ATLS Hemorrhage Control and Damage Control Surgery 2 — Questions and Answers
Question 1: To maximize benefit in traumatic hemorrhage, tranexamic acid (TXA) should be administered:
- Within 3 hours of injury, with the first dose given as early as possible (Correct answer)
- Only after 24 hours when coagulopathy is confirmed by laboratory values
- Exclusively in penetrating trauma patients with TBI
- As a slow continuous infusion without an initial loading dose
Correct answer: Within 3 hours of injury, with the first dose given as early as possible
Evidence from the CRASH-2 trial shows TXA is most effective within 3 hours of injury; benefit decreases with time and may be harmful if given after 3 hours.
Question 2: Which hemostatic dressing is recommended by ATLS guidelines for uncontrolled external extremity hemorrhage not amenable to tourniquet?
- Standard dry gauze with firm direct pressure alone
- Combat gauze (kaolin-impregnated) or similar zeolite/chitosan-based hemostatic agent (Correct answer)
- Petroleum-impregnated gauze to keep the wound moist
- Silver-impregnated antimicrobial dressings
Correct answer: Combat gauze (kaolin-impregnated) or similar zeolite/chitosan-based hemostatic agent
ATLS recommends hemostatic dressings such as kaolin-impregnated combat gauze or chitosan-based products packed firmly into wounds that cannot be controlled with a tourniquet.
Question 3: A patient with an unstable pelvic ring fracture and hemodynamic instability should initially receive:
- Immediate surgical exploration of the retroperitoneum
- Pelvic binder or circumferential sheet wrap for provisional stabilization (Correct answer)
- Greater than 2 liters of crystalloid to restore blood pressure before any intervention
- CT pelvis with contrast prior to any mechanical intervention
Correct answer: Pelvic binder or circumferential sheet wrap for provisional stabilization
A pelvic binder or sheet wrap reduces pelvic volume, tamponades venous bleeding, and stabilizes the fracture as the critical first step before imaging or surgery.
Question 4: When REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) is placed in Zone 1, it is used to address hemorrhage from:
- Isolated pelvic venous bleeding below the aortic bifurcation
- Intra-abdominal and thoracoabdominal hemorrhage above the celiac axis (Correct answer)
- Extremity arterial injuries distal to the femoral vessels
- Carotid and subclavian artery injuries in the neck
Correct answer: Intra-abdominal and thoracoabdominal hemorrhage above the celiac axis
Zone 1 REBOA placement (descending thoracic aorta) controls hemorrhage from abdominal solid organs and major vessels by occluding aortic flow above the bleeding site.
Question 5: A tourniquet applied to control extremity hemorrhage should be positioned:
- As close to the wound as possible to minimize ischemic tissue
- 2–3 inches proximal to the wound with sufficient pressure to obliterate the distal pulse (Correct answer)
- At the most distal point of the limb for greatest mechanical advantage
- Removed and re-applied every 30 minutes to prevent limb ischemia
Correct answer: 2–3 inches proximal to the wound with sufficient pressure to obliterate the distal pulse
Tourniquets must be placed proximal to the injury and tightened enough to eliminate the distal pulse, ensuring arterial hemorrhage is controlled.
Question 6: Which temporary abdominal closure technique is most commonly used after damage control laparotomy?
- Primary fascial closure with running PDS suture
- Negative pressure wound therapy (vacuum-assisted closure device) (Correct answer)
- Simple skin stapling without fascial approximation
- No closure at all — the abdomen is left open without coverage
Correct answer: Negative pressure wound therapy (vacuum-assisted closure device)
Negative pressure wound therapy (VAC) is the preferred temporary abdominal closure after DCS as it manages fluid, prevents fascial retraction, and facilitates reoperation.
Question 7: Class III hemorrhage (30–40% blood volume loss) is most characteristically associated with which clinical findings?
- Normal heart rate and blood pressure with mild anxiety
- Tachycardia, decreased pulse pressure, altered mental status, and decreased urine output (Correct answer)
- Bradycardia, hypertension, and respiratory depression (Cushing's response)
- Loss of consciousness with otherwise normal vital signs
Correct answer: Tachycardia, decreased pulse pressure, altered mental status, and decreased urine output
Class III hemorrhage (1,500–2,000 mL) produces marked tachycardia, narrow pulse pressure, anxiety or confusion, and decreased urine output reflecting organ hypoperfusion.
ATLS Hemorrhage Control and Damage Control Surgery 2
To maximize benefit in traumatic hemorrhage, tranexamic acid (TXA) should be administered: