ATLS Post Test 2 American College of
Surgeons STUDY BUNDLES A+ Graded
1. A trauma patient with a suspected tension pneumothorax undergoes needle
decompression in the 5th intercostal space at the anterior axillary line. Which
subsequent finding best confirms successful decompression and dictates the next
immediate step?
A. Immediate improvement in oxygen saturation and reduction of dyspnea; proceed to
tube thoracostomy.
B. Audible hiss of air and relief of hypotension; obtain urgent chest radiograph before
chest tube.
C. Persistent hypotension despite decompression; perform immediate resuscitative
thoracotomy.
D. Subcutaneous emphysema at the puncture site; observe and reassess in 15 minutes.
Answer: A. Immediate improvement in oxygen saturation and reduction of dyspnea;
proceed to tube thoracostomy.
Rationale: Successful needle decompression is indicated by a rush of air and clinical
improvement (improved oxygenation, reduced dyspnea, improved hemodynamics). The
definitive treatment is tube thoracostomy; chest radiograph is not required before chest
tube placement in a decompensating patient. Persistent hypotension suggests other causes
(e.g., hemothorax, cardiac tamponade) and does not mandate immediate thoracotomy
without further evaluation.
Page 1 of 78
,2. In a patient with severe pelvic fracture and hemodynamic instability, which
resuscitation strategy best aligns with current ATLS and damage control principles?
A. Aggressive crystalloid infusion to maintain systolic BP > 120 mmHg prior to pelvic
binding.
B. Permissive hypotension with balanced blood product transfusion, pelvic binder
application, and early angioembolization or preperitoneal packing.
C. Immediate open laparotomy to pack the pelvis and control hemorrhage.
D. Rapid infusion of vasopressors to maintain mean arterial pressure > 65 mmHg.
Answer: B. Permissive hypotension with balanced blood product transfusion, pelvic
binder application, and early angioembolization or preperitoneal packing.
Rationale: Current ATLS and damage control resuscitation advocate for permissive
hypotension (target SBP 80-90 mmHg) until hemorrhage control, early balanced
transfusion (1:1:1 ratio), pelvic binder, and prompt angioembolization or preperitoneal
packing. Aggressive crystalloid worsens coagulopathy and acidosis; laparotomy is not the
initial approach for pelvic bleeding; vasopressors do not address hypovolemia.
Page 2 of 78
,3. Which finding on FAST examination is most specific for cardiac tamponade in a
trauma patient with hypotension and distended neck veins?
A. Pericardial effusion with diastolic collapse of the right ventricle.
B. Dilated inferior vena cava with >50% collapse on inspiration.
C. Left ventricular hyperkinesis with septal bounce.
D. Pericardial thickening >5 mm with calcification.
Answer: A. Pericardial effusion with diastolic collapse of the right ventricle.
Rationale: Diastolic collapse of the right ventricle on echocardiography is a highly specific
sign of cardiac tamponade. IVC plethora supports increased right atrial pressure but is not
specific. Left ventricular hyperkinesis and septal bounce are not typical. Pericardial
thickening/calcification suggests constrictive pericarditis, not acute tamponade.
4. A patient with a severe traumatic brain injury (TBI) has an initial GCS of 6. Which
combination of interventions is most appropriate to prevent secondary brain injury
during the primary survey?
A. Hyperventilation to PaCO2 25-30 mmHg, maintain MAP > 50 mmHg, and administer
mannitol.
B. Maintain normocapnia (PaCO2 35-40 mmHg), ensure adequate oxygenation, maintain
CPP 60-70 mmHg, and treat hypotension aggressively.
C. Immediate lumbar puncture to rule out meningitis, then hypertonic saline.
D. Prophylactic anticonvulsants and therapeutic hypothermia to 33°C for 48 hours.
Answer: B. Maintain normocapnia (PaCO2 35-40 mmHg), ensure adequate
oxygenation, maintain CPP 60-70 mmHg, and treat hypotension aggressively.
Rationale: ATLS and BTF guidelines emphasize avoiding hypoxia and hypotension,
maintaining normocapnia, and targeting CPP 60-70 mmHg to prevent secondary injury.
Prophylactic hyperventilation is not recommended; lumbar puncture is contraindicated;
therapeutic hypothermia and prophylactic anticonvulsants are not routine initial measures.
Page 3 of 78
, 5. In a patient with suspected abdominal compartment syndrome after massive
resuscitation, which parameter most reliably indicates the need for decompressive
laparotomy?
A. Intra-abdominal pressure (IAP) of 12 mmHg with abdominal distension.
B. IAP of 20 mmHg with new organ dysfunction (e.g., rising airway pressures, oliguria).
C. IAP of 15 mmHg with mild abdominal pain.
D. IAP of 10 mmHg with decreased bowel sounds.
Answer: B. IAP of 20 mmHg with new organ dysfunction (e.g., rising airway
pressures, oliguria).
Rationale: Abdominal compartment syndrome is defined as sustained IAP >20 mmHg with
new organ dysfunction. IAP 12-15 mmHg without organ failure is intra-abdominal
hypertension and does not mandate surgery. Decreased bowel sounds alone are
nonspecific.
6. A patient with a suspected spinal cord injury presents with hypotension and
bradycardia. Which management strategy is most appropriate after ruling out
hemorrhage?
A. Aggressive fluid resuscitation to maintain MAP > 85 mmHg.
B. Vasopressors (e.g., norepinephrine) to maintain MAP 85-90 mmHg for 7 days.
C. Atropine for bradycardia and fluid restriction.
D. Immediate high-dose steroids within 8 hours of injury.
Answer: B. Vasopressors (e.g., norepinephrine) to maintain MAP 85-90 mmHg for 7
days.
Rationale: Neurogenic shock from spinal cord injury causes hypotension and bradycardia;
after hemorrhage is excluded, vasopressors are used to maintain MAP 85-90 mmHg for 5-7
days per current guidelines. Fluid overload can worsen edema; steroids are not
recommended; atropine is only for symptomatic bradycardia.
Page 4 of 78
Surgeons STUDY BUNDLES A+ Graded
1. A trauma patient with a suspected tension pneumothorax undergoes needle
decompression in the 5th intercostal space at the anterior axillary line. Which
subsequent finding best confirms successful decompression and dictates the next
immediate step?
A. Immediate improvement in oxygen saturation and reduction of dyspnea; proceed to
tube thoracostomy.
B. Audible hiss of air and relief of hypotension; obtain urgent chest radiograph before
chest tube.
C. Persistent hypotension despite decompression; perform immediate resuscitative
thoracotomy.
D. Subcutaneous emphysema at the puncture site; observe and reassess in 15 minutes.
Answer: A. Immediate improvement in oxygen saturation and reduction of dyspnea;
proceed to tube thoracostomy.
Rationale: Successful needle decompression is indicated by a rush of air and clinical
improvement (improved oxygenation, reduced dyspnea, improved hemodynamics). The
definitive treatment is tube thoracostomy; chest radiograph is not required before chest
tube placement in a decompensating patient. Persistent hypotension suggests other causes
(e.g., hemothorax, cardiac tamponade) and does not mandate immediate thoracotomy
without further evaluation.
Page 1 of 78
,2. In a patient with severe pelvic fracture and hemodynamic instability, which
resuscitation strategy best aligns with current ATLS and damage control principles?
A. Aggressive crystalloid infusion to maintain systolic BP > 120 mmHg prior to pelvic
binding.
B. Permissive hypotension with balanced blood product transfusion, pelvic binder
application, and early angioembolization or preperitoneal packing.
C. Immediate open laparotomy to pack the pelvis and control hemorrhage.
D. Rapid infusion of vasopressors to maintain mean arterial pressure > 65 mmHg.
Answer: B. Permissive hypotension with balanced blood product transfusion, pelvic
binder application, and early angioembolization or preperitoneal packing.
Rationale: Current ATLS and damage control resuscitation advocate for permissive
hypotension (target SBP 80-90 mmHg) until hemorrhage control, early balanced
transfusion (1:1:1 ratio), pelvic binder, and prompt angioembolization or preperitoneal
packing. Aggressive crystalloid worsens coagulopathy and acidosis; laparotomy is not the
initial approach for pelvic bleeding; vasopressors do not address hypovolemia.
Page 2 of 78
,3. Which finding on FAST examination is most specific for cardiac tamponade in a
trauma patient with hypotension and distended neck veins?
A. Pericardial effusion with diastolic collapse of the right ventricle.
B. Dilated inferior vena cava with >50% collapse on inspiration.
C. Left ventricular hyperkinesis with septal bounce.
D. Pericardial thickening >5 mm with calcification.
Answer: A. Pericardial effusion with diastolic collapse of the right ventricle.
Rationale: Diastolic collapse of the right ventricle on echocardiography is a highly specific
sign of cardiac tamponade. IVC plethora supports increased right atrial pressure but is not
specific. Left ventricular hyperkinesis and septal bounce are not typical. Pericardial
thickening/calcification suggests constrictive pericarditis, not acute tamponade.
4. A patient with a severe traumatic brain injury (TBI) has an initial GCS of 6. Which
combination of interventions is most appropriate to prevent secondary brain injury
during the primary survey?
A. Hyperventilation to PaCO2 25-30 mmHg, maintain MAP > 50 mmHg, and administer
mannitol.
B. Maintain normocapnia (PaCO2 35-40 mmHg), ensure adequate oxygenation, maintain
CPP 60-70 mmHg, and treat hypotension aggressively.
C. Immediate lumbar puncture to rule out meningitis, then hypertonic saline.
D. Prophylactic anticonvulsants and therapeutic hypothermia to 33°C for 48 hours.
Answer: B. Maintain normocapnia (PaCO2 35-40 mmHg), ensure adequate
oxygenation, maintain CPP 60-70 mmHg, and treat hypotension aggressively.
Rationale: ATLS and BTF guidelines emphasize avoiding hypoxia and hypotension,
maintaining normocapnia, and targeting CPP 60-70 mmHg to prevent secondary injury.
Prophylactic hyperventilation is not recommended; lumbar puncture is contraindicated;
therapeutic hypothermia and prophylactic anticonvulsants are not routine initial measures.
Page 3 of 78
, 5. In a patient with suspected abdominal compartment syndrome after massive
resuscitation, which parameter most reliably indicates the need for decompressive
laparotomy?
A. Intra-abdominal pressure (IAP) of 12 mmHg with abdominal distension.
B. IAP of 20 mmHg with new organ dysfunction (e.g., rising airway pressures, oliguria).
C. IAP of 15 mmHg with mild abdominal pain.
D. IAP of 10 mmHg with decreased bowel sounds.
Answer: B. IAP of 20 mmHg with new organ dysfunction (e.g., rising airway
pressures, oliguria).
Rationale: Abdominal compartment syndrome is defined as sustained IAP >20 mmHg with
new organ dysfunction. IAP 12-15 mmHg without organ failure is intra-abdominal
hypertension and does not mandate surgery. Decreased bowel sounds alone are
nonspecific.
6. A patient with a suspected spinal cord injury presents with hypotension and
bradycardia. Which management strategy is most appropriate after ruling out
hemorrhage?
A. Aggressive fluid resuscitation to maintain MAP > 85 mmHg.
B. Vasopressors (e.g., norepinephrine) to maintain MAP 85-90 mmHg for 7 days.
C. Atropine for bradycardia and fluid restriction.
D. Immediate high-dose steroids within 8 hours of injury.
Answer: B. Vasopressors (e.g., norepinephrine) to maintain MAP 85-90 mmHg for 7
days.
Rationale: Neurogenic shock from spinal cord injury causes hypotension and bradycardia;
after hemorrhage is excluded, vasopressors are used to maintain MAP 85-90 mmHg for 5-7
days per current guidelines. Fluid overload can worsen edema; steroids are not
recommended; atropine is only for symptomatic bradycardia.
Page 4 of 78
