A 3-year-old child is brought to the emergency department with multiple bruises in various stages of healing. X-rays reveal several metaphyseal fractures and posterior rib fractures. The parents claim the injuries resulted from normal play activities. Which of the following patterns would most strongly suggest non-accidental trauma?

Loop-shaped bruises on the back

Irregular bruises on the forehead

A 44-year-old man is brought to the emergency department 25 minutes after falling off the roof of a house. He was cleaning the roof when he slipped and fell. He did not lose consciousness and does not have any nausea. On arrival, he is alert and oriented and has a cervical collar on his neck. His pulse is 96/min, respirations are 18/min, and blood pressure is 118/78 mm Hg. Examination shows multiple bruises over the forehead and right cheek. The pupils are equal and reactive to light. There is a 2-cm laceration below the right ear. Bilateral ear canals show no abnormalities. The right wrist is swollen and tender; range of motion is limited by pain. The lungs are clear to auscultation. There is no midline cervical spine tenderness. There is tenderness along the 2nd and 3rd ribs on the right side. The abdomen is soft and nontender. Neurologic examination shows no focal findings. Two peripheral venous catheters are placed. Which of the following is the most appropriate next step in management?

Focused Assessment with Sonography in Trauma

A 7-year-old boy is brought to the emergency department by his mother 1 hour after falling off his bike and landing head-first on the pavement. His mother says that he did not lose consciousness but has been agitated and complaining about a headache since the event. He has no history of serious illness and takes no medications. His temperature is 37.1°C (98.7°F), pulse is 115/min, respirations are 20/min, and blood pressure is 100/65 mm Hg. There is a large bruise on the anterior scalp. Examination, including neurologic examination, shows no other abnormalities. A noncontrast CT scan of the head shows a non-depressed linear skull fracture with a 2-mm separation. Which of the following is the most appropriate next step in management?

Contact child protective services

A 23-year-old man presents with a blunt force injury to the head from a baseball bat. He is currently unconscious, although his friends say he was awake and speaking with them en route to the hospital. He has no significant past medical history and takes no current medications. The vital signs include: temperature 37.0°C (98.6°F), blood pressure 165/85 mm Hg, pulse 50/min, and respiratory rate 19/min. On physical examination, there is a blunt force injury to the left temporoparietal region approximately 10.1–12.7 cm (4–5 in) in diameter. There is anisocoria of the left pupil, which is unresponsive to light. The patient is intubated and fluid resuscitation is initiated. A noncontrast computed tomography (CT) scan of the head is acquired and shown in the exhibit (see image). Which of the following is the most appropriate medical treatment for this patient?

Placement of a ventriculoperitoneal (VP) shunt

Placing the head of the bed at 0 degrees

A trauma 'huddle' is called. Morphine is administered for pain. Low-flow oxygen is begun. A traumatic diaphragmatic rupture is suspected. Infusion of 0.9% saline is begun. Which of the following is the most appropriate next step in management?

CT of the chest, abdomen, and pelvis

A 25-year-old man is admitted to the emergency department because of an episode of acute psychosis with suicidal ideation. He has no history of serious illness and currently takes no medications. Despite appropriate safety precautions, he manages to leave the examination room unattended. Shortly afterward, he is found lying outside the emergency department. A visitor reports that she saw the patient climbing up the facade of the hospital building. He does not respond to questions but points to his head when asked about pain. His pulse is 131/min, respirations are 22/min, and blood pressure is 95/61 mm Hg. Physical examination shows a 1-cm head laceration and an open fracture of the right tibia. He opens his eyes spontaneously. Pupils are equal, round, and reactive to light. Breath sounds are decreased over the right lung field, and the upper right hemithorax is hyperresonant to percussion. Which of the following is the most appropriate next step in management?

Perform an endotracheal intubation

Perform an open reduction of the tibia fracture

A 60-year-old man is brought to the emergency department 25 minutes after falling and hitting his left flank on a concrete block. He has severe left-sided chest pain and mild shortness of breath. He underwent a right knee replacement surgery 2 years ago. He has type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for 42 years. Current medications include metformin, sitagliptin, and a multivitamin. He appears uncomfortable. His temperature is 37.5°C (99.5°F), pulse is 102/min, respirations are 17/min, and blood pressure is 132/90 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows multiple abrasions on his left flank and trunk. The upper left chest wall is tender to palpation and bony crepitus is present. There are decreased breath sounds over both lung bases. Cardiac examination shows no murmurs, rubs, or gallops. The abdomen is soft and nontender. Focused assessment with sonography for trauma is negative. An x-ray of the chest shows nondisplaced fractures of the left 4th and 5th ribs, with clear lung fields bilaterally. Which of the following is the most appropriate next step in management?

Adequate analgesia and conservative management

Admission and surveillance in the intensive care unit

Prophylactic antibiotic therapy

Continuous positive airway pressure

A 75-year-old man is brought to the emergency department because of a 5-hour history of worsening chest pain and dyspnea. Six days ago, he fell in the shower and since then has had mild pain in his left chest. He appears pale and anxious. His temperature is 36.5°C (97.7°F), pulse is 108/min, respirations are 30/min, and blood pressure is 115/58 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 88%. Examination shows decreased breath sounds and dullness to percussion over the left lung base. There is a 3-cm (1.2-in) hematoma over the left lower chest. An x-ray of the chest shows fractures of the left 8th and 9th rib, increased opacity of the left lung, and mild tracheal deviation to the right. Which of the following is the most appropriate next step in management?

Chest tube insertion in the fifth intercostal space at the midaxillary line

Admission to the ICU and observation

Needle thoracentesis in the eighth intercostal space at the posterior axillary line

Trauma in special populations (pediatric, geriatric) for USMLE Step 2 CK: High-Yield Surgery Lessons

Pediatric Trauma - Little People, Different Rules

Anatomy & Physiology: Larger head/occiput, larger tongue, higher larynx (anterior/cephalad). Softer, more compliant chest wall.
- Airway: Prone to obstruction. Use shoulder roll for neutral alignment.
- Breathing: Pulmonary contusions common without rib fractures.
- Circulation: Excellent compensators. Hypotension is a LATE, pre-arrest sign. Tachycardia is the earliest indicator of shock.
- Exposure: High surface area-to-volume ratio; prone to hypothermia.
Vitals & Volumes:
- Normal SBP (lower limit) = 70 + (2 x age in years).
- Estimated Blood Volume = 80 mL/kg.
- Fluid Bolus: 20 mL/kg warm crystalloid.
- Blood Transfusion: 10 mL/kg pRBCs.
Assessment Tools:
- Use Broselow Tape for rapid size/dose estimation.
- Use Pediatric GCS (verbal component differs).

⭐ High-Yield: Hypotension is a sign of decompensated shock, often indicating >45% blood volume loss. Act aggressively before it appears.

PediaTape for Pediatric Emergency Drug Dosing

Geriatric Trauma - The Silver Challenge

Physiology: ↓ physiologic reserve, multiple comorbidities (CAD, COPD, CKD), and polypharmacy (anticoagulants, β-blockers) complicate presentation and management.
Mechanism: Ground-level falls are a major source of significant injury.
Injury Patterns:
- C-Spine: High incidence of fractures, especially odontoid (C2).
- Chest: Rib fractures are poorly tolerated, often leading to pneumonia. >2 rib fractures significantly ↑ mortality.
- Head: ↑ risk of intracranial hemorrhage, especially with anticoagulants.
Assessment Pitfalls:
- Classic signs of shock may be absent. β-blockers can mask tachycardia.
- Baseline hypotension or hypertension can confuse interpretation.
- Maintain a high index of suspicion for occult injuries.

⭐ In elderly patients on beta-blockers, hypotension without tachycardia is a common presentation of hypovolemic shock. Do not wait for a heart rate >100 to initiate resuscitation.

Management:
- Lower threshold for trauma team activation and ICU admission.
- Aggressive pain control to prevent splinting and pneumonia.
- Early discussion of goals of care is crucial.

Management Nuances - Peds vs. Geri Priorities

Priority	Pediatric Considerations	Geriatric Considerations
Airway	Smaller, funnel-shaped (cricoid narrowing); large occiput causes flexion.	C-spine arthritis; dentures may obstruct; less airway reactivity.
Breathing	Higher metabolic rate; rapid desaturation. Chest wall is very compliant.	↓ Physiologic reserve; rib fractures common & poorly tolerated.
Circulation	Tachycardia is the primary response to volume loss. Hypotension is a late, pre-arrest sign.	Pre-existing CVD. Beta-blockers blunt tachycardic response. High risk of occult hemorrhage.
Disability	Modified GCS (Verbal). Fontanelle/sutures can accommodate ↑ICP initially.	Baseline cognitive changes common. High index of suspicion for subdural hematoma (SDH), even with minor trauma.
Exposure	High surface area-to-volume ratio → rapid hypothermia.	Thin, fragile skin. Prone to hypothermia. Pre-existing conditions affect healing.
Fluids	Initial bolus: 20 mL/kg crystalloid. Use Broselow Tape for sizing.	Cautious fluid resuscitation to avoid fluid overload (CHF risk).

High‑Yield Points - ⚡ Biggest Takeaways

Pediatric trauma: Always consider non-accidental trauma (NAT). Children have large physiologic reserves but decompensate abruptly. Use the Broselow tape for dosing.

Geriatric trauma: Carries high mortality due to limited reserve and comorbidities (e.g., β-blockers) that blunt vital sign responses to shock.

Occult hypoperfusion is common in the elderly; guide resuscitation with lactate/base deficit, not just vitals.

Rib fractures in geriatric patients are a major predictor of morbidity from resulting pneumonia.

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