Internal Hemorrhage and the Classes of Hemorrhage Practice Questions

25 multiple-choice questions on Internal hemorrhage and the classes of hemorrhage for paramedic and EMT students, from Chapter 31 (Bleeding). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. Besides external wounds, the four regions that can hide life-threatening blood loss are the:

   1. A. Head, neck, chest, and abdomen
   2. B. Skull, spine, pelvis, and arms
   3. C. Chest, neck, back, and both lower legs
   4. D. Chest, abdomen, pelvis, and thighs
   Show answer

   Answer: D. Chest, abdomen, pelvis, and thighs

   The teaching 'blood on the floor and four more' points to the chest, abdomen, pelvis and retroperitoneum, and thighs. In adults, the closed skull cannot hold enough blood to cause hemorrhagic shock.

2. A 72-year-old taking apixaban has sudden severe back and flank pain without any trauma. He is pale and sweaty, with HR 118 and BP 94/60 mmHg. You should suspect:

   1. A. An acute lumbar disc herniation
   2. B. Spontaneous retroperitoneal bleeding
   3. C. A kidney stone without any bleeding
   4. D. A pulmonary embolism despite apixaban
   Show answer

   Answer: B. Spontaneous retroperitoneal bleeding

   Anticoagulated patients can bleed spontaneously into the retroperitoneum, which can hold liters of blood with few external signs; a ruptured aortic aneurysm must also be considered. A disc herniation can cause severe back pain but not pallor and shock. A kidney stone causes severe pain and tachycardia but not this degree of hypotension and pallor. Pulmonary embolism causes chest pain and dyspnea rather than flank pain, and apixaban makes it less likely. Treat for shock and transport, reporting the anticoagulant.

3. An unstable pelvic fracture can cause blood loss of:

   1. A. About 100 mL
   2. B. About 250 mL
   3. C. 2,000 mL or more
   4. D. About 500 to 750 mL
   Show answer

   Answer: C. 2,000 mL or more

   The pelvis has large veins and arteries and a large retroperitoneal space, so it can hold much of the circulating volume. Treat a suspected unstable pelvis as a major source of hidden hemorrhage.

4. Each side of the adult chest can hold about how much blood?

   1. A. 3,000 mL
   2. B. 300 mL
   3. C. 800 mL
   4. D. 6,000 mL
   Show answer

   Answer: A. 3,000 mL

   Each hemithorax can hold roughly 3 L, enough to cause class IV shock. Massive hemothorax causes decreased breath sounds and dullness on the affected side along with shock.

5. A 40-year-old woman was ejected from a vehicle. She has pelvic pain, hypotension, and a leg-length discrepancy. You should apply a pelvic binder centered over the:

   1. A. Iliac crests
   2. B. Lower rib margins
   3. C. Upper thighs
   4. D. Greater trochanters
   Show answer

   Answer: D. Greater trochanters

   Centering the binder over the greater trochanters closes the pelvic ring and reduces the space for bleeding. Placement over the iliac crests is the common error and does not compress the ring.

6. Paramedics suspect an unstable pelvis in a crash victim. Repeated rocking of the pelvis to test stability is avoided because it can:

   1. A. Dislodge clots and worsen bleeding
   2. B. Damage the lumbar spinal cord and nerves
   3. C. Dislocate both of the hips
   4. D. Tear the femoral nerves
   Show answer

   Answer: A. Dislodge clots and worsen bleeding

   Rocking or springing the pelvis disrupts clot in the pelvic veins and can restart major bleeding. If the mechanism and findings suggest a pelvic fracture, apply a binder rather than repeatedly testing.

7. A traction splint on an isolated midshaft femur fracture helps control bleeding by:

   1. A. Compressing the femoral artery against the bone
   2. B. Restoring thigh shape and reducing space for blood
   3. C. Raising the leg so blood returns to the heart
   4. D. Squeezing blood from the thigh back into the veins
   Show answer

   Answer: B. Restoring thigh shape and reducing space for blood

   Traction restores the cylindrical shape of the thigh, reducing the volume available for blood and limiting bone-end movement that tears vessels. It is not used with pelvic or hip fractures.

8. A man was kicked in the flank two days ago. He now has bruising over the flank (Grey Turner sign) and is tachycardic. This finding suggests:

   1. A. A simple rib contusion
   2. B. Bleeding inside the skull
   3. C. Retroperitoneal bleeding
   4. D. A superficial skin bruise
   Show answer

   Answer: C. Retroperitoneal bleeding

   Flank ecchymosis appears hours to days after bleeding into the retroperitoneum, as from renal or pelvic injury. Periumbilical bruising (Cullen sign) reflects blood tracking to the umbilicus.

9. A 60-year-old with a known stomach ulcer passes large amounts of maroon and bright red stool and is now pale, with HR 124 and BP 86/50 mmHg. This picture suggests:

   1. A. Hemorrhoids, since the blood is red
   2. B. A minor lower GI bleed that will stop
   3. C. A brisk, massive upper GI bleed
   4. D. A slow bleed that has stopped by now
   Show answer

   Answer: C. A brisk, massive upper GI bleed

   Brisk upper GI bleeding can pass through the bowel so fast that it appears red or maroon instead of black, and the shock signs show the volume is large. Do not assume a red color means a minor or distal source. Hemorrhoids rarely cause shock, and ongoing passage of blood with hypotension does not suggest that bleeding has stopped.

10. Bright red blood passed from the rectum is called:

    1. A. Melena
    2. B. Hematemesis
    3. C. Hemoptysis
    4. D. Hematochezia
    Show answer

    Answer: D. Hematochezia

    Hematochezia usually indicates lower GI bleeding, though very brisk upper GI bleeding can also cause it. Melena is black, tarry stool from digested blood, usually from the upper GI tract.

11. A man was stabbed once in the upper abdomen. The wound is 1 cm long and barely bleeding, but he is anxious, pale, and has HR 124. You should conclude:

    1. A. A small wound means only shallow injury
    2. B. A small wound can hide major bleeding
    3. C. His heart rate is from pain and anxiety
    4. D. He can be assessed further on scene first
    Show answer

    Answer: B. A small wound can hide major bleeding

    The size of a stab wound tells you nothing about its depth or the organs and vessels injured beneath it. Tachycardia and pallor after a stab wound are shock until proven otherwise, so treat for shock and transport promptly to a trauma center. Attributing the tachycardia to pain or anxiety, or lingering on scene, risks missing a major bleed.

12. A patient with suspected internal bleeding has normal vital signs at the scene. The most useful approach during transport is to:

    1. A. Repeat vitals often and track trends
    2. B. Rely on the SpO2 reading to track it
    3. C. Rely on abdominal swelling to track it
    4. D. Reassess when he reports new pain
    Show answer

    Answer: A. Repeat vitals often and track trends

    Early internal bleeding often produces subtle signs, so a rising heart rate, narrowing pulse pressure, increasing restlessness, or worsening skin signs over serial checks (about every 5 minutes in an unstable or high-risk patient) are what reveal it. Abdominal distension is a late, unreliable sign, SpO2 often stays normal until late, and waiting for new pain means waiting for symptoms that may never be reported.

13. Abdominal distension from internal bleeding is:

    1. A. A late and unreliable sign
    2. B. An early and sensitive sign
    3. C. The first sign in most bleeds
    4. D. Proof of a bowel injury
    Show answer

    Answer: A. A late and unreliable sign

    The adult abdomen can hold liters of blood before it visibly distends, so a flat abdomen does not rule out hemorrhage. Rely on mechanism, tenderness, and perfusion signs.

14. Class I hemorrhage is a loss of up to about:

    1. A. 5% of blood volume
    2. B. 30% of blood volume
    3. C. 40% of blood volume
    4. D. 15% of blood volume
    Show answer

    Answer: D. 15% of blood volume

    Class I (up to about 750 mL in an adult) causes little change in vital signs, similar to donating a unit of blood. Class II begins at about 15%, with tachycardia and a narrowing pulse pressure.

15. A man with a stab wound is anxious, with HR 108, BP 126/98 mmHg, and RR 24. His estimated blood loss is about 1,000 mL. This is consistent with:

    1. A. Class I hemorrhage
    2. B. Class II hemorrhage
    3. C. Class III hemorrhage
    4. D. Class IV hemorrhage
    Show answer

    Answer: B. Class II hemorrhage

    Class II (15% to 30%) produces tachycardia, a narrowing pulse pressure, and anxiety with a normal systolic pressure. Class III is when the systolic pressure begins to fall.

16. A patient is confused, with HR 128, BP 82/60 mmHg, and RR 32. She has lost an estimated 1,800 mL. This is consistent with:

    1. A. Class I hemorrhage
    2. B. Class II hemorrhage
    3. C. Class III hemorrhage
    4. D. Class IV hemorrhage
    Show answer

    Answer: C. Class III hemorrhage

    Class III (30% to 40%, about 1,500 to 2,000 mL) is when hypotension usually appears, with marked tachycardia and confusion. Class IV adds lethargy, profound hypotension, and negligible urine output.

17. Class IV hemorrhage is a loss of more than:

    1. A. 10% of blood volume
    2. B. 40% of blood volume
    3. C. 20% of blood volume
    4. D. 25% of blood volume
    Show answer

    Answer: B. 40% of blood volume

    Losing more than 40% (about 2 L in an adult) is immediately life threatening, with lethargy, very weak pulses, and severe hypotension. These patients need blood and surgical control without delay.

18. A driver struck the steering wheel and has right upper quadrant tenderness and lower right rib fractures. The organ most at risk of bleeding is the:

    1. A. Spleen
    2. B. Pancreas
    3. C. Stomach
    4. D. Liver
    Show answer

    Answer: D. Liver

    Lower right rib fractures and RUQ tenderness point to the liver, the largest solid organ, which bleeds heavily when lacerated. The spleen is the concern with left lower rib injuries.

19. The definitive treatment for most significant internal hemorrhage is:

    1. A. Large volumes of IV crystalloid
    2. B. High-flow oxygen by mask
    3. C. Surgical or interventional control
    4. D. A pneumatic antishock garment (PASG)
    Show answer

    Answer: C. Surgical or interventional control

    Internal bleeding cannot be compressed in the field, so the prehospital priority is rapid transport to a trauma center for surgery or angioembolization. Fluids support perfusion but do not stop the bleeding.

20. Under the 2021 National Guideline for Field Triage of Injured Patients, a suspected pelvic fracture is a reason to transport to:

    1. A. The highest-level trauma center available
    2. B. The closest emergency department
    3. C. Any hospital with an orthopedic surgeon on call
    4. D. A freestanding emergency center
    Show answer

    Answer: A. The highest-level trauma center available

    Suspected pelvic fracture is a red (high-risk injury) criterion, along with penetrating injuries to the torso and others. These patients need immediate surgical and blood bank resources.

21. A 66-year-old had a cardiac catheterization through the right groin this morning. He now has new back pain, a swelling in the groin, and HR 116 with BP 90/60 mmHg. You should suspect:

    1. A. A new heart attack from the procedure
    2. B. Bleeding from the femoral access site
    3. C. A pulled muscle in the lower back
    4. D. An allergic reaction to the contrast dye
    Show answer

    Answer: B. Bleeding from the femoral access site

    A femoral artery puncture can bleed into the thigh or track into the retroperitoneum, causing back or flank pain, groin swelling, and shock with little external blood. Apply firm pressure just above the puncture site, treat for shock, and transport. A new MI does not explain groin swelling, muscle strain does not cause hypotension, and a contrast reaction would cause hives or wheezing rather than these findings.

22. A man fell from a ladder and has closed fractures of both femurs. His vital signs are currently normal. You should anticipate:

    1. A. A minor loss of less than 200 mL
    2. B. A loss of about 500 mL in total
    3. C. Little blood loss once both legs are splinted
    4. D. Shock from up to 3 L of hidden blood loss
    Show answer

    Answer: D. Shock from up to 3 L of hidden blood loss

    Each closed femur fracture can lose 1 to 1.5 L, so bilateral fractures can cause class III to IV hemorrhage. Intact skin does not mean the blood stays in the vessels. Splinting reduces further loss, but the blood already in the thighs is still lost from the circulation.

23. Why can a patient lose a large volume of blood into the retroperitoneum with few early signs?

    1. A. The space is large and lies behind the peritoneum
    2. B. Blood there is reabsorbed within just a few minutes
    3. C. Blood there does not reduce circulating volume
    4. D. Bleeding there clots instantly and stops
    Show answer

    Answer: A. The space is large and lies behind the peritoneum

    Retroperitoneal bleeding from the kidneys, pelvis, or aorta does not irritate the peritoneum early and causes little tenderness or distension. Any blood leaving the vessels reduces circulating volume, wherever it pools.

24. A patient with a suspected severe internal bleed has been packaged. For a critical trauma patient, the ideal goal for scene time is no more than about:

    1. A. 20 minutes
    2. B. 30 minutes
    3. C. 10 minutes
    4. D. 45 minutes
    Show answer

    Answer: C. 10 minutes

    The 'platinum 10 minutes' guides limiting scene time for critical trauma, because internal bleeding is controlled only in the operating room or interventional suite. IV access and other procedures should be done en route.

25. Hemoptysis after blunt chest trauma most likely indicates:

    1. A. Bleeding from the upper stomach lining
    2. B. Bleeding around a fractured rib
    3. C. Injury to the lung tissue or airways
    4. D. A tear in the diaphragm
    Show answer

    Answer: C. Injury to the lung tissue or airways

    Coughing up blood after chest trauma suggests pulmonary contusion or tracheobronchial injury. Blood from the stomach is vomited rather than coughed up. A rib fracture bleeds into the chest wall or pleural space rather than the airway, and a diaphragm tear does not put blood into the bronchi.