ITLS Adult Basic 2 — Questions and Answers

Question 1: During an ITLS Basic primary survey, you find a patient responsive only to painful stimuli. What is the most appropriate airway maneuver for this patient with a suspected cervical spine injury?

Head-tilt chin-lift
Jaw thrust without head extension (Correct answer)
Nasopharyngeal airway insertion only
Immediate oral intubation

Correct answer: Jaw thrust without head extension

The jaw thrust without head extension is the preferred airway maneuver for trauma patients with suspected cervical spine injury, as it opens the airway without moving the neck.

In ITLS Basic, the jaw thrust maneuver is performed by placing fingers behind the angles of the mandible and lifting forward while maintaining inline stabilization of the cervical spine. This displaces the tongue from the posterior pharynx without extending the neck. The head-tilt chin-lift is contraindicated in suspected spinal injury as it hyperextends the cervical spine. A nasopharyngeal airway is an adjunct that can supplement but not replace manual airway positioning. Oral intubation is an advanced procedure not within the ITLS Basic scope. If the jaw thrust fails to open the airway, a modified chin lift with minimal head tilt may be necessary, as airway management always takes priority over potential spinal injury.

Question 2: What is the primary purpose of the ITLS initial assessment performed from the doorway or upon approach?

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

The ITLS initial assessment or 'general impression' is a rapid visual evaluation performed in the first few seconds of patient contact. The provider observes the patient's apparent age, sex, overall appearance, level of consciousness, obvious distress, and gross abnormalities. This 'across the room' assessment categorizes patients as: stable (alert, no apparent distress), potentially unstable (concerning mechanism or appearance), or unstable (obvious life threats). This determines the pace and approach—unstable patients receive rapid trauma survey while stable patients may receive a focused assessment. It is not a detailed examination but rather a gestalt that prioritizes care. Mechanism of injury is evaluated separately during scene size-up. GCS and injury identification come during the primary and secondary surveys.

Question 3: In ITLS Basic, which of the following patients meets criteria for rapid transport to a trauma center?

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

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

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

ITLS transport decision criteria include physiologic indicators (GCS <14, systolic BP <90, respiratory rate <10 or >29), anatomic indicators (penetrating injuries to head/neck/torso, flail chest, two or more proximal long bone fractures, amputation, pelvic fracture), and mechanism indicators (high-speed MVC, ejection, death in same vehicle, falls >20 feet). A penetrating abdominal wound meets anatomic criteria due to the high risk of visceral organ damage and internal hemorrhage that may not be immediately apparent. Isolated wrist fractures, superficial lacerations, and sprained ankles from low mechanisms do not meet trauma center criteria. The goal is to get severely injured patients to definitive surgical care within the golden hour.

Question 4: When performing a primary survey on a trauma patient, you notice paradoxical chest wall movement. What condition does this indicate?

Simple pneumothorax
Flail chest (Correct answer)
Cardiac tamponade
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.

Flail chest occurs when two or more adjacent ribs are fractured in two or more places, creating a free-floating segment of chest wall that moves independently. During spontaneous inspiration, negative intrathoracic pressure pulls the flail segment inward (opposite of normal expansion), and during expiration it moves outward—this is paradoxical movement. The underlying pulmonary contusion is typically more clinically significant than the mechanical instability. In ITLS Basic, treatment includes high-flow oxygen, positive pressure ventilation if respiratory distress is severe, and careful positioning. Simple pneumothorax presents with decreased breath sounds. Cardiac tamponade shows Beck's triad. Pulmonary embolism is rare in the acute trauma setting and presents differently.

Question 5: A basic-level EMT is assessing a responsive trauma patient who complains of difficulty breathing. Oxygen saturation reads 88%. What is the most appropriate immediate intervention?

Apply a nasal cannula at 2 L/min
Apply a non-rebreather mask at 15 L/min (Correct answer)
Begin bag-valve-mask ventilation
Perform needle decompression

Correct answer: Apply a non-rebreather mask at 15 L/min

For a responsive trauma patient with hypoxia, a non-rebreather mask at 15 L/min providing approximately 90% FiO2 is the most appropriate initial oxygen delivery method at the basic level.

An SpO2 of 88% represents significant hypoxia requiring high-flow oxygen. The non-rebreather mask at 15 L/min delivers 60-90% FiO2, appropriate for a responsive, spontaneously breathing patient. A nasal cannula at 2 L/min delivers only 24-28% FiO2—insufficient for this level of hypoxia. Bag-valve-mask ventilation is reserved for patients with inadequate respiratory effort (rate <10, very shallow breaths, or apnea); this patient is responsive and breathing, though with difficulty. Needle decompression is an advanced skill not available at the basic level and requires specific indications (tension pneumothorax). If the patient's condition deteriorates despite the non-rebreather, assisted ventilations with BVM would be the next step.

Question 6: During patient packaging for transport, which action is essential when securing a patient with a suspected spinal injury to a long backboard?

Secure the head first, then the torso
Secure the torso first, then the head (Correct answer)
Only secure the extremities
Place the patient in a lateral recumbent position

Correct answer: Secure the torso first, then the head

The torso is secured first to prevent the body from shifting when the head is strapped, which could cause dangerous cervical spine movement.

Proper spinal immobilization technique requires securing the torso to the backboard first using straps across the chest and pelvis. If the head were secured first and the torso subsequently moved during strapping, the cervical spine would be subjected to lateral or rotational forces. Once the torso is firmly secured and unable to shift, the head is then padded laterally and strapped to maintain neutral alignment. Manual inline stabilization must be maintained throughout until mechanical immobilization is complete. Securing only extremities provides no spinal protection. Lateral recumbent positioning may be used for airway management in non-spinal patients but is not appropriate for suspected spinal injury on a backboard.

ITLS Adult Basic 2

During an ITLS Basic primary survey, you find a patient responsive only to painful stimuli.
What is the most appropriate airway maneuver for this patient with a suspected cervical spine injury?