Advanced Trauma Life S up port (ATLS) 11th Edition
Test Bank: 200 Questions & Answers (Verified
Answers)
Q1. A 28-year-old male is brought in after a high-speed motorcycle crash. He
is unresponsive, making gurgling sounds, and has massive facial trauma with
avulsed teeth. Manual jaw-thrust fails to clear the airway. What is the most
appropriate immediate next step?
A) Insert a nasopharyngeal airway
B) Perform direct laryngoscop y and intubate
C) Perform a surgical cricothyroidotomy
D) Suction the oropharynx and attempt oral intubation
Ans: D | Rationale: In a patient with massive facial trauma and blood/teeth in
the airway , suctioning is the first priority to visualize the vocal cords.
Nasopharyngeal airways are contraindicated in severe midface trauma
(cribriform plate fracture risk). If oral intubation fails, a surgical airway is the
next step.
Q2. A 45-year-old female presents with severe respiratory distress after a
stab wound to the right chest. She has absent breath sounds on the right,
tracheal deviation to the left, and hypotension. According to ATLS 11th
Edition, what is the preferred site for immediate needle decompression in an
adult?
A) 2nd intercostal space, mid-clavicular line
B) 5th intercostal space, anterior axillary line
C) 4th intercostal space, mid-axillary line
D) 3rd intercostal space, anterior axillary line
Ans: B | Rationale: ATLS 11th Edition recommends the 5th intercostal space,
slightly anterior to the mid-axillary line (or anterior axillary line) as the
primary site for adults due to lower failure rates compared to the 2nd ICS
MCL, which has thicker chest wall tissue.
Q3. A 30-year-old male with a flail chest from blunt trauma is tachy pneic and
hy poxic. Despite 100% O2 via non-rebreather, his SpO2 is 88%. What is the
most likely underlying cause of his hypoxia, and what is the definitive airway
management?
A) Pneumothorax; needle decompression
B) Underlying pulmonary contusion; endotracheal intubation with PEEP
C) Hemothorax; tube thoracostomy
D) Cardiac tamponade; pericardiocentesis
Ans: B | Rationale: Flail chest is almost always accompanied by underlying
pulmonary contusion, which causes V/Q mismatch and hypoxia. Positive
pressure ventilation (intubation with PEEP) splints the flail segment internally
and forces fluid out of the alveoli.
Page 1 of 108
,Q4. A 22-year-old male presents with a large, sucking chest wound from a
shotgun blast. The wound is roughly 4 cm in diameter. What is the
immediate management of the wound?
A) Apply an occlusive dressing taped on all four sides
B) Apply a vented chest seal or occlusive dressing taped on three sides
C) Pack the wound with hemostatic gauze
D) Insert a chest tube directly through the wound
Ans: B | Rationale: An open pneumothorax requires a vented chest seal or a
dressing taped on three sides to allow air to escape during exhalation but
prevent air entry during inhalation. Taping all four sides converts it to a
tension pneumothorax.
Q5. A 50-year-old male presents with Beck’s triad (hy potension, muffled
heart sounds, JVD) after a steering wheel impact. FAST exam shows
pericardial fluid. What is the definitive treatment?
A) Pericardiocentesis
B) Tube thoracostomy
C) Emergency department thoracotomy (or operative pericardial window)
D) Rapid infusion of 2L crystalloid
Ans: C | Rationale: While pericardiocentesis can be a temporizing measure in
extremis, the definitive treatment for cardiac tamponade from trauma is an
ED thoracotomy or operative pericardial window to evacuate the clot and
repair the injury.
Q6. A 19-year-old female has a massive hemothorax. A 36-French chest tube
is placed, yielding 1,600 mL of blood immediately. What is the next step?
A) Clamp the chest tube
B) Administer 1L of crystalloid and reassess
C) Perform an emergency thoracotomy
D) Insert a second chest tube
Ans: C | Rationale: Immediate indications for thoracotomy in hemothorax
include >1,500 mL of blood immediately upon chest tube insertion, or >200
mL/hr for 2-4 hours. This patient has a massive hemothorax requiring
surgical exploration.
Q7. A 60-year-old male with COPD presents after a fall. He has absent breath
sounds on the left. A chest tube is placed, but he remains hypoxic. A repeat
X-ray shows the lung is not expanding, and the tube is seen entering a
fissure. What is the likely issue?
A) The tube is clogged with a clot
B) The tube is malpositioned in a fissure
C) The patient has a bronchopleural fistula
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,D) The patient has a tension pneumothorax on the right
Ans: B | Rationale: Chest tubes can migrate or be placed into lung fissures,
preventing proper drainage of the pleural space and lung expansion.
Repositioning or placing a new tube is required.
Q8. A 35-year-old male presents with paradoxical chest wall movement after
a rollover crash. He is hemodynamically stable but tachypneic. What is the
primary initial treatment for the flail segment?
A) Surgical fixation of the ribs
B) Positive pressure ventilation
C) Pain control and aggressive pulmonary hygiene
D) Taping the chest wall
Ans: C | Rationale: If the patient is hemodynamically stable and not in severe
respiratory failure, the initial treatment for flail chest is aggressive pain
control (e.g., epidural or regional block) and pulmonary hygiene to prevent
atelectasis and pneumonia. Intubation is reserved for respiratory failure.
Q9. A 40-year-old male presents with severe facial trauma. He is conscious
but making stridorous sounds. Blood is pooling in his mouth. What is the
most critical initial maneuver?
A) Cricothyroidotomy
B) Suctioning and positioning (prone or lateral if C-spine cleared)
C) Insert a nasopharyngeal airway
D) Bag-valve-mask ventilation
Ans: B | Rationale: In a conscious patient with facial trauma and blood in the
airway , suctioning and positioning to allow gravity to clear the blood is the
first step. If he loses consciousness and cannot be intubated, a surgical
airway is next.
Q10. A 25-year-old female is intubated for severe TBI. After intubation, her
SpO2 drops to 85%, and she has absent breath sounds on the right with
tracheal deviation. What is the immediate next step?
A) Order a stat chest X-ray
B) Perform needle decompression on the right
C) Disconnect the ventilator and manually ventilate
D) Perform a right-sided tube thoracostomy
Ans: B | Rationale: This is a tension pneumothorax, likely exacerbated by
positive pressure ventilation. Immediate needle decompression is required
before a chest tube can be placed.
Q11. A 55-year-old male presents with a large anterior chest wall defect from
a crush injury. He is in severe respiratory distress. What is the immediate
Page 3 of 108
, management of the chest wall defect?
A) Cover with a sterile, occlusive dressing
B) Pack the wound with saline-soaked gauze
C) Intubate and ap ply positive pressure ventilation
D) Apply a pressure dressing
Ans: A | Rationale: A large open chest wound (sucking chest wound) must be
immediately covered with a sterile, occlusive dressing (or vented chest seal)
to prevent further air entry and tension pneumothorax.
Q12. A 30-year-old male presents with a severe mandible fracture. He is
unconscious and cannot protect his airway. Direct laryngoscop y fails due to
bleeding and distorted anatomy. What is the best alternative advanced
airway?
A) Laryngeal Mask Airway (LMA)
B) Nasotracheal intubation
C) Surgical cricothyroidotomy
D) Blind oral intubation
Ans: C | Rationale: When oral intubation fails due to massive facial
trauma/bleeding, and nasotracheal intubation is contraindicated (midface
trauma) , a surgical cricothyroidotomy is the definitive emergency airway.
LMAs do not protect against aspiration.
Q13. A 22-year-old male presents with a stab wound to the left 4th
intercostal space. He is hypotensive and tachycardic. FAST is positive for
pericardial fluid. He loses pulses in the ED. What is the next step?
A) Continue CPR and prepare for transport
B) Perform an ED resuscitative thoracotomy
C) Perform pericardiocentesis
D) Administer epinephrine
Ans: B | Rationale: In a patient with penetrating thoracic trauma who loses
pulses in the ED (or arrives in arrest), an ED resuscitative thoracotomy is
indicated to relieve tamponade, control hemorrhage, and perform open
cardiac massage.
Q14. A 40-year-old female presents with a flail chest and underlying
pulmonary contusion. She is intubated. What ventilator strategy is most
appropriate to minimize further lung injury?
A) High tidal volume, low PEEP
B) Low tidal volume, high PEEP (Lung protective strategy)
C) High-frequency oscillatory ventilation
D) Pressure control ventilation with high tidal volumes
Ans: B | Rationale: Patients with pulmonary contusions are at high risk for
Page 4 of 108
Test Bank: 200 Questions & Answers (Verified
Answers)
Q1. A 28-year-old male is brought in after a high-speed motorcycle crash. He
is unresponsive, making gurgling sounds, and has massive facial trauma with
avulsed teeth. Manual jaw-thrust fails to clear the airway. What is the most
appropriate immediate next step?
A) Insert a nasopharyngeal airway
B) Perform direct laryngoscop y and intubate
C) Perform a surgical cricothyroidotomy
D) Suction the oropharynx and attempt oral intubation
Ans: D | Rationale: In a patient with massive facial trauma and blood/teeth in
the airway , suctioning is the first priority to visualize the vocal cords.
Nasopharyngeal airways are contraindicated in severe midface trauma
(cribriform plate fracture risk). If oral intubation fails, a surgical airway is the
next step.
Q2. A 45-year-old female presents with severe respiratory distress after a
stab wound to the right chest. She has absent breath sounds on the right,
tracheal deviation to the left, and hypotension. According to ATLS 11th
Edition, what is the preferred site for immediate needle decompression in an
adult?
A) 2nd intercostal space, mid-clavicular line
B) 5th intercostal space, anterior axillary line
C) 4th intercostal space, mid-axillary line
D) 3rd intercostal space, anterior axillary line
Ans: B | Rationale: ATLS 11th Edition recommends the 5th intercostal space,
slightly anterior to the mid-axillary line (or anterior axillary line) as the
primary site for adults due to lower failure rates compared to the 2nd ICS
MCL, which has thicker chest wall tissue.
Q3. A 30-year-old male with a flail chest from blunt trauma is tachy pneic and
hy poxic. Despite 100% O2 via non-rebreather, his SpO2 is 88%. What is the
most likely underlying cause of his hypoxia, and what is the definitive airway
management?
A) Pneumothorax; needle decompression
B) Underlying pulmonary contusion; endotracheal intubation with PEEP
C) Hemothorax; tube thoracostomy
D) Cardiac tamponade; pericardiocentesis
Ans: B | Rationale: Flail chest is almost always accompanied by underlying
pulmonary contusion, which causes V/Q mismatch and hypoxia. Positive
pressure ventilation (intubation with PEEP) splints the flail segment internally
and forces fluid out of the alveoli.
Page 1 of 108
,Q4. A 22-year-old male presents with a large, sucking chest wound from a
shotgun blast. The wound is roughly 4 cm in diameter. What is the
immediate management of the wound?
A) Apply an occlusive dressing taped on all four sides
B) Apply a vented chest seal or occlusive dressing taped on three sides
C) Pack the wound with hemostatic gauze
D) Insert a chest tube directly through the wound
Ans: B | Rationale: An open pneumothorax requires a vented chest seal or a
dressing taped on three sides to allow air to escape during exhalation but
prevent air entry during inhalation. Taping all four sides converts it to a
tension pneumothorax.
Q5. A 50-year-old male presents with Beck’s triad (hy potension, muffled
heart sounds, JVD) after a steering wheel impact. FAST exam shows
pericardial fluid. What is the definitive treatment?
A) Pericardiocentesis
B) Tube thoracostomy
C) Emergency department thoracotomy (or operative pericardial window)
D) Rapid infusion of 2L crystalloid
Ans: C | Rationale: While pericardiocentesis can be a temporizing measure in
extremis, the definitive treatment for cardiac tamponade from trauma is an
ED thoracotomy or operative pericardial window to evacuate the clot and
repair the injury.
Q6. A 19-year-old female has a massive hemothorax. A 36-French chest tube
is placed, yielding 1,600 mL of blood immediately. What is the next step?
A) Clamp the chest tube
B) Administer 1L of crystalloid and reassess
C) Perform an emergency thoracotomy
D) Insert a second chest tube
Ans: C | Rationale: Immediate indications for thoracotomy in hemothorax
include >1,500 mL of blood immediately upon chest tube insertion, or >200
mL/hr for 2-4 hours. This patient has a massive hemothorax requiring
surgical exploration.
Q7. A 60-year-old male with COPD presents after a fall. He has absent breath
sounds on the left. A chest tube is placed, but he remains hypoxic. A repeat
X-ray shows the lung is not expanding, and the tube is seen entering a
fissure. What is the likely issue?
A) The tube is clogged with a clot
B) The tube is malpositioned in a fissure
C) The patient has a bronchopleural fistula
Page 2 of 108
,D) The patient has a tension pneumothorax on the right
Ans: B | Rationale: Chest tubes can migrate or be placed into lung fissures,
preventing proper drainage of the pleural space and lung expansion.
Repositioning or placing a new tube is required.
Q8. A 35-year-old male presents with paradoxical chest wall movement after
a rollover crash. He is hemodynamically stable but tachypneic. What is the
primary initial treatment for the flail segment?
A) Surgical fixation of the ribs
B) Positive pressure ventilation
C) Pain control and aggressive pulmonary hygiene
D) Taping the chest wall
Ans: C | Rationale: If the patient is hemodynamically stable and not in severe
respiratory failure, the initial treatment for flail chest is aggressive pain
control (e.g., epidural or regional block) and pulmonary hygiene to prevent
atelectasis and pneumonia. Intubation is reserved for respiratory failure.
Q9. A 40-year-old male presents with severe facial trauma. He is conscious
but making stridorous sounds. Blood is pooling in his mouth. What is the
most critical initial maneuver?
A) Cricothyroidotomy
B) Suctioning and positioning (prone or lateral if C-spine cleared)
C) Insert a nasopharyngeal airway
D) Bag-valve-mask ventilation
Ans: B | Rationale: In a conscious patient with facial trauma and blood in the
airway , suctioning and positioning to allow gravity to clear the blood is the
first step. If he loses consciousness and cannot be intubated, a surgical
airway is next.
Q10. A 25-year-old female is intubated for severe TBI. After intubation, her
SpO2 drops to 85%, and she has absent breath sounds on the right with
tracheal deviation. What is the immediate next step?
A) Order a stat chest X-ray
B) Perform needle decompression on the right
C) Disconnect the ventilator and manually ventilate
D) Perform a right-sided tube thoracostomy
Ans: B | Rationale: This is a tension pneumothorax, likely exacerbated by
positive pressure ventilation. Immediate needle decompression is required
before a chest tube can be placed.
Q11. A 55-year-old male presents with a large anterior chest wall defect from
a crush injury. He is in severe respiratory distress. What is the immediate
Page 3 of 108
, management of the chest wall defect?
A) Cover with a sterile, occlusive dressing
B) Pack the wound with saline-soaked gauze
C) Intubate and ap ply positive pressure ventilation
D) Apply a pressure dressing
Ans: A | Rationale: A large open chest wound (sucking chest wound) must be
immediately covered with a sterile, occlusive dressing (or vented chest seal)
to prevent further air entry and tension pneumothorax.
Q12. A 30-year-old male presents with a severe mandible fracture. He is
unconscious and cannot protect his airway. Direct laryngoscop y fails due to
bleeding and distorted anatomy. What is the best alternative advanced
airway?
A) Laryngeal Mask Airway (LMA)
B) Nasotracheal intubation
C) Surgical cricothyroidotomy
D) Blind oral intubation
Ans: C | Rationale: When oral intubation fails due to massive facial
trauma/bleeding, and nasotracheal intubation is contraindicated (midface
trauma) , a surgical cricothyroidotomy is the definitive emergency airway.
LMAs do not protect against aspiration.
Q13. A 22-year-old male presents with a stab wound to the left 4th
intercostal space. He is hypotensive and tachycardic. FAST is positive for
pericardial fluid. He loses pulses in the ED. What is the next step?
A) Continue CPR and prepare for transport
B) Perform an ED resuscitative thoracotomy
C) Perform pericardiocentesis
D) Administer epinephrine
Ans: B | Rationale: In a patient with penetrating thoracic trauma who loses
pulses in the ED (or arrives in arrest), an ED resuscitative thoracotomy is
indicated to relieve tamponade, control hemorrhage, and perform open
cardiac massage.
Q14. A 40-year-old female presents with a flail chest and underlying
pulmonary contusion. She is intubated. What ventilator strategy is most
appropriate to minimize further lung injury?
A) High tidal volume, low PEEP
B) Low tidal volume, high PEEP (Lung protective strategy)
C) High-frequency oscillatory ventilation
D) Pressure control ventilation with high tidal volumes
Ans: B | Rationale: Patients with pulmonary contusions are at high risk for
Page 4 of 108
