Pre-hospital trauma management: DipIMC practice questions
PHEM curriculum unit 2.5 · Theme 2: Providing Pre-hospital Emergency Medical Care
The DipIMC is blueprinted against phase 1 of the UK Pre-hospital Emergency Medicine (PHEM) curriculum. This page covers unit 2.5, Manage injury in the pre-hospital environment.
Below are 3 free practice questions from the DipIMC.Ninja bank, in the Part A single best answer format. Every answer names the textbook page, guideline or statute it was written from, so you can check it rather than take it on trust. The bank holds 70 questions on this unit.
Question 1 · Paediatrics & Obstetrics · Moderate
An ambulance crew attends a 3-year-old boy at home who, according to his mother's partner, 'fell over in the garden' an hour ago. He is quiet and clings to his mother. On full examination the paramedic finds several injuries. Which finding should most strongly raise concern about non-accidental injury?
AA graze across the front of the right knee
BA small bruise on the centre of the forehead
CA bruise over the front of the left shin
DBruising over the pinna of the right ear
EAn abrasion across the left palm and wrist
Show answer
Answer: D
Bruising over the pinna of the right ear
ABC of Prehospital Emergency Medicine lists injury patterns to be considered non-accidental unless there is a very good explanation: fingertip bruising, bruising in unusual places such as the pinna of the ear or the abdomen, and marks of objects such as a belt buckle; any injury inconsistent with the history, or an unexplained delay, should raise major concern. The Oxford Handbook of Pre-Hospital Care similarly lists unusual injury patterns (finger marks, burns and bites), an injury pattern inconsistent with the history, and abnormal child–carer interaction. Of the five findings, only bruising of the pinna appears in ABC's list of injury patterns to be treated as non-accidental unless a very good explanation exists; neither book lists a graze to the knee, a forehead bruise, a shin bruise or a palm abrasion among its warning patterns. The whole picture still matters. The Handbook's first priority is the child: take him to hospital, raise the concern with hospital staff and document it clearly; ABC adds that handover should be to a senior member of staff with detailed notes, a copy kept, and local child protection procedures followed.
Where this comes from
ABC of Prehospital Emergency Medicine
Ch. 29 Care of Special Groups: The Paediatric Patient · Safeguarding · p. 164“bruising in an unusual place such as the pinna of the ear or abdomen”
Ch. 29 Care of Special Groups: The Paediatric Patient · Safeguarding · p. 164“handover at the hospital should be to a senior member of staff”
Oxford Handbook of Pre-Hospital Care
Ch. 8 Child health · Child abuse and neglect · p. 534“Unusual patterns of injury, for example, finger marks, burns, and bites.”
Ch. 8 Child health · Child abuse and neglect · p. 534“Concern must be raised with hospital staff and this should be clearly documented.”
A helicopter emergency medical service (HEMS) team attends a 3-year-old girl who has fallen from a second-floor window. She is pale and mottled, with a heart rate of 180 and a capillary refill time of 6 seconds. She is cold and no peripheral veins are visible. According to NICE NG39 (Major trauma: assessment and initial management), what is the recommended approach to circulatory access?
AConsider intra-osseous access as first-line access
BTwo peripheral cannula attempts, then intra-osseous
CExternal jugular cannulation before any other route
DFemoral central venous access at the scene first
ENo vascular access until the major trauma centre
Show answer
Answer: A
Consider intra-osseous access as first-line access
NICE NG39 makes a specific recommendation for children under 16 with major trauma: consider intra-osseous (IO) access as first-line access if peripheral access is anticipated to be difficult. A cold, shut-down 3-year-old with no visible veins is that child. For major trauma patients in general in the pre-hospital setting, NG39 recommends peripheral intravenous access first and intra-osseous access if it fails; 'two attempts, then IO' is close to that adult sequence, and to the general advice in ABC of Prehospital Emergency Medicine (IO after two failed intravenous attempts), but it is not the NG39 recommendation for a child whose veins are predictably difficult. Central venous access is an in-hospital step in NG39, not a scene intervention, and external jugular cannulation is not in NG39's sequence. Withholding access is wrong in a shocked child: ABC notes that vascular access is required to treat shock and that hypotension in children is a late, preterminal sign. The NG39 numbers quoted here are the Bookshelf edition's sequential recommendation numbers (32 and 33), not NICE's 1.x.y numbering.
Ch. 29 Care of Special Groups: The Paediatric Patient · Initial management of the seriously ill or injured child: circulation · p. 161“If it is not possible to gain intravenous access after two attempts”
Ch. 29 Care of Special Groups: The Paediatric Patient · Initial management of the seriously ill or injured child: circulation · p. 161“hypotension is a late and preterminal sign”
A BASICS doctor attends a 2-year-old boy who pulled a pan of hot water over himself 20 minutes ago. Cooling is under way. The scald covers the front of his trunk and both arms: some areas are blistered, and these are surrounded by a wider margin of red, unblistered skin that blanches with brisk capillary refill. According to the RCSEd Faculty of Pre-Hospital Care burns consensus statement, how should she estimate the size of the burn?
AAdult rule of nines, including the blistered and reddened skin
BAdult rule of nines, excluding the reddened skin areas
CPaediatric Lund and Browder chart, including the reddened skin
DChild's palm without fingers as 1%, counting all reddened skin
EPaediatric Lund and Browder chart, excluding reddened skin
Show answer
Answer: E
Paediatric Lund and Browder chart, excluding reddened skin
The Faculty of Pre-Hospital Care/British Burn Association consensus recommends the Lund and Browder chart (or an electronic equivalent) as the optimal method of estimating total body surface area (TBSA), and states that an appropriately scaled paediatric chart should be used because body proportions differ in children. Only partial- and full-thickness burns are counted: areas with superficial characteristics — erythema, dry surface, no blistering, intact skin, blanching with brisk capillary refill — are excluded. Counting the red margin overestimates the burn. The adult rule of nines is inaccurate in a small child, whose head is a much larger share of the body surface (ABC Ch. 29; OHPC Ch. 8). The palm method (the child's palm including the fingers, about 1%) is an alternative for small burns only, and it too counts only the burned, not the reddened, skin — the reddened area is usually considerably larger than the burn itself. The consensus asks only for a pre-hospital band (<20%, 20–50%, >50%) to guide fluids and destination; do not delay cooling or transfer for precise calculation.
ABC of Prehospital Emergency Medicinep. 163Ch. 29 Care of Special Groups: The Paediatric Patient · Management of paediatric trauma emergencies — Burns“The rule of nines (used in adults) is not accurate.”
Oxford Handbook of Pre-Hospital Carepp. 528–529Ch. 8 Child health · Burns“an adult burns chart or the ‘rule of nines’ do not apply”