PANCE Exam: Trauma Review Questions & Answers

Question: What percentage of cervical fractures are visualized on lateral, odontoid, and AP films of the neck?
Cross-table lateral: 85%–90%
Odontoid: 10%
Anterior/Posterior: <5%

Question: Describe the three types of fractures involving the odontoid process:

Type I odontoid fracture is an avulsion of the tip of the dens at the insertion site of the alar ligament. Although a type I fracture is mechanically stable, it often is seen in association with atlanto-occipital dislocation and must be ruled out because of this potentially life-threatening complication.

Type II fractures occur at the base of the dens and are the most common type of odontoid fracture. This type is associated with a high prevalence of nonunion due to the limited vascular supply and small area of cancellous bone.

Type III odontoid fracture occurs when the fracture line extends into the body of the axis.

Question: What are the two clinical decision-making criteria used to assess the need for radiographic imaging of the C-spine?

1. To be clinically cleared using the Canadian C-Spine Rules (CCR), a patient must be alert (GCS 15), not intoxicated, and not have a distracting injury (e.g., long bone fracture, large laceration). The patient can be clinically cleared providing the following:
- The patient is not high risk (age >65 years or dangerous mechanism or paresthesias in extremities).
- A low-risk factor that allows safe assessment of range of motion exists. This includes simple rear end motor vehicle collision, seated position in the emergency department, ambulation at any time posttrauma, delayed onset of neck pain, and the absence of midline cervical spine tenderness.
- The patient is able to actively rotate their neck 45° left and right.

2. The NEXUS criteria states that a patient with suspected C-spine injury can be cleared provided the following are met:
- No posterior midline cervical spine tenderness is present.
- No evidence of intoxication is present.
- The patient has a normal level of alertness.
- No focal neurologic deficit is present.
- The patient does not have a painful distracting injury.

On a lateral C-spine X-ray, how much soft tissue prevertebral swelling is normal from C2 through C4?
Prevertebral space extends between the anterior border of the vertebra to the posterior wall of the pharynx in the upper vertebral level (C2-C4) or to the trachea in the lower vertebral level (C6).
- At the level of C2, prevertebral space should not exceed 7 mm.
- At the level of C3 and C4, it should not exceed 5 mm, or it should be less than half the width of the involved vertebrae.
- At the level of C6, prevertebral space is widened by the presence of the esophagus and cricopharyngeal muscle. At this level, the space should be no more than 22 mm in adults or 14 mm in children younger than 15 years.
- Children younger than 24 months may exhibit a physiologic widening of the prevertebral space during expiration; therefore, obtain images in small children during inspiration to assess prevertebral space adequately.
If the prevertebral space is widened at any level, a hematoma secondary to a fracture is the most likely diagnosis.

Question: On a lateral C-spine X-ray, how much soft tissue predental soft tissue swelling is normal?
The predental space, also known as the atlantodental interval, is the distance between the anterior aspect of the odontoid and the posterior aspect of the anterior arch of C1. This space should be no more than 3 mm in an adult and 5 mm in a child. Suspect transverse ligament disruption if these limits are exceeded.

Question: How much anterior subluxation is allowable on an adult lateral C-spine and still within the normal limits?

3.5 mm.

Question: How much angulation is normal on an adult lateral C-spine, measured across a single interspace?
Up to 11°.

Question: On a lateral C-spine, what does “fanning” of the spinous processes suggest?
This is evident as an exaggerated widening of the space between two spinous process tips and suggests posterior ligamentous disruption.

Question: What are the three most unstable C-spine injuries?

1. Rupture of the transverse ligament of the atlas.
2. Fracture of the dens (odontoid fracture).
3. Burst fracture with posterior ligamentous disruption (flexion teardrop fracture).

Question: Describe a Jefferson fracture:
This fracture is caused by a compressive downward force that is transmitted evenly through the occipital condyles to the superior articular surfaces of the lateral masses of C1. The process displaces the masses laterally and causes fractures of the anterior and posterior arches, along with possible disruption of the transverse ligament.
Radiographically, the fracture is characterized by bilateral lateral displacement of the articular masses of C1. The odontoid view shows unilateral or bilateral displacement of the lateral masses of C1 with respect to the articular pillars of C2.

Describe a hangman fracture:
The name of this injury is derived from the typical fracture that occurs after hangings. Presently, it commonly is caused by motor vehicle collisions and entails bilateral fractures through the pedicles of C2 due to hyperextension.
Radiographically, a fracture line should be evident extending through the pedicles of C2 along with obvious disruption of the spinolaminar contour line

Question: What is a clay-shoveler fracture?
Abrupt flexion of the neck, combined with a heavy upper body and lower neck muscular contraction, results in an oblique fracture of the base of the spinous process, which is avulsed by the intact supraspinous ligament. Fracture also occurs with direct blows to the spinous process or with trauma to the occiput that causes forced flexion of the neck
Radiographically, this injury is commonly observed in a lateral view, since the avulsed fragment is readily evident

Question: Describe the key features of spinal (neurogenic) shock:
An acute onset of flaccidity and areflexia with the loss of anal sphincter tone and fecal incontinence. A priapism or loss of bulbocavernosus reflex may also occur. Hypotension with SBPs in the 80–100 mm Hg range is common with paradoxical bradycardia at 40–60 beat per minute. The classic skin findings are the presence of flushed, dry, and warm peripheral skin.

Question: A trauma patient presents with a decreasing level of consciousness and an enlarging right pupil. What is your diagnosis?
Probable uncal herniation with oculomotor nerve compression.

Question: The corneal reflex tests what nerves?
The ophthalmic branch (V1) of the trigeminal (fifth) nerve (afferent), and the facial (seventh) nerve (efferent).

Question: Name five clinical signs of basilar skull fracture:

1. Periorbital ecchymosis (raccoon eyes)
2. Retroauricular ecchymosis (Battle sign)
3. Otorrhea or rhinorrhea
4. Hemotympanum or bloody ear discharge
5. First, second, seventh, and eighth CN deficits

A trauma patient presents with anisocoria, neurological deterioration, and/or lateralizing motor findings. What should be the immediate treatment?

1. Immediate intubation (maintain continued C-spine immobilization) with a controlled ventilatory rate. The use of routine hyperventilation should be avoided.
- Consider pharmacologic paralysis and sedation

2. Obtain venous access and restore intravascular volume.

3. Monitor blood pressure (ICP), oxygen saturation, and neurologic status constantly while obtaining non–contrast-enhanced CT scan.
- GOALS: MAP between 90 and 100 mm Hg, Oxygen saturation 100%, ICP < 20 mm Hg, PacO2 = 33–37, Hct = 30–34, CVP = 8–14.

4. Control rising intracranial pressures (ICPs)
- Elevate head of bed (HOB) 30°
- Consider mannitol 25–50 g IV q4h
- Consider phenytoin during the first 7 days only for patients with significant risk factors for posttraumatic seizures (cortical contusion, SDH, penetrating head wound).
- Determine if the placement of a ventriculostomy catheter is warranted.

5. Determine the need for any acute neurosurgical procedures.

6. Repeat head CT in 24 hours.

Question: How is posterior column function tested? Why is it significant?
Position and vibration sensation are carried in the posterior columns and are usually spared in anterior cord syndrome. Light touch sensation may also be spared. Pain and temperature sensation cross near the level of entry and are carried in the more posterior spinothalamic tract.

Question: Define increased intracranial pressure:
Intracranial pressure (ICP) > 20 mm Hg.

Question: Where is the most common site of a basilar skull fracture?
Through the floor of the anterior cranial fossa.

Question: What cardiovascular injury is commonly associated with a sternal fracture?
Myocardial contusions (blunt myocardial injury).

Question: Which valve is most commonly injured during blunt trauma?
Aortic valve.

Question: What plain film X-ray finding most accurately indicates traumatic rupture of the aorta?
Widening of the mediastinum > 8 cm.

Question: What is the differential diagnosis of distended neck veins in a trauma patient?
Tension pneumothorax and pericardial tamponade are the primary conditions with additional possibilities being pulmonary embolism right heart failure. It should be fully understood that JVD may not be present in a hypovolemic patient.

What is the most sensitive indicator of compensated shock in children?
Because cardiac output (CO) depends on both stroke volume (SV) and heart rate (HR), the body typically tries to maintain CO when SV decreases by increasing the HR. A patient in the early stages of shock is typically tachycardic.

Question: What initial fluid bolus should be administered to children in shock?
20 mL/kg.

Question: A radial pulse on examination indicates a BP of at least what level?
Approximately 80 mm Hg.

Question: A femoral pulse on examination indicates a BP of at least what level?
70 mm Hg.

Question: A carotid pulse indicates a BP of at least what level?
60 mm Hg.

Question: What is the most common complaint of patients with a traumatic aortic injury?
For those patient that are still alive, they frequently complain of retrosternal or intrascapular pain. The most common signs and symptoms are those of acute exsanguinating hemorrhage and shock.

Question: When should amputation be considered in a lower extremity injury?
Severe open fractures with popliteal artery and posterior tibial nerve injuries can be treated with current techniques; however, treatment is at a high cost and multiple surgeries are required. The result is often a leg that is painful, nonfunctional, and less efficient than a prosthesis.

Question: How long does it take to prepare fully cross-matched blood?
30–60 minutes at a minimum.

Question: Should a chest tube be placed into an entrance or exit wound in the appropriate anatomical location rather than making a surgical incision in the chest?
No. The tube might follow the bullet track into the diaphragm or lung.

Question: Why do simple through-and-through wounds of the extremities fare better regardless of the velocity of the bullet?
The bullet’s short path in the tissue results in (1) little or no deformation of slower bullets and (2) less time for higher velocity bullet to yaw, which results in less tissue damage.

Question: Is the heat from firing a bullet significant enough to sterilize a bullet and its wound?
No, contaminants from the body surface and viscera can be carried along the bullet’s path.

Should intra-articular bullets be removed?
In most cases they should be removed because of the potential for synovitis to develop, leading to severe damage of articular cartilage.

Question: What artery is usually involved in an epidural hematoma?
The middle meningeal artery.

Question: Where are epidural hematomas located?
Between the dura and inner table of the skull.

Question: Where are subdural hematomas located?
Beneath the dura, over the brain, and in the arachnoid.

Question: What risk is associated with not treating a septal hematoma of the nose?
Aseptic necrosis followed by absorption of the septal cartilage, resulting in septal perforation referred to as a “saddle-nose deformity.”

Question: What are the most commonly injured organs as a result of blunt trauma?
The spleen, liver, and retroperitoneum.

Question: A patient who was recently hit in the eye during a bar room brawl complains of diplopia when looking up.

The injured eye does not appear able to look up. What is the diagnosis?
Orbital blowout fracture with entrapment of inferior rectus or inferior oblique.

Question: What is the LD50 for falling in adults?
25–30 feet.

Question: What clinical history and physical examination findings are most suggestive of a laryngeal fracture?
Obtaining a mechanism of injury (MOI) of the patient sustaining a direct blow to the anterior or anterolateral neck is highly suggestive of a possible laryngeal injury. The physical examination findings of subcutaneous emphysema, the loss of the normal contour of the thyroid cartilage, and a palpable tracheal defect are most concerning for this condition.

Question: What formula should be used to calculate the fluid requirements for resuscitation of an adult burn victim during the first 24 hours of care?
The Parkland formula: 2–4 mL × kg × % BSA involved. One half of this is given in the first 8 hours, and the second half is given over the next 16 hours.

Question: What is the adult dose of epinephrine for acute anaphylactic shock?

0.3 mg of 1:10,000 IV or 0.3 mg of 1:1000 SQ.

How should neurogenic shock be managed?
The treatment of all patients with a suspected etiology of shock should start with the ABCs of
Airway,
Breathing, and
Circulation. Additionally, appropriate fluid resuscitation should be instituted to restore the intravascular volume, blood pressure, and perfusion to vital organs. The use of vasopressors may prove beneficial, and typically vasopressors are required only for a brief 24–72 hours. Invasive hemodynamic monitoring may also be indicated but should be based upon the patient’s age, associated injuries, and chronic medical conditions.

Question: What is the most common cause of airway obstruction in trauma?

Unconscious patients: Tongue

Conscious patients: Dentures, avulsed teeth or other foreign bodies, oral secretions, and blood are the most common

Question: How much lactated Ringer solution should be infused while performing a diagnostic peritoneal lavage?
Adults: 1 L of warmed normal saline
Children: 10 cc/kg of warmed normal saline

Question: What abdominal injuries are generally not recognized with the diagnostic peritoneal lavage (DPL) procedure?
Diaphragmatic and retroperitoneal injuries.

Question: What two organs that do not typically bleed enough to produce a positive DPL when injured?
The bladder and the small bowel.

Question: What criteria is used to indicate a positive diagnostic peritoneal lavage (DPL)?
10 mL of gross blood on initial aspiration
>100,000 RBCs
>500 WBCs
Bacteria
Bile
Food particles

Question: Identify the zones of the neck and the appropriate method of evaluation for penetrating injuries to each zone:
ZONE I: Extends from the clavicles to the cricoid cartilage
ZONE II: Extends from the cricoid cartilage to the angle of the mandible
ZONE III: Extends from the angle of the mandible to the base of the skull

For zone II injuries in patients who present with hemodynamic instability or with “hard signs” (rapidly expanding hematoma), immediate surgical exploration is strongly indicated. Stable patients may be evaluated in the same manner as stable zone I or III injured patients.
For stable patients presenting with injuries in zone I or III, an initial nonoperative evaluation is indicated, most frequently with the use of angiography. Other considerations are the use of computed tomographic (CT) or magnetic resonance (MR) angiography. There is also an emerging role for the use of bedside duplex ultrasound depending upon the experience of the clinician. Any unstable patient with a zone I or III related injury should undergo immediate surgical exploration.

What is the etiology for the cause of death in an untreated tension pneumothorax?
Decreased cardiac output. As a result of the mediastinal shift, the superior and inferior vena cava is compressed creating an impaired venus return and decreased cardiac output.

Question: What is the best method to open an airway while maintaining C-spine precautions?
The jaw thrust maneuver.

Question: What is the formula for determining the appropriate ET tube size for children older than 1 year?
The internal diameter of the appropriate endotracheal tube for a child will roughly equal the size of that child’s little finger.
Uncuffed ET tube size = (age in years/4) + 4
Cuffed ET tube size = (age in years/4) + 3

Question: What is the correct ET tube size for a 1-year-old child?

4.0–4.5 mm.

Question: What is the correct ET tube size for a 6-month-old child?

4.0 mm.

Question: What is the average distance from the mouth to 2 cm above the carina in men and in women?
Men: 23 cm; women: 21 cm.

Question: When should blood products be supplemented with fresh frozen plasma for a trauma patient receiving multiple units of transfused blood?
A significant amount of ongoing research is being conducted on this topic and the common conclusion is that the higher the fresh frozen plasma to packed red blood cell ratio (FFP:PRBC) the higher the patient survivability. The current recommendation is for a ratio of 1:3, for every three units of PRBC, a single unit of FFP should be infused.
For each 5 units of transfused blood, fresh frozen plasma should be given.

Question: What is the Cushing reflex?
The Cushing reflex is a hypothalamic response to ischemia in the brain. It consists of an increase in sympathetic outflow to the heart as an attempt to increase arterial blood pressure and total peripheral resistance, accompanied by bradycardia. The primary features of this reflex are increased systolic blood pressure and bradycardia.

Question: A core temperature of less than 33°C (mild hypothermia) is commonly associated with what complications?
Metabolic acidosis, tachypnea, tachycardia, mental status changes, impaired coagulation, and decreased urine output.

What are the six most lethal conditions involved with blunt force thoracic trauma?

1. Airway obstruction
2. Tension pneumothorax
3. Cardia tamponade
4. Open pneumothorax
5. Massive hemothorax
6. Flail chest

Question: What, potentially life-threatening, conditions are most difficult to diagnose in patients experiencing blunt chest trauma?
- Traumatic rupture of the aorta
- Major tracheobronchial disruption
- Blunt cardia injury
- Diaphragmatic tear
- Esophageal perforation
- Pulmonary contusion

Question: What are the three components to the Glasgow coma scale, and how many points is each worth?

1. Eye opening: 4 points
2. Verbal response: 5 points
3. Motor response: 6 points

Question: What responses are measured while determining the Glasgow coma scale in a patient and what are their numerical values?


Question: What results are normal in the oculocephalic reflex?
Conjugate eye movement is opposite to the direction of head rotation.

When testing a patient’s oculovestibular reflex, which direction of nystagmus is anticipated in response to cold water irrigation: toward or away from the irrigated ear?
Away from the irrigated ear. Recall that nystagmus is defined as the direction of the fast component of saccadic eye movement. (Remember:COWS =
Cold
Opposite,
Warm
Same.)

Question: What does tonic eye movement toward an irrigated ear in response to warm caloric testing in a comatose patient signify?
Life.

Question: What common finding on a sinus X-ray suggests a basilar skull fracture?
Blood in the sphenoid sinus with a transsphenoid fracture pattern.

Question: The best view of the zygomatic arch on a face X-ray is:
Standard facial series are the norm and are obtained with varying angulation of the X-ray beam vector. The Caldwell projection allows for visualization of the orbital floor and zygomatic process above the dense petrous pyramids. A submental vertex view affords excellent detail of the zygomatic arches. However, computed tomography (CT) scans have replaced radiographs in the evaluation of midfacial trauma and are the current modality of choice.

Question: Describe central cord syndrome:
Traumatically, most commonly caused by severe neck hyperextension and injury to the ligamentum flavum with the following patient presentation:
Arm > leg weakness
Distil > proximal arm weakness
Variable sensory deficits
Bladder dysfunction
Frequently presents with a gradual improvement with traumatic mechanism of injury

Question: Under what conditions does trench (immersion) foot develop?
Trench foot occurs when the extremity is exposed for several days to wet or cold conditions at temperatures that are above freezing. The extremity develops superficial damage resembling partial thickness burns.

Question: Describe pernio (chilblain):
Exposure of an extremity for a prolonged period of time to dry, cold but above freezing temperatures. Patients develop superficial, small, edematous, painful ulcerations over the chronically exposed areas, most commonly the feet. Sensitivity of the surrounding skin, erythema, and pruritus may also develop.

Question: Describe frostnip:
The skin becomes numb and blanched and then cessation of discomfort occurs. A sudden loss of the “cold” sensation at the location of injury is a reliable sign of precipitant frostbite. Frostnip will proceed to frostbite if treatment is not initiated.

How is frostnip treated?
It is treated by warming the affected area(s) by using the hands, breathing on the skin, or by placing the exposed extremities under the armpit. The affected part should not be rubbed because this treatment does not thaw the tissues completely.

Question: What are the proper classifications of frostbite?

Superficial (first-degree injury): Erythema, edema, waxy appearance, hard white plaques, and sensory deficit.

Partial full-thickness (second-degree injury): Erythema, edema, and formation of blisters filled with clear or milky fluid and which are high in thromboxane. (These blisters form within 24 hours of injury.)

Complete full-thickness (third-degree injury): Damage affecting muscles, tendons, and bone, with resultant tissue loss.

Question: What is the appropriate treatment for frostbite?
Do not use dry heat! The exposed extremity should be rewarmed rapidly by immersing the affected area in 38–41°C circulating water for 20 minutes or until flushing is observed. Elevation of the extremity will minimize the possibility of developing edema. Refreezing thawed tissue greatly increases damage. Remember to provide tetanus prophylaxis.

Question: What are the signs/symptoms of anterior cord syndrome?
The common etiology is related to an anterior spinal artery infarction or injury. Patients presents with paralysis with loss of pain and temperature sensation below the level of the lesion that spares touch, vibration, and proprioception because that blood supply received from the posterior spinal arteries.

Question: What are some common complications of frostbite?
Wound infection primary with Staphylococcus aureus, beta-hemolytic streptococci, gram-negative rods, or anaerobes. Tetanus (frostbite is considered a high-risk wound), hyperglycemia, metabolic acidosis, and tissue loss. In rare cases, rhabdomyolysis and compartment syndrome.

Question: What is the half-life of carboxyhemoglobin?
4–6 hours on room air but can be reduced to approximately 40 minutes with the administration of 100% oxygen.

Question: What is the best method for transporting an amputated extremity?
Wrap the extremity in sterile gauze, place it in waterproof plastic bag, and then immerse in ice.

Question: What organ is most severely affected in a blast injury?
The lungs.

Question: What organ is most commonly affected in a blast injury?
The middle and inner ear.

Question: What is the most effective method for decontaminating the skin following radiation exposure?
Wash with soap and water after removing all clothes.

What is the best emergency treatment of an Ellis III dental fracture in an adult?
Cover the exposed surface with a calcium hydroxide composition (e.g., Dycal) or a glass ionomer. Provide immediate dental follow-up and analgesics as needed. Initiate antibiotics with coverage of intraoral flora (e.g., penicillin, clindamycin).

Question: What are the classic findings of shaken baby syndrome?
- Failure to thrive
- Lethargy
- Seizures
- Retinal hemorrhages
- CT may show subarachnoid hemorrhage or subdural hematoma from torn bridging veins

Question: How do you treat a patient with a severe, high concentration hydrofluoric acid burn?
Ensure that the caregivers are adequately protected. Decontaminate the patient with copious amounts of clean water while removing all of their clothing. If calcium gluconate gel is available, apply liberally to the affected area. For digital burns, if calcium gluconate gel is not available, the fingers may be soaked in magnesium hydroxide (Mylanta). Treat inhalation injuries with oxygen and 2.5% calcium gluconate nebulizer.

Question: How should an ocular burn secondary to hydrofluoric acid be treated?
Generously irrigate with sterile water or saline for at least 15 minutes. Local anesthetic may be required. If pain persists, irrigate with a 1% solution of calcium gluconate.

Question: What electrolyte is depleted in a victim of a hydrofluoric acid burn?
Hypocalcemia.

Question: An unconscious 60-year-old patient presents to the emergency department with a head injury. An ECG shows significant ST segment elevation. What is your main concern?
Although MI should be considered and is quite probable, do not forget the possibility of an intracerebral hemorrhage. This may also cause significant ST segment elevation.

Question: A near-drowning victim is comatose and intubated. A diagnosis of severe pulmonary edema is made. What specific pulmonary treatment should be provided in the emergency department?
It is important to give these patients PEEP early to increase alveolar pressure and alveolar volume. The increased lung volume increases the surface area by reopening and stabilizing collapsed or unstable alveoli.

Question: What laboratory abnormalities may be found with heat stroke?
ABG analysis may reveal respiratory alkalosis due to direct CNS stimulation and metabolic acidosis due to lactic acidosis, hypoglycemia, hypernatremia, hypokalemia, and hypophosphatemia. CK levels exceeding 100,000 IU/mL are common. Elevated white blood cell counts are common as well as serum uric acid levels, blood urea nitrogen, and serum creatinine in patients whose course is complicated by renal failure myoglobinuria and proteinuria are frequently found on urinalysis.

What distinguishes heat stroke from heat exhaustion?
Heatstroke is the most severe form of the heat-related illnesses and is defined as a body temperature higher than 41.1°C (106°F) associated with neurologic dysfunction. Heat exhaustion is a milder form of heat-related illness that develops after several hours or days of exposure to high temperatures and inadequate or unbalanced replacement of fluids.

Question: How should a patient with heat stroke be treated?
Heatstroke is a medical emergency and the rapid reduction of the core body temperature is the cornerstone of treatment because the duration of hyperthermia is the primary determinant of outcome.
Appropriate considerations include removal of restrictive clothing and spraying water on the body, covering the patient with ice water–soaked sheets, or placing ice packs in the axillae and groin may reduce the patient’s temperature significantly. Patients who are unable to protect their airway should be intubated. Patients who are awake and responsive should receive supplemental oxygen. Intravenous lines may be placed in anticipation of fluid resuscitation and for the infusion of dextrose and thiamine if indicated.

Question: What complications can result from heat stroke?
Renal failure, rhabdomyolysis, DIC, and seizures. Remember: Antipyretics are not recommended to reduce the core body temperature.

Question: A young boy presents for evaluation after suffering a coral snake bite. He has no complaints and appears to be in no distress. What is appropriate management?
The onset of symptoms may be delayed up to 10 to 12 hours but may then be rapidly progressive. Admit this patient to the intensive care unit and monitor for impending respiratory failure. Coral snake venom has significant neurotoxicity and neuromuscular dysfunction is common.

Question: Describe the appearance of a coral snake:
This is a round snake with red, yellow, and black stripes and a black spot on the head, which can easily be mistaken for the nonvenomous milk snake. The mnemonic “Red on yellow, kill a fellow; red on black, venom lack,”

Question: Which type of rattlesnake bite leads to most deaths?
The Western diamond back rattlesnake accounts for nearly all lethal snakebites in the United States. However, it accounts for only 3% of the snakebites seen. Treat with 10 to 20 vials of antivenin.

Question: What are the physical attributes of a pit viper?
The deep pits on each side of the triangular shaped head between the eye and the nostril tend to be a commonly recognizable feature. Research indicates that the pits are very sensitive detectors of radiant heat, thereby enabling the snake to find warm-blooded prey in the dark. Additionally, a pair of elongated fangs that are folded back against the palate of their triangular shaped head are a key feature.

Question: What is the recommended dose for steroids for treating patients with acute spinal cord injuries?
Give high dose methylprednisolone (Solu-Medrol) 30 mg/kg bolus over 15 minutes followed by 45 minutes normal saline drip. Over the subsequent 23 hours, the patient should receive an infusion of 5.4 mg/kg/h of methylprednisolone.

A patient with a temperature of 29°C develops ventricular fibrillation. Is defibrillation likely to be successful?
Defibrillation is not indicated for patients experiencing severe hypothermia until they have been appropriated warmed.

Question: A straight (Miller) blade is preferred for intubating children of less than what age?
Approximately 4 years of age.

Question: What is the Parkland formula for treating a pediatric burn victim weighing less than 25 kg?
Ringer lactate at 3–4 mL/% TBSA burned/kg. One half of this should be infused over the first 8 hours with the remaining infused over the next 16 hours.

Question: How much fluid is required for maintenance of pediatric patients?
100 mL/kg/day for each kg up to 10 kg, 50 mL/kg/day for each kg from 10 to 20 kg, and 20 mL/kg/day for each kg thereafter.

Question: A trauma patient, from a high speed MVC, presents with a complaint of a severe burning pain in the upper extremities and associated neck pain. On physical examination, the patient has good strength in his upper extremities and a significant decrease in sensation at his fingertips. There are no obvious neurologic deficits in the lower extremities with normal rectal tone. Radiographically, the patient’s C-spine series is negative. What condition do you suspect and what diagnostic test should you order?
Central cord syndrome. This injury is common with a hyperextension injury of the spinal cord. Impairment in the upper extremities is usually greater than in the lower extremities and is especially prevalent in the muscles of the hand. Pain and temperature sensations, as well as the sensation of light touch and of position sense, may be impaired below the level of injury. Neck pain and urinary retention are common complaints. MRIs demonstrates direct evidence of spinal cord impingement from bone, a disc, or a hematoma and are the diagnostic modality of choice. CT scanning of the cervical spine shows spinal canal compromise and allows the indirect approximation of the degree of spinal cord impingement.

Question: What is the common patient presentation of a laryngeal fracture and how are they diagnosed?
Common signs of laryngeal injury include stridor, subcutaneous emphysema, hemoptysis, hematoma, ecchymosis, laryngeal tenderness, vocal cord immobility, loss of anatomical landmarks, and bony crepitus. CT scanning is the imaging modality of choice to assess laryngeal anatomy. The Schaefer classification of laryngeal injuries is based on a combination of the CT and endoscopic findings, which dictate treatment modalities.

Question: When does dysbaric air embolism (DAE) typically occur?
DAE develops within minutes of surfacing after SCUBA diving. Symptoms are sudden and dramatic; they include loss of consciousness, focal neurologic symptoms (such as monoplegia, convulsions, blindness, and confusion), and sensory disturbances. Sudden loss of consciousness or other acute neurologic deficits immediately after surfacing is because of DAE unless proven otherwise. Treatment includes high flow oxygen and rapid transport for hyperbaric oxygen treatment.

A 2-year-old has jammed a pencil into her lateral soft palate. What complication might develop?
Penetrating injury to the internal carotid artery (ICA) with resultant neurologic deficit is a well-documented complication in children. In addition to the potential of thrombotic injury, the development of a collection of air in the retropharyngeal space can result in mediastinitis.

Question: In a trauma patient, what is the physical examination finding of dimpling of the unilateral cheek associated with?
Zygomatic arch fracture.

Question: A patient sustains blunt force trauma to his face and mouth and you observe that a tooth has been fractured. Upon closer examination you note that blood is originating from the tooth and there is no additional intraoral injury. What is the Ellis classification?
Ellis III fractures involve enamel, dentin, and pulp; patients complain of pain with manipulation, air, and temperature. Pinkish or reddish markings around surrounding dentin or blood in the center of the tooth from the exposed pulp may present.

Question: What is the most common location involved in the malposition of an orotracheal endotracheal tube?
The right mainstem bronchus is the common location for a tube placed in the trachea; however, the most common location for an improperly placed endotracheal tube is the esophagus.

Question: A diver descends to 33 feet. How many atmospheres of pressure is he experiencing?
2 atmospheres. Sea level is considered 1 atm and atmospheric pressure doubles every 33 ft. 2 atm = 33 feet; 3 atm = 66 feet.

Question: What are the most common complaints in patients with carbon monoxide poisoning?
A headache is most common, followed by dizziness, weakness, and nausea.

Question: A patient presents after experiencing trauma to the head. He has an elevated systolic blood pressure and bradycardia. What is this reflex?
Cushing reflex.

Question: What is the name for a flexion mechanism fracture through the anterior aspect of a vertebral body that is associated with ligamentous damage and an anterior cord syndrome?
A flexion teardrop fracture occurs when flexion of the spine, along with vertical axial compression, causes a fracture of the anteroinferior aspect of the vertebral body. This fragment is displaced anteriorly and resembles a teardrop. For this fragment to be produced, significant posterior ligamentous disruption must occur. Since the fragment displaces anteriorly, a significant degree of anterior ligamentous disruption exists. This injury involves disruption of all three columns, making this an extremely unstable fracture that frequently is associated with spinal cord injury.

Question: What nerves control the corneal reflex?
The afferent limb is V1 (ophthalmic) of the trigeminal nerve; the efferent limb is the facial or 7th cranial nerve.

A patient presents with a hypertension-type neck injury after receiving a blow to the forehead. She complains of weakness in her arms and no weakness in her lower extremities. What is the most likely diagnosis?
Central cord syndrome.

Question: You are evaluating a patient with an obvious traumatic spinal cord injury. On physical examination, he has motor paralysis, loss of gross proprioception, loss of vibratory sensation on one side, and loss of pain and temperature sensation on the opposite side. What is the likely diagnosis?
Brown-Séquard syndrome.

Question: A patient presents after sustaining a high-speed traumatic injury to the chest. A systolic murmur over the precordium is auscultated and the patient has a slightly hoarse voice, and her pulse is stronger in the upper extremities. What is the most likely diagnosis?
Traumatic rupture of the aorta.

Question: What is the most common X-ray finding in traumatic rupture of the aorta?
Widening of the superior mediastinum.

Question: A patient presents with a history of blunt chest trauma, a 5/6 systolic murmur that radiates to the axillae, and an infarct pattern on ECG. What is the likely diagnosis?
Traumatic ventricular septal defect.

Question: A patient who has been involved in a motor vehicle accident has X-ray findings of retroperitoneal air with obliteration of the right psoas margin on a flat plate of the abdomen. What is a likely diagnosis?
Duodenal injury. Patients that are hemodynamically normal should undergo an Upper Gastrointestinal (UGI) study with a water-soluble contrast (Gastrografin).

Question: About how many liters of blood can a patient lose in the retroperitoneal space after sustaining a pelvic fracture?
4 L before venous tamponade occurs.

Question: What is the most common cause of superior vena cava obstruction?
Bronchogenic carcinoma.

Question: What laboratory abnormalities are found in times of stress?
Increased cortisol, glucose intolerance, cholesterol, and platelet adhesion plus impaired lipoprotein ratios

Question: A patient opens his eyes to voice, makes incomprehensible sounds, and withdraws from painful stimulus. What is his GCS?
E3, V2, M4 = 9.

What acronym is commonly used during the evaluation of a patient with suspected rhabdomyolysis?

MUSCLE =
Rhabdomyolysis (evaluation)
Myoglobinuria
Urinalysis
Serum potassium
Creatinine
Lysis sign on CBC (hemolysis)
Enzyme (CPK) increase

Question: A trauma patient has blood at the urinary meatus. What test should be ordered?
Retrograde urethrogram; 10 mL of radiocontrast solution should be injected into the urinary meatus.

Question: In blunt trauma, what is the most common renal pedicle injury?
Renal artery thrombosis.

Question: A trauma patient presents with a “rocking horse” type of ventilation. What is the diagnosis?
Probable high spinal cord injury with intercostal muscle paralysis.

Question: What is the differential diagnosis for a trauma patient presenting with subcutaneous emphysema.
Pneumothorax, tension pneumothorax, tracheal/bronchial injury, or pneumomediastinum.

Question: What rib fracture has the worst prognosis?
The first rib. First and second rib fractures are associated with bronchial tears, vascular injury, and myocardial contusions.

Question: A patient presents to the emergency department after a motor vehicle accident with hematuria and fractures of the tenth and eleventh ribs. What internal organ might be damaged?
The spleen is the most commonly injured organ in blunt trauma and be especially suspicious of splenic trauma if the tenth or eleventh ribs are fractured and the patient has hematuria.

Question: For a trauma victim, what test is most helpful for evaluating retroperitoneal organs?
CT.

Question: Where should the incision be made to perform a DPL on a trauma patient with a suspected pelvic fracture?
A supraumbilical incision should be made to avoid insertion of the DPL catheter into a contained pelvic hematoma. Performing a FAST examination may be more clinically appropriate especially if the patient does not have hemodynamically normal vital signs.

Question: What is an absolute contraindication to DPL?
The only absolute contraindication is the obvious need for laparotomy. Relative contraindications are previous abdominal surgery, morbid obesity, and pregnancy.

What findings represent a positive DPL in blunt trauma?
RBC > 100,000 cells/mm3, WBC > 500 cells/mm3, bile, bacteria, or vegetable material.

Question: What type of intracranial hemorrhage is more common in the geriatric patient?
Subdural hematomas are most common.

Question: The inability to pass a nasogastric tube in a trauma victim suggests damage to what organ?
A rupture of the left hemidiaphragm secondary to a diaphragmatic hernia.


REFERENCES
Britt L, Trunkey DD, Feliciano DV Acute Care Surgery—Principles and Practice. New York, NY: Springer-Verlag; 2007.
Doherty GM, Way L. Current Surgical Diagnosis and Treatment. 12th ed. New York, NY: McGraw-Hill; 2006.
Peitzman AB, Rhodes M, Schwab CW, Yealy DM, Fabian TC. The Trauma Manual. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2002.
Tintinalli MJ, Kelen MG, Stapczynski MJ, Ma MO, Cline MD. Tintinalli’s Emergency Medicine—A Comprehensive Study Guide. 6th ed. New York, NY: McGraw-Hill; 2004.