atls.yolasite.com ATLS Practice Test 4 1. 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 toward it. Both legs are stiffly extended. His Glasgow Coma Scale score is a. two. b. four. c. six. d. nine. e. twelve. 2. Which one of the following statements concerning massive hemothorax is TRUE? a. It is usually caused by blunt thoracic trauma. b. It is commonly confused with a pneumothorax. c. The diagnosis should be confirmed by upright, plain chest roentgenograms prior to treatment. d. The initial draining of 1,000 mL of blood after chest tube insertion requires immediate thoracotomy. e. The condition should be suspected in situations associated with shock and unilateral absent breath sounds. 3. 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 trachea. 4. 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. 1 atls.yolasite.com 5. 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 lateral cervical spine roentgenogram. 6. A 17-year-old helmeted motorcyclist loses consciousness when he is struck broad side by an automobile at an intersection. He arrives in the emergency department with a blood pressure of 140/92, pulse rate of 88 beats per minute, a respiratory rate of 18 breaths per minute, and a Glasgow Coma Scale score of seven. Appropriate initial immobilization of this patient should include a semi-rigid cervical collar and a. a scoop stretcher. b. a long spine board. c. a short spine board. d. cervical traction tongs. e. pneumatic antishock garment. 7. A 34-year-old man is brought to the hospital after being pinned to the wall of a building by a cement truck. He is in obvious shock, and has deformities and marked swelling of both thighs, although no open wounds are present. His shock a. cannot be explained without concomitant pelvic fracture. b. signifies a loss of approximately 15% of his blood volume. c. is consistent with blood loss from bilateral femoral fractures. d. will likely be reversed if appropriate traction splints are applied. e. cannot be explained by his observed injuries unless a major arterial injury exists. 8. Prior to passage of a urinary catheter, it is essential to a. examine the abdomen. b. determine pelvic stability. c. examine the rectum and perineum. d. perform a retrograde urethrogram. e. know the history and mechanism of injury. 9. 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. total fluids in 24 hours = 4 x weight (kg) x percent body surface area burned. 2 atls.yolasite.com 10. The LEAST likely cause of a depressed level of consciousness in the multisystem injured patient is a. shock. b. head injury. c. hyperglycemia. d. impaired oxygenation. e. alcohol and other drugs. 11. Establishing a diagnosis of shock must include a. confirming hypoxemia. b. the finding of acidosis. c. confirming increased vascular resistance. d. documenting hypotension and low cardiac output. e. evidence of inadequate perfusion of the body's organs. 12. A seven-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 (2.4 inch) 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. apply a hemostat to bleeding vessels. d. direct pressure on the femoral artery at the groin. e. application of the pediatric PASG and inflation of the right leg compartment. 13. For the trauma patient with cerebral edema, hypercarbia should be avoided to prevent a. metabolic acidosis. b. respiratory acidosis. c. cerebral vasodilatation. d. neurogenic pulmonary edema. e. reciprocal high levels of PaCO2. 14. A 23-year-old man sustains four stab wounds to the right upper hemithorax during an altercation and is brought by ambulance to a community hospital. The wounds are all above the nipple. He is endotracheally intubated, closed tube thoracostomy is performed, and two liters of Ringer's lactate solution are infused through two large-calibre IVs. His blood pressure now is 60/0, pulse rate is 160 beats per minute, and respiratory rate is 14 breaths per minute (ventilated with 100% O2). The most appropriate next step in managing this patient is a. angiography. b. thoracotomy. c. CT of the chest. d. application of PASG. e. immediate transfer to another facility. 3 atls.yolasite.com 15. An 80-year-old female presents after being struck by a scooter. Her respiratory rate is 20, heart rate is 86, and blood pressure is 100/70 mm Hg. Her Glasgow Coma Scale score is 12, and she is bleeding from a scalp laceration. Which one of the following treatment steps is the priority? a. administering 1 L of crystalloid b. controlling bleeding from the scalp c. performing a neurological examination d. obtaining a CT scan of the head e. obtaining detailed information about medication and previous history 16. The cause of upper airway obstruction most likely to be alleviated by a properly placed oral airway is a. foreign body. b. facial fractures. c. copious, tenacious oral secretions. d. hematoma of the posterior pharynx. e. posterior displacement of tongue. 17. The primary indication for transferring a patient to a higher level trauma center is a. multisystem injuries, including severe head injury. b. unavailability of a surgeon or operating room staff. c. unavailability of an intensive care unit bed or ICU staff. d. resource limitations as determined by the referring physician. e. a widened mediastinum on chest roentgenogram after blunt thoracic trauma. 18. A patient is brought to the emergency department 20 minutes after a motor vehicular crash. He is conscious and there is no obvious external trauma. He arrives at the hospital intubated and completely immobilized on a long spine board. His blood pressure is 60/40 and his pulse rate is 70 beats per minute. His skin is warm and he has no rectal tone. Which one of the following statements is TRUE? a. Vasoactive medications have no role in early management. b. The hypotension should be managed with volume resuscitation alone. c. Flexion and extension views of the c-spine should be performed early. d. Occult abdominal visceral injuries can be excluded as a cause of hypotension. e. Flaccidity of the lower extremities and loss of deep tendon reflexes are expected. 19. A 25-year-old female in the third trimester of pregnancy is involved in a motor vehicle crash in which she is the front seat passenger. The driver is dead on scene. Which one of the following statements concerning this patient is true? a. The patient should be told as soon as possible that her husband is dead. b. Palpation of clearly definable fetal parts allows for assessment of the stage of pregnancy. c. The thick-walled uterus provides protection for the fetus. d. Absence of fetal movements indicates maternal shock. e. Clear fluid from the vagina is an indication for hospital admission. 4 atls.yolasite.com 20. Cervical spine injury a. is excluded by a normal neurologic examination. b. is not present if the patient has normal range of neck motion. c. can be detected safely by careful flexion and extension of the neck. d. can be excluded by a crosstable lateral roentgenogram of the c-spine. e. may be first manifested by neurologic deficit after movement of the neck. 21. Typical pelvic fracture patterns and injuries following major mechanisms of injury include: a. lateral compression forces, resulting in open book pelvic fractures. b. anterior-posterior compression, resulting in shifting of the iliac bones vertically. c. Vertical displacement of the hemipelvis, typically resulting in disruption of the sacrospinous ligaments. d. direct blows to the iliac crest of the pelvis, resulting in sacral fractures. e. posterior displacement of the knee and femur in motor vehicle crashes, resulting in acetabular fractures with anterior hip dislocation. 22. 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. 23. Which one of the following statements concerning intraosseous infusion in children is TRUE? a. Only crystalloid solutions may be safely infused through the needle. b. Aspiration of bone marrow confirms appropriate positioning of the needle. c. Intraosseous infusion is the preferred route for volume resuscitation in small children. d. Intraosseous infusion may be utilized indefinitely in the management of injured children. e. Swelling in the soft tissue around the intraosseous site is not a reason to discontinue infusion. 24. A 26-year-old seat-belted driver is brought to the hospital after a car crash. Primary survey reveals no evidence of serious injury except for diffuse, mild abdominal tenderness. Bowel sounds are hypoactive and liver dullness is questionable. Abdominal films reveal free air. The patient should a. undergo peritoneal lavage. b. undergo prompt laparotomy. c. be carefully observed for further evidence of intra-abdominal injury. d. have a contrast roentgenographic study of the gastrointestinal tract. e. be suspected of having a ruptured diaphragm and accompanying pneumothorax. 5 atls.yolasite.com 25. A 31-year-old woman sustains multiple injuries in a motor vehicle collision. She is hemodynamically normal, not in respiratory distress, GCS is 8, and has facial fractures. Breath sounds are slightly decreased in the right hemithorax. Bowel sounds are normal. She has a right open femur fracture. Chest film shows a small right pneumothorax and a widened mediastinum. Surgical specialty capabilities are not available locally, but are available 50 miles away. Prior to transport, all of the following should be performed EXCEPT a. chest tube insertion. b. endotracheal tube insertion. c. CT scan of the head. d. speak directly to the receiving physician. e. infusion of crystalloid. 26. A four-year-old girl, weighing approximately 20 kg (44 pounds), is admitted in shock after an automobile crash. How much crystalloid should be given as an initial fluid bolus? a. 200 mL. b. 400 mL. c. 440 mL. d. 600 mL. e. 880 mL. 27. Which of the following injuries is most likely to be missed by FAST or DPL? a. Mesenteric laceration b. Splenic capsular laceration c. Ileal rupture d. Hepatic fractures e. Duodenal rupture 28. In managing the head-injured patient, the most important initial step is to a. secure the airway. b. immobilize the neck. c. support the circulation. d. control scalp hemorrhage. e. determine the Glasgow Coma Scale score. 29. A previously healthy, 70 kg (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 his 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. 6 atls.yolasite.com 30. 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. increasing the volume of blood loss to produce shock. e. reducing the volume of crystalloid required for resuscitation. 31. Which one of the following findings should prompt immediate management during the primary survey? a. Distended abdomen b. Glasgow Coma Scale Score of 11 c. Pulse rate of 120 beats per minute d. Temperature of 36.5oC (97.8oF) e. Respiratory rate of 32 breaths per minute. 32. During the primary and secondary surveys, the injured patient should be completely immobilized until a. the neurologic examination has been completed. b. the patient is transferred to a definitive care area. c. the patient is able to indicate that he has no neck pain. d. a spinal fracture has been excluded clinically or by roentgenograms. e. the patient complains of potential pressure sores due to the spine board. 33. 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 that is open on one side over the wound. e. initiation of two, large-calibre IVs with Ringer's lactate. 34. Important screening roentgenograms to obtain in the multiple-system trauma patient are a. skull, chest, and abdomen. b. chest, abdomen, and pelvis. c. cervical spine, chest, and pelvis. d. skull, cervical spine, and chest. e. cervical spine, chest, and abdomen. 7 atls.yolasite.com 35. All of the following statements regarding pulse oximetry are true EXCEPT: a. Excessive surrounding room light can interfere with the accuracy of the readings. b. Significant levels of dysfunctional hemoglobin can affect the accuracy of the readings. c. It provides a continuous, noninvasive measurement of the partial pressure of oxygen. d. It is dependent on differential light absorption by oxygenated and deoxygenated hemoglobin. e. It provides a continuous, noninvasive measurement of pulse rate that is updated with each heart beat. 36. A 56-year-old man is thrown violently against the steering wheel of his truck during a motor vehicular crash. On arrival in the emergency department he is diaphoretic and complains of chest pain. His blood pressure is 60/40 and his respiratory rate is 40 breaths per minute. Which of the following would best differentiate 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 37. An 18-year-old man is brought to the hospital after smashing his motorcycle into a tree. He is conscious and alert, but paralyzed in both arms and legs. His skin is pale and cold. He complains of thirst and difficulty in breathing. His airway is clear. His blood pressure is 60/40 and his pulse rate is 140 beats per minute. Breath sounds are full and equal bilaterally. He should a. undergo exploratory celiotomy (laparotomy). b. be treated for neurogenic shock. c. be treated for hypovolemic shock. d. undergo immediate nasotracheal intubation. e. be placed in cervical traction tongs before any other treatment is instituted. 38. A 52-year-old woman sustains 50% total body-surface flame burns in an explosion. She has circumferential burns around the chest and of both upper arms. Adequate resuscitation is initiated. She is nasotracheally intubated and is being mechanically ventilated. Her carboxyhemoglobin level is 10%. Her arterial blood gas analysis reveals PaO2 of 40 mm Hg, PaCO2 of 60 mm Hg, and pH of 7.25. Appropriate immediate management at this time is to a. ensure adequate tissue perfusion. b. increase the rate of fluid resuscitation. c. add positive end-expiratory pressure (PEEP). d. reassess for the presence of a pneumothorax. e. administer intravenous narcotics in small amounts. 8 atls.yolasite.com 39. A 25-year-old man is brought to the hospital after being involved in a motor vehicular crash when his car struck a bridge abutment. He is intoxicated, has a Glasgow Coma Scale score of 13, and complains of abdominal pain. His blood pressure was 80 mm Hg systolic by palpation on admission to the hospital, but it rapidly increased to 110/70 with the administration of intravenous fluids. His heart rate is now 120 beats per minute. The chest roentgenogram shows loss of the aortic knob, widening of the mediastinum, no rib fractures, and no hemopneumothorax. Contrast CT angiography a. is not indicated. b. should be performed after tube thoracostomy. c. is not necessary if non-contrast CT scan of the chest is normal. d. should be performed after a FAST scan. e. is positive for aortic rupture in 80% of similar cases. 40. A 32-year-old man is trapped from the waist down beneath his overturned car for a period exceeding eight hours. On arrival in the emergency department, both lower extremities are cool, mottled, insensate, and motionless. Despite normal vital signs, pulses cannot be palpated below the femoral vessels and the muscles of the lower extremities 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. Performing lower extremity fasciotomies e. Immediately transferring the patient to a trauma center 9