1 . A 34 year old man is injured in a motor vehicle collision.

Physical examination i normal

except for diffuse abdominal tenderness. Capillary refill is normal. Vital signs obtained en

route to the hospital are blood pressure 100/60; pulse, 120/min; respirations 28/min. How

should this patient be managed in the field?

A. Intravenous (I.V.) of 0.9% normal saline (NS) at "keep open" rate

B. I.V. of RL at 20 ml/kg bolus

C. Pneumatic antishock trousers (PASG); inflate all three compartments

D. Insert an oralpharygeal airway and assist ventilations

1-A

2 . What is Sellick's maneuver?

A. A method allowing the rescuer to hold a mask on the face with both hands

B. A system used to calculate minute volume

C. Another name for Mallampati

D. Posteriorly directed pressure applied to the cricoid cartilage

2-D

3 . Proper immobilization of a forearm (radius and ulna) fracture involves splinting which of the

following?

A. Elbow and fracture site

B. Fracture site only

C. Wrist and fracture site

D. Wrist, elbow, and fracture site

3-D

4 . What treatment is NOT indicated in the routine management of the patient with a head injury?

A. Administration of 100% oxygen

B. Fluid resuscitation to a BP of 110-120 systolic if the patient is hypotensive

C. Hyperventilation

D. Stabilization of the cervical spine

4-C
5. Which of the following sets of vital signs is most compatible with a diagnosis of isolated

head injury with increasing intracranial pressure?

A. BP 170/100, pulse 50/min

B. BP 80/60, pulse 130/min

C. BP 80/60, pulse 5O/min

D. BP 170/100, pulse 130/mi

5-A

6. Which one of the following should be performed, at the scene of a "load and go", prior to

moving the trauma patient to the ambulance?

A. Apply traction splint for femur fracture

B. Decompress tension pneumothorax

C. Initiate intravenous line

D. Obtain vital signs

6-B

7 . What site is first choice for pediatric intraosseous infusion?

A. Proximal tibia

B. Distal humerus

C. Proximal femur

D. Distal fibula

7-A

8 . Which of the following will generally suffer the LEAST structural damage from a gunshot

wound from a rifle?

A. Spleen

B. Kidney

C. Liver

D. Lung

8-D
9 . A 34 year old man has a gunshot wound to the right groin area. Arterial bleeding, which

cannot be controlled with direct pressure, is coming from the wound. The patient appears

confused, diaphoretic, and has weak peripheral pulses. What is the appropriate fluid

resuscitation for this patient?

A. I.V. at "keep open" rate

B. Apply a hemostatic agent and gain IV access given enough fluid to maintain

peripheral pulses

C. I.V. wide open rate; give at least two liters, then reassess patient

D. No I.V. should be started in this situation

9-B

10 . Which one of the following is typically associated with, post-traumatic hemorrhage, EARLY

shock?

A. Ventricular dysrhythmias

B. Hypotension

C. Loss of 30% to 45% of blood volume

D. Larrowed pulse pressure

10-D

11 . Among the following, what is the most common cause of preventable trauma death in the

injured adult patient?

A. Airway obstruction

B. Cardiac tamponade

C. Hemorrhagic shock

D. Spinal injury

11-A

12 . A 49 year old man is involved in a motor vehicle collision. First responders are doing CPR.

Findings include a distended abdomen and obviously deformed pelvis and a quick look at the

monitor shows asystole. Which of the following is the most appropriate act?

A. Establish IV access and administer a 20mL/kg bolus

B. Establish IV access and administer a 1 liter bolus

C. Establish IV access and administer a 2-4 liter bolus

D. Resuscitative efforts should not be started and the patient pronounced dead

12-D
13. Which area of the spine is most susceptible to injury in a rear-impact motor vehicle crash?

A. Cervical

B. Thoracic

C. Lumbar

D. Sacral-coccygeal

13-A

14. An unrestrained 18 year old male on the way to a post-graduation party leaves the road, bounces

through a ditch and hits a tree. You find him behind the bent steering wheel, unconscious,

cool, pale and clammy, with labored respirations of 30 and shallow, thready radial pulses of

about 120, flat neck veins, trachea midline, an asymmetrical chest with absent breath

sounds on the left. You assume he has a

A. Cardiac tamponade

B. Tension pneumothorax

C. Massive hemothorax

D. Simple pneumothorax

14-B

15.Which one of the following mnemoics can be used to help predict which partints might potentially
have difficult laryngscopy and intubation?

A-MMAP

B-IPPV

C-RSI

D-BOOTS

15- is A

16.Which of the following is an example of a tertiary phase blast injury?

A-Crushing injury due to structural collapse

B-sharpnel injuries

C-pulmonary contusion

D-exposure to radiation

16-A

17-the most common threat to life among truma patients is:

THE ANSWER IS

-inadequate tissue oxygenation

Answer Question
SUPINE, head down 15 degrees to distend neck veins and
How should you position the patient before placing a
prevent embolism, only turn head away if C-SPINE HAS
subclavian or IJ line?
BEEN CLEARED FIRST.
Intraosseous infusion should be limited to emergency
resuscitation and shoudl be discontinued as soon as other How long can you keep an IO line in?
venous access is obtained.
The saphenous vein can be accessed approximately 1 cm
anterior and 1 cm superior to the medial malleolus. Make Where do you want to make an incision for a saphenous
a 2.5 cm transverse incision through the skin and SQ vein cutdown and how long should your incision be?
tissue, careful not to injure the vessel.
This may NOT be a pneumothorax, for intubated patients A patient arrives to the trauma bay intubated and there
always suspect a right main-stem before attempting needle are absent breath sounds over the left hemithorax, where
decompression. should you place your decompression needle?
Into the 2nd intercostal space in the midclavicular line of Where would you insert a large caliber needle to
the affected hemithorax. decompress a tension pnuemothorax?
For an open pneumothorax, (sucking chest wound) air
passes preferentially through the chest wall defect (least
2/3
resistance) if the diameter of the defect is at least ___ the
diameter of the trachea.
Flail chest results from multiple rib fractures - by
2 or more ribs fractured in 2 or more places definition this would be ___ or more ribs, fractured in
___ or more places.
Both tension pneumothorax and massive hemothorax are
Percussion - hyperresonant with pnuemo, dull with
associated with decreased breath sounds on auscultation,
hemothorax.
so you can tell which it is by _______.
No, they might have a massive internal hemorrhage and If a patient doesn't have JVD, does this mean they don't
be hypovolemic. have a tension pneumo or tamponade?
1500 mL or 1/3 or more of the patient's total blood
volume. (Some also define it as continued blood loss of By definition, how much blood is in the chest cavity to
200 mL/hr for 2-4 hours- but ATLS does NOT use this call it a "massive hemothorax"?
rate for any mandatory treatment decisions).
#38 French - inserted at the 4th or 5th intercostal space, What size chest tube might you use to evacuate a
just anterior to the midaxillary line. massive hemothorax?
A rise in venous pressure with inspiration while breathing
spontaneously, and is a true paradoxical venous pressure What is Kussmaul's sign?
abnormality associated with cardiac tamponade.
"Closed heart massage for cardiac arrest or PEA is
INEFFECTIVE in patients with hypovolemia." Patients
How well do CPR compressions work on someone with
with PENETRATING thoracic injuries who arrive
a penetrating chest injury and hypovolemia?
pulseless, but with myocardial electrial activity, may be
candidates for an ED thoacotomy.
NO - Only PEA with PENETRATING thoracic injuries Are patients with PEA who have sustained blunt thoracic
should get an ED thoracotomy. injuries candidates for an ED thoracotomy?
Evacuate pericardial blood, direcly control hemorrhage,
cardiac massage, cross-clamp the descending aorta to slow
An ED thoracotomy can allow you to do what?
blood loss below the diaphragm and increase perfusion to
the heart and brain.
CHEST TUBE - positive pressure ventilation can turn a For a patient with a traumatic simple pneumothorax,
simple pneumo into a tension pneumo, so put in a chest what should you do BEFORE you start positive pressure
tube first. ventilation or take them to surgery for a GA?
YES - A simple hemothorax, if not fully evacuated, may
Should you evacuate a simple hemothorax if it is not
result in a retained, clotted hemothroax with lung
causing any respiratory problems?
entrapment or, if infected, develop into an empyema.
tracheobronchial - Use bronchoscopy to confirm, you may
A pneumothorax associated with a persistent large air
need more than one chest tube before definitive operative
leak after tube thoracostomy suggests a _______ injury.
management.
Widened mediastinum, obliteration of aortic knob,
deviation of trachea to the right, depression of left
What radiographic findings are suggestive of traumatic
mainstem bronchus, deviation of esophagus (NG tube) to
aortic disruption?
right, widened paratracheal stripe, fx'd 1st/2nd ribs or
scapula.
an ESOPHAGEAL RUPTURE - a forceful blow causes A deceleration injury victim with a left pnuemothorax or
expulsion of gastric contents into the esophagus, hemothorax without rib fractures, is in pain or shock out
producing a linear tear in the lower esophagus allowing of proportion to the apparent injury, and has particulate
leakage into the mediastinum. matter in their chest tube may have _________.
Fractures for the lower ribs (10-12) should increase
hepatosplenic
suspicion for _____ injury.
Why are upper torso, facial, and arm plethora with
Temporary compression of the superior vena cava.
petechiae associated with crush injuries to the chest?
Trachea & bronchi, pleural spaces and parenchyma,
How does ATLS suggest you should review a chest
mediastinum, diaphragm, bones, soft tissues, tubes &
radiograph?
lines.
Puncture the skin 1-2 cm inferior to the left xiphohondral
You should use a size 16 or 18 gauge 6" needle for
junction at a 45 degree angle to the skin towards the heart,
pericardiocentesis. How do you insert it?
aiming toward the top of the left scapula.
ECG Changes - extreme ST-changes, widened QRS, What's a good way to know if you've advanced your
PVCs, etc... Withdrawl needle until ECG returns to needle too far during pericardiocentesis and have entered
baseline. ventricular muscle?
Lock the stopcock and leave the catheter in place in case it
needs to be reevacuated. If possible, use the Seldinger What should you do with your needle after you
technique to pass a 14 gauge flexible catheter over the successfully evacuate blood during pericardiocentesis?
guidewire. This is NOT a definitive treatment.
For patients with facial fractures or basillar skull
through the mouth fractures, gastric tubes should be inserted ____ before
doing a DPL.
inability to void, unstable pelvic fracture, blood at urethral
You need to do retrograde urethrography PRIOR to foley
meatus, scrotal hematoma, perineal ecchymoses, or high-
placement if _____.
riding prostate.
98 DPL is considered to be __% sensitive for detecting intraperitoneal bleeding.
Mediastinum, hepatorenal fossa, splenorenal fossa, pouch of Douglas. What are the four places you should look first when doing a FAST scan?
Change in sensorium (brain injury/EtOH or drug intoxication), change in sensation
DPL is indicated when a patient with multiple blunt injuries is hemodynamically
(spinal cord injury), injury to adjacent structures (pelvis, lumbar spine), lap-belt sign
unstable, especially when they have _____.
(from seatbelt), or if patient is going for long studies (CT, ortho surgery...).
An existing indication for laparotomy. What is the only ABSOLUTE contraindication to DPL?
Morbid obesity, advanced cirrhosis, preexisting coagulopathy, and previous abdominal
What are some RELATIVE contraindications to DPL?
operations (adhesions).
PELVIC FRACTURES (don't want to enter pelvic hematoma) and ADVANCED
When should you use an open SUPRAUMBILICAL approach for a DPL?
PREGNANCY (don't want to damage enlarged uterus).

Free blood (>10 mL) or GI contents (vegetable fiber, When doing a DPL, what INITIAL findings (not from
bile). lab) would mandate a laparotomy?
Adult - 1,000 mL warm isotonic crystalloid. Kid - 10
mL/kg
>100,000 red cells/mm^3, 500 white cells/mm^3, or
BACTERIA (on gram stain).
No, if they need an emergent laparotomy they are unstable Your trauma patient needs an urgent laparotomy, can you
- unstable patients should NOT go to the CT scanner!
Unstable, GSW, peritoneal irritation, fascial penetration
25-33%
NO
No - not if they remain hemodynamically stable (Of all
patients who are initially thought to havea ISOLATED
solid organ injury, <5% will have hollow viscus injury as organ injury?
well).
Closed book - the pelvic volume is compressed, so not as
much room for blood.
AP = Open Book, LATERAL = Closed Book
CLOSED BOOK - 60-70% (Open book 15-20%, vertical
shear 5-15%)
Angiography
DECOMPRESS BLADDER, DECOMPRESS
STOMACH
30%
Superficial parasympathetic fibers of the CN III
(occulomotor).
10mm Hg (Pressures >20, particularly if sustained, are
associated with poor outcomes).
Venous Blood & CSF (decreased in equal volumes, when The Monro-Kellie Doctrine describes compensatory
this is exhausted, herniation can occur and brain perfusion mechanisms inside the calvarium to stabilize pressure -
will likely be inadequate).
Minor = 13-15, Moderate = 8-12
The "BEST" response. (Better predictor than worst
response)
PERIORBITAL ECCHYMOSIS (raccoon eyes),
What signs might you see if a patient has a basillar skull
RETROAURICULAR ECCHYMOSIS (Battle sign), and
fracture?
otorrhea/rhinorrhea.
If you don't get gross blood upon initial DPL aspiration,
what do you do next for an adult? For a child?
You've just put a bunch of fluid in the belly and aspirated
more fluid for your DPL. No gross GI contents or
anything alarming are present, what QUANTATIVE
things would make the DPL positive?
take them to the CT scanner first to evaluate injuries?
What are some indications for laparotomy in patients
with penetrating abdominal wounds?
What percentage of stab wounds to the anterior abdomen
do NOT penetrate the peritoneum?
Does an early normal serum amylase level exclude major
pancreatic trauma?
Do you need to operate on anyone with an isolated soild
Which is LESS likely to have a life-threating
hemorrhage - an open book or closed book pelvic
fracture?
Anterior/posterior forces causes _____ book pelvic
fractures, and lateral forces cause _____ book fractures.
Which are more common, open or closed book pelvic
fracturs?
If a patient with a pelvic fracture is positive for
intraperitoneal gross blood, a ex-lap is warranted. What
is your next move if that same patient is NEGATIVE for
gross intraperitoneal blood?
What do you need to do BEFORE you do a DPL? (Other
than getting stuff together and surgically prepping, etc...)
What is "adequate" fluid return when getting DPL fluid
back?
A blown pupil in a patient with a traumatic injury is
caused by compression of which nerve?
What is a "normal" ICP in the resting state?
what are the 2 main/first ones?
Patients with a GCS of 3-8 meet the accepted definition
of "coma" or "severe brain injury." What are the GCS
scores for "minor" and "moderate" brain injury?
When calculating GCS and there is right/left assymetry
in the motor response - which one do you use?
EVERYTHING - Know it COLD! What do you need to know about the GCS?
Abnormal CT (or no scan available), penetrating head
injury, prolonged LOC, worsening LOC, moderate to
What things might require a person with MINOR brain
severe HA, significant drug/alcohol intoxication, skull fx,
injury get admitted?
oto/rhinorrhea, nobody at home to watch, GCS stays <15,
focal neuro deficits.
What would you want to do if a patient with a minor
CT scan - Everything but the 30 min amnesia makes them
brain injury fails to reach a GCS of 15 within 2 hour post
HIGH risk for neurosurgical intervention (as would a
injury, had LOC >5 min, are older than 65, emesis x 2, or
basillar skull fx).
had retrograde amnesia >30 minutes?
What 2 things do you need to do first for everyone with a
CT scan, admit to faciolity capable of definitive
MODERATE brain injury (according to ATLS
neurosurgical care (Moderate = GCS 9-12)
algorithm)?
Dilate (to increase blood flow) - so you might want to High levels of CO2 will cause cerebral vasculature to
HYPERventilate people with brain injuries. _____.
Ideally, you want to wait to perform a GCS on a person
BP is normalized
with SEVERE brain injury until what?
100 If a patient has a systolic over 100 with evidence of A FAST scan, DPL, or ex-lap should take priority over a
intracranial mass (blown pupil, unequal motor exam) CT scan if you can't get the brain injured patient's BP up
THEN a CT would take first priority. to ____ mm Hg.
A midline shift of greater than ___ often indicates the
5mm
need for neurosurgical evacuation of the mass/blood.
Your patient has a dilated pupil and you want to give
0.25-1.0 g/kg via rapid bolus mannitol on the way to the CT scanner or OR. What is
the correct dose?
A cast cutter should be removed to remove a trauma
the patient experiences pain or paresthesias during an
victim's helmet if there is evidence of a c-spine injury or
initial attempt to remove the helmet.
if _____.