ATLS protocols

ATLS protocols US Medical PG Question 1: A 35-year-old woman with no significant past medical history is brought in by ambulance after a major motor vehicle collision. Temperature is 97.8 deg F (36.5 deg C), blood pressure is 76/40, pulse is 110/min, and respirations are 12/min. She arouses to painful stimuli and makes incomprehensible sounds, but is unable to answer questions. Her abdomen is distended and diffusely tender to palpation. Bedside ultrasound shows blood in the peritoneal cavity. Her husband rushes to the bedside and states she is a Jehovah’s Witness and will refuse blood products. No documentation of blood refusal is available for the patient. What is the most appropriate next step in management?

• A. In accordance with the husband's wishes, do not transfuse any blood products
• B. Observe and reassess mental status in an hour to see if patient can consent for herself
• C. Attempt to contact the patient’s parents for additional collateral information
• D. Consult the hospital ethics committee
• E. Administer blood products (Correct Answer)

ATLS protocols Explanation: **Administer blood products** - In emergency situations where a patient is incapacitated and there is no **advance directive** or **legal proxy** explicitly refusing treatment, the principle of **presumed consent** applies, allowing life-saving interventions. - The patient's husband's statement is not legally binding without a living will or medical power of attorney, especially when the patient's capacity to consent or refuse treatment is compromised due to critical injury. *In accordance with the husband's wishes, do not transfuse any blood products* - The husband's stated wishes are not legally sufficient to refuse life-saving treatment for an incapacitated adult unless he holds **durable power of attorney for health care** specifically outlining these wishes, which is not stated here. - Deferring necessary treatment based solely on the husband's assertion could lead to the patient's death and potentially expose the medical team to **malpractice liability**. *Observe and reassess mental status in an hour to see if patient can consent for herself* - The patient presents with **severe hypovolemic shock** (BP 76/40, HR 110/min) and signs of significant hemorrhage, indicating an urgent, life-threatening situation. - Delaying emergent treatment to wait for a change in mental status would likely result in irreversible harm or death, as her condition is rapidly deteriorating. *Attempt to contact the patient’s parents for additional collateral information* - Contacting other family members for more information would cause a **critical delay** in a life-threatening situation. - Even if parents confirm the patient's faith, their input is still not a legally binding refusal of treatment without proper documentation or court order. *Consult the hospital ethics committee* - Ethics committee consultations are appropriate for complex ethical dilemmas that are not immediately life-threatening or when there is sufficient time for deliberation. - In this **critical emergency** with an actively hemorrhaging patient in shock, consulting the ethics committee would cause an unacceptable delay in life-saving treatment.

ATLS protocols US Medical PG Question 2: A 52-year-old obese man is brought to the emergency department 30 minutes after he was involved in a high-speed motor vehicle collision. He was the unrestrained driver. On arrival, he is lethargic. His pulse is 112/min, respirations are 10/min and irregular, and blood pressure is 94/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 91%. The pupils are equal and react sluggishly to light. He withdraws his extremities to pain. There are multiple bruises over his face, chest, and abdomen. Breath sounds are decreased over the left lung base. Two large bore peripheral venous catheters are inserted and 0.9% saline infusion is begun. Rapid sequence intubation is initiated and endotracheal intubation is attempted without success. Bag and mask ventilation is continued. Pulse oximetry shows an oxygen saturation of 84%. The patient has no advance directive and family members have not arrived. Which of the following is the most appropriate next step in the management of this patient?

• A. Nasotracheal intubation
• B. Video laryngoscopy
• C. Cricothyrotomy (Correct Answer)
• D. Comfort measures only
• E. Tracheostomy

ATLS protocols Explanation: ***Cricothyrotomy*** - In a trauma patient with **failed endotracheal intubation** and declining oxygen saturation (from 91% to 84% despite bag-mask ventilation), an emergent cricothyrotomy is indicated for **immediate airway control**. - This procedure provides a definitive airway in a **can't intubate/can't ventilate** scenario, preventing further hypoxia and potential brain damage. *Nasotracheal intubation* - **Nasotracheal intubation** is generally contraindicated in patients with suspected **facial or skull base fractures** due to the risk of intracranial intubation. - Given the high-speed collision and facial bruises, such fractures are possible, making this a less safe option compared to cricothyrotomy. *Video laryngoscopy* - While **video laryngoscopy** can be helpful for difficult airways, it was already implied that intubation was attempted and failed, suggesting the issue might be with visualization or access, not just technique. - Critically, the patient's oxygen saturation is dropping rapidly, requiring a quicker, more definitive solution than another attempt at orotracheal intubation. *Comfort measures only* - The patient has **no advance directive**, and family members have not arrived to make decisions regarding end-of-life care. - Despite the severity of his injuries, the patient is still alive and does not have clear indications for **comfort measures only** at this stage; resuscitative efforts are warranted. *Tracheostomy* - **Tracheostomy** is a surgical procedure for establishing a long-term airway and is not suitable for **emergent airway management** in a rapidly decompensating trauma patient. - It typically requires specialized surgical expertise and takes longer to perform than a cricothyrotomy, which is a faster, life-saving measure in this acute situation.

ATLS protocols US Medical PG Question 3: A 3-year-old child is brought to the emergency department with multiple bruises in various stages of healing. X-rays reveal several metaphyseal fractures and posterior rib fractures. The parents claim the injuries resulted from normal play activities. Which of the following patterns would most strongly suggest non-accidental trauma?

• A. Circular bruises on the knees
• B. Loop-shaped bruises on the back (Correct Answer)
• C. Linear bruises on the shins
• D. Irregular bruises on the forehead

ATLS protocols Explanation: ***Loop-shaped bruises on the back*** - **Loop-shaped bruises** are highly suspicious for **non-accidental trauma** as they are pathognomonic for impact with an object like a looped cord or belt - Bruises on the **back** of a young child are particularly concerning as the back is a non-bony prominence and less likely to be injured during normal play activities - Combined with the metaphyseal and posterior rib fractures already identified, patterned bruises strongly indicate inflicted trauma *Circular bruises on the knees* - Circular bruises on the knees are very common in toddlers and young children due to normal falls and play, which typically involve kneeling and crawling - This pattern is generally considered consistent with accidental injury and not indicative of abuse *Linear bruises on the shins* - Linear bruises on the shins can result from bumping into objects while playing or exploring, which is common in active children - The shins are bony prominences frequently injured during normal play activities *Irregular bruises on the forehead* - Irregular bruises on the forehead can result from accidental falls or bumps, which are common in young children learning to walk or play - While head injuries should always be carefully evaluated, irregular bruises on the forehead are common accidental injuries in ambulatory toddlers

ATLS protocols US Medical PG Question 4: A 6-month-old male presents to the emergency department with his parents after his three-year-old brother hit him on the arm with a toy truck. His parents are concerned that the minor trauma caused an unusual amount of bruising. The patient has otherwise been developing well and meeting all his milestones. His parents report that he sleeps throughout the night and has just started to experiment with solid food. The patient’s older brother is in good health, but the patient’s mother reports that some members of her family have an unknown blood disorder. On physical exam, the patient is agitated and difficult to soothe. He has 2-3 inches of ecchymoses and swelling on the lateral aspect of the left forearm. The patient has a neurological exam within normal limits and pale skin with blue irises. An ophthalmologic evaluation is deferred. Which of the following is the best initial step?

• A. Genetic testing
• B. Complete blood count and coagulation panel (Correct Answer)
• C. Ensure the child's safety and alert the police
• D. Peripheral blood smear
• E. Hemoglobin electrophoresis

ATLS protocols Explanation: ***Complete blood count and coagulation panel*** - The unusual amount of **bruising** after minor trauma, along with a family history of an unknown blood disorder, strongly suggests a potential **bleeding disorder**. A **CBC** and a **coagulation panel** (PT, aPTT, fibrinogen) are essential initial steps to evaluate for abnormalities in platelets, clotting factors, or other hematologic conditions. - These tests can help narrow down the differential diagnosis between **platelet dysfunction**, **coagulopathies** (like hemophilia or von Willebrand disease), or other less common bleeding disorders, guiding further specific investigations. - **Important consideration:** The presence of **blue sclera** (described as "blue irises") raises concern for **osteogenesis imperfecta (OI)**, a connective tissue disorder causing bone fragility. However, initial hematologic screening is still appropriate given the family history of blood disorder and presentation of excessive bruising. If coagulation studies are normal, imaging and further workup for OI would be indicated. *Genetic testing* - While a genetic component is plausible given the patient's family history and clinical presentation (blue sclera may suggest osteogenesis imperfecta), **genetic testing** is typically performed *after* initial laboratory workup has identified a specific type of bleeding or inherited disorder. - Starting with genetic testing without basic hematologic parameters is not the most efficient or cost-effective initial diagnostic approach. *Ensure the child's safety and alert the police* - While child abuse should always be considered in cases of unexplained or excessive bruising, the presence of a **family history of a blood disorder** and the **blue sclera** (suggesting possible osteogenesis imperfecta) make **medical causes** more immediate concerns for initial investigation. - Pursuing a medical workup first often clarifies whether abuse is the primary explanation, although child protective services should be notified if suspicion remains high after medical evaluation. *Peripheral blood smear* - A **peripheral blood smear** provides information on red blood cell morphology, platelet size and number, and white blood cell differential. While useful in assessing for some hematologic conditions, it is often performed *after* a CBC has indicated abnormalities or in conjunction with specialized testing. - It would not be the *best initial step* as it doesn't directly assess clotting factor function, which is critical in evaluating significant bruising severity. *Hemoglobin electrophoresis* - **Hemoglobin electrophoresis** is used to diagnose **hemoglobinopathies** like sickle cell anemia or thalassemia. - The patient's symptoms (easy bruising) are not characteristic of hemoglobinopathies, and while he has pale skin, this test would not be the initial step to investigate a bleeding disorder.

ATLS protocols US Medical PG Question 5: A 25-year-old man is brought to the emergency department 30 minutes after he was involved in a motorcycle collision. He was not wearing a helmet. Physical examination shows left periorbital ecchymosis. A CT scan of the head shows a fracture of the greater wing of the left sphenoid bone with compression of the left superior orbital fissure. Physical examination of this patient is most likely to show which of the following findings?

• A. Complete loss of vision of the left eye
• B. Decreased sense of smell
• C. Absent left corneal reflex (Correct Answer)
• D. Numbness of the left cheek
• E. Impaired left lateral gaze

ATLS protocols Explanation: ***Absent left corneal reflex*** - Compression of the **superior orbital fissure** damages cranial nerves passing through it, including the **ophthalmic division (V1)** of the trigeminal nerve, which mediates the **afferent limb of the corneal reflex**. - V1 damage causes loss of corneal sensation, resulting in an absent reflex. - While multiple cranial nerves traverse the superior orbital fissure (CN III, IV, V1, VI), the **corneal reflex** is a reliable and easily tested clinical sign of V1 involvement. *Complete loss of vision of the left eye* - The **optic nerve (CN II)**, responsible for vision, passes through the **optic canal**, not the superior orbital fissure. - Fractures specifically affecting the superior orbital fissure do not directly compress the optic nerve. *Decreased sense of smell* - The **olfactory nerve (CN I)**, which governs the sense of smell, passes through the **cribriform plate** of the ethmoid bone. - Injury to the greater wing of the sphenoid bone or superior orbital fissure does not affect the olfactory pathway. *Numbness of the left cheek* - Sensory innervation to the cheek is supplied by the **maxillary division (V2)** of the trigeminal nerve. - V2 exits via the **foramen rotundum**, not the superior orbital fissure, and would not be affected by this fracture. *Impaired left lateral gaze* - The **abducens nerve (CN VI)** passes through the superior orbital fissure and innervates the **lateral rectus muscle** for lateral gaze. - While CN VI damage can occur with superior orbital fissure compression and cause lateral gaze impairment, the question emphasizes the fracture of the **greater wing** with **compression** rather than complete superior orbital fissure syndrome. - In isolated compression scenarios, **sensory deficits (V1)** such as absent corneal reflex are often more readily apparent on initial examination than subtle extraocular movement limitations, making the corneal reflex a key clinical finding to assess.

ATLS protocols US Medical PG Question 6: A 27-year-old man is brought to the emergency department by emergency medical services. The patient was an unrestrained passenger in a head-on collision that occurred 15 minutes ago and is currently unresponsive. His temperature is 99.5°F (37.5°C), blood pressure is 60/33 mmHg, pulse is 180/min, respirations are 17/min, and oxygen saturation is 95% on room air. A FAST exam demonstrates fluid in Morrison’s pouch. Laboratory values are drawn upon presentation to the ED and sent off. The patient is started on IV fluids and an initial trauma survey is started. Twenty minutes later, his blood pressure is 95/65 mmHg, and his pulse is 110/min. The patient is further stabilized and is scheduled for emergency surgery. Which of the following best represents this patient’s most likely initial laboratory values?

• A. Hemoglobin: 10 g/dL, Hematocrit: 30%, MCV: 110 µm^3
• B. Hemoglobin: 19 g/dL, Hematocrit: 55%, MCV: 95 µm^3
• C. Hemoglobin: 7 g/dL, Hematocrit: 21%, MCV: 75 µm^3
• D. Hemoglobin: 11 g/dL, Hematocrit: 33%, MCV: 88 µm^3 (Correct Answer)
• E. Hemoglobin: 15 g/dL, Hematocrit: 45%, MCV: 90 µm^3

ATLS protocols Explanation: ***Hemoglobin: 11 g/dL, Hematocrit: 33%, MCV: 88 µm^3*** - The patient experienced significant trauma and is experiencing **hemorrhagic shock**, as evidenced by his initial **hypotension** (BP 60/33 mmHg), **tachycardia** (pulse 180/min), and positive **FAST exam** for fluid in Morrison's pouch, indicating intra-abdominal bleeding. - The initial hemoglobin and hematocrit could be mildly decreased due to acute blood loss, but significant drops are often *not immediately apparent* as plasma volume has not yet moved into the intravascular compartment to dilute the remaining red blood cells. A hemoglobin of 11 g/dL and hematocrit of 33% are consistent with **acute blood loss** before significant hemodilution occurs. MCV of 88 µm^3 is within the normal range for **normocytic anemia** seen in acute hemorrhage. *Hemoglobin: 10 g/dL, Hematocrit: 30%, MCV: 110 µm^3* - While a hemoglobin of 10 g/dL and hematocrit of 30% are consistent with anemia due to blood loss, an **MCV of 110 µm^3** (macrocytic) is not typically seen in acute hemorrhage. - Macrocytic anemia usually results from conditions like **B12 or folate deficiency**, alcoholism, or liver disease, which are not suggested by the acute traumatic scenario. *Hemoglobin: 19 g/dL, Hematocrit: 55%, MCV: 95 µm^3* - This indicates **polycythemia** (abnormally high red blood cell count), which is the opposite of what would be expected in a patient experiencing acute hemorrhagic shock. - These values would suggest conditions like **polycythemia vera** or severe dehydration, which are not relevant in this acute trauma setting. *Hemoglobin: 7 g/dL, Hematocrit: 21%, MCV: 75 µm^3* - While a hemoglobin of 7 g/dL and hematocrit of 21% represent significant anemia consistent with major blood loss, these values are typically seen *later* as **hemodilution** occurs, or in cases of chronic blood loss. - An **MCV of 75 µm^3** (microcytic) is generally indicative of **iron deficiency anemia** or thalassemia, which develops over time and is not characteristic of acute traumatic blood loss. *Hemoglobin: 15 g/dL, Hematocrit: 45%, MCV: 90 µm^3* - These values are within the **normal range** for hemoglobin and hematocrit, which would not be expected in a patient presenting with signs of **hemorrhagic shock** and a positive FAST exam indicating significant internal bleeding. - This would suggest either very minor blood loss or that the values were taken before any bleeding had occurred or before hemodilution had a chance to manifest.

ATLS protocols US Medical PG Question 7: A 36-year-old male is taken to the emergency room after jumping from a building. Bilateral fractures to the femur were stabilized at the scene by emergency medical technicians. The patient is lucid upon questioning and his vitals are stable. Pain only at his hips was elicited. Cervical exam was not performed. What is the best imaging study for this patient?

• A. AP and lateral radiographs of hips
• B. Lateral radiograph (x-ray) of hips
• C. Magnetic resonance imaging (MRI) of hips, knees, lumbar, and cervical area
• D. Anterior-posterior (AP) and lateral radiographs of hips, knees, lumbar, and cervical area
• E. Computed tomography (CT) scan of cervical spine, hips, and lumbar area (Correct Answer)

ATLS protocols Explanation: ***Computed tomography (CT) scan of cervical spine, hips, and lumbar area*** - In **high-energy trauma** (fall from height), a CT scan is the **gold standard** for evaluating the **spine and pelvis**, providing detailed cross-sectional images superior to plain radiographs. - Since the **cervical exam was not performed**, cervical spine imaging is **mandatory** per ATLS (Advanced Trauma Life Support) protocols. High-energy falls carry significant risk of **cervical spine injury** even without obvious neurological symptoms. - CT allows comprehensive assessment of **hip fractures, pelvic injuries, and the entire spine** (cervical, thoracic, lumbar), identifying both obvious and **subtle fractures** that may be missed on plain films. - This approach provides the most **efficient and thorough evaluation** in the acute trauma setting, allowing for appropriate surgical planning and ruling out life-threatening spinal instability. *AP and lateral radiographs of hips* - Plain radiographs provide **limited detail** and may **miss subtle fractures**, particularly in complex areas like the pelvis and acetabulum. - This option **fails to address cervical spine clearance**, which is essential in all high-energy trauma patients, especially when cervical exam has not been performed. - Radiographs are insufficient for **comprehensive trauma evaluation** after a fall from height. *Lateral radiograph (x-ray) of hips* - A single lateral view is **grossly insufficient** for evaluating hip and pelvic fractures, providing only a **two-dimensional perspective** that can miss significant injuries. - This option **completely neglects spinal evaluation**, which is dangerous in an uncleared trauma patient with a high-energy mechanism. *Magnetic resonance imaging (MRI) of hips, knees, lumbar, and cervical area* - While MRI excels at evaluating **soft tissues, ligaments, and bone marrow**, it is **not the initial imaging modality** for acute bony trauma due to longer scan times and lower sensitivity for acute fractures compared to CT. - MRI is **time-consuming and impractical** in the emergency setting for initial fracture assessment, potentially delaying definitive treatment. - CT is superior for evaluating **acute skeletal injuries** in the trauma bay. *Anterior-posterior (AP) and lateral radiographs of hips, knees, lumbar, and cervical area* - Multiple plain radiographs have **limited sensitivity** for complex or non-displaced fractures, particularly in the **spine and pelvis**, making them inadequate for high-energy trauma evaluation. - Obtaining multiple radiographic views requires **numerous patient repositionings**, which risks further injury if **spinal instability** is present. - Plain films provide significantly **less diagnostic information** than CT scanning for trauma assessment.

ATLS protocols US Medical PG Question 8: A 63-year-old man is brought to the emergency department, 30 minutes after being involved in a high-speed motor vehicle collision. He is obtunded on arrival. He is intubated and mechanical ventilation is begun. The ventilator is set at a FiO2 of 60%, tidal volume of 440 mL, and positive end-expiratory pressure of 4 cm H2O. On the third day of intubation, his temperature is 37.3°C (99.1°F), pulse is 91/min, and blood pressure is 103/60 mm Hg. There are decreased breath sounds over the left lung base. Cardiac examination shows no abnormalities. The abdomen is soft and not distended. Arterial blood gas analysis shows: pH 7.49 pCO2 29 mm Hg pO2 73 mm Hg HCO3- 20 mEq/L O2 saturation 89% Monitoring shows a sudden increase in the plateau airway pressure. An x-ray of the chest shows deepening of the costophrenic angle on the left side. Which of the following is the most appropriate next step in management?

• A. CT scan of the chest
• B. Administer levofloxacin
• C. Close observation
• D. Increase the PEEP
• E. Insertion of a chest tube (Correct Answer)

ATLS protocols Explanation: ***Insertion of a chest tube*** - The sudden increase in **plateau airway pressure**, decreased breath sounds over the left lung base, worsening hypoxemia (O2 sat 89%) despite high FiO2, and **deepening of the costophrenic angle on the left side** indicate a **traumatic hemothorax**. - Deepening of the costophrenic angle on chest X-ray is a classic sign of **pleural fluid accumulation** (hemothorax or pleural effusion), not pneumothorax. - In a trauma patient (high-speed motor vehicle collision) on day 3 of mechanical ventilation, this represents a **delayed hemothorax** requiring immediate drainage. - **Chest tube insertion** is the definitive management to evacuate blood, re-expand the lung, and improve ventilation and oxygenation. *CT scan of the chest* - While CT scan would provide detailed anatomical information, the clinical presentation with sudden respiratory decompensation and clear chest X-ray findings of hemothorax requires **immediate intervention**. - Delaying treatment to obtain CT imaging in an unstable ventilated patient could worsen hypoxemia and lead to cardiovascular compromise. - CT scan may be obtained later if needed to evaluate for ongoing bleeding or other injuries. *Administer levofloxacin* - Antibiotics would be appropriate for **pneumonia or empyema**, but the patient has no clear signs of infection (afebrile at 37.3°C, acute presentation over hours not days). - The primary problem is **mechanical compression** from pleural fluid accumulation, not infection. - Antibiotics do not address the life-threatening respiratory compromise from hemothorax. *Close observation* - Close observation is inappropriate given the acute deterioration with increased plateau pressures and worsening hypoxemia. - The patient requires urgent intervention to prevent further respiratory failure and potential cardiovascular collapse. - Expectant management would be negligent in this clinical scenario. *Increase the PEEP* - Increasing **Positive End-Expiratory Pressure (PEEP)** would worsen the situation by increasing intrathoracic pressure against an already compressed lung. - Higher PEEP could impair venous return, decrease cardiac output, and potentially convert a simple hemothorax to a tension physiology. - PEEP adjustments do not address the underlying problem of pleural space fluid accumulation requiring drainage.

ATLS protocols US Medical PG Question 9: A 43-year-old man is brought to the emergency department 25 minutes after being involved in a high-speed motor vehicle collision in which he was a restrained passenger. On arrival, he has shortness of breath and is in severe pain. His pulse is 130/min, respirations are 35/min, and blood pressure is 90/40 mm Hg. Examination shows superficial abrasions and diffuse crepitus at the left shoulder level. Cardiac examination shows tachycardia with no murmurs, rubs, or gallops. The upper part of the left chest wall moves inward during inspiration. Breath sounds are absent on the left. He is intubated and mechanically ventilated. Two large bore intravenous catheters are placed and infusion of 0.9% saline is begun. Which of the following is the most likely cause of his symptoms?

• A. Cardiac tamponade
• B. Flail chest (Correct Answer)
• C. Diaphragmatic rupture
• D. Phrenic nerve paralysis
• E. Sternal fracture

ATLS protocols Explanation: ***Flail chest*** - The inward movement of the **left chest wall during inspiration (paradoxical movement)** is a classic sign of **flail chest**, caused by fractures of three or more adjacent ribs in two or more places. - This condition is often associated with significant pain, **shortness of breath**, and can compromise ventilation, leading to **tachycardia** and **hypotension** due to impaired gas exchange and hypovolemia from associated injuries. *Cardiac tamponade* - While it causes **tachycardia and hypotension**, it typically presents with muffled heart sounds, jugular venous distension, and pulsus paradoxus, which are not described. - The primary respiratory findings would not be *absent breath sounds* or *paradoxical chest wall motion*. *Diaphragmatic rupture* - This typically presents with **abdominal contents in the chest**, leading to respiratory distress and potentially absent breath sounds on the affected side. - However, it does not explain the **diffuse crepitus at the left shoulder level** or the **paradoxical chest wall movement**. *Phrenic nerve paralysis* - **Unilateral phrenic nerve paralysis** would lead to paralysis of the diaphragm on one side, causing **elevated hemidiaphragm** on chest X-ray and reduced lung expansion. - It would not cause *diffuse crepitus*, *paradoxical chest wall movement*, or the acute, severe presentation described after trauma. *Sternal fracture* - A sternal fracture can cause severe chest pain and can be associated with cardiac contusion or other intrathoracic injuries. - However, it does not directly explain **absent breath sounds** or **paradoxical chest wall movement** as the primary cause of respiratory distress, although it can coexist with flail chest.

ATLS protocols US Medical PG Question 10: A 27-year-old man presents to the emergency department with severe dyspnea and sharp chest pain that suddenly started an hour ago after he finished exercising. He has a history of asthma as a child, and he achieves good control of his acute attacks with Ventolin. On examination, his right lung field is hyperresonant along with diminished lung sounds. Chest wall motion during respiration is asymmetrical. His blood pressure is 105/67 mm Hg, respirations are 22/min, pulse is 78/min, and temperature is 36.7°C (98.0°F). The patient is supported with oxygen, given corticosteroids, and has had analgesic medications via a nebulizer. Considering the likely condition affecting this patient, what is the best step in management?

• A. CT scan
• B. ABG
• C. Chest X-rays (Correct Answer)
• D. Tube insertion
• E. Sonogram

ATLS protocols Explanation: ***Chest X-rays*** - The patient's presentation with **sudden onset dyspnea** and **sharp chest pain** post-exercise, along with **hyperresonance** and **diminished lung sounds** in the right lung field, is highly suggestive of a **spontaneous pneumothorax**. - However, the patient is **hemodynamically stable** (BP 105/67, HR 78/min) with no signs of tension physiology (no severe hypotension, marked tachycardia, or cardiovascular collapse). - In a stable patient with suspected pneumothorax, **chest X-ray is the appropriate first step** to confirm the diagnosis, determine the size of the pneumothorax, and guide subsequent management (observation for small pneumothorax <20%, aspiration, or tube thoracostomy for larger pneumothoraces). - Immediate intervention without imaging is reserved for unstable patients with tension pneumothorax. *Tube insertion* - Chest tube insertion is the definitive treatment for large pneumothoraces (>20%) or hemodynamically unstable patients with tension pneumothorax. - In this **stable patient**, proceeding directly to tube insertion without imaging confirmation would be premature and not following standard of care. - The diagnosis should be confirmed and the size estimated via chest X-ray before determining if tube thoracostomy is necessary. *CT scan* - CT scan is not indicated as the initial diagnostic test for suspected pneumothorax. - It provides more detail than needed for this clinical scenario and causes unnecessary delay and radiation exposure when chest X-ray is sufficient. - CT may be useful for detecting small pneumothoraces not visible on X-ray or evaluating underlying lung disease, but is not the first-line test. *ABG* - An Arterial Blood Gas (ABG) might show hypoxia and respiratory alkalosis, providing information about gas exchange. - However, ABG does not confirm the diagnosis of pneumothorax or guide immediate management decisions. - It is an adjunctive test that does not take priority over diagnostic imaging in this scenario. *Sonogram* - Lung ultrasound can rapidly detect pneumothorax by showing absent lung sliding and is increasingly used in emergency settings, particularly for bedside evaluation. - While potentially useful, **chest X-ray remains the standard initial imaging modality** for suspected pneumothorax in most emergency departments, as it provides clear documentation of pneumothorax size and is more universally available and interpreted. - Ultrasound may be preferred in specific situations (unstable patients, point-of-care evaluation), but chest X-ray is the conventional first-line imaging test.

ATLS protocols Flashcard 1 of 10

Question: An entire torso burn is _____% of the body surface area.

Answer: 18

ATLS protocols Flashcard 2 of 10

Question: Is placement of a foley (urethral) catheter contraindicated in urethral injury?_____

Answer: Relatively contraindicated

ATLS protocols Flashcard 3 of 10

Question: A _____ is indicated when an emergency airway is required or orotracheal / nasotracheal intubation is unsuccessful / contraindicated

Answer: cricothyrotomy

ATLS protocols Flashcard 4 of 10

Question: An entire arm burn is _____% of the body surface area.

Answer: 9

ATLS protocols Flashcard 5 of 10

Question: Commotio cordis is ventricular fibrillation caused by _____

Answer: blunt cardiac injury

Extra Information:  https://onlinemeded.org?ref=anki 

ATLS protocols Flashcard 6 of 10

Question: Patients with atlantoaxial instability can acutely present with neurological deficits due to _____ if their subluxation is worsened

Answer: spinal cord compression

Extra Information: Watch associated Bootcamp video [https://app.bootcamp.com/med-school/gross-anatomy/videos/back?index=4] https://onlinemeded.org?ref=anki 

ATLS protocols Flashcard 7 of 10

Question: Tension pneumothorax needs immediate needle decompression and _____ placement

Answer: chest tube

Extra Information:   Watch Pneumothorax [https://dashboard.sketchy.com/study/medical/courses/medical-pathophysiology/units/medical-pathophysiology-pulmonary/videos/medical-pathophysiology-pulmonary-acute-lung-disorders-pneumothorax?utm_source=anki&utm_medium=partnership&utm_campaign=february_update&utm_content=medical]Watch associated Bootcamp video [https://app.bootcamp.com/med-school/pulmonology/videos/lung-pathology-special-topics?index=6] https://onlinemeded.org/spa/pulmonary-hypertension?ref=anki 

ATLS protocols Flashcard 8 of 10

Question: Epidural hematoma may present on physical exam with _____ palsy

Answer: CN III

Extra Information:   Watch Epidural Hematoma, Subdural Hematoma, & Subarachnoid Hemorrhage [https://dashboard.sketchy.com/study/medical/courses/medical-pathophysiology/units/medical-pathophysiology-neuro/videos/medical-pathophysiology-neuro-cerebrovascular-epidural-hematoma-subdural-hematoma-and-subarachnoid-hemorrhage?utm_source=anki&utm_medium=partnership&utm_campaign=february_update&utm_content=medical]Watch associated Bootcamp video [https://app.bootcamp.com/med-school/neurology/videos/aneurysms-and-intracranial-hemorrhage?index=7] https://onlinemeded.org/spa/surgery?ref=anki Atlas: 

ATLS protocols Flashcard 9 of 10

Question: A(n) _____ is indicated when an emergency airway is required or orotracheal / nasotracheal intubation is unsuccessful / contraindicated

Answer: cricothyrotomy

Extra Information:  https://onlinemeded.org?ref=anki 

ATLS protocols Flashcard 10 of 10

Question: Is placement of a foley (urethral) catheter contraindicated in urethral injury? _____

Answer: Relatively contraindicated

Extra Information: Watch associated Bootcamp video [https://app.bootcamp.com/med-school/musculoskeletal/videos/high-yield-step-1-anatomy?index=43] https://onlinemeded.org?ref=anki