A 22-year-old man is hypotensive and tachycardic after a shotgun wound to the left
shoulder. His blood pressure is initially 80/40 mm Hg. After initial fluid resuscitation his
blood pressure increases to 122/84 mm Hg. His heart rate is now 100 beats per minute
and his respiratory rate is 28 breaths per minute. A tube thoracostomy is performed for
decreased left chest breath sounds with the return of a small amount of blood and no air
leak. After chest tube insertion, the most appropriate next step is:
a. reexamine the chest
b. perform an aortogram
c. obtain a CT scan of the chest
d. obtain arterial blood gas analyses
e. perform transesophageal echocardiography
Which of the following is true regarding the initial resuscitation of a trauma
patient?
a. A patient that presents with a torso gunshot wound and is hypotensive should receive
crystalloid fluid resuscitation until the blood pressure is normal
b. Evidence of improved perfusion after fluid resuscitation could include
improvement in Glasgow coma scale score on reevaluation
c. Massive transfusion is defined as transfusion of more than >10 of packed red blood
cells and plasma in 24 hours
d. When tranexamic acid is administered by pre-hospital providers a second dose is
required within 24 hours
e. Fluid resuscitation is far more important than bleeding control in trauma patients
In managing a patient with a severe traumatic brain injury, the most important
initial step
a. Secure the airway
b. obtain a c-spine film
c. support the circulation
d. control scalp hemorrhage
e. determine the GCS score Feedback
A previously healthy, 70-kg (154-pound) man suffers an estimated acute blood loss
of 2 liters. Which one of the following statements applies 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. An ABG would demonstrate a base deficit between -6 and -10 mEq/L
e. His systolic blood pressure will be maintained with an elevated diastolic pressure.
The physiologic hypervolemia of pregnancy has clinical significance in the
management of the severely injured, gravid woman:
a. reducing the need for blood transfusion
b. resulting in an elevated hematocrit
c. complicating the management of closed head injury
d. reducing the volume of crystalloid required for resuscitation
e. increasing the volume of blood loss to produce maternal hypotension
The best assessment of fluid resuscitation of the adult burn patient is:
a. Urine output of 0.5 mL/kg/hr
,b. normalization of blood pressure
c. normalization of the heart rate d. measuring a normal central venous pressure e.
providing 4 mL/kg/percent body burn/24 hours of crystalloid fluid
The diagnosis of shock must include: a. hypoxemia b. acidosis c. hypotension d.
increased vascular resistance e. evidence of inadequate organ perfusion
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 wound
of his medial right thigh. Immediate management of the wound should consist of: a.
application of a tourniquet b. direct pressure on the wound c. packing the wound with
gauze d. direct pressure on the femoral artery at the groin e. debridement of devitalized
tissue
For the patient with severe traumatic brain injury, profound hypocarbia should be
avoided to prevent
a. respiratory acidosis
b. metabolic acidosis
c. cerebral vasoconstriction with diminished perfusion
d. neurogenic pulmonary edema e. shift of the oxyhemoglobin dissociation curve correct
After being involved in a motor vehicle crash, a 25-year-old man is brought to a
hospital that has surgery capabilities available.. Computed tomography of the chest
and abdomen shows an aortic injury and splenic laceration with free abdominal
fluid. His blood pressure falls to 70 mm Hg after CT. The next step is:
a. obtain contrast angiography
b. transfer to a higher level trauma center c. perform an exploratory laparotomy d.
infuse additional crystalloid fluids e. Obtain transesophageal echocardiography
Which one of the following statements regarding abdominal trauma in the pregnant
patient is TRUE?
a. The fetus is in jeopardy only with major maternal 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. With penetrating trauma,
injury to the mother's 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.
The first maneuver to improve oxygenation after chest injury is to
a. intubate the patient b. assess arterial blood gases c. administer supplemental oxygen
d. ascertain the need for a chest tube e. obtain a chest x-ray
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 pressure. He does not
follow commands, but he does moan periodically. His right arm is deformed and
does not respond to pressure; however, his left hand reaches purposefully toward
the stimulus. Both legs are stiffly extended. His GCS score is
a: 2 b: 4 c: 6 d: 9 e: 12
Which one of the following findings in an adult is most likely to require immediate
management during the primary survey?
a. distended abdomen b. Glasgow Coma Scale score of 11 c. temperature of 36.5°C
(97.8°F) d. deformity of the right thigh e. respiratory rate of 40 breaths per
minute
,1.a or c 2.e 3. B ATLS continues to support the use of a 3-for-1 rule (3 mL of crystalloid
should be used as replacement for every 1 mL of blood loss), but also encourages frequent
reassessments if large amounts of crystalloid are not providing adequate resuscitation. ATLS also
dictates treatment based on the class of hypovolemic shock. The initial resuscitation in adult
trauma patients typically involves using crystalloid solutions to restore and maintain blood
pressure within normal or acceptable ranges. The goal is to ensure adequate perfusion to vital
organs while monitoring the patient's response to resuscitation.
A 6-year-o boy is struck by an automobile and brought to the ED. He is lethargic,
but withdraws purposefully from painful stimuli. His blood pressure is 90mmHg
systolic, heart rate 140 beats per minute and his respiratory rate is 36 breaths per
minute. The preferred route of venous access in this patient is:
A. Percutaneous femoral vein cannulation
B. Cutdown on the saphenous vein at the ankle
C. Intraosseous catheter placement in the proximal tibia
D. Percutaneous peripheral veins in the upper extremities
E. Central venous access via the subclavian or internal jugular vein
A young man sustains a gunshot wound to the abdomen and is brought promptly to
the ED by prehospital personnel. His skin is cool and diaphoretic, and he is
confused. His pulse is thready and his femoral pulse is only weakly palpable. The
definitive treatment in managing this patient is to:
A. Administer O-negative blood
B. Apply external warming devices
C. Control internal hemorrhage operatively
D. Apply a pneumatic antishock garment (PASG)
E. Infuse large volumes of intravenous crystalloid solutions.
Regarding shock in the child, which of the following is FALSE?
A. Vital signs are age-related
B. Children have greater physiologic reserves than do adults
C. Tachycardia is the primary physiologic response to hypovolemia
D. The absolute volume of blood loss required to produce shock is the same as in
adults
E. An initial fluid bolus for resuscitation should approximate 20ml/kg Ringers
Lactate
A 33-year-old man is struck by a car travelling at 56km/h (35mph). He has obvious
fractures of the left tibia near the knee, pain in the pelvic area, and severe dyspnea.
His heart rate is 182 beats per minute, and his respiratory rate is 48 breaths per
minute with no breath sounds heard in the left chest. A tension pneumothorax is
relieved by immediate needle decompression and tube thoracostomy.
Subsequently, his heart rate decreases to 144 beats per minute, his respirartory rate
decreases to 36 breaths per minute and his blood pressure is 81/53 mmHg.
Warmed Ringers lactate is adminstered intravenously. The next priority should be
, to:
A. Perform external fixation of the pelvis
B. Obtain abdominal and pelvic CT-scans
C. Perform arterial embolization of the pelvic vessel
D. Perform diagnostic peritoneal lavage or FAST
E. Perform a urethrogram and cystogram
A 42-year-old man, injured in a motor vehicle crash, suffers a closed head injury,
multiple palpable left rib fractures, and bilateral femur fractures. He is intubated
orotracheally without difficulty. Initially, his ventilations are Reasily assisted with
a bag-mask device. It becomes more difficult to ventilate the patient over the next
5 minutes, and his hemoglobin oxygen saturation level decreases from 98% to
89%. The most appropriate next step is to:
A. Obtain a chest x-ray
B. Decrease the tidal
volume C. Decrease PEEP
D. Increase the rate of assisted ventilations
E. Perform needle decompression of the left chest.
A 30-year-old man sustains a severely comminuted, open, distal right femur
fracture in a motorcycle crash. The wound is actively bleeding. Normal sensation is
present over the lateral aspect of the foot but decreased over the medial foot and
great toe. Normal motion of the foot is observed. Dorsalis pedis and posterior tibial
pulses are easily palpable on the left, but heard only by Doppler on the right.
Immediate efforts to improve circulation to the injured extremity should involve:
A. Immediate angiography
B. Tamponade of the wound with a pressure dressing
C. Wound exploration and removal of bony fragments
D. Realignment of the fracture segments with a traction splint
E. Fasciotomy of all four compartments in the lower extremity
An 18-yeard-old, unhelmeted motorcyclist is brought by ambulance to the ED
following a crash. He had decreased level of consciousness at the scene, but then
was alert and conversational during transportation. Now his GCS is only 11.
Which of the following statements is TRUE?
A. Cerebral perfusion is intact
B. Intravascular volume status is normal
C. The patient is in a postictal state
D. Intra-abdominal visceral injury is unlikely
E. The patient probably has an acute epidural hematoma
A previously healthy, 70kg (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 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.
shoulder. His blood pressure is initially 80/40 mm Hg. After initial fluid resuscitation his
blood pressure increases to 122/84 mm Hg. His heart rate is now 100 beats per minute
and his respiratory rate is 28 breaths per minute. A tube thoracostomy is performed for
decreased left chest breath sounds with the return of a small amount of blood and no air
leak. After chest tube insertion, the most appropriate next step is:
a. reexamine the chest
b. perform an aortogram
c. obtain a CT scan of the chest
d. obtain arterial blood gas analyses
e. perform transesophageal echocardiography
Which of the following is true regarding the initial resuscitation of a trauma
patient?
a. A patient that presents with a torso gunshot wound and is hypotensive should receive
crystalloid fluid resuscitation until the blood pressure is normal
b. Evidence of improved perfusion after fluid resuscitation could include
improvement in Glasgow coma scale score on reevaluation
c. Massive transfusion is defined as transfusion of more than >10 of packed red blood
cells and plasma in 24 hours
d. When tranexamic acid is administered by pre-hospital providers a second dose is
required within 24 hours
e. Fluid resuscitation is far more important than bleeding control in trauma patients
In managing a patient with a severe traumatic brain injury, the most important
initial step
a. Secure the airway
b. obtain a c-spine film
c. support the circulation
d. control scalp hemorrhage
e. determine the GCS score Feedback
A previously healthy, 70-kg (154-pound) man suffers an estimated acute blood loss
of 2 liters. Which one of the following statements applies 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. An ABG would demonstrate a base deficit between -6 and -10 mEq/L
e. His systolic blood pressure will be maintained with an elevated diastolic pressure.
The physiologic hypervolemia of pregnancy has clinical significance in the
management of the severely injured, gravid woman:
a. reducing the need for blood transfusion
b. resulting in an elevated hematocrit
c. complicating the management of closed head injury
d. reducing the volume of crystalloid required for resuscitation
e. increasing the volume of blood loss to produce maternal hypotension
The best assessment of fluid resuscitation of the adult burn patient is:
a. Urine output of 0.5 mL/kg/hr
,b. normalization of blood pressure
c. normalization of the heart rate d. measuring a normal central venous pressure e.
providing 4 mL/kg/percent body burn/24 hours of crystalloid fluid
The diagnosis of shock must include: a. hypoxemia b. acidosis c. hypotension d.
increased vascular resistance e. evidence of inadequate organ perfusion
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 wound
of his medial right thigh. Immediate management of the wound should consist of: a.
application of a tourniquet b. direct pressure on the wound c. packing the wound with
gauze d. direct pressure on the femoral artery at the groin e. debridement of devitalized
tissue
For the patient with severe traumatic brain injury, profound hypocarbia should be
avoided to prevent
a. respiratory acidosis
b. metabolic acidosis
c. cerebral vasoconstriction with diminished perfusion
d. neurogenic pulmonary edema e. shift of the oxyhemoglobin dissociation curve correct
After being involved in a motor vehicle crash, a 25-year-old man is brought to a
hospital that has surgery capabilities available.. Computed tomography of the chest
and abdomen shows an aortic injury and splenic laceration with free abdominal
fluid. His blood pressure falls to 70 mm Hg after CT. The next step is:
a. obtain contrast angiography
b. transfer to a higher level trauma center c. perform an exploratory laparotomy d.
infuse additional crystalloid fluids e. Obtain transesophageal echocardiography
Which one of the following statements regarding abdominal trauma in the pregnant
patient is TRUE?
a. The fetus is in jeopardy only with major maternal 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. With penetrating trauma,
injury to the mother's 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.
The first maneuver to improve oxygenation after chest injury is to
a. intubate the patient b. assess arterial blood gases c. administer supplemental oxygen
d. ascertain the need for a chest tube e. obtain a chest x-ray
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 pressure. He does not
follow commands, but he does moan periodically. His right arm is deformed and
does not respond to pressure; however, his left hand reaches purposefully toward
the stimulus. Both legs are stiffly extended. His GCS score is
a: 2 b: 4 c: 6 d: 9 e: 12
Which one of the following findings in an adult is most likely to require immediate
management during the primary survey?
a. distended abdomen b. Glasgow Coma Scale score of 11 c. temperature of 36.5°C
(97.8°F) d. deformity of the right thigh e. respiratory rate of 40 breaths per
minute
,1.a or c 2.e 3. B ATLS continues to support the use of a 3-for-1 rule (3 mL of crystalloid
should be used as replacement for every 1 mL of blood loss), but also encourages frequent
reassessments if large amounts of crystalloid are not providing adequate resuscitation. ATLS also
dictates treatment based on the class of hypovolemic shock. The initial resuscitation in adult
trauma patients typically involves using crystalloid solutions to restore and maintain blood
pressure within normal or acceptable ranges. The goal is to ensure adequate perfusion to vital
organs while monitoring the patient's response to resuscitation.
A 6-year-o boy is struck by an automobile and brought to the ED. He is lethargic,
but withdraws purposefully from painful stimuli. His blood pressure is 90mmHg
systolic, heart rate 140 beats per minute and his respiratory rate is 36 breaths per
minute. The preferred route of venous access in this patient is:
A. Percutaneous femoral vein cannulation
B. Cutdown on the saphenous vein at the ankle
C. Intraosseous catheter placement in the proximal tibia
D. Percutaneous peripheral veins in the upper extremities
E. Central venous access via the subclavian or internal jugular vein
A young man sustains a gunshot wound to the abdomen and is brought promptly to
the ED by prehospital personnel. His skin is cool and diaphoretic, and he is
confused. His pulse is thready and his femoral pulse is only weakly palpable. The
definitive treatment in managing this patient is to:
A. Administer O-negative blood
B. Apply external warming devices
C. Control internal hemorrhage operatively
D. Apply a pneumatic antishock garment (PASG)
E. Infuse large volumes of intravenous crystalloid solutions.
Regarding shock in the child, which of the following is FALSE?
A. Vital signs are age-related
B. Children have greater physiologic reserves than do adults
C. Tachycardia is the primary physiologic response to hypovolemia
D. The absolute volume of blood loss required to produce shock is the same as in
adults
E. An initial fluid bolus for resuscitation should approximate 20ml/kg Ringers
Lactate
A 33-year-old man is struck by a car travelling at 56km/h (35mph). He has obvious
fractures of the left tibia near the knee, pain in the pelvic area, and severe dyspnea.
His heart rate is 182 beats per minute, and his respiratory rate is 48 breaths per
minute with no breath sounds heard in the left chest. A tension pneumothorax is
relieved by immediate needle decompression and tube thoracostomy.
Subsequently, his heart rate decreases to 144 beats per minute, his respirartory rate
decreases to 36 breaths per minute and his blood pressure is 81/53 mmHg.
Warmed Ringers lactate is adminstered intravenously. The next priority should be
, to:
A. Perform external fixation of the pelvis
B. Obtain abdominal and pelvic CT-scans
C. Perform arterial embolization of the pelvic vessel
D. Perform diagnostic peritoneal lavage or FAST
E. Perform a urethrogram and cystogram
A 42-year-old man, injured in a motor vehicle crash, suffers a closed head injury,
multiple palpable left rib fractures, and bilateral femur fractures. He is intubated
orotracheally without difficulty. Initially, his ventilations are Reasily assisted with
a bag-mask device. It becomes more difficult to ventilate the patient over the next
5 minutes, and his hemoglobin oxygen saturation level decreases from 98% to
89%. The most appropriate next step is to:
A. Obtain a chest x-ray
B. Decrease the tidal
volume C. Decrease PEEP
D. Increase the rate of assisted ventilations
E. Perform needle decompression of the left chest.
A 30-year-old man sustains a severely comminuted, open, distal right femur
fracture in a motorcycle crash. The wound is actively bleeding. Normal sensation is
present over the lateral aspect of the foot but decreased over the medial foot and
great toe. Normal motion of the foot is observed. Dorsalis pedis and posterior tibial
pulses are easily palpable on the left, but heard only by Doppler on the right.
Immediate efforts to improve circulation to the injured extremity should involve:
A. Immediate angiography
B. Tamponade of the wound with a pressure dressing
C. Wound exploration and removal of bony fragments
D. Realignment of the fracture segments with a traction splint
E. Fasciotomy of all four compartments in the lower extremity
An 18-yeard-old, unhelmeted motorcyclist is brought by ambulance to the ED
following a crash. He had decreased level of consciousness at the scene, but then
was alert and conversational during transportation. Now his GCS is only 11.
Which of the following statements is TRUE?
A. Cerebral perfusion is intact
B. Intravascular volume status is normal
C. The patient is in a postictal state
D. Intra-abdominal visceral injury is unlikely
E. The patient probably has an acute epidural hematoma
A previously healthy, 70kg (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 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.
