1.

A 32-year-old female falls form the 10th floor of her apartment building in an
apparent suicide attempt. Upon presentation, the patient has obvious head and
extremity injuries. Primary survey reveals that the patient is totally apneic. By
which method is the immediate need for a definitive airway in this patient best
provided?

(A) orotracheal intubation

(B) nasotracheal intubation
(C) percutaneous cricothyroidotomy
(D) intubation over a bronchoscope
(E) needle cricothyroidotomy

2. An 18-year-old man is brought to the emergency department after falling down a

flight of stairs and losing consciousness for 3 minutes. A cervical collar is in place.
The cervical spine is considered to be free of serious injury following which
procedure?

(A) a physical examination revealing no pain or tenderness

(B) a lateral cervical spine x-ray
(C) complexity negative findings on neurological examination
(D) anteroposterior (AP), lateral, and odontoid views of the neck
(E) flexion and extension views of the neck

3. A 16-year-old boy presents to the emergency department with a stab wound to the
anterior midneck. On physical examination, it is difficult to determine if the plane
of the platsyma has been violated. However, subcutaneous emphysema is found
on palpation. What is the next management step?

(A) esophagogram
(B) arteriography
(C) surgical exploration
(D) esophagoscopy
(E) CT scan of the neck with oral and intravenous contrast

4. A 20-year-old woman presents to the emergency department after being hit in the
face during a baseball game. On physical examination, the patient's blood pressure is
90mmHg, and there is significant bleeding from the nose that cannot be controlled
either by fracture reduction or by anterior and posterior nasopharyngeal packing.
What is the next step in management?

(A) external carotid artery ligation

(B) bilateral internal maxillary artery ligation
(C) angiographic evaluation and embolization
(D) foley catheter balloon tamponade of bleeding
(E) insertion of nasogastric tube
5. A 30-year-old man is brought in the emergency department in respiratory distress
following a shotgun wound to the face. There is a possible cervical spine injury.
Which is the best way to gain rapid control of the airway?

(A) nasotracheal intubation

(B) percutaneous jet ventilation
(C) cricotyroidotomy
(D) endotracheal intubation
(E) aspiration of blood from pharynx and kaw thrust

6. Following a car crash in which her face hit the steering wheel, a 37-year-old
woman presents to the emergency department with facial deformity. Facial x-rays
showed a transverse fracture through the articulation of the maxillary and nasal
bones with the frontal bone. The fracture also passed below the zygomatic bone.
What is the diagnosis?

(A) sphenoid wing fracture

(B) LeFort II fracture
(C) Petrous temporal fracture
(D) Palatal split
(E) Mandibular disruption

7. A 40-year-old man is hit in the face with a baseball bat and presents to the
emergency department with massive facial swelling, ecchymosis, and an
elongated face. There is mobility of the middle third of the face on digital
manipulation of the maxilla. What is likely the diagnosis.

(A) lamdoid injury

(B) odontoid fracture
(C) LeFort III fracture
(D) Palatal split
(E) Mandibular disruption

8. With regard to neck injuries, which of the following is true?

(A) The internal jugular vein may be ligated unilaterally without unfavorable
sequelae.
(B) Unilateral ligation of the common carotid artery results in neurologic
deficiency in 90% of cases.
(C) Esophageal injuries should be drained externally only when extensive
devitalization is present.
(D) Tracheostomy is indicated in dealing with most laryngeal or tracheal
injuries.
(E) Injuries to the trachea must be drained externally.
9. A 24-year-old woman with blunt trauma to the head sustained in a car accident
presents with a history of loss of consciousness for approximately 10 minutes at
the scene of the accident. She is currently fully awake, oriented, and responsive.
With regard to the appropriate care of this woman, which of the following
statements is true?

(A) In this setting, a fully awake patient who has a normal examination does
not require hospital admission for observation.
(B) If skull x-rays show no fracture, the likelihood of significant intracranial
injury is low, and hospital admission is unwarranted.
(C) If fundoscopic examination of this patient shows no papilledema, elevated
intracranial pressure can be ruled out.
(D) The initial effects of elevated intracranial pressure are bradycardia and
hypertension.
(E) If this patient were to exhibit a sudden fall in blood pressure and alteration
in mental status, spinal cord or brain stem injury would be most likely.

10. A 20-year-old woman presents to the emergency department with a stab wound to
the neck above the angle of mandible. The patient's blood pressure is
110/80mmHg, her pulse rate is 100bpm, and her respiration rate is 24 breaths per
minute. Between initial presentations and insertion of intravenous lines, the
hematoma in the upper neck enlarges significantly. What should be the next step
in the patient's management?

(A) barium swallow

(B) flexible endoscopy
(C) operative exploration
(D) Doppler ultrasound
(E) Angiography

11. A 65-year-old man is brought into the emergency department with a gunshot
wound to the neck. His blood pressure is 80/50 mmHg. The patient undergoes
rapid resuscitation and is brought immediately to the OR, where a carotid artery
injury is found in zone II (between the angle of mandible and cricoid). The patient
has no internal carotid flow; just before surgery, his neurological status
deteriorates, and he becomes unresponsive. The operative management should be
which of the following?

(A) immediate intravascular bypass shunt

(B) ligation of the internal carotid artery
(C) primary anastomosis
(D) interposition saphenous vein graft
(E) patch vein graft
12. A 19-year-old man is brought to the emergency department with a stab wound at
the base of the neck (zone I). The most important concern for patients with such
injuries is which of the following?

(A) upper extremity ischemia

(B) cerebral infarction
(C) exsanguinating hemorrhage
(D) mediastinitis
(E) tracheal stenosis

13. A 64-year-old woman is admitted to the emergency department with multiple

injuries. She requires a central venous pressure line. To minimize the possibility of
infection, the principal management of the catheter should be which of the
following?

(A) repeated attempts via the same cannula in the neck

(B) after failure at one site, use of the same cannula at another site
(C) use of multiport catheters
(D) avoidance of wound contamination by application of tincture of iodine for
more than 4 seconds
(E) selection of subclavian vein over femoral vein

14. A 40-year-old woman was involved in a car accident. She was unconscious for 5
minutes. X-ray revealed a depressed fracture in the frontal region. Which is true of
skull fracture?

(A) It always requires surgical exploration

(B) It is compound if multiple.
(C) It requires burr holes if compound
(D) In the anterior cranial fossa, it may produce rhinorrhea
(E) It requires steroid administration

15. A 30-year-old man is brought to the emergency department following a high-speed

car accident. He was the driver, an the windshield of the car was broken. On
examination, he is alert, awake, oriented, and in no respiratory distress. He is
unable to move any of his four extremities; however, his extremities are warm and
pink. His vital signs on admission are: heart rate 54 bpm and blood pressure 70/40
mmHg. What is the diagnosis?

(A) hemorrhagic shock

(B) cardiogenic shock
(C) neurogenic shock
(D) septic shock
(E) irreversible shock
Questions 16 and 17

A 14-year-old boy with a known bleeding tendency since infancy has severe epistaxis.
Examination reveals an equinus contracture of the right leg and a large hemarthrosis.

16. What is the most likely diagnosis?

(A) diethylstilbestrol (DES) was taken by the mother during pregnancy

(B) aplastic anemia
(C) hemophilia
(D) Wilson's disease with cirrhosis

17. Treatment should include which of the following:

(A) penicillamine
(B) transfusion of factor VIII to 30% of normal
(C) transfusion of factor VIII to 10% of normal
(D) platelet transfusion
(E) exploration of joint

18. A 10-year-old boy with history of prolonged bleeding after minor injury is
scheduled for tonsillectomy. The bleeding time, PT, and fibrinogen are normal.
What would be the most helpful investigation?

(A) fibrinolysis (euglobulin clot lysis time)

(B) platelet count
(C) thrombin time
(D) partial thromboplastin time (PTT)
(E) factor VII assay

19. In a 12-year-old boy who sustained severe head injury caused by a fall from the
third floor of a building, the syndrome of diabetes insipidus is characterized by
which of the following?

(A) low serum sodium

(B) high urinary specific gravity or osmolality
(C) high serum osmolality
(D) low urine output
(E) expanded extracellular fluid volume

20. A 30-year-old woman with a history of an uneventful tonsillectomy at age 4 is

scheduled for exploratory laparotomy. Preoperative assessment that identifies the
risk of intraoperative bleeding is which of the following?

(A) bleeding time

(B) platelet count
(C) PT and PTT
(D) Complete blood cell count
(E) None of the above
21. A 43-year-old woman with von Willebrand's disease is scheduled for FESS. It can
be stated that preoperative evaluation will reveal which of the following?

(A) normal bleeding time, PT, and PTT

(B) platelet aggregate with restocetin
(C) increased bleeding time and PTT, and normal PT
(D) increased bleeding time and PT, and normal PTT
(E) increased bleeding time, and normal PT and PTT

22. Following admission to the emergency department, a 26-year-old woman with

severe epistaxis states that both her father and sister have a bleeding disorder. The
hemostatic disorder transmitted by autosomal-dominant mode is which of the
following?

(A) factor X deficiency

(B) von Willebrand's disease
(C) factor VIII deficiency (true hemophilia)
(D) factor IX deficiency (Christmas disease)
(E) factor V deficiency (parahemophilia)

23. A 75-year-old man is found to have prolonged bleeding from intravenous puncture
sites. Platelet aggregation is inhibited by which of the following?

(A) Adenosine diphosphate (ADP)

(B) calcium
(C) magnesium
(D) aspirin
(E) serotonin

Question 24 and25

A 64-year-old woman undergoing modified radical neck dissection under general

anesthesia is transfused with 2 U of packed red blood cells (RBCs).

24. A hemolytic transfusion reaction during anesthesia will be characterized by which

of the following?

(A) shaking chills and muscle spasms

(B) fever and oliguria
(C) hyperpyrexia and hypotension
(D) tachycardia and cyanosis
(E) bleeding and hypotension
25. The specific test to identify the cause of transfusion reaction for the patient is
which of the following?

(A) PT
(B) PTT
(C) Platelet count
(D) Bleeding time
(E) Free plasma hemoglobin

26. A 56-year-old man underwent total laryngectomy. He bled excessively and

urgently required blood over and above that which had been requested before
surgery. In deciding on an appropriate blood transfusion protocol, what should be
kept in mind?

(A) Group AB is the universal donor.

(B) Serum from the recipient stored for 1 week is suitable for testing
(C) Hypothermia is indicated if cryoglobulin is found.
(D) Cross-matching should be done before dextran administration.
(E) All of the above should be remembered.

27. A 60-year-old man with carcinoma of the esophagus is admitted with severe
malnutrition. Nutritional support is to be initiated. What should his daily caloric
intake be?

(A) 1 kcal/kg body weight/day

(B) 5 kcal/kg body weight/day
(C) 15 kcal/kg body weight/day
(D) 30 kcal/kg body weight/day
(E) 100 kcal/kg body weight/day