A&E ATLS TEST – answers at the end

1-1. A 22-year-old man sustains a shotgun wound to the left shoulder. His blood pressure is
initially 80/40. After two liters of Ringer's lactate solution his blood pressure increases to
122/84. His pulse rate is now 100 beats per minute and his respiratory rate is 28 breaths per
minute. His breath sounds are decreased in the left hemithorax, and a closed tube thoracostomy
is performed with the return of a small amount of blood with no air leak. The most appropriate
next step is to

a. re-examine the chest.

b. perform an aortogram.
c. obtain a CT scan of the chest.
d. obtain arterial blood gas analyses.
e. perform transesophageal echocardiography. ;

1-2. A four-year-old girl, weighing approximately 20 kg (44 pounds), is admitted in shock after an
automobile crash. The initial fluid challenge or bolus should consist of Ringer's lactate solution in
the volume of

a. 200 mL.
b. 400 mL.
c. 440 mL.
d. 600 mL.
e. 880 mL.
1-3. All of the following are considered minimal precautions for the prevention of the spread of
communicable diseases during resuscitation EXCEPT

a. goggles. b. face mask. c. water-impervious gown. d. water-impervious leggings.

e. needle-impenetrable sterile gloves.

1-4. In managing the head-injured patient, the most important initial step is to

a. secure the airway.

b. immobilize the neck.
C. support the circulation.
d. control scalp hemorrhage.
e. determine the Glasgow Coma Scale Score.

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 1-5. A previously healthy, 70 kg (175 pound) man suffers an estimated acute blood loss of two liters.
Which one of the following statements apply to this patient?

a. His pulse pressure will be widened.

b. His urinary output will be at the lower limits of normal.
c. He will have tachycardia, but no change in his systolic blood pressure.
d. His systolic blood pressure will be decreased with a narrowed, pulse pressure.
e. His systolic blood pressure will be maintained with an elevated diastolic pressure.

1-6. The "physiologic hypervolemia" of pregnancy has clinical significance in the management of the
severely injured, gravid woman by

a. reducing the need for blood transfusion.

b. increasing the risk of pulmonary edema.
c. complicating the management of closed head injury.
d. increasing the volume of blood loss to produce shock.
e. reducing the volume of crystalloid required for resuscitation.

1-7. A 17-year-old helmeted motorcyclist loses consciousness when he is struck broad side by an
automobile at an intersection. He arrives in the emergency department with a blood pressure of 140/92,
pulse rate of 88. beats per minute, a respiratory rate of 18 breaths per minute, and a Glasgow Coma
Scale Score of seven. Appropriate initial immobilization of this patient should include a semi-rigid
cervical collar and

a. a scoop stretcher.
b.
a long spine board. a short
C.
spine board. cervical
d.
traction tongs.
e.
the pneumatic antishock garment.

1-8. A 34-year-old man is brought to the hospital after being pinned to the wall of a building
by a cement truck. He is in obvious shock, and has deformities and marked swelling of both thighs,
although no open wounds are present. His shock

a. cannot be explained without concomitant pelvic fracture.

b. signifies a loss of approximately 15 % of his blood volume.
c. is consistent with blood loss from bilateral femoral fractures.
d. will likely be reversed if appropriate traction splints are applied.
e. cannot be explained by his observed injuries unless a major arterial injury exists.

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 1-9. Prior to passage of a urinary catheter in a man, it is essential to

a examine the abdomen.

b.
C.
d.
e.

determine pelvic stability.

examine the rectum and perineum. perform a
retrograde urethrogram.
know the history and mechanism of injury.

1-10. The best guide for adequate fluid resuscitation of the burn patient is

a. adequate urinary output.

b. reversal of systemic acidosis.
c. normalization of the heart rate.
d. a normal central venous pressure.
e. four ml/kg/percent body burn/24 hours.

1-11. The LEAST likely cause of a depressed level of consciousness in the multisystem injured patient
is
a. shock.
b. head injury.
c. hyperglycemia.
d. impaired oxygenation.
e. alcohol and other drugs.

1-12. Establishing a diagnosis of shock must include

a. confirming hypoxemia.
b. the finding of acidosis.
c. confirming increased vascular resistance.
d. documenting hypotension and low cardiac output.
e. evidence of inadequate perfusion of the body's organs.

1-13. A seven-year-old boy is brought to the emergency department by his parents several minutes
after he fell through a window. He is bleeding profusely from a 6-cm (2.4-inch) wound of his medial
right thigh. Immediate management of the wound should consist of

a. application of a tourniquet.

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 b. direct pressure on the wound.
c. apply a hemostat to bleeding vessels.
d. direct pressure on the femoral artery at the groin.
e. application of the pediatric PASG and inflation of the right leg compartment.

1-14. For the trauma patient with cerebral edema, hypercarbia should be avoided to prevent

a. metabolic acidosis.
b. respiratory acidosis.
c. cerebral vasodilatation.
d. neurogenic pulmonary edema.
e. reciprocal high levels of PaCO 2.

1-15. A 25-year-old man is brought to the hospital after being involved in a motor vehicular crash
when his car struck a bridge abutment. He is intoxicated, has a Glasgow Coma Scale Score of
13, and complains of abdominal pain. His blood pressure was 80 mm Hg systolic by palpation on
admission to the hospital, but it rapidly increased to 110/70 with the administration of intravenous
fluids. His heart rate is now 120 beats per minute. The chest roentgenogram shows loss of the
aortic knob, widening of the mediastinum, no rib fractures, and no hemopneumothorax. Contrast
angiography

a. is not indicated.
b. should be performed after a CT scan of the chest.
c. is not necessary if the CT scan of the chest is normal.
d. should be performed.after diagnostic peritoneal lavage.
e. is positive for aortic rupture in 80% of similar cases.

1-16. Which one of the following statements regarding abdominal trauma in the pregnant patient
is TRUE?

a. The fetus is in jeopardy only with major abdominal trauma.

b. Leakage of amniotic fluid is an indication for hospital admission.
c. Indications for peritoneal lavage are different from those in the nonpregnant
patient.
d. Penetration of an abdominal hollow viscus is more common in late than in early
pregnancy.
e. The secondary survey follows a different pattern from that of the nonpregnant
patient.

1-17. The first maneuver to improve oxygenation after chest injury is

a. intubate the patient.

b. assess arterial blood gases.
C. administer supplemental oxygen.
d. ascertain the need for a chest tube.

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 e. obtain a lateral cervical spine roentgenogram.

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 1-18. A 25-year-old man, injured in a motor vehicular crash, is admitted to the emergency
department. His pupils react sluggishly and his eyes open to painful stimuli. He does not follow
commands, but he does moan periodically. His right arm is deformed and.does not respond to painful
stimulus; however, his left hand reaches toward it. Both legs are stiffly ,ended. His Glasgow
Coma Scale Score is

a. two. B. four c. six d. nine e. twelve

1-19. Which one of the following statements concerning massive hemothorax is TRUE?

a. It is usually caused by blunt thoracic trauma.

b. It is commonly confused with a pneumothorax.
c. The diagnosis should be confirmed by upright, plain chest roentgenograms prior to
treatment.
d. The initial draining of 1,000 mL of blood after chest tube insertion requires
immediate thoracotomy.
e. The condition should be suspected in situations associated with shock and unilateral
absent breath sounds.

1-20. Which one of the following findings should prompt immediate management during the primary
survey?

a. Distended abdomen
b. Glasgow Coma Scale Score of 11
c. Pulse rate of 120 beats per minute
d. Temperature of 36.5' C (97.8' F)
e. Respiratory rate of 32 breaths per minute.

1-21. During the primary and secondary surveys, the patient injured by blunt trauma should be
completely immobilized until

a. the neurologic examination has been completed.

b. the patient is transferred to a definitive care area.
c. the patient is able to indicate that he has no neck pain.
d. a spinal fracture has been excluded by roentgenograms.
e. the patient complains of potential pressure sores due to the spine board.

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 1-22. The most important, immediate step in the management of an open pneumothorax is

a. endotracheal intubation.
b. operation to close the wound.
c. placing a chest tube through the chest wound.
d. placement of an occlusive dressing over the wound.
e. initiation of two, larg e-caliber IVs with Ringer's lactate.

1-23. Important screening roentgenograms to obtain in the multiple-system trauma patient are

a. skull, chest, and abdomen.

b. chest, abdomen, and pelvis.
c. cervical spine, chest, and pelvis.
d. skull, cervical spine, and chest.
e. cervical spine, chest, and abdomen.

1-24 All of the following statements regarding pulse oximetry are true EXCEPT:

a. Excessive surrounding room light can interfere with the accuracy of the readings.
b. Significant levels of dysfunctional hemoglobin can affect the accuracy of the readings.
c. It provides a continuous, noninvasive measurement of the partial pressure of oxygen.
d. It is dependent on differential light absorption by oxygenated and deoxygenated
hemoglobin.
e. It provides a continuous, noninvasive measurement of pulse rate that is updated with each
heart beat.

1-25. A 56-year-old man is thrown violently against the steering wheel of his truck during a
motor vehicular crash. On arrival in the emergency department he is diaphoretic and cQalpl g of
chest pain. His blood pressure is 60/40 and his respiratory rate is 40 moths per minute. Which of
the following would best differentiate cardiac tamponade from tension pneumothorax as the cause
of his hypotension?

a . Tachycardia b. Pulse volume c . Breath sounds d . Pulse pressure e . Jugular venous pressure

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 1-26. Bronchial intubation of the right or left mainstem bronchus can easily occur during infant
endotracheal intubation because

a. the trachea is relatively short. '

b. the distance from the lips to the larynx is relatively short.
c. the use of tubes without cuffs allows the tube to slip distally.
d. the mainstem bronchi are less angulated iin their relation to the trachea.
e. so little friction exists between the endotracheal tube''and the wall of the trachea.

1-27. A 52-year-old woman sustains 50 % total body-surface flame burns in an explosion. She has
burns around the chest and of both upper arms. Adequate resuscitation is initiated. She is
nasotracheally intubated and is being mechanically ventilated. Her carboxyhemoglobin level is
10%. Her arterial blood gas analyses reveal PaO 2 of 40 mm Hg, PaCO 2 of 60 mm Hg, and pH of
7.25. Appropriate immediate management at this time is to

a. ensure adequate tissue perfusion.

b. increase the rate of fluid resuscitation.
c. add positive end-expiratory pressure (PFFP).
d reassess for the presence of a pneumothorax.
e administer intravenous narcotics in small amounts.

1-28. A 23-year-old man sustains four stab wounds to the upper right hemithorax during an
altercation and is brought by ambulance to a community hospital. The wounds are all above the
nipple. He is endotracheally intubated, closed tube thoracostomy is performed, and two liters
of ,Ringer's lactate solution are infused through two large-caliber IVs. His blood pressure now is
60/0, pulse 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
a. angiography..
b. thoracotomy.

. It

c. CT of the chest.

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 d. application of PASG.
e. immediate transfer to another facility

1-29. All of the following suggest urethral injury EXCEPT:

a. scrotal hematoma.
b. blood in the Wctal lumen...
c. blood at the external urethral meatus.
d. high-riding prostate on rectal examination. ,
e. absence of a palpable prostate on rectal examination.

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 1-30. A 38-year-old construction worker is brought to the hospital after being crushed in a
foundation cave-in. A pneumatic antishock garment (PASG) was applied and inflated by
prehospital personnel. He has no symptoms of respiratory compromise. His blood pressure is
120/80 and his pulse rate is 110 beats per minute. He is conscious and alert. He reportedly has
open fractures of both legs. Examination of the patient's legs is best accomplished by

a. Moist heat
b. Early amputation
c. Padding and elevation
d. Vasodilators and heparin
e. Topical application of silvasulphadiazine

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 a. deflating the garment one leg at a time.
b. keeping the PASG inflated and obtaining roentgenograms.
c. deflating the PASG guided by the patient's circulatory status.
d. immediately and temporarily deflating and removing the PASG.
e. deflating one leg compartment and keeping the PASG abdominal compartment
inflated.

1-31. The primary indication for transferring a patient to a higher level trauma center is

a. multisystem injuries, including severe head injury.

b. unavailability of a surgeon or operating room staff.
c. unavailability of an intensive care unit bed or ICU staff.
d. resource limitations as determined by the referring physician.
e. a widened mediastinum on chest roentgenogram after blunt thoracic trauma.

1-32. A patient is brought to the emergency department 20 minutes after a motor vehicular
crash. He is conscious and there is no obvious external trauma. He arrives at the hospital
intubated and completely immobilized on a long spine board. His blood pressure is 60/40 and his
pulse rate is 70 beats per minute. His skin is warm and he has no rectal tone. Which one of the
following statements is TRUE?

a. Vasoactive medications have no role in early management.

b. The hypotension should be managed with volume resuscitation alone.
c. Flexion and extension views of the c-spine should be performed early.
d. Occult abdominal visceral injuries can be excluded as a cause of hypotension.
e. Flaccidity of the lower extremities and loss of deep tendon reflexes are expected.

1-33. Which one of the following is the recommended method for treating frostbite?

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 1-34. A 32-year-old man is trapped from the waist down beneath his overturned car for a period
exceeding eight hours. On arrival in the emergency department, both lower extremities are cool,
mottled, insensate, and motionless. Despite normal vital signs, pulses cannot be palpated below the
femoral vessels and the muscles of the lower extremities are firm and hard. During the initial
management of this patient, which of the following is most likely to improve the chances for limb
salvage?

a. Applying skeletal traction

b. Administering anticoagulant drugs
c. Administering thrombolytic therapy
d. Performing lower extremity fasciotomies
e. Immediately transferring the patient to a trauma center

1-35. Cervical spine injury

a. is excluded by a normal neurologic examination.

b. is not present if the patient has normal range of neck motion.
c. can be detected safely by careful flexion and extension of the neck.
d. can be excluded by a crosstable lateral roentgenogram of the c-spine.
e. may be first manifested by neurologic deficit after movement of the neck.

1-36.. An 18-year-old man is brought to the hospital after smashing his motorcycle into a tree. He is
conscious and alert, but paralyzed in both arms and legs. His skin is pale and cold. He complains of
thirst and difficulty in breathing. His airway is clear. His blood pressure is 60/40 and his pulse rate is
140 beats per minute. Breath sounds are full and equal bilaterally. He should

a. undergo exploratory celiotomy ( = laparotomy)

b. be treated for neurogenic shock.
C. be treated for hypovolemic, shock.
d. undergo immediate nasotracheal intubation.
e. be placed in cervical traction tongs before any other treatment is instituted.

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 1-37. A 64-year-old man, involved in a high-speed car crash, is resuscitated initially in a small rural
hospital with limited resources. He has a closed head injury with a Glasgow Coma Scale Score of
13. He has a widened mediastinum on chest roentgenogram with fractures of left ribs two through
four, but no pneumothorax. After infusing four liters of Ringer's lactate solution, hid blood
pressure is 100/74, pulse rate is 110 beats per minute, and respiratory rate is 18 breaths per
minute. He has gross hematuria and a pelvic fracture. The referring physician decides to transfer
this patient to a facility capable of delivering a higher level of care which is 128 km (80 miles)
away. Before transfer, the physician should first

a. intubate the patient.

b. perform diagnostic peritoneal lavage.
c. apply the pneumatic antishock garment.
d. call the receiving hospital and speak to the surgeon on call.
e. discuss the advisability of transfer with the patient's family.

1-3S. Hemorrhage of 20% of the patient's blood volume is associated usually with

a. oliguria.
b. confusion.
c. hypotension.
d. tachycardia.
e. blood transfusion requirement.

1-39. Which one of the following statements concerning intraosseous infusion in children is
TRUE?

a. Only crystalloid solutions may be safely infused through the needle.

b. Aspiration of bone marrow confirms appropriate positioning of the needle.
c. Intraosseous infusion is the preferred route for volume resuscitation in small
children.
d. Intraosseous infusion may be utilized indefinitely in the management of injured
children.
e. Swelling in the soft tissue around the intraosseous site is not a reason to
discontinue infusion.

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 1-40. A 26-year-old seat-belted driver is brought to the hospital after a car crash. Primary survey
reveals no evidence of serious injury except for diffuse, mild abdominal tenderness. Bowel sounds
are hypoactive and liver dullness is questionable. Abdominal films reveal free air. The patient should

a. undergo peritoneal lavage.

b. undergo prompt celiotomy = (laparotomy)

c. be carefully observed for further evidence of intra-abdominal injury.
d. have a contrast roentgenographic study of her gastrointestinal tract,
e. be suspected of having a ruptured diaphragm and accompanying pneumothorax.

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 POSSIBLE ANSWERS

1.1 (a)
1.2 (b)
1.3 (e)
1.4 (a)
1.5 (d)
1.6 (d)
1.7 (b)
1.8 (c)
1.9 (c)
1.10 (a)
1.11 (c )
1.12 (e)
1.13 (b)
1.14 (c )
1.15 (d)
1.16 (b)
1.17 (c )
1.18 (d)
1.19 (e)
1.20 (e)
1.21 (d)
1.22 (d)
1.23 (c )
1.24 (e)
1.25 (c )
1.26 (a)
1.27 (d)
1.28 (b)
1.29 (b)
1.30 (c )
1.31 (d)
1.32 (e)
1.33 (a)
1.34 (d)
1.35 (e)
1.36 (c)
1.37 (d)
1.38 (d)
1.39 (b)
1.40 (b)

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