ATLS Practice Test 11
Questions
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.
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.
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.
1
, 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.
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.
5. A 42-year-old man is stabbed in the left upper quadrant. He is mildly hypotensive with systolic
blood pressure of 95 mm Hg, heart rate 115 beats per minute. He is otherwise alert. Focused
assessment with sonography for trauma is equivocal for fluid. Local wound exploration reveals a
peritoneal violation. Which of the following is the best next step?
A. Immediate exploratory laparotomy.
B. Serial abdominal examinations and observation in the ward.
C. Diagnostic peritoneal lavage.
D. Computed tomography scan of the abdomen and pelvis with intravenous contrast.
E. Local wound closure and discharge with outpatient follow-up.
6. A 19-year-old male presents after a gunshot wound to the chest. He is intubated and his systolic
blood pressure is 70 mm Hg. A single large-bore left thoracostomy tube placed for decreased
breath sounds drains 2,500 milliliters of blood rapidly. Which action is most appropriate
immediately?
A. Activate the massive transfusion protocol and transfer to the radiology suite for
angiographic embolization.
B. Perform emergent median sternotomy in the emergency department.
C. Prepare for emergent exploratory thoracotomy and operative hemorrhage control.
D. Close the thoracostomy tube and repeat chest radiography to confirm position.
E. Administer intravenous tranexamic acid and observe for response.
2
Questions
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.
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.
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.
1
, 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.
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.
5. A 42-year-old man is stabbed in the left upper quadrant. He is mildly hypotensive with systolic
blood pressure of 95 mm Hg, heart rate 115 beats per minute. He is otherwise alert. Focused
assessment with sonography for trauma is equivocal for fluid. Local wound exploration reveals a
peritoneal violation. Which of the following is the best next step?
A. Immediate exploratory laparotomy.
B. Serial abdominal examinations and observation in the ward.
C. Diagnostic peritoneal lavage.
D. Computed tomography scan of the abdomen and pelvis with intravenous contrast.
E. Local wound closure and discharge with outpatient follow-up.
6. A 19-year-old male presents after a gunshot wound to the chest. He is intubated and his systolic
blood pressure is 70 mm Hg. A single large-bore left thoracostomy tube placed for decreased
breath sounds drains 2,500 milliliters of blood rapidly. Which action is most appropriate
immediately?
A. Activate the massive transfusion protocol and transfer to the radiology suite for
angiographic embolization.
B. Perform emergent median sternotomy in the emergency department.
C. Prepare for emergent exploratory thoracotomy and operative hemorrhage control.
D. Close the thoracostomy tube and repeat chest radiography to confirm position.
E. Administer intravenous tranexamic acid and observe for response.
2
