ATLS EXAM WITH QUESTIONS AND ANSWERS
2022 SOLUTIONS ALL CORRECT ANSWERS
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A 22-year-old man is hypotensive and tachycardic after a
... [Show More] shotgun wound to the left shoulder. His
blood pressure is initially 80/40 mm Hg. After initial fluid resuscitation his blood pressure increases to
122/84 mm Hg. His heart rate is now 100 beats per minute and his respiratory rate is 28 breaths per
minute. A tube thoracostomy is performed for decreased left chest breath sounds with the return of a
small amount of blood and no air leak. After chest tube insertion, the most appropriate next step is:
ANS: re-examine the chest
A construction worker falls two stories from a building and sustains bilateral calcaneal fractures. In
the emergency department, he is alert, vital signs are normal, and he is complaining of severe pain in
both heels and his lower back. Lower extremity pulses are strong and there is no other deformity. The
suspected diagnosis is most likely to be confirmed by: ANS: complete spine x-ray series
What is true regarding the initial resuscitation of a trauma patient? ANS: Evidence of improved
perfusion after fluid resuscitation could include improvement in Glasgow Coma Scale score on
reevaluation
In managing a patient with a severe traumatic brain injury, the most important initial step is to: ANS:
secure the airway
A previously healthy, 70-kg (154-pound) man suffers an estimated acute blood loss of 2 liters. What
applies to this patient? ANS: An ABG would demonstrate a base deficit between -6 and -10 mEq/L.
The physiological hypervolemia of pregnancy has clinical significance in the management of the
severely injured, gravid woman by: ANS: increasing the volume of blood loss to produce maternal
hypotension.
The best assessment of fluid resuscitation of the adult burn patient is: ANS: urinary output of 0.5
mL/kg/hr
The diagnosis of shock must include: ANS: evidence of inadequate organ perfusion
A 7-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 wound of his medial right thigh. Immediate
management of the wound should consist of: ANS: direct pressure on the wound
For the patient with severe traumatic brain injury, profound hypocarbia should be avoided to prevent:
ANS: cerebral vasoconstriction with diminished perfusion
After being involved in a motor vehicle crash, a 25-year-old man is brought to a hospital that has
surgery capabilities available.. Computed tomography of the chest and abdomen shows an aortic
injury and splenic laceration with free abdominal fluid. His blood pressure falls to 70 mm Hg after CT.
The next step is: ANS: perform an exploratory laparotomy
What statements regarding abdominal trauma in the pregnant patient is TRUE? ANS: Leakage of
amniotic fluid is an indication for hospital admission.
The first maneuver to improve oxygenation after chest injury is: ANS: administer supplemental
oxygen
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 pressure. He does not follow commands, but he does
moan periodically. His right arm is deformed and does not respond to pressure; however, his left
hand reaches purposefully toward the stimulus. Both legs are stiffly extended. His GCS score is:
ANS: 9
A 20-year-old woman who is at 32 weeks gestation, is stabbed in the upper right chest. In the
emergency department, her blood pressure is 80/60 mm Hg. She is gasping for breath, extremely
anxious, and yelling for help. Breath sounds are diminished in the right chest. The most appropriate
first step is to: ANS: perform needle or finger decompression of the right chest
What findings in an adult is most likely to require immediate management during the primary survey?
ANS: respiratory rate of 40 breaths per minute
The most important, immediate step in the management of an open pneumothorax is: ANS:
placement of an occlusive dressing over the wound
The following are contraindications for tetanus toxoid administration: ANS: history of neurological
reaction or severe hypersensitivity to the product
A 56-year-old man is thrown violently against the steering wheel of his truck during a motor vehicle
crash. On arrival in the emergency department he is diaphoretic and complaining of chest pain. His
blood pressure is 60/40 mm Hg and his respiratory rate is 40 breaths per minute. What best
differentiates cardiac tamponade from tension pneumothorax as the cause of his hypotension? ANS:
breath sounds
Bronchial intubation of the right or left mainstem bronchus can easily occur during infant endotracheal
intubation because: ANS: The trachea is relatively short.
A 23-year-old man sustains 4 stab wounds to the upper right chest during an altercation and is
brought by ambulance to a hospital that has full surgical capabilities. His wounds are all above the
nipple. He is endotracheally intubated, closed tube thoracostomy is performed, fluid resuscitation is
initiated through 2 large-caliber IVs. FAST exam does not reveal intraabdominal injuries. His blood
pressure now is 60/0 mm Hg, heart rate is 160 beats per minute, and respiratory rate is 14 breaths
per minute (ventilated with 100% O2). 1500 mL of blood has drained from the right chest. The most
appropriate next step in managing this patient is to: ANS: urgently transfer the patient to the operating
room
A 39-year-old man is admitted to the emergency department after an automobile collision. He is
cyanotic, has insufficient respiratory effort, and has a GCS score of 6. His full beard makes it difficult
to fit the oxygen facemask to his face. The most appropriate next step is to: ANS: restrict cervical
motion and attempt orotracheal intubation using 2 people
A patient is brought to the emergency department after a motor vehicle crash. He is conscious and
there is no obvious external trauma. He arrives at the hospital completely immobilized on a long spine
board. His blood pressure is 60/40 mm Hg and his heart rate is 70 beats per minute. His skin is
warm. What do you expect to see with the patient? ANS: Flaccidity of the lower extremities and loss
of deep tendon reflexes are expected.
What is the most effective method for initially treating frostbite? ANS: Moist heat
A 32-year-old man's right leg is trapped beneath his overturned car for nearly 2 hours before he is
extricated. On arrival in the emergency department, his right lower extremity is cool, mottled,
insensate, and motionless. Despite normal vital signs, pulses cannot be palpated below the right
femoral artery and the muscles of the lower extremity are firm and hard. During the management of
this patient, what is most likely to improve the chances for limb salvage? ANS: surgical consultation
for right lower extremity fasciotomy
A patient arrives in the emergency department after being beaten about the head and face with a
wooden club. He is comatose and has a palpable depressed skull fracture. His face is swollen and
ecchymotic. He has gurgling respirations and vomitus on his face and clothing. The most appropriate
step after providing supplemental oxygen and elevating his jaw is to: ANS: suction the oropharynx
A 22-year-old man sustains a gunshot wound to the left chest and is transported to a small
community hospital no surgical capabilities are available. In the emergency department, a chest tube
is inserted and 700 mL of blood is evacuated. The trauma center accepts the patient in transfer. Just
before the patient is placed in the ambulance for transfer, his blood pressure decreases to 80/68 mm
Hg and his heart rate increases to 136 beats per minute. The next step should be to: ANS: repeat the
primary survey and proceed with transfer
A 64-year-old man involved in a high-speed car crash, is resuscitated initially in a small hospital
without surgical capabilities. He has a closed head injury with a GCS score of 13. He has a widened
mediastinum on chest x-ray with fractures of left ribs 2 through 4, but no pneumothorax. After
initiating fluid resuscitation, his blood pressure is 110/74 mm Hg, heart rate is 100 beats per minute,
and respiratory rate is 18 breaths per minute. He has gross hematuria and a pelvic fracture. You
decide to transfer this patient to a facility capable of providing a higher level of care. The facility is 128
km (80 miles) away. Before transfer, you should first: ANS: call the receiving hospital and speak to
the surgeon on call
Hemorrhage of 20% of the patient's blood volume is associated usually with ANS: tachycardia
What statement concerning intraosseous infusion is TRUE? ANS: Aspiration of bone marrow
confirms appropriate positioning of the needle.
A young woman sustains a severe head injury as the result of a motor vehicle crash. In the
emergency department, her GCS is 6. Her blood pressure is 140/90 mm Hg and her heart rate is 80
beats per minute. She is intubated and mechanically ventilated. Her pupils are 3 mm in size and
equally reactive to light. There is no other apparent injury. The most important principle to follow in
the early management of her head injury is to ANS: avoid hypotension
A 33-year-old woman is involved in a head-on motor vehicle crash. It took 30 minutes to extricate her
from the car. Upon arrival in the emergency department, her heart rate is 120 beats per minute, BP is
90/70 mm Hg, respiratory rate is 16 breaths per minute, and her GCS score is 15. Examination
reveals bilaterally equal breath sounds, anterior chest wall ecchymosis, and distended neck veins.
Her abdomen is flat, soft, and not tender. Her pelvis is stable. Palpable distal pulses are found in all 4
extremities. Of the following, the most likely diagnosis is: ANS: cardiac tamponade
A hemodynamically normal 10-year-old girl is hospitalized for observation after a Grade III
(moderately severe) splenic injury has been confirmed by computed tomography (CT). What
mandates prompt celiotomy (laparotomy)? ANS: development of peritonitis on physical exam
A 40-year-old woman who was a restrained driver in a motor vehicle crash is evaluated in the
emergency department. She is hemodynamically normal and found to be paraplegic at the level of
T10. What precaution should be taken during evaluation and management? ANS: Log rolling using 4
people is a safe approach to restrict spinal motion when moving her.
A trauma patient presents to your emergency department with inspiratory stridor and a suspected cspine injury. Oxygen saturation is 88% on high-flow oxygen via a nonrebreathing mask. The most
appropriate next step is to: ANS: restrict cervical motion and establish a definitive airway
When applying the Rule of Nines to infants ANS: The head is proportionally larger in infants than in
adults
A healthy young male is brought to the emergency department following a motor vehicle crash. His
vital signs are a blood pressure of 84/60, pulse 123, GCS 10. The patient moans when his pelvis is
palpated. After initiating fluid resuscitation, the next step in management is: ANS: placement of a
pelvic binder
What situations requires Rh immunoglobulin administration to an injured woman? ANS: positive
pregnancy test, Rh negative, and has torso trauma
A 22-year-old female athlete is stabbed in her left chest at the third interspace in the anterior axillary
line. On admission to the emergency department and 15 minutes after the incident, she is awake and
alert. Her heart rate is 100 beats per minute, blood pressure 80/60 mm Hg, and respiratory rate 20
breaths per minute. A chest x-ray reveals a large left hemothorax. A left chest tube is placed with an
immediate return of 1600 mL of blood. The next management step for this patient is: ANS: prepare
for an exploratory thoracotomy
A 6-year-old boy walking across the street is struck by the front bumper of a sports utility vehicle
traveling at 32 kph (20 mph). What's true about this patient? ANS: A pulmonary contusion may be
present in the absence of rib fractures.
Adjuncts used during the primary survey ANS: ECG
Pulse ox
CO2 monitoringV
Ventilatory rate
ABGs
Foleys (UOP)
Gastric catheter
FAST or eFAST
DPL
Urinary output is sensitive for ANS: Patient's volume status and renal perfusion
"Golden hour" ANS: The time from injury to definitive care, during which treatment of shock and
traumatic injuries should occur because survival potential is best; also called the Golden Period.
Leading cause of trauma deaths worldwide ANS: MVCs
Trimodal death distribution ANS: 1st: seconds to minutes of injury (apnea)
2nd: minutes to several hours (EDH, SDH, liver lac, pelvic fractures, spleen ruptures)
3rd: several days to weeks after injury (sepsis and multi-organ failure)
An 18-year-old male was the unrestrained driver in a MVC involving contact with a tree, He is being
transported to the ED by ambulance after a prolonged extrication process. He is receive oxygen by
mask and IVF via one large-bore IV, and he is immobilized on a long spine board. How would you
prepare for arrival of this patient? ANS: Airway equipment for possible intubation
IV equipment to place a second IV and get blood work
Lab/Xray available
Monitor equipment ready
Notify blood bank and have transfusion protocol available
Consider appropriate transfer
AMPLE hx ANS: Allergies
Medications currently used
Past illnesses/Pregnancy
Last meal
Events/Environment related to the injury
Blunt trauma MOI ANS: Seatbelt use
Steering wheel deofrmation
Presence/activation of airbags
Direction of impact
Damage to vehicle
Patient position
Ejection from vehicle?
Penetrating trauma MOI ANS: Body region
Velocity of weapon
Caliber
Heat loss can occur at moderated temperatures ANS: 59 to 68 F (15-20 C)
Prehospital phase should include what interventions and considerations? ANS: Airway maintenance
Breathing support
Control of bleeding and shock
Immobilization
Immediate transport to closest appropriate facility
Hospital preparation for trauma ANS: Resuscitation area
Airway équipement
Warmed IV crystalloid solution
Monitoring devices
Protocol for requesting additional assistance
Transfer agreements
Primary survey ANS: Airway maintenance with restriction of cervical spine motion
Breathing
Circulation
Disability
Exposure/Environmental control
Patients with maxillofacial or head trauma should be presumed to have ANS: A cervical pine injury
and cervical spine motion must be restricted
PITFALL: equipment failure ANS: Test regularly
Ensure spare equipment and batteries are readily available
PITFALL: unsuccessful intubation ANS: Identify patients with difficult anatomy
Identify the most experienced/skilled airway manager on team
Ensure appropriate equipment is available
Be prepared to prefer a surgical airway
PITFALL: progressive airway loss ANS: Recognize the dynamic status of the airway
Recognize the injuries that can result in progressive airway loss
Frequently reassess the patient for signs of deterioration of the airway
In a trauma patient with hypotension, what are the two most important causes to consider in order of
importance? ANS: Tension pneumothorax
Hemorrhage
What is the best way to manage rapid external blood loss? ANS: Direct manual pressure on the
wound
What are the major areas of internal hemorrhage? ANS: Chest
Abdomen
Retroperitoneum
Pelvis
Long bones
How should fluids be administered in trauma patients with shock? ANS: Warm IVFs
If unresponsive to initial IVF, give blood transfusion immediately
What are the uses for ETCO2? ANS: Detect ROSC
Confirm ET intubation
Help avoid hypoventilation and hyperventilation
You'd like to insert a foley catheter for a trauma patient but you notice urethras injury. What test
should be performed prior to the insertion of a urinary catheter? ANS: Retrograde urethrogram
DDX for blood in gastric aspirate in a trauma patient ANS: Swallowed blood
Traumatic gastric tube placement
UGI injury
What's a C/I to NGT insertion? ANS: Fracture of the cribriform/midface fracture (insert OG instead)
What injuries are at high risk of compartment syndrome in trauma patients? ANS: Long bones
Crush injuries
Circumferential thermal burns
Prolonged ischemia to the limb
What's normal UOP? ANS: Adult: 0.5 ml/kg/hr
Child: 1-2 ml/kg/hr
MIST for obtaining info from EMS ANS: Mechanism and time of injury
Injuries found and suspected
Symptoms and signs
Treatment initiated
Retroperitoneal organs ANS: Abdominal aorta
IVC
Duodeum
Pancreas
Kidneys
Ureters
Posterior aspects of ascending/descending colon
Bladder
Rectum
Reproductive organs
What's the most frequently injured abdominal organ in blunt trauma? Followed by? ANS: Spleen (40-
55%)
Liver (35-45%)
Small bowel (5-10%)
Which patients should you consider transferring, and what tests should be performed prior to
transfer? ANS: The patients whose injuries exceed your ability to care for them, either sue to
specialize needs, or resource availably. Only perform testing that enables the referring physician to
resuscitate, stabilize, and ensure the safer transfer of the patient
What's a pulse oximetry measure? ANS: Oxygen saturation by relative absorption of light by
oxyhemoglobin and deoxyhemoglobin
Gastric catheter placement can induce vomiting ANS: Be prepared to logroll
Ensure suction is immediately available
Special populations that may have physiological responses that do not follow expected patterns ANS:
Children
Pregnant females
Elderly
Obese individuals
Athletes
Why is info about mechanism of injury so important? ANS: The patient's condition is greatly
influenced by MOI. It can enhance the understanding of the patient's condition and anticipated
injuries
Possible adjuncts to secondary survey ANS: X-rays of spine and extremities
CT scans of head, chest, abdomen, spine
Contrast urography and angiography
TEE
Bronchoscopy
Esophagoscopy
Frontal impact MVC ANS: Cervical spine fracture
Flail chest
Myocardial contusion
Pneumothroax
Traumatic aortic disruption
Fractured spleen or liver
Posterior fracture/dislocation hip/knee
Head injury
Facial fractures
Side impact MVC ANS: Contralateral neck sprain
Head injury Cervical spine fracture
Flail chest
Pneumothorax
Traumatic aortic disrution
Diaphragmatic rupture
Fractured spleen/liver/kidney
Fractured pelvis or acetabulum
Rear impact MVC ANS: Cervical spine injury
Head injury
Soft tissue injury to neck
MVC vs pedestrian ANS: Head injury
Traumatic aortic disruption
Abdominal visceral injuries
Fractured lower extremities/ pelvis
Fall from heigh ANS: Head injury
Axial spine injury
Abdominal visceral injuries
Fractured pelvis or acetabulum
Bilateral LE fractures
Anterior stab wound ANS: Cardiac tamponade
Hemothorax
Pneumothorax
Hemopneumothorax
Left stab wound ANS: Left diaphragm injury
Spleen injury
Hemopneumothoax
Abdomen stab wound ANS: Visceral injury
Extremity GSW ANS: Neurovascular injury
Fractures
Compartment syndrome
Thermal burns ANS: Eschar on extremities or chest
Electrical burns ANS: Cardiac arrhythmias
Myonecrosis
Compartment syndrome
Inhalation burns ANS: CO poisoning
Upper airway swelling
Pulmonary edema
What is your first step when a patient condition changes? ANS: ABCDEs
What's the importance of meticulous record keeping? ANS: Crucial during patient assessment and
management because often more than one clinician cares for an individual patient and allows those
to evaluate the patient's needs and clinical status
What info should be provided to the receiving facility for a transferring patient? ANS: As much info as
possible!
Event of injury, patient exam, treatments done, responses of treatments, tests and results, and
possible injuries
What key information should prehospital providers obtain and report to the receiving hospital? ANS:
Events associated with injury
What patient sign can be quickly observed to assess a patient's hemodynamic status? ANS: Skin
perfusion
Definitive airway ANS: A tube placed in the trachea with the cuff inflated below the vocal cords, the
tube connected to a form of oxygen-enriched assisted ventilation and the airway secured in place
with an appropriate stabilizing method
What's critical management for trauma patients, especially those with sustained head injuries? ANS:
Maintaining oxygenation and printing hypercarbia
Triad of largyneal fracture ANS: Hoarseness
Subcutaneous emphysema
Palpable fracture
In a conscious trauma patient, airway adequacy can quickly be assessed by ANS: Talking to the
patient-- A positive verbal response with clear voice indicated patent airways, ventilation, and brain
perfusion
What can conform a suspected laryngeal fracture? ANS: CT scan
For a patient who is gurgling, initial assessment for ventilation should include ANS: Looking for
symmetrical chest rise and listening for breath sounds
Decreased or absent breath sounds over one or both hemithoraxes should alert the examiner to the
presence of? ANS: Pneumothorax, hemothoax, contusion, or flail chest
Adjuncts of ventilation problems
ANS: Pulse ox to measure oxygen saturation and gauge peripheral perfusion
Capnography to assess adequacy fo ventilation
What are the symptoms of inadequate ventilation?
ANS: Difficulty breathing
SOB
Request to sit up to breath
LEMON assessment of difficult intubation
ANS: Look externally
Evaluate the 3-3-2 rule
Mallampati
Obstruction
Neck mobility
Types of definitive airways
ANS: Orotracheal tube
Nasotracheal tube
Surgical airways (cricothyroidotomy and tracheostomy)
Laryngeal manipulation for visualization ANS: Backward, upward, and rightward pressure on thyroid
cartilage can aid in visualizing vocal cords
Which surgical airway is recommended in children under 12? ANS: Needle cricothyroidotomy
What're adjuncts that might be used during intubation? ANS: Suction
Manual laryngealmanipulation (BURP)
Elastic bougie
Anesthetics, analgesics, and neuromuscular blocking agents
Why is continual pulse ox monitoring necessary in critically injured patients? ANS: Because changes
in oxygenation occur rapidly and are impossible to detect clinically
What indicates that the endotracheal tube is in the proper position? ANS: Equal breath sounds
bilaterally
Carbon dioxide monitor (capnograph or colorimetric CO2 device)
Confirmed with CXR
What suggests sufficient ventilation? ANS: ABG or continual end-tidal carbon dioxide analysis
On exam, an unrestrained driver is hoards and has minimal subcutaneous neck emphysema. This
patient likely has a/an ANS: Obstructed airway
In an agitated trauma patient who refuses to lay down ANS: Assessment of airway adequacy may
include suctioning
What's an indication for rapid sequence intubation? ANS: Patients who need airway control, have
intact gag reflex, especially those who have sustained head injury
A surgical airway is indicated in the presence of ANS: Edema of the glottis
Fracture of larynx
Severe oropharyngeal hemorrhage that obstructs airway
Inability to place an endotracheal tube
Possible causes of confusion after traumatic event? ANS: Hemorrhage
Brain injury
Stroke
Intoxication
What's the most common cause of shock after an injury? ANS: Hemorrhage
What're the early clinical manifestations of shock? ANS: Tachycardia and cutaneous vasoconstriction
What's the preferred method of vascular access for a patient involved in a MVC? ANS: 2 large bore
PIVs in the antecubital veins
What's the most appropriate means to restore cardiac output and end organ perfusion in hemorrhagic
shock? ANS: Stopping the source of bleeding and ensuring appropriate volume repletion
A 24-year-old male arrives in ED already intubated. He has significant crepitus of the right chest wall
and diminished breath sounds. You place a chest tube and note a large amount of bubbling in the
water seal chamber. His O2 saturation remains at 85% and he has goodCO2 return on capnography.
The most likely cause of his low oxygen saturation is ANS: Tracheobronchial tree injury
Most injuries to the tracheobronchial tree occur where? ANS: Within 2.5 cm from the carina
Do the vast majority of thoracic injuries (blunt and penetrating) require operative intervention? ANS:
No, most are treated with technical procedures
Airway thoracic injuries ANS: Airway obstruction (laryngeal injury, posterior dislocation of clavicular
head, or penetrating trauma)
Tracheobronchial tree injury
Breathing thoracic injuries ANS: Tension pneumothorax
Open pneumothorax
Massive hemothorax
Circulation thoracic injuries ANS: Massive hemothorax
Cardiac tamponade
Traumatic circulatory arrest
What's the most common cause of a tension pneumothorax? ANS: Mechanical positive-pressure
ventilation in patients with a visceral pleural inury
Where is the ideal location for needle decompression of a tension pneumothorax? ANS: 5th
intercostal space, slightly anterior to midaxillary line
What do you need to remember when treating an open pneumothorax? ANS: Place a dressing on the
site and only secure is on 3 sides so air can escape, then place a chest tube
Massive hemothorax ANS: Accumulation of >1500 ml of blood in one side of chest
Causes of PEA? ANS: Hypovolemia
Hypoxia
Hydrogen acidosis
Hypo/hyperkalemia
Hypoglycemia
Hypothermia
Toxins
Tamponade
Tension pneumo
Thrombosis
Indications of a thoracotomy ANS: Immediate return of > 1500 ml of blood or significant bleeding
Persistent blood transfusions
Penetrating anterior chest wounds medial to the nipple line
Posterior wounds medial to the scapula
A 26-year-old male sustained a posterior stab wound. Blood and bubbling are coming from the
wound. ANS: Open pneumothorax
A 46-year-old male sustained a gunshot wound to the chest ANS: Massive hemothorax
A 65-year-old female who takes warfarin was involved in a MVC. She initially presented complaining
of sternal pain. BP deteriorated to 90/60 after arriving to the ED ANS: Cardiac tamponade
Eight life-threatening injuries during the secondary survey? ANS: Simple pneumothorax
Hemothorax
Flail chest
Pulmonary contusion
Blunt cardiac injury
Traumatic aortic disruption
Traumatic diaphragmatic injury
Blunt esophageal rupture
A patient with a simple pneumothorax ANS: May be watched for progression if pneumothorax is small
(<15%) and patient is stable and does not require transfer
A 38-year-old male presents to the ED after a head-on, high-speed collision. His vitals are HR 130,
BP 156/90, RR 20, and O2 sat 92% on 15L of O2. His voice is raspy and he complains of chest pain
that radiates to his back. A CXR shows a widened mediastinum, obliteration of the aortic notch, and
depression of the left mainstream bronchus. You should ANS: Administer agents to manage his pain
and lower his HR and BP (aortic disruption)
What's a characteristic that is shared by all traumatic aortic disruption survivors? ANS: Contained
hematoma
A 36-year-old female was involved in an altercation, sustaining a knife wound to the chest, below the
left nipple. She is mildly short of breath with an oxygen sat of 92%. BP is 115/80. ANS: Simple
pneumothorax
A 56-year-old male archer was riding a horse when it bucked and the saddle struck him in the chest
wall. You note paradoxical chest wall movement on the left anterior chest. CXR is negative. ANS:
Flail chest due to costochondral disruption
What would confirm a diaphragmatic injury in a patient? ANS: Presence of NGT
What is a common finding associated with traumatic asphyxia? ANS: Upper torso, facial, and arm
plethora with petechiae secondary to acute temporary compression of SVC. Massive swelling and
cerebral edema may be present.
Why are rib fractures in older adults a more significant concern than in young patients? ANS: The
incidence of PNA and mortality is doubled in older patients
Pulmonary contusion/flail chest is best treated by? ANS: Supplemental oxygen, pain control, and
recognition if the patient is unable to ventilate properly
The cause of hypoxia associated with flail chest is ANS: Pulmonary contusion
A patient arrives in your hospital after a fall from 20 ft landing on his right side. He has been intubated
and two large-bore IVs have been started. His o2 sat is 82%, he has a good capnography waveform,
and significant deformity to right chest wall. He has no breath sounds on the right. His BP is 75/30.
Your next step should be to ANS: Perform a needle decompression or finger throacostomy on the
right side
You have completed a secondary survey on a patient who feel from a standing height. You note
exquisite tenderness posterolaterally on the left chest wall at 9-11 ribs. This should raise suspicion for
what other injury? ANS: Splenic injury
A patient's CXR reveals left pneumothorax. Additionally, the left diaphragm is obscured and there is
an air fluid level in the left hemithorax. You decide to place a chest tube. The patient is at increased
risk for damage to ANS: Abdominal contents that have become displaced into the chest cavity
Stab wounds most commonly injury? ANS: Liver (40%)
Small bowel (30%)
Diaphragm (20%)
Colon (15%)
Gunshot wounds most commonly injury? ANS: Small bowel (50%)
Colon (40%)
Liver (30%)
Abd vascular structures (25%)
When is a retrograde urethrogram mandatory? ANS: Patient is unable to void, requires pelvic binder,
or has blood at the meatus, scrotal hematoma, or perineal ecchymosis
A 28-year-old male, helmeted motorcyclist was in a high speed MVC, striking head-on into the side of
a vehicle. He arrives on a backboard and with a cervical collar in place via pre-hospital BLS transport.
Vitals are: BP 100/75, HR 115, RR 20, GCS 15. The patient reports a brief loss of consciousness and
is complaining of pain in the chest, abdomen, and pelvis. What're the priorities for management?
ANS: Rapidly assess ABCs
Auscultate the lungs, provide supplemental oxygen, and apply pulse ox
A 28-year-old male, helmeted motorcyclist was in a high speed MVC, striking head-on into the side of
a vehicle. He arrives on a backboard and with a cervical collar in place via pre-hospital BLS transport.
Vitals are: BP 100/75, HR 115, RR 20, GCS 15. The patient reports a brief loss of consciousness and
is complaining of pain in the chest, abdomen, and pelvis. What's the interpretation of the VS and the
initial therapy? ANS: VS are consistent with hemorrhagic shock from intraabdominal or pelvic sound
Maintain IV/IO access and initiate volume resuscitation, including blood transfusion if indicated
Pelvic binder application may be appropriate
Will retroperitoneal injuries prevent with obvious signs of peritoneal irritation? ANS: No,
retroperitoneal structures are separated from anterior peritoneum by the intraperitoneal viscera,
therefore no peritonitis may be present
A patient was found 10' from his motorcycle, laying on his right side. He was wearing a helmet. He
was going ~45 mph. He had brief LOC. He states he has no allergies, medications that he takes, no
current illness. Last meal was 6 hours ago. Based on mechanism, what intra-abdominal and/or pelvic
injuries is he likely to have sustained? ANS: Visceral lacerations (liver/spleen)
Bowel visceral/vascular injuries
Retroperitoneal visceral/vascular injuries (kidneys/adrenal)
Pelvic fractures
A patient was found 10' from his motorcycle, laying on his right side. He was wearing a helmet. He
was going ~45 mph. He had brief LOC. He states he has no allergies, medications that he takes, no
current illness. Last meal was 6 hours ago. How would the risk of intra-abdominal injury change if the
patient described stroking the handlebar into the epigastrium? ANS: A direct blow to the epigastrium
would raise the risk of a pancreas, duodenal, or small bowel injury
A 30-year-old male presents with a 2 cm stab wound to the mid-abdomen, 3 cm to the right of the
umbilicus. VS are BP 85/60, HR 130, RR 25, GCS 14. Neck veins are flat. Chest exam is CTAB. The
abdomen is tender. What's the ONE BEST therapy to treat this patient's injury? ANS: Airway appears
intact. Breathing has increased rate. Circulation demonstrated hemorrhagic shock. Penetrating
abdominal injury with shock is one of the indications for emergent laparotomy.
In a patient with a possible pelvic fracture, how frequently should the pelvis be tested for mechanical
stability? ANS: The pelvis should not be tested in a hemodynacilly unstable patient. Mechanical
instability of he pelvic ring should be assumed in patients who have suspected pelvic fractures. Avoid
manually manipulating the pelvis (dislodge an existing clot)
Hypotension + pelvic fracture = ANS: High mortality
A 12-year-old male complains of LUQ tenderness and L shoulder pain 8 hours after playing rugby.
ABCDE are normal. Circulatory assessment remains normal. Abdominal exam reveals mild LUQ TTP
without peritoneal signs. FAST demonstrated fluid in the hepatorenal space and the plenorenal
recess. What's the appropriate next step? ANS: Observation
A 29-year-old woman is the restrained driver in a head-on collision. Airbags deployed. ABCDE are
normal. The patient complains of lower abd and back pain. A lower abd contusion is present and
associated with tenderness. There is no evidence of diffuse peritonitis. Your institution has NOT
surgical capabilities. What's the most appropriate treatment plan? ANS: The patient should be
urgently transferred for surgical intervention
A 50-year-old male arrives to the ED following fall of 26'. He hs gurgling respirations and is not
responsive to voice. VS are BP 80/5-, RR 30, HR 138, O2 sat is undetectable. Your hospital does not
have surgical capabilities. The first step in management is ANS: Application of oxygen and securing
an airway
A 25-year-old ale arrives at the ED following a motorcycle crash. BP is 80/60, HR 140. Airway and
breathing are controlled. There are no open wounds. The abd is not distended. Both legs are
externally rotated but soft. The pelvis is tender. The scrotum is swollen and ecchymotic. While
vascular access is obtained, what the next most appropriate step? ANS: Application of a pelvic binder
A 45-year-old male with a BMI of 48 was working in an industrial plant when 2 pieces of wood flew off
a sa and struck him in the abdomen and right chest. CXR demonstrates rib fractures. What's true
about this scenario? ANS: Despite multiple imaging studies, detection of intestinal and retroperitoneal
injuries may be difficult
Your institution does not have surgical capabilities. You have intubated a 25-year-old man who was in
a rollover MVC. You have also placed bilateral chest tubes for pneumothoraxes. The patient's SBP is
continually < 90 and HR > 140. Potential therapy and evaluation includes ANS: Activation of massive
transfusion protocol, application of pelvic binder, and CXR
What's the primary goal of treatment for patient's with suspected TBIs? ANS: To prevent secondary
brain injury by ensuring adequate oxygenation and maintain BP that's sufficient to perfuse the brain
Cerebral perfusion pressure (CPP) ANS: MAP - ICP
A 23-year-old male fell from a bike, striking his head on the curb. He was not wearing a helmet. The
patient has a 10 cm laceration to the temporal-parietal region of the left scalp. He is initially able to
say hi name. VS are HR 115, BP 100/60, oxygen sat 88%, GCS initially 12. 2 hours after transfer to a
local hospital, he has sonorous respirations, a HR of 120, BP 100/70, and GCS of 6. What the initial
priorities in the management of this patient? ANS: Airway protection with a subglottic device
Oxygenation to prevent hypoxia
Maintain SBP > 100 mmHg
A 23-year-old male fell from a bike, striking his head on the curb. He was not wearing a helmet. The
patient has a 10 cm laceration to the temporal-parietal region of the left scalp. He is initially able to
say hi name. VS are HR 115, BP 100/60, oxygen sat 88%, GCS initially 12. 2 hours after transfer to a
local hospital, he has sonorous respirations, a HR of 120, BP 100/70, and GCS of 6. What are the
signs that the patient's injury is progressing? ANS: Decreased GCS indicates worsening intracranial
pathology with possible intracranial HTN and impending herniation... [Show Less]