ATLS Practice Test 11
Answers & Explanations
1. A 34-year-old man is brought to the emergency department after a high-speed motorcycle
collision. He is conscious but agitated. Blood pressure is 90/60 mm Hg, heart rate is 128 beats per
minute, respiratory rate is 28 breaths per minute, and oxygen saturation by pulse oximetry is 94
percent on room air. There is obvious deformity and swelling of the left thigh. Focused
assessment with sonography for trauma is negative for pericardial fluid and free intraperitoneal
fluid. Pelvic X-ray shows no fracture. A pelvic binder is in place. There is no external chest
wound. Which action is the most appropriate next step for initial management?
A. Immediate computed tomography angiography of the chest, abdomen, and pelvis.
B. Rapid intravenous infusion of two liters of crystalloid solution and observe response.
C. Apply a tourniquet to the left thigh and prepare for immediate transfemoral amputation.
D. Initiate massive transfusion protocol and obtain cross-matched blood.
E. Perform exploratory laparotomy in the operating room.
D.
The patient is hemodynamically unstable with hypotension and tachycardia and has a major
femoral shaft fracture, a common source of significant hemorrhage. Ultrasound does not
exclude ongoing intrathoracic or pelvic bleeding. In a patient with ongoing hemodynamic
instability after a high-energy mechanism and an obvious potential source of major
hemorrhage, early activation of the massive transfusion protocol is indicated to replace lost
whole blood components, correct coagulopathy, and improve oxygen-carrying capacity.
Early blood component therapy improves outcomes compared with large-volume
crystalloid alone.
A. Computed tomography angiography is appropriate for hemodynamically stable patients
to localize bleeding, but this unstable patient should not be delayed for scanning;
immediate resuscitation and hemorrhage control take priority.
B. Large-volume crystalloid alone is no longer preferred because it dilutes clotting factors,
can worsen coagulopathy, and does not address oxygen-carrying capacity. Crystalloid may
be used briefly, but definitive resuscitation in a patient with suspected massive hemorrhage
requires blood products.
C. Applying a tourniquet is indicated for life-threatening extremity hemorrhage under
direct visualization of severe external bleeding. In a femoral shaft fracture with no
described external exsanguination and with bleeding likely internal, routine tourniquet or
immediate amputation is not appropriate.
E. Exploratory laparotomy is indicated if there is clinical or imaging evidence of intra-
abdominal hemorrhage in an unstable patient. Focused ultrasonography was negative, and
there is a clear extremity source of hemorrhage.
1
,2. A 65-year-old woman fell from a standing height and is brought to the trauma bay. She is on
warfarin therapy for a history of atrial fibrillation. She is somnolent but arousable, with a
Glasgow Coma Scale score of 12. Pupils are equal and reactive. Blood pressure is 150/80, and
heart rate is 74 beats per minute. Noncontrast head computed tomography shows a small acute
subdural hematoma over the left convexity with 4 millimeters of midline shift. Her international
normalized ratio is 3.5. Which immediate step is most appropriate?
A. Admit to the intensive care unit for observation and repeat head computed tomography in
24 hours.
B. Reverse anticoagulation with vitamin K and prothrombin complex concentrate now.
C. Administer mannitol and hyperventilate to reduce intracranial pressure.
D. Start tranexamic acid infusion and delay anticoagulation reversal until neurosurgical
consult.
E. Perform immediate craniotomy for hematoma evacuation.
B.
In a patient on warfarin with an acute intracranial hemorrhage and an elevated international
normalized ratio, rapid reversal of anticoagulation is essential to limit hematoma expansion
and secondary brain injury. Prothrombin complex concentrate provides rapid replacement
of vitamin K–dependent clotting factors and, together with intravenous vitamin K, achieves
prompt and sustained correction. This is the standard of care in warfarin-associated
intracranial hemorrhage.
A. Observation alone is unsafe with an elevated international normalized ratio and
radiographic midline shift because hematoma expansion is likely; reversal should not be
delayed.
C. Mannitol and hyperventilation temporarily reduce intracranial pressure but do not
address coagulopathy; they are adjunctive measures and are not the first intervention when
anticoagulation reversal is required.
D. Tranexamic acid reduces fibrinolysis but does not correct clotting factor deficiency from
warfarin and should not replace urgent prothrombin complex concentrate in this setting.
Delaying reversal until neurosurgical consultation risks hematoma expansion.
E. Immediate craniotomy is indicated for significant mass effect with rapid neurologic
deterioration. With a small hematoma and a correctable coagulopathy, emergent reversal
is the priority; surgical evacuation may be necessary later but should follow stabilization
and reversal when feasible.
3. A 28-year-old woman is ejected from a rollover motor vehicle crash. She is intubated in the field
for an altered level of consciousness. On arrival, oxygen saturation is 88 percent on a mechanical
ventilator with fraction of inspired oxygen of 1.0 and positive end-expiratory pressure of 10 cm
water. Chest auscultation reveals diminished breath sounds on the right. Breath sounds improve
transiently after tube thoracostomy on the right drains minimal air and blood. Repeat chest
radiograph shows near-complete right lung opacification with mediastinal shift to the right.
Which of the following is the most likely diagnosis and best next step?
A. Massive hemothorax; remove the chest tube and prepare for urgent thoracotomy.
B. Tension pneumothorax with lung collapse; insert a second larger-bore chest tube.
2
, C. Right mainstem bronchial injury with complete lung collapse; perform emergent
bronchoscopy and prepare for surgical repair.
D. Acute respiratory distress syndrome due to aspiration; increase positive end-expiratory
pressure and admit to intensive care unit.
E. Pulmonary contusion causing consolidation; continue chest tube drainage and supportive
care.
C.
Massive opacification of the right hemithorax with ipsilateral mediastinal shift suggests
loss of ventilation to the entire right lung rather than accumulation of air or blood. A
bronchial transection or major bronchial injury can cause complete collapse and inability to
ventilate the right lung, with mediastinal shift due to atelectasis. Definitive diagnosis
requires bronchoscopy, and surgical repair may be necessary. Persistent hypoxia despite
high ventilator settings and a chest tube points to this airway disruption.
A. Massive hemothorax typically produces layering of blood on the affected side and would
usually drain a large volume of sanguinous fluid through a chest tube. Removal of a chest
tube is not appropriate in suspected massive hemothorax.
B. Tension pneumothorax classically causes mediastinal shift away from the affected side
and would usually be accompanied by large quantities of air escaping from a chest tube.
The chest tube in this case drained minimal air; adding another chest tube might be
reasonable if tension physiology persists, but the radiograph pattern of near-complete
opacification rather than hyperlucency argues against pneumothorax.
D. Acute respiratory distress syndrome does not develop immediately in the trauma bay to
the point of unilateral complete opacification. Increasing positive end-expiratory pressure
is supportive but would not correct a major airway disruption.
E. Pulmonary contusion can cause unilateral opacification but is unlikely to produce rapid
complete opacification with such severe refractory hypoxia immediately after trauma.
4. A 50-year-old man presents after being trapped under heavy equipment for 8 hours. On arrival, he
is hemodynamically stable but complains of severe pain and swelling of both lower extremities.
Laboratory tests show serum creatine kinase of 40,000 units per liter and potassium of 6.2
milliequivalents per liter. Urinalysis reveals dark brown urine positive for heme but with only
rare red blood cells on microscopy. Which of the following is the most appropriate immediate
management step?
A. Initiate aggressive intravenous isotonic crystalloid infusion and urinary alkalinization with
intravenous sodium bicarbonate.
B. Administer intravenous insulin and glucose, then stabilize potassium with nebulized
salbutamol.
C. Begin emergent hemodialysis.
D. Administer furosemide and restrict fluids to prevent pulmonary edema.
E. Give oral potassium-binding resin and observe.
3
Answers & Explanations
1. A 34-year-old man is brought to the emergency department after a high-speed motorcycle
collision. He is conscious but agitated. Blood pressure is 90/60 mm Hg, heart rate is 128 beats per
minute, respiratory rate is 28 breaths per minute, and oxygen saturation by pulse oximetry is 94
percent on room air. There is obvious deformity and swelling of the left thigh. Focused
assessment with sonography for trauma is negative for pericardial fluid and free intraperitoneal
fluid. Pelvic X-ray shows no fracture. A pelvic binder is in place. There is no external chest
wound. Which action is the most appropriate next step for initial management?
A. Immediate computed tomography angiography of the chest, abdomen, and pelvis.
B. Rapid intravenous infusion of two liters of crystalloid solution and observe response.
C. Apply a tourniquet to the left thigh and prepare for immediate transfemoral amputation.
D. Initiate massive transfusion protocol and obtain cross-matched blood.
E. Perform exploratory laparotomy in the operating room.
D.
The patient is hemodynamically unstable with hypotension and tachycardia and has a major
femoral shaft fracture, a common source of significant hemorrhage. Ultrasound does not
exclude ongoing intrathoracic or pelvic bleeding. In a patient with ongoing hemodynamic
instability after a high-energy mechanism and an obvious potential source of major
hemorrhage, early activation of the massive transfusion protocol is indicated to replace lost
whole blood components, correct coagulopathy, and improve oxygen-carrying capacity.
Early blood component therapy improves outcomes compared with large-volume
crystalloid alone.
A. Computed tomography angiography is appropriate for hemodynamically stable patients
to localize bleeding, but this unstable patient should not be delayed for scanning;
immediate resuscitation and hemorrhage control take priority.
B. Large-volume crystalloid alone is no longer preferred because it dilutes clotting factors,
can worsen coagulopathy, and does not address oxygen-carrying capacity. Crystalloid may
be used briefly, but definitive resuscitation in a patient with suspected massive hemorrhage
requires blood products.
C. Applying a tourniquet is indicated for life-threatening extremity hemorrhage under
direct visualization of severe external bleeding. In a femoral shaft fracture with no
described external exsanguination and with bleeding likely internal, routine tourniquet or
immediate amputation is not appropriate.
E. Exploratory laparotomy is indicated if there is clinical or imaging evidence of intra-
abdominal hemorrhage in an unstable patient. Focused ultrasonography was negative, and
there is a clear extremity source of hemorrhage.
1
,2. A 65-year-old woman fell from a standing height and is brought to the trauma bay. She is on
warfarin therapy for a history of atrial fibrillation. She is somnolent but arousable, with a
Glasgow Coma Scale score of 12. Pupils are equal and reactive. Blood pressure is 150/80, and
heart rate is 74 beats per minute. Noncontrast head computed tomography shows a small acute
subdural hematoma over the left convexity with 4 millimeters of midline shift. Her international
normalized ratio is 3.5. Which immediate step is most appropriate?
A. Admit to the intensive care unit for observation and repeat head computed tomography in
24 hours.
B. Reverse anticoagulation with vitamin K and prothrombin complex concentrate now.
C. Administer mannitol and hyperventilate to reduce intracranial pressure.
D. Start tranexamic acid infusion and delay anticoagulation reversal until neurosurgical
consult.
E. Perform immediate craniotomy for hematoma evacuation.
B.
In a patient on warfarin with an acute intracranial hemorrhage and an elevated international
normalized ratio, rapid reversal of anticoagulation is essential to limit hematoma expansion
and secondary brain injury. Prothrombin complex concentrate provides rapid replacement
of vitamin K–dependent clotting factors and, together with intravenous vitamin K, achieves
prompt and sustained correction. This is the standard of care in warfarin-associated
intracranial hemorrhage.
A. Observation alone is unsafe with an elevated international normalized ratio and
radiographic midline shift because hematoma expansion is likely; reversal should not be
delayed.
C. Mannitol and hyperventilation temporarily reduce intracranial pressure but do not
address coagulopathy; they are adjunctive measures and are not the first intervention when
anticoagulation reversal is required.
D. Tranexamic acid reduces fibrinolysis but does not correct clotting factor deficiency from
warfarin and should not replace urgent prothrombin complex concentrate in this setting.
Delaying reversal until neurosurgical consultation risks hematoma expansion.
E. Immediate craniotomy is indicated for significant mass effect with rapid neurologic
deterioration. With a small hematoma and a correctable coagulopathy, emergent reversal
is the priority; surgical evacuation may be necessary later but should follow stabilization
and reversal when feasible.
3. A 28-year-old woman is ejected from a rollover motor vehicle crash. She is intubated in the field
for an altered level of consciousness. On arrival, oxygen saturation is 88 percent on a mechanical
ventilator with fraction of inspired oxygen of 1.0 and positive end-expiratory pressure of 10 cm
water. Chest auscultation reveals diminished breath sounds on the right. Breath sounds improve
transiently after tube thoracostomy on the right drains minimal air and blood. Repeat chest
radiograph shows near-complete right lung opacification with mediastinal shift to the right.
Which of the following is the most likely diagnosis and best next step?
A. Massive hemothorax; remove the chest tube and prepare for urgent thoracotomy.
B. Tension pneumothorax with lung collapse; insert a second larger-bore chest tube.
2
, C. Right mainstem bronchial injury with complete lung collapse; perform emergent
bronchoscopy and prepare for surgical repair.
D. Acute respiratory distress syndrome due to aspiration; increase positive end-expiratory
pressure and admit to intensive care unit.
E. Pulmonary contusion causing consolidation; continue chest tube drainage and supportive
care.
C.
Massive opacification of the right hemithorax with ipsilateral mediastinal shift suggests
loss of ventilation to the entire right lung rather than accumulation of air or blood. A
bronchial transection or major bronchial injury can cause complete collapse and inability to
ventilate the right lung, with mediastinal shift due to atelectasis. Definitive diagnosis
requires bronchoscopy, and surgical repair may be necessary. Persistent hypoxia despite
high ventilator settings and a chest tube points to this airway disruption.
A. Massive hemothorax typically produces layering of blood on the affected side and would
usually drain a large volume of sanguinous fluid through a chest tube. Removal of a chest
tube is not appropriate in suspected massive hemothorax.
B. Tension pneumothorax classically causes mediastinal shift away from the affected side
and would usually be accompanied by large quantities of air escaping from a chest tube.
The chest tube in this case drained minimal air; adding another chest tube might be
reasonable if tension physiology persists, but the radiograph pattern of near-complete
opacification rather than hyperlucency argues against pneumothorax.
D. Acute respiratory distress syndrome does not develop immediately in the trauma bay to
the point of unilateral complete opacification. Increasing positive end-expiratory pressure
is supportive but would not correct a major airway disruption.
E. Pulmonary contusion can cause unilateral opacification but is unlikely to produce rapid
complete opacification with such severe refractory hypoxia immediately after trauma.
4. A 50-year-old man presents after being trapped under heavy equipment for 8 hours. On arrival, he
is hemodynamically stable but complains of severe pain and swelling of both lower extremities.
Laboratory tests show serum creatine kinase of 40,000 units per liter and potassium of 6.2
milliequivalents per liter. Urinalysis reveals dark brown urine positive for heme but with only
rare red blood cells on microscopy. Which of the following is the most appropriate immediate
management step?
A. Initiate aggressive intravenous isotonic crystalloid infusion and urinary alkalinization with
intravenous sodium bicarbonate.
B. Administer intravenous insulin and glucose, then stabilize potassium with nebulized
salbutamol.
C. Begin emergent hemodialysis.
D. Administer furosemide and restrict fluids to prevent pulmonary edema.
E. Give oral potassium-binding resin and observe.
3
