You are called to assist a 44-year-old male who was struck in the head with a large socket wrench at work. On arrival, the patient is conscious but confused; he complains he developed a sudden-onset severe headache moments after a wrench slipped off under pressure striking him in the temporal region of the skull. Co-workers state he was unconscious with abnormal posturing for about three minutes prior to EMS arrival. He states the headache went from the worst headache of his life to a dull throbbing headache and new-onset dizziness and nausea. His pupils are unequal with the right eye sluggish to respond while his grips remain equal but weak. As you continue your evaluation, he suddenly develops projectile vomiting and loses consciousness. Which of the following injuries is most likely to cause his presentation?

Correct Answer: B

Rationale: The correct answer is B: Epidural hematoma. In this case, the patient's history of a sudden-onset severe headache after head trauma, unequal pupils, weakness, dizziness, nausea, and subsequent projectile vomiting with loss of consciousness are indicative of an epidural hematoma. Epidural hematomas typically result from arterial bleeding between the dura mater and skull, leading to an increase in intracranial pressure and neurological deterioration. The delay in symptoms and sudden deterioration are consistent with the progression of an epidural hematoma. The other choices, subdural hematoma (A), subarachnoid hematoma (C), and intracerebral hematoma (D), do not fit the clinical presentation as well and are less likely based on the symptoms described.

Correct Answer: A

Rationale: The correct answer is A: "Aggressive fluid infusion." This is crucial to maintain adequate perfusion to the kidneys and prevent acute kidney injury due to rhabdomyolysis from electric shock. Electroshock can cause muscle breakdown leading to myoglobin release, which can damage the kidneys. Immediate angiography is not indicated as the first step in management. Intravenous pyelography and debridement of necrotic muscle are not relevant in this scenario. Admission to the ICU for observation may be considered after initial fluid resuscitation.

Correct Answer: D

Rationale: The correct answer is D: Tachycardia. When a patient experiences a hemorrhage of 20% of their blood volume, the body responds by increasing the heart rate to compensate for the decreased blood volume and maintain adequate circulation. This compensatory mechanism results in tachycardia. Oliguria (A) is a decrease in urine output and is not typically associated with a hemorrhage. Confusion (B) may occur if the brain is not receiving enough oxygen due to severe bleeding but is not specific to a 20% blood volume loss. Hypotension (C) is usually associated with a more significant blood loss, typically exceeding 20%.

Correct Answer: D

Rationale: The correct answer is D because the absence of a palpable prostate on rectal exam is not a direct indicator of urethral injury. A palpable prostate is more related to prostate health rather than urethral injury. Scrotal hematoma, blood in the rectal lumen, and blood in the external urethral meatus are all signs that suggest urethral injury due to trauma or other causes. These symptoms are more specific to the urethra and its surrounding structures, making them more relevant indicators of urethral injury compared to the absence of a palpable prostate.

Correct Answer: B

Rationale: The correct answer is B: 2L of iv crystalloid and vasopressors if BP does not respond. This patient presents with symptoms of spinal cord injury with hypotension, which indicates neurogenic shock. Initial management involves fluid resuscitation to maintain perfusion. If the BP does not respond to fluids, vasopressors are indicated to support blood pressure. The other choices are incorrect because the patient does not have signs of hemorrhagic shock, so transfusing pRBCs (choice A) is unnecessary. Mannitol and steroids (choice C) are not indicated in the acute management of spinal cord injury. Laparotomy (choice D) is not indicated based on the clinical presentation.