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ATLS Practice Test 4
Answers & Explanations
1. A 5-year-old boy falls 3 meters from a tree and strikes his abdomen on a branch. He is alert and
crying. Vital signs: heart rate 132 beats per minute, respiratory rate 30 per minute, blood pressure
86/48 mm Hg, capillary refill is 3 seconds. Focused sonography shows free fluid in Morrison’s
pouch. What is the next best step?
A. Computed tomography of the abdomen and pelvis with intravenous contrast
B. Immediate exploratory laparotomy
C. Diagnostic peritoneal lavage
D. Serial abdominal examinations with observation
E. Intravenous fluid bolus and repeat sonography in 1 hour
B.
A pediatric patient with hemodynamic instability (hypotension and tachycardia for age) and
positive FAST scan has presumed intra-abdominal bleeding. In this context, operative exploration
is indicated, not further imaging. Children compensate until late in shock — hypotension is a
preterminal sign.
A. CT is reserved for stable patients; this child is not stable.
C. Diagnostic peritoneal lavage is obsolete with FAST available.
D. Observation is inappropriate in an unstable child with positive FAST.
E. A single bolus may be given, but ongoing instability mandates laparotomy.
2. A 28-year-old woman, 26 weeks pregnant, is struck in the abdomen. Vital signs: HR 100, BP
105/70 mm Hg, pallor noted. Why might her blood pressure remain near normal despite
significant hemorrhage?
A. Estrogen-mediated vasodilation
B. Increased plasma volume and delayed hypotension
C. Measurement error due to cuff size
D. Maternal catecholamine surge
E. Compression of aorta by uterus
B.
Pregnancy increases plasma volume by approximately 40%, masking early blood loss.
Hypotension appears only after major hemorrhage; hence, tachycardia and pallor significantly
precede BP drop.
A. Estrogen vasodilates but is not compensatory.
C. Technical issue – irrelevant.
D. Catecholamines can transiently support BP but not the key reason.
E. Aortocaval compression lowers BP, not preserve it.
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3. A stable trauma patient has isolated hip pain after a fall. No leg shortening or external rotation,
but cannot bear weight. Pelvic X-ray normal. What is the best next step?
A. MRI of hip
B. CT of pelvis
C. Observation and repeat X-ray in 24 hours
D. Apply traction
E. Discharge with analgesia
A.
Elderly patients can have occult, non-displaced femoral-neck fractures with a normal X-ray. MRI
(or CT if MRI unavailable) detects incomplete fractures that need surgical fixation.
B. CT less sensitive than MRI for trabecular injury.
C. Delay risks fracture displacement.
D. Traction is not indicated for possible hip fracture.
E. Unsafe; risks displacing possible fracture.
4. An 82-year-old woman on warfarin and aspirin sustains a minor fall. She is alert, BP 110/70 mm
Hg. One hour later, she becomes confused. Which agent should be administered immediately
after confirming INR 6.2?
A. Fresh frozen plasma
B. Desmopressin
C. Platelet transfusion
D. Recombinant factor VIIa
E. Prothrombin complex concentrate (PCC) plus vitamin K
E.
ATLS emphasizes rapid reversal of vitamin K antagonists with 4-factor PCC + vitamin K.
A. Works but is slow and risks fluid overload, especially in elderly.
B. Indicated mainly for uremic platelet dysfunction.
C. For antiplatelet agents, not warfarin.
D. Off-label, transient benefit.
5. A 9-year-old boy is struck in the anterior neck by bicycle handlebars. He is alert but has hoarse
voice, mild stridor, and subcutaneous crepitus over the neck. Oxygen saturation is 94%. What is
the most appropriate next step?
A. Immediate orotracheal intubation with rapid sequence induction
B. Needle cricothyrotomy
C. Awake fiber-optic intubation with surgical backup
D. Observation with humidified oxygen and serial exams
E. Surgical tracheostomy under general anesthesia
2
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C.
Blunt laryngotracheal injury risks total airway collapse if sedated for RSI. Controlled, awake
fiber-optic intubation preserves spontaneous breathing until the airway is secure. However,
always have a surgical airway kit ready.
A. RSI may worsen obstruction or cause complete loss of airway.
B. Needle cricothyrotomy is a rescue measure if the airway lost, not first-line while stable.
D. Observation is unsafe; progressive edema can cause rapid obstruction.
E. Tracheostomy requires existing airway control first.
6. During the secondary survey of a stable patient, you note periorbital ecchymosis with blood-
tinged clear fluid dripping from the nose. What should you do next?
A. Insert a nasogastric tube to decompress stomach
B. Suspect basilar skull fracture and avoid nasal instrumentation
C. Ignore the finding since nasal bleeding is common after trauma
D. Pack the nose tightly to stop the fluid leak
E. Discharge the patient with sinus precautions
B.
Clear nasal discharge post-trauma is likely cerebrospinal fluid rhinorrhea. It indicates a basilar
skull fracture — nasal instrumentation (e.g. nasogastric, nasotracheal) risks intracranial insertion.
Observation, CT, and neurosurgical consultation are indicated.
A. Nasal tubes are contraindicated.
C. Dismissing these findings may miss a basilar skull fracture.
D. Packing may worsen leak or raise intracranial pressure.
E. Outpatient management is unsafe.
7. A 26-year-old pregnant trauma patient at 36 weeks gestation is in cardiac arrest. CPR is ongoing.
When should resuscitative hysterotomy (perimortem cesarean section) be performed?
A. Immediately, as soon as arrest is identified
B. After 4 minutes of unsuccessful resuscitation
C. Only if fetal heart tones are detected
D. Only if the mother is stable enough for surgery
E. Never in the emergency department
B.
If maternal arrest persists beyond 4 minutes, resuscitative hysterotomy should be initiated to
relieve aortocaval compression and potentially save both mother and fetus. Ideal delivery
completion is within 5 minutes of arrest.
A. Initial 4 minutes focus on maternal resuscitation.
C. Presence of fetal heart tones is not required; procedure aids maternal venous return.
D. Dangerous delay.
E. Emergency department is precisely where it is performed.
3
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8. A 21-year-old male has a stab wound to the anterior neck at the level of the cricoid cartilage. He
is breathing spontaneously, speaking in short sentences, and has a small expanding neck
hematoma with mild stridor. Laryngoscopy reveals partial airway obstruction from anterior
swelling. What is the recommended immediate airway management?
A. Perform awake orotracheal intubation using rapid sequence technique.
B. Attempt blind nasotracheal intubation.
C. Perform awake fiberoptic nasotracheal intubation with surgical backup.
D. Immediate cricothyroidotomy in the emergency department.
E. Observe and prepare for possible intubation if obstruction progresses.
C.
An expanding neck hematoma with partial airway compromise is best managed by securing the
airway in a controlled manner using awake fiberoptic nasotracheal intubation when feasible,
because it allows visualization and avoids losing the airway. Surgical backup for immediate
surgical airway is mandatory because the airway can deteriorate unpredictably.
A. Rapid sequence orotracheal intubation may fail when the airway anatomy is distorted by a
hematoma and may precipitate complete airway loss. Awake, controlled intubation is safer.
B. Blind nasotracheal intubation has a high failure rate and risk of bleeding in penetrating
neck injury; it is not recommended.
D. Immediate cricothyroidotomy is indicated when nonoperative intubation is impossible. In a
patient who can still cooperate, the less invasive visualized approach with surgical backup
is preferred.
E. Observation risks rapid progression to complete obstruction; proactive airway control is
indicated.
9. An 83-year-old man presents after a low-speed motor vehicle crash. He has mild abdominal pain
but normal FAST. Two hours later, his blood pressure drops and hemoglobin decreases. What is
the most likely cause?
A. Solid organ laceration missed on FAST
B. Delayed hollow viscus perforation
C. Retroperitoneal bleed from pelvic vessel injury
D. Intrathoracic bleeding
E. Acute myocardial infarction
C.
Older adults tend to have fragile vessels and osteoporotic bones — minor pelvic fractures can
cause massive retroperitoneal hemorrhage not detected by FAST. Sudden hypotension with drop
in hemoglobin after initially normal imaging strongly suggests a hidden retroperitoneal bleed.
A. FAST is sensitive for large intraperitoneal bleeding; missed solid organ injury is less likely
if performed properly.
B. Perforation causes peritonitis, not sudden hemorrhage.
D. There are no respiratory signs.
E. Myocardial infarction may mimic shock but would not cause falling hemoglobin.
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ATLS Practice Test 4
Answers & Explanations
1. A 5-year-old boy falls 3 meters from a tree and strikes his abdomen on a branch. He is alert and
crying. Vital signs: heart rate 132 beats per minute, respiratory rate 30 per minute, blood pressure
86/48 mm Hg, capillary refill is 3 seconds. Focused sonography shows free fluid in Morrison’s
pouch. What is the next best step?
A. Computed tomography of the abdomen and pelvis with intravenous contrast
B. Immediate exploratory laparotomy
C. Diagnostic peritoneal lavage
D. Serial abdominal examinations with observation
E. Intravenous fluid bolus and repeat sonography in 1 hour
B.
A pediatric patient with hemodynamic instability (hypotension and tachycardia for age) and
positive FAST scan has presumed intra-abdominal bleeding. In this context, operative exploration
is indicated, not further imaging. Children compensate until late in shock — hypotension is a
preterminal sign.
A. CT is reserved for stable patients; this child is not stable.
C. Diagnostic peritoneal lavage is obsolete with FAST available.
D. Observation is inappropriate in an unstable child with positive FAST.
E. A single bolus may be given, but ongoing instability mandates laparotomy.
2. A 28-year-old woman, 26 weeks pregnant, is struck in the abdomen. Vital signs: HR 100, BP
105/70 mm Hg, pallor noted. Why might her blood pressure remain near normal despite
significant hemorrhage?
A. Estrogen-mediated vasodilation
B. Increased plasma volume and delayed hypotension
C. Measurement error due to cuff size
D. Maternal catecholamine surge
E. Compression of aorta by uterus
B.
Pregnancy increases plasma volume by approximately 40%, masking early blood loss.
Hypotension appears only after major hemorrhage; hence, tachycardia and pallor significantly
precede BP drop.
A. Estrogen vasodilates but is not compensatory.
C. Technical issue – irrelevant.
D. Catecholamines can transiently support BP but not the key reason.
E. Aortocaval compression lowers BP, not preserve it.
1
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3. A stable trauma patient has isolated hip pain after a fall. No leg shortening or external rotation,
but cannot bear weight. Pelvic X-ray normal. What is the best next step?
A. MRI of hip
B. CT of pelvis
C. Observation and repeat X-ray in 24 hours
D. Apply traction
E. Discharge with analgesia
A.
Elderly patients can have occult, non-displaced femoral-neck fractures with a normal X-ray. MRI
(or CT if MRI unavailable) detects incomplete fractures that need surgical fixation.
B. CT less sensitive than MRI for trabecular injury.
C. Delay risks fracture displacement.
D. Traction is not indicated for possible hip fracture.
E. Unsafe; risks displacing possible fracture.
4. An 82-year-old woman on warfarin and aspirin sustains a minor fall. She is alert, BP 110/70 mm
Hg. One hour later, she becomes confused. Which agent should be administered immediately
after confirming INR 6.2?
A. Fresh frozen plasma
B. Desmopressin
C. Platelet transfusion
D. Recombinant factor VIIa
E. Prothrombin complex concentrate (PCC) plus vitamin K
E.
ATLS emphasizes rapid reversal of vitamin K antagonists with 4-factor PCC + vitamin K.
A. Works but is slow and risks fluid overload, especially in elderly.
B. Indicated mainly for uremic platelet dysfunction.
C. For antiplatelet agents, not warfarin.
D. Off-label, transient benefit.
5. A 9-year-old boy is struck in the anterior neck by bicycle handlebars. He is alert but has hoarse
voice, mild stridor, and subcutaneous crepitus over the neck. Oxygen saturation is 94%. What is
the most appropriate next step?
A. Immediate orotracheal intubation with rapid sequence induction
B. Needle cricothyrotomy
C. Awake fiber-optic intubation with surgical backup
D. Observation with humidified oxygen and serial exams
E. Surgical tracheostomy under general anesthesia
2
, mcatest.wixsite.com/atls
C.
Blunt laryngotracheal injury risks total airway collapse if sedated for RSI. Controlled, awake
fiber-optic intubation preserves spontaneous breathing until the airway is secure. However,
always have a surgical airway kit ready.
A. RSI may worsen obstruction or cause complete loss of airway.
B. Needle cricothyrotomy is a rescue measure if the airway lost, not first-line while stable.
D. Observation is unsafe; progressive edema can cause rapid obstruction.
E. Tracheostomy requires existing airway control first.
6. During the secondary survey of a stable patient, you note periorbital ecchymosis with blood-
tinged clear fluid dripping from the nose. What should you do next?
A. Insert a nasogastric tube to decompress stomach
B. Suspect basilar skull fracture and avoid nasal instrumentation
C. Ignore the finding since nasal bleeding is common after trauma
D. Pack the nose tightly to stop the fluid leak
E. Discharge the patient with sinus precautions
B.
Clear nasal discharge post-trauma is likely cerebrospinal fluid rhinorrhea. It indicates a basilar
skull fracture — nasal instrumentation (e.g. nasogastric, nasotracheal) risks intracranial insertion.
Observation, CT, and neurosurgical consultation are indicated.
A. Nasal tubes are contraindicated.
C. Dismissing these findings may miss a basilar skull fracture.
D. Packing may worsen leak or raise intracranial pressure.
E. Outpatient management is unsafe.
7. A 26-year-old pregnant trauma patient at 36 weeks gestation is in cardiac arrest. CPR is ongoing.
When should resuscitative hysterotomy (perimortem cesarean section) be performed?
A. Immediately, as soon as arrest is identified
B. After 4 minutes of unsuccessful resuscitation
C. Only if fetal heart tones are detected
D. Only if the mother is stable enough for surgery
E. Never in the emergency department
B.
If maternal arrest persists beyond 4 minutes, resuscitative hysterotomy should be initiated to
relieve aortocaval compression and potentially save both mother and fetus. Ideal delivery
completion is within 5 minutes of arrest.
A. Initial 4 minutes focus on maternal resuscitation.
C. Presence of fetal heart tones is not required; procedure aids maternal venous return.
D. Dangerous delay.
E. Emergency department is precisely where it is performed.
3
, mcatest.wixsite.com/atls
8. A 21-year-old male has a stab wound to the anterior neck at the level of the cricoid cartilage. He
is breathing spontaneously, speaking in short sentences, and has a small expanding neck
hematoma with mild stridor. Laryngoscopy reveals partial airway obstruction from anterior
swelling. What is the recommended immediate airway management?
A. Perform awake orotracheal intubation using rapid sequence technique.
B. Attempt blind nasotracheal intubation.
C. Perform awake fiberoptic nasotracheal intubation with surgical backup.
D. Immediate cricothyroidotomy in the emergency department.
E. Observe and prepare for possible intubation if obstruction progresses.
C.
An expanding neck hematoma with partial airway compromise is best managed by securing the
airway in a controlled manner using awake fiberoptic nasotracheal intubation when feasible,
because it allows visualization and avoids losing the airway. Surgical backup for immediate
surgical airway is mandatory because the airway can deteriorate unpredictably.
A. Rapid sequence orotracheal intubation may fail when the airway anatomy is distorted by a
hematoma and may precipitate complete airway loss. Awake, controlled intubation is safer.
B. Blind nasotracheal intubation has a high failure rate and risk of bleeding in penetrating
neck injury; it is not recommended.
D. Immediate cricothyroidotomy is indicated when nonoperative intubation is impossible. In a
patient who can still cooperate, the less invasive visualized approach with surgical backup
is preferred.
E. Observation risks rapid progression to complete obstruction; proactive airway control is
indicated.
9. An 83-year-old man presents after a low-speed motor vehicle crash. He has mild abdominal pain
but normal FAST. Two hours later, his blood pressure drops and hemoglobin decreases. What is
the most likely cause?
A. Solid organ laceration missed on FAST
B. Delayed hollow viscus perforation
C. Retroperitoneal bleed from pelvic vessel injury
D. Intrathoracic bleeding
E. Acute myocardial infarction
C.
Older adults tend to have fragile vessels and osteoporotic bones — minor pelvic fractures can
cause massive retroperitoneal hemorrhage not detected by FAST. Sudden hypotension with drop
in hemoglobin after initially normal imaging strongly suggests a hidden retroperitoneal bleed.
A. FAST is sensitive for large intraperitoneal bleeding; missed solid organ injury is less likely
if performed properly.
B. Perforation causes peritonitis, not sudden hemorrhage.
D. There are no respiratory signs.
E. Myocardial infarction may mimic shock but would not cause falling hemoglobin.
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