A&E ATLS TEST answers at the end 1-1. A 22-year-old man sustains a shotgun wound to the left shoulder.

. His blood pressure is initially 80/40. After two liters of Ringer's lactate solution his blood pressure increases to 122/84. His pulse rate is now 100 beats per minute and his respiratory rate is 28 breaths per minute. His breath sounds are decreased in the left hemithora ! and a closed tube thoracostomy is performed with the return of a small amount of blood with no air leak. "he most appropriate ne t step is to a. b. c. d. e. re-e amine the chest. perform an aortogram. obtain a #" scan of the chest. obtain arterial blood gas analyses. perform transesophageal echocardiography.

1-2. A four-year-old girl! weighing appro imately 20 %g &44 pounds'! is admitted in shoc% after an automobile crash. "he initial fluid challenge or bolus should consist of (inger)s lactate solution in the *olume of a. 200 m+. b. 400 m+. c. 440 m+. d. ,00 m+. e. 880 m+. 1- . All of the following are considered minimal precautions for the pre*ention of the spread of communicable diseases during resuscitation -.#-/" a. goggles. b. face mas%. c. water-imper*ious gown. d. water-imper*ious leggings. e. needle-impenetrable sterile glo*es. 1-4. 0n managing the head-in1ured patient! the most important initial step is to

a. b.
#.

d. e.

secure the airway. immobili2e the nec%. support the circulation. control scalp hemorrhage. determine the 3lasgow #oma 4cale 4core.

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1-!. A pre*iously healthy! 80 kg "1#! pound' man suffers an estimated acute blood loss of two liters. 9hich one of the following statements apply to this patient: a. b. c. d. e. His pulse pressure will be widened. His urinary output will be at the lower limits of normal. He will ha*e tachycardia! but no change in his systolic blood pressure. His systolic blood pressure will be decreased with a narrowed! pulse pressure. His systolic blood pressure will be maintained with an ele*ated diastolic pressure.

1-,. "he ;physiologic hyper*olemia; of pregnancy has clinical significance in the management of the se*erely in1ured! gra*id woman by a. b. c. d. e. reducing the need for blood transfusion. increasing the ris% of pulmonary edema. complicating the management of closed head in1ury. increasing the *olume of blood loss to produce shoc%. reducing the *olume of crystalloid re<uired for resuscitation.

1-8. A 18-year-old helmeted motorcyclist loses consciousness when he is struc% broad side by an automobile at an intersection. He arri*es in the emergency department with a blood pressure of 140/52! pulse rate of 88. beats per minute! a respiratory rate of 18 breaths per minute! and a 3lasgow #oma 4cale 4core of se*en. Appropriate initial immobili2ation of this patient should include a semi-rigid cer*ical collar and 1-$. A 64-year-old man is brought to the hospital after being pinned to the wall of a building by a a. b.
#.

a scoop stretcher. a long spine board. a short spine board. cer*ical traction tongs. the pneumatic antishoc% garment.

d. e.

cement truc%. He is in ob*ious shoc%! and has deformities and mar%ed swelling of both thighs! although no open wounds are present. His shoc% a. b. c. d. e. cannot be e plained without concomitant pel*ic fracture. signifies a loss of appro imately 1= > of his blood *olume. is consistent with blood loss from bilateral femoral fractures. will li%ely be re*ersed if appropriate traction splints are applied. cannot be e plained by his obser*ed in1uries unless a ma1or arterial in1ury e ists.

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1-5. /rior to passage of a urinary catheter in a man! it is essential to a b.

#.

d. e.

e amine the abdomen. determine pel*ic stability. e amine the rectum and perineum. perform a retrograde urethrogram. %now the history and mechanism of in1ury. 1-10. "he best guide for ade<uate fluid resuscitation of the burn patient is a. b. c. d. e. ade<uate urinary output. re*ersal of systemic acidosis. normali2ation of the heart rate. a normal central *enous pressure. four ml/%g/percent body burn/24 hours.

1-11. "he +-A4" li%ely cause of a depressed le*el of consciousness in the multisystem in1ured patient is a. b. c. d. e. shoc%. head in1ury. hyperglycemia. impaired o ygenation. alcohol and other drugs.

1-12. -stablishing a diagnosis of shoc% must include a. b. c.

d.

e.

confirming hypo emia. the finding of acidosis. confirming increased *ascular resistance. documenting hypotension and low cardiac output. e*idence of inade<uate perfusion of the body)s organs.

1-1 . A se*en-year-old boy is brought to the emergency department by his parents se*eral minutes after he fell through a window. He is bleeding profusely from a ,-cm &2.4-inch' wound of his medial right thigh. 0mmediate management of the wound should consist of

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a. b. c. d. e.

application of a tourni<uet. direct pressure on the wound. apply a hemostat to bleeding *essels. direct pressure on the femoral artery at the groin. application of the pediatric /A43 and inflation of the right leg compartment.

1-14. ?or the trauma patient with cerebral edema! hypercarbia should be a%oided to pre*ent a. b. c. d. e. metabolic acidosis. respiratory acidosis. cerebral *asodilatation. neurogenic pulmonary edema. reciprocal high le*els of /a#@ 2.

1-1!. A 2=-year-old man is brought to the hospital after being in*ol*ed in a motor *ehicular crash when his car struc% a bridge abutment. He is into icated! has a 3lasgow #oma 4cale 4core of 16! 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 110/80 with the administration of intra*enous fluids. His heart rate is now 120 beats per minute. "he chest roentgenogram shows loss of the aortic %nob! widening of the mediastinum! no rib fractures! and no hemopneumothora . #ontrast angiography a. b. c. d. e. is not indicated. should be performed after a #" scan of the chest. is not necessary if the #" scan of the chest is normal. should be performed.after diagnostic peritoneal la*age. is positi*e for aortic rupture in 80> of similar cases.

1-1&. 9hich one of the following statements regarding abdominal trauma in the pregnant patient is "(A-: a. b. c. d. e. "he fetus is in 1eopardy only with ma1or abdominal trauma. +ea%age of amniotic fluid is an indication for hospital admission. 0ndications for peritoneal la*age are different from those in the nonpregnant patient. /enetration of an abdominal hollow *iscus is more common in late than in early pregnancy. "he secondary sur*ey follows a different pattern from that of the nonpregnant patient.

1-18. "he first maneu*er to impro*e o ygenation after chest in1ury is a. b.

#.

d.

intubate the patient. assess arterial blood gases. administer supplemental o ygen. ascertain the need for a chest tube.

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e.

obtain a lateral cer*ical spine roentgenogram.

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1-1$. A 2=-year-old man! in1ured in a motor *ehicular crash! is admitted to the emergency department. His pupils react sluggishly and his eyes open to painful stimuli. He does not follow commands! but he does moan periodically. His right arm is deformed and.does not respond to painful stimulus$ howe*er! his left hand reaches toward it. Both legs are stiffly !ended. His 3lasgow #oma 4cale 4core is a. two. B. four c. si d. nine e. twel*e

1-15. 9hich one of the following statements concerning massi*e hemothora is "(A-: a. b. c. d. e. 0t is usually caused by blunt thoracic trauma. 0t is commonly confused with a pneumothora . "he diagnosis should be confirmed by upright! plain chest roentgenograms prior to treatment. "he initial draining of 1!000 m+ of blood after chest tube insertion re<uires immediate thoracotomy. "he condition should be suspected in situations associated with shoc% and unilateral absent breath sounds.

1-20. 9hich one of the following findings should prompt immediate management during the primary sur*ey: a. b. c. d. e. Cistended abdomen 3lasgow #oma 4cale 4core of 11 /ulse rate of 120 beats per minute "emperature of 6,.=) # &58.8) ?' (espiratory rate of 62 breaths per minute.

1-21. Curing the primary and secondary sur*eys! the patient in1ured by blunt trauma should be completely immobili2ed until a. b. c. d. e. the neurologic e amination has been completed. the patient is transferred to a definiti*e care area. the patient is able to indicate that he has no nec% pain. a spinal fracture has been e cluded by roentgenograms. the patient complains of potential pressure sores due to the spine board.

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1-22. "he most important! immediate step in the management of an open pneumothora is a. b. c. d. e. endotracheal intubation. operation to close the wound. placing a chest tube through the chest wound. placement of an occlusi*e dressing o*er the wound. initiation of two! larg e-caliber 0Ds with (inger)s lactate.

1-26. 0mportant screening roentgenograms to obtain in the multiple-system trauma patient are a. b. c. d. e. s%ull! chest! and abdomen. chest! abdomen! and pel*is. cer*ical spine! chest! and pel*is. s%ull! cer*ical spine! and chest. cer*ical spine! chest! and abdomen.

All of the following statements regarding pulse o imetry are true E'(E)T* a. b. c. d. e. - cessi*e surrounding room light can interfere with the accuracy of the readings. 4ignificant le*els of dysfunctional hemoglobin can affect the accuracy of the readings. 0t pro*ides a continuous! nonin*asi*e measurement of the partial pressure of o ygen. 0t is dependent on differential light absorption by o ygenated and deo ygenated hemoglobin. 0t pro*ides a continuous! nonin*asi*e measurement of pulse rate that is updated with each heart beat.

1-2=. A =,-year-old man is thrown *iolently against the steering wheel of his truc% during a motor *ehicular crash. @n arri*al in the emergency department he is diaphoretic and cEalpl g of chest pain. His blood pressure is ,0/40 and his respiratory rate is 40 moths per minute. 9hich of the following would best differentiate cardiac tamponade from tension pneumothora as the cause of his hypotension:
a . "achycardia b. /ulse *olume c . Breath sounds d . /ulse pressure e . Fugular *enous pressure

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1-2,. Bronchial intubation of the right or left mainstem bronchus can easily occur during infant endotracheal intubation because

0t

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a. b. c. d. e.

the trachea is relati*ely short. ) the distance from the lips to the laryn is relati*ely short. the use of tubes without cuffs allows the tube to slip distally. the mainstem bronchi are less angulated iin their relation to the trachea. so little friction e ists between the endotracheal tube))and the wall of the trachea.

1-28. A =2-year-old woman sustains =0 > total body-surface flame burns in an e plosion. 4he has burns around the chest and of both upper arms. Ade<uate resuscitation is initiated. 4he is nasotracheally intubated and is being mechanically *entilated. Her carbo yhemoglobin le*el is 10>. Her arterial blood gas analyses re*eal /a@ 2 of 40 mm Hg! /a#@ 2 of ,0 mm Hg! and pH of 8.2=. Appropriate immediate management at this time is to a. b. c. d e ensure ade<uate tissue perfusion. increase the rate of fluid resuscitation. add positi*e end-e piratory pressure &/??/'. reassess for the presence of a pneumothora . administer intra*enous narcotics in small amounts.

1-28. A 26-year-old man sustains four stab wounds to the upper right hemithora during an altercation and is brought by ambulance to a community hospital. "he wounds are all abo*e the nipple. He is endotracheally intubated! closed tube thoracostomy is performed! and two liters of !(inger)s lactate solution are infused through two large-caliber 0Ds. His blood pressure now is ,0/0! pulse rate is 1,0 beats per minute! and respiratory rate is 14 breaths per minute &*entilated with 100> 02'. "he most appropriate ne t step in managing this patient is a. angiography.. b. c. d. e. thoracotomy. #" of the chest. application of /A43. immediate transfer to another facility .

1-25. All of the following suggest urethral in1ury -.#-/"G a. b. c. d. e. scrotal hematoma. blood in the 9ctal lumen... blood at the e ternal urethral meatus. high-riding prostate on rectal e amination. ! absence of a palpable prostate on rectal e amination.

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1- +. A 68-year-old construction wor%er is brought to the hospital after being crushed in a foundation ca*e-in. A pneumatic antishoc% garment &/A43' was applied and inflated by prehospital personnel. He has no symptoms of respiratory compromise. His blood pressure is 120/80 and his pulse rate is 110 beats per minute. He is conscious and alert. He reportedly has open fractures of both legs. - amination of the patient)s legs is best accomplished by a. b. c. d. e. deflating the garment one leg at a time. %eeping the /A43 inflated and obtaining roentgenograms. deflating the /A43 guided by the patient)s circulatory status. immediately and temporarily deflating and remo*ing the /A43. deflating one leg compartment and %eeping the /A43 abdominal compartment inflated.

1-61. "he primary indication for transferring a patient to a higher le*el trauma center is a. b. c. d. e. multisystem in1uries! including se*ere head in1ury. una*ailability of a surgeon or operating room staff. una*ailability of an intensi*e care unit bed or 0#A staff. resource limitations as determined by the referring physician. a widened mediastinum on chest roentgenogram after blunt thoracic trauma.

1-62. A patient is brought to the emergency department 20 minutes after a motor *ehicular crash. He is conscious and there is no ob*ious e ternal trauma. He arri*es at the hospital intubated and completely immobili2ed on a long spine board. His blood pressure is ,0/40 and his pulse rate is 80 beats per minute. His s%in is warm and he has no rectal tone. 9hich one of the following statements is "(A-: a. b. c. d. e. Dasoacti*e medications ha*e no role in early management. "he hypotension should be managed with *olume resuscitation alone. ?le ion and e tension *iews of the c-spine should be performed early. @ccult abdominal *isceral in1uries can be e cluded as a cause of hypotension. ?laccidity of the lower e tremities and loss of deep tendon refle es are e pected.

1-66. 9hich one of the following is the recommended method for treating frostbite:

a. b. c. d. e.

Hoist heat -arly amputation /adding and ele*ation Dasodilators and heparin "opical application of sil*asulphadia2ine

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1- ,. A 62-year-old man is trapped from the waist down beneath his o*erturned car for a period e ceeding eight hours. @n arri*al in the emergency department! both lower e tremities are cool! mottled! insensate! and motionless. Cespite normal *ital signs! pulses cannot be palpated below the femoral *essels and the muscles of the lower e tremities are firm and hard. Curing the initial management of this patient! which of the following is most li%ely to impro*e the chances for limb sal*age: a. b. c. d. e. Applying s%eletal traction Administering anticoagulant drugs Administering thrombolytic therapy /erforming lower e tremity fasciotomies 0mmediately transferring the patient to a trauma center

1-6=. #er*ical spine in1ury a. b. c. d. e. is e cluded by a normal neurologic e amination. is not present if the patient has normal range of nec% motion. can be detected safely by careful fle ion and e tension of the nec%. can be e cluded by a crosstable lateral roentgenogram of the c-spine. may be first manifested by neurologic deficit after mo*ement of the nec%.

1-6,.. An 18-year-old man is brought to the hospital after smashing his motorcycle into a tree. He is conscious and alert! but paraly2ed in both arms and legs. His s%in is pale and cold. He complains of thirst and difficulty in breathing. His airway is clear. His blood pressure is ,0/40 and his pulse rate is 140 beats per minute. Breath sounds are full and e<ual bilaterally. He should a. b.
#.

d. e.

undergo e ploratory celiotomy & I laparotomy' be treated for neurogenic shoc%. be treated for hypo*olemic! shoc%. undergo immediate nasotracheal intubation. be placed in cer*ical traction tongs before any other treatment is instituted.

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1- #. A ,4-year-old man! in*ol*ed in a high-speed car crash! is resuscitated initially in a small rural hospital with limited resources. He has a closed head in1ury with a 3lasgow #oma 4cale 4core of 16. He has a widened mediastinum on -hest roentgenogra. with /ra-tures o/ le/t ribs two through four! but no pneumothora . After infusing four liters of (inger)s lactate solution! hid blood pressure is 100/84! pulse rate is 110 beats per minute! and respiratory rate is 18 breaths per minute. He has gross hematuria and a pel*ic fracture. "he referring physician decides to transfer this patient to a facility capable of deli*ering a higher le*el of care which is 128 %m &80 miles' away. Before transfer! the physician should first a. b. c. d. e. intubate the patient. perform diagnostic peritoneal la*age. apply the pneumatic antishoc% garment. call the recei*ing hospital and spea% to the surgeon on call. discuss the ad*isability of transfer with the patient)s family.

1-64. Hemorrhage of 20> of the patient)s blood *olume is associated usually with a. b. c. d. e. oliguria. confusion. hypotension. tachycardia. blood transfusion re<uirement.

1-65. 9hich one of the following statements concerning intraosseous infusion in children is "(A-: a. b. c. d. e. @nly crystalloid solutions may be safely infused through the needle. Aspiration of bone marrow confirms appropriate positioning of the needle. 0ntraosseous infusion is the preferred route for *olume resuscitation in small children. 0ntraosseous infusion may be utili2ed indefinitely in the management of in1ured children. 4welling in the soft tissue around the intraosseous site is not a reason to discontinue infusion.

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1-,+. A 2,-year-old seat-belted dri*er is brought to the hospital after a car crash. /rimary sur*ey re*eals no e*idence of serious in1ury e cept for diffuse! mild abdominal tenderness. Bowel sounds are hypoacti*e and li*er dullness is <uestionable. Abdominal films re*eal free air. "he patient should a. b. c. d. e. undergo peritoneal la*age. undergo prompt celiotomy I &laparotomy' be carefully obser*ed for further e*idence of intra-abdominal in1ury. ha*e a contrast roentgenographic study of her gastrointestinal tract! be suspected of ha*ing a ruptured diaphragm and accompanying pneumothora .

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/@440B+- AJ49-(4 1.1 &a' 1.2 &b' 1.6 &e' 1.4 &a' 1.= &d' 1., &d' 1.8 &b' 1.8 &c' 1.5 &c' 1.10 1.11 1.12 1.16 1.14 1.1= 1.1, 1.18 1.18 1.15 1.20 1.21 1.22 1.26 1.24 1.2= 1.2, 1.28 1.28 1.25 1.60 1.61 1.62 1.66 1.64 1.6= 1.6, 1.68 1.68 1.65 1.40

&a' &c ' &e' &b' &c ' &d' &b' &c ' &d' &e' &e' &d' &d' &c ' &e' &c ' &a' &d' &b' &b' &c ' &d' &e' &a' &d' &e' &c' &d' &d' &b' &b'

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