10 free Paramedic practice questions: Advanced Trauma Assessment and Resuscitation

The patient is developing decompensated shock from occult blood loss: The blood pressure did fall, but the skin is warm and dry and the radial pulse is strong, which are not signs of decompensated shock. A falling blood pressure alongside a heart rate returning toward normal fits the same improving picture as the EtCO₂ and pupil, not hemorrhage.

The endotracheal tube has slipped out of the trachea into the esophagus: Waveform capnography and equal bilateral breath sounds were already confirmed. If the tube had slipped into the esophagus, the EtCO₂ would not read a normal, well-formed value; it would fall toward zero or become erratic, not normalize.

Cerebral perfusion pressure has fallen to a critically low level: A critically low cerebral perfusion pressure would worsen brain perfusion and would be expected to make the pupil finding and level of consciousness worse, not better, over this same 10 minutes.

Two minutes of compressions before any shock: A period of compressions before the shock belongs to an unwitnessed arrest of unknown duration. This collapse was witnessed and the rhythm is already on the monitor, so the shock goes now.

Rapid transport with compressions only: Moving a patient in ventricular fibrillation away from a defibrillator that is already attached delays the one intervention that reverses this rhythm.

Needle decompression of the left chest: A blunt blow to the sternum can cause a pneumothorax, and that is not what stopped this heart. The monitor already shows the rhythm that did.

A single area of point tenderness over one rib with a normal 12-lead: Point tenderness over a single rib with a normal 12-lead describes an isolated rib fracture rather than a cardiac injury: blunt cardiac injury is marked by dysrhythmias and ECG changes, not a normal tracing.

Diffuse abdominal tenderness with a rigid abdomen: points toward an abdominal organ injury from the same mechanism, not a cardiac one: blunt cardiac injury presents with chest pain and dysrhythmias, not abdominal findings.

A widened pulse pressure with warm, flushed skin: describes a distributive shock pattern, not the dysrhythmias and retrosternal pain that mark a blunt cardiac injury.

The community hospital, because it is closest: The nearest facility is the right destination when the problem is one that facility can actually fix, or when the patient cannot survive the longer ride, such as an unmanageable airway or an arrest. This patient has a patent airway, is breathing at 28, and can tolerate 22 minutes with resuscitation running. Choosing proximity here trades a few minutes of drive time for the definitive care that stops the bleeding, which is the wrong trade.

The trauma center, only if air transport is available: Making the trauma center conditional on air transport inverts the decision. Air is a tool for shortening a long transport or reaching a scene ground units cannot, and with the trauma center 22 minutes out by ground, setting up a landing zone would usually cost more time than it saves. Destination is decided by the patient's physiology, and mode of travel is a separate question that never changes which hospital is correct.

The community hospital, to stabilize before transfer: Stopping at a non-surgical hospital to stabilize before transfer is the most seductive wrong answer here, because caution sounds like good judgment. A patient bleeding from an unstable pelvis cannot be stabilized without surgical control, so the stop adds a second assessment, a second packaging, and a second transport to the clock while the bleeding continues. The genuine exception is the patient who cannot survive the longer trip at all, and this one can.

Increased cardiac output from pain and anxiety: Pain and anxiety do raise heart rate and respiratory rate, and this patient is described as anxious, so part of the picture genuinely fits. What distress alone does not do is narrow the pulse pressure while turning the skin cool and pale; a stress response typically leaves the skin warm and the pulse pressure intact or wide. Assigning these findings to nerves is the specific error that lets an intra-abdominal bleed leave the scene undiagnosed.

Increased intrathoracic pressure from a pneumothorax: Rising intrathoracic pressure from a pneumothorax would explain tachycardia and tachypnea and belongs in any fall-from-height differential. Two findings shut it down: breath sounds are clear bilaterally and the neck veins are flat. Tension physiology obstructs venous return and distends those veins, so flat veins point toward an emptying circulation rather than an obstructed one, which is what the key describes.

Sympathetic blockade from a spinal cord injury: produces the mirror image of this patient, with warm dry flushed skin below the injury, a normal or slow heart rate because the cardiac accelerator fibers are cut off, and a wide pulse pressure from lost vascular tone. Here the skin is cool and pale, the pulse is 116, and the pulse pressure is narrow. Every finding runs in the opposite direction, which is what makes neurogenic and hemorrhagic shock such a clean pair to learn against each other.

Secure the patient to a long backboard: A long backboard is now an extrication and movement device rather than a treatment, reserved for moving a patient who cannot be moved another way, and even patients who do require motion restriction are generally secured to the stretcher instead. Applying it here layers the highest-cost option onto a patient whose examination is entirely negative. The key recognizes that a reliable negative exam ends the question, while this treats a mechanism the patient's own findings have already cleared.

Restrict motion only during extrication: Restricting motion only during extrication is a real practice, and limiting movement while you move someone is reasonable when the examination is unreliable or positive. This patient meets every criterion for a reliable negative exam and can self-extricate, so there is nothing to restrict, and a partial measure still communicates that an injury is suspected when the assessment says it is not. The key acts on the completed assessment rather than splitting the difference.

Apply a cervical collar for the mechanism: Applying a collar for the mechanism is the reflex this item is written against, and a low-speed rear-end collision is exactly where collars used to go on automatically. Mechanism raises suspicion but does not override a reliable negative examination, and a collar carries its own costs, including airway restriction, raised intracranial pressure, and discomfort. The key follows the assessment-based criteria that are the current standard, and mechanism alone does not satisfy them.

Apply chemical heat packs directly to the skin: Chemical heat packs have a real role in active rewarming, applied over a barrier to the trunk, the axillae, and the groin as part of a warming plan. Placed directly against the skin of a cold, poorly perfused patient they burn, because vasoconstricted skin cannot carry the heat away and a shivering, distracted patient may not report the injury as it develops. They also add a small amount of heat while wet clothing keeps removing a much larger amount, so the key attacks the source of the loss and this option does not.

Leave the clothing in place during transport: Leaving the clothing in place follows the instinct that undressing someone in 18-degree weather has to make things worse, and there is a genuine principle about not exposing a trauma patient longer than necessary. Wet fabric held against skin conducts heat away many times faster than air does, and evaporation from it keeps pulling heat for the entire transport. A brief exposure to cut the clothing away, followed immediately by dry insulation, is a clear net gain measured over the whole trip, which is exactly what the key does.

Massage the extremities to restore warmth: Massaging cold extremities is the folk version of rewarming and is specifically avoided. Rubbing cold-injured tissue causes mechanical damage to cells that are already compromised, and moving cold peripheral blood back toward the core can push the core temperature down further. It also leaves the wet clothing exactly where it is, so it corrects neither the ongoing heat loss nor the clotting problem that makes hypothermia matter in a bleeding trauma patient.

Cardiac tamponade: deserves consideration in any crushed chest, and it shares part of the picture, since it distends neck veins and produces a shocky patient. Its signature is hypotension with muffled heart tones and a heart that cannot fill, whereas this patient is at 108/72 with equal breath sounds and a stable chest wall. More decisively, tamponade does not produce a color change that stops in a clean horizontal line at the collarbones, and that cutoff is a compression pattern rather than a cardiac one.

Tension pneumothorax: also engorges the neck veins and would explain a pulse of 112, so it is a defensible instinct after a crush injury. The exam rules it out directly: breath sounds are equal, the trachea is midline, and the SpO2 is 95%. Air trapped in a pleural space also does not stain a face purple with petechiae or turn the sclerae red, and the key is the only option that accounts for those color findings.

Facial fractures with swelling: would explain deformity, swelling, and even periorbital bruising after a direct blow to the face. The mechanism here is a chest-level crush under a vehicle, not a facial impact, and fractures do not produce symmetric petechiae across the entire face with bilateral red sclerae and a deeply blue neck. Above all, a facial injury cannot explain why the discoloration ends abruptly at the collarbones with normal skin below.

Chest wall and intercostal vessels only: Chest wall and intercostal vessel injury is what a shallow or tangential wound produces, and intercostal artery bleeding is a real entity worth knowing. Calling this injury wall-only requires knowing the depth of the track, which the field never does. At the sixth intercostal space the diaphragm may sit directly under the blade at end-exhalation, so limiting suspicion to the wall underestimates the trajectory, while the key keeps both cavities in play.

Pericardium and heart: the correct suspicion for a wound in the cardiac box, the region bounded roughly by the clavicles, the nipples, and the costal margin over the sternum and medial chest. This wound is in the anterior axillary line, well lateral to that box, and the patient is alert at 124/78 with no tamponade findings. A left lateral sixth-space track heads toward the diaphragm and spleen rather than the pericardium.

Trachea and major bronchi: injured by penetrating wounds of the neck or the upper mediastinum, and they announce themselves loudly with subcutaneous emphysema, a persistent air leak, hemoptysis, or respiratory distress. This patient breathes at 18 with equal breath sounds and a room-air SpO2 of 98%. The anatomy alone rules it out, since a wound at the sixth intercostal space in the anterior axillary line is nowhere near those structures.

As normal for a patient of this age: A systolic of 104 would be unremarkable in a young adult, and that is exactly the trap. An older adult with stiffened vessels and a chronically higher baseline is often already hypoperfusing at a number that looks reassuring on the monitor, and reading it as normal is the most common way occult geriatric hemorrhage gets missed.

As an effect of the metoprolol: Metoprolol and lisinopril do lower blood pressure, which makes it tempting to subtract their effect and call the reading explained. Field triage does not permit that subtraction: the threshold is applied to the pressure actually measured, because a medication that lowers the baseline also removes the reserve the patient would need during blood loss.

As elevated from the pain of the injury: Pain raises blood pressure through sympathetic stimulation rather than lowering it, so pain cannot explain a reading at the low end of the range. Nothing in this presentation suggests the pressure is artificially high.