What is the ATLS primary survey and why is the order important?

The ATLS primary survey is a systematic ABCDE assessment designed to identify and treat immediately life-threatening conditions in a prioritized order: Airway (with C-spine protection) — an obstructed airway kills faster than any other problem; Breathing — tension pneumothorax and open pneumothorax can kill within minutes; Circulation with Hemorrhage Control — uncontrolled hemorrhage is the most common preventable cause of trauma death; Disability — rapid neurological assessment; Exposure/Environment — complete examination and prevent hypothermia. The order is intentional: A kills faster than B, B faster than C. You do not move to the next step until the life threat at the current step is controlled (or simultaneously treated by another team member in a team-based approach). If a patient deteriorates at any point, the survey restarts from A.

How do you differentiate tension pneumothorax from massive hemothorax clinically?

Both present with absent or decreased breath sounds and shock, but they differ on several clinical findings: Tension pneumothorax — absent breath sounds on the affected side + tracheal deviation AWAY from affected side + hypotension + distended neck veins (obstructive shock — impaired venous return); treatment is immediate needle decompression without waiting for imaging. Massive hemothorax — absent or decreased breath sounds + flat neck veins (hypovolemic shock — blood in chest causing hypovolemia) + dull percussion over affected side vs. hyperresonant in tension; treatment is chest tube drainage (chest tube in 4th-5th ICS anterior axillary line). In ATLS, if the patient is in extremis with absent breath sounds on one side, treat for tension pneumothorax empirically — the risk of missing a tension is greater than the risk of treating a hemothorax with a needle.

What is damage control surgery and when is it indicated?

Damage control surgery (DCS) is an abbreviated surgical strategy for the most severely injured patients who cannot tolerate a lengthy definitive repair. The approach involves three phases: (1) Initial abbreviated surgery — control of hemorrhage (packing, vascular ligation or shunting) and contamination (bowel clamping) only; the abdomen is temporarily closed with a negative pressure wound device; (2) ICU resuscitation — correct the "lethal triad" of hypothermia, coagulopathy, and acidosis through warming, blood products, and correction of pH; (3) Planned return to OR — definitive repair of injuries once the patient is physiologically stable. DCS is indicated when patients have the lethal triad, require massive transfusion, have multiple high-energy injuries, or when operative time would exceed 90 minutes. The physiological limits that trigger DCS: temperature 15, or transfusion >10 units PRBCs.

What injuries should be suspected with a rapid deceleration mechanism?

Rapid deceleration injuries occur when the body stops suddenly while internal organs continue to move forward — typically motor vehicle collisions, falls from height, or aircraft crashes. Classic deceleration injuries: (1) Thoracic aortic injury — the aorta is relatively fixed at the ligamentum arteriosum (aortic isthmus) while the mobile descending aorta shears; CXR findings: widened mediastinum >8 cm, loss of aortic knob, deviation of trachea/nasogastric tube to the right, left apical cap, left hemothorax; confirm with CTA; (2) Mesenteric injury — the bowel loops decelerate at the fixed mesenteric attachments causing tears; (3) Duodenal hematoma or perforation — fixed retroperitoneal position makes it vulnerable; (4) Liver and spleen — lacerations from deceleration forces; (5) Cervical spine injury — particularly C1/C2 (atlas/axis) ligamentous injuries and C5-C6 fractures from flexion-extension.

ATLS Practice Test PDF (Free Printable 2026)

Download a free ATLS practice test PDF with Advanced Trauma Life Support exam questions. Print and study offline for the ACS ATLS provider course written examination.

ATLS - Advanced Trauma Life SupportMay 4, 20267 min read

ATLS Practice Test PDF – Free Printable Advanced Trauma Life Support Exam Prep

Preparing for the ATLS (Advanced Trauma Life Support) provider course examination? A printable ATLS practice test PDF gives you an offline format to review the primary survey, shock recognition, specific injury patterns, and the trauma management algorithms that the ATLS written examination assesses. The ATLS course is taught by the American College of Surgeons and is required for surgeons, emergency medicine physicians, and other physicians who manage trauma patients. This page provides a free PDF download and a comprehensive ATLS exam preparation guide.

The ATLS provider course is a two-day program consisting of didactic sessions, skills station practice, and written and practical examinations. Passing requires an 80% score on the 40-question written exam. ATLS certification is valid for four years and is recognized worldwide as the standard for initial trauma management training. The course principles emphasize a systematic, reproducible approach to the trauma patient regardless of specific injury pattern.

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ATLS Certification Fast Facts

ATLS Exam Content Areas

Your ATLS practice test PDF covers all major trauma management concepts tested on the ATLS provider written examination.

Primary Survey and Airway Management

The ATLS primary survey ABCDE framework provides a systematic trauma assessment: Airway with Cervical Spine Protection (jaw thrust maneuver — maintains C-spine alignment while opening airway; oral airway — used in unconscious patients without gag reflex; nasopharyngeal airway — safer with intact gag reflex; definitive airway indications — GCS ≤8, airway obstruction, respiratory failure, hemorrhagic shock — RSI for intubation with in-line C-spine stabilization; surgical airway — cricothyrotomy for failed intubation "can't intubate, can't oxygenate" scenario), Breathing (exposure and inspection — respiratory rate, accessory muscle use, tracheal deviation; auscultation and percussion; immediate threats — tension pneumothorax: absent breath sounds + tracheal deviation + hypotension = needle decompression 2nd ICS MCL before CXR; hemothorax: chest tube 4th-5th ICS AAL; open pneumothorax: three-sided occlusive dressing; massive hemothorax: >1500 mL initial drain or >200 mL/hr suggests thoracotomy), Circulation with Hemorrhage Control (direct pressure as first-line; tourniquet for extremity hemorrhage — proximal, tight, time noted; pelvic binder for unstable pelvic fracture reducing pelvic volume; IV access — two large-bore IVs or IO if no peripheral access; shock assessment — mental status + skin + pulse), Disability (GCS — Eye 1-4, Verbal 1-5, Motor 1-6; pupillary exam — unilateral dilated fixed pupil = ipsilateral uncal herniation; lateralizing motor findings), and Exposure/Environment (full exposure + log roll; prevent hypothermia — lethal triad: hypothermia, coagulopathy, acidosis).

Shock and Hemorrhage Management

Hemorrhagic shock classification and management: Class I — up to 750 mL blood loss (15% EBV), normal vital signs, anxiety; Class II — 750-1500 mL (15-30% EBV), tachycardia >100, tachypnea 20-30, decreased pulse pressure, anxiety/fright; Class III — 1500-2000 mL (30-40% EBV), tachycardia >120, hypotension, oliguria, confusion — this class usually requires blood transfusion; Class IV — >2000 mL (>40% EBV), extreme tachycardia, significantly depressed BP, anuric, confused/lethargic — immediately life-threatening. Damage control resuscitation principles: limit crystalloid infusion (isotonic saline/LR causes coagulopathy and abdominal compartment syndrome with large volumes), early balanced blood transfusion (1:1:1 ratio packed RBCs:FFP:platelets — massive transfusion protocol), permissive hypotension (target systolic 80-90 mmHg for penetrating torso injuries without TBI — allows clot formation; NOT appropriate for TBI), tranexamic acid (TXA) within 3 hours of injury for major hemorrhage, and damage control surgery (abbreviated laparotomy — hemorrhage and contamination control, packing, abdominal closure with temporary coverage, ICU resuscitation, then definitive repair).

Head, Spinal, and Thoracic Trauma

Traumatic brain injury management: primary vs. secondary injury (primary injury = initial mechanical damage; secondary injury = hypoxia, hypotension, elevated ICP — prevention is the goal), GCS as TBI severity guide (mild GCS 13-15, moderate GCS 9-12, severe GCS ≤8), Cushing's triad as sign of herniation (hypertension + bradycardia + irregular respirations — late finding, brain about to herniate), immediate management — airway + avoid hypoxia (SpO2 >95%) + avoid hypotension (SBP >90 mmHg, target >110 for TBI with polytrauma), hyperventilation only as bridge therapy for impending herniation (PaCO2 35-40 normal; 30-35 for herniation management temporarily), mannitol 1 g/kg for herniation, and neurosurgical consultation. Spinal injury: neurogenic shock vs. hypovolemic shock (neurogenic — bradycardia with hypotension, warm extremities — loss of sympathetic tone; hypovolemic — tachycardia with hypotension, cold extremities — must exclude hemorrhage first). Thoracic injuries: flail chest (paradoxical movement — ≥3 consecutive ribs broken in ≥2 places; treatment = positive pressure ventilation; pain control essential), traumatic aortic injury (deceleration mechanism — CXR widened mediastinum >8cm, loss of aortic knob, left hemothorax; CT angiography confirms; avoid hypotension), and diaphragmatic injury (left more common, stomach/bowel in chest on CXR).

How to Use This PDF

Memorize the shock classification table (Classes I-IV) and primary survey decision points — these are consistently the highest-tested areas. After this PDF, take online ATLS practice tests at atls certification for instant scored feedback.

Free ATLS Practice Tests Online

After completing this PDF, take full online ATLS practice tests at atls certification — instant scoring across primary survey, shock management, traumatic brain injury, thoracic trauma, and special populations with explanations for every answer. Use both: PDF for offline trauma algorithm review, online for timed ATLS written exam simulation.