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ATLS Practice Test 1

Answers & Explanations

1. c 21. b

2. d 22. b

3. d 23. e

4. c 24. c

5. d 25. c

6. d 26. e

7. e 27. d

8. a 28. c

9. c 29. c

10. e 30. e

11. d 31. c

12. e 32. a

13. d 33. e

14. a 34. e

15. d 35. d

16. d 36. d

17. c 37. d

18. a 38. b

19. a 39. c

20. e 40. b

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1. c​
.
Treatment of frostbite should be immediate to decrease the duration of tissue freezing,
although rewarming should not be undertaken if there is the risk of refreezing. The
injured part should be placed in circulating water at a constant 40°C (104°F) until pink
color and perfusion return (usually within 20 to 30 minutes). This is best accomplished in
a large tank, such as a whirlpool tank. Avoid dry heat since this risks burning the skin,
and do not rub or massage the area since this causes more tissue injury. Rewarming can
be extremely painful, and adequate analgesia is essential. Cardiac monitoring during
rewarming is advised.

2. d​.
Short, large­caliber peripheral intravenous lines are preferred for the rapid infusion of
large volumes of fluid.

3. d​
.
A spinal cord injury would generally cause absent reflexes at the level of the injury,
hyper­reflexia inferior to it, and normal reflexes superior to it.

4. c​
.
Most injured patients who are in hypovolemic shock require early surgical intervention or
angioembolization, as well as fluid resuscitation.

5. d​
.
The absolute volume of blood loss required to produce shock is ​less​than in adults.
However, the percentage volume of blood loss required to produce shock is ​ more​ than in
adults. Note: Up to a 30% diminution in circulating blood volume may be required to
cause a decrease in the child’s systolic blood pressure. Tachycardia and poor skin
perfusion often are the only keys to early recognition of hypovolemia.

6. d.
In this scenario, airway and breathing have been addressed. The next priority is
circulation. The patient is in hypovolemic shock. He is receiving IV fluids. Sources of
hemorrhage must be sought. Thus, a FAST scan or DPL should be performed quickly.
Almost simultaneously, a pelvic binder should be applied and pressure applied to external
hemorrhage sites; but, these are not provided as answer choices. The other answer
choices are not the next priorities, and would delay resuscitation.

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7. e.
There is a high probability of a tension pneumothorax. Associated signs would be absent
breath sounds, hyperresonance, JVD, hypotension, and tracheal deviation. Needle
thoracentesis should be done immediately. There is not enough time to obtain a chest
x­ray.

8. a.
The patient is in hypovolemic shock from a gunshot wound in the abdomen. Further
diagnostic tests at this time would only delay the necessary surgical intervention, which is
needed immediately.

9. c.
Transfer should be considered whenever the patient’s treatment needs exceed the
capabilities of the institution. This decision requires an assessment of the patient’s
injuries by the physician.

10. e.
Of the choices, only bilateral compartment syndrome in the legs is consistent with the
mechanism and presentation of this case. Paralysis of the affected muscles is a late sign
of compartment syndrome. ​ Note​: Central cord syndrome is characterized by a
disproportionately greater loss of motor strength in the arms than in the legs. Usually this
syndrome occurs after a cervical spine hyperextension injury in a patient with
preexisting cervical canal stenosis.

11. d.
There is neurovascular compromise of the right foot. Realignment of the fracture
segments with a traction splint may alleviate compression on and/or “unkink” any vessels
and nerves. ​Note​: Arteriography or CT angiography must not delay re­establishing
arterial blood flow, and is indicated only after consultation with a surgeon.

12. e.
A lucid interval between time of injury and neurologic deterioration is the classic
presentation of an epidural hematoma.

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13. d.
In the ATLS “ABCDE’s,” we are at “C.” Two liters of crystalloid have been infused
with minimal improvement in vital signs. This indicates >40% blood loss (see Table
14.2 in the ATLS Manual) and the need for immediate transfusion of packed RBCs, and
probably platelets and plasma. Concomitantly, surgical consultation and transfer
processes should be initiated. Given that the trajectory of the bullet avoids the abdominal
cavity, FAST or DPL are lesser priorities. A chest x­ray is not a high priority at this
stage.

14. a.
In the setting of acute trauma, the absence of breath sounds indicates either a hemothorax
or a pneumothorax. Dullness to percussion indicates either a hemothorax or
consolidation. Thus, only hemothorax has both these features. ​ Note​: There would likely
still be some breath sounds and some resonance to percussion with diaphragmatic rupture
and contralateral tension pneumothorax.

15. d​.
Optimal immediate management includes maintaining the airway, assisting breathing as
necessary, initiating fluid therapy, and transferring the patient to the operating room. All
these should occur simultaneously.

16. d​
.
The highest priority is the airway. With a GCS score of 6, the airway needs to be
protected ­ ideally with an endotracheal tube.

17. c​
.
Although surgery may not be necessary, the patient should be in a facility with surgical
Note​
capabilities should the need arise, e.g. onset of hemorrhaging. ​ : typing and
crossmatching for blood should also be done, but this can happen at the facility he is
transferred to.

18. a​
.
Children sustain “spinal cord injury without radiographic abnormalities” (SCIWORA)
more commonly than adults. ​ Note​
: An infant with a traumatic brain injury may become
hypertensive​from cerebral edema (​ Cushing response)​ . Initial therapy for traumatic brain
does not​
injury ​ include the administration of corticosteroids. Children have ​ fewer​
focal
mass lesions as a result of traumatic brain injury when compared to adults. Young
more​
children are ​ tolerant of expanding intracranial mass lesions than adults due to
fontanelles and open cranial sutures.
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19. a​
.
Immobilization of the entire spine ​ must​ include the use of a long spine board, semi­rigid
cervical collar, bolstering devices (e.g. to prevent the head from turning), and appropriate
straps. A scoop­style stretcher facilitates loading the patient on to the stretcher. Air
splints may be indicated for musculoskeletal injuries of the extremities, but are not
required for spine immobilization.

20. e​
.
The central guiding principle that underlies all other triage principles, rules, and strategies
is, “Do the most good for the most patients using available resources.” Choice e. comes
closest to this statement.

21. b​.
Electricity causes forced contraction of muscles, possibly leading to rhabdomyolysis.
This results in myoglobin release, which can cause acute renal failure. Aggressive fluid
infusion may prevent myoglobin from clogging the renal tubules. If the patient’s urine is
dark, assume that hemochromogens are in the urine. Fluid administration should be
increased to ensure a urinary output of 100 mL/hr in adults or 2 mL/ kg/hr in children
<30 kg. Metabolic acidosis should be corrected by maintaining adequate perfusion.

22. b​
.
n​
I​ traumatic brain injury​ (TBI), pr​
imary injury occurs during the initial insult, while
secondary injury occurs gradually and may involve an array of cellular processes. The
goal in resuscitating the patient with brain injuries is to prevent secondary brain injury.
This may involve prompt neurosurgical interventions, treating shock, normalization of
BP, treatment of elevated ICP, normalizing blood gases, and so on.

23. e​
.
Shock is an abnormality of the circulatory system that results in inadequate organ
perfusion. No vital sign or laboratory test can diagnose shock; rather, the initial diagnosis
is a clinical one.

24. c​
.
A surgical airway (i.e., cricothyroidotomy or tracheostomy) is established when edema of
the glottis, fracture of the larynx, or severe oropharyngeal hemorrhage obstructs the
airway. A surgical cricothyroidotomy is preferable to a tracheostomy because it is easier
to perform, associated with less bleeding, and requires less time to perform.

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25. c​
.
Remember, the first priority is the airway. With a GCS of 6, she cannot protect her
airway, so endotracheal intubation is necessary. Also, this will allow for
hyperventilation, which will help lower ICP and, thus, buy some time. She almost
certainly has an epidural hematoma, so arrangements for surgical evacuation of the
hematoma should be made as soon as possible. ​ Note​
: All the other choices are
possibilities later on, except for choice b. This because corticosteroids are not indicated
for traumatic brain injury.

26. e​
.
If there is a fracture of the cribriform plate, The nasogastric tube could go directly into
the brain. An orogastric tube would be a much safer alternative.

27. d​
.
This child has sustained a “spinal cord injury without radiographic abnormalities”
(SCIWORA) until proven otherwise. We must assume that an unstable injury exists,
maintain immobilization of the spine, and obtain appropriate consultation.

28. c​
.
Immediate​
chest tube insertion is indicated for massive hemothorax and tension
pneumothorax.

29. c​.
Tension pneumothorax, particularly on the left side, can mimic cardiac tamponade. Both
conditions may present with elevation of venous pressure and decline in arterial pressure.
Cardiac tamponade is indicated by the presence of Beck’s triad: jugular venous
distention, hypotension, and muffled heart tones. However, muffled heart tones are
difficult to assess in a noisy exam area, and distended neck veins may be absent due to
hypovolemia. Kussmaul’s sign (a rise in venous pressure with inspiration when
breathing spontaneously) is also indicative of cardiac tamponade, as well as ​ right­sided
heart fa​ilure, ​
restrictive cardiomyopathy​ , and ​ . ​
constrictive pericarditis​ Another sign of
tamponade is ​ pulsus paradoxus​: a drop of at least 10 mm Hg in systolic blood pressure
with inspiration.​Tension pneumothorax may be differentiated from cardiac tamponade
by the findings of absent breath sounds, tracheal deviation, and hyperresonant percussion
over the affected hemithorax. ​ Note​: Cardiac tamponade most commonly results from
penetrating injuries, although it can also be caused by blunt injury. It is often
life­threatening. It cannot be excluded by chest x­ray; however, it can be diagnosed by
FAST scan.
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30. e​
.
This patient has lost a significant amount of blood internally (at least 2 liters). Of the
choices, only hemorrhage into the chest or abdomen could possibly cause this.

31. c​
.
Although a positive Kleihauer­Betke test (a maternal blood smear allowing quantification
of fetal RBCs in maternal blood) indicates fetomaternal hemorrhage, a negative test ​
does
not exclude​minor degrees of fetomaternal hemorrhage that are capable of sensitizing the
Rh­negative mother. ​Note​: Fetomaternal hemorrhage may occur in blunt or penetrating
abdominal trauma. As little as 0.01 mL of Rh­positive blood can sensitize an
Rh­negative mother, so any fetomaternal hemorrhage should warrant Rh immunoglobulin
therapy (e.g. RhoGAM 300 mcg IM to mother within 72 hours). Proof of fetal maternal
hemorrhage is not necessary, and if there is any doubt, the immunoglobulin should be
administered. Of course, if the mother is Rh­positive, Rh isoimmunization is not an
issue.

32. a​
.
Signs of aortic rupture on a chest radiograph include:
Widened mediastinum
Obliteration of the aortic knob
Obscuration of the aortopulmonary window
Deviation of the trachea to the right
Depression of the left mainstem bronchus
Elevation of the right mainstem bronchus
Deviation of the esophagus (nasogastric tube) to the right
Widened paratracheal stripe
Widened paraspinal interfaces
Presence of a pleural or apical cap
Left hemothorax
Fractures of the first or second ribs or scapula
Note​: Mediastinal emphysema is ​ not​
a sign of aortic rupture, but rather of esophageal
rupture (e.g. Boerhaave syndrome), asthma or other conditions leading to alveolar
rupture, etc.

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33. d​.
In a patient with a severe cardiac contusion and who is receiving parenteral fluids, there
is an increased risk of fluid overload and consequent pulmonary edema. This is because
they may be such myocardial damage that the heart fails to pump properly. Central
venous pressure monitoring provides early warning of impending fluid overload.

34. e​
.
In lateral C­spine films, the base of the skull, all seven cervical vertebrae, and the
superior part of the first thoracic vertebra must be visualized. The patient’s shoulders
may need to be pulled down when obtaining the lateral cervical spine film. If all seven
cervical vertebrae are not visualized on the lateral film, a swimmer’s view should be
obtained. ​ Note​
: C­spine films are done during the secondary survey, not the primary
survey; do not exclude serious cervical spine injury (e.g. unstable ligamentous spine
injuries); should be done for unconscious patients with penetrating cervical injuries; and
should not delay endotracheal intubation should this be required.

35. d​.
The patient has a flail chest and a pulmonary contusion. He is likely hypoventilating due
to the intense pain. Gaseous exchange is impaired due to the pulmonary contusion.
Ventilation can be improved by providing analgesia. One way of doing this is by
performing intercostal nerve blocks. One must be careful not to administer too much
fluid because of the risk of fluid overload and pulmonary edema. If these measures do
not correct the problem, it may be necessary to intubate and mechanically ventilate.
Note​: Intravenous sedation by itself will worsen the hypoventilation. Increasing the FIO​
2
may not be possible since he already appears to be getting 100% oxygen. External
stabilization of the chest wall would not have a significant effect, and would take too
long.

36. d​.
Hyperflexion fractures in the thoracolumbar spine are unstable because the ligamentum
flavum, interspinous ligaments, and supraspinous ligaments usually are disrupted. ​ Note​
:
If properly performed, log­rolling should not be destabilizing to fractures. The scoop
stretcher should not be used to immobilize a patient ­ it cannot replace a long spine board
or a firm, padded gurney. In addition, the scoop stretcher should not be used to transport
the patient. Furthermore, the patient should not be transferred to the gurney by picking
up only the foot and head ends of the scoop stretcher. Without firm support under the
stretcher, it can sag in the middle and result in loss of neutral alignment of the spine.
Injury to any part of the cord or the cauda equina commonly results in bladder and bowel

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dysfunction. Neurogenic shock commonly accompanies spinal cord injury above the
level of T6.

37. d​.
Urinary output is one of the prime monitors of resuscitation and patient response. It is a
reasonably sensitive indicator of renal perfusion and, therefore, organ perfusion in
general. ​Note​ : CVP, or JVP, can provide useful information, especially for complex
cases. It is affected by both volume status and right heart function, so is not be ideal for
monitoring only volume status per se. Blood pressure, pulse pressure, and pulse rate are
signs indicative of shock and its reversal, but give no information regarding organ
perfusion. For example, an increase in blood pressure should not be equated with a
concomitant increase in cardiac output. Also, compensatory mechanisms can preclude a
measurable fall in systolic pressure until up to 30% of blood volume is lost. Hemoglobin
and hematocrit values remain unchanged from baseline immediately after acute blood
loss; and during resuscitation, they may fall secondary to crystalloid infusion and
re­equilibration of extracellular fluid into the intravascular space.

38. b​.
Trauma to the midface can produce fractures and dislocations that compromise the
nasopharynx and oropharynx. Facial fractures can be associated with hemorrhage,
increased secretions, and dislodged teeth, which cause additional difficulties in
maintaining a patent airway. Fractures of the mandible, especially bilateral body
fractures, can cause loss of normal airway structural support. Airway obstruction can
result if the patient is in a supine position. Patients who refuse to lie down may be
experiencing difficulty in maintaining their airway or handling secretions. Furthermore,
providing general anesthesia, sedation, or muscle relaxation can lead to the total loss of
airway due to diminished or absent muscle tone.

39. c​
.
This presentation is consistent with intubation of the right mainstem bronchus. The
placement of the endotracheal tube should be assessed, and the tube repositioned if
necessary. A quickly­done AP chest film can determine endotracheal tube positioning,
and also rule out pneumothorax and hemothorax. ​ Note​: A diagnosis of tension
pneumothorax is not supported by the signs.

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40. b​.
The placental vasculature is maximally dilated throughout gestation, yet it is exquisitely
sensitive to catecholamine stimulation. An abrupt decrease in maternal intravascular
volume can result in a profound increase in uterine vascular resistance, reducing fetal
oxygenation despite reasonably normal maternal vital signs. ​ Note​: Placental abruption
may result from trauma, hypertension, or coagulopathy; but, it is not the direct result of
increased catecholamines in the mother.

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