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ATLS Practice Test 4

E= 2
V= 2
M= 5
Total = 9

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2. e.
The condition should be suspected in situations associated with shock and unilateral absent breath
sounds. Other differential diagnosis includes tension pneumothorax. Differentiation on physical
examination can be made by percussion; hyperresonance supports a pneumothorax, whereas
dullness suggests a massive hemothorax. The initial draining of 1,500 mL of blood after chest
tube insertion almost always requires immediate thoracotomy.

3. d.
A FAST scan is part of the primary survey. It can detect pericardial hemorrhage and abdominal
hemorrhage, and thus direct life-saving treatment. Given the chest radiograph findings indicative
of traumatic aortic rupture, CT angiography should also be done, but has a lower priority than a
FAST scan. If the patient were to start exsanguinating, immediate thoracotomy would be
required - CT scan or not. There is no indication for tube thoracostomy.

4. b.
Leakage of amniotic fluid is an indication for hospital admission. Penetration of an abdominal
hollow viscus is less common in late than in early pregnancy. Indications for peritoneal lavage
are the same as those in the nonpregnant patient. The secondary survey follows the same pattern
as that of the nonpregnant patient.

5. c.
Supplemental oxygen must be administered to all trauma patients. It is simple and instant and
should be one of the first maneuvers done. Because changes in oxygenation occur rapidly and
are impossible to detect clinically, pulse oximetry must be used at all times.

6. b.
A long spine board is the basic apparatus for splinting the spine. It provides an effective splint
and permits safe transfers of the patient with a minimal number of assistants. Other equipment
required includes semirigid cervical collar, head immobilization, and straps. Note that with a
GCS of 7, the patient should also be intubated.

7. c.
Femoral fractures may result in significant blood loss into the thigh. The patient likely has at
least 30% loss of blood volume.

8. c.
A urethral catheter must not be inserted if there is a tear in the urethra. Signs that may indicate a
tear are scrotal hematoma, high-riding prostate, perineal ecchymoses, blood at urethral meatus,
inability to void, and unstable pelvic fracture (the first two would only apply to males of course).
If any of these is present, retrograde urethrography should be done prior to catheter insertion.

9. a.
The goal is to maintain normal blood volume. Monitoring of hourly urinary output can reliably
assess circulating blood volume, assuming there is no osmotic diuresis (e.g. due to glycosuria).
The Parkland formula is only a rough, albeit useful, guide.

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10. c.
Shock, head injury, impaired oxygenation, and alcohol and other drugs are all more likely causes
of depressed level of consciousness in the multisystem injured patient than is hyperglycemia.

11. e.
Shock is defined as an abnormality of the circulatory system that results in inadequate organ
perfusion and tissue oxygenation.

12. b.
Direct pressure on the wound is the best way to stop the hemorrhage. If this fails, a tourniquet
may be considered. Clamping of a vessel is not recommended unless it can be clearly visualized.

13. c.
Hypercarbia causes cerebral vasodilation, which would worsen cerebral edema.

14. b.
The patient is still in shock after initial attempts at fluid resuscitation. Possible reasons are
hemorrhaging from the great vessels, cardiac tamponade, or both. Thoracotomy is indicated
provided a surgeon, qualified by training and experience, is available.

15. b.
The following suggest urethral injury and, thus, the need for retrograde urethrography:
inability to void,
unstable pelvic fracture,
blood at urethral meatus,
scrotal hematoma,
perineal ecchymoses, or
high-riding or absent or mobile prostate.

16. e.
In patients who have a decreased level of consciousness, the tongue can fall backward and
obstruct the hypopharynx. This form of obstruction can be corrected readily by the chin-lift or
jaw-thrust maneuvers. The airway can then be maintained with an oropharyngeal or
nasopharyngeal airway.

17. d.
Patients whose injuries exceed an institution’s capabilities for definitive care should be identified
and transferred early.

18. e.
The patient has hypotension without tachycardia or cutaneous vasoconstriction, which indicates
neurogenic shock. He, therefore, most likely has a spinal cord injury superior to T7. Along with
this, he can be expected to have spinal shock in which there is flaccidity of the lower extremities
and loss of deep tendon reflexes. The duration of this state is variable. Judicious use of

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vasopressors and atropine may be necessary in early management, along with moderate volume
replacement. Flexion and extension views of the c-spine should not be performed since these can
worsen the injuries. There should be a high index of suspicion for occult abdominal injuries,
especially since there is inability to perceive abdominal pain.

19. e.
Clear fluid from the vagina is either amniotic fluid or urine. Amniotic fluid has a pH of 7 to 7.5,
while urine is usually acidic. The presence of the former indicates ruptured chorioamnionic
membranes, and hospitalization is required. Other criteria for admission include vaginal
bleeding; uterine irritability; abdominal tenderness, pain or cramping; evidence of hypovolemia;
and changes in or absence of fetal heart tones. Palpation of clearly definable fetal parts may
indicate that they are outside the uterus. The wall of the uterus cannot be expected to provide
sufficient protection in a motor vehicle crash. Absence of fetal movements does not indicate
maternal shock; conversely, the mother may have normal vital signs while the fetus is in critical
condition or worse. The fetus may be in jeopardy even with apparently minor maternal injury.

20. e.
Cervical spine injury may be first manifested by neurologic deficit after movement of the neck.
C-spine injury may be present with a normal neurologic examination; and also with normal range
of motion of the neck. Flexion and extension of the neck should never initially be done to detect
C-spine injury as this may lead to further injuries. Nevertheless, active flexion and extension of
the neck is used to clinically confirm the absence of C-spine injury when the probability of it is
determined to be low. C-spine injury cannot be excluded by a crosstable lateral roentgenogram
alone – at least two additional views are needed: anteroposterior (AP) and open mouth odontoid.
Alternatively, CT scanning from the occiput to T1 with sagittal and coronal reconstructions may
be done.

21. c.
The most likely type of shock, given the history and the presentation, is hypovolemic shock.
Neurogenic shock would be characterized by the lack of tachycardia. Since airway and breathing
do not appear to be threatened, attention should be directed to circulation (ABCDEs). Depending
on further diagnostic studies, he may undergo exploratory laparotomy, be placed in cervical
traction tongs, etc.; but the priority, presently, is for fluid resuscitation.

22. c.
The four patterns of force leading to pelvic fractures include anterior-posterior compression,
lateral compression, vertical shear, and complex (combination) pattern. AP compression results
in open book fractures. Lateral compression results in closed book fractures. A vertical shear
fracture results from a high-energy shear force applied in a vertical plane across the pelvic ring.
This disrupts the sacrospinous and sacrotuberous ligaments, and leads to major pelvic instability.

23. d.
This patient has late signs of compartment syndrome and requires lower extremity fasciotomies
to relieve the high pressures in the osteofascial compartments.

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24. d.

As can be seen from the table above demonstrating the Classes of Hemorrhage, a 20% loss of
blood volume is a class II hemorrhage. Therefore, it is expected that the patient would be
tachycardic, have normal systolic BP but decreased pulse pressure, be mildly tachypneic, mildly
oliguric, mildly anxious, and would require crystalloids but not a blood transfusion. Thus,
answers a. and d. are correct. The student must choose the best answer, which is probably d.

25. b.
Proper positioning of the needle is confirmed by aspiration of bone marrow. Crystalloids, blood
products, and drugs may be safely infused through the needle. Intraosseous infusion is not the
preferred route for volume resuscitation; rather, two peripheral intravenous catheters are
preferred. To minimize the risk of developing osteomyelitis, an intraosseous catheter should be
removed as soon as other venous access has been obtained. Similarly, swelling in the soft tissue
around the intraosseous site is a reason to discontinue infusion.

26. b.
The patient should undergo prompt laparotomy. The indications for prompt laparotomy include:
● Free air, retroperitoneal air, or rupture of the hemidiaphragm.
● Peritonitis.
● Penetrating abdominal wound with hypotension.
● Blunt abdominal trauma with hypotension and a positive FAST or clinical evidence of
intraperitoneal bleeding.
● Blunt or penetrating abdominal trauma with a positive DPL.
● Gunshot wound traversing the peritoneal cavity or visceral/vascular retroperitoneum.
● Evisceration.
● Bleeding from the stomach, rectum, or genitourinary tract from penetrating trauma.
● Contrast-enhanced CT that demonstrates ruptured gastrointestinal tract, intraperitoneal
bladder injury, renal pedicle injury, or severe visceral parenchymal injury after blunt or
penetrating trauma.

27. c.
A head CT would delay transfer to a facility that can provide definitive care, and this delay would
tend to worsen outcomes.

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28. b.
20 kg x 20 mL/kg = 400 mL

29 e.
The duodenum is retroperitoneal, so a duodenal rupture would result in blood and GI contents
accumulating in the retroperitoneum, not the peritoneal cavity where it would be detected by
FAST or DPL. CT or MRI is the modality of choice to assess the retroperitoneum.

30. a.
Remember the ABCDEs of ATLS apply in all situations. Airway is always first and foremost.

31. d.
This is a class III hemorrhage. From the table below, the systolic blood pressure and the pulse
pressure would be decreased. Also, the urinary output would be below normal.

32. d.
Because of increased intravascular volume, pregnant patients can lose a significant amount of
blood before tachycardia, hypotension, and other signs of hypovolemia occur. Crystalloid fluid
resuscitation and early type-specific blood administration are indicated to support the physiologic
hypervolemia of pregnancy.

33. e.
With a respiratory rate of 32 breaths per minute, there is clearly respiratory distress. Attention
should immediately be directed to the airway and breathing. A pulse rate of 120 beats per minute
is also of concern, but of lesser priority. A GCS of 11 is not an indication for intubation.

34. d.
Once a spinal fracture has been excluded clinically or by roentgenograms, the injured patient may
be allowed to move.

35. d.
Initial management of an open pneumothorax is accomplished by promptly closing the defect
with a sterile occlusive dressing. The dressing should be large enough to overlap the wound’s
edges and then taped securely on three sides in order to provide a flutter-type valve effect. As the
patient inhales, the dressing occludes the wound, preventing air from entering. During exhalation,
the open end of the dressing allows air to escape from the pleural space. A chest tube remote
from the wound should be placed as soon as possible.

36. c.
Cervical spine, chest, and pelvis radiographs, as well as FAST, would be indicated. Skull and
abdomen radiographs have little utility compared to other modalities, such as CT and US.

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37. c.
The pulse oximeter colorimetrically measures the oxygen saturation of hemoglobin and the pulse
rate continuously. It does not measure the partial pressure of oxygen. It also does not measure
carbon dioxide, which reflects the adequacy of ventilation.

38. c.
If a tension pneumothorax were present, breath sounds would be absent. If cardiac tamponade
were present, breath sounds would be present. Both conditions would be associated with
tachycardia, decreased pulse volume, decreased pulse pressure, and elevated jugular venous
pressure.

39. a.
The trachea is relatively short in infants, so intubation of a bronchus is more likely.

40. d.
The arterial blood gas analysis shows acute respiratory acidosis; thus, the causes of this must be
found and corrected. The differential diagnosis includes the circumferential chest burn restricting
inspiration, which would require a fasciotomy; and pneumothorax, which would require chest
tube insertion. Smoke inhalation is another possibility, the management of which is supportive
care. Adding positive end-expiratory pressure (PEEP) would increase PaO2 somewhat, but
would not be as beneficial as improving any hypoventilation.