ITLS - International Trauma Life Support Exam — Questions and Answers

Question 1: A trauma patient presents with cool, mottled extremities, delayed capillary refill, and thready radial pulses but has a blood pressure of 118/90. What stage of shock is this patient in?

Irreversible shock
Decompensated shock
No shock—blood pressure is normal
Compensated shock—the body is maintaining blood pressure through vasoconstriction despite significant volume loss (Correct answer)

Correct answer: Compensated shock—the body is maintaining blood pressure through vasoconstriction despite significant volume loss

This patient is in compensated shock. Despite maintaining a near-normal systolic pressure through intense vasoconstriction, the clinical signs (cool skin, mottling, delayed capillary refill, narrowed pulse pressure) reveal inadequate tissue perfusion.

Question 2: You are treating a patient with signs of compensated hemorrhagic shock. Which of the following findings would you most likely expect to see first?

Tachycardia and cool, clammy skin. (Correct answer)
Unconsciousness and absent peripheral pulses.
A significant drop in systolic blood pressure.
Bradycardia and flushed, warm skin.

Correct answer: Tachycardia and cool, clammy skin.

In the early (compensated) stage of hemorrhagic shock, the body attempts to maintain blood pressure and vital organ perfusion. The initial response involves the sympathetic nervous system, leading to an increased heart rate (tachycardia) and peripheral vasoconstriction, which causes the skin to become cool and clammy. A drop in blood pressure is a sign of decompensated shock.

Question 3: At what gestational age does ITLS recommend performing a perimortem cesarean section in a pregnant patient in cardiac arrest, and what is the goal?

At approximately 23-24 weeks viable gestation, ideally within 4-5 minutes of arrest, to both save the fetus and improve maternal resuscitation by relieving aortocaval compression (Correct answer)
Only after 30 minutes of unsuccessful CPR
Only at full term (40 weeks)
Perimortem cesarean section is never performed prehospitally

Correct answer: At approximately 23-24 weeks viable gestation, ideally within 4-5 minutes of arrest, to both save the fetus and improve maternal resuscitation by relieving aortocaval compression

Perimortem cesarean section is recommended at ≥23-24 weeks gestational age, with delivery within 4-5 minutes of cardiac arrest. The dual purpose is fetal survival and improvement of maternal hemodynamics by relieving aortocaval compression.

Question 4: Which mechanism of injury is most commonly associated with fetal death in blunt abdominal trauma?

Uterine rupture
Maternal shock
Placental abruption (Correct answer)
Direct fetal injury

Correct answer: Placental abruption

Placental abruption is the most frequent cause of fetal death in blunt abdominal trauma, occurring even without apparent external injury.

Question 5: A patient has a penetrating object (knife) embedded in the skull. What is the correct prehospital management?

Apply a cervical collar directly over the wound
Remove the object to allow wound assessment
Push the object deeper for better stabilization
Stabilize the object in place, control bleeding around it, and transport for surgical removal (Correct answer)

Correct answer: Stabilize the object in place, control bleeding around it, and transport for surgical removal

Embedded objects in the skull must never be removed in the field, as they may be tamponading blood vessels or plugging the dural defect. Stabilize in place with bulky dressings and transport for neurosurgical removal.

Question 6: 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?

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

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

Administering a warm fluid bolus as rapidly as possible.
Vigorously rubbing the extremities to stimulate circulation.
Handling the patient gently to avoid precipitating ventricular fibrillation. (Correct answer)
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 8: According to ITLS guidelines, a Rapid Trauma Survey is performed instead of a Focused Exam when which of the following is present?

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

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 9: How often should reassessments be performed on unstable and stable trauma patients during transport according to ITLS guidelines?

Every 30 minutes for all patients
Continuously without pause for the entire transport
Every 5 minutes for unstable patients and every 15 minutes for stable patients (Correct answer)
Only once during transport regardless of patient status

Correct answer: Every 5 minutes for unstable patients and every 15 minutes for stable patients

ITLS requires reassessment of vital signs, mental status, and primary survey findings every 5 minutes for unstable patients and every 15 minutes for stable patients to detect deterioration or improvement.

Question 10: What is the single most important prehospital intervention for a hemodynamically unstable patient with suspected significant intra-abdominal hemorrhage following blunt trauma?

Applying a pneumatic anti-shock garment (PASG).
Initiating two large-bore IVs and rapidly infusing 2 liters of crystalloid.
Performing a detailed abdominal assessment to locate the source of pain.
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 11: Which of the following best describes a key physiological difference in how children compensate for hemorrhagic shock compared to adults?

Children can maintain a normal blood pressure despite significant blood loss. (Correct answer)
Bradycardia is the primary and most reliable initial sign of shock.
Children become hypotensive very early in the shock process.
Peripheral vasodilation is the main compensatory mechanism.

Correct answer: Children can maintain a normal blood pressure despite significant blood loss.

Children have very effective compensatory mechanisms, including intense vasoconstriction and an increased heart rate. This allows them to maintain a normal systolic blood pressure until they have lost a substantial percentage of their circulating blood volume (up to 45%). Hypotension is therefore a late and ominous sign of decompensated shock in a child. Tachycardia is the earliest sign.

Question 12: 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)
Open pneumothorax
Tension pneumothorax
Pulmonary contusion

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 13: What physiologic change in the elderly makes rib fractures more likely from minor trauma and more dangerous when they occur?

Enlarged rib cage from emphysema provides less protection
Increased bone density makes ribs more brittle
Elderly ribs are flexible like children's ribs
Decreased bone density (osteoporosis) and reduced chest wall compliance increase fracture risk, while decreased respiratory reserve makes complications more likely (Correct answer)

Correct answer: Decreased bone density (osteoporosis) and reduced chest wall compliance increase fracture risk, while decreased respiratory reserve makes complications more likely

Osteoporosis weakens bones, and calcification of costal cartilage reduces chest wall flexibility, making rib fractures common from minor mechanisms. Reduced pulmonary reserve means rib fractures more often lead to pneumonia, respiratory failure, and death.

Question 14: An elderly patient falls and strikes their chin, causing a hyperextension injury of the neck. They present with significant motor weakness in their arms and hands but are able to move their legs with near-normal strength. This clinical picture is most typical of:

Anterior Cord Syndrome
Posterior Cord Syndrome
Brown-Séquard Syndrome
Central Cord Syndrome (Correct answer)

Correct answer: Central Cord Syndrome

Central Cord Syndrome is characterized by motor impairment that is disproportionately greater in the upper extremities than the lower extremities. [2, 4, 5, 9] It is often caused by hyperextension injuries in older patients with pre-existing cervical spondylosis.

Question 15: A construction worker has a partial amputation of the lower leg with massive, pulsatile bleeding that is not controlled by direct pressure. According to ITLS guidelines, what is the most appropriate immediate action?

Immediately package the patient for transport without further intervention.
Apply a hemostatic dressing deep into the wound.
Elevate the limb above the heart and apply pressure to the femoral artery.
Apply a tourniquet high and tight on the thigh. (Correct answer)

Correct answer: Apply a tourniquet high and tight on the thigh.

For catastrophic extremity hemorrhage that is not controlled by direct pressure, the immediate application of a tourniquet is the priority intervention. The initial placement should be 'high and tight' on the affected limb to ensure arterial compression.

Question 16: How does pregnancy alter the normal location of abdominal organs, potentially changing the presentation of intra-abdominal injury?

The spleen enlarges and descends into the lower quadrants
The liver is displaced into the pelvis
The stomach is displaced posteriorly
The bowel is displaced superiorly, moving pain referral zones upward (Correct answer)

Correct answer: The bowel is displaced superiorly, moving pain referral zones upward

As the uterus enlarges, it displaces bowel loops superiorly, so bowel injuries may cause pain and tenderness in atypical upper abdominal locations.

Question 17: 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)
Altitude has no effect on shock
Higher altitude increases blood pressure and helps compensate for volume loss

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 18: What is the most reliable method to confirm correct endotracheal tube placement in the field?

Observing bilateral chest rise
Listening for bilateral breath sounds
Continuous waveform capnography (Correct answer)
Noting condensation in the tube

Correct answer: Continuous waveform capnography

Continuous waveform capnography is the gold standard for confirming and monitoring endotracheal tube placement, as it provides real-time verification of exhaled CO2 from the lungs.

Question 19: 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?

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

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 20: 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 white; third-degree burns are red
Second-degree burns are painless; third-degree burns are painful
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 21: 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
Pericardial (cardiac) tamponade (Correct answer)
Tension pneumothorax
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 22: Why are children at higher risk for hypothermia in the trauma setting compared to adults?

Children produce less body heat than adults
Children are always outdoors when injured
Children have a larger body surface area to mass ratio, thinner skin, less subcutaneous fat, and limited shivering capacity, causing more rapid heat loss (Correct answer)
Pediatric trauma patients receive colder IV fluids

Correct answer: Children have a larger body surface area to mass ratio, thinner skin, less subcutaneous fat, and limited shivering capacity, causing more rapid heat loss

Children lose heat faster due to their higher body surface area to mass ratio, less insulating subcutaneous fat, thinner skin, and in infants, immature thermoregulatory mechanisms including limited shivering ability.

Question 23: You have placed an NPA in your patient and now observe mild hemorrhage from the nares. You should:

Contact medical control as an NPA will not cause hemorrhage
Immediately remove the NPA and reinsert it on the opposite nare
Leave the NPA in place so as not to disturb the clot or reactivate bleeding (Correct answer)
Immediately remove the NPA and pack the nose with gauze

Correct answer: Leave the NPA in place so as not to disturb the clot or reactivate bleeding

Explanation: <br> Mild hemorrhage from the nose after insertion of the airway is not an indication to remove it. In fact, it is probably better to keep an NPA in place so as not to disturb the clot or reactivate the bleeding

Question 24: In a trauma patient at 36 weeks gestation, which finding best indicates significant hemorrhage despite vital signs appearing normal?

Respiratory rate of 18
Fetal heart rate of 170 bpm (Correct answer)
Mild tachycardia (HR 95)
Blood pressure of 110/70

Correct answer: Fetal heart rate of 170 bpm

Fetal tachycardia (>160 bpm) can be an early indicator of maternal hypovolemia even before maternal vital signs deteriorate.

Question 25: The 'expectant' triage category is most appropriately applied when:

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

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 26: Which of the following is a late sign of hypovolemic shock specifically relevant to pregnant trauma patients?

Uterine irritability
Maternal tachycardia
Maternal hypotension (Correct answer)
Fetal heart rate changes

Correct answer: Maternal hypotension

Pregnant patients can compensate for up to 1,500 mL blood loss before maternal hypotension appears, making it a late sign.

Question 27: 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?

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

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 28: When placing IV access in a critically injured pregnant patient, which site is preferred?

Antecubital fossa or above (Correct answer)
Saphenous vein
Femoral vein
Foot dorsum

Correct answer: Antecubital fossa or above

IV access should be established above the diaphragm because the gravid uterus may compress the inferior vena cava, reducing flow from lower extremity IVs.

Question 29: Routine use of hyperventilation in the traumatic brain injury (TBI) patient will:

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

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

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

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 31: 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
Increase the squeeze force on the bag
Reposition the airway and reassess (Correct answer)
Switch to a smaller mask

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 32: 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?

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

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

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

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 34: A 45-year-old male is found unconscious after falling from a ladder. His initial vital signs are BP 190/110 mmHg, HR 52 bpm, and he has irregular, gasping respirations. His right pupil is dilated and non-reactive. These findings are most indicative of:

Neurogenic shock
Decompensated hemorrhagic shock
Spinal shock
Cushing's triad due to increased intracranial pressure (Correct answer)

Correct answer: Cushing's triad due to increased intracranial pressure

The patient's clinical presentation of hypertension (with a widening pulse pressure), bradycardia, and irregular respirations constitutes Cushing's triad. This triad is a late and critical sign of severely increased intracranial pressure (ICP), suggesting impending brainstem herniation. [24, 25]

Question 35: A construction worker falls 20 feet and lands on his feet, then collapses. He has bilateral heel pain and lower back pain. What injury should be suspected based on this mechanism?

Ankle sprains bilateral
Hip dislocations from ground impact
Bilateral calcaneal fractures with associated lumbar burst fracture from axial loading (Correct answer)
Isolated bilateral calcaneal fractures

Correct answer: Bilateral calcaneal fractures with associated lumbar burst fracture from axial loading

Feet-first landing from height causes bilateral calcaneal fractures, and the axial loading force continues up the skeletal system to the lumbar spine, commonly causing burst fractures at L1-L2 (the thoracolumbar junction).

Question 36: 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 37: An elderly patient is found on the ground after a fall. She is alert but confused and cannot recall the events. What important consideration must ITLS providers evaluate beyond the injuries from the fall?

What caused the fall—was it a mechanical trip or did a medical event (syncope, stroke, cardiac dysrhythmia) cause the fall? (Correct answer)
If the patient's neighbors heard the fall
Whether the patient has health insurance
Whether the patient was exercising before the fall

Correct answer: What caused the fall—was it a mechanical trip or did a medical event (syncope, stroke, cardiac dysrhythmia) cause the fall?

In elderly patients, falls are often symptoms of underlying medical events. ITLS providers must determine if a medical cause precipitated the fall, as this affects both immediate treatment and hospital evaluation.

Question 38: What is the difference between whole blood and component therapy (packed red blood cells, plasma, platelets) in trauma resuscitation?

Whole blood is only used in surgical settings, never prehospital
Component therapy is always superior to whole blood
There is no difference; they are identical products
Whole blood provides all components in physiologic ratios, while component therapy separates products and may require balanced ratios (1:1:1) to approximate the benefits of whole blood (Correct answer)

Correct answer: Whole blood provides all components in physiologic ratios, while component therapy separates products and may require balanced ratios (1:1:1) to approximate the benefits of whole blood

Whole blood contains red cells, plasma, platelets, and clotting factors in natural ratios. Component therapy separates these, requiring balanced transfusion (1:1:1 ratio of RBCs:plasma:platelets) to approximate whole blood's hemostatic and oxygen-carrying benefits.

Question 39: During rapid sequence intubation of a trauma patient, which agent is preferred for induction when increased ICP is suspected?

Midazolam
Propofol
Etomidate (Correct answer)
Ketamine

Correct answer: Etomidate

Etomidate is preferred for RSI in trauma patients with suspected elevated ICP because it provides hemodynamic stability and does not increase intracranial pressure.

Question 40: A chemical plant worker has concentrated hydrofluoric acid on his left hand. What is the unique danger of this chemical burn beyond tissue destruction?

It is impossible to decontaminate in the prehospital setting
It only causes superficial burns that mask deeper injuries
It produces toxic fumes that damage the lungs
Fluoride ions penetrate deep tissues and cause fatal hypocalcemia and cardiac arrest (Correct answer)

Correct answer: Fluoride ions penetrate deep tissues and cause fatal hypocalcemia and cardiac arrest

Hydrofluoric acid is uniquely dangerous because fluoride ions penetrate deeply, binding calcium and magnesium, causing systemic hypocalcemia that can trigger fatal cardiac dysrhythmias.

Question 41: During a rapid trauma assessment on an unresponsive patient, which finding most urgently requires immediate intervention before continuing the survey?

A deformed left forearm
Absent breath sounds on the left side (Correct answer)
Bruising over the mastoid process
Abdominal rigidity

Correct answer: Absent breath sounds on the left side

Absent breath sounds indicate a potential tension pneumothorax or massive hemothorax, both immediately life-threatening conditions requiring intervention during the primary survey before proceeding.

Question 42: 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?

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

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 43: 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
All radiation patients must be decontaminated with bleach
Radiation cannot cause burns and the patient likely has a chemical injury
Provider safety through contamination control and limiting exposure time, distance, and shielding (Correct answer)

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 44: A trauma patient with an open neck wound develops progressive subcutaneous emphysema and respiratory distress. What airway complication should be suspected?

Pericardial tamponade
Simple pneumothorax
Esophageal perforation
Tracheal or bronchial disruption (Correct answer)

Correct answer: Tracheal or bronchial disruption

Progressive subcutaneous emphysema from a neck wound combined with respiratory distress suggests tracheal or bronchial disruption, allowing air to dissect into subcutaneous tissues.

Question 45: 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:

Liver
Stomach
Kidney
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 46: What anatomical difference makes children more susceptible to cervical spine injuries at the C1-C3 level compared to the adult pattern of lower cervical injuries?

Children have stronger neck muscles
Children have fused cervical vertebrae
There is no difference in cervical injury patterns between children and adults
Children have proportionally larger and heavier heads, higher fulcrum of cervical motion (C1-C3 vs. C5-C6 in adults), and more horizontal facet joints that allow greater mobility (Correct answer)

Correct answer: Children have proportionally larger and heavier heads, higher fulcrum of cervical motion (C1-C3 vs. C5-C6 in adults), and more horizontal facet joints that allow greater mobility

Children's disproportionately large, heavy heads create a higher fulcrum of cervical motion (C1-C3 versus C5-C6 in adults), and their more horizontal facet joints and ligamentous laxity allow greater mobility, concentrating forces at the upper cervical spine.

Question 47: 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?

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

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 48: 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?

C5-C6
L1-L2
T1-T2
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 49: Why should ITLS providers avoid using the Trendelenburg position (legs elevated, head down) for treating hemorrhagic shock?

Evidence shows it does not sustainably improve blood pressure, may increase ICP, compromise respirations from abdominal viscera pressure on the diaphragm, and is potentially harmful in head-injured patients (Correct answer)
It causes all patients to vomit
It is only used for neurogenic shock, not hemorrhagic shock
The position is too difficult to achieve in the field

Correct answer: Evidence shows it does not sustainably improve blood pressure, may increase ICP, compromise respirations from abdominal viscera pressure on the diaphragm, and is potentially harmful in head-injured patients

The Trendelenburg position provides only transient blood pressure improvement, can increase intracranial pressure (harmful in TBI), impairs diaphragmatic excursion from abdominal contents pressing on it, and may increase aspiration risk.

Question 50: An electrician is found unconscious after contact with a high-voltage wire. He has small entry and exit burns on his hands and feet. What is the most critical and immediate concern for this patient beyond the surface burns?

Fluid loss calculated solely based on the visible burn surface area.
Severe internal tissue damage and potential cardiac dysrhythmias. (Correct answer)
Infection of the small entry and exit wounds.
Rapid development of hypothermia due to skin damage.

Correct answer: Severe internal tissue damage and potential cardiac dysrhythmias.

High-voltage electricity travels through the body, causing extensive internal damage to muscles and organs (rhabdomyolysis) that is not visible externally. The current can also disrupt the heart's electrical conduction system, leading to life-threatening dysrhythmias like ventricular fibrillation. Therefore, cardiac monitoring and aggressive fluid resuscitation are paramount, as the visible burns are a poor indicator of the true injury severity.

Question 51: A patient has sustained a penetrating injury to the chest and you have identified an open pneumothorax (sucking chest wound). What is the appropriate initial management for this injury in the field?

Log roll the patient onto the injured side.
Immediately perform a needle decompression.
Apply an occlusive dressing taped on three sides. (Correct answer)
Pack the wound with sterile gauze.

Correct answer: Apply an occlusive dressing taped on three sides.

The correct management for an open pneumothorax is to apply an occlusive dressing taped on three sides. This creates a one-way valve effect, allowing air to escape from the pleural space during exhalation but preventing air from entering during inhalation, which helps to prevent the development of a tension pneumothorax.

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.

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60 min

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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
Your progress is auto-saved every 30 seconds