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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 bodys 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 doesnt
follow commands, but he does moan periodically.
His right arm is deformed, and doesnt 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 36,5C
(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 doesnt 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 mans 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 patients
family

38. Hemorrhage of 20% 0f the patients 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