PRETEST DISCUSSION ATLS COURSE FOR DOCTORS
1. A 22 years old man sustained a shotgun wound to the left shoulder. His BP is initially 80/40. After 2 liters of RL solution. His BP pressure increases to 122/84 mm Hg. His HR now 100 beats/minute. His breath sound are decreased in the left hemithorax, a closed tube thoracostomy is performed with the return of a small amount of blood and no air leak. The most appropriate next step is to : (a) reexamine the chest (b) perform aortogram (c) obtain a CT scan of the Chest (d) obtain arterial blood gas analysis (e) perform transesophageal echocardiography
2. A young construction workers falls 2 stories from a building and sustain bilateral calcaneal fractures. In the emergency departement, he is alert, vital sign are normal, and he is complaining of severe pain in both leg and lower back pain. Lower extremity pulses are strong and there is no apparent deformity. The next appropriate diagnostic study to perform is (a) angiography (b) compartment pressures (c) CT Scan of abdomen (d) Doppler ultrasound study (e) Complete X ray series
3. All the following are considered minimal precautions for the prevention of the spread of communicable diseases during resuscitation EXCEPT (a) goggles (b) face mask (c) water impervious gown (d) water impervious legging (e) needle impenetrable sterile gloves
4. In managing the head injuried patient, the most important initial steps is to (a) secure the airway (b) obtain c-spine film (c) support the circulation (d) control scalp hamorrhage (e) determine the GCS Score
5. A previously healthy, 70 kg man suffers an estimated blood loss of 2 liters. Which one of the following statement apply to this patient (a) his pulse pressure will be widened (b) his urinary output will be at the lower limit of normal (c) he will have tachycardia, but no change in his systolic BP (d) he systolic BP will be decreased with a narrowed pulse pressure (e) his systolic BP will be maintained with an elevated diastolis pressurre
6. The “physiologic hypervolemia” of pregnancy has clinical significance in the management of the severely injured, gravid woman by (a) reducing the need for blood transfusion (b) increasing the risk of pulmonaru edema (c) complicating the management of closed head injury (d) increasing the volume of blood loss to produce hypotension (e) reducing the volume of crystalloid required for resuscitation
7. A 17 y/o helmeted motorcyclist loses consciousness when he is struck broad side by a automobile at an intersection. He arrives in a emergency department with a BP of 140/92 mmHg, HR of 88 beats/minute, RR of 18 breath/minute, and GCS score of 7. Appropriate initial immobilization of this patient should include a semirigid cervical collar and (a) a scoop stretcher (b) a long spine board (c) a short spine board (d) cervical traction tongs (e) PASG
8. A 34 y/o man is brought to the hospital after being pinned to the wall of building by a cement truck. He is obvious shock, and has deformities and marked swelling of both thighs. Although no open wound are present. His shock (a) cannot be explained without concomitant pelvic fractute (b) signifies a loss of approximately 15% of his blood volume (c) is consistent with blood loss from bilateral femoral fracture (d) will likely be reversed if appropriate traction splint are applied (e) cannot be explained by his observed injuries unless a major arteraial injury exists
9. Prior to passage of urinary catheter in a man, it is essential to (a) (b) (c) (d) (e)
examine the abdomen determine pelvic stability examine the rectum and perineum perform a retrograde urethrogram know the history and mechanism of injury
10. The best guide for adequate resuscitation of the burn patient is (a) (b) (c) (d) (e)
fluid
adequate urinary output reversal of systemic acidosis normalization of the heart rate a normal central venous pressure 4mL/kg/percent body burn/24 hours
11. A 36 y/o woman is beaten about the head and face, and is brought to the local community hospital in full spinal immobilization, His BP is 130/88 mmHg, HR is 70/minutes, and RR is 18/minute. Pulse oximetry indicated 98% Hb saturation while she is being given 100% Oxygen via non rebreathing mask. Her aireway is clear. She is marked swelling of her face and several superficial lacerations of her scalp that are not actively bleeding. She does not respond to verbal stimuli, but localizes to the painful stimuli and opens her eyes, She moves all extremities equally. The remainder of fer physycal examination is normal. There is no neurosurgeon at the local hospital. After ensuring a patient aireway, the most appropriate course of action is to (a) admit the patient to the hospital for observation (b) obtain x ray of her facial bones prior to transfer (c) obtain complete x ray evalution of the cervical spine (d) transfer the patient to a neurosurgeon without performing CT Scan (e) perform DPL or request abdominal ultrasonorgraphy
12. Establishing a diagnosis of shock must include (a) confiriming hypoxemia (b) the finding of acidosis (c) confirming increased vascular resistance (d) documenting hypotension and low urinary output (e) evidence of inadequate perfusion of the body’s organs
13. A 7 y/o boy is brought to the Emergency Dept 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 (a) application of torniquet (b) direct pressure of the wound (c) apply a hemostat to bleeding vessels (d) direct pressure of the femoral artery a the groin (e) irrigation and debridement of devitalized tissue and tetanus propilaxis
14. For the trauma patient with cerebral edema, hypercarbia should be avoided to prevent (a) metabolic acidosis (b) respiratory acidosis (c) cerebral vasodilatation (d) neurogenic pulmonary edema (e) reciprocal high level of PaCO2
15. A 29 y/o man is brought to the hospital after being involved in a MVC when his car struck a bridge abutment. He is intoxicated, has GCS 13 and complains of abdominal pain. His BP was 80 mmHg systolic by palpation on admission to the hospital, but it rapidly increased to 110/70 mmHg with the administration of IV fluid. His HR now is 120/minute. The chest x ray show loss of aortic knob, widening of mediastinum, no rib fracture and no hemopneumothorax, Contrast angiography (a) is not indicated (b) should be performed after CT scan of the chest (c) is positive for aortic rupture in 80% of similar cases (d) is not necessary if the CT Scan of the chest is normal (e) should be performed after DPL
16. Which one of the following statements regarding abdominal trauma in the pregnant patient is TRUE? (a) the fetus is in jeopardy only with major abdominal trauma (b) Leakage of amniotic fluid is an indication for hospital admission (c) Indication for DPL are different from those in non pregnant patient (d) penetration of abdominal hollow viscus is more common in late than in early pregnancy (e) the secondary survey follow a different pattern from that of non pregnant patient
17. The first manuever to improve oxygenation after chest injury is (a) intubate the patient (b) asses arterial blood gases (c) administer supplemental O2 (d) ascertain the need for a chest tube (d) obtain a lateral cervical spine x ray
18. A 25 y/o man injured in MVC, is admitted to the emergency dept. His pupils react sluggishly and his eyes open to painful stimuli/ He doesn’t follow commands, but he does moan periodically. His right arm is deformed, and doesn’t respond to painful stimulus, however, his left hand reaches toward it. Both leg are stiffly extended. His GCS Score is (a) 2 (b) 4 (c) 6 (d) 9 (e) 12
19. A 20 y/o woman, at 32 weeks gestation, is stabbed in the upper right chest. In emergency dept, her BP 80/60 mmHg. She is gasping for breath, extremely anxious, and yelling for help. Breath sound are diminished in the right chest. The most appropriate first step is to (a) perform tracheal intubation (b) perform needle decompression pf the right chest (c) provide reassurance the gravid uterus to the left side (d) manually displace the gravid uterus to the left side of the abdomen (e) initiate two large caliber peripheral IV lines and crystalloid infusion
20. Which one of the following finding in an adult should prompt immediate management during primary survey (a) distended abdomen (b) GCS score of 11 (c) Temperature of 36,5⁰C (d) HR of 120/minute (e) RR of 40/minute
21. During the primary and secondary survey, the patient injured by blunt (a) the neurologic examination has been completed (b) patient is transferred to a definitive care area (c) a spinal fracture has been excluded radiographically (d) the patient is able to indicate that has been no neck pain (e) the patient complain of potential pressure sores due to the spine board
22. The most, immediate step in the management of an open pneumothorax is (a) endotracheal intubation (b) operation to close the wound (c) placing a chest tube through the chest wound (d) placement of an occlusive dressing over the wound (e) initation of two large calibre IV with RL
23. Important screening x rays to obtain in the multiple system trauma patient are (a) skull, chest and abdomen (b) chest, abdomen and pelvis (c) skull, cervical spine and pelvis (d) cervical spine, chest and pelvis (e) cervical spine, chest and abdomen
24. All the following statement regarding pulse oxymetry are true EXCEPT (a) excessive surrounding room light can interfere with the accuracy of the reading (b) significant levels of dysfunctional hemoglobin can affect the accuracy of the reading (c) it provides a continuous measurement of partial pressure of oxygen (d) it is dependent on differential light absorption by oxygenated and deoxygenated hemoglobin (e) it provides a continuous, non invasive measurement of pulse rate that is updated with each HR
25. A 56 y/o is thrown violently againts the steering wheel of his truck during a MVC. On arrival in the emergency department he is diaphoretic and complaining of chest pain. His BP is 60/40 mmHg and his RR is 40/minutes. Which of the following would best differentiate cardiac tamponade from tension pneumothorax is the cause of hypotension (a) tachycardia (b) pulse volume (c) breath sound (d) pulse pressure (e) JVP
26. Bronchial intubation at the right or left mainstem bronchus can easily occur during infant endotracheal intubation because (a) the trachea is relatively short (b) the distance from the lips to the larynx is relatively short (c) the use of tubes without cuffs allow the tube to slip easily (d) the mainstem bronchi are less angulated in their relation to the trachea (e) do little friction exists between endotracheal tube and the wall of the trachea
27. 52 y/o woman sustaining 50% total body surface flame burns in an explosion. She has burns around the chest and both upper arms. Adequate resuscitation is initiated. She is nasotracheally intubated and is being mechanically ventilated’ Her carboxyHb level is 10%, Her arterial BGA reveal PaO2 of 40 mmHg, PaCO2 of 60 mmHg, and pH of 7,25. Approriate immediate management at the time is to (a) ensure adequate tissue perfusion (b) increase the rate of fluid resuscitation (c) add PEEP (d) reasses for the presence of pneumothorax (e) administer IV narcotics in small amounts
28. A 23 y/o man sustain 4 stab wound in the upper right chest during an altercation and is brought by ambulance to the community hospital that has full surgical capabilities. This wound are all above the nipple. He is endotracheally intubated, closed tube trachestomy is performed, and 2 liters of RL solution are infused through 2 large caliber IVs/ His BP now is 60/0 mmHg, HR is 160/minute and RR 14/minute (ventilated with 100% O2). The most appropriate next step in managing this patient is (a) angiography (b) thoracotomy (c) CT of the chest (d) application of PASG (e) immediate transfer to a trauma center
29. All of the following suggest urethral injury EXCEPT (a) scrotal hematoma (b) blood in rectal lumen (c) blood in external urethral meatus (d) high riding prostate on rectal exam (d) absence of a palpable prostate on rectal examination
30. A 39 y/o man is admitted on emergency dept after an automobile collision. He is cyanotic, has insufficient respiratory effort, and has GCS score of 6. There is no significant facial trauma, his trachea is midline, and he has a chronic severe nasal septum deviation precluding nasotracheal intubation. His full beard makes a difficult to fit the oxygen face mask to his face. The most appropriate next step is (a) perform a surgical cricothyroidotomy (b) force a nasotracheal tube past the deviated nasal septum (c) attempt orotracheal intubation using 2 people and inline stabilization of the cervical spine (e) ventilate him with a bag valve mask device until cspine injury can be excluded (e) ventilate patient with a bag valve mask device until his beard be shaved for better mask fit
31. A skier loses control and falls 15 meter from the edge of
cliff. The patient is fully immobilized and transported by the rescue team to the first aid station at the bottom of the mountain. On arrival his BP is 90/60 mmHg, HR is 70 m/minute, and RR 16/minute’ His GCS score is 14. He withdraws appropriately from painful stimuli above the clavicles, but doesn’t appear to have any response to have a pain below his clavicles. Reportedly , his right femur is deformed , and he has open fractures of the tibia and fibula on the left. Both extremities are immobilized in the PASG with only leg compartment inflated. The doctor caring for the patient should at this time (a) empirically administer Mannitol (b) move the patient from the spine board (c) institute IV vasopressor therapy (d) remove PASG (e) document and time the neurologic finding
32. A patient is brought to ED 20 minutes after MVC. He is conscious and there is no obvious external trauma. He is arrives is hospital intubated and completedly immobilization by long spine board, His BP is 60/40 mmHg, HR 70/minutes. His skin is warm and he has no rectal tone. Which one of the following statement is TRUE (a) vasoactive medications have no role inearly management (b) the hypotension should be managed with volume resucitation alone (c) flexion and extension views of the c spine should be performed early (d) occult abdominal visceral injuries can be excluded as a cause of hypotension (e) flaccidity of lower extremities and loss of deep tendon reflexes are expected
33. Which one the following is the recommended method for treating frostbite? (a) moist heat (b) early amputation (c) padding and elevation (d) vasodilators and heparin (e) tophical application of silversulphadiazine
34. A 32 y/o man’s right leg is trapped beneath his overturned car for nearly 2 hours before he is extricated. On arrival in ED, both lower extremities are cool, mottled, insensate and motionless. Despite normal vital sign, pulses cannot be palpated below the femoral vessels and the muscles of the lower extremities are firm and hard. During the initial management of this patient, which of the following is most likely to improve the chances for limb salvages (a) applying skeletal traction (b) administering anticoagulant drugs (c) administering thrombotyc therapy (d) performing lower extremity fasciotomes (e) immediately transferring the patient to a trauma care
35. A patient arrives in the ED 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 acchymotic. He has gasping respirations and vomitus on his face and clothing, The most appropriate step after providing supplemental oxygen and elevating the jaw is (a) request a CT scan (b) insert a naspgastric tube (c) suction the oropharynx (d) obtain a lateral cervical spine x ray (e) ventilate the patient with bag valve mask
36.A 22 y/o man sustained a gunshot wound to the left chest and is transported to a small community hospital at which surgical capabilites are not available. In the ED, a chest tube is inserted and 700 ml of blood is evacuated. The trauma center accepts the patient to transfer. Just before the patient is placed in the ambulance for transfer, his BP decrease to 80/60 mmHg and his HR increases in 136/minute. The next step should be (a) clamp the chest tube (b) cancel the patient transfer (c) perform an emergency departement thoracotomy (d) repeat the primary survey and proceed with transfer (e) delay the transfer untul the referring doctor can contact a thoracic surgeon
37. A 64 y/o man involved in a high speed crash, is resuscitated in a small rural hospital with limited resources. He has closed head injury with GCS score of 13. He has widened mediastinum on chest x ray with fractures of left ribs 2 through 4, but no pneumothorax. After infusing 4 liters of RL solution, his BP is 100/74 mmHg. HR 110/minutes and RR 18/minute. He has gross hematuria and a pelvic fracture. The referring doctor decides to transfer this patient to a facility capable of delivering a higher level of care. The facility is 128 km away. Before transfer the doctor should first (a) intubate the patient (b) perform DPL (c) apply PASG (d) call the receiving hospital and speak to the surgeon on call (e)discuss the advisability of transfer with the patient’s family
38. Hemorrhage of 20% 0f the patient’s blood volume is associated with (a) oliguria (b) confusion (c) hypotension (d) tachycardia (e) blood transfusion requirements
39. Which one of the following statements is true (a) only crystalloid solution may be safely infused through the needle (b) aspiration of bone marrow confirm appropriate positioning of the needle (c) Intraosseous infusion is the preferred route for volume resuscitation in small children (d) intraosseus infusion may be utilized indefinitely in the management of injured (e) swelling in the soft tissues around the intraosseus site is not a reason to discontinue infusion
40. A 26 y/o seat belted driver is brought to the hospital after a car crash. Primary survey reveals no evidence of serious injury except for diffuse, mild abdominal tenderness. Bowel sound are hypoactive and liver dullness is questionable, Abdominal films reveal free air. The patient should : (a) undergo peritoneal lavage (b) undergo prompt celiotomy (c) have a contrast x ray of her gastrointestinal tract (d) be carefully observed for further evidence of intraabdominal injury (e) be suspected of having a ruptured diapraghm and accompanying pneumothorax
