ATLS Practice Test 12
Answers & Explanations
1. A 42-year-old male restrained driver is brought to the emergency department after a high-speed
frontal collision. He is alert but complains of severe left chest pain and shortness of breath. On
examination his left hemithorax is dull to percussion, breath sounds are decreased on the left, and
his blood pressure is 96/58 mm Hg with a heart rate of 120 beats per minute. A portable upright
chest radiograph shows an air-fluid level occupying most of the left hemithorax and mediastinal
shift toward the right. Which intervention is most appropriate at this time?
A. Emergent left anterolateral thoracotomy in the emergency department.
B. Tube thoracostomy on the left side.
C. Pericardiocentesis.
D. Immediate transfer to the operating room for exploratory laparotomy.
E. Needle decompression of the left chest.
B.
The clinical presentation and chest radiograph indicate a large hemothorax producing
hypovolemia and mediastinal shift. In a patient who is hemodynamically unstable but not in
extremis from cardiac arrest, the immediate priority is evacuation of intrathoracic blood by
insertion of a chest tube and allow ongoing assessment of blood loss and need for definitive
thoracic surgical control.
A. An emergent left anterolateral thoracotomy is reserved for patients in extremis with
witnessed loss of vital signs from thoracic hemorrhage or for those with massive ongoing
external hemorrhage not controllable by chest tube. This patient is unstable but not in
cardiac arrest; chest tube placement is the appropriate first step.
C. Pericardiocentesis addresses pericardial tamponade, which usually presents with
hypotension, muffled heart sounds, and jugular venous distension. The radiograph and
dullness with air-fluid level favour hemothorax rather than tamponade.
D. Exploratory laparotomy addresses intra-abdominal hemorrhage. Imaging and exam
indicate a primary thoracic process; laparotomy would not relieve intrathoracic blood or
respiratory compromise.
E. Needle decompression is effective for tension pneumothorax where intrathoracic
pressure is elevated from air. The presence of an air-fluid level and dullness on percussion
indicates fluid rather than isolated tension pneumothorax; a needle decompression would
not evacuate a large collection of blood.
2. A 68-year-old man with known coronary artery disease arrives after chest trauma with chest pain.
Electrocardiography shows diffuse ST-segment depression and troponin is mildly elevated.
Transthoracic echocardiography shows moderate pericardial effusion without tamponade. Which
is the most appropriate next step?
1
, A. Admit for observation and serial echocardiography and electrocardiography.
B. Urgent pericardiocentesis to remove the effusion immediately.
C. Start intravenous heparin infusion for presumed myocardial ischemia.
D. Immediate transfer for pericardial window or operative drainage.
E. Administer thrombolysis for suspected acute coronary thrombosis.
A.
A moderate pericardial effusion without signs of tamponade can be managed with close
observation and serial imaging and monitoring for progression. Immediate
pericardiocentesis or operative drainage is reserved for hemodynamic compromise or
evidence of ongoing hemorrhage into the pericardial space.
B. Immediate pericardiocentesis is indicated for cardiac tamponade or hemodynamic
instability; in a stable patient without tamponade, the risks of pericardiocentesis may
outweigh benefits.
C. Systemic anticoagulation in the context of chest trauma and potential hemorrhagic
pericardial effusion risks exacerbating bleeding and is not indicated until trauma-related
causes are excluded.
D. Operative drainage is indicated for hemodynamic compromise or active bleeding; it is
not the immediate step in a stable patient.
E. Thrombolysis is contraindicated in recent trauma given risk of bleeding.
3. A 54-year-old woman with severe chronic obstructive pulmonary disease presents after blunt
chest trauma. She is tachypneic and hypoxic on supplemental oxygen. Chest radiograph shows
multiple left-sided rib fractures with flail segment and near-complete atelectasis of the left lung.
She is in severe pain and unable to cough effectively. Which is the most appropriate next step?
A. Analgesia including regional nerve block or epidural analgesia, aggressive pulmonary
toilet, and admission to a monitored setting.
B. Immediate surgical fixation of the fractured ribs in the emergency department.
C. Early tracheostomy to assist with secretion clearance and ventilation.
D. Routine opioid boluses and discharge once oxygenation improves.
E. Observation with incentive spirometry and oral analgesics on the general ward.
A.
Flail chest with respiratory compromise in a patient with chronic lung disease requires
aggressive pain control (which may include regional or epidural analgesia), assisted
pulmonary hygiene, and close monitoring because inadequate analgesia leads to
hypoventilation, atelectasis, and pneumonia. Early multimodal analgesia improves
ventilation and outcomes.
B. Surgical stabilization of ribs may be considered in select cases, but is not typically an
immediate emergency procedure.
C. Tracheostomy is not an immediate intervention for flail chest and is invasive; it may be
required if prolonged ventilatory support is anticipated after initial stabilization.
D. Routine opioid boluses alone may suppress respiratory drive in patients with chronic
lung disease and are insufficient for adequate analgesia and pulmonary toilet; discharge
would be unsafe given respiratory compromise.
2
, E. Observation with only incentive spirometry and oral analgesics underestimates the risk
in this patient with severe chronic lung disease and flail chest; closer monitoring and
advanced analgesic strategies are warranted.
4. A six-year-old child is struck by a car at low speed and brought to the trauma bay. He is alert but
frightened. His vital signs are: respiratory rate 28 breaths per minute, heart rate 140 beats per
minute, blood pressure 88/48 mm Hg, and oxygen saturation 94 percent on room air. He has an
obvious deformed left femur and a distended, tender abdomen with seat-belt contusion across the
lower abdomen. Which of the following is the most appropriate next diagnostic step?
A. Immediate computed tomography scan of the abdomen and pelvis with intravenous
contrast.
B. Focused assessment with sonography for trauma of the abdomen (extended to the pelvis)
and serial abdominal examinations.
C. Diagnostic peritoneal lavage.
D. Urgent laparotomy without further imaging because of mechanism and hypotension.
E. Plain abdominal radiograph and pelvic radiograph.
B.
Focused assessment with sonography for trauma, extended to the pelvis, is the most
appropriate next diagnostic step in a hemodynamically unstable or borderline child with
blunt abdominal trauma and concerning mechanism. In pediatric patients, sonography is
rapid, repeatable, and avoids ionizing radiation. It helps identify free intraperitoneal fluid
that suggests significant intra-abdominal injury and guides the decision for operative
management or further imaging.
A. Computed tomography with intravenous contrast provides excellent detail but is not the
immediate next step in a child with hypotension. Transport to the scanner and time delay
risk deterioration; use sonography first to triage.
C. Diagnostic peritoneal lavage is invasive and rarely necessary now that focused
sonography is widely available. It carries morbidity and is not first line in centers with
reliable sonography.
D. Urgent laparotomy is indicated if the child is truly hemodynamically unstable from
intra-abdominal hemorrhage and not responding to resuscitation. This child has borderline
hypotension but is alert and has not had resuscitation attempts documented; sonography
first is appropriate.
E. Plain radiographs have low sensitivity for intraperitoneal injury and would delay more
informative bedside assessment; they are not the best next step.
5. An 82-year-old woman on daily aspirin falls and sustains a ground-level fall with head impact.
She is awake with a Glasgow Coma Scale score of 15, but has a moderate scalp hematoma and is
somnolent at times per the caregiver. She takes an angiotensin-converting enzyme inhibitor and a
statin. What is the best management regarding head imaging?
A. No imaging is necessary because she is fully oriented and has no focal deficit.
B. Perform computed tomography of the head because age greater than 65 years and head
impact are indications for imaging.
3
Answers & Explanations
1. A 42-year-old male restrained driver is brought to the emergency department after a high-speed
frontal collision. He is alert but complains of severe left chest pain and shortness of breath. On
examination his left hemithorax is dull to percussion, breath sounds are decreased on the left, and
his blood pressure is 96/58 mm Hg with a heart rate of 120 beats per minute. A portable upright
chest radiograph shows an air-fluid level occupying most of the left hemithorax and mediastinal
shift toward the right. Which intervention is most appropriate at this time?
A. Emergent left anterolateral thoracotomy in the emergency department.
B. Tube thoracostomy on the left side.
C. Pericardiocentesis.
D. Immediate transfer to the operating room for exploratory laparotomy.
E. Needle decompression of the left chest.
B.
The clinical presentation and chest radiograph indicate a large hemothorax producing
hypovolemia and mediastinal shift. In a patient who is hemodynamically unstable but not in
extremis from cardiac arrest, the immediate priority is evacuation of intrathoracic blood by
insertion of a chest tube and allow ongoing assessment of blood loss and need for definitive
thoracic surgical control.
A. An emergent left anterolateral thoracotomy is reserved for patients in extremis with
witnessed loss of vital signs from thoracic hemorrhage or for those with massive ongoing
external hemorrhage not controllable by chest tube. This patient is unstable but not in
cardiac arrest; chest tube placement is the appropriate first step.
C. Pericardiocentesis addresses pericardial tamponade, which usually presents with
hypotension, muffled heart sounds, and jugular venous distension. The radiograph and
dullness with air-fluid level favour hemothorax rather than tamponade.
D. Exploratory laparotomy addresses intra-abdominal hemorrhage. Imaging and exam
indicate a primary thoracic process; laparotomy would not relieve intrathoracic blood or
respiratory compromise.
E. Needle decompression is effective for tension pneumothorax where intrathoracic
pressure is elevated from air. The presence of an air-fluid level and dullness on percussion
indicates fluid rather than isolated tension pneumothorax; a needle decompression would
not evacuate a large collection of blood.
2. A 68-year-old man with known coronary artery disease arrives after chest trauma with chest pain.
Electrocardiography shows diffuse ST-segment depression and troponin is mildly elevated.
Transthoracic echocardiography shows moderate pericardial effusion without tamponade. Which
is the most appropriate next step?
1
, A. Admit for observation and serial echocardiography and electrocardiography.
B. Urgent pericardiocentesis to remove the effusion immediately.
C. Start intravenous heparin infusion for presumed myocardial ischemia.
D. Immediate transfer for pericardial window or operative drainage.
E. Administer thrombolysis for suspected acute coronary thrombosis.
A.
A moderate pericardial effusion without signs of tamponade can be managed with close
observation and serial imaging and monitoring for progression. Immediate
pericardiocentesis or operative drainage is reserved for hemodynamic compromise or
evidence of ongoing hemorrhage into the pericardial space.
B. Immediate pericardiocentesis is indicated for cardiac tamponade or hemodynamic
instability; in a stable patient without tamponade, the risks of pericardiocentesis may
outweigh benefits.
C. Systemic anticoagulation in the context of chest trauma and potential hemorrhagic
pericardial effusion risks exacerbating bleeding and is not indicated until trauma-related
causes are excluded.
D. Operative drainage is indicated for hemodynamic compromise or active bleeding; it is
not the immediate step in a stable patient.
E. Thrombolysis is contraindicated in recent trauma given risk of bleeding.
3. A 54-year-old woman with severe chronic obstructive pulmonary disease presents after blunt
chest trauma. She is tachypneic and hypoxic on supplemental oxygen. Chest radiograph shows
multiple left-sided rib fractures with flail segment and near-complete atelectasis of the left lung.
She is in severe pain and unable to cough effectively. Which is the most appropriate next step?
A. Analgesia including regional nerve block or epidural analgesia, aggressive pulmonary
toilet, and admission to a monitored setting.
B. Immediate surgical fixation of the fractured ribs in the emergency department.
C. Early tracheostomy to assist with secretion clearance and ventilation.
D. Routine opioid boluses and discharge once oxygenation improves.
E. Observation with incentive spirometry and oral analgesics on the general ward.
A.
Flail chest with respiratory compromise in a patient with chronic lung disease requires
aggressive pain control (which may include regional or epidural analgesia), assisted
pulmonary hygiene, and close monitoring because inadequate analgesia leads to
hypoventilation, atelectasis, and pneumonia. Early multimodal analgesia improves
ventilation and outcomes.
B. Surgical stabilization of ribs may be considered in select cases, but is not typically an
immediate emergency procedure.
C. Tracheostomy is not an immediate intervention for flail chest and is invasive; it may be
required if prolonged ventilatory support is anticipated after initial stabilization.
D. Routine opioid boluses alone may suppress respiratory drive in patients with chronic
lung disease and are insufficient for adequate analgesia and pulmonary toilet; discharge
would be unsafe given respiratory compromise.
2
, E. Observation with only incentive spirometry and oral analgesics underestimates the risk
in this patient with severe chronic lung disease and flail chest; closer monitoring and
advanced analgesic strategies are warranted.
4. A six-year-old child is struck by a car at low speed and brought to the trauma bay. He is alert but
frightened. His vital signs are: respiratory rate 28 breaths per minute, heart rate 140 beats per
minute, blood pressure 88/48 mm Hg, and oxygen saturation 94 percent on room air. He has an
obvious deformed left femur and a distended, tender abdomen with seat-belt contusion across the
lower abdomen. Which of the following is the most appropriate next diagnostic step?
A. Immediate computed tomography scan of the abdomen and pelvis with intravenous
contrast.
B. Focused assessment with sonography for trauma of the abdomen (extended to the pelvis)
and serial abdominal examinations.
C. Diagnostic peritoneal lavage.
D. Urgent laparotomy without further imaging because of mechanism and hypotension.
E. Plain abdominal radiograph and pelvic radiograph.
B.
Focused assessment with sonography for trauma, extended to the pelvis, is the most
appropriate next diagnostic step in a hemodynamically unstable or borderline child with
blunt abdominal trauma and concerning mechanism. In pediatric patients, sonography is
rapid, repeatable, and avoids ionizing radiation. It helps identify free intraperitoneal fluid
that suggests significant intra-abdominal injury and guides the decision for operative
management or further imaging.
A. Computed tomography with intravenous contrast provides excellent detail but is not the
immediate next step in a child with hypotension. Transport to the scanner and time delay
risk deterioration; use sonography first to triage.
C. Diagnostic peritoneal lavage is invasive and rarely necessary now that focused
sonography is widely available. It carries morbidity and is not first line in centers with
reliable sonography.
D. Urgent laparotomy is indicated if the child is truly hemodynamically unstable from
intra-abdominal hemorrhage and not responding to resuscitation. This child has borderline
hypotension but is alert and has not had resuscitation attempts documented; sonography
first is appropriate.
E. Plain radiographs have low sensitivity for intraperitoneal injury and would delay more
informative bedside assessment; they are not the best next step.
5. An 82-year-old woman on daily aspirin falls and sustains a ground-level fall with head impact.
She is awake with a Glasgow Coma Scale score of 15, but has a moderate scalp hematoma and is
somnolent at times per the caregiver. She takes an angiotensin-converting enzyme inhibitor and a
statin. What is the best management regarding head imaging?
A. No imaging is necessary because she is fully oriented and has no focal deficit.
B. Perform computed tomography of the head because age greater than 65 years and head
impact are indications for imaging.
3
