ATLS Practice Test 2

Answers & Explanations

1. d. 21. e.

2. a. 22. c.

3. c. 23. d.

4. d. 24. d.

5. e. 25. d.

6. a. 26. b.

7. c. 27. c.

8. b. 28. b.

9. b. 29. d.

10. d. 30. c.

11. c. 31. d.

12. d. 32. b.

13. b. 33. d.

14. a. 34. c.

15. d. 35. a.

16. e. 36. e.

17. c. 37. d.

18. c. 38. c.

19. c. 39. a.

20. e. 40. d.

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1. d​.
The patient has taken a turn for the worse. He is in shock. It is imperative that you now
repeat the primary survey, going through the ABCDE’s, in an effort to stabilize the
patient prior to transfer. Questions that need to be answered include: Is the airway
compromised? Is breathing compromised? Is the patient bleeding from elsewhere besides
the chest? And so forth. Once relatively stable, the transfer should proceed because the
patient will certainly need surgical intervention emergently. ​Note​: Clamping the chest
tube will not stop any hemorrhage in the chest, and would probably only impair
breathing.

2. a​
.
Traumatic brain injuries tend to cause increased intracranial pressure (ICP) due to
bleeding and swelling. In order to prevent secondary brain injury, it is important to
maintain normal cerebral perfusion pressure (CPP). CPP = MAP – ICP. If the MAP is
too low, ischemia and infarction will result. Therefore, hypotension must be avoided.
Note​: Administering an osmotic diuretic, such as mannitol, is an intervention reserved
for when ICP is dangerously high; giving it inappropriately may lower the blood
pressure too much .

3. c​
.
The pliability, or compliance, of a child’s chest wall allows impacting forces to be
transmitted to the underlying pulmonary parenchyma, causing a pulmonary contusion.
Rib fractures and mediastinal injuries are not common. Therefore, a pulmonary
contusion may be present in the absence of rib fractures.

4. d​
.
This patient requires an airway and assisted ventilation immediately. Bag­mask
ventilation is not effective. A c­spine injury must be assumed. Therefore, one member
of the trauma team should manually stabilize the patient’s head and neck using inline
immobilization techniques while another member of the trauma team intubates him.

5. e​
.
The presentation is that of neurogenic shock. The only correct choice is e., which is the
presentation of spinal shock. Neurogenic shock results from impairment of the
descending sympathetic pathways in the cervical or upper thoracic spinal cord. This
condition results in the loss of vasomotor tone and sympathetic stimulation to the heart.
Loss of vasomotor tone causes vasodilation of visceral and lower­extremity blood
vessels, pooling of blood, and, consequently, hypotension. Loss of sympathetic
innervation to the heart may cause the development of bradycardia, or at least a failure of
tachycardia in response to hypovolemia. In this condition, the blood pressure may not be
restored by fluid infusion alone, and massive fluid resuscitation may result in fluid
overload and pulmonary edema. The blood pressure may often be restored by the
judicious use of vasopressors after moderate volume replacement. Atropine may be used
to counteract hemodynamically significant bradycardia. Spinal shock refers to the
flaccidity (loss of muscle tone) and loss of reflexes seen after spinal cord injury. The
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“shock” to the injured cord may make it appear completely nonfunctional, although the
cord may not necessarily be destroyed. The duration of this state is variable.

6. a​
.
Of the choices, only choice a. is a contraindication to tetanus toxoid.

7. c​
.
This patient is hemorrhaging from his aorta and spleen. The most important intervention
at this point is laparotomy and stopping the hemorrhage. Simultaneously, packed red
cells and possibly other blood products should be transfused; however, this is not as
important as stopping the bleeding.

8. b​.
Leakage of amniotic fluid indicates that there is rupture of the membranes. As well as
indicating trauma to the mother and fetus, it may cause induction of labor, and increase
the risk of maternal and neonatal infection. In such a circumstance, labor may have to be
induced artificially. Hospital admission is indicated.

9. b​
.
carboxyhemoglobin level > 10% is an indication of inhalation injury. The other choices
are correct.

10. d​.
The presentation is that of compartment syndrome. A right lower extremity fasciotomy is
required.

11. c​
.
A definitive airway is required. However, prior to this the vomitus and over materials that
can possibly be aspirated or obstruct the visualization of the vocal cords must be
removed.

12. d​.
The patient is stable enough to be transported to the other facility, which is about one
hour away. He cannot remain at the present facility because of its limited resources. For
example, he needs to be evaluated for traumatic brain injury, aortic disruption, pelvic
fracture, urethral tear, etc. He will need blood products. You should speak to the
surgeon at the receiving facility so that they can be as prepared as possible, thus avoiding
unnecessary delays in treatment.
13. b​.
The leukocyte count increases. It is not unusual to see WBC counts
of 12,000/mm3 during pregnancy, or as high as 25,000/mm3 during labor.

14. a​
.
Airway always has the highest priority.

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15. d​
.
He has lost about 40% of blood volume (Class III or IV hemorrhage). As such, his
systolic blood pressure will be decreased, pulse pressure narrowed, heart rate increased,
urinary output below normal. He will also be tachypneic, confused, lethargic, and
anxious.

16. e​
.
Plasma volume increases steadily throughout pregnancy and plateaus at 34 weeks of
gestation. A smaller increase in RBC volume occurs, resulting in a decreased hematocrit
(physiologic anemia of pregnancy). In late pregnancy, a hematocrit of 31% to 35% is
normal. Healthy pregnant patients can lose 1200 to 1500 mL of blood before exhibiting
signs and symptoms of hypovolemia. However, this amount of hemorrhage may result in
fetal distress evidenced by an abnormal fetal heart rate.

17. c​
.
After securing the airway, supplemental oxygen should be administered as needed.
Oxygenated air is best provided via a tight­fitting oxygen reservoir face mask with a flow
rate of at least 11 L/min.

18. c​
.
See the GCS scoring table below.
His eyes open to painful stimuli only, making E = 2.
He does not follow commands, but he does moan periodically, making V = 2.
His left hand reaches purposefully toward a painful stimulus, making M = 5.
His GCS score is, therefore, 2+2+5 = 9

GCS E V M

1 No response No response No response to pain

2 Eye opening with pain Incomprehensible sounds Extension with pain

3 Eye opening on command Inappropriate words Flexion with pain

4 Spontaneous eye opening Confused Withdrawal from pain

5 ­ Oriented Localizes pain

6 ­ ­ Obeys commands

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19. c​
.
She very likely has a tension pneumothorax. Needle decompression of the right chest
must be done immediately. ​ Note​ : Her airway is obvious OK. Choices d. and e. are also
correct, but are of lower priority.

20. e​
.
All of the choices indicate abnormalities. ATLS protocols prioritize management
according to the ABCDE’s. Airway abnormality is not one of the choices; however,
breathing abnormality is ­ a respiratory rate of 40 should prompt rapid assessment of
possible causes and the appropriate management.

21. e​
.
The patient likely has a high cervical spinal cord injury. A definitive airway must be
established while maintaining inline immobilization.

22. c​
.
In infants, the surface area of the head is about 18% of total BSA, compared to 9% in
adults.

23. d​
.
Less invasive diagnostic options for relatively asymptomatic patients (who may have
pain at the site of the stab wound) include serial physical examinations over a 24­hour
period, DPL, or diagnostic laparoscopy. Serial physical examinations are labor intensive,
but have an overall accuracy rate of 94%. ​ Note​: a negative FAST does not exclude the
possibility of a significant intraabdominal injury producing small volumes of fluid.

24. d​
.
Elevated central venous pressure, per se, is not a criterion for transfer to a burn center.
All of the other choices are criteria for transfer.

25. d​.
In class 3 hemorrhage, systolic blood pressure starts to decrease. This corresponds to a
1500 mL to 2000 mL blood loss, or 30% to 40% loss of blood volume. When there is
less than this amount of blood loss, blood pressure is maintained through compensatory
mechanisms such as tachycardia and peripheral vasoconstriction. ​ Note​: “Class 0”
hemorrhage does not exist.

26. b​.
Direct pressure on the wound is the best option when there is a localized source of
bleeding, as in this case. When bleeding is widespread or diffuse, the application of a
tourniquet or direct pressure on a proximal artery may be indicated. ​Note​
: Packing the

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wound with gauze is much less effective, especially when there is arterial bleeding.
Debridement of devitalized tissue will not effect hemostasis, and is of lower priority
anyway.

27. c​
.
Hyperventilation acts by reducing PaCO​ 2​and causing cerebral vasoconstriction.
Aggressive and prolonged hyperventilation may cause severe cerebral vasoconstriction,
causing impaired cerebral perfusion, and promoting cerebral ischemia in the already
injured brain. This is particularly true if the PaCO​2​is allowed to fall below 30 mm Hg.
However, hypercarbia (PaCO​ 2​> 45 mm Hg) will promote vasodilation and increase
intracranial pressure, and thus it should be avoided. Hyperventilation should be used
only in moderation and for as limited a period as possible. In general, it is preferable to
keep the PaCO​ at approximately 35 mm Hg, the low end of the normal range (35 mm Hg
2​
to 45 mm Hg). Brief periods of hyperventilation (PaCO​ 2​of 25 to 30 mm Hg) may be
necessary for acute neurologic deterioration while other treatments are initiated.
Hyperventilation will lower ICP in a deteriorating patient with an expanding intracranial
hematoma until emergent craniotomy can be performed.

28. b​
.
This patient exhibits two out of three of the Beck's triad of cardiac tamponade:
hypotension and jugular venous distention. There is no mention of muffled heart sounds.
However, tension pneumothorax may also present with these two signs; but, with tension
pneumothorax, one side of the chest does not exhibit breath sounds, unlike in this patient.
Therefore, the most likely diagnosis is cardiac tamponade.

29. ​​
d .
Free intraperitoneal air indicates perforation of a hollow viscus, and this mandates urgent
laparotomy. ​ Note​
: A serum amylase of 200 is mildly elevated, and may indicate
pancreatic injury or pancreatitis; but, does not warrant laparotomy. A leukocyte count of
14,000 may be a normal response to the trauma and does not warrant laparotomy.
Extraperitoneal bladder rupture, if minor, may be left to heal on its own. A fall in the
hemoglobin from 12 g/dL to 8 g/dL over 24 hours may be the result of crystalloid
infusions and movement of extracellular fluid into the intravascular space. It is vital to
ensure that the hemoglobin does not continue to decrease significantly.

30. c​
.
Anterior cord syndrome is characterized by the loss of motor control and pain and
temperature sensation inferior to level of spinal cord injury, but with preservation of
proprioception and vibration.

31. ​​
d.
Hemorrhage of 20 percent of blood volume (about one litre) is classified as Class II
hemorrhage. In this class, heart rate is 100 to 120 beats per minute (tachycardia), systolic
blood pressure is normal, pulse pressure is decreased, urinary output is 20 to 30 mL per
hour (lower end of normal), and the patient is mildly anxious.
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32. b​.
Aspiration of bone marrow confirms that the needle tip is in the bone marrow. ​ Note​:
Any fluid that can be infused intravenously can also be infused intraosseously.
Peripheral IV is the preferred route for volume resuscitation in small children.
Intraosseous infusion should only be utilized until an alternative parenteral route can be
established so that the risk of infection is minimized. Swelling in the soft tissues around
the intraosseous site is a reason to discontinue infusion at that site.

33. 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
flutter­type valve effect.

34. ​
c​
.
In the setting of trauma, Rh immunoglobulin would only be administered to Rh negative,
pregnant women. In addition, it would only be administered if there were any chance of
fetal blood mixing in with maternal blood . There is no chance of this happening for an
isolated wrist fracture. Therefore, choice c. is the correct answer.

35. a​
.
The chest tube was inserted because of decreased breath sounds in the left hemithorax.
And this scenario paints a picture of left hemothorax rather than left pneumothorax, given
the favorable response to fluid resuscitation. So, one would expect a much greater
drainage of blood from the chest tube; however, only a small amount of blood drained
out. Therefore, the next logical step would be to reexamine the chest to see what
difference, if any, the tube thoracostomy made. ​ Note​
: The other choices listed would
each take too long. In addition, transesophageal echocardiography is a modality one
would use for assessing mediastinal structures, such as the aorta.

36. e​
.
He is complaining of severe pain in both heels and his lower back. A spine fracture must
be assumed until proven otherwise. Therefore, complete spine x­ray series are required.

37. d​.
If 1500 mL or more of fluid is immediately evacuated upon chest tube insertion, early
thoracotomy is almost always required. ​ Note​: Patients who have an initial output of less
than 1500 mL of fluid, but continue to bleed, may also require thoracotomy. This
decision is not based solely on the rate of continuing blood loss (200 mL/hr for 2 to 4
hours), but also on the patient’s physiologic status. The persistent need for blood
transfusions is an indication for thoracotomy.

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38. ​
c​
.
Cardiac tamponade and tension pneumothorax are clinically similar in that both cause
hypotension (decreased pulse volume), tachycardia, jugular venous distention, decreased
pulse pressure, and so on. The major difference between the two is that in cardiac
tamponade breath sounds are still present, while in tension pneumothorax breath sounds
are absent on the side of the affected hemithorax.

39. a​
.
Choice a. is incorrect ­ Class I is the easiest and Class IV is the most difficult for
intubation. The other choices are correct.

40. ​​
d .
If 1500 mL or more of fluid is immediately evacuated upon chest tube insertion, early
thoracotomy is almost always required.