Triage principles — MCQs

8 questions

A 45-year-old man was a driver in a motor vehicle collision. The patient is not able to offer a medical history during initial presentation. His temperature is 97.6°F (36.4°C), blood pressure is 104/74 mmHg, pulse is 150/min, respirations are 12/min, and oxygen saturation is 98% on room air. On exam, he does not open his eyes, he withdraws to pain, and he makes incomprehensible sounds. He has obvious signs of trauma to the chest and abdomen. His abdomen is distended and markedly tender to palpation. He also has an obvious open deformity of the left femur. What is the best initial step in management?

A 35-year-old man and his 9-year-old son are brought to the emergency department following a high-speed motor vehicle collision. The father was the restrained driver. He is conscious. His pulse is 135/min and his blood pressure is 76/55 mm Hg. His hemoglobin concentration is 5.9 g/dL. His son sustained multiple body contusions and loss of consciousness. He remains unresponsive in the emergency department. A focused assessment of the boy with sonography is concerning for multiple organ lacerations and internal bleeding. The physician decides to move the man's son to the operating room for emergency surgical exploration. The father says that he and his son are Jehovah's witnesses and do not want blood transfusions. The physician calls the boy's biological mother who confirms this religious belief. She also asks the physician to wait for her arrival before any other medical decisions are undertaken. Which of the following is the most appropriate next step for the physician?

A 27-year-old man is brought to the emergency department after a motor vehicle accident. He was the unrestrained driver in a head on collision. The patient is responding incoherently and is complaining of being in pain. He has several large lacerations and has been impaled with a piece of metal. IV access is unable to be obtained and a FAST exam is performed. His temperature is 98.2°F (36.8°C), blood pressure is 90/48 mmHg, pulse is 150/min, respirations are 13/min, and oxygen saturation is 98% on room air. Which of the following is the best next step in management?

A 35-year-old woman with no significant past medical history is brought in by ambulance after a major motor vehicle collision. Temperature is 97.8 deg F (36.5 deg C), blood pressure is 76/40, pulse is 110/min, and respirations are 12/min. She arouses to painful stimuli and makes incomprehensible sounds, but is unable to answer questions. Her abdomen is distended and diffusely tender to palpation. Bedside ultrasound shows blood in the peritoneal cavity. Her husband rushes to the bedside and states she is a Jehovah’s Witness and will refuse blood products. No documentation of blood refusal is available for the patient. What is the most appropriate next step in management?

A 52-year-old obese man is brought to the emergency department 30 minutes after he was involved in a high-speed motor vehicle collision. He was the unrestrained driver. On arrival, he is lethargic. His pulse is 112/min, respirations are 10/min and irregular, and blood pressure is 94/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 91%. The pupils are equal and react sluggishly to light. He withdraws his extremities to pain. There are multiple bruises over his face, chest, and abdomen. Breath sounds are decreased over the left lung base. Two large bore peripheral venous catheters are inserted and 0.9% saline infusion is begun. Rapid sequence intubation is initiated and endotracheal intubation is attempted without success. Bag and mask ventilation is continued. Pulse oximetry shows an oxygen saturation of 84%. The patient has no advance directive and family members have not arrived. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old soldier is brought back to a military treatment facility 45 minutes after sustaining injuries in a building fire from a mortar attack. He was trapped inside the building for around 20 minutes. On arrival, he is confused and appears uncomfortable. He has a Glasgow Coma Score of 13. His pulse is 113/min, respirations are 18/min, and blood pressure is 108/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows multiple second-degree burns over the chest and bilateral upper extremities and third-degree burns over the face. There are black sediments seen within the nose and mouth. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in management?

A 3-month-old boy is brought to the emergency department by his mom for breathing difficulty after a recent fall. His parents say that he rolled off of the mattress and landed on the hard wood floor earlier today. After an extensive physical exam, he is found to have many purplish bruises and retinal hemorrhages. A non-contrast head CT scan shows a subdural hemorrhage. He was treated in the hospital with full recovery from his symptoms. Which of the following is the most important follow up plan?

A 67-year-old woman is brought by ambulance from home to the emergency department after she developed weakness of her left arm and left face droop. According to her husband, she has a history of COPD, hypertension, and hyperlipidemia. She takes hydrochlorothiazide, albuterol, and atorvastatin. She is not on oxygen at home. She is an active smoker and has smoked a pack a day for 20 years. Her mother died of a heart attack at age 60 and her father died of prostate cancer at age 55. By the time the ambulance arrived, she was having difficulty speaking. Once in the emergency department, she is no longer responsive. Her blood pressure is 125/85 mm Hg, the temperature is 37.2°C (99°F), the heart rate is 77/min, and her breathing is irregular, and she is taking progressively deeper inspirations interrupted with periods of apnea. Of the following, what is the next best step?

Triage principles US Medical PG Practice Questions and MCQs

Question 1: A 45-year-old man was a driver in a motor vehicle collision. The patient is not able to offer a medical history during initial presentation. His temperature is 97.6°F (36.4°C), blood pressure is 104/74 mmHg, pulse is 150/min, respirations are 12/min, and oxygen saturation is 98% on room air. On exam, he does not open his eyes, he withdraws to pain, and he makes incomprehensible sounds. He has obvious signs of trauma to the chest and abdomen. His abdomen is distended and markedly tender to palpation. He also has an obvious open deformity of the left femur. What is the best initial step in management?

A. Emergency open fracture repair
B. Packed red blood cells
C. Exploratory laparotomy
D. Intubation (Correct Answer)
E. 100% oxygen

Explanation: ***Intubation*** - The patient's **Glasgow Coma Scale (GCS) score is 7** (E=1, V=2, M=4), which is below 8 and indicates a severe head injury needing **airway protection** via intubation. - A GCS ≤ 8 mandates **definitive airway management** to prevent aspiration and ensure adequate ventilation. *Emergency open fracture repair* - While the patient has an open femur fracture, it is not the most immediate life-threatening concern after a major trauma; **airway and breathing** take precedence. - **Hemorrhage control** and **stabilization** often precede definitive orthopedic repair in polytrauma. *Packed red blood cells* - Although the patient is likely in **hemorrhagic shock** (tachycardia, hypotension, obvious trauma), administering blood products without first securing the airway is not the initial priority. - **Circulation** management, including fluid resuscitation and blood products, follows **airway and breathing** establishment. *Exploratory laparotomy* - The patient's distended and tender abdomen strongly suggests intra-abdominal injury, but this is a **diagnostic and therapeutic procedure** that comes after initial resuscitation and stabilization. - **Emergent laparotomy** for abdominal trauma is considered once the patient's airway, breathing, and circulation are secured. *100% oxygen* - Administering 100% oxygen is part of initial resuscitation, but it does not address the fundamental problem of an unsecured airway and the risk of **hypoventilation** or **aspiration** in a patient with a GCS of 7. - Oxygen supplementation helps improve saturation in spontaneously breathing patients but cannot protect a compromised airway.

Question 2: A 35-year-old man and his 9-year-old son are brought to the emergency department following a high-speed motor vehicle collision. The father was the restrained driver. He is conscious. His pulse is 135/min and his blood pressure is 76/55 mm Hg. His hemoglobin concentration is 5.9 g/dL. His son sustained multiple body contusions and loss of consciousness. He remains unresponsive in the emergency department. A focused assessment of the boy with sonography is concerning for multiple organ lacerations and internal bleeding. The physician decides to move the man's son to the operating room for emergency surgical exploration. The father says that he and his son are Jehovah's witnesses and do not want blood transfusions. The physician calls the boy's biological mother who confirms this religious belief. She also asks the physician to wait for her arrival before any other medical decisions are undertaken. Which of the following is the most appropriate next step for the physician?

A. Seek a court order for medical treatment of the son
B. Proceed to surgery on the son without transfusion
C. Wait for the son's mother before providing further treatment
D. Consult hospital ethics committee for medical treatment of the son
E. Transfuse packed red blood cells to the son but not to father (Correct Answer)

Explanation: ***Transfuse packed red blood cells to the son but not to father*** - In a **life-threatening emergency**, physicians can override parental refusal of treatment for a **minor** under the doctrine of **parens patriae** (state's interest in protecting children) and the **emergency exception** to informed consent. - The 9-year-old son is **unresponsive with internal bleeding** requiring immediate intervention; delaying transfusion would likely result in death. - The father is a **competent adult** with decision-making capacity who has the right to refuse blood products for himself based on his religious beliefs—this autonomy must be respected. - No court order is required in an **immediate life-threatening emergency** for a minor; the physician can proceed with necessary treatment including blood transfusion. *Seek a court order for medical treatment of the son* - While court orders can be obtained to override parental refusal for minors, this approach is appropriate for **non-emergent situations** where there is time for judicial review. - In this **immediate emergency**, seeking a court order would cause dangerous delays that could result in the child's death. - Courts have consistently upheld the right of physicians to provide life-saving treatment to minors in emergencies without prior judicial approval. *Wait for the son's mother before providing further treatment* - Delaying treatment for a critically injured, unresponsive child with ongoing internal bleeding would constitute **medical negligence**. - The child's life takes precedence over waiting for additional parental discussion when immediate intervention is required. - Both parents have already expressed their religious objection, so waiting for the mother's arrival would not change the ethical obligation to save the child's life. *Consult hospital ethics committee for medical treatment of the son* - Ethics committees provide valuable guidance for **complex or non-urgent ethical dilemmas**, but they are not designed for immediate emergency decision-making. - The time required for committee consultation would delay life-saving treatment for a critically ill child. - In this clear emergency scenario, the ethical and legal framework already supports immediate intervention to save the minor's life. *Proceed to surgery on the son without transfusion* - Operating on a child with severe internal bleeding and significant blood loss without providing transfusion support would likely be **futile and potentially harmful**. - The surgical exploration itself would exacerbate blood loss, making transfusion a **critical component** of appropriate care. - This approach would fail to provide the standard of care and could constitute medical negligence.

Question 3: A 27-year-old man is brought to the emergency department after a motor vehicle accident. He was the unrestrained driver in a head on collision. The patient is responding incoherently and is complaining of being in pain. He has several large lacerations and has been impaled with a piece of metal. IV access is unable to be obtained and a FAST exam is performed. His temperature is 98.2°F (36.8°C), blood pressure is 90/48 mmHg, pulse is 150/min, respirations are 13/min, and oxygen saturation is 98% on room air. Which of the following is the best next step in management?

A. Reattempt intravenous access
B. Obtain intraosseous access (Correct Answer)
C. Place a central line
D. Administer oral fluids
E. Exploratory laparotomy

Explanation: ***Obtain intraosseous access*** - The patient is in **hypotensive shock** (BP 90/48 mmHg, HR 150/min) after a severe trauma, and **IV access cannot be obtained**. **Intraosseous (IO) access** provides a rapid and reliable route for fluid and medication administration in emergent situations when peripheral IV access is difficult or impossible. - While central line placement is also a viable option, **IO access is generally faster and easier to establish** in an emergency setting by a wide range of providers, making it the **best initial step** when peripheral IV fails. *Reattempt intravenous access* - Although obtaining IV access is critical, the question states that it "is unable to be obtained," implying initial attempts have failed or are proving too difficult/time-consuming given the patient's critical state. - Persisting with repeated attempts risks significant delay in resuscitation, which is detrimental for a patient in shock. *Place a central line* - A central line provides reliable access for fluid and medication, but its placement is generally **more time-consuming** and technically challenging than IO access, especially in an agitated, unstable patient in a chaotic emergency setting. - The immediate priority is rapid access for fluids to address the patient's shock, for which IO is superior in terms of speed of establishment. *Administer oral fluids* - The patient is **unstable**, **incoherently responding**, and likely has significant internal injuries given the mechanism of injury (head-on collision, impalement). - Oral fluids would be **ineffective** and potentially dangerous (risk of aspiration) in this critical, hemodynamically unstable patient who requires immediate intravenous fluid resuscitation. *Exploratory laparotomy* - While the patient likely has significant internal injuries requiring surgical intervention (impalement, hypovolemic shock), an **exploratory laparotomy** is a definitive treatment step, not the *best next step in management* for immediate resuscitation. - **Hemodynamic stabilization** with fluid resuscitation must occur *before* or *simultaneously with* definitive surgical intervention to improve survival chances.

Question 4: A 35-year-old woman with no significant past medical history is brought in by ambulance after a major motor vehicle collision. Temperature is 97.8 deg F (36.5 deg C), blood pressure is 76/40, pulse is 110/min, and respirations are 12/min. She arouses to painful stimuli and makes incomprehensible sounds, but is unable to answer questions. Her abdomen is distended and diffusely tender to palpation. Bedside ultrasound shows blood in the peritoneal cavity. Her husband rushes to the bedside and states she is a Jehovah’s Witness and will refuse blood products. No documentation of blood refusal is available for the patient. What is the most appropriate next step in management?

A. In accordance with the husband's wishes, do not transfuse any blood products
B. Observe and reassess mental status in an hour to see if patient can consent for herself
C. Attempt to contact the patient’s parents for additional collateral information
D. Consult the hospital ethics committee
E. Administer blood products (Correct Answer)

Explanation: **Administer blood products** - In emergency situations where a patient is incapacitated and there is no **advance directive** or **legal proxy** explicitly refusing treatment, the principle of **presumed consent** applies, allowing life-saving interventions. - The patient's husband's statement is not legally binding without a living will or medical power of attorney, especially when the patient's capacity to consent or refuse treatment is compromised due to critical injury. *In accordance with the husband's wishes, do not transfuse any blood products* - The husband's stated wishes are not legally sufficient to refuse life-saving treatment for an incapacitated adult unless he holds **durable power of attorney for health care** specifically outlining these wishes, which is not stated here. - Deferring necessary treatment based solely on the husband's assertion could lead to the patient's death and potentially expose the medical team to **malpractice liability**. *Observe and reassess mental status in an hour to see if patient can consent for herself* - The patient presents with **severe hypovolemic shock** (BP 76/40, HR 110/min) and signs of significant hemorrhage, indicating an urgent, life-threatening situation. - Delaying emergent treatment to wait for a change in mental status would likely result in irreversible harm or death, as her condition is rapidly deteriorating. *Attempt to contact the patient’s parents for additional collateral information* - Contacting other family members for more information would cause a **critical delay** in a life-threatening situation. - Even if parents confirm the patient's faith, their input is still not a legally binding refusal of treatment without proper documentation or court order. *Consult the hospital ethics committee* - Ethics committee consultations are appropriate for complex ethical dilemmas that are not immediately life-threatening or when there is sufficient time for deliberation. - In this **critical emergency** with an actively hemorrhaging patient in shock, consulting the ethics committee would cause an unacceptable delay in life-saving treatment.

Question 5: A 52-year-old obese man is brought to the emergency department 30 minutes after he was involved in a high-speed motor vehicle collision. He was the unrestrained driver. On arrival, he is lethargic. His pulse is 112/min, respirations are 10/min and irregular, and blood pressure is 94/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 91%. The pupils are equal and react sluggishly to light. He withdraws his extremities to pain. There are multiple bruises over his face, chest, and abdomen. Breath sounds are decreased over the left lung base. Two large bore peripheral venous catheters are inserted and 0.9% saline infusion is begun. Rapid sequence intubation is initiated and endotracheal intubation is attempted without success. Bag and mask ventilation is continued. Pulse oximetry shows an oxygen saturation of 84%. The patient has no advance directive and family members have not arrived. Which of the following is the most appropriate next step in the management of this patient?

A. Nasotracheal intubation
B. Video laryngoscopy
C. Cricothyrotomy (Correct Answer)
D. Comfort measures only
E. Tracheostomy

Explanation: ***Cricothyrotomy*** - In a trauma patient with **failed endotracheal intubation** and declining oxygen saturation (from 91% to 84% despite bag-mask ventilation), an emergent cricothyrotomy is indicated for **immediate airway control**. - This procedure provides a definitive airway in a **can't intubate/can't ventilate** scenario, preventing further hypoxia and potential brain damage. *Nasotracheal intubation* - **Nasotracheal intubation** is generally contraindicated in patients with suspected **facial or skull base fractures** due to the risk of intracranial intubation. - Given the high-speed collision and facial bruises, such fractures are possible, making this a less safe option compared to cricothyrotomy. *Video laryngoscopy* - While **video laryngoscopy** can be helpful for difficult airways, it was already implied that intubation was attempted and failed, suggesting the issue might be with visualization or access, not just technique. - Critically, the patient's oxygen saturation is dropping rapidly, requiring a quicker, more definitive solution than another attempt at orotracheal intubation. *Comfort measures only* - The patient has **no advance directive**, and family members have not arrived to make decisions regarding end-of-life care. - Despite the severity of his injuries, the patient is still alive and does not have clear indications for **comfort measures only** at this stage; resuscitative efforts are warranted. *Tracheostomy* - **Tracheostomy** is a surgical procedure for establishing a long-term airway and is not suitable for **emergent airway management** in a rapidly decompensating trauma patient. - It typically requires specialized surgical expertise and takes longer to perform than a cricothyrotomy, which is a faster, life-saving measure in this acute situation.

Question 6: A 28-year-old soldier is brought back to a military treatment facility 45 minutes after sustaining injuries in a building fire from a mortar attack. He was trapped inside the building for around 20 minutes. On arrival, he is confused and appears uncomfortable. He has a Glasgow Coma Score of 13. His pulse is 113/min, respirations are 18/min, and blood pressure is 108/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows multiple second-degree burns over the chest and bilateral upper extremities and third-degree burns over the face. There are black sediments seen within the nose and mouth. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in management?

A. Insertion of nasogastric tube and enteral nutrition
B. Intravenous antibiotic therapy
C. Intubation and mechanical ventilation (Correct Answer)
D. Immediate bronchoscopy
E. Intravenous corticosteroid therapy

Explanation: ***Intubation and mechanical ventilation*** - The patient exhibits several signs of impending **airway compromise** due to **inhalation injury**, including perioral burns, black sediments in the nose and mouth, and being trapped in a fire. - While current oxygen saturation is 96%, **airway edema** can rapidly worsen, leading to respiratory failure. **Early intubation** is crucial to secure the airway before it becomes obstructed. *Insertion of nasogastric tube and enteral nutrition* - A nasogastric tube is often placed in burn patients to decompress the stomach and provide nutritional support, but it is **not the immediate priority** when there is a risk of airway obstruction. - **Enteral nutrition** is important but should be initiated only after airway control is established and the patient is stable for feeding. *Intravenous antibiotic therapy* - **Prophylactic antibiotics** are generally **not recommended** in the immediate management of burn patients unless there is clear evidence of infection, which is not present here. - Unnecessary antibiotic use can lead to **antibiotic resistance** and fungal infections. *Immediate bronchoscopy* - While **bronchoscopy** can confirm the extent of inhalation injury, it is not the primary immediate step. **Securing the airway** through intubation takes precedence over diagnostic procedures when airway compromise is imminent. - Bronchoscopy can be considered *after* intubation to assess the lower airway for damage and guide further management. *Intravenous corticosteroid therapy* - **Corticosteroids** are typically **contraindicated** in the management of inhalation injury because they can **impair immune function** and increase the risk of infection in burn patients. - Evidence does not support the routine use of corticosteroids to reduce inflammation in inhalation injury, and they may worsen outcomes.

Question 7: A 3-month-old boy is brought to the emergency department by his mom for breathing difficulty after a recent fall. His parents say that he rolled off of the mattress and landed on the hard wood floor earlier today. After an extensive physical exam, he is found to have many purplish bruises and retinal hemorrhages. A non-contrast head CT scan shows a subdural hemorrhage. He was treated in the hospital with full recovery from his symptoms. Which of the following is the most important follow up plan?

A. Provide parents with anticipatory guidance
B. Referral to genetics for further testing
C. Reassurance that accidents are common
D. Inform child protective services (Correct Answer)
E. Provide home nursing visits

Explanation: ***Inform child protective services*** - The combination of **multiple purplish bruises**, **retinal hemorrhages**, and **subdural hemorrhage** in a 3-month-old infant after a minor fall (rolling off a mattress) is highly suggestive of **abusive head trauma** (shaken baby syndrome). - Healthcare professionals have a **legal and ethical obligation** to report suspected child abuse to Child Protective Services (CPS) to ensure the child's safety and initiate an investigation. *Provide parents with anticipatory guidance* - While anticipatory guidance on child safety and development is generally important, it is **insufficient and inappropriate** as the primary follow-up in a case of suspected child abuse. - Focusing solely on guidance would **neglect the immediate safety concerns** and the need for investigation into the injuries. *Referral to genetics for further testing* - While some genetic conditions can predispose to easy bruising or bleeding, the specific pattern of injuries (**retinal hemorrhages, subdural hemorrhage, multiple bruises, and a history inconsistent with the severity of injuries**) overwhelmingly points to trauma, not a genetic disorder. - Genetic testing would be a secondary consideration, if at all, after abuse has been ruled out or addressed. *Reassurance that accidents are common* - Reassuring parents that "accidents are common" would be **medically negligent and dangerous** in this scenario, as the injuries sustained are typically not caused by a simple fall from a mattress in an infant of this age. - This response would dismiss critical signs of potential abuse and leave the child at risk. *Provide home nursing visits* - Home nursing visits might be beneficial for monitoring general health and development, but they do **not address the immediate and grave concern** of potential child abuse. - The primary need is for an investigation into the cause of the injuries and protection for the child, which falls under the purview of CPS.

Question 8: A 67-year-old woman is brought by ambulance from home to the emergency department after she developed weakness of her left arm and left face droop. According to her husband, she has a history of COPD, hypertension, and hyperlipidemia. She takes hydrochlorothiazide, albuterol, and atorvastatin. She is not on oxygen at home. She is an active smoker and has smoked a pack a day for 20 years. Her mother died of a heart attack at age 60 and her father died of prostate cancer at age 55. By the time the ambulance arrived, she was having difficulty speaking. Once in the emergency department, she is no longer responsive. Her blood pressure is 125/85 mm Hg, the temperature is 37.2°C (99°F), the heart rate is 77/min, and her breathing is irregular, and she is taking progressively deeper inspirations interrupted with periods of apnea. Of the following, what is the next best step?

A. Start tissue plasminogen activator (tPA)
B. Intubate the patient (Correct Answer)
C. Consult a cardiologist
D. Obtain an MRI of brain
E. Obtain non-contrast enhanced CT of brain

Explanation: ***Intubate the patient*** - The patient's **irregular breathing pattern with progressively deeper inspirations interrupted by periods of apnea** (known as **Cheyne-Stokes respiration**) combined with unresponsiveness due to probable acute stroke indicates imminent respiratory failure and the need for **airway protection**. - **Intubation** secures the airway, ensures adequate ventilation, and prevents aspiration during a neurological emergency. *Start tissue plasminogen activator (tPA)* - Although this patient likely has an **acute ischemic stroke**, the first priority is managing the **compromised airway and breathing**. - **tPA** administration is time-sensitive but requires stabilization of vital signs and exclusion of hemorrhage via neuroimaging, which hasn't occurred yet. *Consult a cardiologist* - While the patient has significant **cardiovascular risk factors** (**hypertension, hyperlipidemia, smoking, COPD, family history**), an acute cardiac event is not the immediate concern. - The pressing issue is **acute neurological deterioration with respiratory compromise**. *Obtain an MRI of brain* - An **MRI** offers detailed imaging for stroke but is **time-consuming** and **less accessible** in an emergency compared to CT. - The patient's critical respiratory status requires immediate intervention before non-urgent diagnostic imaging. *Obtain non-contrast enhanced CT of brain* - A **non-contrast CT scan of the brain** is crucial for differentiating between **ischemic** and **hemorrhagic stroke** and guiding treatment, specifically for tPA administration. - However, ensuring a **patent airway and stable ventilation** takes precedence over imaging in a patient with impending respiratory arrest.

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