Management: Hemorrhage Control, Permissive Hypotension, Eviscerations, Impaled Objects, and Transport Practice Questions

25 multiple-choice questions on Management: hemorrhage control, permissive hypotension, eviscerations, impaled objects, and transport for paramedic and EMT students, from Chapter 37 (Abdominal and Genitourinary Trauma). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. A 45-year-old driver with a suspected liver injury has P 124/min and BP 86/58 mmHg with a patent airway. A community hospital with no surgeon on call is 8 minutes away; a Level I trauma center is 22 minutes away by ground. The best destination is the:

   1. A. Community hospital, since it is much closer
   2. B. Community hospital for fluids, then transfer
   3. C. Trauma center, bypassing the closer hospital
   4. D. Nearest hospital that can obtain a CT scan
   Show answer

   Answer: C. Trauma center, bypassing the closer hospital

   Bleeding from a solid organ cannot be compressed and is stopped only by surgery or interventional radiology. A systolic pressure under 90 mmHg is a red criterion in the 2021 National Guideline for the Field Triage of Injured Patients, which directs him to the highest-level trauma center available, and 14 extra minutes is far less than the delay of an interhospital transfer. A hospital with no surgeon cannot control the bleeding, so the shorter drive gains nothing. Stopping there for fluids and then transferring adds the time to repackage and move him again, often an hour or more, and fluids do not stop the bleeding. CT is for stable patients; an unstable patient goes to the operating room or angiography, so CT capability is the wrong criterion. The usual exception, an airway you cannot manage, does not apply because his airway is patent.

2. For a hypotensive patient with suspected intra-abdominal bleeding, the target scene time is ideally:

   1. A. 20 to 30 minutes
   2. B. Until two IVs run
   3. C. Until the BP is normal
   4. D. 10 minutes or less
   Show answer

   Answer: D. 10 minutes or less

   Patients with internal hemorrhage need surgery, so the platinum 10 minutes guides scene time, with IV access and other care done en route. Waiting for a normal blood pressure only delays definitive control.

3. A 28-year-old with an abdominal gunshot wound is alert with a strong radial pulse and a BP of 88/60 mmHg. Your fluid plan should be to:

   1. A. Hold boluses and reassess often
   2. B. Give 2 L of crystalloid rapidly
   3. C. Infuse until the BP reaches 120
   4. D. Start a dopamine infusion now
   Show answer

   Answer: A. Hold boluses and reassess often

   An alert patient with a radial pulse is already perfusing adequately under permissive hypotension, so boluses are held and he is reassessed en route. Pushing the pressure to normal risks dislodging clots and diluting clotting factors.

4. Raising blood pressure to normal with large fluid volumes in uncontrolled abdominal bleeding can:

   1. A. Seal bleeding vessels more quickly
   2. B. Dislodge clots and worsen bleeding
   3. C. Prevent the need for any surgery
   4. D. Lower the risk of hypothermia
   Show answer

   Answer: B. Dislodge clots and worsen bleeding

   Aggressive crystalloid raises pressure against fragile clots, dilutes clotting factors, and cools the patient, worsening the lethal triad. Permissive hypotension limits these effects until surgical control.

5. A patient with abdominal trauma begins vomiting while secured supine on a long board. You should first:

   1. A. Seat him upright at once
   2. B. Give water to rinse his mouth
   3. C. Press firmly over the stomach
   4. D. Tilt the board and suction
   Show answer

   Answer: D. Tilt the board and suction

   Tilting the secured patient as a unit lets vomit drain while maintaining spinal precautions, and suction clears the airway. Pressing on the abdomen could worsen internal injury and provoke more vomiting.

6. A 40-year-old has an abdominal stab wound through which a piece of yellow, fatty omentum protrudes. Your care of the protruding tissue is to:

   1. A. Cover it with a moist sterile dressing
   2. B. Gently replace the omentum, then dress it
   3. C. Cut it off flush with the skin surface
   4. D. Leave it uncovered so the fluid can drain
   Show answer

   Answer: A. Cover it with a moist sterile dressing

   Protruding omentum is managed like eviscerated bowel: leave it in place, cover it with a moist sterile dressing and an occlusive layer, and transport. Replacing it, however gently, carries contamination into the peritoneal cavity and can injure it; that is the surgeon's job. Cutting it off can cause bleeding from its vessels and removes tissue the surgeon needs to inspect. Leaving it uncovered lets it dry, cool, and become contaminated.

7. An eviscerated organ should not be pushed back into the abdomen because doing so can:

   1. A. Stop the bowel from bleeding
   2. B. Restore its blood supply
   3. C. Contaminate the peritoneum
   4. D. Make the dressing too tight
   Show answer

   Answer: C. Contaminate the peritoneum

   Exposed bowel picks up debris and bacteria, and replacing it carries contamination into the peritoneal cavity and can injure the organs further. Replacement is left to the surgeon, who can inspect and clean the bowel.

8. The solution used to moisten an evisceration dressing should be:

   1. A. Sterile normal saline
   2. B. Hydrogen peroxide
   3. C. Povidone-iodine scrub
   4. D. Tap water from the scene
   Show answer

   Answer: A. Sterile normal saline

   Sterile saline keeps exposed bowel moist without damaging tissue. Hydrogen peroxide and iodine are cytotoxic and would harm the bowel surface.

9. A 41-year-old construction worker has a 30-cm (12-in) piece of rebar impaled in the abdomen. You should:

   1. A. Remove it to control the bleeding
   2. B. Pull it out slowly while applying pressure
   3. C. Push it through to the back for transport
   4. D. Stabilize it in place with bulky dressings
   Show answer

   Answer: D. Stabilize it in place with bulky dressings

   An impaled object may be tamponading bleeding vessels, so it is stabilized in place and removed only in the operating room. Removing it in the field can trigger uncontrolled hemorrhage.

10. A 30-year-old has a screwdriver impaled in the epigastrium. The handle bobs with each heartbeat. He is alert, his airway is clear, and his BP is 118/76 mmHg. You should:

    1. A. Remove it because it lies against a vessel
    2. B. Cut it off short to stop the bobbing
    3. C. Stabilize it and transport rapidly
    4. D. Push it deeper so it stops moving
    Show answer

    Answer: C. Stabilize it and transport rapidly

    Movement with each heartbeat means the tip lies against or within the heart or a great vessel such as the aorta, and the object may be plugging the hole. Stabilize it in place with bulky dressings, limit movement, and transport rapidly to a trauma center with surgical capability. Field removal is reserved for an object that blocks the airway or prevents effective chest compressions, and neither applies; pulling out an object that touches a vessel can release the tamponade and cause fatal bleeding. Cutting a rigid object transmits force and vibration to the vessel, and is done, with careful stabilization, only when the object is too long to transport. Pushing it deeper could tear the vessel further. (PHTLS 10th ed., impaled objects; Caroline 9th ed.)

11. A long impaled object is too long to fit in the ambulance. The best approach is to:

    1. A. Pull it out and pack the wound tightly
    2. B. Have it cut, stabilizing it during cutting
    3. C. Bend it until it fits the patient space
    4. D. Leave the patient until a surgeon can arrive
    Show answer

    Answer: B. Have it cut, stabilizing it during cutting

    Fire and rescue crews can cut the object while you stabilize it to limit movement and vibration in the wound. Bending or removing it risks additional internal injury.

12. A patient with a stab wound to the abdomen is nauseated and retching during transport. Giving ondansetron per protocol:

    1. A. Is reasonable to reduce vomiting
    2. B. Will hide all signs of peritonitis
    3. C. Is forbidden in all trauma patients
    4. D. Should wait until after surgery
    Show answer

    Answer: A. Is reasonable to reduce vomiting

    Treating nausea is appropriate in abdominal trauma. Retching raises intra-abdominal pressure, can push out more bowel through a wound, and threatens the airway. Antiemetics do not mask peritonitis or shock, and they are not contraindicated in trauma; check for QT risks as usual.

13. A man who smells strongly of alcohol was kicked in the abdomen. He is drowsy, with HR 122 and BP 88/56 mm Hg. Your interpretation should be that:

    1. A. Alcohol alone explains his vital signs here
    2. B. He can be monitored at the scene for sobering
    3. C. Shock is from injury until proven otherwise
    4. D. He needs no exam until he is fully sober
    Show answer

    Answer: C. Shock is from injury until proven otherwise

    Intoxication can blunt pain and alter mental status, which makes the abdominal exam unreliable, but alcohol should not be blamed for tachycardia and hypotension after trauma. Assume hemorrhage, treat for shock, and transport to a trauma center. Waiting for sobriety delays recognition of serious injury.

14. A 29-year-old with a gunshot wound to the abdomen is pale and tachycardic. Which destination is most appropriate?

    1. A. The closest ED for stabilization first
    2. B. The nearest trauma center with surgery
    3. C. A stroke center with a CT scanner
    4. D. A cardiac center with a cath lab
    Show answer

    Answer: B. The nearest trauma center with surgery

    He needs immediate surgical control of bleeding, so transport to a trauma center that can provide surgery and blood is the priority. Stopping first at a closer ED without surgical capability delays definitive care, and stroke or cardiac centers are not organized for emergency trauma surgery and massive transfusion.

15. IV access for a patient with suspected intra-abdominal bleeding should be obtained:

    1. A. On scene, before the patient moves
    2. B. After arrival at the receiving hospital
    3. C. In the leg on the side of the injury
    4. D. En route, without delaying transport
    Show answer

    Answer: D. En route, without delaying transport

    IV attempts should not lengthen scene time in a bleeding patient. Large-bore access above the diaphragm is preferred when abdominal or pelvic venous injury is possible.

16. A patient with a suspected inferior vena cava injury from a gunshot wound needs IV access. The best site is:

    1. A. A proximal tibial intraosseous site
    2. B. An arm vein above the diaphragm
    3. C. The femoral vein on either side
    4. D. A vein on the top of the foot
    Show answer

    Answer: B. An arm vein above the diaphragm

    Fluid or blood given below the diaphragm must travel up the inferior vena cava, so with an IVC injury much of it can pour out of the hole into the abdomen. An arm vein (or an external jugular or humeral intraosseous site) drains through the superior vena cava straight to the heart. A tibial intraosseous needle drains through the leg veins into the IVC, so it shares the same problem even though it is quick to place. The femoral vein empties directly into the iliac veins and IVC. A vein on the top of the foot is the farthest from the heart and also drains through the IVC. (ATLS 10th ed., Shock: vascular access; PHTLS 10th ed.)

17. A 26-year-old with a penetrating abdominal wound is pale and anxious with an SpO2 of 90%. The best oxygen strategy is to:

    1. A. Withhold oxygen to avoid lung toxicity
    2. B. Wait for the SpO2 to fall below 85% first
    3. C. Intubate on scene before moving him
    4. D. Titrate oxygen to an SpO2 of 94% to 98%
    Show answer

    Answer: D. Titrate oxygen to an SpO2 of 94% to 98%

    Hemorrhagic shock already reduces oxygen delivery, and an SpO2 of 90% adds hypoxemia, so give supplemental oxygen titrated to 94% to 98% (the BTS target for most acutely ill adults; PHTLS aims for at least 94%), remembering that poor perfusion can make the reading unreliable. Withholding oxygen for fear of toxicity makes no sense in a hypoxemic patient in shock; the harm comes from prolonged hyperoxia, which titration avoids. Waiting for SpO2 to fall below 85% allows dangerous hypoxemia. He is protecting his own airway, so intubating on scene would delay surgery and can drop his pressure through induction drugs and positive pressure.

18. A 34-year-old with an abdominal gunshot wound is in shock and has fentanyl ordered for pain. The most important consideration is:

    1. A. Giving it orally to protect the IV
    2. B. Holding it until a full exam is done
    3. C. Using small, titrated doses in shock
    4. D. Giving a larger dose than usual
    Show answer

    Answer: C. Using small, titrated doses in shock

    Fentanyl has less hemodynamic effect than morphine, but any opioid can lower the BP of a patient in shock, so give small titrated doses and monitor. Oral routes are inappropriate for a likely surgical patient.

19. You are dressing a loop of eviscerated small bowel. Which first layer should go directly on the bowel?

    1. A. Sterile gauze soaked in sterile saline
    2. B. Dry sterile gauze held firmly in place
    3. C. Absorbent cotton wet with sterile water
    4. D. Aluminum foil placed directly on bowel
    Show answer

    Answer: A. Sterile gauze soaked in sterile saline

    Saline-soaked sterile gauze keeps the exposed bowel from drying without sticking to it; it is then covered with an occlusive layer and blankets to hold in moisture and heat. Dry gauze adheres to the bowel surface and dries it, and firm pressure can compress the bowel's blood supply. Absorbent cotton sheds fibers that stick to the bowel and are hard to remove, whatever liquid it is wet with. Aluminum foil can cut the bowel and does not keep it moist; if used at all, it belongs only as an outer occlusive layer over a moist dressing. (Caroline 9th ed., eviscerations; PHTLS 10th ed.)

20. During transport, a patient with an evisceration begins coughing and vomiting. You should be most concerned that this can:

    1. A. Pull the eviscerated bowel back inside
    2. B. Push more bowel out through the wound
    3. C. Stop the abdominal bleeding fully
    4. D. Relieve the pressure on the bowel
    Show answer

    Answer: B. Push more bowel out through the wound

    Coughing, vomiting, and straining raise intra-abdominal pressure and can force more organs out of the wound. Antiemetics per protocol and positioning help limit this.

21. A 38-year-old woman has an abdominal stab wound with steady external bleeding from the wound edges. You should first:

    1. A. Apply direct pressure with a dressing
    2. B. Apply a tourniquet above the wound
    3. C. Pack gauze deep into the peritoneal cavity
    4. D. Pour saline into the wound tract
    Show answer

    Answer: A. Apply direct pressure with a dressing

    External bleeding from the abdominal wall is controlled with direct pressure, but deep packing into the peritoneal cavity cannot reach the bleeding source and risks organ injury. Tourniquets are for extremities.

22. REBOA, a physician-performed procedure used at some trauma centers for noncompressible torso hemorrhage, works by:

    1. A. Compressing the aorta from outside the abdomen
    2. B. Sealing the bleeding liver with a balloon
    3. C. Draining blood out of the peritoneal cavity
    4. D. Occluding the aorta from inside with a balloon
    Show answer

    Answer: D. Occluding the aorta from inside with a balloon

    Resuscitative endovascular balloon occlusion of the aorta passes a catheter through the femoral artery and inflates a balloon inside the aorta, cutting off flow below it to slow torso or pelvic bleeding and support central pressure while the patient goes to surgery. It is a temporary bridge that causes ischemia below the balloon, so the patient still needs blood and surgical control. Compressing the aorta from outside the abdomen describes an external junctional device, not REBOA. Balloon tamponade of a liver wound tract is a separate surgical technique; REBOA does not seal any organ. Draining the peritoneal cavity does not stop bleeding. REBOA is not in the 2019 National EMS Scope of Practice Model for paramedics, and the 2019 ACS-COT/ACEP/NAEMSP/NAEMT joint statement does not recommend prehospital REBOA except by physician-led teams, ideally within research.

23. A patient with an evisceration is cold and shivering in the ambulance. To limit heat loss from the wound, you should:

    1. A. Remove the dressing to let the bowel breathe
    2. B. Use cold saline to keep the bowel moist
    3. C. Keep the occlusive layer and add blankets
    4. D. Switch to a dry dressing to stop evaporation
    Show answer

    Answer: C. Keep the occlusive layer and add blankets

    Exposed bowel loses heat quickly by evaporation, so keep the moist dressing covered with its occlusive layer, cover the patient with blankets, and warm the ambulance; warm saline is preferred if the dressing needs remoistening. Removing the dressing increases heat and moisture loss and exposes the bowel to contamination. Cold saline cools the patient further and worsens trauma coagulopathy. A dry dressing sticks to and dries the bowel surface, injuring it; the occlusive layer, not a dry dressing, is what limits evaporation. (Caroline 9th ed., eviscerations; PHTLS 10th ed., hypothermia prevention.)

24. A 19-year-old was shot in the abdomen, and his BP is now 66/40 mmHg with a weak carotid pulse only. Transport time is 25 minutes, and your protocol targets a palpable radial pulse. Which action best follows this protocol?

    1. A. Give several liters of crystalloid rapidly
    2. B. Give blood or small crystalloid boluses
    3. C. Withhold fluids until he reaches surgery
    4. D. Start a vasopressor before giving any fluid
    Show answer

    Answer: B. Give blood or small crystalloid boluses

    With a BP of 66/40 mmHg and only a carotid pulse he is near arrest and below the permissive hypotension endpoints (systolic about 80 to 90 mmHg, a palpable radial pulse, preserved mentation). Blood products are preferred where available; otherwise give small crystalloid boluses (about 250 mL) and reassess until a radial pulse returns. Several liters of crystalloid dilute clotting factors, cool the patient, and push against fragile clots. Withholding all fluid (delayed resuscitation helped in a short urban transport trial) does not meet a protocol that targets a radial pulse when he has lost it with 25 minutes to go. Vasopressors do not replace lost volume and are not first-line in hemorrhagic shock. Note that some systems (NICE NG39) titrate to a central pulse instead, so follow local protocol.

25. When you notify the trauma center about a patient with penetrating abdominal trauma, you should include:

    1. A. Mechanism, vitals, care, and ETA
    2. B. The patient's home address and phone
    3. C. A request to delay the trauma team page
    4. D. The number of IV attempts made on scene
    Show answer

    Answer: A. Mechanism, vitals, care, and ETA

    A concise report of mechanism, injuries found, vital sign trends, treatments, and arrival time lets the team activate surgery and blood. Demographics alone do not help them prepare.