trauma 10/25

A 28-year-old man presents by EMS after being the restrained driver in a high-speed vehicle collision. On examination, he is noted to have malocclusion. When the forehead is held stationary and the upper teeth are grasped, there is movement of the nasal complex. Involvement of which of the following structures characterizes this injury as a LeFort II fracture rather than a LeFort I fracture?

• Lacrimal bone

• Mandible

• Maxilla

• Zygoma

Answer explanation

A 36-year-old man presents to the emergency department with ankle pain. He states that he was jumping to grab a ball when he was playing basketball and felt a “pop” at the back of his ankle. On exam, he has a positive Thompson test. What is the most appropriate next step in management?

• Apply a splint with the ankle in slight plantarflexion

• Consult orthopedics for surgical evaluation

• Obtain CT angiography of the extremity to rule out vascular compromise

• Place the patient in a controlled ankle movement boot

Answer explanation

Initial management of Achilles tendon ruptures consists of conservative management, analgesics/anti-inflammatories, and immobilization with the ankle in slight plantarflexion. All patients should be discharged with close follow-up with orthopedic surgery, as many of these patients will be managed operatively.

A 46-year-old woman presents as a restrained driver who required prolonged extraction from a high-speed motor vehicle collision. In the ED, her HR is 125 bpm, BP is 80/50 mm Hg, RR is 22/min, and SpO₂ is 97% on room air. The exam reveals mobility of her right iliac crest and a large volume of fluid in Morrison pouch on the FAST exam. A chest radiograph is normal. Two large-bore IVs are placed and blood products are ordered. Which of the following is the most appropriate next step in management?

• Activation of the interventional radiology suite

• CT scan of the abdomen and pelvis

• Immediate placement of an external fixation device by an orthopedic surgeon

• Transfer to the operating room for laparotomy

Answer explanation

Which type of clavicle fracture is most prone to nonunion complication and, therefore, should always be referred to an outpatient orthopedic surgeon after evaluation in the emergency department?

• Displaced midshaft clavicle fracture

• Intra-articular distal clavicle fracture

• Proximal clavicle fracture

• Superiorly displaced distal clavicle fracture

Answer explanation

Emergent evaluation by an orthopedic surgeon is required for open fractures, neurovascular compromise, and tenting of the skin. Consultation should be considered with Type 2 clavicle fracture ( distal fracture) and superior displacement. These have a higher likelihood of nonunion.

A 40-year-old woman presents with full-thickness burns to 20% of her body after she was trapped in a factory following an industrial explosion. Which of the following best describes her injuries?

• Primary blast injury

• Secondary blast injury

• Tertiary blast injury

• Quaternary blast injury

Answer explanation

A 33-year-old woman weighing 50 kg presents to the emergency department with thermal burns to bilateral anterior thighs and bilateral anterior legs after spilling boiling water while cooking. On exam, her legs and thighs are erythematous with fluid-filled blisters and are hyperalgesic to pain. A small area on her left thigh measuring 7 cm by 7 cm appears gray, is leather-like to touch, and is not painful. Which of the following represents the appropriate amount of fluid resuscitation in the first 24 hours according to the Parkland formula?

• 1,500 mL

• 1,800 mL

• • 
    3,600 mL

• • 
    7,200 mL

Answer explanation

A 54-year-old woman presents to the emergency department as a pedestrian struck by a motor vehicle. She arrives unresponsive, intubated, collared, and on a backboard. Initial vital signs reveal pulse 54 bpm, blood pressure 72/41 mm Hg, and oxygenation 98%. ECG shows sinus bradycardia, which improves with atropine. CT scan of the chest, abdomen, and pelvis shows no signs of internal bleeding. Extremities are warm to the touch without obvious deformities. A bedside echocardiogram shows a grossly normal ejection fraction. Her blood pressure does not improve despite fluid boluses, so norepinephrine is started. What should be the minimum goal mean arterial pressure for this patient?

• 55 mm Hg

• 65 mm Hg

• 75 mm Hg

• 85 mm Hg

Answer explanation

After the patient has been adequately volume resuscitated, norepinephrine should be initiated to maintain mean arterial pressure (MAP) to at least 85 to 90 mm Hg. This goal is set higher than the typical MAP of 65 mm Hg because the injured spinal cord is especially vulnerable to ischemic injury.

While performing a physical exam on a trauma patient, you find crepitus over the lateral left chest wall, palpable step-offs over ribs four through eight, and that this segment of the chest wall is sucking inward during inhalation and moving outward during exhalation. What is the best management for this patient’s illness?

• Antibiotics

• Immediate surgical repair

• Mechanical ventilation and pain management

• Pain management and tube thoracostomy

Answer explanation

Flail chest occurs in 5–13% of traumatic chest wall injuries and is most often the result of blunt chest trauma. Flail chest is diagnosed based on the paradoxical movement of the chest wall with respiration. This occurs due to the negative pleural pressures on the detached segment. Treatment begins with conservative management, including fluid resuscitation, pulmonary support, and pain control via oral, IV, or regional anesthesia. Intubation and ventilatory support are more often needed for patients with flail chest due to chest wall instability.

tube thoracostomy is indicated for open chest wounds or hemo- or pneumothorax, not for flail chest.

A 28-year-old woman presents with intense pain, tearing, and ocular foreign body sensation in both eyes that began yesterday. She reports no trauma, significant medical problems, or contact lens use and reports that she works as a ski patrol for a local resort. Her physical examination is significant for bilateral decreased visual acuity, injected conjunctiva, and diffuse punctuate corneal lesions with a discrete superior border. Her pupils are equal, round, and reactive to light. Given this patient’s clinical presentation, which of the following is the most likely diagnosis?

• Epidemic keratoconjunctivitis

• Episcleritis

• Iritis

• Optic neuritis

• Ultraviolet keratitis

Answer explanation

An 87-year-old woman presents to the ED with facial pain after tripping and striking her face on her bedpost. On physical exam, you note the above. Which of the following radiographic signs is associated with this injury?

• Hampton hump

• Lightbulb sign

• Steeple sign

• Teardrop sign

Answer explanation