ITLS - International Trauma Life Support Exam — Questions and Answers

Question 1: 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.
A pre-existing higher likelihood of having a smoking history.
An increased probability that the fractured ribs will puncture the lung.
Decreased chest wall compliance and an ineffective cough leading to atelectasis. (Correct answer)

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 2: The use of external laryngeal manipulation:

Improves glottic visualization (Correct answer)
Decreases the risk of airway trauma
Reduces gastric distention
Causes aspiration

Correct answer: Improves glottic visualization

Explanation: <br> Manipulating the thyroid cartilage can help bring the vocal cords into view during endotracheal intubation. This is called external laryngeal manipulation (ELM). The movement is usually pressing the thyroid cartilage backward against the esophagus and then upward and slightly to the patient’s right side.

Question 3: 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?

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

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 4: 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
They are the same assessment performed at different speeds
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)
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 5: An 80 kg adult patient has full-thickness burns to his entire chest and abdomen. According to the Parkland formula, what is the total amount of fluid to be administered over the first 8 hours from the time of the burn?

1440 mL
720 mL
2880 mL (Correct answer)
5760 mL

Correct answer: 2880 mL

The Parkland formula is 4 mL x patient's weight in kg x percentage of Total Body Surface Area (%TBSA) burned. Using the Rule of Nines, the entire anterior torso (chest + abdomen) is 18% TBSA. The total 24-hour fluid is 4 mL x 80 kg x 18 = 5760 mL. Half of this amount (5760 / 2 = 2880 mL) must be infused over the first 8 hours from the time of the injury.

Question 6: What is the lethal triad of trauma, and why does it create a vicious cycle?

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

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 7: 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:

Femur fracture, intra-abdominal/thoracic injury, and contralateral head injury. (Correct answer)
Bilateral femur fractures and a significant chest injury.
Head injury, cervical spine fracture, and pelvic fracture.
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 8: A patient with severe maxillofacial trauma has blood continuously pooling in the oropharynx despite repeated suctioning. What airway management strategy is most appropriate?

Continue aggressive oral suctioning indefinitely
Perform a surgical cricothyrotomy for definitive airway control (Correct answer)
Insert a nasopharyngeal airway bilaterally
Place the patient in a recovery position and allow drainage

Correct answer: Perform a surgical cricothyrotomy for definitive airway control

When continuous oral bleeding overwhelms suctioning capacity and threatens the airway, a surgical cricothyrotomy provides a definitive airway below the level of hemorrhage, bypassing the compromised upper airway entirely.

Question 9: A motorcycle crash victim has weakness and loss of pain/temperature sensation in both arms but relatively preserved leg function. What spinal cord injury pattern is this?

Complete spinal cord transection
Anterior cord syndrome
Central cord syndrome (Correct answer)
Brown-Séquard syndrome

Correct answer: Central cord syndrome

Central cord syndrome involves greater motor impairment in the upper extremities than the lower, with variable sensory loss. It occurs from cervical hyperextension that damages the central portion of the spinal cord where upper extremity fibers are located.

Question 10: A trauma patient has unequal pupils—the right pupil is fixed and dilated while the left is reactive. What does this finding most likely indicate?

Normal pupillary variation
Right-sided uncal herniation compressing the right oculomotor nerve (Correct answer)
Left-sided brain injury with contralateral effect
Direct trauma to the right eye

Correct answer: Right-sided uncal herniation compressing the right oculomotor nerve

A unilateral fixed, dilated pupil in a trauma patient indicates ipsilateral uncal herniation, where the medial temporal lobe herniates through the tentorial notch and compresses the ipsilateral CN III (oculomotor nerve).

Question 11: In the Incident Command System (ICS), 'span of control' refers to:

The geographic area controlled by a single unit
The number of transport units available to an incident
The number of subordinates one supervisor can effectively manage (Correct answer)
The chain of command from field to hospital administration

Correct answer: The number of subordinates one supervisor can effectively manage

Span of control in ICS refers to the optimal number of subordinates a supervisor can effectively manage, typically 3-7 with an ideal of 5.

Question 12: How does a traumatic aortic injury typically present in the prehospital setting, and why is the mortality rate so high?

Aortic injuries only occur in penetrating trauma
It always presents with cardiac arrest
It presents with obvious external chest bleeding
80-90% die at the scene from exsanguination; survivors may have upper extremity hypertension with lower extremity hypotension (pseudocoarctation), and wide mediastinum on imaging (Correct answer)

Correct answer: 80-90% die at the scene from exsanguination; survivors may have upper extremity hypertension with lower extremity hypotension (pseudocoarctation), and wide mediastinum on imaging

Traumatic aortic injury kills 80-90% at the scene. Survivors have a partial tear contained by the adventitia, which can rupture at any time. Findings may include BP differential between upper and lower extremities and interscapular pain.

Question 13: A 32-week pregnant patient is involved in an MVC and is placed supine on a backboard. Her blood pressure drops significantly. What is the most likely cause and immediate intervention?

Hemorrhagic shock requiring massive fluid resuscitation
Cardiac tamponade from steering wheel impact
Neurogenic shock from spinal injury
Supine hypotensive syndrome from the gravid uterus compressing the inferior vena cava; tilt the backboard 15-30 degrees to the left (Correct answer)

Correct answer: Supine hypotensive syndrome from the gravid uterus compressing the inferior vena cava; tilt the backboard 15-30 degrees to the left

In late pregnancy, the gravid uterus compresses the IVC when the patient is supine, reducing venous return by up to 30%. Tilting the board 15-30 degrees left (or manually displacing the uterus) immediately relieves the compression.

Question 14: A patient with a severe crush injury to the forearm complains of pain that is out of proportion to the visible injury. The forearm is tense, swollen, and the patient reports 'pins and needles' in their hand. These findings are most suggestive of which limb-threatening condition?

Complete transection of the radial nerve.
A simple contusion with expected swelling.
Acute compartment syndrome. (Correct answer)
Arterial occlusion from a brachial artery laceration.

Correct answer: Acute compartment syndrome.

The classic signs and symptoms of acute compartment syndrome include pain out of proportion to the injury, a tense or 'woody' feeling compartment, and neurological deficits such as paresthesia (pins and needles). This is a surgical emergency caused by swelling within a closed fascial space, which compromises circulation and nerve function.

Question 15: The Pediatric Assessment Triangle (PAT) is a rapid assessment tool used to form a general impression of a sick child. Which of the following are the three components of the PAT?

Level of Consciousness, Motor Response, Pupil Reaction
Heart Rate, Respiratory Rate, Blood Pressure
Appearance, Work of Breathing, Circulation to Skin (Correct answer)
Airway, Breathing, Circulation

Correct answer: Appearance, Work of Breathing, Circulation to Skin

The Pediatric Assessment Triangle (PAT) consists of three key observational components: Appearance (evaluating tone, interactiveness, consolability, look/gaze, and speech/cry), Work of Breathing (assessing for abnormal sounds, positioning, and retractions), and Circulation to Skin (checking for pallor, mottling, or cyanosis). This tool allows for a rapid 'from the doorway' evaluation without touching the patient.

Question 16: A 4-year-old child struck by a car presents with altered mental status but stable vital signs. Why is the ITLS provider particularly concerned about intra-abdominal injury in this patient?

Children have proportionally larger solid organs, less protective subcutaneous fat, and more flexible rib cages that provide less protection, making abdominal organs more vulnerable (Correct answer)
Pediatric abdominal injuries are always minor
Children have stronger abdominal muscles that mask injuries
Children cannot have internal bleeding from blunt trauma

Correct answer: Children have proportionally larger solid organs, less protective subcutaneous fat, and more flexible rib cages that provide less protection, making abdominal organs more vulnerable

Pediatric anatomy makes children more susceptible to abdominal organ injury: relatively larger liver and spleen, less subcutaneous fat padding, and a more pliable rib cage that transmits rather than absorbs force.

Question 17: 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.
Initiate rapid transport and apply pressure during transit.
Immediately apply a tourniquet proximal to the wound. (Correct answer)
Establish IV access and begin rapid fluid resuscitation.

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 18: What is the primary purpose of the ITLS initial assessment performed from the doorway or upon approach?

To form a general impression of the patient's condition (Correct answer)
To calculate the Glasgow Coma Scale score
To determine the exact mechanism of injury
To identify all injuries present

Correct answer: To form a general impression of the patient's condition

The initial assessment (general impression) helps providers quickly categorize the patient as stable, potentially unstable, or unstable, guiding the urgency and approach of subsequent assessment.

Question 19: Why do elderly patients with traumatic brain injury have worse outcomes than younger patients with comparable injuries?

Brain scans are less accurate in the elderly
Elderly patients refuse surgical treatment more often
Brain atrophy increases subdural space, bridging veins are more vulnerable, reduced cognitive reserve limits recovery, and anticoagulant use worsens hemorrhage (Correct answer)
Hospital treatment protocols differ based on age

Correct answer: Brain atrophy increases subdural space, bridging veins are more vulnerable, reduced cognitive reserve limits recovery, and anticoagulant use worsens hemorrhage

Multiple age-related factors compound TBI severity: brain atrophy creates more space for bleeding before symptoms appear, stretched bridging veins tear easily, cognitive reserve is diminished, and common anticoagulant use worsens bleeding.

Question 20: What are the early, subtle signs of hemorrhagic shock that may precede changes in blood pressure?

Bradycardia and flushed warm skin
Anxiety, tachycardia, narrowed pulse pressure, pallor, and delayed capillary refill (Correct answer)
Pupillary dilation and fever
Polyuria and increased appetite

Correct answer: Anxiety, tachycardia, narrowed pulse pressure, pallor, and delayed capillary refill

Early shock signs reflect sympathetic activation and peripheral vasoconstriction occurring while blood pressure is still maintained: anxiety, mild tachycardia, slight narrowing of pulse pressure, skin pallor, and delayed capillary refill (>2 seconds).

Question 21: Which intervention for a pregnant patient in traumatic cardiac arrest should be performed SIMULTANEOUSLY with standard ACLS measures?

Emergent thoracotomy
Bilateral chest decompression
Manual left uterine displacement and preparation for perimortem cesarean (Correct answer)
High-dose epinephrine administration

Correct answer: Manual left uterine displacement and preparation for perimortem cesarean

Manual uterine displacement to relieve aortocaval compression should begin immediately alongside CPR, and PMCD should be prepared if arrest persists beyond 4 minutes.

Question 22: 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?

Cauda Equina Syndrome
Brown-Séquard Syndrome (Correct answer)
Anterior Cord Syndrome
Central 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 23: A trauma patient develops shock during air transport at altitude. How does altitude affect hemorrhagic shock physiology?

Altitude only affects patients with pneumothorax
Reduced atmospheric pressure at altitude decreases oxygen partial pressure, worsening tissue hypoxia in a patient already compromised by hemorrhage-related reduced oxygen delivery (Correct answer)
Higher altitude increases blood pressure and helps compensate for volume loss
Altitude has no effect on shock

Correct answer: Reduced atmospheric pressure at altitude decreases oxygen partial pressure, worsening tissue hypoxia in a patient already compromised by hemorrhage-related reduced oxygen delivery

At altitude, reduced atmospheric pressure decreases the partial pressure of inspired oxygen (PiO2), compounding the already reduced oxygen delivery caused by hemorrhagic anemia. This accelerates tissue hypoxia and shock progression.

Question 24: A patient involved in a motorcycle collision has significant tenderness in the left upper abdominal quadrant and complains of pain in their left shoulder (Kehr's sign). The patient is pale, with a heart rate of 120 and a blood pressure of 98/60 mmHg. These findings are most concerning for a lacerated:

Kidney
Liver
Stomach
Spleen (Correct answer)

Correct answer: Spleen

The spleen is located in the left upper quadrant of the abdomen and is the most commonly injured organ in blunt abdominal trauma. An injury to the spleen can cause significant internal bleeding and irritation of the diaphragm. This diaphragmatic irritation refers pain to the left shoulder via the phrenic nerve, a phenomenon known as Kehr's sign.

Question 25: A 45-year-old male involved in a high-speed MVC presents with JVD, muffled heart sounds, and hypotension. What is the most likely diagnosis?

Aortic dissection
Cardiac tamponade (Correct answer)
Flail chest
Tension pneumothorax

Correct answer: Cardiac tamponade

Beck's triad—JVD, muffled heart sounds, and hypotension—is the classic presentation of cardiac tamponade, caused by blood accumulating in the pericardial sac and compressing the heart.

Question 26: In a rear-impact motor vehicle crash, which area of the spine is most susceptible to injury?

Thoracic
Sacral-coccygeal
Lumbar
Cervical (Correct answer)

Correct answer: Cervical

Explanation: <br> The sudden increase in acceleration produces posterior displacement of the occupants and possible hyperextension of the cervical spine if the headrest is not properly adjusted. The potential for cervical spine injuries is great.

Question 27: A patient with multiple stab wounds to the abdomen is hypotensive with a distended abdomen. Estimated time to the trauma center is 45 minutes. What is the appropriate fluid management strategy?

Use permissive hypotension with 250 mL crystalloid boluses, targeting a systolic BP of 80-90 mmHg while prioritizing rapid transport (Correct answer)
Administer 2 liters of normal saline as rapidly as possible
Withhold all fluids until the patient reaches the operating room
Administer hypertonic saline at maximum rate

Correct answer: Use permissive hypotension with 250 mL crystalloid boluses, targeting a systolic BP of 80-90 mmHg while prioritizing rapid transport

For penetrating abdominal trauma with uncontrolled hemorrhage, permissive hypotension limits crystalloid to maintain minimal acceptable perfusion while avoiding clot disruption and hemodilution until surgical hemorrhage control.

Question 28: A construction worker has cement powder mixed with water on both arms for 30 minutes. What makes cement burns unique in their management?

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

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 29: Which age-related physiological change is the primary reason that a seemingly minor head injury can cause a life-threatening subdural hematoma in a geriatric patient?

Arteriosclerosis of the cerebral arteries, making them prone to rupture
Thickening of the dura mater, making it less pliable
Cerebral atrophy causing stretching of the bridging veins (Correct answer)
Increased intracranial pressure due to decreased CSF absorption

Correct answer: Cerebral atrophy causing stretching of the bridging veins

As people age, their brain tissue atrophies (shrinks), which increases the space between the brain and the skull. This stretching places tension on the bridging veins that cross this space, making them highly susceptible to tearing from even minor acceleration-deceleration forces, leading to a subdural hematoma.

Question 30: Routine use of hyperventilation in the traumatic brain injury (TBI) patient will:

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

Correct answer: cause vasoconstriction and increased cerebral ischemia.

Explanation: <br> 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 31: 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?

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

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 32: Which physiologic change of pregnancy increases the risk of aspiration during airway management?

Increased gastric motility
Reduced lower esophageal sphincter tone (Correct answer)
Decreased gastric acid production
Elevated diaphragm position

Correct answer: Reduced lower esophageal sphincter tone

Progesterone reduces lower esophageal sphincter tone and slows gastric emptying, increasing aspiration risk in pregnant patients.

Question 33: When should an incident commander request mutual aid during a mass casualty incident?

Early in the incident when the scope appears to exceed local capability (Correct answer)
Only after receiving hospitals have reached maximum capacity
After the scene has been fully secured and all patients triaged
Only after all local resources have been completely exhausted

Correct answer: Early in the incident when the scope appears to exceed local capability

Mutual aid should be requested early in a MCI because response times mean additional resources must be mobilized well before the incident reaches its peak demand.

Question 34: What is the correct application technique for a traction splint on a midshaft femur fracture?

Secure the ischial pad at the groin, apply manual traction to realign, then apply mechanical traction at the ankle (Correct answer)
Apply traction at the hip and secure at the knee
Wrap the splint around both legs for bilateral stabilization
Apply the splint without any traction to avoid further injury

Correct answer: Secure the ischial pad at the groin, apply manual traction to realign, then apply mechanical traction at the ankle

Traction splint application involves anchoring the ischial pad against the ischial tuberosity, applying manual traction to realign the limb, then transferring to mechanical traction via the ankle hitch until muscle spasm is overcome and the patient reports pain relief.

Question 35: What is neurogenic shock, and how does it differ from hypovolemic shock in its presentation?

Neurogenic shock only occurs in brain injuries, not spinal injuries
Neurogenic shock presents with hypotension and bradycardia due to loss of sympathetic tone, while hypovolemic shock presents with hypotension and tachycardia (Correct answer)
They are the same condition with different names
Neurogenic shock causes hypertension, while hypovolemic shock causes hypotension

Correct answer: Neurogenic shock presents with hypotension and bradycardia due to loss of sympathetic tone, while hypovolemic shock presents with hypotension and tachycardia

Neurogenic shock results from spinal cord injury disrupting sympathetic outflow, causing vasodilation (hypotension) and unopposed vagal tone (bradycardia)—the opposite of the tachycardia seen in hypovolemic shock.

Question 36: When is it appropriate to apply a tourniquet in the prehospital setting according to current ITLS guidelines?

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)
Tourniquets are no longer recommended in civilian EMS

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 37: When managing a trauma patient with both a severe traumatic brain injury (TBI) and hemorrhagic shock, the ITLS fluid resuscitation strategy differs from that of isolated hemorrhagic shock. What is the target systolic blood pressure for this specific patient population?

80-90 mmHg
70-80 mmHg
At least 110 mmHg (Correct answer)
Greater than 140 mmHg

Correct answer: At least 110 mmHg

In a patient with both hemorrhagic shock and a severe TBI, it is critical to maintain adequate cerebral perfusion pressure (CPP). Hypotension can be devastating to the injured brain. Therefore, the standard permissive hypotension target is abandoned, and fluid is administered to maintain a higher systolic blood pressure, typically at or above 110 mmHg, to ensure the brain remains adequately perfused.

Question 38: 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
Carbon monoxide poisoning only
Third-degree burns to the lungs
Impending upper airway obstruction from thermal injury (Correct answer)

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 39: 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?

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

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 40: 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
Bladder
Kidneys

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 41: A patient with left lower rib fractures (ribs 9-11) has left upper quadrant tenderness and a blood pressure that drops from 110/70 to 90/60 over 15 minutes. What injury is most likely?

Left kidney laceration
Splenic laceration with progressive hemorrhage (Correct answer)
Left-sided pneumothorax
Gastric perforation

Correct answer: Splenic laceration with progressive hemorrhage

The spleen sits beneath ribs 9-12 on the left. Lower left rib fractures combined with LUQ tenderness and declining blood pressure strongly suggest splenic laceration with ongoing hemorrhage.

Question 42: A restrained pregnant driver at 34 weeks gestation is involved in a moderate-speed MVC. She has no complaints and vital signs are normal. Should she be transported for evaluation?

Only if there is visible damage to the vehicle
Yes, all pregnant trauma patients beyond 20 weeks require minimum 4-6 hours of fetal monitoring regardless of apparent injury severity, as placental abruption can be delayed (Correct answer)
No, she has no complaints and is hemodynamically stable
Only if she requests transport

Correct answer: Yes, all pregnant trauma patients beyond 20 weeks require minimum 4-6 hours of fetal monitoring regardless of apparent injury severity, as placental abruption can be delayed

ALL pregnant trauma patients beyond 20 weeks should be transported for fetal monitoring, regardless of complaint severity. Placental abruption can be occult initially, with delayed presentation of fetal distress or maternal hemorrhage.

Question 43: When assessing a burn patient, how do you differentiate between a superficial partial-thickness (second-degree) burn and a full-thickness (third-degree) burn?

Both have identical appearances and can only be differentiated by biopsy
Second-degree burns are painless; third-degree burns are painful
Second-degree burns are white; third-degree burns are red
Second-degree burns have blisters and are painful; third-degree burns are waxy, leathery, and painless (Correct answer)

Correct answer: Second-degree burns have blisters and are painful; third-degree burns are waxy, leathery, and painless

Superficial partial-thickness burns preserve nerve endings, causing pain and blistering, while full-thickness burns destroy all skin layers including nerve endings, resulting in a painless, leathery or waxy appearance.

Question 44: What is the most dangerous type of electrical burn injury and why?

Lightning strike because it always causes cardiac arrest
Low-voltage AC because it causes more skin damage
High-voltage AC because it causes internal tissue destruction disproportionate to visible burns (Correct answer)
High-voltage DC because it produces the most heat externally

Correct answer: High-voltage AC because it causes internal tissue destruction disproportionate to visible burns

High-voltage AC causes the most dangerous electrical burns because current travels through the body along blood vessels and nerves, destroying deep tissues while skin burns may appear minimal.

Question 45: A patient is rescued from a structural fire. They have no significant cutaneous burns but are coughing, have a hoarse voice, and possess soot around their nose and mouth. Which finding is the most reliable indicator of a significant inhalation injury requiring aggressive airway management?

A respiratory rate of 24 breaths per minute.
A progressively worsening hoarse voice. (Correct answer)
A carboxyhemoglobin level of 5%.
Presence of soot on the face.

Correct answer: A progressively worsening hoarse voice.

A hoarse voice, stridor, or brassy cough indicates laryngeal edema from direct thermal injury to the upper airway. This swelling can rapidly progress to complete airway obstruction. While soot and tachypnea are clues, the change in voice is a more direct and ominous sign of impending airway compromise that necessitates early and definitive airway control.

Question 46: 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?

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

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 47: A patient involved in a high-speed collision has a suspected high thoracic spinal cord injury. Which set of vital signs is most characteristic of neurogenic shock?

BP 86/58 mmHg, HR 58 bpm, warm and dry skin (Correct answer)
BP 80/50 mmHg, HR 130 bpm, cool and clammy skin
BP 110/70 mmHg, HR 110 bpm, pale and diaphoretic skin
BP 180/100 mmHg, HR 50 bpm, irregular respirations

Correct answer: BP 86/58 mmHg, HR 58 bpm, warm and dry skin

Neurogenic shock is a distributive shock resulting from the loss of sympathetic tone below the level of a high spinal cord injury. This leads to massive vasodilation, causing hypotension. The loss of sympathetic stimulation to the heart results in bradycardia (or a normal heart rate) rather than the expected tachycardia. The skin is typically warm and dry due to peripheral vasodilation. [1, 11, 12, 14]

Question 48: A patient has sustained a posterior hip dislocation in a head-on MVC. In what position will the affected leg typically be found?

Flexed, internally rotated, and adducted (Correct answer)
Extended, neutral rotation
Extended, externally rotated, and abducted
Flexed, externally rotated, and abducted

Correct answer: Flexed, internally rotated, and adducted

Posterior hip dislocation classically presents with the leg flexed, internally rotated, and adducted, as the femoral head displaces posteriorly behind the acetabulum.

Question 49: You are managing the airway of an unconscious adult trauma patient with a suspected cervical spine injury. Which of the following is the most appropriate initial manual maneuver to open the airway?

Placement in the recovery position
Head-tilt, chin-lift
Jaw-thrust maneuver (Correct answer)
Flexion of the neck

Correct answer: Jaw-thrust maneuver

In a trauma patient with a suspected cervical spine injury, the jaw-thrust maneuver is the recommended technique to open the airway. This method minimizes movement of the head and neck, unlike the head-tilt, chin-lift, which is contraindicated due to the risk of exacerbating a spinal injury.

Question 50: 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.
Minimizing on-scene time and ensuring rapid transport to a trauma center. (Correct answer)
Applying a pneumatic anti-shock garment (PASG).

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 51: What is spinal shock, and how does it affect the neurological assessment of a spinal cord injury patient?

It only affects sensory function, not motor function
It is a temporary loss of all spinal cord function below the injury level, making it impossible to determine the true extent of permanent injury during the acute phase (Correct answer)
It lasts only a few seconds after the injury
It is the same as neurogenic shock and causes hypotension

Correct answer: It is a temporary loss of all spinal cord function below the injury level, making it impossible to determine the true extent of permanent injury during the acute phase

Spinal shock is the temporary loss of all reflex and voluntary function below the level of spinal cord injury, lasting hours to weeks. During this phase, even incomplete injuries may appear as complete transections.

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%

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