10 free Paramedic practice questions: Advanced Trauma Procedures

Along the inferior margin of the rib above, following the bundle: The inferior margin of the rib above is exactly where the neurovascular bundle sits. Following the bundle is the one path you want to avoid.

Through the center of the interspace at a 45 degree angle: A 45 degree angle makes the path through the chest wall longer. An angled needle can also skid off a rib. A needle placed perpendicular to the chest wall reaches the pleural space reliably.

Under the inferior border of the rib above the interspace: Going under the inferior border of the rib above puts the needle straight into the neurovascular bundle. The groove under each rib holds the vessels and the nerve, and a needle there causes bleeding.

The right distal tibia, since it sits away from the femur fracture: The distal tibia is one of the standard sites, and the right leg is away from the femur fracture. The right distal tibia is still below the unstable pelvis. Fluid given there has to drain back through the damaged pelvic veins, so both legs are out for this patient.

The sternum, since the pelvis and both legs are involved: Sternal access belongs to specialized devices, not standard Paramedic practice. The standard sites are the proximal tibia, the distal tibia, and the proximal humerus.

The left proximal tibia, which is the most familiar landmark: The proximal tibia is the most familiar landmark, and the proximal tibia works when the legs and pelvis are not hurt. The left leg is below both the unstable pelvis and the femur fracture. Anything given there drains into a damaged venous return. A familiar site does not help if the fluid never reaches the central circulation.

Apply a tourniquet as high on the thigh as it will physically reach: A tourniquet works when there is a limb between the device and the bleeding vessel. A groin wound sits above that point. A tourniquet as high on the thigh as it will reach still cannot compress the artery feeding this wound.

Place a pelvic binder to compress the bleeding vessels: A pelvic binder is for an unstable pelvic ring and the bleeding that comes with it. A binder does not compress a stab wound through the soft tissue of the groin.

Apply a pressure dressing and elevate the affected leg: Direct pressure alone has already failed on this wound, and a pressure dressing is not going to do better. Elevation does not control arterial bleeding. This wound needs to be packed, not covered.

Perform a surgical cricothyrotomy now, since two intubation attempts failed: Failed intubation by itself is not a failed airway. Intubation and ventilation both have to fail. Ventilation is working here, so cutting the neck adds bleeding and the risk of a false passage for no benefit.

Insert a second supraglottic airway of a smaller size: The supraglottic airway already would not seat in this patient's anatomy. A smaller one is not likely to do any better. The two person BVM with an oral airway is already working.

Make a third intubation attempt using a different blade: More attempts on a face this badly injured can turn a working airway into a lost one. A patient who is oxygenating well does not need another intubation attempt right now.

It lowers the blood pressure in patients who have lost blood: Nitrous oxide has little effect on blood pressure compared with opioids. The reason to withhold nitrous oxide here is trapped gas, not the patient's volume status.

It depresses the respiratory drive in patients with rib fractures: Nitrous oxide is self administered, and the mask falls away as the patient gets sedated. A mask that falls away limits respiratory depression. The danger in this patient is gas expanding inside the chest.

It is only approved for patients with isolated extremity injuries: Nitrous oxide is not limited to isolated extremity injuries. The restriction here comes from a possible pneumothorax, not from the type of injury. Plenty of falls cause no chest injury at all.

Insert an endotracheal tube and ventilate: Intubation is for a patient who cannot ventilate or cannot protect the airway. Intubation is often part of caring for a critical chest trauma patient, but a tube does nothing for the air trapped in the pleural space. Positive pressure ventilation forces more air through the one-way leak. Intubating before you decompress can push this patient into cardiac arrest.

Apply CPAP: CPAP is for medical lung problems like pulmonary edema and some asthma and COPD patients. The pressure opens collapsed air sacs and pushes edema fluid back out of the lungs. Here, CPAP adds more positive pressure to the tension pneumothorax. CPAP is contraindicated in a suspected pneumothorax and in a patient with low blood pressure.

Confirm tracheal deviation before intervening: Waiting for tracheal deviation is the most dangerous option. Tracheal deviation shows up late, is hard to see in the field, and is missing in many patients with a tension pneumothorax. This patient already has absent breath sounds on one side, distended neck veins, and a very low blood pressure. Waiting for a late sign only delays the decompression this patient needs now.

Apply a pelvic binder at the iliac crests: The iliac crests are the landmark you can feel, so they seem like the place for the binder. The instability in this patient's ring sits below the crests. Squeezing the crests pushes the iliac wings together while the ring stays open, so the pelvis never gets smaller. The trochanters work because the femoral heads sit right under them.

Repeatedly assess pelvic stability by springing: Springing the pelvis is how you check stability, and one gentle palpation already found the pelvis unstable. Springing the pelvis again can break up the clot forming around the broken ring and restart the bleeding. Check pelvic stability once, never repeatedly.

Log roll the patient to inspect the lower back: Log rolling to look at the back is part of a normal trauma assessment. This patient has an unstable pelvis and is in shock. Rolling shifts the broken ring and tears the clot that is forming there. Look at the back after the binder is on.

Blind clamping of the bleeding vessel: Blind clamping belongs in an operating room with good lighting and exposure, and even surgeons clamp vessels while looking at them. A clamp pushed into a bleeding neck wound in the field can catch the carotid artery, the vagus nerve, or the jugular vein. A blind clamp can turn a venous bleed you could control into an arterial or nerve injury. Direct pressure with an occlusive dressing controls the same bleeding without hurting anything you cannot see.

A circumferential pressure dressing around the neck: A circumferential pressure dressing is exactly right for bleeding on an arm or a leg. The neck holds the trachea and both carotid arteries. A wrap tight enough to stop the bleeding also squeezes the airway and the blood supply to the brain. That's why neck bleeding gets pressure on one side and never a wrap.

A tourniquet placed above the wound: A tourniquet needs a spot where a band can squeeze everything below it without cutting off something the patient needs. An arm or a leg works. The neck does not, and a band above a neck wound strangles the patient. Tourniquets are also for arterial bleeding. This bleeding is dark and steady, which means the bleeding is coming from a vein.

Decompress the left chest with a needle: Needle decompression is for a tension pneumothorax. A wound at the base of the neck can injure the top of the lung, so a tension pneumothorax is worth thinking about here. Every finding that would point to one is missing. The breath sounds are clear and equal, the trachea is midline, and the chest wall is stable. Both conditions cause obstructive shock. A tension pneumothorax blocks flow with air trapped on one side of the chest, and this patient has air inside the heart. Putting a needle into a normal chest gives the patient a pneumothorax, the injury you were trying to treat.

Elevate the head of the stretcher to 45 degrees: Raising the head helps a patient with pulmonary edema or trouble breathing who has blood pressure to spare. Sitting up eases the work of breathing for those patients. In this patient, raising the head lifts the wound even higher above the heart. The pressure in the neck veins drops lower, and more air gets pulled in with every breath.

Infuse a rapid crystalloid bolus: A fluid bolus is the usual move for a trauma patient with a blood pressure of 82/54 and a pulse of 130. Fluid can help once the cause is fixed. This hypotension comes from a blockage, not from blood loss. The right ventricle is filling, but it cannot push the frothy air forward into the pulmonary artery. Fluid does not clear air out of the heart. Sealing the wound and turning the patient left side down with the head lowered is what gets blood moving forward again.

Apply a vest-type extrication device first: A vest-type device is the standard choice for a seated patient with a possible spinal injury and stable vital signs. Putting one on costs several minutes. A patient in decompensated hemorrhagic shock does not have several minutes. Protecting the spine does not help a patient who bleeds out before reaching surgery.

Wait for the rescue company to remove the roof: Taking the roof off is for a patient who cannot be reached or removed through the openings already there. Both doors on the patient's side open normally. Waiting for the roof to come off adds time and gives you no access you do not already have.

Allow the patient to step out unassisted: Letting a patient step out alone is for a patient who is alert and oriented, with no neurologic complaint and no distracting injury. This patient answers slowly and is in shock, so you cannot count on the patient to cooperate. Standing a bleeding patient up can end with the patient collapsing in the doorway.