PHTLS Pre Test 100% Question and Answer
Below are 50 high-cognitive-level PHTLS Pre-Test questions based on the 10th Edition guidelines,
emphasizing TCCC/MARCH, whole blood, TXA, balanced resuscitation, and modern trauma care. These
will test application and analysis rather than simple recall.
PHTLS PRE-TEST: 50 HIGH-LEVEL MULTIPLE-CHOICE QUESTIONS
2025/2026 Edition (10th Edition Guidelines)
1. A 28-year-old soldier presents with a gunshot wound to the left thigh. Tourniquet applied at point of
injury 8 minutes ago. Radial pulse absent below injury. Patient received 1 unit whole blood en route. BP
94/62, HR 128. Per MARCH protocol, what is your next priority after confirming tourniquet conversion
readiness?
A. Immediately remove tourniquet to assess bleeding control
B. Establish proximal IV access and prepare for potential massive transfusion
C. Apply pelvic binder prophylactically
D. Administer TXA 1g IV over 10 minutes
Rationale: Despite tourniquet and 1 unit whole blood, patient remains hypotensive with tachycardia,
indicating ongoing hemorrhagic shock requiring balanced resuscitation preparation before tourniquet
manipulation risks uncontrolled bleeding.
2. A 6-year-old pedestrian struck by vehicle at 35 mph presents with altered mental status, abdominal
distension, and femur fracture. Weight 22 kg. HR 160, BP 72/48, capillary refill 4 seconds. Which
crystalloid strategy aligns with balanced resuscitation principles?
A. 440 mL bolus (20 mL/kg) repeated every 5 minutes until SBP >90
B. 220 mL bolus (10 mL/kg) with reassessment, prioritizing whole blood if available
C. 110 mL bolus (5 mL/kg) with permissive hypotension target SBP 70 + (2 × age)
D. No crystalloid—immediate whole blood transfusion only
Rationale: Pediatric balanced resuscitation emphasizes permissive hypotension (target SBP 70 + 2×age =
82 mmHg) and minimal crystalloid to avoid dilutional coagulopathy, with whole blood preferred when
available.
3. A 34-year-old motorcycle crash victim has open book pelvic fracture with 8 cm pubic diastasis on X-
ray. BP 78/52, HR 142. Pelvic binder applied at scene. After 2 units whole blood, patient remains
unstable. What is the pathophysiological rationale for mechanical stabilization versus immediate
angioembolization?
,A. Binder reduces venous bleeding only; arterial sources require immediate embolization
B. Binder stabilizes pelvic volume, reducing venous plexus bleeding while allowing temporary
tamponade; unstable patients require hemorrhage control before definitive radiology
C. Binder is ineffective in open book fractures >5 cm diastasis
D. Binder application delays necessary surgical pelvic fixation
Rationale: Pelvic binders reduce pelvic volume and stabilize the bony ring, creating temporary
tamponade of venous hemorrhage; hemodynamically unstable patients require OR or REBOA, not
interventional radiology delays.
4. A 42-year-old patient with penetrating chest trauma receives TXA 1g IV at 45 minutes post-injury
during ground transport. Which factor most limits TXA efficacy at this timing?
A. Patient's pre-existing fibrinogen levels
B. Fibrinolysis has already progressed to refractory coagulopathy
C. Dose insufficient for penetrating trauma mechanism
D. Route of administration inappropriate for chest trauma
Rationale: TXA inhibits fibrinolysis most effectively when administered within 3 hours; after 1 hour,
fibrinolytic activity peaks and clot degradation may be irreversible, reducing TXA's antifibrinolytic
benefit.
5. A 3-year-old falls from second-story window. GCS 12, HR 155, BP 85/58, respiratory rate 32. No
external bleeding. Abdomen soft but distended. Which assessment finding best indicates need for
balanced resuscitation over crystalloid-only approach?
A. Tachypnea alone
B. Tachycardia disproportionate to blood pressure (narrow pulse pressure 27 mmHg)
C. Altered mental status alone
D. Soft abdominal exam
Rationale: Narrow pulse pressure in pediatric trauma indicates significant stroke volume reduction and
early cardiovascular collapse, signaling need for blood products in balanced resuscitation rather than
crystalloid dilution.
6. A combat medic notes a casualty with traumatic amputation at knee level. Tourniquet applied at 12
minutes post-injury. Patient received 500 mL Hextend. Current BP 102/68, HR 118. Per TCCC guidelines,
why is Hextend contraindicated for continued resuscitation?
A. Hextend causes allergic reactions in 15% of patients
B. Hextend's hydroxyethyl starch impairs clotting and increases bleeding risk
C. Hextend is incompatible with whole blood transfusion
D. Hextend requires refrigeration unavailable in field
, Rationale: Hydroxyethyl starch solutions impair coagulation by reducing factor VIII and vWF activity,
exacerbating trauma-induced coagulopathy; TCCC recommends crystalloid or blood products instead.
7. A 56-year-old unrestrained driver in head-on collision has steering wheel deformity, chest bruising,
and seat belt sign. BP 88/60, HR 132. FAST positive in splenorenal recess. After 1 unit whole blood,
patient develops worsening dyspnea and JVD. What pathophysiology explains this deterioration?
A. Simple pneumothorax from rib fractures
B. Tension pneumothorax from air entering pleural space with one-way valve effect, compromising
venous return
C. Cardiac tamponade from myocardial contusion
D. Neurogenic shock from spinal cord injury
Rationale: Worsening hypotension, tachycardia, JVD, and dyspnea after fluid resuscitation suggests
tension physiology where intrathoracic pressure exceeds venous pressure, requiring immediate needle
decompression.
8. A 19-year-old stabbing victim has 3 cm wound at left 4th intercostal space, mid-clavicular line. Patient
talking, RR 24, HR 110, BP 118/76. Breath sounds equal. What is the anatomical rationale for immediate
chest seal versus observation?
A. Anterior chest wounds in "box" area have high probability of cardiac/major vessel involvement;
seal prevents tension physiology from sucking wound
B. Small wounds (<5 cm) rarely cause pneumothorax
C. Equal breath sounds exclude significant injury
D. Mid-clavicular location indicates lung parenchyma only
Rationale: The cardiac box (sternal borders to mid-clavicular lines, clavicle to costal margin) contains
heart, great vessels, and mediastinum; vented chest seals prevent tension pneumothorax while allowing
air egress.
9. A 7-year-old involved in ATV rollover has obvious deformity of right lower leg, pale and cool
extremity, capillary refill >5 seconds. Distal pulses absent. Pain 8/10. Which factor most determines limb
salvage versus amputation?
A. Time from injury to definitive orthopedic care
B. Ischemia time >6 hours causes irreversible muscle necrosis; vascular compromise requires
immediate reduction or revascularization
C. Degree of comminution on X-ray
D. Patient's pain tolerance
Rationale: Skeletal muscle tolerates ischemia for approximately 6 hours before irreversible necrosis;
vascular compromise in pediatric patients requires emergent reduction or surgical revascularization to
prevent compartment syndrome and limb loss.
Below are 50 high-cognitive-level PHTLS Pre-Test questions based on the 10th Edition guidelines,
emphasizing TCCC/MARCH, whole blood, TXA, balanced resuscitation, and modern trauma care. These
will test application and analysis rather than simple recall.
PHTLS PRE-TEST: 50 HIGH-LEVEL MULTIPLE-CHOICE QUESTIONS
2025/2026 Edition (10th Edition Guidelines)
1. A 28-year-old soldier presents with a gunshot wound to the left thigh. Tourniquet applied at point of
injury 8 minutes ago. Radial pulse absent below injury. Patient received 1 unit whole blood en route. BP
94/62, HR 128. Per MARCH protocol, what is your next priority after confirming tourniquet conversion
readiness?
A. Immediately remove tourniquet to assess bleeding control
B. Establish proximal IV access and prepare for potential massive transfusion
C. Apply pelvic binder prophylactically
D. Administer TXA 1g IV over 10 minutes
Rationale: Despite tourniquet and 1 unit whole blood, patient remains hypotensive with tachycardia,
indicating ongoing hemorrhagic shock requiring balanced resuscitation preparation before tourniquet
manipulation risks uncontrolled bleeding.
2. A 6-year-old pedestrian struck by vehicle at 35 mph presents with altered mental status, abdominal
distension, and femur fracture. Weight 22 kg. HR 160, BP 72/48, capillary refill 4 seconds. Which
crystalloid strategy aligns with balanced resuscitation principles?
A. 440 mL bolus (20 mL/kg) repeated every 5 minutes until SBP >90
B. 220 mL bolus (10 mL/kg) with reassessment, prioritizing whole blood if available
C. 110 mL bolus (5 mL/kg) with permissive hypotension target SBP 70 + (2 × age)
D. No crystalloid—immediate whole blood transfusion only
Rationale: Pediatric balanced resuscitation emphasizes permissive hypotension (target SBP 70 + 2×age =
82 mmHg) and minimal crystalloid to avoid dilutional coagulopathy, with whole blood preferred when
available.
3. A 34-year-old motorcycle crash victim has open book pelvic fracture with 8 cm pubic diastasis on X-
ray. BP 78/52, HR 142. Pelvic binder applied at scene. After 2 units whole blood, patient remains
unstable. What is the pathophysiological rationale for mechanical stabilization versus immediate
angioembolization?
,A. Binder reduces venous bleeding only; arterial sources require immediate embolization
B. Binder stabilizes pelvic volume, reducing venous plexus bleeding while allowing temporary
tamponade; unstable patients require hemorrhage control before definitive radiology
C. Binder is ineffective in open book fractures >5 cm diastasis
D. Binder application delays necessary surgical pelvic fixation
Rationale: Pelvic binders reduce pelvic volume and stabilize the bony ring, creating temporary
tamponade of venous hemorrhage; hemodynamically unstable patients require OR or REBOA, not
interventional radiology delays.
4. A 42-year-old patient with penetrating chest trauma receives TXA 1g IV at 45 minutes post-injury
during ground transport. Which factor most limits TXA efficacy at this timing?
A. Patient's pre-existing fibrinogen levels
B. Fibrinolysis has already progressed to refractory coagulopathy
C. Dose insufficient for penetrating trauma mechanism
D. Route of administration inappropriate for chest trauma
Rationale: TXA inhibits fibrinolysis most effectively when administered within 3 hours; after 1 hour,
fibrinolytic activity peaks and clot degradation may be irreversible, reducing TXA's antifibrinolytic
benefit.
5. A 3-year-old falls from second-story window. GCS 12, HR 155, BP 85/58, respiratory rate 32. No
external bleeding. Abdomen soft but distended. Which assessment finding best indicates need for
balanced resuscitation over crystalloid-only approach?
A. Tachypnea alone
B. Tachycardia disproportionate to blood pressure (narrow pulse pressure 27 mmHg)
C. Altered mental status alone
D. Soft abdominal exam
Rationale: Narrow pulse pressure in pediatric trauma indicates significant stroke volume reduction and
early cardiovascular collapse, signaling need for blood products in balanced resuscitation rather than
crystalloid dilution.
6. A combat medic notes a casualty with traumatic amputation at knee level. Tourniquet applied at 12
minutes post-injury. Patient received 500 mL Hextend. Current BP 102/68, HR 118. Per TCCC guidelines,
why is Hextend contraindicated for continued resuscitation?
A. Hextend causes allergic reactions in 15% of patients
B. Hextend's hydroxyethyl starch impairs clotting and increases bleeding risk
C. Hextend is incompatible with whole blood transfusion
D. Hextend requires refrigeration unavailable in field
, Rationale: Hydroxyethyl starch solutions impair coagulation by reducing factor VIII and vWF activity,
exacerbating trauma-induced coagulopathy; TCCC recommends crystalloid or blood products instead.
7. A 56-year-old unrestrained driver in head-on collision has steering wheel deformity, chest bruising,
and seat belt sign. BP 88/60, HR 132. FAST positive in splenorenal recess. After 1 unit whole blood,
patient develops worsening dyspnea and JVD. What pathophysiology explains this deterioration?
A. Simple pneumothorax from rib fractures
B. Tension pneumothorax from air entering pleural space with one-way valve effect, compromising
venous return
C. Cardiac tamponade from myocardial contusion
D. Neurogenic shock from spinal cord injury
Rationale: Worsening hypotension, tachycardia, JVD, and dyspnea after fluid resuscitation suggests
tension physiology where intrathoracic pressure exceeds venous pressure, requiring immediate needle
decompression.
8. A 19-year-old stabbing victim has 3 cm wound at left 4th intercostal space, mid-clavicular line. Patient
talking, RR 24, HR 110, BP 118/76. Breath sounds equal. What is the anatomical rationale for immediate
chest seal versus observation?
A. Anterior chest wounds in "box" area have high probability of cardiac/major vessel involvement;
seal prevents tension physiology from sucking wound
B. Small wounds (<5 cm) rarely cause pneumothorax
C. Equal breath sounds exclude significant injury
D. Mid-clavicular location indicates lung parenchyma only
Rationale: The cardiac box (sternal borders to mid-clavicular lines, clavicle to costal margin) contains
heart, great vessels, and mediastinum; vented chest seals prevent tension pneumothorax while allowing
air egress.
9. A 7-year-old involved in ATV rollover has obvious deformity of right lower leg, pale and cool
extremity, capillary refill >5 seconds. Distal pulses absent. Pain 8/10. Which factor most determines limb
salvage versus amputation?
A. Time from injury to definitive orthopedic care
B. Ischemia time >6 hours causes irreversible muscle necrosis; vascular compromise requires
immediate reduction or revascularization
C. Degree of comminution on X-ray
D. Patient's pain tolerance
Rationale: Skeletal muscle tolerates ischemia for approximately 6 hours before irreversible necrosis;
vascular compromise in pediatric patients requires emergent reduction or surgical revascularization to
prevent compartment syndrome and limb loss.
