ATLS Practice Test 9
Answers & Explanations
1. A 22-year-old man sustains a gunshot wound to the left chest and is 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:
a. clamp the chest tube.
b. cancel the patient's transfer.
c. perform an emergency department thoracotomy.
d. repeat the primary survey and proceed with transfer.
e. delay the transfer until the referring doctor can contact a thoracic surgeon.
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 xABCDE’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 only impair breathing and perhaps even venous return.
2. A young woman sustains a severe head injury as the result of a motor vehicle crash. In the
emergency department, her GCS is 6. Her blood pressure is 140/90 mm Hg and her heart rate is
80 beats per minute. She is intubated and 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:
a. avoid hypotension.
b. administer an osmotic diuretic.
c. aggressively treat systemic hypertension.
d. reduce metabolic requirements of the brain.
e. distinguish between intracranial hematoma and cerebral edema.
1
, 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
may 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. A 6-year-old boy walking across the street is struck by the front bumper of a sports utility vehicle
traveling at 32 kph (20 mph). Which one of the following statements is TRUE?
a. A flail chest is probable.
b. A symptomatic cardiac contusion is expected.
c. A pulmonary contusion may be present in the absence of rib fractures.
d. Transection of the thoracic aorta is more likely than in an adult patient.
e. Rib fractures are commonly found in children with this mechanism of injury.
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. A 39-year-old man is admitted to the emergency department after an automobile collision. He is
cyanotic, has insufficient respiratory effort, and has a GCS Score of 6. His full beard makes it
difficult to fit the oxygen facemask to his face. The most appropriate next step is to:
a. perform a surgical cricothyroidotomy.
b. attempt nasotracheal intubation.
c. ventilate him with a bag-mask device until C-spine injury can be excluded.
d. attempt orotracheal intubation using 2 people and inline stabilization of the cervical
spine.
e. ventilate the patient with a bag-mask device until his beard can be shaved for better mask
fit.
d.
This patient requires an airway and assisted ventilation immediately. Bag-mask ventilation is not
effective. A C-spine 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.
2
, 5. A patient is brought to the emergency department 20 minutes after a motor vehicle crash. He is
conscious and there is no obvious external trauma. He arrives at the hospital completely
immobilized on a long spine board. His blood pressure is 60/40 mm Hg and his heart rate is 70
beats per minute. His skin is warm. Which one of the following statements is TRUE?
a. Vasoactive medications have no role in this patient's management.
b. The hypotension should be managed with transfusions 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.
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 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 “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. The following are contraindications for tetanus toxoid administration:
a. history of neurological reaction or severe hypersensitivity to the product
b. local side effects
c. muscular spasms
d. pregnancy
e. all of the above
a.
Of the choices, only choice a. is a contraindication to tetanus toxoid. Pain and redness at the
injection site are common and not a contraindication to future administration.
7. After being involved in a motor vehicle crash, a 25-year-old man is brought to a hospital with a
general surgeon on duty. He has a GCS of 13 and complains of abdominal pain. His blood
pressure was 80 mm Hg systolic by palpation on arrival at the hospital, but increases to 110/70
mm Hg with the administration of blood products. His heart rate remains 120 beats per minute.
Computed tomography shows an aortic injury and splenic laceration with free abdominal fluid.
His blood pressure falls to 70 mmHg after CT. The next step is:
3
Answers & Explanations
1. A 22-year-old man sustains a gunshot wound to the left chest and is 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:
a. clamp the chest tube.
b. cancel the patient's transfer.
c. perform an emergency department thoracotomy.
d. repeat the primary survey and proceed with transfer.
e. delay the transfer until the referring doctor can contact a thoracic surgeon.
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 xABCDE’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 only impair breathing and perhaps even venous return.
2. A young woman sustains a severe head injury as the result of a motor vehicle crash. In the
emergency department, her GCS is 6. Her blood pressure is 140/90 mm Hg and her heart rate is
80 beats per minute. She is intubated and 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:
a. avoid hypotension.
b. administer an osmotic diuretic.
c. aggressively treat systemic hypertension.
d. reduce metabolic requirements of the brain.
e. distinguish between intracranial hematoma and cerebral edema.
1
, 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
may 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. A 6-year-old boy walking across the street is struck by the front bumper of a sports utility vehicle
traveling at 32 kph (20 mph). Which one of the following statements is TRUE?
a. A flail chest is probable.
b. A symptomatic cardiac contusion is expected.
c. A pulmonary contusion may be present in the absence of rib fractures.
d. Transection of the thoracic aorta is more likely than in an adult patient.
e. Rib fractures are commonly found in children with this mechanism of injury.
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. A 39-year-old man is admitted to the emergency department after an automobile collision. He is
cyanotic, has insufficient respiratory effort, and has a GCS Score of 6. His full beard makes it
difficult to fit the oxygen facemask to his face. The most appropriate next step is to:
a. perform a surgical cricothyroidotomy.
b. attempt nasotracheal intubation.
c. ventilate him with a bag-mask device until C-spine injury can be excluded.
d. attempt orotracheal intubation using 2 people and inline stabilization of the cervical
spine.
e. ventilate the patient with a bag-mask device until his beard can be shaved for better mask
fit.
d.
This patient requires an airway and assisted ventilation immediately. Bag-mask ventilation is not
effective. A C-spine 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.
2
, 5. A patient is brought to the emergency department 20 minutes after a motor vehicle crash. He is
conscious and there is no obvious external trauma. He arrives at the hospital completely
immobilized on a long spine board. His blood pressure is 60/40 mm Hg and his heart rate is 70
beats per minute. His skin is warm. Which one of the following statements is TRUE?
a. Vasoactive medications have no role in this patient's management.
b. The hypotension should be managed with transfusions 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.
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 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 “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. The following are contraindications for tetanus toxoid administration:
a. history of neurological reaction or severe hypersensitivity to the product
b. local side effects
c. muscular spasms
d. pregnancy
e. all of the above
a.
Of the choices, only choice a. is a contraindication to tetanus toxoid. Pain and redness at the
injection site are common and not a contraindication to future administration.
7. After being involved in a motor vehicle crash, a 25-year-old man is brought to a hospital with a
general surgeon on duty. He has a GCS of 13 and complains of abdominal pain. His blood
pressure was 80 mm Hg systolic by palpation on arrival at the hospital, but increases to 110/70
mm Hg with the administration of blood products. His heart rate remains 120 beats per minute.
Computed tomography shows an aortic injury and splenic laceration with free abdominal fluid.
His blood pressure falls to 70 mmHg after CT. The next step is:
3
