Pediatric trauma considerations — MCQs

10 questions

A previously healthy 10-year-old boy is brought to the emergency department for the evaluation of one episode of vomiting and severe headache since this morning. His mother says he also had difficulty getting dressed on his own. He has not had any trauma. The patient appears nervous. His temperature is 37°C (98.6°F), pulse is 100/min, and blood pressure is 185/125 mm Hg. He is confused and oriented only to person. Ophthalmic examination shows bilateral optic disc swelling. There is an abdominal bruit that is best heard at the right costovertebral angle. A complete blood count is within normal limits. Which of the following is most likely to confirm the diagnosis?

A 41-year-old man is admitted to the emergency room after being struck in the abdomen by a large cement plate while transporting it. On initial assessment by paramedics at the scene, his blood pressure was 110/80 mm Hg, heart rate 85/min, with no signs of respiratory distress. On admission, the patient is alert but in distress. He complains of severe, diffuse, abdominal pain and severe weakness. Vital signs are now: blood pressure 90/50 mm Hg, heart rate 96/min, respiratory rate 19/min, temperature 37.4℃ (99.3℉), and oxygen saturation of 95% on room air. His lungs are clear on auscultation. The cardiac exam is significant for a narrow pulse pressure. Abdominal examination reveals a large bruise over the epigastric and periumbilical regions. The abdomen is distended and there is diffuse tenderness to palpation with rebound and guarding, worst in the epigastric region. There is hyperresonance to percussion in the epigastric region and absence of hepatic dullness in the right upper quadrant. Aspiration of the nasogastric tube reveals bloody contents. Focused assessment with sonography for trauma (FAST) shows free fluid in the pelvic region. Evaluation of the perisplenic and perihepatic regions is impossible due to the presence of free air. Aggressive intravenous fluid resuscitation is administered but fails to improve upon the patient’s hemodynamics. Which of the following is the next best step in management?

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?

A 34-year-old man presents to the emergency department by ambulance after being involved in a fight. On arrival, there is obvious trauma to his face and neck, and his mouth is full of blood. Seconds after suctioning the blood, his mouth rapidly fills up with blood again. As a result, he is unable to speak to you. An attempt at direct laryngoscopy fails as a result of his injuries. His vital signs are pulse 102/min, blood pressure 110/75 mmHg, and O2 saturation 97%. Which of the following is indicated at this time?

A 6-month-old male presents to the emergency department with his parents after his three-year-old brother hit him on the arm with a toy truck. His parents are concerned that the minor trauma caused an unusual amount of bruising. The patient has otherwise been developing well and meeting all his milestones. His parents report that he sleeps throughout the night and has just started to experiment with solid food. The patient’s older brother is in good health, but the patient’s mother reports that some members of her family have an unknown blood disorder. On physical exam, the patient is agitated and difficult to soothe. He has 2-3 inches of ecchymoses and swelling on the lateral aspect of the left forearm. The patient has a neurological exam within normal limits and pale skin with blue irises. An ophthalmologic evaluation is deferred. Which of the following is the best initial step?

A 6-month-old boy is brought to the emergency department by his mother, who informs the doctor that her alcoholic husband hit the boy hard on his back. The blow was followed by excessive crying for several minutes and the development of redness in the area. On physical examination, the boy is dehydrated, dirty, and irritable and when the vital signs are checked, they reveal tachycardia. He cries immediately upon the physician touching the area around his left scapula. The doctor strongly suspects a fracture of the 6th, 7th, or 8th retroscapular posterior ribs. Evaluation of his skeletal survey is normal. The clinician is concerned about child abuse in this case. Which of the following is the most preferred imaging technique as the next step in the diagnostic evaluation of the infant?

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?

An 8-year-old boy and his 26-year-old babysitter are brought into the emergency department with severe injuries caused by a motor vehicle accident. The child is wheeled to the pediatric intensive care unit with a severe injury to his right arm, as well as other external and internal injuries. He is hemorrhaging and found to be hemodynamically unstable. He subsequently requires transfusion and surgery, and he is currently unconscious. The pediatric trauma surgeon evaluates the child’s arm and realizes it will need to be amputated at the elbow. Which of the following is the most appropriate course of action to take with regards to the amputation?

A 32-year-old man is brought to the emergency department after a skiing accident. The patient had been skiing down the mountain when he collided with another skier who had stopped suddenly in front of him. He is alert but complaining of pain in his chest and abdomen. He has a past medical history of intravenous drug use and peptic ulcer disease. He is a current smoker. His temperature is 97.4°F (36.3°C), blood pressure is 77/53 mmHg, pulse is 127/min, and respirations are 13/min. He has a GCS of 15 and bilateral shallow breath sounds. His abdomen is soft and distended with bruising over the epigastrium. He is moving all four extremities and has scattered lacerations on his face. His skin is cool and delayed capillary refill is present. Two large-bore IVs are placed in his antecubital fossa, and he is given 2L of normal saline. His FAST exam reveals fluid in Morison's pouch. Following the 2L normal saline, his temperature is 97.5°F (36.4°C), blood pressure is 97/62 mmHg, pulse is 115/min, and respirations are 12/min. Which of the following is the best next step in management?

Q10

A 24-year-old woman is brought to the emergency department after being assaulted. The paramedics report that the patient was found conscious and reported being kicked many times in the torso. She is alert and able to respond to questions. She denies any head trauma. She has a past medical history of endometriosis and a tubo-ovarian abscess that was removed surgically two years ago. Her only home medication is oral contraceptive pills. Her temperature is 98.5°F (36.9°C), blood pressure is 82/51 mmHg, pulse is 136/min, respirations are 24/min, and SpO2 is 94%. She has superficial lacerations to the face and severe bruising over her chest and abdomen. Her lungs are clear to auscultation bilaterally and her abdomen is soft, distended, and diffusely tender to palpation. Her skin is cool and clammy. Her FAST exam reveals fluid in the perisplenic space. Which of the following is the next best step in management?

Pediatric trauma considerations US Medical PG Practice Questions and MCQs

Question 1: A previously healthy 10-year-old boy is brought to the emergency department for the evaluation of one episode of vomiting and severe headache since this morning. His mother says he also had difficulty getting dressed on his own. He has not had any trauma. The patient appears nervous. His temperature is 37°C (98.6°F), pulse is 100/min, and blood pressure is 185/125 mm Hg. He is confused and oriented only to person. Ophthalmic examination shows bilateral optic disc swelling. There is an abdominal bruit that is best heard at the right costovertebral angle. A complete blood count is within normal limits. Which of the following is most likely to confirm the diagnosis?

A. Serum IGF-I level
B. Oral sodium loading test
C. Echocardiography
D. CT angiography (Correct Answer)
E. High-dose dexamethasone suppression test

Explanation: ***CT angiography*** - The patient presents with **malignant hypertension** (BP 185/125 mmHg, confusion, optic disc swelling) and an **abdominal bruit** especially at the **right costovertebral angle**, pointing strongly towards **renovascular hypertension** due to **renal artery stenosis**. - **CT angiography** is the most appropriate imaging modality to confirm **renal artery stenosis** by visualizing the renal arteries and identifying any narrowing. *Serum IGF-I level* - This test is used to screen for **growth hormone disorders** like **acromegaly** or **gigantism**, which are not indicated by the patient's symptoms. - The patient's presentation is focused on acute severe hypertension and neurological changes, rather than chronic growth disturbances. *Oral sodium loading test* - This test is used to confirm the diagnosis of **primary aldosteronism**, where **aldosterone levels** fail to suppress after a sodium load. - While primary aldosteronism can cause hypertension, it typically doesn't present with an **abdominal bruit** or the acute, severe neurological symptoms seen here. *Echocardiography* - **Echocardiography** assesses the heart's structure and function, which could show signs of **hypertensive heart disease** (e.g., left ventricular hypertrophy) due to long-standing uncontrolled hypertension. - However, it does not identify the underlying cause of the hypertension in this acute setting, especially when an **abdominal bruit** suggests a vascular origin. *High-dose dexamethasone suppression test* - This test is used to differentiate between **Cushing's disease** (pituitary ACTH-dependent) and other causes of **Cushing's syndrome** (e.g., ectopic ACTH production, adrenal tumor) due to excess cortisol. - The patient's symptoms are inconsistent with Cushing's syndrome, and the **abdominal bruit** points away from this diagnosis.

Question 2: A 41-year-old man is admitted to the emergency room after being struck in the abdomen by a large cement plate while transporting it. On initial assessment by paramedics at the scene, his blood pressure was 110/80 mm Hg, heart rate 85/min, with no signs of respiratory distress. On admission, the patient is alert but in distress. He complains of severe, diffuse, abdominal pain and severe weakness. Vital signs are now: blood pressure 90/50 mm Hg, heart rate 96/min, respiratory rate 19/min, temperature 37.4℃ (99.3℉), and oxygen saturation of 95% on room air. His lungs are clear on auscultation. The cardiac exam is significant for a narrow pulse pressure. Abdominal examination reveals a large bruise over the epigastric and periumbilical regions. The abdomen is distended and there is diffuse tenderness to palpation with rebound and guarding, worst in the epigastric region. There is hyperresonance to percussion in the epigastric region and absence of hepatic dullness in the right upper quadrant. Aspiration of the nasogastric tube reveals bloody contents. Focused assessment with sonography for trauma (FAST) shows free fluid in the pelvic region. Evaluation of the perisplenic and perihepatic regions is impossible due to the presence of free air. Aggressive intravenous fluid resuscitation is administered but fails to improve upon the patient’s hemodynamics. Which of the following is the next best step in management?

A. Emergency laparoscopy
B. Abdominal ultrasound
C. Diagnostic peritoneal lavage (DPL)
D. Emergency laparotomy (Correct Answer)
E. CT scan

Explanation: ***Emergency laparotomy*** - The patient presents with **hemodynamic instability** unresponsive to fluid resuscitation, coupled with clear signs of **perforation** (hyperresonance, absent hepatic dullness, free air on FAST limited view). This clinical picture is a direct indication for immediate surgical intervention. - The presence of bloody nasogastric tube contents, diffuse tenderness with rebound and guarding, and a history of significant blunt trauma further support the need for urgent exploratory **laparotomy** to identify and repair the source of injury. *Emergency laparoscopy* - While laparoscopy can be used for abdominal exploration, it is **contraindicated in hemodynamically unstable patients** due to the need for pneumoperitoneum, which can further compromise cardiovascular stability. - In cases of suspected visceral perforation with extensive free air and massive bleeding, **laparoscopy may be technically challenging** and less efficient than open laparotomy for rapid control of hemorrhage and contamination. *Abdominal ultrasound* - An abdominal ultrasound (**FAST exam**) has already been partially performed, revealing free fluid and raising suspicion of free air, making further ultrasound redundant. - While useful for initial trauma assessment, an ultrasound **cannot definitively rule out all abdominal injuries**, especially hollow viscus perforations or retroperitoneal hematomas, and is insufficient for unstable patients with clear signs of peritonitis. *Diagnostic peritoneal lavage (DPL)* - **DPL is largely replaced by FAST and CT scans** in most trauma centers, especially given the availability of imaging. - Although it can detect intraperitoneal bleeding or perforation, it is an **invasive procedure** with potential complications and would only confirm what is already strongly suspected clinically; it does not address the need for immediate therapeutic intervention in an unstable patient. *CT scan* - A CT scan would be the imaging modality of choice for a **hemodynamically stable** patient with blunt abdominal trauma. - However, performing a CT scan on an **unstable patient** would unnecessarily delay definitive surgical management, which is critical given the signs of ongoing internal bleeding and likely perforation.

Question 3: 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?

A. Circular bruises on the knees
B. Loop-shaped bruises on the back (Correct Answer)
C. Linear bruises on the shins
D. Irregular bruises on the forehead

Explanation: ***Loop-shaped bruises on the back*** - **Loop-shaped bruises** are highly suspicious for **non-accidental trauma** as they are pathognomonic for impact with an object like a looped cord or belt - Bruises on the **back** of a young child are particularly concerning as the back is a non-bony prominence and less likely to be injured during normal play activities - Combined with the metaphyseal and posterior rib fractures already identified, patterned bruises strongly indicate inflicted trauma *Circular bruises on the knees* - Circular bruises on the knees are very common in toddlers and young children due to normal falls and play, which typically involve kneeling and crawling - This pattern is generally considered consistent with accidental injury and not indicative of abuse *Linear bruises on the shins* - Linear bruises on the shins can result from bumping into objects while playing or exploring, which is common in active children - The shins are bony prominences frequently injured during normal play activities *Irregular bruises on the forehead* - Irregular bruises on the forehead can result from accidental falls or bumps, which are common in young children learning to walk or play - While head injuries should always be carefully evaluated, irregular bruises on the forehead are common accidental injuries in ambulatory toddlers

Question 4: A 34-year-old man presents to the emergency department by ambulance after being involved in a fight. On arrival, there is obvious trauma to his face and neck, and his mouth is full of blood. Seconds after suctioning the blood, his mouth rapidly fills up with blood again. As a result, he is unable to speak to you. An attempt at direct laryngoscopy fails as a result of his injuries. His vital signs are pulse 102/min, blood pressure 110/75 mmHg, and O2 saturation 97%. Which of the following is indicated at this time?

A. Cricothyroidotomy (Correct Answer)
B. Continuous positive airway pressure (CPAP)
C. Cardiopulmonary resuscitation
D. Nasogastric tube
E. Endotracheal intubation

Explanation: ***Cricothyroidotomy*** - The patient has an actively bleeding airway that cannot be managed with suction, and **endotracheal intubation** failed, indicating a need for an **emergency surgical airway**. - **Cricothyroidotomy** is the most rapid and effective method to establish a definitive airway in such a circumstance, bypassing the upper airway obstruction caused by blood and trauma. *Continuous positive airway pressure (CPAP)* - **CPAP** provides positive pressure ventilation and is used for respiratory support in conditions like **sleep apnea** or **congestive heart failure**, not for airway obstruction due to trauma and bleeding. - It would not address the actively bleeding airway or the inability to ventilate, and could potentially worsen the situation by pushing blood further into the lungs. *Cardiopulmonary resuscitation* - **CPR** is indicated for **cardiac arrest** or profound bradypnea/apnea, which is not the primary issue here, as the patient still has a pulse and blood pressure. - While the patient's airway is compromised, his vital signs do not indicate the need for chest compressions or rescue breaths as the initial intervention. *Nasogastric tube* - A **nasogastric tube** is used for **gastric decompression** or **enteral feeding**, and it does not play a role in securing an airway in an emergency situation. - Attempting to place an NG tube would divert critical time and resources away from establishing a patent airway. *Endotracheal intubation* - **Endotracheal intubation** was already attempted and **failed** due to the patient's severe facial and neck trauma, and the continuous bleeding. - This option is therefore not viable, and a surgical airway is required as the next step.

Question 5: A 6-month-old male presents to the emergency department with his parents after his three-year-old brother hit him on the arm with a toy truck. His parents are concerned that the minor trauma caused an unusual amount of bruising. The patient has otherwise been developing well and meeting all his milestones. His parents report that he sleeps throughout the night and has just started to experiment with solid food. The patient’s older brother is in good health, but the patient’s mother reports that some members of her family have an unknown blood disorder. On physical exam, the patient is agitated and difficult to soothe. He has 2-3 inches of ecchymoses and swelling on the lateral aspect of the left forearm. The patient has a neurological exam within normal limits and pale skin with blue irises. An ophthalmologic evaluation is deferred. Which of the following is the best initial step?

A. Genetic testing
B. Complete blood count and coagulation panel (Correct Answer)
C. Ensure the child's safety and alert the police
D. Peripheral blood smear
E. Hemoglobin electrophoresis

Explanation: ***Complete blood count and coagulation panel*** - The unusual amount of **bruising** after minor trauma, along with a family history of an unknown blood disorder, strongly suggests a potential **bleeding disorder**. A **CBC** and a **coagulation panel** (PT, aPTT, fibrinogen) are essential initial steps to evaluate for abnormalities in platelets, clotting factors, or other hematologic conditions. - These tests can help narrow down the differential diagnosis between **platelet dysfunction**, **coagulopathies** (like hemophilia or von Willebrand disease), or other less common bleeding disorders, guiding further specific investigations. - **Important consideration:** The presence of **blue sclera** (described as "blue irises") raises concern for **osteogenesis imperfecta (OI)**, a connective tissue disorder causing bone fragility. However, initial hematologic screening is still appropriate given the family history of blood disorder and presentation of excessive bruising. If coagulation studies are normal, imaging and further workup for OI would be indicated. *Genetic testing* - While a genetic component is plausible given the patient's family history and clinical presentation (blue sclera may suggest osteogenesis imperfecta), **genetic testing** is typically performed *after* initial laboratory workup has identified a specific type of bleeding or inherited disorder. - Starting with genetic testing without basic hematologic parameters is not the most efficient or cost-effective initial diagnostic approach. *Ensure the child's safety and alert the police* - While child abuse should always be considered in cases of unexplained or excessive bruising, the presence of a **family history of a blood disorder** and the **blue sclera** (suggesting possible osteogenesis imperfecta) make **medical causes** more immediate concerns for initial investigation. - Pursuing a medical workup first often clarifies whether abuse is the primary explanation, although child protective services should be notified if suspicion remains high after medical evaluation. *Peripheral blood smear* - A **peripheral blood smear** provides information on red blood cell morphology, platelet size and number, and white blood cell differential. While useful in assessing for some hematologic conditions, it is often performed *after* a CBC has indicated abnormalities or in conjunction with specialized testing. - It would not be the *best initial step* as it doesn't directly assess clotting factor function, which is critical in evaluating significant bruising severity. *Hemoglobin electrophoresis* - **Hemoglobin electrophoresis** is used to diagnose **hemoglobinopathies** like sickle cell anemia or thalassemia. - The patient's symptoms (easy bruising) are not characteristic of hemoglobinopathies, and while he has pale skin, this test would not be the initial step to investigate a bleeding disorder.

Question 6: A 6-month-old boy is brought to the emergency department by his mother, who informs the doctor that her alcoholic husband hit the boy hard on his back. The blow was followed by excessive crying for several minutes and the development of redness in the area. On physical examination, the boy is dehydrated, dirty, and irritable and when the vital signs are checked, they reveal tachycardia. He cries immediately upon the physician touching the area around his left scapula. The doctor strongly suspects a fracture of the 6th, 7th, or 8th retroscapular posterior ribs. Evaluation of his skeletal survey is normal. The clinician is concerned about child abuse in this case. Which of the following is the most preferred imaging technique as the next step in the diagnostic evaluation of the infant?

A. Bedside ultrasonography
B. Magnetic resonance imaging
C. Babygram
D. Chest computed tomography scan
E. Skeletal survey in 2 weeks (Correct Answer)

Explanation: ***Skeletal survey in 2 weeks*** - A repeat **skeletal survey in 2 weeks** is the most appropriate next step in suspected child abuse cases with an initial normal survey, as it allows for the detection of **healing fractures** that may not be apparent immediately after injury. - New bone formation and callus development around a fracture site become radiographically visible after approximately 7 to 14 days, improving the detection rate of subtle or undisplaced fractures. *Bedside ultrasonography* - While **ultrasonography** can detect acute fractures, especially in cartilage and non-ossified bones, its utility in a comprehensive assessment for multiple non-displaced rib fractures as part of a child abuse workup is limited. - It is highly **operator-dependent** and may not provide the full skeletal overview required in suspected child abuse. *Magnetic resonance imaging* - **MRI** is excellent for evaluating soft tissue injuries, bone marrow edema, and non-ossified cartilaginous structures. However, it is not the primary imaging modality for detecting acute or subacute fractures of ossified bone and requires **sedation** in infants, making it less practical for routine skeletal screening. - The **high cost** and limited availability of MRI also make it less suitable as a first-line diagnostic tool for rib fractures in this context. *Babygram* - A **babygram** is a single large radiograph of an infant's entire body, often used to rapidly assess for gross developmental anomalies or immediate concerns. - It provides **less detailed imaging** of individual bones compared to a standard skeletal survey and is insufficient for reliably detecting subtle or non-displaced rib fractures. *Chest computed tomography scan* - A **chest CT scan** is highly sensitive for detecting acute rib fractures, even subtle ones. However, it exposes the infant to **significant radiation** and is usually reserved for specific clinical indications, such as suspected internal organ injury, rather than as a primary screening tool for rib fractures in child abuse in an otherwise stable patient. - It does not provide a comprehensive view of the entire skeleton, which is crucial for identifying other potential abuse-related injuries elsewhere.

Question 7: 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?

A. Chest fluoroscopy
B. Barium study
C. CT of the chest, abdomen, and pelvis (Correct Answer)
D. MRI chest and abdomen
E. ICU admission and observation

Explanation: ***CT of the chest, abdomen, and pelvis*** - A suspected **traumatic diaphragmatic rupture** requires a comprehensive imaging study to assess the diaphragm, surrounding organs, and potential associated injuries. - **CT scan** of the chest, abdomen, and pelvis provides detailed anatomical information, can identify herniated abdominal contents, and is essential for surgical planning in trauma settings. *Chest fluoroscopy* - While fluoroscopy can detect diaphragmatic motion, it is **less sensitive** for identifying tears or herniated contents in the **acute trauma setting**. - It does not provide the comprehensive view of surrounding organs and associated injuries often needed in trauma. *Barium study* - A barium study is primarily used to evaluate the **gastrointestinal tract**, but it is generally **not the initial imaging modality** for diaphragmatic rupture due to its limited ability to visualize the diaphragm itself or other solid organ injuries. - It would be performed after suspicion is increased or for very specific indications, not as a primary diagnostic tool. *MRI chest and abdomen* - While MRI offers excellent soft tissue contrast, its use in **acute trauma** is limited by **longer acquisition times**, potential contraindications with metallic implants (though less common in acute trauma), and lower availability compared to CT. - CT remains the **gold standard** for rapid, comprehensive imaging in unstable trauma patients. *ICU admission and observation* - While observation in the ICU is important for monitoring and supportive care, it is **not the next step for diagnosis** of a suspected diaphragmatic rupture. - Definitive diagnosis through imaging (CT) is crucial before determining specific management strategies, including potential surgical intervention.

Question 8: An 8-year-old boy and his 26-year-old babysitter are brought into the emergency department with severe injuries caused by a motor vehicle accident. The child is wheeled to the pediatric intensive care unit with a severe injury to his right arm, as well as other external and internal injuries. He is hemorrhaging and found to be hemodynamically unstable. He subsequently requires transfusion and surgery, and he is currently unconscious. The pediatric trauma surgeon evaluates the child’s arm and realizes it will need to be amputated at the elbow. Which of the following is the most appropriate course of action to take with regards to the amputation?

A. Obtain an emergency court order from a judge to obtain consent to amputate the child’s arm
B. Find the child’s parents to obtain consent to amputate the child’s arm
C. Amputate the child’s arm at the elbow joint (Correct Answer)
D. Wait for the child’s babysitter to recover from her injuries to obtain her consent to amputate the child’s arm
E. Wait for the child to gain consciousness to obtain his consent to amputate his arm

Explanation: ***Amputate the child’s arm at the elbow joint*** - In an emergency situation where a child's life is at risk and a procedure is immediately necessary to save their life or prevent significant harm, **implied consent** allows for medical intervention without explicit parental consent. The child's **hemodynamic instability** and **severe hemorrhage** indicate an immediate threat to life. - The decision to amputate to save the child's life is a **medically necessary emergency intervention**. Waiting for consent would cause a dangerous delay. *Obtain an emergency court order from a judge to obtain consent to amputate the child’s arm* - While court orders can be used in cases of parental refusal or unavailability for non-emergency procedures, the **urgent nature** of this life-threatening situation precludes waiting for a court order. - The delay in obtaining a court order could significantly worsen the child's prognosis or lead to death. *Find the child’s parents to obtain consent to amputate the child’s arm* - Although parental consent is generally required for minors, the child's **critical condition** and **hemodynamic instability** mean delaying life-saving treatment to locate parents would be medically irresponsible. - The principle of **beneficence** (acting in the best interest of the patient) and avoiding harm takes precedence in this emergency. *Wait for the child’s babysitter to recover from her injuries to obtain her consent to amputate the child’s arm* - A babysitter is generally not legally authorized to provide consent for major medical procedures for a child, especially an amputation. - Even if the babysitter had some form of temporary custody, her own injury makes her an unreliable source of consent, and the delay would be critical. *Wait for the child to gain consciousness to obtain his consent to amputate his arm* - An 8-year-old child is generally not considered mature enough to provide **informed consent** for such a major medical decision. - The child is **unconscious and hemodynamically unstable**, making it impossible to obtain consent and dangerously delaying a life-saving procedure.

Question 9: A 32-year-old man is brought to the emergency department after a skiing accident. The patient had been skiing down the mountain when he collided with another skier who had stopped suddenly in front of him. He is alert but complaining of pain in his chest and abdomen. He has a past medical history of intravenous drug use and peptic ulcer disease. He is a current smoker. His temperature is 97.4°F (36.3°C), blood pressure is 77/53 mmHg, pulse is 127/min, and respirations are 13/min. He has a GCS of 15 and bilateral shallow breath sounds. His abdomen is soft and distended with bruising over the epigastrium. He is moving all four extremities and has scattered lacerations on his face. His skin is cool and delayed capillary refill is present. Two large-bore IVs are placed in his antecubital fossa, and he is given 2L of normal saline. His FAST exam reveals fluid in Morison's pouch. Following the 2L normal saline, his temperature is 97.5°F (36.4°C), blood pressure is 97/62 mmHg, pulse is 115/min, and respirations are 12/min. Which of the following is the best next step in management?

A. Diagnostic peritoneal lavage
B. Emergency laparotomy (Correct Answer)
C. Upper gastrointestinal endoscopy
D. Close observation
E. Diagnostic laparoscopy

Explanation: ***Emergency laparotomy*** - The patient remains **hemodynamically unstable** (BP 97/62 mmHg, HR 115/min after 2L IV fluids) with evidence of **intra-abdominal fluid on FAST exam** (fluid in Morison's pouch). - This clinical picture indicates active intra-abdominal hemorrhage requiring **immediate surgical intervention** to identify and control the source of bleeding. *Diagnostic peritoneal lavage* - **Diagnostic peritoneal lavage (DPL)** has largely been replaced by the focused abdominal sonography for trauma (FAST) exam and CT scans. - While it can detect intra-abdominal bleeding, it is **invasive** and would delay definitive treatment in a hemodynamically unstable patient with positive FAST. *Upper gastrointestinal endoscopy* - This procedure is primarily for diagnosing and treating **upper gastrointestinal bleeding** or mucosal abnormalities. - It is **not indicated** for evaluating traumatic intra-abdominal hemorrhage or hemodynamic instability following blunt abdominal trauma. *Close observation* - Close observation is appropriate for **hemodynamically stable patients** with blunt abdominal trauma and minor injuries or equivocal findings. - This patient's persistent hypotension, tachycardia, and positive FAST findings rule out observation as a safe or appropriate next step. *Diagnostic laparoscopy* - **Diagnostic laparoscopy** is a minimally invasive surgical procedure used to evaluate the abdominal cavity. - While it can be diagnostic, it is generally **contraindicated in hemodynamically unstable patients** as it can prolong the time to definitive hemorrhage control if a major injury is found.

Question 10: A 24-year-old woman is brought to the emergency department after being assaulted. The paramedics report that the patient was found conscious and reported being kicked many times in the torso. She is alert and able to respond to questions. She denies any head trauma. She has a past medical history of endometriosis and a tubo-ovarian abscess that was removed surgically two years ago. Her only home medication is oral contraceptive pills. Her temperature is 98.5°F (36.9°C), blood pressure is 82/51 mmHg, pulse is 136/min, respirations are 24/min, and SpO2 is 94%. She has superficial lacerations to the face and severe bruising over her chest and abdomen. Her lungs are clear to auscultation bilaterally and her abdomen is soft, distended, and diffusely tender to palpation. Her skin is cool and clammy. Her FAST exam reveals fluid in the perisplenic space. Which of the following is the next best step in management?

A. Emergency laparotomy (Correct Answer)
B. Abdominal radiograph
C. Abdominal CT
D. Fluid resuscitation
E. Diagnostic peritoneal lavage

Explanation: ***Emergency laparotomy*** - The patient presents with **hemodynamic instability** (BP 82/51 mmHg, HR 136/min) and a **positive FAST exam** showing fluid in the perisplenic space, indicating intra-abdominal hemorrhage. - According to **ATLS guidelines**, a hemodynamically unstable patient with a positive FAST exam requires **immediate operative intervention** to control bleeding. This is the definitive management for ongoing hemorrhage. - While fluid resuscitation is initiated simultaneously (en route to OR), **surgical control of the bleeding source** is the priority and should not be delayed. *Fluid resuscitation* - Fluid resuscitation with IV crystalloids is essential and should be started immediately in this patient with hypovolemic shock. - However, in a patient with **uncontrolled intra-abdominal hemorrhage** (positive FAST, hemodynamic instability), fluids alone will not stop the bleeding. Continued fluid resuscitation without surgical intervention can lead to dilutional coagulopathy and worsening outcomes. - Fluid resuscitation occurs **concurrently with preparation for surgery**, not as a separate step that delays definitive management. *Diagnostic peritoneal lavage* - DPL is an invasive diagnostic procedure that has largely been replaced by FAST exam in modern trauma care. - Given that the **FAST is already positive**, DPL would provide no additional useful information and would only **delay definitive surgical management**. - In hemodynamically unstable patients with positive FAST, proceeding directly to laparotomy is indicated. *Abdominal radiograph* - Plain radiographs have **limited sensitivity** for detecting intra-abdominal bleeding or solid organ injury. - They may show free air (indicating hollow viscus perforation) but cannot assess for fluid or characterize solid organ injuries. - This would **delay necessary operative intervention** without providing actionable information. *Abdominal CT* - CT abdomen is the imaging modality of choice for **hemodynamically stable** trauma patients to characterize injuries and guide management. - For **unstable patients**, CT is **contraindicated** as it delays definitive treatment and removes the patient from a resuscitation environment where deterioration can be immediately addressed.

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