1997 Edition Advanced Trauma Life Support Wtritten Test

TEST # 1 Pretest Only

NOTE : It is understood that medical practices vary practices vary with institutional policies and incividual preferences. This test was designed in conjunction with the material presented in the 1997 edition of the ATLS Course. Please answer the questions accordingly. Questions about test items are referred to the ACS ATLS Division. The course Director or Coordinator may not give credit for a response that you mark incorrectly according to the answer key. IMPORTANT DERECTIONS BEFORE YOU BEGIN THIS TEST: This test consists of 40 multiple-choice questions. Please use the answer sheet provided with this test. Enter your name, course site, and date at the top of the answer form. Use a pencil to blacken the space provided for your response for each item. If you change your response to a question, erase your forst mark completely. Read each question thoroghly and select the one best answer.

 Please do not write on or in this test booklet. 1-1. A 22-year-old man sustains a shotgun wound to the left shoulder. His blood pressure is initially 80/40 mm Hg. After 2 liters of Ringers lactate solution his blood pressure increases t0 122/84 mm Hg. His heart 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 and no air leak. The most appropriate next step is to (A) (B) (C) (D) (E) reexamine the chest. perform an aortogram. obtain a CT scan of the chest. Obtain arterial blood gas analyses. Perform transesophageal echocardiography.

1-2. A young construction worker falls 2 stories from a building and sustains bilateral calcaneal fractures. In the emergensy departement, he is alert, vital signs are normal, and he is complining of severe pain in both legs and lower back pain. Lower extremity pulses are strong and there is no apparent deformity. The next appropriate diagnostic study to perform is (A) Angiography. (B) Compartement pressures. (C) CT scan of the abdomen. (D) Doppler-ultrasound studies. (E) Complete spine x-ray series. 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-impervios gown. (D) Water-impervios leggings. (E) Needle-impenetrable sterile gloves. 1-4. In managing the head-injured patient, the most important initial step is to

(A) Secure the ariway. (B) Obtain c-spine film. (C) Support the circulation. (D) Control scalp hemorrhage. (E) Determine the GCS score. 1-5. A previously helthy, 70-kg (175-pound) man suffers an estimated acute blood loss of 2 liters. Which one of the following statements apply to this patient? (A) (B) (C) (D) His pulse pressure will be widened. His urinary output will be at the lower limits of normal. He will have tachycardia, but no change in his sytolic blood pressure. His sytstolic blood pressure will be decreased with a narrowed pulse pressure.

(E) His systolic blood pressure will be mainted with an elebated diastolic pressure. 1-6. The physiologic hypervolemia of pregnancy has clinical significance in the management of the severely injured, gravid woman by (A) (B) (C) (D) (E) reducing the need for blood transfusion. Increasing the risk of ppulmonary edema. Complicating the management of closed head injury. Increasing the volume of blood loss to produce hypotension. 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 depertement with a blood pressure of 140/92 mm Hg, heart rate of 88 beats per minute, a respiratory rate of 18 breaths per minute, and a GCS score of 7. Appropriate initial immobilization of this patient should include a semirigid cervical collar and (A) (B) (C) (D) (E) a scoop stretcher a long spine board. A short spine board Cervical tracdtion tongs. The pneumatic antishock garment.

1-8. A 34-year-old man is brough to the hospital after being pinned to the wall of a building by a cement truck. He is in obvious shock, an has deformities and marked swelling of both thighs, although no open wounds are present. His shock (A) (B) (C) (D) (E) 1-9. (A) (B) (C) (D) (E) 1-10. (A) (B) (C) (D) (E) cannot be explained without concomitant pelvic fracture. Signifies a loss of approximately 15% of his blood volume. Is consistent with blood loss from bilateral femoral fractures. Will likely be reversed if appropriate traction splints are applied. Cannot be explained by his obserbed injuries unless a major arterial injury exists. Prior to passage of a urinary catheter in a man, it is essential to Examine the abdomen Determine pelvic stability Esamine the rectum and perineum. Perform a retrograde urethogram. Know the history and mecahnism of injury. The best guide for adequate fluid resuscitation of the bur patient is adequate urinary output. Reversal of systemic acidosis Normalization of the heart rate A normal central venous pressure. 4 mL/kg/percent body bur/24 hours

1-11. A 36-year-old woman is beaten about the head and face, and is brougth to a local community hospital in full spinal immobilization. Her blood pressure is 130/88 mm Hg, heart rate is 70 beats per minute, and respiraatory rate is 18 breaths per minute. The pulse oximeter indicated 98% hemoglobin saturation while she is being given 100% oxygen via a nonrebreathing mask. Her airway is clear. She has marked swelling of her face and several superficial lacerations of her scalp that are not actively bleeding. She does not respond to verbal stimuli, but localizes to painful stimuli and opens her eyes. She moves all extremities equally. The remainder of her physical exmination is normal. There is no neurosurgeion at the local hospital. After ensuring a patent airway, the most appropriate course of action is to (A) (B) (C) (D) (E) 1-12. (A) (B) (C) (D) (E) admit the patient to the hospital for observation. obatin x-rays of her facial bones prior to trasnfer. Obtain complete x-ray evaluation of the cervical spine. Transfer the patient to a neurosurgeon without performing a CT scan. Perform diagnostic peritoneal lavage or request abdominal ultrasonography. Establishing a diagnosis of shock must include confirming hypoxemia the finding of acidosis confiriming increased vascular resistance documenting hypotension and low cardiac out put. Evidence of inadequate perfusion of the codys organs.

1-13. A 7-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) (B) (C) (D) (E) 1-14. prevent (A) (B) (C) (D) (E) application of a tourniquet direct pressure on the wound apply a hemostat to bleeding vessels direct pressure on the femoral artery at the groin irrigation and debridement of devitlaized tissue and tetanus prophylaxis For the trauma patient with cerebral edema, hypercarbia should be avoided to metabolic acidosis respiratory acidosis cerebral vasodilatation neurogenic pulmonary edema reciprocal high levels of Paco2

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 intocated, has a GCS score of 13, and complains of abdominal pain. His blood pressure to 110/70 mm Hg with the administration of intravenous fluids. His heart rate is now 120 beats per minute. The chest

x-ray shows loss of the aortic knob, widening of the mediastinum, no rib fractures, and no hemopneumothorax. Contrast angiography (A) (B) (C) (D) (E) is not indicated should be performed after a CT scan of the chest is positive for aortic rupture in 80% of similar cases is not necessary if the CT scan of the chest is normal should be performed after diagnostics peritoneal lavage

1-16. Which one of the following statements regarding abdominal trauma in the pregnant patient is TRUE? (A) (B) (C) (D) (E) 1-17. (A) (B) (C) (D) (E) the fetus is in jeopardy only with major abdominal trauma leakage of amniotic fluid is an indication for hospital admission indications for peritoneal lavage are different from those in the nonpregnant patient penertration of an abdominal hollow viscus is more mommon in late than erarly pregnancy the secondary survey follows a different pattern from that of the nonpregnant patient The first maneuver to improve oxygenation after ches injury is intubate the patient assess arterial blood gases administer supplekmental oxygen ascertain the need for a chest tube obtain a lateral cervical spine x-ray

1.18. A 25-year-old man, injured in a motor vehicular crash, is admitted to the emergency departement. His pupils react sluggishly and his eyes open to painful stimuli. He does not follew 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 egs are stiffly extended. His GCS score is (A) (B) (C) (D) (E) 2. 4. 6. 9. 12.

1-19. A 20-year-old woman, at 32 weeks gestation, is stabbed in the uupper right chest. In the emergency departement, her blood pressure is 80/60 mm Hg. She is gasping for breath, extremely anxious, and yelling for help. Breath sounds are diminished in the right chest. The most appropriate first step is to (A) (B) (C) perfom tracheal intubation perfom neddle decompression of the right chest provide reassurace that she and her baby will be fine

(D) (E)

manually displace the gravid uterus to the left side of the abdomen initiate 2, large-caliber peripheral IV lines and crystalloid infusion.

1-20. Which one of the following findings in an adult sould prompt immediate management during the primary survey? (A) (B) (C) (D) (E) 1.21. (A) (B) (C) (D) (E) 1.22. (A) (B) (C) (D) (E) 1.23. (A) (B) (C) (D) (E) 1.24. (A) (B) (C) (D) distended abdomen glasgow coma scale score of 11 temperature of 120 beats per minute heart rate of 120 beats per minute respiratory rate of 40 breaths per minute During the primary and secondary survey, the patient injured by blunt trauma should be completely immobilized until the neurologic examination has been completed the patient is transferred to a definitive care area a spinal fractura has been excluded radiographically the patient is able to indicate that he has no neck pain the patient complains of potential pressure sores due to the sppine board The most important, immediate step in the management of an open pneumothorax is endotracheal intubation. Operation to close the wound Placing a chest tube through the ches wound Placement of an occlusive dressing over the wound Initation of 2, large-caliber Ivs with Ringers lactate Important screening x-rays to obtain in the multiple-system trauma patient are skull, chest, and abdomen chest, abdomen, and pelvis skull, servical spine, and chest cervical spine, chest, and pelvis cervical spine, chest, and abdomen All of the following statements regarding pulse oximetry are true EXCEPT Excessive surrounding room light can interfera with the accuracy of the readings. Signficant lebels of dysfunctional hemoglobin can affect the accuracy of the readings. It provides a continousw, noninvasive meaurement of the partialk pressure of oxygen. It is dependent on differential light absorption by oxygenated and deoxygenated hemoglobin

(E) 1.25.

It provides a continous, nonivasive measurement of pulse rate that is updated with each heart beat. A 56-year-old man is thrown violently against the steering wheel of his truck during a motor vehicular cras. On arrival in the emergency departement he is diaphoretic and complaning of chest pain. His blod pressure is 60/40 breaths per minute. Which of the following would best differentiate cardiac tamponade from tension penumothorax as the cause of his hypotension? tachycardia pulse volume breath sounds pulse pressure jugular venous pressure Bronchial intubation of the right of left mainstem bronchus can easily occur during infant endotracheal intubation because the trachea is relatively short the distance from the lips to the larynx is relatively short the use of tubes without cuffs allows the tube to slip distally the mainstem bronchi are less angulated in their relation to trachea so little friction exists between the endoracheal tube and the wall of the trachea.

(A) (B) (C) (D) (E) 1.26. (A) (B) (C) (D) (E)

1.2752- year-old woman sustains 50 % total body-surface flame burn in an explosion. She has burns around the chest and both upper arms. Adequate resuscitation is initiaded. She is nosotrachelly intubated and is mechanically ventilated. Her corboxyghemoglobin level is 10 %. Her arterial blood gas analyses reveal Pao of 40 mm Hg (5.3 kPa), Paco 2 of 60 mm Hg (8 kPa), and pH of 7.25. Appropriate immediate management at time is to (A) (B) (C) (D) (E) ensure adequate tissue perfusion. increase the rate of fluid resuscition. add positive end-expiratory pressure (PEEP). Reassess for the presense of a pneumothorax. administer intravenous narcotics in small amounts.

1.28. A. 23-year-old man sustains 4 stab wounds to the upper right chest during an altercation and is brounght by ambulance to a community hospital that hass full surgical capatibilities. The wounds are all above the nipple. He is endotrachelly intubated, closed tube thoracostomy is performed, and 2 liters of Ringgers 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% 0 2). The most appropriate next step in managing this patient is. (A) (B) (C) (D) angiograpy. Thoracotony CT of the chest Application of PASG.

(E) 1.29. (A) (B) (C) (D) (E)

Immediate transfer to a trauma center. All of the following suggest urethral injury EXCEPT scrotal hematoma blood in the rectal lumen. blood at the external urethral meatus high-riding prostate on rectal examination. absence of palpable prostate on rectal examination.

1.30. A 39-year-old is admitted to the emergency department after an automobile collision. He is cyanotic, has insufficient respiratory effort, and has a GCS score of 6. There is no significant facial trauma; his trachea is midline; and he has a chronic, severe nasal septum deviation precluding nasotraheal intubation. His full beard makes it difficult to fit the oxygen face mask to his face. The most appropriate next step is to (A) (B) (C) (D) (E) perform a surgical cricothyroidotomy force a nasotracheal tube past the deviated nasal septum. Attempt orotracheal intubation using 2 people and inline stabilization of the cervical spine. ventilate him a bag-valve mask device until c-spine injury can be excluded. ventilate the patient with a bag-valve mask device until his beard can be shaved for better mask fit.

1.31. A skier loses and fall 15 meters (50 feet) from the edge of a cliff. The patient is fully immobilized and transported by the rescue team to the first aid station at the bottom of the mountain. On arrival his blood pressure is 90/60 mm Hg, heart rate is 70 beats per minute, and respiratory rate is 16 breaths per minute. His GCS score is 14. He withdraws appropriately from painful stimuli above the clavicles, but does not appear to have any response to pain below his clavicles. Reportedly, his right femur is deformed, and he has open fractures of the tibia and fibula on the left. Both extremities are immobilized in the pneumatic antis chock garment with only the only the leg compartments inflated. The doctor caring for the patient should at this time (A) (B) (C) (D) (E) empirically administer Mannitol move the patient from spine board Institute intravenous vasopressor therapy remove pneumatic antis hock garment document and time the neurologic findings.

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 incubated and completely immobilized on a long spine board. His blood pressure is 60/40 mm Hg and heart rate is 70 beats per minute. His skin is warm and has no rectal tone. Which one of the following statements is TRUE ? (A) vasoactive medications have no role in early management.

(B) (C) (D) (E) 1.33. (A) (B) (C) (D) (E)

The hypotension should be managed with volume resuscitation alone. Flexion and extension views of the c-spine should be performed early. Occult abdominal visceral injuries can be excluded as a cause of hypotension. Flaccidity of the lower extremities and loss of deep tendon reflexes are expected. Which one of the following is the recommended method for treating frostbite? Moist heat Early amputation Padding and elevation Vasodilators and heparin Topical application of silvasulphadiazine

1.34. A 32-year-old mans right leg is trapped beneath his overturned car for nearly 2 hours before is extricated. 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) (B) (C) (D) (E) Applying skeletal traction Administering anticoagulant drugs Administering thrombolytic therapy Performing lower extremity fasciotomies Immediately transferring the patient to a trauma center

1-35. A patient arrives in the emergency department after being beaten about the head and face with a wooden club. He Is comatose and has a palpable depressed skull fracture. His face is swollen and ecchymosed. He has gurgling respirations and vomit us on his face and clothing. The most appropriate step after providing supplemental oxygen and elevating the jaw is to (A) (B) (C) (D) (E) request a CT scan insert a gastric tube suction the or pharynx. obtain a lateral cervical spine x-ray. ventilate the patient with a bag-valve mask.

1-36. A 22-year-old man sustains a gunshot wound to the left chest and transported to a small community hospital at which surgical capabilities are not available. In the emergency department, a chest tube is inserted and 700 mL of blood is evacuated. The trauma center accepts the patient in transfer. Just before the patient is placed in the ambulance for transfer, his blood pressure decreases to 80/68 mm Hg and his heart rate increases to 136 beats per minute. The next step should be to 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 GCS score

of 13. He has a widened mediastinum on chest x-ray with fractures of left ribs 2 through 4, but no pneumothorax. After infusing 4 liters of Ringers lactate solution, his blood pressure is 100/74 mm Hg, heart rate is 110 beats per minute, and respiratory rate is 18 breaths per minute. He has gross hematuria and a pelvic fracture. The referring doctor decides to transfer this patient to a facility capable of delivering a higher level of care. The facility is 128 km (80 miles) away. Before transfer, the doctor should first (A) (B) (C) (D) (E) 1-38. (A) (B) (C) (D) (E) intubate the patient perform diagnostic peritoneal lavage. apply the pneumatic anti shock garment. call the receiving hospital and speak to the surgeon on call. discuss the advisability of transfer with the patients family. Hemorrhage of 20 % of the patients blood volume is associated usually with oliguria confusion hypotension tachycardia blood transfusion requirement.

1-39. which one of the following statements concerning intraosseous infusion in childen is TRUE? (A) (B) (C) (D) (E) only crystalloid solutions may safely infused through the needle. aspiration of bone marrow confirms appropriate positioning of the needle. Intraosseous infusion is the preferred route for volume resuscitation in small children. Intaosseuos infusion may be utilized indefinitely in the management of injured children Swelling in the soft tissue around the introsseous site is not a reason to discontinue infusion.

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 expect for diffuse, mild abdominal tenderness. Bowel sounds are hypoactive and liver dullness is questionable. Abdominal films reveal free air. The patient should (A) (B) (C) (D) (E) undergo peritoneal lavage. Undergo prompt celiotomy. have a contrast x-ray of her gastrointestinal tract. be carefully observed for further evidence of intra abdominal injury. be suspected of having a ruptured diaphragm and accompanying pneumothorax.

American college of Surgeons

Multiple-Choice Response Sheet

1997 ATLS Test # 1 (Resided July 1998) Name___________________________________________date_____ / _____ / _______ Course Site______________________________________________________________ Important Instructions: Use a pencil only. If you change an answer, please erase your 1 st mark completely. Select the one best answer accordingly to the ATLS Course materials.
1.1. (A) (E) 1.2. (A) (E) 1.3. (A) (E) 1.4. (A) (E) 1.5. (A) (E) 1.6. (A) (E) 1.7. (A) (E) 1.8. (A) (E) 1.9. (A) (E) 1.10. (A) (E) 1.11. (A) (E) (B) (C) (D) (E) 1-31. (A) (B) (C) (D) (B) (C) (D) (E) 1.30. (A) (B) (C) (D) (B) (C) (D) (E) 1-29. (A) (B) (C) (D) (B) (C) (D) (E) 1-28. (A) (B) (C) (D) (B) (C) (D) (E) 1-27. (A) (B) (C) (D) (B) (C) (D) (E) 1-26. (A) (B) (C) (D) (B) (C) (D) (E) 1-25. (A) (B) (C) (D) (B) (C) (D) (E) 1-24. (A) (B) (C) (D) (B) (C) (D) (E) 1-23. (A) (B) (C) (D) (B) (C) (D) (E) 1-22. (A) (B) (C) (D) (B) (C) (D) (E) 1-21. (A) (B) (C) (D)

1.12.

(A) (E)

(B)

(C)

(D)

(E)

1-32. (A)

(B)

(C)

(D)

1.13.

(A) (E)

(B)

(C)

(D)

(E)

1-33. (A)

(B)

(C)

(D)

1.14.

(A) (E)

(B)

(C)

(D)

(E)

1-34. (A)

(B)

(C)

(D)

1.15.

(A) (E)

(B)

(C)

(D)

(E)

1-35. (A)

(B)

(C)

(D)

1.16.

(A) (E)

(B)

(C)

(D)

(E)

1-36. (A)

(B)

(C)

(D)

1.17.

(A) (E)

(B)

(C)

(D)

(E)

1-37. (A)

(B)

(C)

(D)

1.18.

(A) (E)

(B)

(C)

(D)

(E)

1-38. (A)

(B)

(C)

(D)

1.19.

(A) (E)

(B)

(C)

(D)

(E)

1-39. (A)

(B)

(C)

(D)

1.20.

(A) (E)

(B)

(C)

(D)

(E)

1-40. (A)

(B)

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(D)