Atls 7Th Edition Questions - Initial Assessment

Front 1

1. Which of the following should prompt transport to a trauma center?
a. Glasgow Coma Scale (GCS) < 14
b. Respiratory rate < 10 breaths/min or greater than 29 breaths/min
c. Systolic blood pressure < 90 mm Hg
d. All of the above

Back 1

d
Explanation: When possible trauma patients should be transported to a trauma center, especially if significant injury is suspected or confirmed. A GCS < 14, respiratory rate < 10 breaths/min or greater than 29 breaths/min and a systolic blood pressure < 90 mmm Hg all suggest potentially life-threatening injury and should prompt transport to a trauma center.

Front 2

2. Which of the following should prompt transport to a trauma center?
a. MVA with death of one victim in the same passenger compartment
b. Restrained passenger in MVA with vehicle traveling greater than 30 mph
c. Fall from greater than 10 ft
d. All motorcycle crashes
e. All of the above
3. Which of the following should prompt transport to a trauma center?

Back 2

a
Explanation: The decision to transport a patient to a trauma center will depend upon many factors. Some situations that should prompt transport to a trauma center include: ejection from auto, death in the same passenger compartment, pedestrian run over or thrown, unrestrained passenger in a high speed MVA (speed > 40 mph, major deformity to vehicle such as > 20 inches, intrusion into the passenger compartment > 12 inches, extrication time > 20 minutes, falls > 20 ft, rollover, pedestrian hit at > 5 mph or motorcycle crash traveling at greater than 20 mph or with separation from the bike.

Front 3

a. Suspected isolated humerus fracture
b. Finger amputation
c. Penetrating injury to the hand
d. Combination trauma with burns
e. All of the above

Back 3

d
Explanation: Some situations that should prompt transport to a trauma center include: flail chest, 2 or more proximal long bone fractures (humerus, femur), amputation proximal (above) the wrist or ankle, penetrating trauma to the head, neck, chest and to the extremities proximal to the knee and elbow, suspected open or depressed skull fracture, paralysis, suspected pelvic fracture, combination trauma with burns and isolated major burns.

Front 4

4. What is the first priority in evaluating a trauma patient following a fall > 20 ft from a power line pole?
a. Protect the cervical spine
b. Evaluate airway
c. Check for a pulse due to the high risk of electrical injury
d. Start chest compressions

Back 4

b
Explanation: Whether managing a medical or trauma patient the ABCs take priority. As soon as the airway has been evaluated (and in practice simultaneously) protect the cervical spine.

Front 5

5. Which of the following would be an indication to intubate a trauma patient?
a. Respiratory rate greater than 29 breaths/min
b. Mandible fracture
c. Glasgow coma scale (GCS) < 10
d. Nonpurposeful motor responses

Back 5

d
Explanation: Definitive airway management is commonly indicated for trauma patients with tracheal/laryngeal fractures that cause airway obstruction, GCS < 8 and nonpurposeful motor responses. Patients with mandible fractures who are protecting their airway usually do not require emergent intubation. A respiratory rate > 29 breaths/min is concerning but does not necessarily require intubation, especially if it is from a tension pneumothorax, massive hemothorax or pulmonary contusion.

Front 6

6. Following intubation a trauma patient deteriorates. Which of the following may be the cause?
a. Unrecognized laryngeal fracture
b. Incomplete upper airway transection
c. Unrecognized pneumothorax
d. Improper endotracheal tube placement
e. All of the above

Back 6

e
Explanation: Airway management of trauma patients can be extremely difficult. If a trauma patient deteriorates following intubation the most common reason would be improper endotracheal tube placement. Tube placement should be reconfirmed by auscultating bilateral breath sounds and watching the chest rise and fall, using an end tidal CO2 detector, visualizing the endotracheal tube through the cords and checking a chest X-ray. Other less common but potentially life-threatening causes of deterioration following intubation include unrecognized laryngeal fracture, incomplete upper airway transection that becomes complete following intubation, worsening pneumothorax or the development of a tension pneumothorax.

Front 7

7. What is the # 1 cause of preventable post-traumatic death?
a. Improper airway management
b. Missed cervical spine fracture
c. Hemorrhage
d. Cardiac contusion

Back 7

c
Explanation: Hemorrhage is the most common cause of preventable post-traumatic death.

Front 8

8. A trauma patient is hypotensive. The primary and secondary surveys do not reveal any external hemorrhage. Which of the following is the least likely cause?
a. Hemorrhage into the thoracic or abdominal cavities
b. Hemorrhage surrounding a femur fracture
c. Pelvic fracture with retroperitoneal hemorrhage
d. Neurogenic shock secondary to spinal cord injury

Back 8

d
Explanation: When a trauma patient is hypotensive suspect hemorrhage. If there is no visible evidence of external hemorrhage suspect occult blood loss. Major sources of occult blood loss include hemorrhage into the thoracic or abdominal cavities, hemorrhage surrounding long bone fractures (femur more commonly than humerous) or a pelvic fracture with retroperitoneal hemorrhage. Neurogenic shock secondary to spinal cord injury is an uncommon cause of hypotension.

Front 9

9. Which trauma patient may not demonstrate tachycardia as an early sign of significant blood loss?
a. Elderly patient on multiple medications
b. Pediatric patient
c. Athlete
d. All of the above
e. Both A + C

Back 9

d
Explanation: Elderly patients, especially those on medications that may attenuate tachycardia such as beta blockers and calcium channel blockers, children and athletes may not respond to hemorrhage in a normal manner, obscuring one of the earliest signs of volume depletion.

Front 10

10. How should rapid external hemorrhage be controlled during the primary survey?
a. Direct manual compression
b. Tourniquets
c. Hemostats
d. Rapid external hemorrhage should be controlled during the secondary survey

Back 10

a
Explanation: Rapid external hemorrhage is best controlled during the primary survey using direct manual compression. Tourniquets can cause tissue injury and distal ischemia and hemostats can cause damage to veins and nerves.

Front 11

11. Which of the following could contribute to a low Glasgow Coma Scale (GCS)?
a. Hemorrhage
b. Hypoglycemia
c. Medications and drugs
d. Cervical spine injury
e. All of the above

Back 11

e
Explanation: The GCS can help to determine a patients level of consciousness. The GCS measures eye opening, verbal and motor responses.

Front 12

12. Classically an epidural hematoma as compared to a subdural hematoma leads to rapid alteration in mental status sometimes after a lucid interval.
a. true
b. false

Back 12

?

Front 13

13. What determines the maximum rate of fluid administration?
a. Internal diameter of the intravenous catheter
b. Size of the vein
c. Length of the intravenous catheter
d. All of the above
e. Both A + C

Back 13

e
Explanation: The maximum rate of fluid administration is determined by the internal diameter of the intravenous catheter and inversely by the length of the intravenous catheter. The size of the vein has less to do with the rate of fluid resuscitation than these mechanical factors.

Front 14

14. According to the ATLS textbook, which warmed initial intravenous fluid is preferred in the resuscitation of trauma patients with hypotension?
a. Normal saline
b. 5% Dextrose in Water (D5W)
c. Ringers lactate
d. Any of the above would be acceptable

Back 14

c
Explanation: Warmed crystalloid solution such as normal saline or Lactated Ringers, is the preferred initial intravenous fluid for the resuscitation of trauma patients with hypotension. The ATLS textbook states that Ringer's Lactate solution is the preferred initial crystalloid solution. The ATLS textbook states that normal saline the second choice because it has the potential to cause hyperchloremic acidosis especially if renal function is impaired. Normal saline is, however, commonly used as the initial intravenous fluid of choice at many trauma centers.

Front 15

15. A female trauma patient has persistent hypotension that is refractory to crystalloid (normal saline or Ringer?s lactate solution). There is not enough time to obtain matched type specific blood. What is the preferred order of resuscitative fluids that should be administered to this patient?
a. Unmatched type specific blood. If unmatched type specific blood is not available administer O negative blood.
b. O negative blood. If O negative blood is not available administer type specific blood.
c. O negative blood. If O negative blood is not available administer O positive blood.
d. Any of the above would be acceptable

Back 15

a
Explanation: If a trauma patient requires blood emergently and there is not enough time to obtain matched type specific blood unmatched type specific blood should be administered. If unmatched type specific blood is unavailable in a timely fashion O negative blood should be administered. O positive blood is not a substitute for O negative blood, especially in a female patient of child bearing age.

Front 16

16. A trauma patient presents with pulseless electrical activity (PEA). Which of the following should be considered in the differential diagnosis?
a. Cardiac tamponade
b. Tension pneumothorax
c. Massive hemorrhage with hypovolemia
d. All of the above

Back 16

d
Explanation: Traumatic causes of PEA include cardiac tamponade, tension pneumothorax and massive hemorrhage with hypovolemia.

Front 17

17. Under what circumstances would insertion of a Foley catheter be relatively contraindicated?
a. Blood at the penile urethral meatus
b. Perineal ecchymosis
c. Nonpalpable prostate (high-riding prostate)
d. Gross hematuria

Back 17

d
Explanation: Urethral injury should be suspected if there is blood at the penile urethral meatus, perineal ecchymosis, a nonpalpable prostate (high-riding prostate), ecchymotic srotum or blood suspected in the scrotum or a pelvic fracture. Do NOT insert a Foley catheter if a urethral injury is suspected!

Front 18

18. What is the best way to diagnose a urethral injury?
a. Abdominal/Pelvic CT scan
b. Retrograde urethrogram
c. Urinalysis
d. Foley catheter insertion

Back 18

b
Explanation: Urethral injury is best diagnosed by a retrograde urethrogram. A Foley catheter should not be inserted if urethral injury is suspected. Neither an abdominal/pelvic CT scan nor urinalysis are the test of choice for diagnosing urethral injury.

Front 19

19. Which of the following is NOT a complication of nasogastric tube insertion?
a. Insertion into the brain via a fractured cribiform plate
b. Pulmonary aspiration of oropharyngeal or gastric contents
c. Bradycardia
d. Vomiting
e. All of the above are complications

Back 19

e
Explanation: Complications associated with nasogastric tube insertion include nasal bleeding, nasal injury, pulmonary aspiration, vomiting, bradycardia and thankfully extremely rarely insertion into the brain via a fractured cribiform plate.

Front 20

20. Which statement regarding a proper color change of an end-tidal carbon dioxide monitor following intubation is CORRECT?
a. Proper color change confirms proper placement of the endotracheal tube in the airway
b. Proper color change rules out esophageal intubation
c. Proper color change can be caused by blood in the endotracheal tube
d. Proper color change confirms adequate ventilation

Back 20

b
Explanation: Proper color change of an end-tidal carbon dioxide monitor following intubation confirms that the endotracheal tube is in the airway. It does NOT comfirm proper placement in the airway or adequate ventilation. Blood in the endotraheal tube would not give a false positive color change. Proper color change over time does rule out esophageal intubation.

Front 21

21. What does the pulse oximeter measure?
a. The percent of hemoglobin saturated with oxygen
b. Partial pressure of oxygen dissolved within the blood (PaO2)
c. The adequacy of ventilation
d. Carbon monoxide

Back 21

a
Explanation: The pulse oximeter measures the percentage of hemoglobin saturated with oxygen. It does not measure the partial pressure of oxygen dissolved in the blood, carbon monoxide or the adequacy of ventilation. Patients who are not adequately ventilated may have normal pulse oximeter readings but very high partial pressures of carbon dioxide dissolved in the blood (PaCO2)

Front 22

22. A normal cervical spine X-ray series including a lateral, AP, odontoid and right and left lateral oblique views rules out cervical spine injury.
a. true
b. false

Back 22

?

Front 23

23. When should the secondary survey begin?
a. After the ABCs have been addressed
b. After the initial resuscitative efforts have been instituted
c. After the primary survey has been completed
d. After the tension pneumothorax has been treated
e. After all of the above have been completed

Back 23

e
Explanation: The secondary survey (a complete examination) should not begin until the ABCs have been addressed, initial resuscitative efforts have been instituted, life-threatening problems have been addressed (pneumothorax, cardiac tamponade, rapid external bleeding) and the primary survey has been completed (patient fully undressed).

Front 24

24. Patients with facial/maxillofacial trauma should be presumed to have potential injury to the cervical spine and should have their cervical spine immobilized during the primary survey.
a. true
b. false

Back 24

a
Explanation: Patients with facial/maxillofacial trauma should be presumed to have potential injury to the cervical spine and should have their cervical spine immobilized during the primary survey pending further examination and work-up.

Front 25

25. Injury to the cervical vasculature (carotid arteries, vertebral arteries) can occur secondary to both penetrating trauma and blunt trauma.
a. true
b. false

Back 25

a
Explanation: Injury to the cervical vasculature (carotid arteries, vertebral arteries) can occur secondary to both penetrating trauma and blunt trauma. Evaluation of the cervical vasculature can be performed using ultrasound, contrast enhanced CT and MRI/MRA as well as angiography.

Front 26

26. Which of the following usually necessitates surgical exploration in the operating room for a penetrating injury to the neck?
a. Expanding hematoma
b. Airway compromise
c. Arterial bleeding
d. Bruit
e. All of the above

Back 26

e
Explanation: Penetrating trauma to the neck associated with any one of the following: expanding hematoma, airway compromise, arterial bleeding or a new bruit usually necessitates surgical exploration in the operating room. In addition patients may also need direct and/or radiographic evaluation of the upper and lower airway (bronchoscopy), esophagus (esophagoscopy and or esophagram) and the carotid arteries (angiography/CT with contrast/MRA).

Front 27

27. A trauma patient presents with a penetrating injury to the neck. It is unclear if the injury penetrates the platysma. What is the best course of action?
a. Explore the wound with either a sterile cotton tipped applicator or an appropriate sterile surgical instrument to determine if the wound does penetrate the platysma and its depth. Involve a surgeon if platysma penetration is confirmed by probing.
b. Don?t explore the wound. Involve a trauma surgeon.
c. Don?t explore the wound. Order radiologic studies.
d. Suture the area closed. Send the patient for follow-up with a head and neck surgeon within 24 hours.

Back 27

b
Explanation: If it is unclear if a penetrating neck injury penetrates the platysma the best course of action would be to involve a trauma surgeon. Exploration of the wound by untrained personnel is not recommended due to the risk of worsening or causing injury.

Front 28

28. Which of the following is an example of a traumatic injury that may not present until days following the initial injury without antecedent signs or symptoms?
a. Small bowel injury
b. Splenic rupture
c. Pancreatic injury
d. All of the above
e. Both A + C

Back 28

e
Explanation: Injury to hollow viscus (small bowel) and the pancreas are often difficult to diagnose and may present days following initial injury without antecedent signs or symptoms. Splenic rupture is usally diagnosed on the initial trauma work-up. Delayed presentation of splenic hematoma may occur.

Front 29

29. Which findings are consistent with tension pneumothorax?
a. Distended neck veins
b. Hyporresonance to percussion
c. Decreased breath sounds
d. All of the above
e. Both A + C

Back 29

e
Explanation: Findings suggestive of tension pneumothorax include distended neck veins, hyperresonance to percussion, decreased breath sounds, tracheal deviation and hypotension. Hypotension and distended neck veins are also a finding with cardiac tamponade. Tension pneumothorax should be treated with needle decompression and tube thoracostomy (chest tube insertion)

Front 30

30. Which radiographic findings are consistent with aortic rupture?
a. Tracheal deviation to the left
b. Depression of left mainstem bronchus
c. Deviation of the esophagus to the left (NG tube is pushed to the right)
d. All of above
e. Both A + C

Back 30

b
Explanation: Radiographic findings consistent with aortic rupture include widened mediastinum, blurring of the aortic knob, rightward deviation of the trachea and esophagus, depression of the left mainstem bronchus, obliteration of the space between the pulmonary artery and the aorta, widened paratracheal stripe, widened paraspinal interfaces, pleural or apical cap, left sided hemothorax or fractures of the 1st or 2nd ribs.

Front 31

31. Elderly patients can develop acute respiratory distress with even minor chest injures.
a. true
b. false

Back 31

a
Explanation: Elderly trauma patients, especially those with underlying pulmonary insufficiency, can develop acute respiratory distress with even minor chest injuries that would not be expected to cause problems in younger patients.

Front 32

32. Pediatric trauma patients without physical exam evidence of muculoskeletal thoracic injury may have life-threatening intrathoracic injury.
a. true
b. false

Back 32

a
Explanation: A high index of suspicion is needed, especially in pediatric trauma patients, in order to diagnose intrathoracic injury. Since children have more pliable chest walls they may have significant intrathoracic injuries without significant external evidence of trauma.

Front 33

33. Which of the following are indications for diagnostic peritoneal lavage (DPL) in a severely injured trauma patient?
a. Unexplained hypotension
b. Abdominal pain and tenderness
c. Inability to perform a reliable abdominal examination due to neurologic injury or altered mental status
d. All of the above
e. Both A + C

Back 33

d
Explanation: Diagnositc peritoneal lavage (DPL) may be helpful in diagnosing intraperitoneal injury in severly injured trauma patients with unexplained hypotension, abdominal pain and tenderness, and in those patients where a reliable abdominal examination is difficult to obtain (neurologic injury and altered mental status)

Front 34

34. A vaginal examination should be performed as part of the secondary survey.
a. true
b. false

Back 34

a
Explanation: A vaginal examination should be performed as part of the secondary survey, especially if there is acute onset of vaginal bleeding following a traumatic event or the history and physical exam suggest a potential mechanism for gynecological injury.

Front 35

35. Male urethral injury is more common than female urethral injury.
a. true
b. false

Back 35

?

Front 36

36. Which form of immobilization should be used if neurologic injury is suspected or confirmed in a trauma patient?
A. Cervical spine immobilization with a soft cervical collar
B. Cervical spine immobilization with a semi-rigid cervical collar
C. Cervical spine immobilization with soft cervical collar + placement of the patient on a long spine board
D. Cervical spine immobilization with semirigid cervical collar + placement of the patient on a long spine board

Back 36

d
Explanation: If there neurologic injury is suspected or confirmed in a trauma patient the patient?s cervical spine should be immobilized with semirigid cervical collar. In addition the patient should be immobilized on a long spine board. A patient in a semi-rigid C-collar on a long board will be maximally protected.

Front 37

37. Adequate maintenance urine output for most adult trauma patients is a minimum of 2 mL/kg/hour.
a. true
b. false

Back 37

b
Explanation: Adequate maintenance urine output for most adult trauma patients is defined as a minimum of 0.5 mL/kg/hour

Front 38

38. Adequate urine output for most pediatric trauma patients is a minimum of 1 mL/kg/hour.
a. true
b. false

Back 38

a
Explanation: Adequate urine output for most pediatric trauma patients is a minimum of 1 mL/kg/hour. This is more than the minimum maintenance urine output for adults of 0.5 mL/kg/hour. For pediatric trauma patients under 1 year old a minimum of 2 mL/kg/hour is recommended.

Front 39

39. Pain medications should NOT be administered to trauma patients in pain prior to the trauma surgeon?s evaluation.
a. true
b. false

Back 39

b
Explanation: The administration of pain medications for trauma patients in pain is an important part of their care. Patients in pain should have their pain treated appropriately both before and after trauma surgeon evaluation.

Front 40

40. What route of administration for pain medications is most appropriate for most severely injured trauma patients.
A. Oral
B. Intramuscular
C. Intravenous
D. Any of the above would be acceptable

Back 40

c
Explanation: Severely injured trauma patients should usually have pain medications administered by the intravenous route. The intravenous route provides the fastest onset of action, allows for easier titration to the desired level of pain relief and minimizes oral intake which may become a factor if the patient is taken to surgery.

Front 41

41. What does the ?D? in the mneumonic ?ABCDEs of the primary survey? represent?
A. disrobe
B. disability: brief neurologic examination
c. drunk
d. document

Back 41

b
Explanation: The ?D? in the ABCDEs mneumonic of the primary survey represents disability: brief neurologic examination. The ?E? represents exposure and is a reminder to fully undress/disrobe the patient. Documentation is important and many trauma patients may also be intoxicated.

Front 42

42. What should be the first intervention once it is determined by the emergency department staff that a trauma patient?s injuries exceed a hospital?s treatment capabilities?
A. Wait for the trauma surgeon to evaluate the patient and come to the same conclusion before starting the transfer process to a trauma facility with sufficient treatment capabilities.
B. Immediately start the process to transfer the patient to a trauma facility with sufficient treatment capabilities.
C. Attempt to get the trauma team from another facility to come to the emergency department to help in the evaluation and management of the patient.
D. Do NOT transfer the patient. This would be an EMTALA violation.

Back 42

b
Explanation: As soon as it is determined by either the emergency department physician or the trauma surgeon that a trauma patient?s injuries exceed a hospitals treatment capabilities the process to transfer the patient to a trauma center with sufficient treatment capabilities should be initiated. Ideally the emergency department physician and the trauma surgeon will make this decision together. As long as appropriate transfer procedures are followed as outlined by the EMTALA law transfer of a patient would not be an EMTALA violation. Good luck getting a trauma team from another hospital to respond to your emergency department!

Front 43

43. What technique should be used to open the airway in a trauma patient with potential or suspected cervical spine injury?
A. Chin lift
B. Head tilt
C. Jaw thrust
D. Any of the above would be acceptable
E. Both A + C

Back 43

e
Explanation: In a trauma patient with potential or suspected cervical spine injury the chin lift or jaw thrust technique to open the airway is preferred over the head tilt. The head tilt may result in further damage to the cervical spine.

Front 44

44. A trauma patient has an open pneumothorax. How should this be treated?
A. Seal the open pneumothorax
B. Do NOT seal the open pneumothorax

Back 44

a
Explanation: An open pneumothorax should be sealed.