10 free Paramedic practice questions: Advanced Trauma Assessment and Resuscitation

The patient is developing decompensated shock from occult blood loss: Decompensated shock from hidden blood loss would drop the blood pressure, and the pressure did fall here. The skin is warm and dry and the radial pulse is strong, and those are not signs of decompensated shock. A blood pressure that comes down while the heart rate returns toward normal fits the same improvement as the EtCO₂ and the pupil.

The endotracheal tube has slipped out of the trachea into the esophagus: A tube that slips into the esophagus loses the EtCO₂ reading. The number falls toward zero or becomes erratic. This patient's EtCO₂ is 39 mmHg, a normal and well formed reading. Waveform capnography and equal breath sounds already confirmed the tube.

Cerebral perfusion pressure has fallen to a critically low level: A critically low cerebral perfusion pressure means the brain is not getting enough blood flow. The pupil and the level of consciousness would get worse. This patient's pupil got better over the same 10 minutes.

Two minutes of compressions before any shock: Two minutes of compressions is the cycle you run after a shock, before the next rhythm check. That cycle does not come before the first shock. This child is already in ventricular fibrillation with a defibrillator attached. Holding the shock for two minutes keeps the heart in ventricular fibrillation for two more minutes.

Rapid transport with compressions only: Rapid transport with compressions underway fits an arrest whose fix is at a trauma center, like a penetrating chest wound with a short down time. This child's fix is a shock, and the defibrillator is already showing ventricular fibrillation. Loading the child first delays the shock.

Needle decompression of the left chest: Needle decompression treats a tension pneumothorax, with absent lung sounds and hypotension from a shifted mediastinum. This child has ventricular fibrillation from a blow to the chest, not a collapsed lung.

A single area of point tenderness over one rib with a normal 12-lead: Point tenderness over one rib with a normal 12-lead fits an isolated rib fracture. Blunt cardiac injury shows dysrhythmias and ECG changes, not a normal 12-lead.

Diffuse abdominal tenderness with a rigid abdomen: A rigid, tender abdomen fits an injured abdominal organ from the same crash. Blunt cardiac injury causes chest pain and dysrhythmias, not abdominal findings.

A widened pulse pressure with warm, flushed skin: a distributive shock pattern. Retrosternal pain and dysrhythmias are what mark a blunt cardiac injury, and warm, flushed skin is not part of that injury.

The community hospital, because it is closest: The closest hospital is the right call when that hospital can fix the problem. The closest hospital is also right when the patient cannot survive a longer ride, like an airway you cannot manage or a cardiac arrest. This patient has an open airway, is breathing at 28, and can handle 22 minutes with resuscitation going. The community hospital has no surgeon to stop the bleeding.

The trauma center, only if air transport is available: Air transport is a tool for a long transport or a scene ground units cannot reach. The trauma center is 22 minutes away by ground. Setting up a landing zone would usually cost more time than air saves. Air or ground does not change which hospital this patient needs.

The community hospital, to stabilize before transfer: Stopping at a closer hospital to stabilize sounds careful. A patient bleeding from an unstable pelvis cannot be stabilized without surgery. The stop adds a second assessment, a second packaging, and a second transport while the bleeding keeps going. The exception is a patient who cannot survive the longer trip at all, and this patient can.

Increased cardiac output from pain and anxiety: Pain and anxiety do raise the heart rate and the breathing rate, and this patient is anxious. Pain and anxiety alone do not narrow the pulse pressure or make the skin cool and pale. A stress response usually leaves the skin warm and the pulse pressure normal or wide. Blaming these findings on anxiety lets a bleed in the abdomen leave the scene undiagnosed.

Increased intrathoracic pressure from a pneumothorax: A pneumothorax with rising pressure in the chest would cause a fast pulse and fast breathing. A pneumothorax belongs on the list after any fall from a height. The breath sounds are clear on both sides and the neck veins are flat. A tension pneumothorax blocks blood from getting back to the heart and makes the neck veins distend. Flat neck veins point to a circulation that is running low on blood.

Sympathetic blockade from a spinal cord injury: A spinal cord injury that blocks the sympathetic nerves causes warm, dry, flushed skin below the injury. The heart rate stays normal or slow, because the nerves that speed up the heart are cut off. The pulse pressure gets wide, because the blood vessels lose their tone. This patient has cool, pale skin, a pulse of 116, and a narrow pulse pressure. Every finding goes the opposite way from neurogenic shock.

Secure the patient to a long backboard: A long backboard is a tool for extrication and for moving a patient who cannot be moved another way. A backboard is not a treatment. Even patients who do need motion restriction are usually secured to the stretcher instead. This patient's exam is completely negative, and a backboard adds the highest-cost option for no reason.

Restrict motion only during extrication: Restricting motion during extrication makes sense when the exam is unreliable or positive. This patient meets every criterion for a reliable, negative exam and can get out of the vehicle without help. There is nothing to restrict, even during extrication. A partial measure still tells everyone that you suspect a spinal injury when the assessment says otherwise.

Apply a cervical collar for the mechanism: Putting a collar on for the mechanism is the old reflex. A low-speed rear-end collision is exactly where collars used to go on automatically. Mechanism raises your suspicion, but mechanism does not overrule a reliable, negative exam. A collar has its own costs, including airway restriction, raised intracranial pressure, and discomfort.

Apply chemical heat packs directly to the skin: Chemical heat packs are part of active rewarming. Heat packs go over a barrier on the trunk, the armpits, and the groin. Placed right on the skin of a cold patient with poor blood flow, they burn. The tight blood vessels in cold skin cannot carry the heat away. A shivering patient in pain may not notice the burn as it happens. Heat packs also add only a little heat while the wet clothing keeps pulling away much more.

Leave the clothing in place during transport: Leaving the clothing on follows the idea that undressing someone in 18°F weather has to make things worse. There is a real rule about not leaving a trauma patient exposed longer than needed. Wet fabric against the skin pulls heat away many times faster than air does. Evaporation from the wet fabric keeps pulling heat for the entire trip. Cutting the clothing off quickly and covering the patient right away with dry insulation saves more heat over the whole transport.

Massage the extremities to restore warmth: Massaging cold arms and legs is an old home remedy for warming someone up, and it is specifically avoided. Rubbing cold-injured tissue damages cells that are already hurt. Pushing cold blood from the arms and legs back to the core can drop the core temperature even more. Massage also leaves the wet clothing on, so the heat loss keeps going and the clotting problem does not get fixed.

Cardiac tamponade: belongs on your list with any crushed chest. Tamponade can distend the neck veins and put a patient in shock. Tamponade shows up as low blood pressure, muffled heart tones, and a heart that cannot fill. This patient's blood pressure is 108/72, the breath sounds are equal, and the chest wall is stable. Tamponade also does not cause a color change that stops in a clean line at the collarbones. A line like that comes from where the chest was crushed, not from the heart.

Tension pneumothorax: A tension pneumothorax also fills the neck veins and could explain a pulse of 112. After a crush injury, a tension pneumothorax is fair to think about. Your physical exam rules it out. The breath sounds are equal, the trachea is midline, and the SpO2 is 95%. Air trapped in the pleural space also does not turn the face purple with pinpoint red spots or turn the whites of the eyes red. Traumatic asphyxia is the only option that explains those color changes.

Facial fractures with swelling: would explain deformity, swelling, and even bruising around the eyes after a direct blow to the face. This patient was crushed at chest level under a vehicle, and nothing struck the face. Fractures do not cause pinpoint red spots across the whole face, red whites in both eyes, and a deep blue neck. Most of all, a facial injury cannot explain why the color change stops at the collarbones with normal skin below.

Chest wall and intercostal vessels only: Chest wall and intercostal vessel injuries come from a shallow or glancing wound. Calling this injury chest-wall-only means knowing how deep the blade went, and you never know the depth in the field. At the sixth intercostal space, the diaphragm may sit right under the blade at the end of exhalation.

Pericardium and heart: The pericardium and heart are the right suspicion for a wound in the cardiac box. The cardiac box runs roughly between the clavicles, the nipples, and the costal margin, over the sternum and the inner chest. This wound is in the anterior axillary line, well outside the box. The patient is alert at 124/78 with no signs of tamponade.

Trachea and major bronchi: Tracheal and bronchial injuries come from wounds to the neck or the upper chest. Those injuries are obvious, with air under the skin, a constant air leak, coughing up blood, or respiratory distress. This patient is breathing at 18 with equal breath sounds and an SpO2 of 98% on room air. A wound at the sixth intercostal space in the anterior axillary line is nowhere near the trachea or the major bronchi.

As normal for a patient of this age: A systolic of 104 would be fine in a young adult. An older adult with stiff vessels and a higher baseline is often already hypoperfusing at a number that looks normal on the monitor. Calling 104 normal is the most common way hidden bleeding gets missed in older patients.

As an effect of the metoprolol: Metoprolol and lisinopril do lower blood pressure. Blaming the medications would make the low reading look explained. Field triage does not let you subtract the medication effect. You apply the threshold to the pressure you actually measured. A medication that lowers the baseline also takes away the reserve this patient would need while bleeding.

As elevated from the pain of the injury: Pain does change the blood pressure, but pain raises it through the sympathetic nervous system. Pain would explain a high reading, not one at the low end of the range. Nothing here suggests the pressure is falsely high.