ITLS - International Trauma Life Support Exam — Questions and Answers

Question 1: Following blunt abdominal trauma in a pregnant patient, which of the following is the most common serious pregnancy-specific complication that can lead to fetal distress or demise?

Premature rupture of membranes
Direct fetal injury
Placental abruption (Correct answer)
Uterine rupture

Correct answer: Placental abruption

Placental abruption, the premature separation of the placenta from the uterine wall, is the most common cause of fetal death following maternal trauma in which the mother survives. [4, 7] The shearing forces from trauma can cause this separation, disrupting oxygen and nutrient supply to the fetus. [15]

Question 2: What clinical signs indicate Cushing's triad, and what does it signify?

JVD, muffled heart sounds, and hypotension indicating cardiac tamponade
Fever, neck rigidity, and altered mental status indicating meningitis
Tachycardia, hypotension, and tachypnea indicating hemorrhagic shock
Hypertension, bradycardia, and irregular respirations indicating critically elevated intracranial pressure (Correct answer)

Correct answer: Hypertension, bradycardia, and irregular respirations indicating critically elevated intracranial pressure

Cushing's triad (hypertension, bradycardia, irregular respirations) is a late and ominous sign of critically elevated ICP with impending brainstem herniation, requiring immediate intervention.

Question 3: A 28-year-old male has a deep, actively bleeding laceration to his right upper arm after an industrial accident. Direct pressure has failed to control the severe arterial bleeding. What is the most appropriate next step according to ITLS guidelines?

Apply a hemostatic agent and continue direct pressure.
Immediately apply a tourniquet proximal to the wound. (Correct answer)
Establish IV access and begin rapid fluid resuscitation.
Initiate rapid transport and apply pressure during transit.

Correct answer: Immediately apply a tourniquet proximal to the wound.

For life-threatening extremity hemorrhage that is not controlled by direct pressure, the immediate application of a tourniquet is the next critical intervention to stop the blood loss. ITLS emphasizes a 'C-ABC' approach, prioritizing catastrophic hemorrhage control before airway and breathing.

Question 4: How do you calculate appropriate fluid resuscitation volumes for a pediatric trauma patient?

Give the same volumes as an adult
Give 10 mL/kg per hour as a continuous infusion
Administer 20 mL/kg isotonic crystalloid boluses, reassessing after each bolus, with consideration for blood products after 40-60 mL/kg without improvement (Correct answer)
Use the Parkland formula for all pediatric trauma

Correct answer: Administer 20 mL/kg isotonic crystalloid boluses, reassessing after each bolus, with consideration for blood products after 40-60 mL/kg without improvement

Pediatric fluid resuscitation uses weight-based dosing: 20 mL/kg boluses of isotonic crystalloid (normal saline or lactated Ringer's), reassessing clinical response after each. If no improvement after 2-3 boluses (40-60 mL/kg), blood transfusion is indicated.

Question 5: What is the difference between a rapid trauma survey and a focused assessment in ITLS, and when is each performed?

The rapid trauma survey is only for unresponsive patients
The rapid trauma survey is a systematic head-to-toe evaluation for unstable or significant-mechanism patients; the focused assessment targets specific injury sites in stable patients with isolated mechanisms (Correct answer)
They are the same assessment performed at different speeds
The focused assessment is always more thorough than the rapid trauma survey

Correct answer: The rapid trauma survey is a systematic head-to-toe evaluation for unstable or significant-mechanism patients; the focused assessment targets specific injury sites in stable patients with isolated mechanisms

ITLS uses two assessment pathways based on patient stability and mechanism: the rapid trauma survey (complete head-to-toe for unstable/significant mechanism) and the focused assessment (targeted evaluation for stable patients with isolated, minor mechanisms).

Question 6: A patient struck in the head with a baseball bat initially loses consciousness, then regains awareness and appears lucid for 30 minutes before rapidly deteriorating. What type of intracranial hemorrhage is most likely?

Intracerebral hemorrhage
Subarachnoid hemorrhage
Subdural hematoma
Epidural hematoma (Correct answer)

Correct answer: Epidural hematoma

An epidural hematoma, typically from tearing of the middle meningeal artery by a temporal bone fracture, classically presents with a 'lucid interval' followed by rapid neurological decline as the arterial bleed expands.

Question 7: Why is the cervical spine of elderly patients more vulnerable to injury, even from low-energy mechanisms?

Elderly patients have more flexible cervical spines that are prone to hyperextension
Degenerative changes (osteoarthritis, spinal stenosis, disc disease) create a rigid, brittle spine with a narrowed spinal canal (Correct answer)
Elderly patients have larger, heavier heads
Cervical spine injuries only occur with high-energy mechanisms regardless of age

Correct answer: Degenerative changes (osteoarthritis, spinal stenosis, disc disease) create a rigid, brittle spine with a narrowed spinal canal

Age-related degenerative changes make the cervical spine rigid and brittle, while spinal stenosis narrows the canal, meaning even minor forces can cause fractures and spinal cord compression.

Question 8: In advanced trauma life support, why is succinylcholine used cautiously in patients with crush injuries older than 24-48 hours?

It has no paralytic effect on crushed muscles
It worsens rhabdomyolysis by increasing muscle contraction
It causes malignant hyperthermia in all crush injury patients
It can trigger fatal hyperkalemia from damaged muscle tissue (Correct answer)

Correct answer: It can trigger fatal hyperkalemia from damaged muscle tissue

In crush injuries older than 24-48 hours, damaged muscle develops extrajunctional acetylcholine receptors that, when activated by succinylcholine, release massive amounts of potassium, potentially causing fatal cardiac arrhythmias.

Question 9: A construction worker has cement powder mixed with water on both arms for 30 minutes. What makes cement burns unique in their management?

Cement burns are superficial and require minimal treatment
Cement is alkaline and causes progressive liquefactive necrosis requiring prolonged irrigation (Correct answer)
Cement only burns when mixed with organic solvents
Cement requires neutralization with vinegar before irrigation

Correct answer: Cement is alkaline and causes progressive liquefactive necrosis requiring prolonged irrigation

Cement (calcium hydroxide) is a strong alkali. Unlike acid burns that coagulate tissue (creating a barrier), alkali burns cause liquefactive necrosis that allows the chemical to penetrate progressively deeper, requiring extended irrigation.

Question 10: A 75-year-old patient with multiple rib fractures is at a significantly higher risk for developing pneumonia compared to a younger patient primarily because of:

A blunted inflammatory response that cannot fight infection.
Decreased chest wall compliance and an ineffective cough leading to atelectasis. (Correct answer)
A pre-existing higher likelihood of having a smoking history.
An increased probability that the fractured ribs will puncture the lung.

Correct answer: Decreased chest wall compliance and an ineffective cough leading to atelectasis.

Geriatric patients have reduced pulmonary reserve and weaker respiratory muscles. Pain from rib fractures causes shallow breathing (splinting) and suppresses the cough reflex. This combination impairs the clearing of secretions, leading to atelectasis (alveolar collapse), which provides an ideal environment for the development of pneumonia.

Question 11: In ITLS Basic, which of the following patients meets criteria for rapid transport to a trauma center?

A patient with a sprained ankle from a ground-level fall
A patient with an isolated wrist fracture and stable vitals
A patient with a superficial laceration to the forearm
A patient with a penetrating wound to the abdomen (Correct answer)

Correct answer: A patient with a penetrating wound to the abdomen

Penetrating wounds to the torso are a physiologic and mechanism-based indicator for rapid transport to a trauma center per ITLS guidelines.

Question 12: In the context of maternal trauma, which finding is the most critical indicator that fetal perfusion is likely compromised?

A fundal height smaller than expected for gestational age
Presence of uterine contractions
Maternal tachycardia
Maternal hypotension (Correct answer)

Correct answer: Maternal hypotension

Uterine blood flow is directly dependent on the mother's blood pressure and cardiac output; it is not autoregulated. [27, 28] Therefore, maternal hypotension is a critical sign that blood is being shunted away from the uterus to preserve the mother's vital organs, severely compromising fetal perfusion and oxygenation. Fetal distress is often an early sign of maternal shock. [28]

Question 13: When managing a 78-year-old trauma patient, which of the following principles is most important to consider?

The mechanism of injury is the most reliable predictor of injury severity.
Geriatric patients require larger volumes of IV fluids to compensate for dehydration.
A normal blood pressure reading reliably rules out the presence of shock.
A ground-level fall should be treated with a high index of suspicion for severe injury. (Correct answer)

Correct answer: A ground-level fall should be treated with a high index of suspicion for severe injury.

Due to factors like osteoporosis, decreased physiologic reserve, and the presence of comorbidities, a seemingly minor mechanism like a ground-level fall can cause life-threatening injuries (e.g., pelvic fractures, intracranial hemorrhage) in the elderly. Therefore, providers must maintain a high index of suspicion.

Question 14: In the assessment of a pediatric trauma patient, which finding should be considered a more significant indicator of shock compared to an adult patient?

Hypotension.
Slow capillary refill.
Altered mental status.
Tachycardia. (Correct answer)

Correct answer: Tachycardia.

Children can maintain their blood pressure for a longer period during shock due to a robust compensatory mechanism. Tachycardia is often one of the earliest and most reliable signs of shock in a pediatric patient. Hypotension is a late and ominous sign, indicating decompensated shock.

Question 15: According to ITLS guidelines, what is the recommended time frame for administering Tranexamic Acid (TXA) to a trauma patient with significant hemorrhage for maximum effectiveness?

As soon as possible, but no later than 3 hours after injury. (Correct answer)
Only after arrival at the trauma center.
Preferably between 3 and 6 hours post-injury.
Within 8 hours of the injury.

Correct answer: As soon as possible, but no later than 3 hours after injury.

ITLS guidelines, supported by major trauma studies like CRASH-2, recommend administering TXA as early as possible to patients with significant hemorrhage. The evidence shows that its effectiveness in reducing mortality diminishes over time and it may be harmful if given more than 3 hours after the injury occurs.

Question 16: A 7-year-old falls off his bicycle, striking the handlebar directly into his upper abdomen. He is now tachycardic, pale, and has significant epigastric tenderness. In pediatric blunt abdominal trauma, which solid organ is most frequently injured?

Spleen (Correct answer)
Pancreas
Kidneys
Bladder

Correct answer: Spleen

In pediatric blunt abdominal trauma, the solid organs are most at risk. The spleen and liver are the most commonly injured organs due to their size and location. The spleen is particularly vulnerable because of its rich blood supply and relatively unprotected position in the left upper quadrant.

Question 17: A 2-year-old has symmetric bilateral rib fractures in various stages of healing along with retinal hemorrhages. What should the ITLS provider consider?

The child has brittle bone disease
The child was in a car seat during a single accident
Non-accidental trauma (child abuse) should be strongly suspected based on the injury pattern inconsistent with a single accidental event (Correct answer)
These are normal findings in active toddlers

Correct answer: Non-accidental trauma (child abuse) should be strongly suspected based on the injury pattern inconsistent with a single accidental event

Bilateral rib fractures in various stages of healing indicate repetitive trauma over time, and retinal hemorrhages are strongly associated with abusive head trauma. This injury pattern is inconsistent with any single accidental mechanism.

Question 18: What is the single most important prehospital intervention for a hemodynamically unstable patient with suspected significant intra-abdominal hemorrhage following blunt trauma?

Performing a detailed abdominal assessment to locate the source of pain.
Initiating two large-bore IVs and rapidly infusing 2 liters of crystalloid.
Applying a pneumatic anti-shock garment (PASG).
Minimizing on-scene time and ensuring rapid transport to a trauma center. (Correct answer)

Correct answer: Minimizing on-scene time and ensuring rapid transport to a trauma center.

Definitive care for significant intra-abdominal hemorrhage is surgical intervention to stop the bleeding. While initiating IV access and treating shock are important, they are supportive measures. The most critical action in the prehospital setting is to recognize the life threat and transport the patient without delay to a facility capable of performing surgery. Prolonged on-scene time for procedures that do not stop the bleeding increases mortality.

Question 19: Routine use of hyperventilation in the traumatic brain injury (TBI) patient will:

cause vasoconstriction and increased cerebral ischemia. (Correct answer)
cause peripheral hypoxia and cyanosis.
cause an increase of end-tidal CO2.
cause vasodilation and decreased intracranial pressure (ICP).

Correct answer: cause vasoconstriction and increased cerebral ischemia.

Explanation: Hyperventilation has only a slight effect on brain swelling, but causes a significant decrease in cerebral perfusion from that same vasoconstriction, resulting in cerebral hypoxia. Thus, both hyperventilation and hypoventilation can cause cerebral ischemia and increased mortality in the TBI patient.

Question 20: Which of the following findings would not make a patient difficult to ventilate with a bag-valve mask?

Elderly patient
Beard
Multiple nose piercings (Correct answer)
Obesity

Correct answer: Multiple nose piercings

Explanation: Predictors of difficult mask ventilation can be remembered using the “BOOTS” mnemonic: B – Beards O – Obesity O – Older patients T – Toothlessness S – Snores or stridor

Question 21: What is the lethal triad of trauma, and why does it create a vicious cycle?

Tachycardia, hypotension, and altered mental status
Pain, anxiety, and confusion
Hemorrhage, infection, and organ failure
Hypothermia, acidosis, and coagulopathy—each worsens the other two, creating a self-reinforcing downward spiral toward death (Correct answer)

Correct answer: Hypothermia, acidosis, and coagulopathy—each worsens the other two, creating a self-reinforcing downward spiral toward death

The lethal triad (hypothermia, acidosis, coagulopathy) creates a self-perpetuating cycle: hemorrhage causes hypothermia and acidosis, both impair clotting, worsened coagulopathy increases hemorrhage, which deepens hypothermia and acidosis.

Question 22: The 'expectant' triage category is most appropriately applied when:

Unlimited resources are available and all patients can receive treatment
A patient verbally refuses triage and treatment on scene
Resources are overwhelmed and a patient's survival probability is extremely low even with treatment (Correct answer)
A patient is confirmed deceased with obvious signs of death only

Correct answer: Resources are overwhelmed and a patient's survival probability is extremely low even with treatment

The expectant category is reserved for patients with unsurvivable injuries when resources are limited, reflecting the MCI principle of doing the most good for the most patients.

Question 23: In the START triage system, what is the first action taken upon arriving at a multiple-casualty scene?

Direct patients who can walk to move to a designated area (Correct answer)
Check all patients for radial pulses
Establish an incident command post
Immediately treat the most critically injured patient

Correct answer: Direct patients who can walk to move to a designated area

START triage begins by directing ambulatory patients to walk to a designated area, quickly categorizing them as 'minor' and freeing rescuers to assess more critical patients.

Question 24: A 10-year-old falls from a tree (15 feet) and is complaining of abdominal pain. Vitals show HR 140, BP 90/60, RR 28. What does the tachycardia and borderline blood pressure indicate in this pediatric patient?

Mild hypovolemia that will resolve without treatment
Pain-related tachycardia with no hemodynamic significance
Significant hemorrhage with decompensating shock—children maintain blood pressure until they have lost 30-40% of blood volume, so hypotension indicates a critical state (Correct answer)
Normal vital signs for an anxious 10-year-old

Correct answer: Significant hemorrhage with decompensating shock—children maintain blood pressure until they have lost 30-40% of blood volume, so hypotension indicates a critical state

In children, blood pressure is maintained until very late in shock (30-40% volume loss). A BP of 90/60 with tachycardia in a 10-year-old with abdominal pain after a significant fall indicates decompensating hemorrhagic shock requiring immediate aggressive intervention.

Question 25: In START triage, failure to follow simple commands after airway and circulatory assessment indicates the patient should be classified as:

Immediate (red) (Correct answer)
Minor (green)
Expectant (black)
Delayed (yellow)

Correct answer: Immediate (red)

Failure to follow simple commands indicates altered mental status, which classifies the patient as immediate (red) in the START algorithm.

Question 26: A patient has a severe bleeding wound in the left axilla (armpit) region that cannot be controlled with direct pressure. Which hemorrhage control technique is most appropriate for this junctional injury?

Applying a pelvic binder.
Application of a standard tourniquet high on the arm.
Placing the patient in the Trendelenburg position.
Wound packing with a hemostatic agent. (Correct answer)

Correct answer: Wound packing with a hemostatic agent.

Junctional hemorrhage occurs where limbs or the head join the torso (e.g., axilla, groin, neck). Standard tourniquets are ineffective in these areas. The appropriate ITLS-recommended technique is to pack the wound tightly with a hemostatic dressing, followed by direct pressure.

Question 27: A patient dove into shallow water and has quadriplegia with loss of sensation below the clavicles. At what spinal level is the injury most likely?

L1-L2
T1-T2
C5-C6
C3-C4 (Correct answer)

Correct answer: C3-C4

Quadriplegia with a sensory level at the clavicles corresponds to the C3-C4 dermatome. The clavicle is innervated by the C3-C4 supraclavicular nerves.

Question 28: A patient rescued from a house fire has singed nasal hairs, hoarseness, and carbonaceous sputum. What should the ITLS provider anticipate?

Smoke inhalation without airway compromise
Third-degree burns to the lungs
Impending upper airway obstruction from thermal injury (Correct answer)
Carbon monoxide poisoning only

Correct answer: Impending upper airway obstruction from thermal injury

Singed nasal hairs, hoarseness, and carbonaceous sputum are classic signs of thermal inhalation injury, which causes progressive upper airway edema that can lead to complete obstruction within hours.

Question 29: How do you identify and manage a flail chest with underlying pulmonary contusion in the prehospital setting?

Tape the flail segment to the adjacent chest wall
Identify paradoxical movement on inspection, provide high-flow oxygen, consider positive pressure ventilation for respiratory failure, position with injured side down if possible, and avoid fluid overload (Correct answer)
Apply tight circumferential bandaging to stabilize the chest
Flail chest requires immediate surgical fixation in the field

Correct answer: Identify paradoxical movement on inspection, provide high-flow oxygen, consider positive pressure ventilation for respiratory failure, position with injured side down if possible, and avoid fluid overload

Flail chest is identified by paradoxical chest wall movement. Treatment focuses on managing the underlying pulmonary contusion: oxygen, positive pressure ventilation when needed (which also internally splints the flail), positioning, and judicious fluid management.

Question 30: Which of the following is considered one of the four essential components to maintain normal perfusion?

SaO2 levels
ETCO2 levels
Fluid levels (Correct answer)
Serum lactate levels

Correct answer: Fluid levels

Explanation: It is important to remember that blood pressure requires a “steady state” activity of all the preceding factors. The heart must be pumping, the blood volume must be adequate, the blood vessels must be intact, and the lungs must be oxygenating the blood.

Question 31: What is the appropriate size endotracheal tube for a 6-year-old child, and how is it calculated?

Use the same size as the child's little finger diameter
All children under 8 get a 4.0 mm tube
Always use a 3.0 mm tube for children
Use the formula (age/4) + 4 for uncuffed tubes, giving a 5.5 mm tube; or (age/4) + 3.5 for cuffed tubes, giving a 5.0 mm cuffed tube (Correct answer)

Correct answer: Use the formula (age/4) + 4 for uncuffed tubes, giving a 5.5 mm tube; or (age/4) + 3.5 for cuffed tubes, giving a 5.0 mm cuffed tube

ETT size is calculated using (age/4) + 4 for uncuffed tubes or (age/4) + 3.5 for cuffed tubes. For a 6-year-old: (6/4) + 4 = 5.5 mm uncuffed, or (6/4) + 3.5 = 5.0 mm cuffed.

Question 32: The primary purpose of establishing a Casualty Collection Point (CCP) during a MCI is to:

Gather and sort casualties for organized evaluation and transport (Correct answer)
Serve as the incident command post for scene management
Provide definitive surgical care to all patients on scene
Store medical equipment and pharmaceutical supplies

Correct answer: Gather and sort casualties for organized evaluation and transport

A Casualty Collection Point is a designated area where casualties are gathered, reassessed, and prepared for organized transport to medical facilities.

Question 33: A patient involved in a motorcycle crash has a fractured pelvis and blood at the urethral meatus. What does this combination suggest, and what precaution must be taken?

Insert a Foley catheter immediately to drain urine
Pelvic fractures do not cause urological injuries
Urethral injury is likely; do NOT insert a urinary catheter as it may convert a partial tear to a complete disruption or create a false passage (Correct answer)
The blood is from an external wound and can be cleaned

Correct answer: Urethral injury is likely; do NOT insert a urinary catheter as it may convert a partial tear to a complete disruption or create a false passage

Blood at the urethral meatus in the setting of pelvic fracture strongly suggests urethral injury. Catheter insertion is contraindicated as it can worsen the injury, convert a partial tear to complete disruption, or create a false passage into surrounding tissues.

Question 34: During the secondary survey of a 38-week pregnant trauma patient, you note sudden relief of her abdominal pain, diffuse rigidity across the entire abdomen, fetal parts palpable through the abdominal wall, and absent fetal heart tones. Which condition does this presentation most likely represent?

Severe preterm labor with rapid cervical dilation
Placental abruption with concealed hemorrhage
Placenta previa with active bleeding
Uterine rupture (Correct answer)

Correct answer: Uterine rupture

Uterine rupture is characterized by a sudden 'pop' or relief of pain as uterine wall integrity fails, followed by diffuse peritoneal irritation as blood and fetal contents spill into the abdomen. Fetal parts become palpable through the abdominal wall and fetal heart tones disappear. This is a life-threatening surgical emergency requiring immediate transport.

Question 35: When is it appropriate to apply a tourniquet in the prehospital setting according to current ITLS guidelines?

Tourniquets are no longer recommended in civilian EMS
Only after all other methods have failed for at least 10 minutes
Only for amputations
For life-threatening extremity hemorrhage that cannot be controlled by direct pressure, applied as early as needed (Correct answer)

Correct answer: For life-threatening extremity hemorrhage that cannot be controlled by direct pressure, applied as early as needed

Current ITLS guidelines support early tourniquet application for life-threatening extremity hemorrhage when direct pressure is ineffective or impractical, reflecting evidence from military and civilian trauma that early tourniquet use saves lives.

Question 36: A patient sustained a stab wound to the central chest. During your assessment, you note hypotension, distended jugular veins, and muffled heart sounds. This triad of signs, known as Beck's Triad, is most indicative of which life-threatening condition?

Aortic dissection
Tension pneumothorax
Pericardial (cardiac) tamponade (Correct answer)
Massive hemothorax

Correct answer: Pericardial (cardiac) tamponade

Beck's Triad, consisting of hypotension, jugular vein distention (JVD), and muffled heart sounds, is the classic presentation for pericardial (cardiac) tamponade. Fluid accumulation in the pericardial sac compresses the heart, leading to decreased cardiac output (hypotension), backup of blood in the venous system (JVD), and insulation of the heart sounds (muffled sounds).

Question 37: Which of the following is a critical principle when managing a patient with severe hypothermia (core temperature < 30°C / 86°F)?

Vigorously rubbing the extremities to stimulate circulation.
Handling the patient gently to avoid precipitating ventricular fibrillation. (Correct answer)
Administering a warm fluid bolus as rapidly as possible.
Focusing solely on active external rewarming with heat packs to the extremities.

Correct answer: Handling the patient gently to avoid precipitating ventricular fibrillation.

The cold myocardium is extremely irritable in severely hypothermic patients. Rough handling or movement can easily trigger lethal dysrhythmias, particularly ventricular fibrillation. Therefore, all interventions must be performed gently. Active rewarming should focus on the core (axilla, groin, trunk), not the periphery, to avoid "afterdrop," where cold blood from the extremities returns to the core and further lowers the core temperature.

Question 38: Why is the pregnant trauma patient at increased risk for aspiration during emergency airway management?

Only in the first trimester due to morning sickness
Pregnancy does not affect airway management
Progesterone-mediated relaxation of the lower esophageal sphincter, decreased gastric motility, increased intra-abdominal pressure, and mechanical upward displacement of the stomach all increase regurgitation risk (Correct answer)
Pregnant patients have larger mouths making intubation messier

Correct answer: Progesterone-mediated relaxation of the lower esophageal sphincter, decreased gastric motility, increased intra-abdominal pressure, and mechanical upward displacement of the stomach all increase regurgitation risk

Pregnancy creates multiple aspiration risk factors: hormonal relaxation of the gastroesophageal sphincter, delayed gastric emptying, increased intra-abdominal pressure from the uterus, and upward stomach displacement, making regurgitation and aspiration more likely during airway management.

Question 39: A patient with a massive scalp laceration has lost approximately 800 mL of blood at the scene. Why are scalp wounds particularly prone to significant hemorrhage?

Scalp arteries are the largest in the body
The brain's blood supply exits through the scalp
Scalp bleeding always indicates skull fracture
The scalp has a rich, interconnected vascular network with vessels that do not vasoconstrict effectively because they are held open by the dense connective tissue of the galea aponeurotica (Correct answer)

Correct answer: The scalp has a rich, interconnected vascular network with vessels that do not vasoconstrict effectively because they are held open by the dense connective tissue of the galea aponeurotica

The scalp's dense vascular network has vessels tethered within the galea aponeurotica, preventing them from retracting and constricting when lacerated, which leads to persistent and often underestimated blood loss.

Question 40: According to ITLS guidelines, a Rapid Trauma Survey is performed instead of a Focused Exam when which of the following is present?

The patient is alert, oriented, and has stable vital signs.
A significant mechanism of injury. (Correct answer)
An isolated injury to a single limb.
The patient complains of pain in only one specific area.

Correct answer: A significant mechanism of injury.

A Rapid Trauma Survey is a quick, systematic head-to-toe assessment to identify all life-threatening injuries. It is indicated for patients with a significant mechanism of injury, an altered mental status, or abnormal findings in the Initial Assessment, as these suggest a higher likelihood of multi-system trauma. A Focused Exam is reserved for patients with a minor, isolated injury and no significant mechanism.

Question 41: You are assessing a patient with a gunshot wound to the right chest who is in profound shock. You note absent breath sounds on the right side and flat neck veins. Which of these two critical thoracic injuries is most likely, given the state of the neck veins?

Massive hemothorax (Correct answer)
Tension pneumothorax
Pulmonary contusion
Open pneumothorax

Correct answer: Massive hemothorax

Both a massive hemothorax and a tension pneumothorax can cause hypotension and absent breath sounds on the affected side. The key differentiator is the state of the neck veins. In a massive hemothorax, significant blood loss into the chest causes hypovolemic shock, resulting in flat neck veins. In a tension pneumothorax, increased intrathoracic pressure compresses the vena cava, impairing venous return and causing jugular vein distention (JVD).

Question 42: A 6-year-old pedestrian is struck by a motor vehicle. The provider should maintain a high index of suspicion for Waddell's Triad, which is a classic pattern of injuries consisting of:

Head injury, cervical spine fracture, and pelvic fracture.
Femur fracture, intra-abdominal/thoracic injury, and contralateral head injury. (Correct answer)
Bilateral femur fractures and a significant chest injury.
Clavicle fracture, splenic laceration, and closed head injury.

Correct answer: Femur fracture, intra-abdominal/thoracic injury, and contralateral head injury.

Waddell's Triad describes the three-part injury pattern commonly seen in pediatric pedestrian-versus-vehicle collisions. The sequence involves: 1) The car's bumper striking the femur; 2) The child's torso striking the hood or fender, causing thoracic or abdominal injuries; and 3) The child being thrown to the ground, resulting in a head injury on the opposite side of the initial impact.

Question 43: When ventilating a trauma patient with a bag-valve-mask, you notice poor chest rise despite a good mask seal. What should you do first?

Perform an emergency tracheostomy
Reposition the airway and reassess (Correct answer)
Switch to a smaller mask
Increase the squeeze force on the bag

Correct answer: Reposition the airway and reassess

Poor chest rise with a good mask seal most likely indicates inadequate airway positioning. Repositioning the airway (adjusting jaw thrust or head position) should be attempted before escalating interventions.

Question 44: A patient presents with a circumferential full-thickness burn to the right lower leg. Several hours later, the foot becomes pale, cool, and pulseless. What complication has developed?

Peripheral neuropathy from the burn
Arterial embolism
Deep vein thrombosis
Compartment syndrome from burn eschar (Correct answer)

Correct answer: Compartment syndrome from burn eschar

Circumferential full-thickness burns create a rigid, non-elastic eschar that acts like a tourniquet as underlying tissue swells, causing compartment syndrome with vascular compromise.

Question 45: Why is hyperventilation no longer recommended as routine management for traumatic brain injury?

Hyperventilation causes cerebral vasoconstriction that reduces ICP but also reduces cerebral blood flow, potentially worsening ischemia in the already injured brain (Correct answer)
Hyperventilation has no effect on intracranial pressure
It was never used in TBI management
Hyperventilation causes cerebral vasodilation and increases ICP

Correct answer: Hyperventilation causes cerebral vasoconstriction that reduces ICP but also reduces cerebral blood flow, potentially worsening ischemia in the already injured brain

While hyperventilation effectively lowers ICP by causing cerebral vasoconstriction and reducing cerebral blood volume, it simultaneously reduces cerebral blood flow, which can worsen ischemia in the injured brain that already has compromised perfusion.

Question 46: When performing suctioning of a trauma patient's airway, what is the maximum recommended duration for each suction attempt?

5 seconds
30 seconds
10 seconds
15 seconds (Correct answer)

Correct answer: 15 seconds

Suctioning should be limited to 15 seconds per attempt to minimize hypoxia, as suctioning removes air as well as fluid from the airway.

Question 47: According to ITLS guidelines, which of the following patients requires the application of spinal motion restriction (SMR)?

A 40-year-old with a gunshot wound to the abdomen who is ambulatory on scene.
A 60-year-old driver in a moderate-speed MVC who is intoxicated and has a distracting forearm fracture. (Correct answer)
A 30-year-old with an isolated stab wound to the arm with controlled bleeding.
A 25-year-old who fell from a standing height, is alert and oriented, and denies any neck or back pain.

Correct answer: A 60-year-old driver in a moderate-speed MVC who is intoxicated and has a distracting forearm fracture.

ITLS guidelines recommend selective spinal motion restriction. SMR is indicated in blunt trauma patients with an altered level of consciousness, evidence of intoxication, a distracting injury, or focal neurologic signs/symptoms, as these factors make a spinal exam unreliable. Penetrating trauma does not typically require SMR unless there is a specific neurologic deficit. [7, 10, 16, 28]

Question 48: A hiker is found with a core temperature of 30°C (86°F). He is conscious but confused and shivering has stopped. How should the ITLS provider manage this patient?

Administer warm IV fluids at maximum rate and vigorously rub extremities
Handle gently, remove wet clothing, insulate, and transport to a hospital for rewarming (Correct answer)
Encourage the patient to exercise to generate heat
Aggressively warm with hot water bottles placed directly on skin

Correct answer: Handle gently, remove wet clothing, insulate, and transport to a hospital for rewarming

Moderate hypothermia (30-34°C) requires gentle handling to avoid triggering ventricular fibrillation, passive rewarming with insulation, and hospital transport for controlled active rewarming.

Question 49: What is the primary prehospital concern when treating a patient with radiation burns from an industrial accident?

Radiation burns are immediately more severe than thermal burns
Provider safety through contamination control and limiting exposure time, distance, and shielding (Correct answer)
All radiation patients must be decontaminated with bleach
Radiation cannot cause burns and the patient likely has a chemical injury

Correct answer: Provider safety through contamination control and limiting exposure time, distance, and shielding

The primary concern with radiation exposure is provider safety. ITLS teaches time (minimize), distance (maximize), and shielding (appropriate PPE) to protect rescuers from contamination and exposure.

Question 50: You are treating a 22-year-old who was stabbed in the right side of his neck. Assessment reveals paralysis and loss of position sense in his right arm and leg, with a loss of pain and temperature sensation on his left side below the injury. This pattern of deficits is most consistent with which spinal cord syndrome?

Brown-Séquard Syndrome (Correct answer)
Cauda Equina Syndrome
Central Cord Syndrome
Anterior Cord Syndrome

Correct answer: Brown-Séquard Syndrome

Brown-Séquard Syndrome results from hemisection (one-sided damage) of the spinal cord. It is characterized by ipsilateral (same-side) loss of motor function and proprioception, and contralateral (opposite-side) loss of pain and temperature sensation. [17, 26, 27]

Question 51: What is the appropriate blood pressure target when managing a trauma patient with both a severe traumatic brain injury (GCS 6) and hemorrhagic shock?

Maintain systolic BP above 90 mmHg to protect cerebral perfusion, even though this conflicts with permissive hypotension strategy (Correct answer)
Blood pressure management is not important in polytrauma
Allow permissive hypotension to protect the clots
Target systolic BP of 60-70 mmHg

Correct answer: Maintain systolic BP above 90 mmHg to protect cerebral perfusion, even though this conflicts with permissive hypotension strategy

TBI patients require adequate cerebral perfusion pressure, making hypotension particularly dangerous. When TBI coexists with hemorrhagic shock, maintaining systolic BP above 90 mmHg takes priority over permissive hypotension to prevent secondary brain injury.

ITLS - International Trauma Life Support Exam

The ITLS written exam is a 50-question multiple-choice test that assesses knowledge of prehospital trauma assessment, management, and intervention techniques for EMS providers at the Basic and Advanced levels.

Questions

60 min

Time Limit

74%

To Pass

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Exam Rules

You can skip questions and return to them later
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No feedback shown until you submit the entire exam
Unanswered questions count as wrong — answer everything
10 pretest questions are mixed in and don't affect your score
Timer auto-submits when time runs out
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These practice questions were written with AI tools. They are not real exam questions. Exam facts are checked against the official sources listed below. Not reviewed by a subject-matter expert. Editorial policy

Sources & references

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