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ATLSPracticeTest2

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A22yearoldmansustainsagunshotwoundtotheleftchestandistransportedtoasmall
communityhospitalatwhichsurgicalcapabilitiesarenotavailable.Intheemergency
department,achesttubeisinsertedand700mLofbloodisevacuated.Thetraumacenter
acceptsthepatientintransfer.Justbeforethepatientisplacedintheambulancefor
transfer,hisbloodpressuredecreasesto80/68mmHgandhisheartrateincreasesto136
beatsperminute.Thenextstepshouldbeto:
a.
clampthechesttube.
b.
cancelthepatient'stransfer.
c.
performanemergencydepartmentthoracotomy.
d.
repeattheprimarysurveyandproceedwithtransfer.
e.
delaythetransferuntilthereferringdoctorcancontactathoracicsurgeon.

Ayoungwomansustainsasevereheadinjuryastheresultofamotorvehiclecrash.In
theemergencydepartment,herGCSis6.Herbloodpressureis140/90mmHgandher
heartrateis80beatsperminute.Sheisintubatedandmechanicallyventilated.Herpupils
are3mminsizeandequallyreactivetolight.Thereisnootherapparentinjury.Themost
importantprincipletofollowintheearlymanagementofherheadinjuryisto:
a.
avoidhypotension.
b.
administeranosmoticdiuretic.
c.
aggressivelytreatsystemichypertension.
d.
reducemetabolicrequirementsofthebrain.
e.
distinguishbetweenintracranialhematomaandcerebraledema.

A6yearoldboywalkingacrossthestreetisstruckbythefrontbumperofasportsutility
vehicletravelingat32kph(20mph).Whichoneofthefollowingstatementsis
TRUE
?
a.
Aflailchestisprobable.
b.
Asymptomaticcardiaccontusionisexpected.
c.
Apulmonarycontusionmaybepresentintheabsenceofribfractures.
d.
Transectionofthethoracicaortaismorelikelythaninanadultpatient.
e.
Ribfracturesarecommonlyfoundinchildrenwiththismechanismofinjury.
A39yearoldmanisadmittedtotheemergencydepartmentafteranautomobile
collision.Heiscyanotic,hasinsufficientrespiratoryeffort,andhasaGCSScoreof6.
Hisfullbeardmakesitdifficulttofittheoxygenfacemasktohisface.Themost
appropriatenextstepisto:
a.
performasurgicalcricothyroidotomy.
b.
attemptnasotrachealintubation.
c.
ventilatehimwithabagmaskdeviceuntilcspineinjurycanbeexcluded.
d.
attemptorotrachealintubationusing2peopleandinlinestabilizationofthe
cervicalspine.
e.
ventilatethepatientwithabagmaskdeviceuntilhisbeardcanbeshavedfor
bettermaskfit.
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Apatientisbroughttotheemergencydepartment20minutesafteramotorvehiclecrash.
Heisconsciousandthereisnoobviousexternaltrauma.Hearrivesatthehospital
completelyimmobilizedonalongspineboard.Hisbloodpressureis60/40mmHgand
hisheartrateis70beatsperminute.Hisskiniswarm.Whichoneofthefollowing
statementsis
TRUE
?
a.Vasoactivemedicationshavenoroleinthispatient'smanagement.
b.Thehypotensionshouldbemanagedwithvolumeresuscitationalone.
c.Flexionandextensionviewsofthecspineshouldbeperformedearly.
d.Occultabdominalvisceralinjuriescanbeexcludedasacauseofhypotension.
e.Flaccidityofthelowerextremitiesandlossofdeeptendonreflexesareexpected.

Thefollowingarecontraindicationsfortetanustoxoidadministration:
a.
Historyofneurologicalreactionorseverehypersensitivitytotheproduct.
b.
Localsideeffects.
c.
Muscularspasms.
d.
Pregnancy.
e.
Alloftheabove.
Afterbeinginvolvedinamotorvehiclecrash,a25yearoldmanisbroughttoahospital
withageneralsurgeononduty.HehasaGCSof13andcomplainsofabdominalpain.
Hisbloodpressurewas80mmHgsystolicbypalpationonarrivalatthehospital,but
increasesto110/70mmHgwiththeadministrationof2litersofintravenousfluid.His
heartrateremains120beatsperminute.Computedtomographyshowsanaorticinjury
andspleniclacerationwithfreeabdominalfluid.Hisbloodpressurefallsto70mmHg
afterCT.Thenextstepis:
a.
contrastangiography.
b.
transfertoahigherleveltraumacenter.
c.
exploratorylaparotomy.
d.
transfusepackedredbloodcells.
e.
transesophagealechocardiography.

Whichoneofthefollowingstatementsregardingabdominaltraumainthepregnant
patientis
TRUE
?
a.
Thefetusisinjeopardyonlywithmajorabdominaltrauma.
b.
Leakageofamnioticfluidisanindicationforhospitaladmission.
c.
Indicationsforperitoneallavagearedifferentfromthoseinthenonpregnant
patient.
d.
Penetrationofanabdominalhollowviscusismorecommoninlatethaninearly
pregnancy.
e.
Thesecondarysurveyfollowsadifferentpatternfromthatofthenonpregnant
patient.

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Allofthefollowingareindicatorsofinhalationinjury,
EXCEPT
:
a.
singeingoftheeyebrowsandnasalvibrissae.
b.
carboxyhemoglobinlevel>4%.
c.
carbondepositsinthemouthornose,andcarbonaceoussputum.
d.
hoarseness.
e.
faceorneckburns.

A32yearoldman'srightlegistrappedbeneathhisoverturnedcarfornearly2hours
beforeheisextricated.Onarrivalintheemergencydepartment,hisrightlowerextremity
iscool,mottled,insensate,andmotionless.Despitenormalvitalsigns,pulsescannotbe
palpatedinferiortothefemoralartery,andthemusclesofthelowerextremityarefirm
andhard.Duringtheinitialmanagementofthispatient,whichofthefollowingismost
likelytoimprovethechancesforlimbsalvage?
a.
Applyingskeletaltraction.
b.
Administeringanticoagulantdrugs.
c.
Administeringthrombolytictherapy.
d.
Performrightlowerextremityfasciotomy.
e.
Immediatelytransferringthepatienttoatraumacenter.

Apatientarrivesintheemergencydepartmentafterbeingbeatenabouttheheadandface
withawoodenclub.Heiscomatoseandhasapalpabledepressedskullfracture.Hisface
isswollenandecchymotic.Hehasgurglingrespirationsandvomitusonhisfaceand
clothing.Themostappropriatestepafterprovidingsupplementaloxygenandelevating
hisjawisto:
a.
requestaCTscan.
b.
insertagastrictube.
c.
suctiontheoropharynx.
d.
obtainalateralcervicalspinexray.
e.
ventilatethepatientwithabagmask.

A64yearoldman,involvedinahighspeedcarcrash,isresuscitatedinitiallyinasmall
hospitalwithlimitedresources.HehasaclosedheadinjurywithaGCSScoreof13.He
hasawidenedmediastinumonchestxraywithfracturesofleftribs2through4,butno
pneumothorax.Afterinfusing2litersofcrystalloidsolution,hisbloodpressureis100/74
mmHg,heartrateis110beatsperminute,andrespiratoryrateis18breathsperminute.
Hehasgrosshematuriaandapelvicfracture.Youdecidetotransferthispatienttoa
facilitycapableofprovidingahigherlevelofcare.Thefacilityis128km(80miles)
away.Beforetransfer,youshouldfirst:
a.
intubatethepatient.
b.
performdiagnosticperitoneallavage.
c.
applythepneumaticantishockgarment.
d.
callthereceivinghospitalandspeaktothesurgeononcall.
e.
discusstheadvisabilityoftransferwiththepatient'sfamily.

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Duringthethirdtrimesterofpregnancy,allofthefollowingchangesoccurnormally,
EXCEPT
a:
a.
decreaseinPaCO
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b.
decreaseinleukocytecount.
c.
reducedgastricemptyingrate.
d.
diminishedresiduallungvolume.
e.
diminishedpelvicligamenttension.

Inmanagingtheheadinjuredpatient,themostimportantinitialstepisto:
a.
securetheairway.
b.
obtaincspinefilm.
c.
supportthecirculation.
d.
controlscalphemorrhage.
e.
determinetheGCSScore.

Apreviouslyhealthy,70kg(154pound)mansuffersanestimatedacutebloodlossof2
liters.Whichoneofthefollowingstatementsappliestothispatient?
a.
Hispulsepressurewillbewidened.
b.
Hisurinaryoutputwillbeatthelowerlimitsofnormal.
c.
Hewillhavetachycardia,butnochangeinhissystolicbloodpressure.
d.
Hissystolicbloodpressurewillbedecreasedwithanarrowedpulsepressure.
e.
Hissystolicbloodpressurewillbemaintainedwithanelevateddiastolicpressure.

Thephysiologichypervolemiaofpregnancyhasclinicalsignificanceinthemanagement
oftheseverelyinjured,gravidwomanby:
a.
reducingtheneedforbloodtransfusion.
b.
increasingtheriskofpulmonaryedema.
c.
complicatingthemanagementofclosedheadinjury.
d.
reducingthevolumeofcrystalloidrequiredforresuscitation.
e.
increasingthevolumeofbloodlosstoproducematernalhypotension.

Thefirstmaneuvertoimproveoxygenationafterchestinjuryis:
a.
intubatethepatient.
b.
assessarterialbloodgases.
c.
administersupplementaloxygen.
d.
ascertaintheneedforachesttube.
e.
obtainachestxray.

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A25yearoldman,injuredinamotorvehicularcrash,isadmittedtotheemergency
department.Hispupilsreactsluggishlyandhiseyesopentopainfulstimulionly.Hedoes
notfollowcommands,buthedoesmoanperiodically.Hisrightarmisdeformedanddoes
notrespondtopainfulstimulushowever,hislefthandreachespurposefullytowardthe
painfulstimulus.Bothlegsarestifflyextended.HisGCSscoreis:
a.
7
b.
8
c.
9
d.
10
e.
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A20yearoldwoman,at32weeksgestation,isstabbedintheupperrightchest.Inthe
emergencydepartment,herbloodpressureis80/60mmHg.Sheisgaspingforbreath,
extremelyanxious,andyellingforhelp.Breathsoundsarediminishedintherightchest.
Themostappropriatefirststepisto:
a.
performtrachealintubation.
b.
insertanoropharyngealairway.
c.
performneedledecompressionoftherightchest.
d.
manuallydisplacethegraviduterustotheleftsideoftheabdomen.
e.
initiate2largecaliberperipheralIVlinesandcrystalloidinfusion.

Whichoneofthefollowingfindingsinanadultshouldpromptimmediatemanagement
duringtheprimarysurvey?
a.
Distendedabdomen.
b.
GlasgowComaScaleScoreof11.
c.
Temperatureof36.5C(97.8F).
d.
Heartrateof120beatsperminute.
e.
Respiratoryrateof40breathsperminute.

Atraumapatientpresentstoyouremergencydepartmentwithinspiratorystridoranda
suspectedcspineinjury.Oxygensaturationis88%onhighflowoxygenviaa
nonrebreathingmask.Themostappropriatenextstepisto:
a.
applycervicaltraction.
b.
performimmediatetracheostomy.
c.
insertbilateralthoracostomytubes.
d.
maintain100%oxygenandobtainimmediatecspinexrays.
e.
maintaininlineimmobilizationandestablishadefinitiveairway.

WhenapplyingtheRuleofNinestoinfants,
a.
itisnotreliable.
b.
thebodyisproportionallylargerininfantsthaninadults.
c.
theheadisproportionallylargerininfantsthaninadults.
d.
thelegsareproportionallylargerininfantsthaninadults.
e.
thearmsareproportionallylargerininfantsthaninadults.

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A60yearoldmansustainsastabwoundtotherightposteriorflank.Witnessesstatethe
weaponwasasmallknife.Hisheartrateis90beatsperminute,bloodpressureis128/72
mmHg,andrespiratoryrateis24breathsperminute.Themostappropriateactiontotake
atthistimeisto:
a.
performacolonoscopy.
b.
performabariumenema.
c.
performanintravenouspyelogram.
d.
performserialphysicalexaminations.
e.
suturerepairthewoundandoutpatientfollowup.

Thefollowingarecriteriafortransfertoaburncenter,
EXCEPT
for:
a.
Partialthicknessandfullthicknessburnsongreaterthan10%oftheBSA
b.
Anyfullthicknessburn
c.
Partialthicknessandfullthicknessburnsinvolvingtheface,hands,feet,
genitalia,perineum,andskinoverlyingmajorjoints
d.
Elevatedcentralvenouspressure
e.
Inhalationinjury

Systolicbloodpressurestartstodecreaseinwhichclassofhemorrhage?
a.
Class0
b.
Class1
c.
Class2
d.
Class3
e.
Class4

A7yearoldboyisbroughttotheemergencydepartmentbyhisparentsseveralminutes
afterhefellthroughawindow.Heisbleedingprofuselyfroma6cmwoundofhis
medialrightthigh.Immediatemanagementofthewoundshouldconsistof:
a.
applicationofatourniquet.
b.
directpressureonthewound.
c.
packingthewoundwithgauze.
d.
directpressureonthefemoralarteryatthegroin.
e.
debridementofdevitalizedtissue.

Forthepatientwithseveretraumaticbraininjury,profoundhypocarbiashouldbe
avoidedtoprevent:
a.
respiratoryalkalosis.
b.
metabolicacidosis.
c.
cerebralvasoconstrictionwithdiminishedperfusion.
d.
neurogenicpulmonaryedema.
e.
shiftoftheoxyhemoglobindissociationcurve.

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A33yearoldwomanisinvolvedinaheadonmotorvehiclecrash.Ittook30minutesto
extricateherfromthecar.Uponarrivalintheemergencydepartment,herheartrateis
120beatsperminute,BPis90/70mmHg,respiratoryrateis16breathsperminute,and
herGCSScoreis15.Examinationrevealsbilaterallyequalbreathsounds,anteriorchest
wallecchymosis,anddistendedneckveins.Herabdomenisflat,soft,andnottender.Her
pelvisisstable.Palpabledistalpulsesarefoundinall4extremities.Ofthefollowing,the
mostlikelydiagnosisis:
a.
hemorrhagicshock.
b.
cardiactamponade.
c.
massivehemothorax.
d.
tensionpneumothorax.
e.
diaphragmaticrupture.

Ahemodynamicallynormal10yearoldgirlisadmittedtothePediatricIntensiveCare
Unit(PICU)forobservationafteraGradeIII(moderatelysevere)splenicinjuryhasbeen
confirmedbycomputedtomography(CT).Whichofthefollowingmandatesprompt
laparotomy?
a.
Aserumamylaseof200.
b.
Aleukocytecountof14,000.
c.
Extraperitonealbladderrupture.
d.
FreeintraperitonealairdemonstratedonfollowupCT.
e.
Afallinthehemoglobinlevelfrom12g/dLto8g/dLover24hours.

A40yearoldwomanrestraineddriveristransportedtotheemergencydepartmentinfull
spinalimmobilization.Sheishemodynamicallynormalandfoundtobeparaplegicatthe
levelofT10.Neurologicexaminationalsodeterminesthatthereislossofpainand
temperaturesensationwithpreservationofproprioceptionandvibration.Thesefindings
areconsistentwiththediagnosisof:
a.
centralcordsyndrome.
b.
spinalshocksyndrome.
c.
anteriorcordsyndrome.
d.
completecordsyndrome.
e.
BrownSquardsyndrome.

Hemorrhageof20%ofthepatient'sbloodvolumeisassociatedusuallywith:
a.
oliguria.
b.
confusion.
c.
hypotension.
d.
tachycardia.
e.
bloodtransfusionrequirement.

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Whichoneofthefollowingstatementsconcerningintraosseousinfusionis
TRUE
?
a.
Onlycrystalloidsolutionsmaybesafelyinfusedthroughtheneedle.
b.
Aspirationofbonemarrowconfirmsappropriatepositioningoftheneedle.
c.
Intraosseousinfusionisthepreferredrouteforvolumeresuscitationinsmall
children.
d.
Intraosseousinfusionmaybeutilizedindefinitely.
e.
Swellinginthesofttissuesaroundtheintraosseoussiteisnotareasonto
discontinueinfusion.

Themostimportant,immediatestepinthemanagementofanopenpneumothoraxis:
a.
endotrachealintubation.
b.
operationtoclosethewound.
c.
placingachesttubethroughthechestwound.
d.
placementofanocclusivedressingoverthewound.
e.
initiationof2largecaliberIVswithcrystalloidsolution.

WhichoneofthefollowingsituationsrequiresRhimmunoglobulinadministrationtoan
injuredwoman?
a.
Negativepregnancytest,Rhnegative,andtorsotrauma.
b.
Positivepregnancytest,Rhpositive,andhastorsotrauma.
c.
Positivepregnancytest,Rhnegative,andhastorsotrauma.
d.
Positivepregnancytest,Rhpositive,andhasanisolatedwristfracture.
e.
Positivepregnancytest,Rhnegative,andhasanisolatedwristfracture.

A22yearoldmanishypotensiveandtachycardicafterashotgunwoundtotheleft
shoulder.Hisbloodpressureisinitially80/40mmHg.After2litersofcrystalloid
solutionhisbloodpressureincreasesto122/84mmHg.Hisheartrateisnow100beats
perminuteandhisrespiratoryrateis28breathsperminute.Hisbreathsoundsare
decreasedinthelefthemithorax,andafterinitialIVfluidresuscitation,aclosedtube
thoracostomyisperformedfordecreasedleftbreathsoundswiththereturnofasmall
amountofbloodandnoairleak.Afterchesttubeinsertion,themostappropriatenextstep
is:
a.
reexaminethechest.
b.
performanaortogram.
c.
obtainaCTscanofthechest.
d.
obtainarterialbloodgasanalyses.
e.
performtransesophagealechocardiography.

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Aconstructionworkerfallstwostoriesfromabuildingandsustainsbilateralcalcaneal
fractures.Intheemergencydepartment,heisalert,vitalsignsarenormal,andheis
complainingofseverepaininbothheelsandhislowerback.Lowerextremitypulsesare
strongandthereisnootherdeformity.Thesuspecteddiagnosisismostlikelytobe
confirmedby:
a.
angiography.
b.
compartmentpressures.
c.
retrogradeurethrogram.
d.
dopplerultrasoundstudies.
e.
completespinexrayseries.

A22yearoldfemaleathleteisstabbedinherleftchestatthethirdinterspaceinthe
anterioraxillaryline.Onadmissiontotheemergencydepartmentand15minutesafterthe
incident,sheisawakeandalert.Herheartrateis100beatsperminute,bloodpressure
80/60mmHg,andrespiratoryrate20breathsperminute.Achestxrayrevealsalarge
lefthemothorax.Aleftchesttubeisplacedwithanimmediatereturnof1600mLof
blood.Thenextmanagementstepforthispatientis:
a.
performathoracoscopy.
b.
performanarchaortogram.
c.
insertasecondleftchesttube.
d.
prepareforanexploratorythoracotomy.
e.
performachestCT.

A56yearoldmanisthrownviolentlyagainstthesteeringwheelofhistruckduringa
motorvehiclecrash.Onarrivalintheemergencydepartmentheisdiaphoreticand
complainingofchestpain.Hisbloodpressureis60/40mmHgandhisrespiratoryrateis
40breathsperminute.Whichofthefollowingbestdifferentiatescardiactamponadefrom
tensionpneumothoraxasthecauseofhishypotension?
a.
Tachycardia.
b.
Pulsevolume.
c.
Breathsounds.
d.
Pulsepressure.
e.
Jugularvenouspressure.

AllofthefollowingaretrueoftheMallampaticlassification,
EXCEPT
:
a.
ClassIVistheeasiestintubation,whileClassIisthemostdifficult..
b.
Ithelpsassessfordifficultintubations.
c.
ItispartoftheLEMONassessment.
d.
Itcomprisesavisualassessmentofthedistancefromthetonguebasetotheroof
ofthemouth,andthereforetheamountofspaceinwhichthereistowork.
e.
ApoorMallampatiscoreisassociatedwithahigherincidenceofobstructivesleep
apnea.

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A23yearoldmansustainsthreestabwoundstotheupperrightchestduringan
altercationandisbroughtbyambulancetoahospitalthathasfullsurgicalcapabilities.
Hiswoundsareallabovethenipple.Heisendotracheallyintubated,closedtube
thoracostomyisperformed,and2litersofcrystalloidsolutionareinfusedthrough2
largecaliberIVs.Hisbloodpressurenowis60/0mmHg,heartrateis160beatsper
minute,andrespiratoryrateis14breathsperminute(ventilatedwith100%O
).1500mL
2
ofbloodhasdrainedfromtherightchest.Themostappropriatenextstepinmanaging
thispatientisto:
a.
performFAST.
b.
obtainaCTofthechest.
c.
performanangiography.
d.
urgentlytransferthepatienttotheoperatingroom.
e.
immediatelytransferthepatienttoatraumacenter.

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