ATLS protocols — MCQs
On this page
A mass casualty incident occurs with 25 casualties arriving simultaneously at a community hospital emergency department. The trauma team has limited resources with 2 operating rooms available and 4 surgeons present. Among the arriving patients: Patient A has traumatic amputation of forearm with tourniquet in place and stable vitals; Patient B has flail chest, respiratory distress, and unstable vitals; Patient C is in cardiac arrest with penetrating chest wound; Patient D has a femur fracture with stable vitals; Patient E has GCS 4 with bilateral blown pupils. Evaluate the triage priority according to ATLS mass casualty protocols.
A 35-year-old pregnant woman at 32 weeks gestation is involved in a motor vehicle collision. She is hemodynamically stable with blood pressure 105/70 mmHg, heart rate 100/min. She has left upper quadrant tenderness and left lower rib fractures. FAST examination shows fluid in the splenorenal recess. Fetal heart tones are 150/min and reassuring. CT scan shows a Grade III splenic laceration. After 6 hours of observation with stable vital signs and hemoglobin, she suddenly develops blood pressure 85/50 mmHg and heart rate 125/min. Evaluate the management priority.
A 50-year-old helmeted motorcyclist is brought to the trauma bay after a collision at 50 mph. He is unconscious with GCS 6. Initial vitals show blood pressure 160/95 mmHg, heart rate 58/min. Pupils are unequal with the right pupil dilated and minimally reactive. He begins to posture with extension of extremities. He is intubated with in-line stabilization. CT scan cannot be immediately obtained due to scanner malfunction. Evaluate the most appropriate immediate management strategy.
A 19-year-old man is stabbed in the left fifth intercostal space at the anterior axillary line. He arrives alert with blood pressure 95/60 mmHg and heart rate 115/min. Chest X-ray shows a small left hemothorax. A chest tube is placed, draining 600 mL of blood initially, then 150 mL/hour for the next 3 hours. His vital signs stabilize after transfusion of 2 units of packed red blood cells. Analyze the indication for thoracotomy.
A 40-year-old woman is brought to the ED after a high-speed rollover collision. She is combative with GCS 13. Blood pressure is 100/65 mmHg, heart rate 110/min. She has abrasions over her abdomen. FAST examination is negative. After receiving 1 liter of crystalloid, her blood pressure improves to 115/70 mmHg and heart rate decreases to 95/min. She continues to complain of severe abdominal pain. Analyze the most appropriate next step in evaluation.
A 24-year-old man sustains a gunshot wound to the right upper quadrant. He arrives hypotensive at 80/50 mmHg with heart rate 125/min. After intubation and initiating transfusion, he undergoes emergency laparotomy revealing a Grade IV liver injury with active hemorrhage. Despite packing, hemorrhage continues with coagulopathy developing. His temperature is 34°C, pH is 7.15, and he has received 12 units of blood. What surgical principle should guide the next management decision?
A 55-year-old man is involved in a frontal motor vehicle collision. He arrives at the emergency department with severe respiratory distress. His blood pressure is 75/40 mmHg, heart rate is 135/min, oxygen saturation is 88% on non-rebreather mask. Trachea is deviated to the right, the left hemithorax has absent breath sounds with hyperresonance to percussion, and jugular venous distension is present. What is the most appropriate immediate intervention?
A 32-year-old construction worker falls 20 feet and presents to the trauma bay. He is alert with a GCS of 15. His vital signs show blood pressure 110/70 mmHg, heart rate 95/min, and respiratory rate 20/min. He complains of severe pelvic pain. Physical examination reveals blood at the urethral meatus and a high-riding prostate on rectal examination. A pelvic binder has been applied. What is the appropriate next step for urinary catheterization?
A 45-year-old woman arrives at the trauma bay after a high-speed motor vehicle collision. She is alert and complaining of chest and abdominal pain. Her blood pressure is 85/50 mmHg, heart rate is 130/min, and oxygen saturation is 94% on room air. After securing the airway and establishing IV access, she receives 2 liters of crystalloid with minimal improvement in blood pressure. FAST examination shows fluid in Morrison's pouch. What is the next step in management according to ATLS protocols?
A 28-year-old man is brought to the emergency department following a motor vehicle collision. He is unresponsive with a Glasgow Coma Scale score of 7. His blood pressure is 90/60 mmHg, heart rate is 120/min, and respiratory rate is 8/min with shallow breaths. He has bruising over the left chest wall and decreased breath sounds on the left side. According to ATLS protocols, what is the most appropriate immediate management?
ATLS protocols US Medical PG Practice Questions and MCQs
Question 1: A mass casualty incident occurs with 25 casualties arriving simultaneously at a community hospital emergency department. The trauma team has limited resources with 2 operating rooms available and 4 surgeons present. Among the arriving patients: Patient A has traumatic amputation of forearm with tourniquet in place and stable vitals; Patient B has flail chest, respiratory distress, and unstable vitals; Patient C is in cardiac arrest with penetrating chest wound; Patient D has a femur fracture with stable vitals; Patient E has GCS 4 with bilateral blown pupils. Evaluate the triage priority according to ATLS mass casualty protocols.
- A. Priority order: C, E, B, A, D - treat most severely injured first
- B. Priority order: B, A, D, with E and C designated expectant (Correct Answer)
- C. Priority order: A, D, B, E, C - treat all patients equally regardless of prognosis
- D. Priority order: B, A, E, D, C - based on severity alone
- E. Immediate evacuation of all patients to a higher level trauma center
Explanation: ***Priority order: B, A, D, with E and C designated expectant*** - In a **mass casualty incident (MCI)** with limited resources, the goal is to provide the **greatest good for the greatest number**; Patient B has life-threatening but **salvageable** injuries (respiratory distress) making them the top priority. - Patients C (cardiac arrest) and E (GCS 4, blown pupils) are classified as **expectant (black tag)** because their survival probability is minimal and resuscitating them would exhaust resources needed for salvageable patients. *Priority order: C, E, B, A, D - treat most severely injured first* - This approach is used in standard trauma situations where resources are ample, but it is incorrect in an **MCI** where resource-heavy, low-prognosis patients are de-prioritized. - Assigning highest priority to **cardiac arrest (C)** and **severe brain injury (E)** would likely result in the deaths of more salvageable patients like Patient B. *Priority order: A, D, B, E, C - treat all patients equally regardless of prognosis* - Treating all patients equally ignores the **ATLS triage categories** (Immediate, Delayed, Minimal, Expectant) and fails to address life-threatening priorities first. - While A and D have stable vitals and are **Delayed (Yellow tag)**, waiting to treat Patient B's airway/breathing emergency would lead to a preventable death. *Priority order: B, A, E, D, C - based on severity alone* - Severity alone does not dictate priority in an MCI; the **likelihood of survival** with the available resources must be considered. - Patient E, despite being "severe," has a **devastating neurological prognosis** (blown pupils, GCS 4) and should not be prioritized over stable patients with better outcomes like A and D. *Immediate evacuation of all patients to a higher level trauma center* - Evacuation is a secondary step; the primary task according to **ATLS protocols** is to perform triage and stabilization at the current facility during the initial influx. - Attempting to evacuate all 25 casualties simultaneously without triage would overwhelm transport systems and delay life-saving **initial stabilization** for patients like B.
Question 2: A 35-year-old pregnant woman at 32 weeks gestation is involved in a motor vehicle collision. She is hemodynamically stable with blood pressure 105/70 mmHg, heart rate 100/min. She has left upper quadrant tenderness and left lower rib fractures. FAST examination shows fluid in the splenorenal recess. Fetal heart tones are 150/min and reassuring. CT scan shows a Grade III splenic laceration. After 6 hours of observation with stable vital signs and hemoglobin, she suddenly develops blood pressure 85/50 mmHg and heart rate 125/min. Evaluate the management priority.
- A. Initiate massive transfusion and reassess after maternal stabilization
- B. Perform emergency cesarean section first, then address splenic injury
- C. Simultaneous laparotomy with splenectomy and obstetric standby for potential cesarean (Correct Answer)
- D. Proceed with splenectomy only, as maternal stabilization is the priority
- E. Perform angioembolization of splenic artery to avoid surgery
Explanation: ***Simultaneous laparotomy with splenectomy and obstetric standby for potential cesarean*** - The patient has failed **non-operative management** of a splenic injury and is now **hemodynamically unstable**, necessitating immediate **laparotomy** to control hemorrhage. - At **32 weeks gestation**, the fetus is viable; therefore, an **obstetric standby** is essential to perform a cesarean section if the mother's condition does not improve or if **fetal distress** occurs during the procedure. *Initiate massive transfusion and reassess after maternal stabilization* - While **massive transfusion** is part of trauma resuscitation, delaying surgery in an unstable patient with a known **Grade III splenic laceration** and hemodynamic collapse is inappropriate. - Definitive **hemorrhage control** (surgery) is the priority once a patient becomes unstable after initial observation. *Perform emergency cesarean section first, then address splenic injury* - Performing a cesarean section first in an unstable trauma patient with **intra-abdominal hemorrhage** increases maternal morbidity and can worsen **hypovolemic shock**. - Maternal stabilization and controlling the source of **bleeding** (splenectomy) is the most critical step to ensure both maternal and fetal survival. *Proceed with splenectomy only, as maternal stabilization is the priority* - While maternal stabilization is the priority, ignoring the viable fetus during a major surgical intervention is suboptimal care. - Failure to involve an **obstetric team** overlooks the risk of **placental abruption** or fetal distress induced by maternal hypotension during surgery. *Perform angioembolization of splenic artery to avoid surgery* - **Angioembolization** is only indicated for stable patients; this patient is **hemodynamically unstable** (BP 85/50, HR 125), which is a contraindication for the interventional radiology suite. - In the setting of active **intraperitoneal hemorrhage** and shock, an emergent **exploratory laparotomy** is the standard of care.
Question 3: A 50-year-old helmeted motorcyclist is brought to the trauma bay after a collision at 50 mph. He is unconscious with GCS 6. Initial vitals show blood pressure 160/95 mmHg, heart rate 58/min. Pupils are unequal with the right pupil dilated and minimally reactive. He begins to posture with extension of extremities. He is intubated with in-line stabilization. CT scan cannot be immediately obtained due to scanner malfunction. Evaluate the most appropriate immediate management strategy.
- A. Administer hypertonic saline and wait for CT scanner to be repaired
- B. Start therapeutic hypothermia protocol and await imaging
- C. Administer mannitol, hyperventilate to pCO2 30-35 mmHg, elevate head of bed, and arrange emergent neurosurgical consultation (Correct Answer)
- D. Transport to another facility for immediate CT scan
- E. Perform bilateral burr holes at bedside
Explanation: ***Administer mannitol, hyperventilate to pCO2 30-35 mmHg, elevate head of bed, and arrange emergent neurosurgical consultation*** - This patient exhibits **Cushing's triad** (hypertension, bradycardia) and asymmetric pupil dilation, indicating a life-threatening **transtentorial herniation** and increased **intracranial pressure (ICP)**. - Immediate medical decompression using **osmotic therapy** (mannitol), **controlled hyperventilation** (causing cerebral vasoconstriction), and **head elevation** is critical to prevent brainstem death while awaiting neurosurgical intervention. *Administer hypertonic saline and wait for CT scanner to be repaired* - While **hypertonic saline** is an effective osmotic agent, waiting for a malfunctioning scanner in the setting of active **herniation** is unsafe and delays definitive care. - Patients with clinical signs of herniation require **immediate neurosurgical consultation** and potentially a transfer if surgery cannot be performed on-site. *Start therapeutic hypothermia protocol and await imaging* - **Therapeutic hypothermia** is not a primary or immediate management strategy for acute **traumatic brain injury** with signs of herniation. - Focus must remain on **ICP reduction** and surgical decompression; hypothermia does not address the acute mass effect evidenced by the blown pupil. *Transport to another facility for immediate CT scan* - Transporting an unstable patient with signs of **imminent herniation** without first initiating **ICP-lowering measures** is dangerous and may lead to death during transit. - **Stabilization** including osmotic therapy and airway protection must be prioritized before considering any inter-facility transfer. *Perform bilateral burr holes at bedside* - **Bedside burr holes** are generally reserved for extreme circumstances where neurosurgical support is unavailable and the patient is rapidly deteriorating. - The priority in a trauma bay setting is focused **medical management** followed by emergent definitive surgery (craniotomy) by a **neurosurgeon**.
Question 4: A 19-year-old man is stabbed in the left fifth intercostal space at the anterior axillary line. He arrives alert with blood pressure 95/60 mmHg and heart rate 115/min. Chest X-ray shows a small left hemothorax. A chest tube is placed, draining 600 mL of blood initially, then 150 mL/hour for the next 3 hours. His vital signs stabilize after transfusion of 2 units of packed red blood cells. Analyze the indication for thoracotomy.
- A. Immediate thoracotomy is indicated due to initial output >500 mL
- B. Continue observation as hourly output is <200 mL/hour
- C. Perform CT angiography before deciding on thoracotomy
- D. Wait for total output to exceed 1500 mL before thoracotomy
- E. Thoracotomy is indicated due to continued bleeding >200 mL/hour for 3 hours (Correct Answer)
Explanation: ***Thoracotomy is indicated due to continued bleeding >200 mL/hour for 3 hours*** - **Emergent thoracotomy** is indicated if the initial chest tube output is **>1500 mL** or if there is persistent bleeding of **>200 mL/hour for 2-4 hours**. - This patient exhibits **ongoing hemorrhage** from a penetrating injury, suggesting a vascular source like **intercostal arteries** or internal mammary arteries that requires surgical ligation. *Immediate thoracotomy is indicated due to initial output >500 mL* - The criteria for **immediate operative intervention** based on initial drainage is a volume exceeding **1500 mL**, not 500 mL. - Initial drainage of 600 mL is significant but often stops with **lung re-expansion** and does not necessitate an immediate trip to the OR. *Continue observation as hourly output is <200 mL/hour* - While the output is exactly **150 mL/hour**, combined with the initial loss and clinical context of a **stab wound**, persistent bleeding warrants high suspicion for internal injury. - Guidelines emphasize that **hemodynamic stability** achieved only after **blood transfusion** in the setting of persistent drainage is a relative indication for exploration. *Perform CT angiography before deciding on thoracotomy* - In a patient with **active bleeding** and a history of **hypotension** (95/60 mmHg), surgical exploration is preferred over imaging to avoid delays in definitive care. - **CTA** is more appropriate for stable patients with suspected **contained vascular injuries** or blunt aortic trauma, not active ongoing hemorrhage. *Wait for total output to exceed 1500 mL before thoracotomy* - Waiting for a **cumulative total** of 1500 mL is not a standard protocol; the rate of **ongoing blood loss** is a more critical indicator of active vessel injury. - Delaying surgery until a specific total is reached can lead to **decompensation** and adverse outcomes in a patient who has already required transfusion.
Question 5: A 40-year-old woman is brought to the ED after a high-speed rollover collision. She is combative with GCS 13. Blood pressure is 100/65 mmHg, heart rate 110/min. She has abrasions over her abdomen. FAST examination is negative. After receiving 1 liter of crystalloid, her blood pressure improves to 115/70 mmHg and heart rate decreases to 95/min. She continues to complain of severe abdominal pain. Analyze the most appropriate next step in evaluation.
- A. Discharge with outpatient follow-up since FAST is negative and vitals normalized
- B. Perform CT scan of abdomen and pelvis with IV contrast (Correct Answer)
- C. Observe for 6 hours and repeat FAST examination
- D. Proceed directly to diagnostic laparoscopy
- E. Perform diagnostic peritoneal lavage
Explanation: ***Perform CT scan of abdomen and pelvis with IV contrast*** - The patient is currently **hemodynamically stable** (a 'responder' to fluids), making **CT imaging** the gold standard for identifying specific intra-abdominal or retroperitoneal injuries. - A **negative FAST** does not exclude injury, especially **hollow viscus** or **solid organ** trauma that has not yet resulted in significant hemoperitoneum. *Discharge with outpatient follow-up since FAST is negative and vitals normalized* - This is dangerous as the high-speed mechanism and **persistent abdominal pain** indicate a high risk of occult internal trauma. - **FAST examination** has low sensitivity for certain injuries, and clinical observation is required even if initial tests are reassuring. *Observe for 6 hours and repeat FAST examination* - While monitoring is part of trauma care, it should not delay definitive diagnosis via **CT scan** in a stable patient with severe pain. - Delaying imaging could lead to missed **internal bleeding** or bowel perforation that may worsen during the observation period. *Proceed directly to diagnostic laparoscopy* - **Laparoscopy** or laparotomy is indicated for hemodynamically **unstable** patients with a positive FAST or signs of peritonitis. - Because this patient is currently stable, non-invasive **CT imaging** is the preferred first-line diagnostic step to guide management. *Perform diagnostic peritoneal lavage* - **Diagnostic Peritoneal Lavage (DPL)** is primarily used for **unstable** patients when ultrasound (FAST) is unavailable or inconclusive. - It is invasive and cannot provide the detailed anatomical information regarding **organ injury grading** that a CT scan provides.
Question 6: A 24-year-old man sustains a gunshot wound to the right upper quadrant. He arrives hypotensive at 80/50 mmHg with heart rate 125/min. After intubation and initiating transfusion, he undergoes emergency laparotomy revealing a Grade IV liver injury with active hemorrhage. Despite packing, hemorrhage continues with coagulopathy developing. His temperature is 34°C, pH is 7.15, and he has received 12 units of blood. What surgical principle should guide the next management decision?
- A. Continue definitive repair with hepatorrhaphy and vascular reconstruction
- B. Perform damage control surgery with abbreviated laparotomy and temporary abdominal closure (Correct Answer)
- C. Proceed with formal right hepatectomy to control bleeding
- D. Convert to total hepatic vascular isolation technique
- E. Administer more blood products until coagulopathy corrects, then continue definitive repair
Explanation: ***Perform damage control surgery with abbreviated laparotomy and temporary abdominal closure*** - The patient presents with the **lethal triad** of trauma: **hypothermia** (34°C), **acidosis** (pH 7.15), and **coagulopathy**, which necessitates immediate cessation of complex surgery. - **Damage control surgery** prioritizes physiological stabilization over anatomical restoration, involving rapid hemorrhage control, packing, and **temporary abdominal closure** to allow ICU-based resuscitation. *Continue definitive repair with hepatorrhaphy and vascular reconstruction* - Pursuing **definitive repair** in the presence of the lethal triad significantly increases mortality due to exhausted physiological reserves. - Extended operative time exacerbates **metabolic acidosis** and **hypothermia**, making successful surgical repair technically and clinically impossible. *Proceed with formal right hepatectomy to control bleeding* - Formal **hepatectomy** is a high-risk, time-consuming procedure that is contraindicated in an unstable patient with **coagulopathy**. - Resective surgery in this acute phase leads to excessive blood loss and high rates of **perioperative death**. *Convert to total hepatic vascular isolation technique* - **Total hepatic vascular isolation** is a complex maneuver that often requires sternotomy and can cause severe **hemodynamic instability** through reduced venous return. - This technique would likely worsen the patient's existing **hypotension** and provide more surgical stress than the patient can physiologically tolerate. *Administer more blood products until coagulopathy corrects, then continue definitive repair* - While **massive transfusion** is necessary, coagulopathy cannot be fully corrected in the operating room while the patient remains **acidotic** and **hypothermic**. - Delaying the conclusion of surgery to wait for lab correction in the OR is futile; stabilization must occur in the **ICU environment** after abbreviated surgery.
Question 7: A 55-year-old man is involved in a frontal motor vehicle collision. He arrives at the emergency department with severe respiratory distress. His blood pressure is 75/40 mmHg, heart rate is 135/min, oxygen saturation is 88% on non-rebreather mask. Trachea is deviated to the right, the left hemithorax has absent breath sounds with hyperresonance to percussion, and jugular venous distension is present. What is the most appropriate immediate intervention?
- A. Insert a large-bore needle into the second intercostal space, midclavicular line on the left (Correct Answer)
- B. Intubate the patient with rapid sequence induction
- C. Initiate massive transfusion protocol
- D. Obtain portable chest X-ray to confirm diagnosis
- E. Perform immediate left-sided tube thoracostomy in the fifth intercostal space
Explanation: ***Insert a large-bore needle into the second intercostal space, midclavicular line on the left*** - The patient presents with classic signs of **tension pneumothorax**, including hypotension, **tracheal deviation**, and absent breath sounds with **hyperresonance**. - **Needle decompression** is the immediate life-saving step in an unstable patient to relieve pressure and restore **venous return** to the heart. *Intubate the patient with rapid sequence induction* - Positive pressure ventilation can worsen a **tension pneumothorax** by increasing intrapleural pressure, potentially causing rapid circulatory collapse. - **Decompression** must always be performed before or concurrently with intubation in the setting of a suspected tension pneumothorax. *Initiate massive transfusion protocol* - While the patient is hypotensive, his physical exam findings (distended neck veins, tracheal shift) point toward **obstructive shock**, not purely hemorrhagic shock. - Fluid resuscitation will not resolve the primary issue of **decreased cardiac output** caused by mediastinal shift. *Obtain portable chest X-ray to confirm diagnosis* - Tension pneumothorax is a **clinical diagnosis**; waiting for radiographic confirmation in an unstable patient is a critical error that delays life-saving treatment. - Treatment should never be delayed for imaging when **respiratory distress** and hemodynamic instability are present. *Perform immediate left-sided tube thoracostomy in the fifth intercostal space* - While **tube thoracostomy** is the definitive treatment, needle decompression is often faster and preferred as the very first step in the emergent setting. - In some settings, immediate **finger thoracostomy** is acceptable, but needle decompression remains a primary ATLS recommendation for rapid relief.
Question 8: A 32-year-old construction worker falls 20 feet and presents to the trauma bay. He is alert with a GCS of 15. His vital signs show blood pressure 110/70 mmHg, heart rate 95/min, and respiratory rate 20/min. He complains of severe pelvic pain. Physical examination reveals blood at the urethral meatus and a high-riding prostate on rectal examination. A pelvic binder has been applied. What is the appropriate next step for urinary catheterization?
- A. Insert a standard Foley catheter to monitor urine output
- B. Perform a retrograde urethrogram before catheter insertion (Correct Answer)
- C. Place a suprapubic catheter immediately
- D. Obtain a CT cystogram first
- E. Attempt gentle catheter insertion with lubrication
Explanation: ***Perform a retrograde urethrogram before catheter insertion*** - The presence of **blood at the urethral meatus** and a **high-riding prostate** are classic indicators of a **posterior urethral injury**, often associated with pelvic fractures. - In any patient where urethral injury is suspected, a **retrograde urethrogram (RUG)** is the gold standard diagnostic step to evaluate urethral integrity and prevent further complications. *Insert a standard Foley catheter to monitor urine output* - Performing blind catheterization in the presence of urethral trauma signs is **contraindicated** as it can worsen the injury. - Attempting to pass a catheter can convert a **partial urethral tear** into a **complete transection**, leading to long-term morbidity like strictures. *Place a suprapubic catheter immediately* - While **suprapubic catheterization** may be necessary if a urethral tear is confirmed, it is not the immediate diagnostic step. - This procedure should follow a **retrograde urethrogram** if the imaging confirms that urethral access is unsafe or impossible. *Obtain a CT cystogram first* - A **CT cystogram** is primarily used to evaluate for **bladder rupture**, not urethral injuries, and requires catheterization to instill contrast. - Using a CT cystogram before ruling out urethral injury risks damaging the urethra further during the prerequisite catheter insertion. *Attempt gentle catheter insertion with lubrication* - Even with **lubrication** and a gentle technique, any attempt at urethral catheterization is unsafe when signs of **meatal blood** are present. - Diagnostic confirmation via **imaging** must always precede catheterization in the setting of suspected urethral trauma.
Question 9: A 45-year-old woman arrives at the trauma bay after a high-speed motor vehicle collision. She is alert and complaining of chest and abdominal pain. Her blood pressure is 85/50 mmHg, heart rate is 130/min, and oxygen saturation is 94% on room air. After securing the airway and establishing IV access, she receives 2 liters of crystalloid with minimal improvement in blood pressure. FAST examination shows fluid in Morrison's pouch. What is the next step in management according to ATLS protocols?
- A. Insert a chest tube to rule out hemothorax
- B. Administer an additional 2 liters of crystalloid
- C. Obtain a CT scan of the abdomen and pelvis with IV contrast
- D. Transfuse O-negative packed red blood cells and prepare for emergency laparotomy (Correct Answer)
- E. Perform diagnostic peritoneal lavage to confirm hemoperitoneum
Explanation: ***Transfuse O-negative packed red blood cells and prepare for emergency laparotomy*** - The patient is in **hemorrhagic shock** and is a **transient responder** to initial fluids; she requires immediate **blood products** and surgical control of bleeding. - A **positive FAST** (fluid in Morrison's pouch) in a **hemodynamically unstable** trauma patient is a definitive indication for **emergency laparotomy**. *Insert a chest tube to rule out hemothorax* - The **FAST exam** has already identified a likely source of bleeding in the **abdomen**, making the chest a secondary concern for primary shock management. - While important in primary survey, clinical signs like **hypotension** and a positive abdominal FAST prioritize the abdomen over an undiagnosed hemothorax. *Administer an additional 2 liters of crystalloid* - Modern **ATLS guidelines** advocate for **balanced resuscitation** and limiting crystalloids to avoid **dilutional coagulopathy**. - Persistent hypotension after an initial fluid bolus (typically 1 liter) indicates the need for **blood transfusion**, not more salt water. *Obtain a CT scan of the abdomen and pelvis with IV contrast* - **CT scans** are strictly contraindicated in **hemodynamically unstable** patients because they must not leave the resuscitation area. - This patient is **unstable** (BP 85/50) and a **transient responder**, meaning surgical intervention must precede advanced imaging. *Perform diagnostic peritoneal lavage to confirm hemoperitoneum* - **DPL** is unnecessary here because the **FAST exam** has already confirmed the presence of **intraperitoneal fluid**. - Both FAST and DPL serve the same purpose in the ATLS algorithm; once one is **positive** in an unstable patient, the next step is surgery.
Question 10: A 28-year-old man is brought to the emergency department following a motor vehicle collision. He is unresponsive with a Glasgow Coma Scale score of 7. His blood pressure is 90/60 mmHg, heart rate is 120/min, and respiratory rate is 8/min with shallow breaths. He has bruising over the left chest wall and decreased breath sounds on the left side. According to ATLS protocols, what is the most appropriate immediate management?
- A. Administer 2 liters of crystalloid fluid bolus
- B. Perform FAST examination to assess for intra-abdominal bleeding
- C. Obtain chest X-ray to confirm diagnosis
- D. Perform endotracheal intubation with cervical spine precautions (Correct Answer)
- E. Insert a needle decompression in the second intercostal space
Explanation: ***Perform endotracheal intubation with cervical spine precautions*** - According to **ATLS protocols**, the primary survey follows the **A-B-C-D-E** sequence, where **Airway** with cervical spine protection is the first priority. - A **Glasgow Coma Scale (GCS)** score of **8 or less** (this patient has 7) is a definitive indication for securing the airway via **endotracheal intubation**. *Administer 2 liters of crystalloid fluid bolus* - Management of **Circulation (C)** comes after ensuring a patent Airway (A) and adequate Breathing (B). - Current ATLS guidelines emphasize **balanced resuscitation** or smaller boluses (e.g., 1L) rather than immediate large-volume crystalloids to avoid **dilutional coagulopathy**. *Perform FAST examination to assess for intra-abdominal bleeding* - The **FAST exam** is a component of the **Circulation (C)** phase and is used to identify the source of shock, but it must not delay airway management. - **Airway (A)** and **Breathing (B)** concerns, such as the patient's GCS of 7 and low respiratory rate, must be addressed first. *Obtain chest X-ray to confirm diagnosis* - Imaging like a **Chest X-ray** is an adjunct to the primary survey and should only be performed after initial life-saving interventions (**A-B-C**). - Clinical signs of airway compromise and inadequate ventilation take precedence over radiological confirmation of thoracic injuries. *Insert a needle decompression in the second intercostal space* - While the patient has signs of thoracic trauma, **Airway (A)** management is the very first step before addressing **Breathing (B)** issues like a potential tension pneumothorax. - Needle decompression is indicated for clinical **tension pneumothorax**, but the patient's immediate inability to protect his airway (GCS < 8) makes intubation the absolute first priority.
Question 11: A 17-year-old male is brought to the emergency department following a motor vehicle accident. He has suffered several wounds and is minimally responsive. There is a large laceration on his forehead as well as a fracture of his nasal bridge. He appears to be coughing and spitting blood. He is already wearing a soft collar. Vitals are as follows: T 36.4C, BP 102/70 mmHg, HR 126 bpm, RR 18/min, and SpO2 is 88% on RA. He has 2 peripheral IVs and received 2L of IV normal saline on route to the hospital. There is frank blood in the oropharynx. Breath sounds are present bilaterally. Abdomen is distended and tender. Pulses are 1+. Which of the following should be the first step in management?
- A. Focused Assessment with Sonography for Trauma (FAST) scan
- B. Type and screen for matched blood transfusion
- C. Blood transfusion with unmatched blood
- D. Cricothyroidotomy
- E. Orotracheal intubation (Correct Answer)
Explanation: ***Orotracheal intubation*** - The patient has suffered multiple traumas, including facial fractures, and is minimally responsive with frank blood in the oropharynx, indicating a **compromised airway**. His SpO2 of 88% on room air is also an indicator that the patient needs immediate assistance with oxygenation. - Ensuring a **patent airway** and adequate ventilation is the first priority in trauma management, following the **ABCDE (Airway, Breathing, Circulation, Disability, Exposure)** approach. *Focused Assessment with Sonography for Trauma (FAST) scan* - While a FAST scan is crucial for evaluating internal bleeding in a trauma patient with abdominal distension and tenderness, it addresses **Circulation** issues, which, in the ABCDE approach, come after addressing the airway and breathing. - Doing a FAST scan first, delaying airway management, could lead to further **hypoxia and irreversible brain damage**. *Type and screen for matched blood transfusion* - This is an important step in managing a patient with potential significant blood loss (indicated by the distended abdomen, tachycardia, and weak pulses). However, it is part of managing **Circulation** and takes time. - Airway management and immediate resuscitation measures take **precedence over waiting for matched blood**, especially when the patient is hypoxic. *Blood transfusion with unmatched blood* - Administering unmatched blood (e.g., O negative) is a critical intervention for severe hemorrhage and hemodynamic instability. The patient's tachycardia, weak pulses, and distended abdomen suggest significant blood loss, which would indicate starting a transfusion as soon as possible. - However, establishing an **adequate airway and ensuring oxygenation** is a more immediate life-saving step, as hypoxia can quickly lead to irreversible damage. *Cricothyroidotomy* - **Cricothyroidotomy** is indicated for a definitive airway when orotracheal intubation is either impossible or contraindicated, particularly in cases of severe facial trauma or upper airway obstruction. - While the patient has facial trauma and blood in the oropharynx, **orotracheal intubation is still the preferred initial method** for airway management unless it's explicitly stated to be impossible.
Question 12: A 19-year-old man is rushed to the emergency department 30 minutes after diving head-first into a shallow pool of water from a cliff. He was placed on a spinal board and a rigid cervical collar was applied by the emergency medical technicians. On arrival, he is unconscious and withdraws all extremities to pain. His temperature is 36.7°C (98.1°F), pulse is 70/min, respirations are 8/min, and blood pressure is 102/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. The pupils are equal and react sluggishly to light. There is a 3-cm (1.2-in) laceration over the forehead. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. There is a step-off palpated over the cervical spine. Which of the following is the most appropriate next step in management?
- A. Rapid sequence intubation (Correct Answer)
- B. CT scan of the spine
- C. X-ray of the cervical spine
- D. MRI of the spine
- E. Rectal tone assessment
Explanation: ***Rapid sequence intubation*** - The patient has a **compromised airway** due to very shallow respirations (8/min), indicating impending respiratory failure, which is prioritized in the management of trauma patients. - Due to the high suspicion of a **cervical spine injury** (diving into a shallow pool, step-off palpable over the cervical spine), **rapid sequence intubation** is the safest way to secure the airway while maintaining **cervical spine immobilization**. *CT scan of the spine* - Imaging studies of the spine are important for diagnosis but must be performed **after securing the airway** and stabilizing vital functions. - While a CT scan is the preferred imaging modality for evaluating bony spinal trauma, it does not address the immediate life-threatening issue of respiratory insufficiency. *X-ray of the cervical spine* - X-rays are less sensitive for detecting all types of cervical spine injuries, especially ligamentous damage, compared to CT or MRI. - As with other imaging, it should be done **after airway management** is secured. *MRI of the spine* - MRI is excellent for evaluating **soft tissue structures** like spinal cord, ligaments, and discs, and is generally performed after initial stabilization and CT for bony injury. - It is not an immediate diagnostic priority when the patient's airway and breathing are acutely compromised. *Rectal tone assessment* - This assessment is part of the neurological examination to evaluate for spinal cord injury, specifically involving the **sacral segments**. - While important for comprehensive neurological assessment, it is not the most appropriate *next step* when the patient has critical airway and breathing compromise.
Question 13: A 45-year-old female presents to the emergency room as a trauma after a motor vehicle accident. The patient was a restrained passenger who collided with a drunk driver traveling approximately 45 mph. Upon impact, the passenger was able to extricate herself from the crushed car and was sitting on the ground at the scene of the accident. Her vitals are all stable. On physical exam, she is alert and oriented, speaking in complete sentences with a GCS of 15. She has a cervical spine collar in place and endorses exquisite cervical spine tenderness on palpation. Aside from her superficial abrasions on her right lower extremity, the rest of her examination including FAST exam is normal. Rapid hemoglobin testing is within normal limits. What is the next best step in management of this trauma patient?
- A. Remove the patient’s cervical collar immediately
- B. Discharge home and start physical therapy
- C. Initiate rapid sequence intubation.
- D. Consult neurosurgery immediately
- E. CT cervical spine (Correct Answer)
Explanation: ***CT cervical spine*** - Given the patient's **mechanism of injury** (motor vehicle accident at 45 mph) and **cervical spine tenderness**, a CT cervical spine is the most appropriate next step to rule out a fracture or other significant injury. - While the patient is alert and stable, the presence of **exquisite tenderness** mandates imaging to ensure no occult injury is missed that could lead to neurological compromise. *Remove the patient’s cervical collar immediately* - Removing the cervical collar prematurely in a trauma patient with cervical spine tenderness is dangerous, as it could lead to further damage if an **unstable fracture** is present. - The collar should remain in place until imaging has ruled out a clinically significant cervical spine injury. *Discharge home and start physical therapy* - Discharging a patient with **cervical spine tenderness** after a high-impact motor vehicle accident without imaging is inappropriate and could result in severe consequences if an injury is present. - Physical therapy would only be considered after a thorough workup has cleared any acute injury. *Initiate rapid sequence intubation.* - **Rapid sequence intubation (RSI)** is used for airway management in patients with impending or actual respiratory failure or inability to protect their airway. - This patient is alert, speaking in complete sentences, has a GCS of 15, and stable vitals, indicating **no immediate need for intubation**. *Consult neurosurgery immediately* - While a neurosurgery consult may be necessary if an injury is identified, the immediate next step is to **diagnose the injury** with imaging. - Consulting neurosurgery without definitive imaging results would be premature in this stable patient.
Question 14: A 45-year-old man was a driver in a motor vehicle collision. The patient is not able to offer a medical history during initial presentation. His temperature is 97.6°F (36.4°C), blood pressure is 104/74 mmHg, pulse is 150/min, respirations are 12/min, and oxygen saturation is 98% on room air. On exam, he does not open his eyes, he withdraws to pain, and he makes incomprehensible sounds. He has obvious signs of trauma to the chest and abdomen. His abdomen is distended and markedly tender to palpation. He also has an obvious open deformity of the left femur. What is the best initial step in management?
- A. Emergency open fracture repair
- B. Packed red blood cells
- C. Exploratory laparotomy
- D. Intubation (Correct Answer)
- E. 100% oxygen
Explanation: ***Intubation*** - The patient's **Glasgow Coma Scale (GCS) score is 7** (E=1, V=2, M=4), which is below 8 and indicates a severe head injury needing **airway protection** via intubation. - A GCS ≤ 8 mandates **definitive airway management** to prevent aspiration and ensure adequate ventilation. *Emergency open fracture repair* - While the patient has an open femur fracture, it is not the most immediate life-threatening concern after a major trauma; **airway and breathing** take precedence. - **Hemorrhage control** and **stabilization** often precede definitive orthopedic repair in polytrauma. *Packed red blood cells* - Although the patient is likely in **hemorrhagic shock** (tachycardia, hypotension, obvious trauma), administering blood products without first securing the airway is not the initial priority. - **Circulation** management, including fluid resuscitation and blood products, follows **airway and breathing** establishment. *Exploratory laparotomy* - The patient's distended and tender abdomen strongly suggests intra-abdominal injury, but this is a **diagnostic and therapeutic procedure** that comes after initial resuscitation and stabilization. - **Emergent laparotomy** for abdominal trauma is considered once the patient's airway, breathing, and circulation are secured. *100% oxygen* - Administering 100% oxygen is part of initial resuscitation, but it does not address the fundamental problem of an unsecured airway and the risk of **hypoventilation** or **aspiration** in a patient with a GCS of 7. - Oxygen supplementation helps improve saturation in spontaneously breathing patients but cannot protect a compromised airway.
Practice by Chapter
Primary survey (ABCDE)
Practice Questions
Airway management in trauma
Practice Questions
Breathing assessment and management
Practice Questions
Circulation assessment and hemorrhage control
Practice Questions
Disability assessment (neurological status)
Practice Questions
Exposure and environmental control
Practice Questions
Secondary survey principles
Practice Questions
Trauma imaging principles
Practice Questions
Trauma team organization
Practice Questions
Mass casualty triage
Practice Questions
Trauma in special populations (pediatric, geriatric)
Practice Questions
Trauma scoring systems
Practice Questions
Trauma quality improvement
Practice Questions
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free