132.

A patient has a gunshot wound in which a bullet has entered the left 6th ICS anteriorly and exited
atraight posteriorly. He is not hypotensive and has no signs of peritoneal irritation. The most suitable
management is

E. Exploratory laparotomy

133. Significant vascular injury os likely to occur with all the following fractures or dislocations EXCEPT

A. Fracture of the midshaft of the humerus

134. A correct statement concerning burn scarring is

C. A pressure garment used for at least 6 months reduces scar hypertophy by causing better alignment
of collagen fibers

135. All the following statements concerning early tangential excision of burn wounds are true EXCEPT

B. In a patient with severe smoke inhalation the procedure should be done under local anesthesia

136. A 55 y/o woman sustains closed fractures of the right tibia and fibula in a skiing accident, and she is
noted to have a loss of sensation over the lateral aspect of the affected calf and foot. The fractures are
non-displaced. The patient's leg is casted, and the fractures heal without complication. Six months after
the injury, the patient develops intense burning, hyperesthesia, and cyanosis of the right foot.the
treatment of choice for her would be

E. Paravertebral sympathetic block

137. The majority of deaths in patients who have pancreatic injuries are due to

E. Associated vascular injuries

138. Whether the nutrition needs of a patient 10 days after a major burn are being met is best assessed
by

B. Measurement of daily body weight

139. All the following problems may be associated with the use of mafenide acetate (Sulfamylon)
EXCEPT

C. Rapis dessicatio of the eschar

140. An 18 y/o man is admitted to the ED shortly after being involved in an automobile accident. He is in
a coma (GCS 7). His pulse is barely palpable at a rate of 140 bpm and BP is 60/0. Breathing is rapid and
shallow, aerating both lung fields. His abdomen is moderately distended with no audible peristalsis.
There are closed fractures of the right forearm and the left lower leg. After rapid IV of 2 L of lactated
Ringer's solution in yhe upper extremities, his pulse is 130 and BP 70/0. The next immediate step should
be to
E. Explore the abdomen

141. A 35 y/o man is brough to an ED shortly after being removed from a burning, smoke-filled
automobile. The patient is confused, agitated, and tachypneic. His general color is normal, his BP is
80/40 mmHg , and his pulse is 160 bpm. No surface burns are noted. Auscultation of his chest reveals
normal air entry bilaterally,wit minimal coarse expiratory wheezes. His abdomen is soft, active bowel
sounds are present, and the remainder of tye physical examination is within normal limits. Results of the
neurologic exams are normal except for an acute confusional state. The immediate treatment for the
most likely cause of this patients agitation and confusion is adminitration

D. 100% oxygen by face mask

A 45 y/o firefighter who weighs 74 kg (163 pounds) sustaibs a 3rd degree burn to 64% of his total body
surface area. The patients arrives in the ED approximately 30 minutes after the time of the accident.

142. When the patient's IV fluid requirements are calculated using the Parkland formula, the initial
orders for choice of fluid and rte of infusion should be

B. Ringer's lactate, 1250 mL/h for 7.5 h

143. Using the Parkland formula, the choice if fluid and rate of infusion for this patient's second 24-hour
post injury period should be

A. 5% dextrose in water to maintai serum sodium concentration at 140 mEq/L amd approximately 1 L of
colloid solution

144. The most frequent nonbacterial, opportinistic wounds is

B. Candida

145. A 26 y/o man undergoess an uncomplicated splenectomy following blunt abdominal trauma.
During anesthesia, he is given oxygen, nitrous oxide, a narcotic, and a muscle relaxant. No other
significant injuries are found during surgery, and transfusion of blood products is not required. In the
recovery room after extubation, the patient is noted to have a BP of 170/100 mmHg, a pulse of 140
bpm, and RR of 8 bpm. Shortly thereafter, his BP is found to have dropped to 100/60 mmHg and his
pulse to 60 bpm; he is not arousable. The disgnostic maneuver most likely to define this patient's
problem is

D. Analysis of arterial blood gas

A 25 y/o man is brought to the ED after falling 20 feet from a ladder. He is unconscious, and there is
blood-tinged, non-clooting flyid in his left ear canal. He withdraws from painful stimuli. His eyes are
closed, but they open in response to pain. He is making unintelligible sounds. His pupils are equal, and
both react sluggishly to light.

146. His GCS is

B. 8

147. Afer control of this patient's airway is achieved, the first diagnostic study to obtain is

C. X-rays of the cervical spine

148. A patient who develops severe symptoms shortly after being bitten by a honey bee should be
treated with

B. Epinephrine

149. A 25 y/o woman is seen beacause of severe muscular pain, nausea, vomiting, and headache
following a bite of a black widow spider. Her management should include

D. Intravenous calcium

150. A 14 y/o girl sustains a steam burn measuring 6 by 7 inches over the ulnar aspect of her right
forearm. Blisters develop over the entire area of the burn wound, and by the time thr patient is seen 6 h
after the injury, some of the blisters have ruptured spontaneously. In addition to debridemeny of the
nephrotic epithelium, all the following therapeutic regimens might be considered appropriate for this
patient EXCEPT

E. Heterograft (pigskin) application with sutures to secure it in place and daily washes, but no dressing

151. In the therapy of hemorrhagic shock, the best clinical sign of successful fluid resuscitation is

B. An increase in urine output

152. A man who weighs 70 kg is transferred to a burn center 4 weeka after sustaining a 2nd and 3rd
degree burn injury to 45% of his total body surface area. Prior to the accident, the patient's weight was
90 kg. The patient has not been given anything by mouth since the injury, except for antacids because of
a previous ulcer history. On PE, the patient's burn wounds are clean, but only minimal healing is evident,
and thick adherent eschar is present. The patient's abdomen is soft and nondistended, and active bowel
sounds are heard. His stools are trace-positive for blood, and he has a right inguinal hernia,which
appears to be easily reducible. He has poor range of motion of all involved joints and had developed
early axillary and popliteal fissae flexion contractures. In mnaging this patient at this stage of his injury,
top priority must be given to correting

D. The nutritional status-by enteral supplementation or parenteral hyperalimentation

155. When a patient is seen with a stab wound of the neck that has injured the left vertebral artery, the
most clinical finding is

E. Stable hematoma

156.for patients seenwithin 1 h of a rattle-snake bie in which venom has been injected, effective
treatment may include all the following measures EXCEPT
E. Cryotherapy

157. For most pancreatic injuries that involve the area to the left of the superior mesenteric vessels and
that disrupt the duct of Wirsung, the preferred treatment is

C. Distal pancreatectomy and drainage

160. Which of the following dtatements concerning injuries of the extrahepatic biliary tree is true?

D. Blunt transection of the common bile duct with significant tissue loss is best treated by implantation
of the duct into the duodenum or the jejunum

161. Which of the following measurements best indicates the adequacy of pulmonary ventilation?

C. Partial pressure of carbon dioxide in arterial blood

163. In a patient suspected of having a blunt abdominal injury and in whom there is an absence of any
other signs of abdominal injury, any one o the following findings woyld be an indication for exploratory
laparotomy EXCEPT

E. An elevated serum amylase level

165. A 55 y/o woman who is undergoing emergency surgery for a bleeding duodenal ulcer is given 5
units of blood during the operation. Postoperatively, her urine output is 10 mL/h, and urinalysis yields
the following: sg 1.027; Na 4 mEq/L; K 38 mEq/L. Which of thw folowing statements concerning this
situation is true?

E. Further evaluation expansion is required

Y/N

169. During exploratory laparotomy for a gunshot wound of the abdomen in a 24 y/o man, a through
and throigh perforation of the rectum, approximately 10 cm from the anal verge, is found. Surgical
managment of this injury might correctly include

(Y)

A. Creation of a proximal double barrel colostomy

B. Presacral drainage with Penrose or sump drains

C. Closure of the perforations if spillage is minimal

E. Removal of all feces from the distal rectum by copious saline irrigation

170-171
An 18 y/o woman is admitted to an emergency room in hemorrhagic shock followinh an automobile
accident. Ater the infusion of 2000 mL of lactated Ringer's solution, her BP and pulse remain unstable,
and she complains of upper abdominal pain. In examination, there is temdernesz and marked
involuntary guarding the lef upper abdominal quadrant. CXR, Hct, and urinalysis are normal.

170. Which of the following procedures would be considered essential for proper management of this
patient?

E. Exploratory laparotomy

171. At surgery, a clean, nonbleeding laceration of the left lobe of the liver (3cm long and 1.5 cm deep)
and a large stellate fracture of the spleen with a near-complete transection in 2 areas are found. Surgical
management of these injuries would include which of the following procedures?

B. Splenectomy

C. Drainage of the liver laceration and splenic area

172. True statements concerning duodenal perforation after blunt abdominal trauma include which of
the following?

A. Retroperitoneal perforation frequently produces few early signs or symptoms

B. Intraperitoneal perforationproduces chemical irritation of the peritoneum due to the highly alkaline
pH of the duodenal content

E. When retroperitoneal air i found during celiotomy, a wide Kocher maneuver should be done to locate
the sire of injury

173. True statements concerning the currently recommended guidelines the use of biological dressings
(homografts or heterografts) in treating burn injuries include which of thr following?

A. They may be applied to granulation tissue but must be removed every 5 days

C. They may be used to trst the readiness of a large burn wound for autografting

D. They may be applied over exposed tendons or neurovascular structures to prevent them from
dessicating

E. They may be applied over reepithelializating, deep, 2nd degree burns, once superficial necrotic debris
has been entirely removed

174. Which of the following retroperitoneal hematomas resulting from blunt abdominal trauma should
be explored?

A. A small, centrally placed, nonexpanding hematoma superior to the pelvis

B. A small, nonexpanding hematoma over the body of the pancreas with an intact panceatic capsule
D. A large, nonexpanding hematoma over the body and head of the pancreas

E. A largw, expanding perirenal hematoma

175. A 19 y/o woman presents with a nonbleeding stab wound, 1 cm long, in the anterior triangle of her
neck, 3cm above her left clavicle. Her BP is 130/90 mmHg, and she has no evidence of respiratory
distress. Examination of the neck reveals that the wound has penetrated the platysma muscle, and that
the left carotid pulse is normal; there is no hematoma or bruit. Appropriate management of this patient
might include

C. Chest X-rays

D. Angiography

E. Formal exploration under general anesthesia

176. True statements concerning hepatic resections for the treatment of liver injuries include which of
the following?

A. When possible, a sublobar resection is preferable to a hepatic lobectomy