ATLS.doc

The primary indication for transferring a patient to a higher level trauma center is: unavailability of a surgeon or operating room staff. multiple system injuries, including severe head injury. resource limitations as determined by the transferring doctor. resource limitations as determined by the hospital administration. widened mediastinum on chest x-ray following blunt thoracic trauma. teen-aged bicycle rider is hit by a truck traveling at a high rate of speed. In the emergency department, she is actively bleeding from open fractures of her legs, and has abrasions on her chest and abdominal wall. Her blood pressure is 80/50 mm Hg, heart rate is 140 beats per minute, respiratory rate is 8 breaths per minute, and GCS score is 6. The first step in managing this patient is to: obtain a lateral cervical spine x-ray. insert a central venous pressure line. administer 2 liters of crystalloid solution. perform endotracheal intubation and ventilation. apply the PASG and inflate the leg compartments. Contraindication to nasogastric intubation is the presence of a: gastric perforation. diaphragmatic rupture. open depressed skull fracture. fracture of the cervical spine. fracture of the cribriform plate. Which one of the following statements regarding patients with thoracic spine injuries is TRUE? Log-rolling may be destabilizing to fractures from T-12 to L-1. Adequate immobilization can be accomplished with the scoop stretcher. Spinal cord injury below T-10 usually spares bowel and bladder function. Hyperflexion fractures in the upper thoracic spine are inherently unstable. These patients rarely present with spinal shock in association with cord injury. young man sustains a ritle wound to the mid-abdomen. He is brought promptly to the emergency department by prehospital personnel. His skin is cool and diaphoretic, and his systolic blood pressure is

58 rnm Hg. Warmed crystalloid fluids are initiated without improvement in his vital signs. The next, most appropriate step is to perform: a celiotomy. an abdominal CT scan. diagnostic laparoscopy. abdominal ultrasonography. a diagnostic peritoneal lavage. young woman sustains a severe head injury as the result of a motor vehicular crash. In the emergency department, her GCS score is 6. Her blood pressure is 140/90 mm Hg and her heart rate is 80 beats per minute. She is intubated and is being mechanically ventilated. Her pupils are 3 mm in size and equally reactive to light. There is no other apparent injury. The most important principle to follow in the early management of her head injury is to: administer an osmotic diuretic. prevent secondary brain injury. aggressively treat systemic hypertension. reduce metabolic requirements of the brain. distinguish between intracranial hematoma and cerebral edema. 22-year-old man is brought to the hospital after crashing his motorcycle into a telephone pole. He is unconscious and in profound shock. He has no open wounds or obvious fractures. The cause of his shock is MOST LIKELY caused by: a subdural hematoma. an epidural hematoma. a transected lumbar spinal cord. a transected cervical spinal cord. hemorrhage into the chest or abdomen. 30-year-old man is struck by a car traveling at 56 kph (35 mph). He has obvious fractures of the left tibia near the knee, pain in the pelvic area, and severe dyspnea. His heart rate is 180 beats per minute, and his respiratory rate is 48 breaths per minute with no breath sounds heard in the left chest. A tension pneumothorax is relieved by immediate needle decompression and tube thoracostomy. Subsequently, his heart rate decreases to 140 beats per minute, his respiratory rate decreases to 36 breaths per minute,

and his blood pressure is 80/50 inm Hg. Warmed Ringer's lactate is administered intravenously. The next priority should be to: perform a urethrogram and cystogram. perform external fixation of the pelvis. obtain abdominal and pelvic CT scans. perform arterial embolization of the pelvic vessels.perform diagnostic peritoneal lavage or abdominal ultrasound. 8-year-old girl is an unrestrained passenger in a vehicle struck from behind. In the emergency department, her blood pressure is 80/60 mm Hg, heart rate is 80 beats per minute, and respiratory rate is 16 breaths per minute. Her GCS score is 14. She complains that her legs feel "funny and won't move right;" however, her spine x-rays do not show a fracture or dislocation. A spinal cord injury in this child: is most likely a central cord syndrome. must be diagnosed by magnetic resonance imaging. can be excluded by obtaining a CT of the entire spine. may exist in the absence of objective findings on x-ray studies. is unlikely because of the incomplete calcification of the vertebral bodies. Immediate chest tube insertion is indicated for which of the following conditions? Pneumothorax Pneumomediastinum Massive hemothorax Diaphragmatic rupture Subcutaneous emphysema 18-year-old, helmeted motorcyclist is brought by ambulance to the emergency department following a high-speed crash. Prehospital persormel report that he was thrown 15 meters (50 feet) off his bfice. He has a history of hypotension prior to arrival in the emergency department, but is now awake, alert, and conversational. Which of the following statements is TRUE? Cerebral perfiision is intacto Intravascular volume status is normal. The patient has sensitive vasomotor reflexes.

Intraabdominal visceral injuries are unlikely. The patient probably has an acute epidural hematoma. crosstable, lateral x-ray of the cervical spine: must precede endotracheal intubation. excludes serious cervical spine injury. is an essential part of the primary survey. is not necessary for unconscious patients with penetrating cervical injuries. is unacceptable unless 7 cervical vertebrae and the C-7 to T-1 relationship are visualized. During resuscitation, which one of the following is the most reliable as a guide to volume replacement? Pulse rate Hematocrit Blood pressure Urinary output Jugular venous pressure Which one of the following is the recommended method for initially treating frostbite? Vasodilators Anticoagulants Warm (40°C) water Padding and elevation Topical application of silvasulphadiazine young man sustains a gunshot wound to the abdomen and is brought promptly to the emergency department by prehospital personnel. His skin is cool and diaphoretic, and he is confused. His pulse is thready and his femoral pulse is only weakly palpable. The defmitive treatment in managing this patient is to: administer 0-negative blood. apply extemal warming devices. control internal hemorrhage operatively. apply the pneumatic antishock garment. infuse large volumes of intravenous crystalloid solution.

To establish a diagnosis of shock: systolic blood pressure must be below 90 mm Hg. the presence of a closed head injury should be excluded. acidosis should be present by arterial blood \gas analysis. the patient must fail to respond to intravenous fluid infu.sion. clinical evidence of inadequate organ perfusion must be present. Absence of breath sounds and dullness to percussion over the left hemithorax are fmdings best explained by: left hemothorax. cardiac contusion. left simple pneumothorax. left diaphragmatic rupture. right tension pneumothorax. 17-year-old helmeted motorcyclist is struck broadside by an automobile at an intersection. He is unconscious at the scene with a blood pressure of 140/90 mm Hg, heart rate of 90 beats per minute, and respiratory rate of 22 breaths per minute. His respirations are sonorous and deep. His GCS score is 6. Immobilization of the entire patient may include the use of all the following EXCEPT: air splints. bolstering devices. a long spine board. a scoop-style stretcher. a semirigid cervical collar. During an altercation, a 32-year-old man sustains a gunshot wound to the right upper hemithorax, above the nipple line with an exit wound posteriorly above the scapula on the right. He is transported by ambulance to a community hospital. He is endotracheally intubated, closed tube thoracostomy is performed, and 2 liters of Ringer's lactate solution are infused through 2 large-caliber IVs. His blood pressure now is 60/0 mm Hg, heart rate is 160 beats per minute, and respiratory rate is 14 breaths per minute (ventilated with 100% 02). The most appropriate next step in managing this patient is: celiotomy. diagnostic peritoneal lavage.

arterial blood gas determination. administer packed red blood cells. chest x-ray to confinn tube placement. Which of the following statements regarding iWhich of the following statements regardingnjury to the central nervous system in children is TRUE? Children suffer spinal cord injury without x-ray abnormality more commonly than adults. An infant with a traumatic brain injury may become hypotensive from cerebral edema. Initial therapy for the child with traumatic brain injury includes the administration of methylprednisolone intravenously. Children have more focal mass lesions as a result of traumatic brain injury when compared to adults . Young children are less tolerant of expanding intracranial mass lesions than adults. 5-year-old boy is struck by an automobile and brought to the emergency department. He is lethargic, but withdraws purposefully from painful stimuli. His blood pressure is 90 mm Hg systolic, heart rate is 140 beats per minute, and his respiratory rate is 36 breaths per minute. The preferred route of venous access in this patient is: percutaneous femoral vein cannulation cutdown on the saphenous vein at the ankle. intraosseous catheter placement in the proximal tibia. percutaneous peripheral veins in the upper extremities. central venous access via the subclavian or interna1 jugular vein. The response to catecholamines in an injured, hypovolemic pregnant woman can be expected to result in: placental abruption. fetal hypoxia and distress. fetal/maternal dysrhythmia. improved uterine blood flow. increased maternal renal blood flow. Cardiac tamponade after trauma: is seldom life-threatening.

can be excluded by an upright, AP chest x-ray. can be confused with a tension pneumothorax. causes a fall in systolic pressure of > 15 mm Hg with expiration. most commonly occurs after blunt injury to the anterior chest wall. 30-year-old man sustains a severely comminuted, open distal right femur fracture in a motorcycle crash. The wound is actively bleeding. Normal sensation is present over the lateral aspect of the foot but decreased over the medial foot and great toe. Normal motion of the foot is observed. Dorsalis pedis and posterior tibial pulses are easily palpable on the left, but heard only by Doppler on the right. Immediate efforts to improve circulation to the injured extremity should involve: immediate angiography. tamponade of the wound with a pressure dressing. wound exploration and removal of bony fragments. realignment of the fracture segments with a traction splint. fasciotomy of all four compartments in the lower extremity. 24-year-old man sustains multiple fractured ribs bilaterally as a result of being crushed in a press at a plywood factory. Examination in the emergency department reveals a flail segment of the patient's thorax. Primary resuscitation includes high-flow oxygen administration via a nonrebreathing mask, and initiation of Ringer' s lactate solution. The patient exhibits progressive confusion, cyanosis, and tachypnea. Management at this time should consist of: intravenous sedation. external stabilization of the chest wall. increasing the F102 in the inspired gas. intercostal nerve blocks for pain relief. endotracheal intubation and mechanical ventilation. 23-year-old man is brought immediately to the emergency department from the hospital' s parking lot where he was shot in the lower abdomen. Examination reveals a single bullet wound. He is breathing and has a thready pulse. However, he is unconscious and has no detectable blood pressure. Optimal immedi'ate management is to: perform diagnostic peritoneal lavage. initiate infusion of packed red blood cells.

insert a nasogastric tube and urinary catheter. transfer the patient to the operating room, while initiating fluid therapy. initiate fluid therapy to return his blood pressure to normotensive 25-year-old woman is brought to the emergency department after a motor vehicle crash. She was initially lucid at the scene and then developed a dilated pupil and contralateral extremity weakness. In t.he emergency department, she is unconscious and has a GCS score of 6. The initial management step for this patient should be to: obtain a CT scan of the head. administer decadron 20 mg IV. perform endotracheal intubation. initiate an W line and administer Mannitol 1 g/kg. perform an emergency linar hole on the side of the dilated pupil. Twenty-seven patients are seriously injured in an aircraft accident at a local airport. The basic principle of triage should be to: treat the most severely injured patients first. establish a field triage area directed by a doctor. rapidly transport all patients to the nearest appropriate hospital. treat the greatest number of patients in the shortest period of time. produce the greatest number of survivors based on available resources. Which one of the following statements is FALSE concerning Rh isoimmunization in the pregnant trauma patient? It occurs in blunt or penetrating abdominal trauma. Minor degrees of fetomaternal hemorrhage produce it. A negative Kleihauer-Betke test excludes Rh isoimmunization. This is not a problem in the traumatized Rh-positive pregnant patient. Initiation of Rh immunoglobulin therapy does not require proof of fetomaternal hemorrhage. 24-year-old woman passenger in an automobile strikes the wind screen with her face during a head-on collision. In the emergency department, she is talking and has marked facial edema and crepitus. The highest priority should be given to:

lateral, c-spine x-ray. upper airway protection. carotid pulse assessment. management of blood loss. determination of associated Injuries. Early central venous pressure monitoring during fluid resuscitation in the emergency department has the greatest utility in a: patient with a splenic laceration. patient with an inhalation injury. 6-year-old child with a pelvic fracture. patient with a severe cardiac contusion. 24-year-old man with a massive hemothorax. 32-year-old man is brought to the hospital unconscious with severe facial injuries and noisy respirations after an automobile collision. In the emergency department, he has no apparent injury to the anterior aspect of his neck. He suddenly becomes apneic, and attempted ventilation with a face mask is unsuccessful. Examination of his mouth reveals a large hematoma of the pharynx with loss of normal anatomic landmarks. Initial management of his airway should consist of: inserting an oropharyngeal airvvay. inserting a nasopharyngeal airway. performing a surgical cricothyroidotomy. performing fiberoptic-guided nasotracheal intubation. performing orotracheal intubation after obtaining a lateral c-spine x-ray. 42-year-old man, injured in a motor vehicle crash, suffers a closed head injury, multiple palpable left rib fractures, and bilateral femur fractures. He is intubated orotracheally without difficulty. Initially, his ventilations are easily assisted with a bag¬valve device. It becomes more difficult to ventilate the patient over the next 5 minutes, and his hemoglobin oxygen saturation level decreases from 98% to89 % . The most appropriate next step is to: obtain a chest x-ray. decrease the tidal volume. auscultate the patient's chest.

increase the rate of assisted ventilations. perform needle decompression of the left chest. 42-year-old man is trapped from the waist down beneath his overtumed tractor for several hours before medical assistance arrives. He is awake and alert until just before arriving in the emergency department. He is now unconscious and responds only to painful stimuli by moaning. His pupils are 3 mm in diameter and symmetrically reactive to light. Prehospital personnel indicate that they have not seen the patient move either of his lower extremities. On examination in the emergency department, no movement of his lower extremities is detected, even in response to painful stimuli. The most likely cause for this fmding is: an epidural hematoma. a pelvic fracture. central cord syndrome. intracerebral hemorrhage. bilateral compartment syndrome. An electrician is electrocuted by a downed power line after a thunderstorm. He apparently made contact with the wire at the level of the right mid thigh. In the emergency department, his vital signs are normal and no dysrhythmia is noted on ECG. On examination, there is an exit wound on the bottom of the right foot. His urine is positive for blood by dip stick but no RBCs are seen microscopically. Initial management should include: immediate angiography. aggressive fluid infusion. intravenous pyleography. debridement of necrotic muscle. admission to the intensive care unit for observation. Which one of the following physical findings suggests a cause of hypotension other than spinal cord injury? priapism. bradycardia. diaphragmatic breathing. presence of deep tendon reflexes.

ability to flex forearms but inability to extend them. Regarding shock in the child, which of the following is FALSE? Vital signs are age-related. Children have greater physiologic reserves than do adults. Tachycardia is the primary physiologic response to hypovolemia. The absolute volume of blood loss required to produce shock is the same as in adults. An initial fluid bolus for resuscitation should approximate 20 mL/kg of Ringer's lactate. All of the following signs on the chest x-ray of a blunt injury victim may suggest aortic rupture EXCEPT:: mediastinal emphysema. presence of a "pleural cap." obliteration of the aortic knob. deviation of the trachea to the right. depression of the left mainstem bronchus An 8-year-old boy falls 4.5 meters (15 feet) from a tree and is brought to the emergency department by his family. His vital signs are normal, but he complains of left upper quadrant pain. An abdominal CT scan reveals a moderately severe laceration of the spleen. The receiving institution does not have 24hour-a-day operating room capabilities. The most appropriate management of this patient would be to: type and crossmatch for blood. request consultation of a pediatrician. transfer the patient to a trauma center. admit the patient to the intensive care unit. prepare the patient for surgery the next day.

1. A 20 year old athlete is involved in motorcycle crash. When he arrives in the ER. He shouts that he cannot move his legs. On physical exam, there are no abnormalities of the chest, abdomen, or pelvis. The patient has no sensation in his legs and cannot move them, but his arms are moving. The patient's respiratory rate is 23, heart rate 88, and blood pressure is 80/60 mm Hg. He is pale and sweaty. What is most likely cause of his condition? a. b. c. d. e.

Neurogenic shock. Cardiac temponade. Myocardial contusion. Hypothermia. Abdominal hemorrhage.

2. A 22 year old male presents following a motorcycle crash. He complains of the inability to move or feel his legs. His blood pressure is 80/50 mm Hg, heart rate is 70, respiratory rate is 18. GCS is 15. Oxygen is 99%on 2L nasal prongs. Chest X-ray, pelvic X-ray, FAST are normal. Extremities are normal. His management should be: a. b. c. d. e.

2L of IV crystalloid and two units of pRBSs. 2L of IV crystalloid, manitol and IV steroids. 1 unit of albumin and compression stockings. Vassopressors and laprotomy. 2L of crystalloid and vassopressors if BPdoes not respond.

3. Which of the following signs is least reliable for diagnosing esophageal intubation? a. b. c. d. e.

Symmetrical chest wall movement. End-tidal CO2. Bilateral breath sounds. Oxygen saturation. Chest X-ray demonstrating the ETT tip positioned above the carnia.

4. A 6 months old infant, being held in her mother's arms, is ejected on impact from a vehicle that is struck head-on by an oncoming car travelling at 64 kph. The infant arrives in the ER with multiple facial injuries, is lethargic, and in severe respiratory distress. Respiratory support is not effective using a bag mask device. And her oxygen saturation is falling. Repeated attempts at orotracheal intubation are unsuccessful. The most appropriate procedure to perform next is: a. b. c. d. e.

Administer hellox and epinephrine. Perform nasotracheal intubation. Perform surgical cricothyriodotomy. Repeat orotracheal intubation. Perform needle cricothyroidtomy with jet insufflations.

5. 28 year old male is brought to ER. He was involved in fight, in which he was beaten with a wooden stick. His chest shows multiple severe bruises. Airway is clear, respiratory rate is 22, heart rate is 126, and systolic blood pressure is 90 mm Hg. Which of the following should be performed during the primary survey? a. GCS.

b. c. d. e.

Tetanus toxoid administration. Cervical spine X-ray. Blood alcohol level. Rectal exam.

6. Which one of the following injuries is addressed in the secondary survey? a. b. c. d. e.

Forearm fracture. Mid-thigh amputation. Open fracture with bleeding. Unstable pelvic fracture. Bilateral femur fractures with obvious deformity.

7. Which one of the following statements is true regarding access in pediatric resuscitation? a. b. c. d. e.

Intraosseous access should only be considered after five percutaneous attempts. Cut-down at the ankle is the preferred initial access technique. Internal jugular cannulation is the next preferred option when percutaneous venous access fails. Intraosseouscannulation should be the first choice for access. Blood transfusion can be delivered through intraosseous access.

8. A 35 year old female sustains multiple injuries in a motor vehicle crash and is transported to a small hospital in full spinal protection. She has a GCS of 4 and is being mechanically ventilated. Intravenous access is established and warmed crystalloid is infused. She remains hemodynamically normal and full spinal protection in maintained. Preparations are made to transfer her to another facility for definitive neurosurgical care. Prior to transport, which of the following tests or treatments is mandatory? a. FAST exam. b. Chest X-ray. ??? c. Lateral cervical spine X-ray.??? d. Administration of methiprednisolone. e. CT of abdomen. 9. A 23 year old male is stabbed below the right nipple. He is alert, and his oxygen is 98%. Chest tube was placed for treatment of hemopnueunthorax. BP 90/60 mm Hg after 1L of crystalloid solution. What is the next step in treatment? a. b. c. d. e.

Place a left-sided chest tube. Re-examine the chest. Inscert central venous catheter. Perform CT scan of the abdomen and pelvis. Prepare for urgent throacotomy.

10. A 22 year old male is assaulted in a bar. A semi-rigid cervical coller is applied, and he is immobilized on a spine board. On initial exam, VS are normal, GCS is 15. Which of the following is an indication for CT in this patient with possible minor traumatic brain injury? a. Presence of hemotympanum. b. Blood alcohol concentration of 0.16%.

c. Presence of an isolated 10 cm scalp laceration. d. Presence of a mandibuler fracture. e. History of assult. 11. A 23 year old construction worker is brought to ER after falling more than 9 meters. VS: HR is 140, BP is 90/60, and RR is 36. He is complaining bitterly of lower abdominal and lower limb pain, and his obvious deformity of both lower legs with bilateral open tibial fractures. Which of the following statements concerning the patient is true? a. b. c. d. e.

Pelvic injury can be ruled out based on the mechanism of injury. Blood loss from the lower limbs is the most likely cause of hypotension. X-ray of the chest and pelvis are important adjacent in his initial assessment. Spinal cord injury is most likely cause of his hypotension. Aortic injury is the most likely cause of his tachycardia.

12. A 25 year old female in the third trimester of pregnancy is brought to ER following a highspeed motor vehicle crash. She is conscious and immobilized on long spine board. RR is 24, HR is 120, and BP is 70/50. Labs show a PaCO2 of 40 mm Hg. Which one of the following statements concerning this patient is true? a. b. c. d. e.

Fetal assessment should take priority. Log rolling the patient to the right will decompress the vena cava. Rh-immunoglubulin therapy should be immediately administered. The patient has likely impending respiratory failure. Vasopressors should be given to the patient.

13. A 30 year old male is stabbed in the right chest. On arrival to ER, he is very short of breath. HR is 120 and BP is 80/50 mm Hg. His neck veins are flat. There is no diminished air entry on the right side, and there is dullness posteriorly on percussion. These findings are most consistent with: a. b. c. d. e.

Tension pneumothorax. Pericardial tamponade. Hypovolemia from liver injury. Hemothorax. Spinal cord injury.

14. A specific aspect of the treatment of thermal injuries is: a. b. c. d. e.

Chemical burns require the immediate removal of clothing. Patients who sustain thermal injury are at lower risk of hypothermia. Patients with circumferential burns need prompt fasciotomies. Electrical burns are associated with extensive skin necrosis (from entry point to exit). The Parkland formula should be used to determine adequacy of resuscitation.

15. A 15 year old male is brought to ER after being involved in a motor vehicle crash. He is unconscious and was intubated at the scene by EMS. On ER, O2 is 92%, HR is 96 and BP is 150/85 mm Hg. Breath sounds are decreased on the left side of the thorax. The next step is:

a. b. c. d. e.

Immediate needle cricothyroidotomy. Immediate needle thoracocentesis. Chest tube insertion. Reassess the position of endotracheal tube. Obtain a chest X-ray.

16. Which one of the following statements is true? a. b. c. d. e.

Elevated ICP will not affect cerebral perfusion. CSF cannot be displaced from the cranial vault. Cerebral blood flow (CBF) is increased when the PaCO2 is below 30 mm Hg. AutoregulationCBF normally occurs between cerebral perfusion pressures of 50 to 150. Hypotonic fluids should be used to limit brain edema in patients with severe head injury.

17. The first priority in the management of a long bone fracture is: a. b. c. d. e.

Reduction of the pain. Prevention of infection in case of an open fracture. Prevention of further soft tissue injury. Control of hemorrhage. Improve long-term function.

18. A 40 year old obese patient with GCS of 8 requires a CT. before transfer to CT you should: a. b. c. d. e.

Give more sedative drugs. Insert a multilumen esophageal airway. Insert a definitive airway. Request a lateral cervical spine film. Insert a nasogastric tube.

19. Lateral cervical spine films: a. b. c. d. e.

Must be performed in the primary survey. Can exclude any significant spinal injury. Should be combined with clinical exam, AP and odontoid, CT. Are indicated in all trauma patients. Require the following films: oblique views, AP, odontoid and flexion-extension views prior to spinal clearance in trauma patients.

20. A 30 year old male is brought to ER after falling 6 m. Flail chest on the right, tachypneic and normal breath sounds. No hyperresonance or dullness. On oxygen by face mask.ABG are: PaO2 of 45, PaCO2 of 28 and pH of 7.47. Abnormalities in the patient's blood gases is due to: a. b. c. d. e.

Hypoventilation. Hypovolemia. Small pneumothorax. Pulmonary contusion. Flail chest.

21. An 82 year old male falls down five stairs and presents to the ER. All are true statements regarding his condition compared to a younger patient with similar mechanism, except: a. He is more likely to have had contracted circulatory volume prior to his injury. b. His risk of cervical spine injury is increased due to degeneration, stenosis, and loss of disk compressibility. c. Intracranial hemorrhage will become sympotmatic more quickly. d. His risk of occult fractures is increased. e. His risk of bleeding may be increased. 22. The most specific test to evaluate for injuries of solid abdominal organs is: a. b. c. d. e.

Abdominal X-ray. Abdominal U/S. DPL Frequent abdominal examination CT of abdomen and pelvis.

23. A 14 year old female is brought to ER after falling from a horse. She is immobolizedon a long spine board with a hard collar and blocks, cervical spine X-rays: a. Will show cervical spine injury in more than 20% of these patients. b. Will exclude cervical spine injury if no abnormalities are found on the X-rays. c. Are not needed if she is awake, alert, neurologically normal, and has no neck pain or midline tenderness. d. Should be performed before addressing potential breathing or circulatory problems. e. May show atlanto-occipital dislocation if the power's ratio is < 1. 24. The most important consequences of inadequate organ perfusion is: a. b. c. d. e.

Multiple organ failure. Decreased base deficit. Acute gloumerulnephritis. Increased ATP production. Vasodilatation.

25. Hypertension following a head injury: a. b. c. d. e.

Should be treated to reduce ICP. May indicate imminent herniation from critically high ICP. Indicates pre-existing hypertension. Mandates prompt administration of mannitol. Should prompt burr hole drainage of potential subdural hematomas.

26. Initial treatment of frostbite injuries involves: a. Application of dry heat. b. Rapid rewarming of the body part in circulating WARM water. c. Debridement of hemorrhagic blisters.

d. Early amputation to prevent septic complications. e. Massage of the affected area. 27. Signs and symptoms of airway compromise include all of the following except: a. b. c. d. e.

Change in voice. Stridor. Decreased pulse pressure. Dyspnea and agitation. Tachypnea.

28. Which one of the following statements is true regarding a pregnant patient who presents following blunt trauma? a. Early gastric decompression is important. b. A hemoglobin level of 10 g/dl indicates recent blood loss. c. The central venous pressure response to volume resuscitation is blunted in pregnant patients. d. A lap belt is the best form of restraint due to the size of the gravid uterus. e. A PaCO2 of 40 mm Hg provides reassurance about the adequacy of respiratory function. 29. A 30 year old is brought to ER after being injured in a motor vehicle crash. BP is 90/60 and HR is 122. She responds to the rapid infusion of 1 liter of crystalloid solution with a rise in her BP to 118/ 88 and a decrease in her HR to 90. Her BP then suddenly decreases to 96/66. The least likely cause of her hemodynamic change is: a. b. c. d. e.

Traumatic brain injury. Ongoing blood loss. Blunt cardiac injury. Inadequate resuscitation. Tension pneumothorax.

30. Limb-threatening extremity injuries: a. b. c. d. e.

Require a tourniquet. Are characterized by the presence of ischemic or crushed tissue. Should be definitively managed by application of a traction splint. Are rarely present without an open wound. Indicates a different order of priorities for the patient's initial assessment and resuscitation.

31. A 29 year old female arrives in ER after being involved in a motor vehicle crash. She is 30 weeks pregnant. She was restrained with a lap and shoulder belt, and an airbag deployed. Which one of the following statements best describes the risk of injury? a. The deployment of the airbag increases the risk of fetal loss. b. The use of seatbelts is associated with increased risk of maternal death. c. The mechanism of injury suggests the need for emergency C-section due to the risk of impending abruption placenta. d. The risk of premature fetal delivery and death is reduced by the use of restraints.

e. The deployment of the airbag increases the risk of maternal abdominal injury. 32. Supraglottic airway devices: a. b. c. d. e.

Are equivalent to endotracheal intubation. Require neck extension for proper placement. Are preferable to endotracheal intubation in a patient who cannot lie flat. Are of value as part of a difficult or failed intubation plan. Provide one form of definitive airway.

33. A 70 year old male suffers blunt chest trauma after being struck by a car. On ER, GCS is 15, BP is 145/90, HR is 72, RR is 24 and O2 saturation on 5L is 91%. Chest X-ray shows multiple rib fractures. ECG shows normal sinus rhythm with no conduction abnormalities. Management should include: a. b. c. d. e.

Placement of a 22-french, right-sided chest tube. Serial troponins and cardiac monitoring. Thoracic splinting, taping, and immobilization. Monitored IV analgesia. Bronchoscopy to exclude tracheobronchial injury.

34. A 15 year old male presenting after a motorcycle crash. Initial exam reveals normal VS. There is a large bruise over his epigastrium that extends to left flank. He has no other appearent injuries. A CT of abdomen shows ruptured spleen surrounded by a large hematoma and fluis in the pelvis. The next step in this patient's management is: a. b. c. d. e.

Splenic artery immobilization. Pneumococcal vaccine. Transfer to pediatrician. Urgent laparotomy. Surgical consultation.

35. A 30 year old male presents with a stab wound to the abdomen. BP is 85/60, HR is 130, RR is 25 and GCS is 14. Neck veins are flat, and chest exam is clear with bilateral breath sounds. Optimal resuscitation should include: a. b. c. d. e.

Transfusion of fresh frozen plasma and platelets. 500 mL of hypertonic saline and transfusion of pRBSs. Resuscitation with crystalloid and pRBCs until base excess is normal. Preparation for laparotmy while initiating fluid resuscitation. Fluid resuscitation and angioemobolization.

36. Initial resuscitation in adult trauma patients should: a. b. c. d. e.

Be with 1-2 liters of crystalloid, monitoring the patient's response. Use crystalloid to normalize BP. Use permissive hypotension in patients with head injury. Be with anon-blood colloid solution. Be a minimum of 2 L of crystalloid in all trauma patients prior to administering blood.

37. A 25 year old male is brought to ER following a bar fight. He has an altered level of consciousness, opens his eyes on command, moans without forming discernible words, and localizes to painful stimuli. Which one of the following concerning this patient is correct? a. b. c. d. e.

Mandatory intubation to protect his airway is required. His GCS suggests a severe head injury. His level of consciousness can be solely attributed to elevated blood alcohol. CT is an important part of neurological exam. Hyperoxia should be avoided.

38. Which one of the following statements regarding genitourinary injuries is true? a. Urethral injuries are associated with pelvic fractures. b. All patients with microscopic hematuria require evaluation of the genitourinary tract. c. Patients with gross hematuria and shock will have a major renal injury as the source of hemorrhage. d. Intraperitoneal bladder injuries are usually managed definitively with a urinary catheter. e. Urinary catheters should be placed in all patients with pelvic fractures during the primary survey. 39. Which one of the following physical findings does not suggest spinal cord injury as the cause of hypotension? a. b. c. d. e.

Priapism. Bradycardia. Distended neck veins. Diaphragmatic breathing. Ability to flex forearms but inability to extend them.

40. Cardiac temponade: a. b. c. d. e.

Is definitively managed by needle pericardiocentesis. Is most common with blunt thoracic trauma and anterior rib fractures. Is easily diagnosed by discovery of Beck's triad in the ER. Is indicated by Kussmaul breathing. Requires surgical intervention.

First group ATLS questions.. 1- triage concept : save more lives with available resources 2- a patient with gun shot , BP 70/0 , Chest tube drained 120 ml , chest sounds normal. next step? - Laboratomy 3- persistent pneumothorax after placing chest tube. Diagnosis? - Tracheobronchial injury 4- which of the following is not part of the initial assessment? - determining incomplete,or complete neurological deficit 5- echomosys in prenium , blood in mayatus ,what will you do? - retrograde urethrogram 6- Class II shock: - normal BP 7- patient with minimal trauma to chest and tenderness,ABCDE are good, how to manage? - pain medication 8- old patient on B-blocker and Coumadin (warfarin), decreased BP, normal pulse, which of the following is true? - excessive fluids cause cardiopulmonary failure. 9- indication for intubation? - maxilofacial injury 10- moderate head injury- GCS 11, what to do? - CT scan+repeat GCS assessment 11-Neurogenic shock except: neurologic deficit 12- Neurogenic shock management: vassopressor 13- initial step in multiple injured pt: ask the patient's name 14- pt. with blunt trauma to abdomen.. Decreased BP, no external bleeding: FAST 15- DPL: most sensitive 16- unsucceful endotracheal intubation: surgical cricothyroidectomy 17- anatomy: choroid plexus produce CSF in the lateral and third ventricle.. 18- failed intubation: bogie 19- unconscious baby then awake then deteriorate: epidural 20- pt fell and can't move lower limb with sensory problem: spinal shock 21- laparotomy indication: CT with retroperitoneal air 22- circumfrential burn: escharotomy 23-Pediatric: flexible mediastinum 24- sacral sparing: good prognosis 25- most common cause of acid base problem in pediatrics: ventilation 26- 80 kg male with 50% burn and received 1 L NS came after 3 hour.. What is the fluid per hour in the next 5 hours?1400 ml/hr 27- X-ray of ruptured aorta except: air in mediastinum 28- indication to anti-Rh in pregnant women except: gunshot wound to the foot 29- pregnant lady with PV bleeding, initial assessment Airway.. 30- difficulty in respiration, loss of sensation in the foot?- possible cervical injury

1. Which of the following is addressed in the secondary survey? Answer: Forearm fracture 2. A young male fallen from height with obvious flail chest. ABG shows pH of 7.47. what is the cause of this abnormality? Answer: pulmonary contusion 3. Cushing's triad which occurs in cases of increased intracranial pressure? Answer: Bradycardia with irregular respirations and isolated increase in SYSTOLIC BLOOD PRESSURE. 4. Trauma in pregnant women, clear fluid leakage from vagina is an indication for hospitalization. 5. blood at the external meatus  do RUG 6. Scenario of pelvic fracture, which statement is correct? Answer: vertical shear force with posterior ligaments disruption. 7. 12 year old boy sustained blunt abdominal trauma while playing football. FAST scan is positive. He is hemodynamically stable. What to do next? Answer: CT abdomen 8. Old patient, had multiple rib fractures, splinting of the right chest, what to do? Answer: give analgesic. 9. Memorize indications for burn transfer ( eg> 10% surface area affected  transfer) 10. In comparison with young adults, elderly patients exhibit which of the following regarding brain injuries? A- increased cerebral blood flow. B- less stretching of bridging veins C- less subdural hematomas D- less brain contusions E- les mobility with angular acceleration and deceleration. 11. Which of the following will be missed by DPL? Answer: subcapsular hematoma of the spleen (because it is a retroperitoneal organ) 12. Which of the following tests will evaluate the retroperitonium? Answer: CT 13. Patient tried to commit suicide with a rope (hyperextension of the neck), when he presented to ER he had hoarsness of voice and crepitation in the neck, what to do? A- needle cricothyroidotomy B- surgical tracheostomy in OR C- direct laryngoscopy and intubation. Answer: ???? 14. Burn victim with signs of inhalation injury (carboneacous material, singed eyebrows)  Intubate. 15. Burn victim, has circumferential burn, core temperature is 34 C. what next? A- escharatomy Brewarm C- oxygen mask (I think the answer is C oxygen mask because you should follow the ABCD priorities) 16. Which of the followings is NORMAL in pregnancy? A-increased residual lung volume Bdecreased plasma volume C- decreased total RBC mass D- widened symphysis pubis. Answer is D 17. Trauma patient was hypotensive then you gave him 1 L of crystalloid and now he is alert and talking. Which of the following statements is correct? He has good cerebral blood flow 18. Which of the followings is a contraindication for nasal intubation? A- depressed skull fracture B- Le Fort III fractures. Answer is B (Le Fort III fractures causes cribriform plate fracture) 19. Which of the followings will benefit from oropharyngeal airway? A- posterior displacement of tongue B- laryngeal edema. Answer is A 20. Patient came with severe head injury GCS is 6 and has poor anal sphincter tone and diagrammatic breathing. His hands are flexed across the chest. What is the cause of his injury? A-isolated head injury. B-lumbosacral verterbral injury. C- Cervical vertebral injury. Answer is C 21. Question about widened mediastinum 22. Question about spinal board? Remove after completing assessment or it leads to decubetus ulcers .. 23. CSF is between? Arachinoid and pia matter. 24. Question about transfer? Transfer after stabilizing the patient.

25. Scenario with scalp laceration .. the priority was to stop the bleeding with direct pressure. The other choices are all after the circulation. 26. Patient with head injury and systemic hypotension, what is the most probable cause of his hypotension? A- bleeding in the brain B- systemic hypovolemia. Answer is B 27. Dorsal column? Carries proprioception from the same side of the body.