-to-end anastomosis of the transected bile duct
D. Roux-en-Y choledochojejunostomy
E. Bridging of the injury with a T tube
 Traumatic bile duct transection
Stable patient:
• biliary-enteric anastomosis (eg, Roux-en-Y choledochojejunostomy).

unstable patient: or the triad of coagulopathy, acidosis and hypothermia):

• Temporary closed suction drain placement; a T-tube may be required in
such instances.
• If the patient cannot tolerate a lengthy operative procedure, a T-tube
bridge between the ends of the defect may be possible.
41. A 29-year-old man sustained a gunshot wound to the right
upper quadrant. He is taken to the operating room and, after
management of a liver injury, is found to have a complete
transection of the common bile duct with significant tissue loss.
Which of the following is the optimal surgical management of
this patient’s injury?

A. Choledochoduodenostomy
B. Loop choledochojejunostomy
C. Primary end-to-end anastomosis of the transected bile duct
D. Roux-en-Y choledochojejunostomy
E. Bridging of the injury with a T tube
42. A 48-year-old woman develops pain in the right lower quadrant while
playing tennis. The pain progresses and the patient presents to the
emergency room later that day with a low-grade fever, a WBC count of
13,000/mm3 and complaints of anorexia and nausea as well as persistent,
sharp pain of the right lower quadrant. On examination, she is tender in the
right lower quadrant with muscular spasm, and there is a suggestion of a
mass effect. An ultrasound is ordered and shows an apparent mass in the
abdominal wall. Which of the following is the most likely diagnosis?

A. Acute appendicitis
B. Cecal carcinoma
C. Hematoma of the rectus sheath
D. Torsion of an ovarian cyst
E. Cholecystis
 Rectus sheath hematoma

uncommon condition characterized by acute abdominal pain and the

appearance of an abdominal wall mass.

Risk Factors:
• F > M.
• 70% were receiving anticoagulants at the time of diagnosis.
• A history of nonsurgical abdominal wall trauma or injury is common
(48%),
• presence of a cough (29%).
• In young women associated with pregnancy.
 Rectus sheath hematoma

Symptoms:
• sudden onset of abdominal pain- often exacerbated by movements
requiring contraction of the abdominal wall.

Physical examination:
• tenderness over the rectus sheath, often with voluntary guarding.
• An abdominal wall mass (~63%)
• Cullen’s sign - Abdominal wall ecchymosis, including periumbilical
ecchymosis.
• Grey Turner’s sign blue discoloration in the flanks.
 Rectus sheath hematoma

• The pain and tenderness associated with this process may be severe
enough to suggest peritonitis.
• If the hematoma expand into the perivesical and preperitoneal spaces, the
hematocrit level may fall. hemodynamic instability is uncommon.

Diagnosis:
• Ultrasonography or CT will - confirm the presence and localize the the
hematoma.

Management:
• Usually, rest and analgesics
• if necessary, blood transfusion.
• In Progression of the hematoma - may necessitate angiographic
embolization of the bleeding vessel or, uncommonly, operative evacuation
of the hematoma and hemostasis.
42. A 48-year-old woman develops pain in the right lower quadrant while
playing tennis. The pain progresses and the patient presents to the
emergency room later that day with a low-grade fever, a WBC count of
13,000/mm3 and complaints of anorexia and nausea as well as persistent,
sharp pain of the right lower quadrant. On examination, she is tender in the
right lower quadrant with muscular spasm, and there is a suggestion of a
mass effect. An ultrasound is ordered and shows an apparent mass in the
abdominal wall. Which of the following is the most likely diagnosis?

A. Acute appendicitis
B. Cecal carcinoma
C. Hematoma of the rectus sheath
D. Torsion of an ovarian cyst
E. Cholecystis
43. A 27-year-old man sustains a single gunshot wound to the left
thigh. In the ER, he is noted to have a large hematoma of his medial
thigh. He complains of paresthesias in his left foot. On examination,
there are weak pulses palpable distal to the injury and the patient is
unable to move his foot. Which of the following is the most
appropriate initial management of this patient?

A. Angiography
B. Immediate exploration and repair in the operating room
C. Fasciotomy of the anterior compartment of the calf
D. Observation for resolution of spasm
E. Local wound exploration at the bedside
 Arterial insufficiency

• Exploration is indicated in the presence of “hard signs” such as

expanding hematoma, pulsatile bleeding, audible bruit, palpable
thrill, and evidence of absent distal pulses or evidence of distal
ischemia.

• “Soft signs” include a hypotension/shock, history of hemorrhage at

the scene of the injury, peripheral nerve deficit, stable hematoma,
and proximity of the injury to a major vessel.
Arterial insufficiency
 Arterial insufficiency

• paresthesias and paralysis are signals that there is significant

ischemia present, and immediate exploration and repair are
warranted.
• The presence of palpable pulses does not exclude an arterial injury
because this presence may represent a transmitted pulsation
through a blood clot.
• When severe ischemia is present, the repair must be completed
within 6 to 8 hours to prevent irreversible muscle ischemia and loss
of limb function.
• Fasciotomy may be required, but should be done in conjunction
with and after reestablishment of arterial flow.
43. A 27-year-old man sustains a single gunshot wound to the left
thigh. In the ER, he is noted to have a large hematoma of his medial
thigh. He complains of paresthesias in his left foot. On examination,
there are weak pulses palpable distal to the injury and the patient is
unable to move his foot. Which of the following is the most
appropriate initial management of this patient?

A. Angiography
B. Immediate exploration and repair in the operating room
C. Fasciotomy of the anterior compartment of the calf
D. Observation for resolution of spasm
E. Local wound exploration at the bedside
44. A 45-year-old male was involved in an accident 10 years ago and
had his spleen removed. He now comes to the ER complaining of high
fever, chills and productive cough. During treatment the patient
deteriorates rapidly with decrease in blood pressure. Which of the
following immunization could have prevented this patient current
event?

A. Influenza virus immunization

B. Pertussis immunization
C. Pneumococcal immunization
D. Up to date anti- tetanus
E. Varicella immunization
 Overwhelming post-splenectomy infection

• Rare, rapidly fatal infection occurring in individuals following

removal of the spleen.
• The infections are typically characterized either meningitis or
sepsis.
• caused by encapsulate organisms.
• Those organism are destroyed only in the spleen.

• Vaccination against encapsulated organisms (especially

pneumococcus, meningococcus, Haemophilus influenzae,) is
recommended before splenectomy.
44. A 45-year-old male was involved in an accident 10 years ago and
had his spleen removed. He now comes to the ER complaining of high
fever, chills and productive cough. During treatment the patient
deteriorates rapidly with decrease in blood pressure. Which of the
following immunization could have prevented this patient current
event?

A. Influenza virus immunization

B. Pertussis immunization
C. Pneumococcal immunization
D. Up to date anti- tetanus
E. Varicella immunization
45. A 22-years-old man is examined following a motor vehicle accident,
his right leg is injured, his elbow and clavicle also injured, which of the
following fractures dislocation is the most likely to result an associated
vascular injury?

A. Knee dislocation
B. Closed posterior elbow dislocation
C. Midclavicular fracture
D. Supracondylar femur fracture
E. Tibial plateau fracture
 Vascular Injury in Orthopedic Trauma

• Vascular injuries from blunt orthopedic trauma, such as

fractures, dislocations, contusions, crush injuries, and traction,
account for only 5% to 25% of injuries that require treatment.
• The femoral or popliteal arteries are most commonly injured
(50% to 60%), followed by the brachial artery (30%)
45. A 22-years-old man is examined following a motor vehicle accident,
his right leg is injured, his elbow and clavicle also injured, which of the
following fractures dislocation is the most likely to result an associated
vascular injury?

A. Knee dislocation
B. Closed posterior elbow dislocation
C. Midclavicular fracture
D. Supracondylar femur fracture
E. Tibial plateau fracture
 Summary
• Trauma approach: ATLS-
– Primary survey: A,B,C,D,E >> stable/ unstable
(FAST)
– Secondary Survey.. (stable = CT)
– Blunt vs penetrating trauma.
• Remember!
– Stable Patient = CT
– GCS
– Indications for intubation
– Indications for Laparotomy
– Indications for thoracotomy