ITLS - International Trauma Life Support Exam — Questions and Answers

Question 1: When splinting a fracture, which principle is fundamental to proper immobilization technique?

Straighten all fractures before splinting
Apply the splint as tightly as possible to prevent movement
Immobilize only the joint above the fracture
Immobilize the joint above and below the fracture site (Correct answer)

Correct answer: Immobilize the joint above and below the fracture site

Proper splinting requires immobilizing the joint above and below the fracture to prevent any movement at the fracture site during patient transport.

Question 2: A pregnant trauma patient at 30 weeks reports she felt the baby 'stop moving' after a car crash 2 hours ago. Which assessment is most important in the field?

Skin color of the patient
Maternal blood pressure
Fetal heart tones (Correct answer)
Uterine fundal height

Correct answer: Fetal heart tones

Absent or abnormal fetal heart tones after trauma indicate possible fetal compromise requiring urgent hospital evaluation.

Question 3: 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?

5760 mL
2880 mL (Correct answer)
720 mL
1440 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 4: 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:

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

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 5: A 34-year-old man has a gunshot wound to the right groin area. Arterial bleeding, which cannot be controlled with direct pressure or a tourniquet, is coming from the wound. The patient appears confused, diaphoretic and has weak peripheral pulses. What is the appropriate fluid resuscitation regimen for this patient?

Intravenous fluid; gives enough fluid to maintain peripheral pulses (Correct answer)
Intravenous fluid at a "keep open" rate
No intravenous access should be established in this situation
Intravenous fluid at a “wide open” rate

Correct answer: Intravenous fluid; gives enough fluid to maintain peripheral pulses

Explanation: <br> Give only enough normal saline to maintain a blood pressure high enough for adequate peripheral perfusion. Maintaining peripheral perfusion may be defined as producing a peripheral pulse (such as a radial pulse)

Question 6: What is the most reliable method to confirm correct endotracheal tube placement in the field?

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

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 7: 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 8: What clinical signs indicate Cushing's triad, and what does it signify?

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

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

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)
Give 10 mL/kg per hour as a continuous infusion
Use the Parkland formula for all pediatric trauma
Give the same volumes as an adult

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

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

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

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

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 12: 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 13: 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?

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)
Mild hypovolemia that will resolve without treatment
Pain-related tachycardia with no hemodynamic significance
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 14: In the context of maternal trauma, which finding is the most critical indicator that fetal perfusion is likely compromised?

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

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 15: A 5-year-old child weighing 20 kg is in decompensated hemorrhagic shock following blunt abdominal trauma. According to ITLS guidelines, what is the correct initial isotonic crystalloid fluid bolus?

A 1,000 mL bolus administered over 30 minutes.
A 400 mL bolus (20 mL/kg) administered as quickly as possible. (Correct answer)
A 200 mL bolus (10 mL/kg) administered as quickly as possible.
A 500 mL bolus administered as quickly as possible.

Correct answer: A 400 mL bolus (20 mL/kg) administered as quickly as possible.

The standard initial fluid bolus for a pediatric trauma patient in shock is 20 mL/kg of an isotonic crystalloid solution (like Normal Saline or Lactated Ringer's). For a 20 kg child, this calculates to 20 kg * 20 mL/kg = 400 mL. This bolus should be administered rapidly.

Question 16: 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)
Left-sided brain injury with contralateral effect
Direct trauma to the right eye
Normal pupillary variation

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 17: When managing a patient with a severe traumatic brain injury who is showing signs of cerebral herniation (e.g., unilateral dilated pupil, posturing), what is the recommended immediate ventilation strategy according to ITLS?

Allow permissive hypercapnia to increase cerebral blood flow.
Provide mild, controlled hyperventilation to a target EtCO2 of 30-35 mmHg. (Correct answer)
Maintain normal ventilation to achieve an EtCO2 of 35-45 mmHg.
Hyperventilate the patient to maintain an EtCO2 of 20-25 mmHg.

Correct answer: Provide mild, controlled hyperventilation to a target EtCO2 of 30-35 mmHg.

While routine hyperventilation is harmful, in the presence of active cerebral herniation, ITLS guidelines recommend controlled, mild hyperventilation as a temporizing measure. Lowering the PaCO2 (and thus EtCO2) to 30-35 mmHg causes cerebral vasoconstriction, which can briefly reduce intracranial pressure until definitive care is available. [3, 22, 25]

Question 18: Which statement best describes the core ethical principle guiding triage decisions during a mass casualty incident?

Prioritize transport over all on-scene treatment in every MCI situation
Do the most good for the greatest number of patients with available resources (Correct answer)
Provide maximum treatment to each individual patient regardless of resource limitations
Treat only patients who have the highest probability of 100% recovery

Correct answer: Do the most good for the greatest number of patients with available resources

MCI triage is governed by the utilitarian principle of doing the most good for the greatest number of patients with the limited resources available.

Question 19: How do you differentiate obstructive shock from hypovolemic shock in a trauma patient?

They cannot be differentiated in the prehospital setting
Hypovolemic shock always causes bradycardia
Obstructive shock only occurs in blunt trauma
Obstructive shock (tension pneumothorax, cardiac tamponade) presents with JVD and often unilateral breath sounds changes, while hypovolemic shock presents with flat neck veins and clear lungs (Correct answer)

Correct answer: Obstructive shock (tension pneumothorax, cardiac tamponade) presents with JVD and often unilateral breath sounds changes, while hypovolemic shock presents with flat neck veins and clear lungs

Obstructive shock causes mechanical obstruction to cardiac output (distended neck veins from impaired venous return) while hypovolemic shock depletes circulating volume (flat neck veins). The physical exam findings help distinguish them and guide treatment.

Question 20: 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.
Applying a pneumatic anti-shock garment (PASG).
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)

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 21: A blunt trauma patient has a rigid, distended abdomen with hemodynamic instability. What is the most likely diagnosis and what is the definitive treatment?

Bowel obstruction requiring NG tube placement
Urinary retention requiring catheterization
Gastric distension from air swallowing
Intra-abdominal hemorrhage from solid organ injury (liver or spleen) requiring emergency surgical exploration (laparotomy) (Correct answer)

Correct answer: Intra-abdominal hemorrhage from solid organ injury (liver or spleen) requiring emergency surgical exploration (laparotomy)

A rigid, distended abdomen with hemodynamic instability following blunt trauma indicates significant intra-abdominal hemorrhage, most commonly from liver or splenic laceration, requiring emergency laparotomy as the only definitive treatment.

Question 22: What is the difference between a simple pneumothorax and an open pneumothorax, and how is each managed in the field?

A simple pneumothorax has no chest wall opening (air enters from a lung tear) and is monitored; an open pneumothorax has a chest wall defect communicating with the pleural space and requires an occlusive dressing with a vented seal (Correct answer)
Open pneumothorax only occurs with rib fractures
Simple pneumothorax is always larger than open pneumothorax
They are the same condition

Correct answer: A simple pneumothorax has no chest wall opening (air enters from a lung tear) and is monitored; an open pneumothorax has a chest wall defect communicating with the pleural space and requires an occlusive dressing with a vented seal

A simple pneumothorax involves air in the pleural space from internal lung injury without a chest wall defect. An open pneumothorax has an external wound creating a communication between the atmosphere and pleural space, requiring a vented occlusive dressing.

Question 23: 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
Hemorrhage, infection, and organ failure
Tachycardia, hypotension, and altered mental status

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 24: JumpSTART is a modification of START triage designed specifically for:

Geriatric patients over age 65
Burn victims with greater than 20% BSA burns
Pediatric patients (Correct answer)
Patients with suspected spinal injuries

Correct answer: Pediatric patients

JumpSTART was developed to address the physiological differences in children during mass casualty triage, as children have different normal vital signs than adults.

Question 25: 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 110/70 mmHg, HR 110 bpm, pale and diaphoretic skin
BP 80/50 mmHg, HR 130 bpm, cool and clammy skin
BP 86/58 mmHg, HR 58 bpm, warm and dry skin (Correct answer)
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 26: 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
Greater than 140 mmHg
At least 110 mmHg (Correct answer)
70-80 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 27: When performing a primary survey on a trauma patient, you notice paradoxical chest wall movement. What condition does this indicate?

Simple pneumothorax
Cardiac tamponade
Flail chest (Correct answer)
Pulmonary embolism

Correct answer: Flail chest

Paradoxical chest wall movement—a segment of the chest wall moving inward during inspiration and outward during expiration—indicates flail chest caused by multiple adjacent rib fractures.

Question 28: 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?

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

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

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

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 30: In the START algorithm, if an apneic adult patient does not begin breathing after airway repositioning, the rescuer should:

Begin CPR immediately with 30:2 compression-to-ventilation ratio
Tag the patient expectant and move to assess the next patient (Correct answer)
Reposition the airway a second time before making a triage decision
Tag the patient immediate and provide rescue ventilations before moving on

Correct answer: Tag the patient expectant and move to assess the next patient

In START triage (for adults), an apneic patient who does not breathe after a single airway opening maneuver is tagged expectant, as CPR is not initiated during active MCI triage.

Question 31: A 34-week pregnant patient involved in a moderate MVC has a heart rate of 116 bpm, pale skin, and a blood pressure of 114/72 mmHg. The fetal heart rate is 94 bpm. How should you interpret this clinical picture?

Early compensated maternal hemorrhagic shock — the fetus is already showing distress before maternal BP drops (Correct answer)
Fetal bradycardia is a normal finding and does not require expedited transport
Stable presentation; tachycardia is normal in pregnancy and the blood pressure is adequate
The maternal vital signs indicate mild anxiety; monitor and reassess in 10 minutes

Correct answer: Early compensated maternal hemorrhagic shock — the fetus is already showing distress before maternal BP drops

Pregnant patients expand their blood volume by 40–50%, allowing them to compensate for significant hemorrhage while appearing relatively stable. However, the fetus receives reduced perfusion much earlier, manifesting as fetal bradycardia (normal FHR is 120–160 bpm). A fetal HR of 94 bpm signals fetal distress even when the mother's BP appears acceptable.

Question 32: 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
Perform an emergency tracheostomy
Switch to a smaller mask
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 33: In the assessment of a pediatric trauma patient, which finding should be considered a more significant indicator of shock compared to an adult patient?

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

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 34: A patient has a gunshot wound to the groin crease with arterial bleeding. A tourniquet cannot be applied at this junctional location. What is the most appropriate hemorrhage control technique?

Pack the wound with hemostatic gauze and apply direct pressure (Correct answer)
Apply pressure with a standard gauze pad only
Apply a tourniquet to the upper thigh
Clamp the vessel with hemostats

Correct answer: Pack the wound with hemostatic gauze and apply direct pressure

Junctional hemorrhage (groin, axilla, neck) cannot be controlled by tourniquet. Wound packing with hemostatic gauze (such as Combat Gauze or Celox) followed by sustained direct pressure is the recommended technique.

Question 35: 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 36: 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?

Pelvic fractures do not cause urological injuries
Insert a Foley catheter immediately to drain urine
The blood is from an external wound and can be cleaned
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)

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 37: Which of the following mechanisms of injury does not commonly cause damage to the spinal cord?

Hyperflexion
Compression
Hyperextension
Lateral stress (Correct answer)

Correct answer: Lateral stress

Explanation: <br> Certain mechanisms of trauma can overcome the protective properties, injuring the spinal column and cord. The most common mechanisms are hyperextension, hyperflexion, compression, and rotation. Less commonly, lateral stress or distraction will injure the cord.

Question 38: 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)
An increased probability that the fractured ribs will puncture the lung.
A pre-existing higher likelihood of having a smoking history.

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 39: A pregnant patient at 32 weeks is in hypovolemic shock after trauma and requires IV fluid resuscitation. Which physiologic consideration is most important when interpreting her hemoglobin and hematocrit values obtained at the receiving facility?

Hemoglobin rises progressively throughout pregnancy, so any value below 14 g/dL is abnormal
Fetal red blood cell production artificially raises the mother's CBC values
Pregnancy causes polycythemia, so hemoglobin values will be falsely elevated
Dilutional anemia of pregnancy means a hematocrit of 31–35% may be her normal baseline, not a sign of acute blood loss (Correct answer)

Correct answer: Dilutional anemia of pregnancy means a hematocrit of 31–35% may be her normal baseline, not a sign of acute blood loss

Plasma volume expands by approximately 50% during pregnancy while red blood cell mass increases by only 20–30%, producing a physiologic dilutional anemia. A hematocrit of 31–35% or hemoglobin of 10–12 g/dL may represent the patient's normal pregnant baseline rather than acute hemorrhage. Trending values and clinical signs of perfusion are more reliable than a single lab snapshot.

Question 40: 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?

Whether the patient has health insurance
Whether the patient was exercising before 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

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 41: What is the correct initial fluid resuscitation strategy for a patient with 40% TBSA burns according to the Parkland formula?

D5W at 250 mL per hour
Lactated Ringer's: 4 mL × body weight (kg) × %TBSA, half in first 8 hours (Correct answer)
Normal saline at a maintenance rate
Colloid solution bolus of 500 mL

Correct answer: Lactated Ringer's: 4 mL × body weight (kg) × %TBSA, half in first 8 hours

The Parkland formula calculates total crystalloid needs as 4 mL × kg × %TBSA burned, with half the calculated volume infused in the first 8 hours from the time of burn and the remainder over the following 16 hours.

Question 42: Why is the semi-recumbent left lateral tilt position preferred over full lateral decubitus when immobilizing a pregnant trauma patient on a backboard?

It improves venous access to the arm
It relieves aortocaval compression while maintaining spinal precautions (Correct answer)
It reduces pain from uterine contractions
It prevents aspiration more effectively

Correct answer: It relieves aortocaval compression while maintaining spinal precautions

A 15–30 degree left tilt with wedging under the right side of the board relieves IVC compression while still allowing spinal immobilization.

Question 43: In a rear-impact motor vehicle crash, which area of the spine is most susceptible to injury?

Sacral-coccygeal
Lumbar
Thoracic
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 44: When placing IV access in a critically injured pregnant patient, which site is preferred?

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

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 45: During the treatment phase of a MCI, how should available medical resources be allocated among patients?

Assign one provider per patient regardless of injury severity
Treat all patients in the chronological order they arrived at the CCP
Allocate resources based on patient triage category, prioritizing immediate patients (Correct answer)
Focus all available resources on expectant patients to attempt to save them

Correct answer: Allocate resources based on patient triage category, prioritizing immediate patients

Resources should be allocated based on triage priority, directing the most personnel and supplies toward immediate patients while minor patients may self-treat or wait.

Question 46: An elderly patient involved in a low-speed MVC denies any complaints and wants to refuse transport. Her vitals show BP 148/92 and HR 76. What ITLS principle applies to this situation?

Normal vitals confirm she is uninjured; she can refuse transport
Low-speed MVCs cannot cause injury in properly restrained adults
All MVC patients regardless of age must be transported by law
Elderly patients may have significant occult injuries despite normal-appearing vital signs and minimal complaints due to decreased pain perception and medication effects (Correct answer)

Correct answer: Elderly patients may have significant occult injuries despite normal-appearing vital signs and minimal complaints due to decreased pain perception and medication effects

ITLS teaches that elderly trauma patients frequently have occult injuries masked by decreased pain perception, medications that alter vital signs, and the inability to mount appropriate physiologic responses. What appears stable may conceal life-threatening injuries.

Question 47: Which of the following assessment findings is associated with neurogenic shock?

Increased pulse, cool clammy skin
Decreased pulse, cool clammy skin
Increased pulse, normal skin color, and temperature
Decreased pulse, normal skin color, and temperature (Correct answer)

Correct answer: Decreased pulse, normal skin color, and temperature

Explanation: <br> A lack of catecholamine release prevents tachycardia, pallor, and sweating. Instead, vasodilation will cause decreased blood pressure, the heart rate will remain normal, or slow and the skin will remain pink, warm, and dry.

Question 48: When is it appropriate to apply a tourniquet in the prehospital setting according to current ITLS guidelines?

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
Only after all other methods have failed for at least 10 minutes

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

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

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 50: 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
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)
It always presents with cardiac arrest
It presents with obvious external chest bleeding

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 51: Which of the following is the primary goal of permissive hypotension in the prehospital management of a patient with suspected non-compressible torso hemorrhage?

To improve cerebral perfusion in patients with associated head trauma.
To increase renal perfusion and prevent acute kidney injury.
To rapidly normalize blood pressure to 120/80 mmHg.
To prevent clot disruption and re-bleeding before surgical control. (Correct answer)

Correct answer: To prevent clot disruption and re-bleeding before surgical control.

Permissive hypotension is a strategy of restricting fluid resuscitation to maintain a lower-than-normal blood pressure (e.g., SBP of 80-90 mmHg) in patients with suspected non-compressible hemorrhage. The goal is to avoid dislodging newly formed clots by excessive intravascular pressure, which could worsen bleeding before the patient reaches definitive surgical care.

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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