TLS MCQ #1 - 50% sure [Thoracic trauma][ chest tube insertion] ATLS MCQ #1 A 22 year old man is hypotensive

and tachycardic after a shotgun wound to the left shoulder. His blood pressure is initially 80/40 mmHg. After 2 liters of crystalloid solution his blood pressure increases to 122/84 mmHg 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 after initial IV fluid resuscitation, a closed tube thoracostomy is performed for decreased left breath sounds with the return of a small amount of blood and no air leak. After chest tube insertion, the most approriate 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 tranesohageal echocardiography the answer is d ; but a website said a (and a makes more sense to me. so i'll go with a)


info: chest tube insertion, p.108

the website: sg/atls.nsf/uploads/52D1762B14313442C125737500476755/%24FILE/Uitleg %2520schriftelijk%2520examen.doc&ei=VoIXTLOdCZLQM_zFmasL&sa =X&oi=translate&ct=result&resnum=1&ved=0CBYQ7gEwAA&prev=/sea rch%3Fq%3D%2522after%2Bchest%2Btube%2Binsertion%2Bthe%2Bm ost%2Bappropriate%2522%2Bnext%2Bstep%2Bis%26hl%3Den



ATLS MCQ #2 - 75% sure [Musculoskeletal trauma][Extremity trauma] ATLS MCQ #2 A construction worker falls two stories from a building and sustains bilateral calcaneal fractures. In the emergency

department, he is alert, vital signs are normal, and he is complaining of severe pain in both heels and his lower back. Lower extremity pulses are strong and there is no other deformity. The suspected diagnosis is most likely to be confirmed by a) angiography b) compartment pressures c) retrograde urethrogram d) Doppler-ultrasound studies e) complete spine x-ray series

the answer is e. info: can't find the info

-------notes: - angiography is found as CT angiography, p.146, which focuses on head traumas (not answer) - compartment pressures are mentioned on page 197 as intracompartmental pressure measurements (not answer) - retrograde urethrogram is not mentioned in the book (or i couldn't find it!) - doppler ultrasound studies is not clearly mentioned in the book (shit) - X-ray evaluation is on page 166-168. page 168 does say something that might be seen as the correct answer.
Term Definition

ATLS MCQ #3 - MCQ #3 [Trauma ATLS 100% sure in women] During the third trimester of pregnancy, all of the following changes

occur normally EXCEPT a a) decrease in PaCO2 b) decrease in leukocyte count c) reduced gastric emptying rate d) diminished residual lung volume e) diminished elvic ligament tension

the answer is b. info: page 261
Term Definition

ATLS MCQ #4 - 100% sure [Head Trauma] ATLS MCQ #4 In managing the head injured patient, the most important initial step is to a) secure the airway b. obtain c-spine film c) support circulation c) control scalp hemorrhage e) determine the GCS score

the answer is a. info: p.154
Term Definition

ATLS MCQ #5 - 100% sure [Shock] ATLS MCQ #5

A previously healthy, 70kg (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) his systolic blood pressure will be

decreased with a narrowed pulse ressure (true) e) his systolic blood pressure will be maintained with an elevated diastolic pressure

the answer is d. info. page 61
Term Definition

ATLS MCQ #6 - 100% sure [Trauma ATLS MCQ #6 in Women]

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) reducing the volume of crystalloid required for resuscitation e) increasing the volume of blood loss to produce maternal hypotension

the answer is e.

info. page 261



ATLS MCQ #7 - 75% sure [Thermal ATLS MCQ #7 Injuries][Injury Due to Burn & Cold]

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) 4mL/kg/percent body burn/24 hours

the answer is a. (not sure..)

info: pg. 216-217

background: The adequacy of therapy is confirmed by simple determination of adequate urine output and of the haemoglobin and haematocrit levels. The most important guide is the patient’s clinical response source:
Term Definition

ATLS MCQ #8 - 100% sure MCQ #8 ATLS [Shock]

Establishing a diagnosis of shock must


a) hypoxemia b) acidosis c) hypotension d) increased vascular resistance e) evidence of inadequate organ perfusion

the answer is e.

the info: p.58
Term Definition

ATLS MCQ #9 - 100% sure #9 ATLS MCQ [Musculoskeletal trauma][Extremity Trauma] 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

the answer is: b

info is: p.79; in obvious external bleeding section on table

background - tourniquet can be found on p.194, 195. they imply that you use a tourniquet if you are choosing life over limb, and if direct pressure isn't working. (p.195)
Term Definition

ATLS MCQ #10 - 100% sure [Head injury]


For the patient with severe traumatic brain injury, profound hypocarbia should be avoided to prevent

a) respiratory alkalosis b) metabolic acidosis c) cerebral vasoconstriction with diminished perfusion d) neurogenic pulmonary edema e) shift of the oxyhemoglobin dissociation curve

the answer is: c

info is: related info on page 136,137

-------background info Carbon dioxide is perhaps the most potent available modulator of cerebrovascular tone and thus cerebral blood flow (CBF) Code=neu -----------

Hypercarbia and hypoxia are both potent cerebral vasodilators that result in increased cerebral blood flow and volume and, potentially, increased ICP; thus, they must be avoided. Orotracheal intubation allows for airway protection in patients who are severely obtunded and allows for better control of oxygenation and ventilation. -----------Term Definition

ATLS MCQ #11 -ATLS MCQ #11 100% sure [Abdominal trauma]

A 25 year old man is brought to a hospital with a general surgeon after being involved in a motor vehicle crash. He has a GCS of 13 and complains of abdominal pain. His blood pressure was 80mHg systolic by palpation on arrival at the hospital, but increases to 110/70 mmHg with the administration of 2 liters of intravenous fluid. 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 70mmHg after CT. The next step is

a) contrast angiography b) transfer to higher level trauma center c) exploratory laparotomy d) transfuse packed red blood cells e) transesophageal echocardiography

the answer is: c

info: page 12 - list

background info: none for now
Term Definition

ATLS MCQ #12 - 100% sureMCQ #12 ATLS [Trauma in Women]

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

the answer is: b

info: page 265, i've marked it

background info: none yet
Term Definition

ATLS MCQ #13 - 75% sure [Thoracic ATLS MCQ #13 trauma]

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 e) obtain a chest x-ray

the answer is: c

the info: can't find it!




ATLS MCQ #14 - 100% sure [Head ATLS MCQ #14 trauma]

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 purposefully toward the painful stimulus. Both legs are stiffly extended. His GCS Score is

a) 2 b) 4 c) 6 d) 9 e) 12

the answer is: d

info: p.138

background info: i used my card on gcs for this.
Term Definition

ATLS MCQ #15 - 75% sure [Trauma ATLS MCQ #15 in Women]

A 20 year old woman, at 32 weeks gestation, is stabbed in the upper right chest. In the emergency department, her blood pressure is 80/60 mmHg. 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) perform tracheal intubation b) insert an oropharyngeal airway c) perform needle decompression of the right chest d) manually displace the gravid uterus to the left side of the abdomen e) initiate 2, large-caliber peripheral IV lines and crystalloid infusion

the answer is: c

info is: p.87

background is:
Term Definition

ATLS MCQ #16 - 50% sureMCQ #16 ATLS [Initial assessment and management] Review X 1

Which one of the following findings in an adult should prompt immediate management during the primary survey?

a) distended abdomen b) glasgow coma scale score of 11 c) temperature of 36.5C (97.8F) d) heart rate of 120 beats per minute e) respiratory rate of 40 breaths per minute

the answer is: e

the info is: page 79; topic on shock; addresses distended abdomen, not RR though :(

background is:
Term Definition

ATLS MCQ #17 - 100% sure MCQ #17 ATLS [Thoracic trauma]

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 2, large-caliber IVs with crystalloid solution

the answer is; d

the info is: page 87

background is:



ATLS MCQ #18 - 100% sureMCQ #18 ATLS [Tetanus immunization]

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

the answer is: a

the info is: some related stuff on page 297

background info: It is a contraindication to use this or any other related vaccine after a serious adverse event temporally associated with a previous dose including an anaphylactic reaction. A history of systemic allergic or neurologic reactions following a previous dose of Tetanus Toxoid is an absolute contraindication for further use.2,5

found a source
Term Definition

ATLS MCQ #19 - 100% sure MCQ #19 ATLS [Thoracic trauma]

A 56 year old man is thrown violently against the steering wheel of his truck during a motor vehicle crash. On arrival in the emergency department he is diaphoretic and complaining of chest pain. His blood pressure is 60/40 mmHg and his respiratory rate is 40 breaths per minute. Which of the following best differentiates 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

the answer is: c

info is: p.87 marked

background info:
Term Definition

ATLS MCQ #20 - ATLS MCQ #20 100% short [Pediatric trauma][Trauma in extremes of age]

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 in their relation to the trachea e) so little friction exists between the endotracheal tube and the wall of the


the answer is: a

the info: p228 marked

background info:
Term Definition

ATLS MCQ #21 - 100% sure MCQ #21 ATLS [Thoracic trauma]

A 23 year old man sustains 4 stab wounds to the upper right chest during an altercation and is brought by ambulance to a hospital that has full surgical capabilities. His wounds are all above the nipple. He is endotracheally intubated, closed tube thoracostomy is performed, and 2 liters of crystalloid solution are infused through 2 largecaliber IVs. His blood pressure now is 60/0 mmHg, heart rate is 160 beats per minute, and respiratory rate is 14 breaths per minute (ventilated with 100% O2). 1500cc of blood has drained from the right chest. The most appropriate next step in managing this patient is to

a) perform FAST b) obtain a CT of the chest c) perform an angiography d) urgently transfer the patient to the operating room

e) immediately transfer the patient to a trauma center

the answer is: d

the info is: read p.90-91

background info:
Term Definition

ATLS MCQ #22 - 100% sureMCQ #22 ATLS [Airway and ventilatory management] Review X1 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.

the answer is: d

the info is: related to anaswer p.33; marked

background info is:
Term Definition

ATLS MCQ #23 - 75%ATLS[Spine and sure MCQ #23 Spinal Cord Trauma]

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 mmHg 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 the patient's management b) the hypotension should be managed with volume resuscitation alone c) flexion and extension views of the cspine 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

the answer is: c

the info is: related topics on p.167; 161




ATLS MCQ #24 - 100% sure MCQ #24 ATLS [Thermal injuries][Injury due to burn & cold]

Which one of the following is the recommended method for initialy treating frostbite?

a) moist heat b) early amputation c) padding and elevation d) vasodilators and heparin e) topical application of silver sulfadiazine

the answer is: a

the info is: p.220

background is:

"4. Use moist heat (warm water) to warm the casualty, rather than dry heat (radiator or fire). Dry heat can cause more damage." source
Term Definition

ATLS MCQ #25 - 75% sure #25 ATLS MCQ [Musculoskeletal trauma][Extremity trauma]

A 32 year old man's right leg is trapped beneath his overturned car for nearly 2 hours before he is extricated. On arrival in the emergency departmnet, his right lower extremity is cool, mottled, insensate, and motionless. Despite normal vital signs, pulses cannot be palpated below the femoral vessel and the muscles of the lower extremity 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) perform right lower extremity fasciotomy e) immediately transferring the patient to a trauma canter

the answer is: d

info is: related on p196-197

background is:
Term Definition

ATLS MCQ #26 - 75% sure [Head ATLS MCQ #26 trauma]

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 ecchymotic. He has gurgling respirations and vomitus on his face and clothing. The most appropriate step after providing supplemental oxygen and elevating his jaw is to

a) requires a CT scan b) insert a gastric tube c) suction the oropharynx d) obtain a lateral cervical spine x-ray e) ventilate the patient with a bag-mask

the answer is: c

the info is: i can't find it

background is:
Term Definition

ATLS MCQ #27 - 50% sure [Thoracic ATLS MCQ #27 trauma][Transfer to Definitive Care]

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 700mL 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 mmHg 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

the answer is:c

the info is: some reference can be found btwn page 270 - 274

Term Definition

ATLS MCQ #28 - 75% sure [Head ATLS MCQ #28 trauma]

A 64 year old man, involved in a highspeed car crash, is resuscitated initially in a small 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 2 liters of crystalloid solution, his blood pressure is 100/74 mmHg, heart rate is 110 beats per minute, and respiratory rate is 18 breaths per minute. He has gross hematuria and a pelvic fracture. You decide to transfer this patient to a facility capable of providing a higher level of care. The facility is 128 km (80 miles) away. Before transfer, you 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

the answer is: c

the info is: related on p.123

Term Definition

ATLS MCQ #29 - 100% sure [Shock] ATLS MCQ #29

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

the answer is; d

info is: page 61

Term Definition

ATLS MCQ #30 - 75% sure [??? deals ATLS MCQ #30 with intraosseous fluid resuscitation]

Which one of the following statements concerning intraosseous infusion is


a) only crystalloid solutions may be safely infused through the needle (NO) b) aspiration of bone marrow confirms appropriate positioning of the needle (POSSIBLE) c) intraosseous infusion is the preferred route for volume resuscitation in small children (NO) d) intraosseous infusion may be utilized indefinitely (NO) e) swelling in the soft tissues around the intraosseous site is not a reason to discontinue infusion

the answer is: b

the info: random unhelpful info p.236


"This route of fluid and medication administration is an alternate one to the preferred intravascular route when the latter can't be established in a timely manner especially during pediatric emergencies. When intravascular access cannot be obtained in pediatric emergencies, intraosseous access is usually the next approach."

". It can be maintained for 24–48 hours, after which another route of access should be obtained." the info is:

"Furthermore, any medication that can be introduced via IV can be introduced via IO."


SOURCE OF DIRETIONS g/docs/northstar/EZIO%2520directions.pdf+intraosseous+infusion+system+directions&hl=en& gl=us&pid=bl&srcid=ADGEESj6FX7bjUc0C5D7KWUFeTb5TaPt3EGkL CJOC9vBJGAdO4EXJTBlmph03TlX98ISaFNWzadJs_GpwYvP0plN2qaI Un1G7arMl9863x6bVhEqWxirhWJBhP-QQ47Hjltels61jbo&sig=AHIEtbTUtqah8qhN5wrnat9mK5aa3zozoQ



ATLS MCQ #31 - 100% sure [Head ATLS MCQ #31 injury]

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 mmHg and her heart rate is 80 beats per minute. She is intubated and mechanically ventilated. Her pupils are 3mm 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

the answer is: A

the info is: page 142,143, #145 background: none for now
Term Definition

ATLS MCQ #32 - 100% sure MCQ #32 ATLS [Thoracic trauma]

A 33 year old woman is involved in a head-on motor vehicle crash. It took 30 minutes to extricate her from the car. Upon arrival in the emergency department, her heart rate is 120 beats per minute, BP is 90/70 mmHg, respiratory rate is 16 breaths per minute, and her GCS score is 15. Examination reveals bilaterally equal breath sounds, anterior chest wall ecchymosis, and distended neck veins. Her abdomen is flat, soft, and not tender. Her pelvis is stable. Palpable distal pulses are found in all 4 extremities. Of the following, the most likely diagnosis is

a) hemorrhagic shock b) cardiac tamponade c) massive hemothorax d) tension pneumothorax e) diaphragmatic rupture

the answer is: b

the info is: p.91-92

background is:
Term Definition

ATLS MCQ #33 - 75% sure #33 ATLS MCQ [Abdominal trauma]

A hemodynamically normal 10 year old girl is admitted to the Pediatric Intensive Care Unit (PICU) for observation after a Grade III (moderately severe) splenic injury has been confirmed by computed tomography (CT). Which of the following mandates prompt celiotomy (laparotomy)?

a) A serum amylase of 200 b) A leukocyte count of 14,000 c) extraperitoneal bladder rupture d) free intraperitoneal air demonstrated on follow-up CT

e) a fall in the hemoglobin level from 12 g/dL to 8 g/dL over 24 hours

the answer is: e

the info is: some related info p.121 under solid organ injuries

Term Definition

ATLS MCQ #34 - 100% sure [Spine ATLS MCQ #34 and spinal cord trauma]

A 40 year old woman restrained driver is transported to the emergency department in full spinal immobilization. She is hemodynamically normal and found to be paraplegic at the level of T10. Neurologic examination also determines that there is loss of pain and temperature sensation with preservation of proprioception and vibration. These findings are consistent with the diagnosis of

a) central cord syndrome b) spinal shock syndrome c) anterior cord syndrome d) complete cord syndrome e) Brown-Sequard syndrome

the answer is: c

the info is: p.163

Term Definition

ATLS MCQ #35 - 100% sure [Spine ATLS MCQ #35 and spinal cord injury]

A trauma patient presents to your emergency department with inspiratory stridor and a suspected c-spine injury. Oxygen saturation is 88% on high-flow oxygen via a nonrebreathing mask. The most appropriate next step is to:

a) apply cervical traction b) perform immediate tracheostomy c) insert bilateral thoracostomy tubes d) maintain 100% oxygen and obtain immediate c-spine x-rays e) maintain inline immobilization and establish a definitive airway

the answer is: e

the info is: related info p.27-28


some info on flashcards for tracheostomy indications (i.e. you don't do it in emergency cases)
Term Definition

ATLS MCQ #36- 100% sure MCQ #36 ATLS [Thermal injury][Injury due to burn & cold]

When applying the Rule of Nines to infants,

a) It is not reliable b) the body is proportionally larger in infants than in adults c) the head is proportionally larger in infants than in adults d) the legs are proportionally larger in infants than in adults e) the arms are proportionally larger in infants than in adults

the answer is: c

the info is: p.223

background info:
Term Definition

ATLS MCQ #37 - 75% sure #37 ATLS MCQ [Abdominal trauma]

A 60 year old man sustains a stab

wound to the right posterior flank. Witnesses state the weapon was a small knife. His heart rate is 90 beats per minute, blood pressure is 128/72 mmHg, and respiratory rate is 24 breaths per minute. The most appropriate action to take at this time is to

a) perform a colonoscopy b) perform a barium enema c) perform an intravenous pyelogram d) perform serial physical examination e) suture repair the wound and outpatient follow up

the answer is: d

the info is: i can't find it

background: slightly helpful is flashcards on kidney injury



ATLS MCQ #38 - 100% sureMCQ #38 ATLS [Trauma in Women]

Which of the following situations requires Rh immunoglobulin administration to an injured woman?

a) Negative pregnancy test, Rh negative, and torso trauma b) positive pregnancy test, Rh positive, and has torso trauma c) positive pregnancy test, Rh negative, and has torso trauma d) positive pregnancy test, Rh positive, and has an isolated wrist fracture e) positive pregnancy test, Rh negative, and has an isolated wrist fracture

the answer is: c

the info is: p.265

background is:
Term Definition

ATLS MCQ #39 - 100% sure MCQ #39 ATLS [Thoracic trauma]

A 22 year old female athlete is stabbed in her left chest at the third interspace in the anterior axillary line. On admission to the emergency department and 15 minutes after the incident, she is awake and alert. Her heart rate is 100 beats per minute, blood pressure 80/60 mmHg, and respiratory rate 20 breaths per minute. A chest x-ray reveals a large left hemothorax. A left chest tube is placed with an immediate return of 1600 mL of blood. the next management step for this patient is

a) perform a thoracoscopy b) perform an arch aortogram c) insert a second left chest tube d) prepare for an exploratory thoracotomy e) perform an chest CT

the answer is: d

the info is: p.90-91

Term Definition

ATLS MCQ #40 - 100% sure MCQ #40 ATLS [Pediatric trauma]

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

the answer is: c

the info is: p.237

Term Definition

ATLS: What the actual course is like actual course is like ATLS: What the

So my group just finished it too. We had a pretest which we were suppose to take after reading the ATLS book. Then took a two day course (half skills sessions, half lectures) ending with a written test and standardized pt. exam. I would be lying though if I said the main instructor didn't help us out by quizzing us with very similar quiz questions throughout the course. Was co-taught by Trauma and EM attendings. All in all it was actually a really good course!
Term Definition



ATLS: Who teaches and Who takes the ATLS: who teaches and who takes the course course

I'm pretty sure extenders can't be ATLS course instructors (teach ATLS to physician and physician extender students). They could become ATLS educators (teach the instructor candidates how to teach ATLS to other people-when I took the instructor course there were even a few non healthcare educators).

They have special ATLS student courses where extenders are allowed because the primary focus is on teaching physicians (extenders can't be ATLS certified which is why I think they can't be ATLS instructors), but if there is an extender who wants the info taught in the class (let's say you have a PA or NP that is on your trauma service, or works in an ER where they might have to work with trauma patients) they are allowed to take the course (but not comprise more than 25% of the class). ------------------In our ATLS class there are some extenders (paramedics, emergency room nurses & techs) who are auditing the course. They do not take the exam but sit through all the lectures and do the skills stations with us. All of the instructors, however, are either EM or Trauma/CC Surgeons. ------------Further reading of ACS website it does appear that to be an ATLS Instructor one must be a physician (although I cannot see where it says you have to be a surgeon or EM). ATLS Educators are required to have a Master's or preferably PhD or EdD. -------------My ATLS instructor certification expired around 2yrs ago. However, my understanding is thus: 1. non-physicians "audit" the course 2. non-physicians that have audited the course can teach components but are not ATLS instructor certified 3. I don't recall any restrictions on physicians having to be surgeons to teach/be instructors. Granted, I believe everyone in my instructor course was a "surgeon"... we had ortho, ent, and neurosurgeons taking the instructor course. I think in general, it just doesn't make sense for someone that will not spend any significant time dealing with traumas to beatls cert or atls instructor cert. I guess an FP/pediatrician/etc.. could in the community do a bit of ED/trauma type stuff. But, beyond that, I am not sure why a hospitalist, radiologist, psych, etc... would spend the time to that involved in ATLS.

--------------I take atls every 4 yrs. since 2008 pa's have been able to take ATLS and "fully participate" in all stations and exams. my most recent cert card says: "emedpa" is recognized as having successfully completed the ATLS course in it's entirety" we pay full price for the course.($750) if you fail the written or the practical you don't get a card. ACS doesn't call that a cert card. everyone else does. prior to 2008 we just got a cme certificate and a letter from the program director stating that we met all course objectives. __________________ Emergency/Disaster Medicine P.A., EMT-P 23 Years working in EM ================




ATLS: Notes from Notes from the first day, 6/23/10 ATLS: the first day, 6/23/10

Introduction Bill Elder

Tim Thomsen - trauma surgeon,

private practice 24 yers, UIHC 6 years Kent Choi - trauma surgeon

- story of man who practiced the atls monthly was had the algorithms and management down pact!! - the key point in that story is to practice

A,B,C,D,E Initial asessment Injury -- primary survey -resuscitation -- reevaluation -- detailed secondary survey -- reevaluation -optimize patient status -- transfer

Initial assessment and mangement - Choi - trauma; trauma and critical care UIHC - 10 yers - 4 y/o MAVA, unresponseive, C-collar, backboard, + bag-mask. Objective: Primary and secondary surveys, management resuscitation, history, biomechanics of injury, anticipate pitfalls - use personal proective gear - airway - ask a question

- Aproach every patient the same way --

in a systematic way - Trauma in the elderly, pediatric trauma (bigger head, airway is anterior), trauma in pregnancy - C-spine - inline stabilization -- don't let them move it - Pitfalls - think about early intubation b/c airway can get swollen and shut and you can't intubate - eg. motorcycle rider caught in a laundry wire by the neck - burn in a house - think about equipment not working - check your equipment

Breathing - RR, chest movement, air entry, oxygen saturation - Pitfall: Iatrogenic pneumothorax -20cm at the teeth is normal

Circulation - other: base deficit, lactate - low perfusion - assess organ perfusion - level of consciousness

- skin color and temperature - pulse rate and character - pulse rate and character - control bleeding - restore volume --> how do find goo dmedicine - reassess patient - Pitfalls - elderly - atherosclerosis, keep on bleeding; children -- bleed, but don't drop BP; they bleed, squeeze their vessels more

Disability - GCS - pupils - observe for neurologic deterioration

Exposure/Enfironment - avoid hypothermia - eg. electric injury through heart? get EKG, etc - eg. electric injury through extremity? worry about compartment syndrome

Resuscitation - protect and secure airway - ventilate and oxygenate -- etCO2,

ABG - stop the bleeding - vigorous shock treatment - protect from hypothermia

Adjuncts to primary survey - ivtal signs, EKG, ABGs, urinary output, urinary catheters, gastric catheter, pulse oximeter, etCO2, CXR, pelvic x-ray, FAST, DPL

Do not delay transfer for diagnostic tests - use time before transfer for resuscitation

SECONDARY SURVEY - Start after primary survey - restart with ABCDEs are reassessed - Make sure vital functions are returning to normal

Parts - history - PE - Neuro

- Diagnostic tests - Reassess

History A M P L E

Head - unconscious? brain vs intoxicated? - always check every orifice, and/or look inside - seat belt sign: cardiac contusion, mesenteric bowel injury, - retroperitoneal injury they can bleed but nt show signs - rectum: gross blood, pelvic fracture going into rectum, rectal tone - pelvis - Extremities - x-ray involved area joint above and joint below - places where you can have blood loss but wont 'be able to see - chest, abd, thigh, retroperitoneal, scalp laceration, (very vascular, can lose "3L of blood"

Brain injjry - early neurosurgical consult

Spine - feel whole spine, any step off - steroid for spinal cord injury; if > 8hr, no steroid; based on physician preference

How do you minimize missed injuries? - reassess pt over and over again

Pain management

Transfer - make sure you have secure airway, adequate IVs - take care of also what might happen on transport - if hemorrhaging, abdominal distension, operate at facilty, then send them


- get info from EMS - assign roles - ABCDE - x-rays chest, pelvis - secondary survey, ABCDE

NOTES - Be respectful to EMTs - get mechanism from EMTs - don't be prideful - what is your leadership life - pay attention to the vital sign - you may be asked to do cricothyrodotomy - answer back is very important - reviewing what they've already done - ask the team, have we missed something? - when you get tertiary center, have an idea of why you're calling - it's important to call out your findings - go through things mentally, in a systematic way. say it out loud. - when things happen, everybody should know about their roles

AIRWAY AND VENTILATORY MANAGEMENT - Miller - director of ED center

Airway - ask them if they are short of breath - If they can answer, airway OK - burn/inhalation injury, look ok, then decompensates 5 minutes later - airway compromise - if intubating, chin lift, jaw thrust - nasoairway -- helps if you're having problems bagging them - possible difficult airway; mouth opening, anatomy (beard, short, thick neck, receding jaw, protruding upper teeth - Oral intubation - cricoid pressure, suction, c-spine - Plan for failure - gum elastic bougie - LMA/LTA - Needle cricothyroidotomy - surgical airway

Airway management

- preoxygenate - cricoid pressure - just enough to push cartilage, light pressure - sedate (medazolam); try to get a look, see if you can ge tan airway, then paralytic (succinylcholine); speaker uses etomodate b/c less CV effects, EtCO2 monitoring; turns yellow

- Nebulized lidocaine works great -- you don't have to already paralyze before intubation - aim 2 cm below the cord b/c if the patient is not paralyzed, the cords move if you barely touch it, then it goes up! - left hand blad; right hand with thier head; move the tongue; sweep the tongue. - Patients always have complications when they head off the CT. Plan ahead for complications

SHOCK Shock - What is shock? How to recognize shock - shallow rapid breathing

- cold, diaphoretic - anxiety - get the history, AMPLE - hypovolemic - cardiogenic -- EKG, etc. arrhythmia, pump failure - Neurogenic - below T4, above T4 hypotension - Other: adrenal insufficiency, DKA

Determining the cause of bleeding - FAST, DPL, physical exam - x-ray

Treatment - direct pressure/tourniquet - pelvic binders - angioembolization -- by IR guys who can do that - reduce and spling fractures -- "all fractures bleed"

Management - monitor response - prevent hypothermia

Rapid responders Transient responders - make sure you're prepared for them to get worse Non-responders

Class I hemorrhage Class II - can be obnoxious, fluids, ?blood Class III Class IV - have lots of blood ready!

Pitfalls - athletes: bradycardia, hypotension -their baseline. so they can look like nonresponders - pregnancy: so don't put them on their back - Medications: B-blockers, Ca channel blockers - Pacemaker: - Hypothermia: - Early coagulopathy: - blood pressure does not equate to cardiac output - misleading Hct/Hgb


Birsche - ED - Most life threatening injuries are identified during the primary survey. - Injuries: tracheal injury, etc - Airway obstruction - signs: stridor, accessory muscle use on inspiration, hoarsness, subcutaneous emphysema from laryngeal tracheal tear - Tension pneumothorax - don't wait for the neck vein to distend! - don't wait 'till cyanosis!

- Open pneumothorax - Flail chest - will need to intubate - intubate - if you have flail chest, likely will get pulmonary contusion - give analgesia so they can take full breath - but not so much analgesia that they are unable to take full breaths

- - you have to be judicious with fluids - pulmonary contusions get worse the first 4 hours or so - you might see them grunting + nasal flaring -- suggests pulmoanry contusion

Massive hemothorax - >100mL blood loss - flat vs distended neck veins - to OR - sometimes will need to put in 2 chest tubes - get blood ready - If put in chest tube, can get destabilized b/c the might had been tamponaded off, and now you've disrupted that tamponade.

Cardiac tamponade - low BP - distended neck veins - FAST exam

Resuscitative thoracotomy - penetrating trauma, pulse in field, lose it in ED - blung trauma, loses pulse in ED - do not do a blunt trauma with PEA.

Other - blung esophageal rupture - endoscopy - contrast swallow - traumatic diaphragmatic injury - traumatic aortic disruption - blunt cardiac injury - cardiac contusion, ectopy, PVCs, etc. abnl EKG - tracheobronchial tree injury - CXR doesn't chang eafter chest tube - pulmonary consuion, intubate sooner rather than later - traumatic asphyxia (petechia, swelling, cerebral edema) - subcutaneous emphysema

Fractures - ribs - old people: if rib fracture, incrased mortality with each increasing rib fracture - kids - worry about associated injuries

RANDOM - If patient has cerebral edema, don't use succinylcholine.

ABDOMINAL INJURY - MVA, seat belt sign - Blunt trauma - ? mechanism to determine suspected abdominal injury - spleen, liver, small bowel - put in NG tube to decompress stomach - urinary catheter - Blunt Trauma - indication for laparotomy in blunt trauma - physiology of pelvic binders - pelvic fractures - wrap/binder

6.23.10 atls lecture
Term Definition

ATLS: Notes from Notes from day:second day: ATLS: the second the Head Trauma 6.24.10 Head Trauma 6.24.10

HEAD TRAUMA - scan them - 58 y/o, fall, GCS 12, after admission, deteriorates to 6 - ddx. head bleed, vs hemorrhage somewhere - i.e. could have both or none, or even be intoxicated

- primary survey: "make sure that when he comes in, you have a plan." ATLS helps you manage the stress - recognize injury, minimize secondary injuries - you need to have a plan. It could be wrong, but you need to have a plan and go with you. You can't teach someone to have a plan. But you can correct an incorrect plan. - The head. It's a box. Keep it very simple, and you can't get confused. - Dural sinus filled with blood, so will bleed a lot. It's just under the skull. - Skull is very vascular. You can bleed to death from a scalp injury. - Cerebral blood flow -- can't measure it directly; need to maximize it; what you can tell is is it adequate vs inadequate cerebral blood flow. based on exam and vital signs. If MAP drops to 40's to 50's, decreased perfusion, decreased mental status - With brain injury, autoregulatory stuff is mesed up. so now it depends on the systolic BP. -- you can control that. - Mass effect - Monroe-Kellie Doctrine - head is a box; - it has the brain, spinal fluid, and blood - any increase in any one of those will mess things up - first thing is to get rid of CSF (shunt CSF); brain will compensate, and all of a sudden it won't (like kids and their

BP) - the braind then gets rid of venous blood -- shunts venous blood out - then arterial blood goes out --> leading to infarction - aftre that, the pressure goes up exponentially, and once it does this, you herniate

Intracranial pressure - keep it below 20 - can MAP - ICP = CPP (check equation) - Keep BP around 100 for patients

- Hypotension is the biggest issue

- Cushing's response --> is to increase ICP, CPP - purpose is to keep CPP up. But if that fails, you get decreased HR, and high BP

- Keep their BP up - Hypotension is the worst thing that can happen for the head

Classification of head injuries - cranial vault

- depressed/nondepressed - open/closed - open, bad. need to take to OR.

- Basilar - with/without CSF leak - if you can tell they have CSF, you are the best doctor. It is hard to see - with/without cranial nerve deficits (double check)

Brain injuries - Focal(ish) - epidural - subdural - intraparenchymal

Diffuse(ish) - concussion - multiple contusions - hypoxic/ischemic injury

Need to assess - cervial spine fracture, carotid injury, vertebral injury --> ischemia

- think abou the neck too for these (above)

EPIDURAL HEMATOMA - hit head - look at side of the head - the vessel is injured where it is secured -- commonly, generally (think aortic tear, meningeal artery, etc) - can be rapidly fatal - take to OR - blood has iron, it's bright on CT - dense stuff is bright. air is dark. - epidural may have normal exam. see CT with epidural

HERNIATION - herniation is a clinical syndrome. If you see a film, doesn't matter as much. all about clinical syndrome.

SUBDURAL HEMATOMA - if small, bone whiteness will hide it - they don't die from the hematoma per say - they have underlying brain injury (unlike the epidural hematoma) because you have blood INSIDE the

brain - if patient doing OK clinically, might sit on it - keywords: hyperdnesity, midline shift - treatment: hemicraniectomy - get a good neuro exam before you intubate them

INTRACEREBRAL HEMATOMA/CONTUSION - these are proressive injury -- it evolves over time - pt can deteriorate quickly - usually temporal pole and frontal area - probably want to intubate before sendimg them off

DIFFUSE BRAIN INJURY - might not see the ventricals - "things look tight"

GCS - if giving GCS, can give the components when presenting your patient (patient had eye opening, etc) - tell them what the patient is doing (not the words decorticate, or decerebrate)

- need to memorize it

GCS 13-15 - neuro exam most important - most people get head CT - if head CT normal, no alcoholol/drug, maybe send home

GCS 9-12 - CT scan all - neuro exam - watch them. could deteriorate

GCS 3-8 - neuro - reevaluate

INDICATIONS FOR CT SCAN - GCS <15 2 hours after injury - p.142

MANAGEMENT - ABCDE - get GCS score - pupils

- lateralization signs - controlled ventilation - goal: PaCO2 at 35mHg - etCO2 - IV - euvolemia, NS or LR - consult neuro - mannitol - use with signs of tentorial herniation - can cause profound hypotension - be careful before using this

Meds - anticonvulsants, sedation, paralytics (note that you do not use paralytics to treat seizures!) duh - use short acting paralytics - sedation with propofol

Scalp wounds - can staple it closed - direct pressure - can be badness in kids

Hyperventilation/mannitol -> don't have to worry so much at university hospital. can get to the OR quickly.


- for patient with increased ICP, hematoma, when you intubate, put them down hard, with intubation drugs. 200 succ (not 100), and 40 etomadate (not 20) - etomidate is a sedative - if you don't hit them hard, they might get increased ICP from the intubation - call neurosurgery early so they can come do a neuro exam before you intubate - call neurosurg early - talk your plan to the team - call out your findings - primary just GCS mostly for disability and crazyness - intubate the bubbles -- facial injury, airway obstruction - make sure you resuscitation - all the evals happen simultaneously - quick primary survey, fix it, secondary survey - surgery intern in code, your job is to do the lines

6.24.10 ATLS course, and head trauma

skills station too



ATLS: Notes from Notes from day:second day: ATLS: the second the Spine Injury 6.24.10 Spine Injury 6.24.10

SPINE INJURY - 38 y/o male, GCS 15 - suspect spine injury always - mechanism of injury - unconscious patient - neuro deficit - for pediatrics, pad them properly cause kids have big heads - p.169-170 - x-rays - crosstable lateral films exclude 85% of fractures - If you add AP and odontoid views, excludes most fracures - 10% of patients with c-spine fracture have a fracture somewhere else - so look for other places of fracture - get them off the board. pressure sores can occur, esp in old, young

- how would you state the injury

Neurogenic shock - high spine injury - can develop airway problems too - cervical or high thoracic - give fluids first - might need to give atropine b/c of bradycardia - some might need pacemaker b/c some go asystolic (presenter story)

Spinal shock - no hemodynamic issues

Consequences - inadequate ventilation - abdominal evaluation can be compromised (no abd pain) - occult compartment syndrome (see it in M&M a lot)

Management - keep BP>50 - maintain perfusion of spinal cord (keep MAP>85 or normotensive); if they are normally hypertensive, need to keep their BP higher

- manage hypotension - transfer for unstable fracture, any neuro deficit (if outside hospital) - preparation for transfer - no studies have shown benefits of steroids - if you do use them, loading dose, run for 24-48 hours - some people do it, others don't "when you are a resident, you just do what you are told. but it doesn't mean you can't ask questions or ask for a valid reason for what you are doing." - usually spinal shock occurs pretty quickly, neurogenic shock occurs over time, sometimes spinal shock occurs before neurogenic shock - remember, document your neuro exam! b/c you have no idea what it was before, and it's hard to note a change

atls lecture 6.24.10
Term Definition

ATLS: Notes from Notes from day:second day: ATLS: the second the Musculoskeletal trauma 6.24.10 Musculoskeletal trauma 6.24.10

Musculoskeletal trauma - splinting - prevents further blood loss

- restore and maintain perfusion - relieves pain - stabilization - rational for splinting - secondary survey - mechanism of injury - time of injury - clean open fractures within 6 hours - concerns - look for vascular compromise - open fracture - assess and manage vascular compromize - managing open fractures - x-ray studies: a joint above and below - Injuries causing compartment syndrome - crus injuries - tibia, forearm - vscular injury (bony injury likely involved) - cast, tight dressing - burns

Symptoms of compartment syndrome - pain on passive stretch

- etc - p.196


- MSK exam - have them move their extremities (instead of you doing it) - put hand on iliac creast and push in (not out; could make open pelvic fracture worse!) - pulses - logroll, spine, step offfs - medial part of leg is L3 - lateral part of arm is C5, and then you go from thumb and around, so C6 thumb, C7 middle finger, C8 pinky, T1 left side of arm

- traction splint - get to right length - straps, adjust straps using good leg - use it - put ankle stirrup - 2 straps above, 2 straps below knee - while doing this, someone is pulling traction - you want to reduce the fracture

- when you release it, keep traction while you pull the pin - pain control - pulse, sensation before and after

Vacuum splint - used in the field - does not reduce, just immobilizes - pretty cool

Compartment syndrome - can miss this - often seen in m&M - if you have lactate trending up, think about this - sedate patient before you do a fasciotomy!!!

Vertical shear pelvic fracture

Open book fracture

Volume is like a cone; volume is proportional to radius squared

Want to binder to be centered over the femoral trochanters (NOT the iliac crest!); while also at the same time you

should internally rotate the legs

Pelvic fracture - legs, limb discrepancy - look at the ring, follow the ring - look at the SI (sacroiliac joints) for widening - look at acetabulum for acetabular fracture - look at pubic symphysis for open book fracture (widened pubic symphaysis) - look at rami for fracture - look to see if there is symmetry between structures on both sides - cystourethrogram if blood in the urethral meatus

MSK lecture, and MSK skills station/Xray station ATLS lecture, 6.24.10
Term Definition

ATLS: Notes from Notes from day:second day: ATLS: the second the Looking at Looking at spine x-rays 6.24.10 spine x-rays 6.24.10

C-spine - adequate, see 7 cervical vertibrae - look at alignment (A and C are most important ones) - look at bone for fracture or

dislocations - cartilage - dens - extra axial soft tissue - facets (usually if you hve a facet problem, can't see it on x-ray) - case: if the film is not adequate, get a CT! can't rely on x-ray if not adequate

- odontoid view - normal odontoid view - c2 fracture - hangmans fracture - c4 fracture - thoracolumbar fracture - burst fraction - in lower spine, do MRI most of the time - chance fracture

atls lecture, 6.23.10
Term Definition

ATLS: Notes from Notes from day:second day: ATLS: the second the Thermal Injuries 6.24.10 Thermal Injuries 6.24.10

Thermal Injuries

Iowa - burn injuries, house fires, industrial fires - more commonly see cold injuries

Burn patient - intubate before you have to - if you wait --> increased swelling -intubation more difficult - breathing -- difficult in chest wall expansion - house fire -- can get arsenic poisoning ('cause arsenic is in a lot of stuff!) so keep that in mind, watch for symptoms

Inhalation injury p.212 - change in voice - singeing

- biggest issues after burn is fluid loss - best thing to use is urinary output - palm of the hand is about 1% - card that you hand when you scrub in is about 1% - 3rd degree doesn't hurt - how much fluid to give? A lot! - Parland formula: 50% first 8 hours,

50% last 16 hours. The time starts at time of injury. So if pt arrives 2 hours later, give first 50% in 6 hours.

Chemical burns - wash them off

Electrical burns - risk of myoglobinuria

You have to get your patients naked!

Criteria for transfer to a burn center p.218-219

>10% BSA in <10 and >50 y/o - etc - p.219

Before you transfer, you must call the transfer center!!

Frostnip - no ice crystal formation - get patient naked - passive warming

- fluids, pain meds, tetanus, etc - <35, call it hypothermia - look hypothermic if palor, greay, cyanotic,confused, shivering if early, variable vital signs

Treatment - warmed environment, blankets, and IV fluids - surgical rewarming techniques, lavage, etc - take care of ABCs

atls lecture, 6.23.10
Term Definition

ATLS: Notes from Notes from day:second day: ATLS: the second the Pediatric trauma 6.24.10 Pediatric trauma 6.24.10

Pediatric trauma - most common cause of death in kids is injury - when kids do badly, it's because of respiratory problem most of the time - kids have a big head -- so put padding under the shoulder blades when they are on the board (body on backboard, head off of it) - <4y/o, trachea is a cone, reaches a point at the cricoid membrane; more

likely to get airway obstruction - c-spine injury are often at C1,C2 at the hinge where head meets neck - SCIWORA - refers to plain films - chest - prone to pulmonary contusions, any chest trauma is going to be significant - abdomen: spleen and liver tend to be below the costal margin; so you will see lots of splenic and liver lacs - a normal BP in kids is not reassuring - when they do drop the BP, they are near the end - urine oiutput: 0-2 years, 1.52mL/kg/hr - kids lose heat fast. prevent hypothermia. - kids - larger tongue; high anterior larynx; larger occiput, etc. - Breslow tape, very important (said the ED guy!!) only caries this and 2 other things to work! - kids do well when restrained in a seat belt whereas adults can get jacked up - Types of injuries, "superman injuries" which is funny actually (not!)

A - obstructs easily; - uncuffed ET tube; only need to put the ET tube in like 1cm in or so; usually no cuff before 6 y/o; not a fast rule though

B - tension pneumothorax; avoid barotrauma C - vascular access; fluids and blood. watch the HR, not the blood pressure D - pediatric GCS score -- diffuse swelling E - gastric dilation; avoid heat loss

Intraosseus IV - ideal spot is anterior tibia, but you can put it in other places

Child abuse - delay in care - injury doesn't match with story - story changes - etc

atls lecture, 6.24.10

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