ATLS Written Exam — Questions and Answers

Question 1: What is the primary responsibility of the referring physician when transferring a trauma patient?

Initiating resuscitation and stabilization before and during transfer (Correct answer)
Obtaining insurance authorization
Waiting for receiving facility to arrange transport
Performing all definitive procedures

Correct answer: Initiating resuscitation and stabilization before and during transfer

The referring physician must assess, resuscitate, and stabilize the patient to the best of the facility's capability.

Question 2: A 45-year-old female sustains a severe pelvic fracture. She is hypotensive despite receiving an initial 1-liter bolus of crystalloid. According to ATLS principles, which of the following is the most critical next step in management?

Giving a second 2-liter bolus of crystalloid solution
Initiating transfusion of packed red blood cells and blood products (Correct answer)
Obtaining a CT scan to fully delineate the fracture pattern
Administering vasopressors to increase blood pressure

Correct answer: Initiating transfusion of packed red blood cells and blood products

This patient is a transient responder or non-responder to the initial fluid bolus, indicating ongoing, significant hemorrhage. The priority is to control the bleeding and restore oxygen-carrying capacity. ATLS guidelines emphasize early use of blood products (in a balanced ratio, such as 1:1:1 of packed RBCs, plasma, and platelets) in patients with severe hemorrhage, rather than continuing with large volumes of crystalloids which can lead to coagulopathy and hypothermia.

Question 3: 4. A 30-year-old woman was walking across a busy intersection when she was hit by a van. She has a clearly broken right femur as well as three broken ribs on the right side. She is in need of a blood transfusion. Which of the following statements is correct?

A massive transfusion is defined as >4u pRBC in 1 hour. (Correct answer)
<12u pRBC transfusion in 24 hours would not be considered a massive transfusion.
Everyone who requires a massive transfusion should be given calcium supplements.
The ACS has created a universal MTP that all trauma centers should follow.

Correct answer: A massive transfusion is defined as >4u pRBC in 1 hour.

A massive transfusion is generally defined by the volume of blood products administered over a specific timeframe, indicating significant hemorrhage. One widely accepted definition, particularly relevant in acute trauma, is the transfusion of more than 4 units of packed red blood cells (pRBC) within one hour. This threshold often triggers institutional massive transfusion protocols to optimize patient outcomes.

Question 4: A 25-year-old male is brought to the emergency department after a high-speed motor vehicle collision. He is agitated, with gurgling sounds heard from his airway. His Glasgow Coma Scale (GCS) is 7. According to ATLS guidelines, which of the following is the most appropriate next step in managing this patient's airway?

Apply a non-rebreather mask with 100% oxygen and wait for vital signs.
Obtain a lateral cervical spine X-ray before any airway intervention.
Perform a chin-lift maneuver and insert a nasopharyngeal airway.
Immediately attempt orotracheal intubation with in-line cervical spine stabilization. (Correct answer)

Correct answer: Immediately attempt orotracheal intubation with in-line cervical spine stabilization.

A GCS score of 8 or less is a strong indication for establishing a definitive airway. The presence of gurgling sounds indicates a partially obstructed airway with secretions or blood, and his agitation may be due to hypoxia. Immediate orotracheal intubation is necessary to protect the airway, ensure adequate ventilation, and prevent aspiration, while maintaining in-line stabilization to protect the cervical spine, which is assumed to be injured in trauma patients.

Question 5: In a pregnant trauma patient at 28 weeks, what is the most important initial intervention to improve hemodynamics?

Fetal monitoring
Emergency cesarean
Tocolytics
Left lateral tilt of 15-30 degrees (Correct answer)

Correct answer: Left lateral tilt of 15-30 degrees

Left lateral tilt relieves aortocaval compression by the gravid uterus, improving venous return and cardiac output by up to 30%.

Question 6: A patient arrives with a GCS of 6 after a fall. CT shows an acute epidural hematoma >30 mL with 8 mm of midline shift. What is the most appropriate management?

Intracranial pressure monitor placement only
Emergent craniotomy for evacuation (Correct answer)
Serial CT scans every 6 hours
Medical management with mannitol and hyperventilation

Correct answer: Emergent craniotomy for evacuation

An epidural hematoma >30 mL with significant midline shift and depressed GCS requires emergent surgical evacuation.

Question 7: What is the earliest and most reliable clinical indicator of adequate resuscitation?

Blood pressure normalization
Urine output of 0.5 mL/kg/hour (Correct answer)
Normal heart rate return
Skin color improvement

Correct answer: Urine output of 0.5 mL/kg/hour

Urine output (0.5 mL/kg/hr adults) is the most reliable indicator of end-organ perfusion.

Question 8: Which triad of physiologic derangements is known as the 'lethal triad' in trauma patients?

Tachycardia, hypotension, and oliguria
Hypothermia, acidosis, and coagulopathy (Correct answer)
Anemia, thrombocytosis, and hypoxia
Hypertension, hyperkalemia, and alkalosis

Correct answer: Hypothermia, acidosis, and coagulopathy

The lethal triad of hypothermia, acidosis, and coagulopathy is a self-perpetuating cycle that greatly increases mortality in trauma patients.

Question 9: A trauma patient has HR 130, BP 70/50, RR 30, and altered mental status. What class of hemorrhagic shock?

Class II
Class I
Class IV (Correct answer)
Class III

Correct answer: Class IV

Tachycardia >120, hypotension, tachypnea >30, and altered mental status indicate Class IV shock (>40% blood volume loss).

Question 10: During exposure in the primary survey, what is the most important environmental consideration?

Documenting all visible injuries
Maintaining patient modesty
Applying monitoring devices
Prevention of hypothermia (Correct answer)

Correct answer: Prevention of hypothermia

Hypothermia prevention is the primary concern, as it contributes to the lethal triad.

Question 11: In a hospital MCI response, what is the role of the Incident Command System (ICS)?

Coordinate media communications only
Direct clinical care at the bedside
Provide a standardized organizational structure with unified command to coordinate all emergency response functions (Correct answer)
Replace the normal chain of hospital command permanently

Correct answer: Provide a standardized organizational structure with unified command to coordinate all emergency response functions

ICS provides a scalable, modular command structure that integrates multiple agencies and departments under unified command, preventing communication failures during complex MCIs.

Question 12: After intubation, a trauma patient's oxygen saturation drops and breath sounds are heard only on the right side. What is the most likely cause?

Esophageal intubation
Right mainstem bronchus intubation (Correct answer)
Left tension pneumothorax
Right-sided hemothorax

Correct answer: Right mainstem bronchus intubation

Unilateral right-sided breath sounds after intubation most commonly indicates right mainstem bronchus intubation.

Question 13: Perimortem cesarean delivery should be initiated within what time frame of maternal cardiac arrest?

Only after 30 minutes of unsuccessful CPR
15 minutes
4 minutes of arrest, delivery by 5 minutes (Correct answer)
10 minutes

Correct answer: 4 minutes of arrest, delivery by 5 minutes

Initiate within 4 minutes, deliver by 5 minutes when fetus is viable (>24 weeks). Improves both maternal and fetal survival.

Question 14: A trauma patient with severe maxillofacial injuries and active oropharyngeal bleeding cannot be intubated via orotracheal or nasotracheal routes. Bag-mask ventilation is also proving ineffective. What is the next definitive airway management step according to ATLS protocols?

Insert a laryngeal mask airway (LMA).
Perform an emergency needle cricothyroidotomy.
Perform a surgical cricothyroidotomy. (Correct answer)
Attempt a retrograde intubation.

Correct answer: Perform a surgical cricothyroidotomy.

In a 'can't intubate, can't oxygenate' scenario, a surgical airway is indicated. A surgical cricothyroidotomy is the preferred emergency surgical airway for adults and older children when other methods of establishing an airway have failed or are contraindicated. A needle cricothyroidotomy is a temporizing measure, especially in younger children, but does not provide adequate ventilation. An LMA is not considered a definitive airway.

Question 15: Which shock type is characterized by hypotension, bradycardia, and warm flushed skin below the injury?

Septic shock
Neurogenic shock (Correct answer)
Cardiogenic shock
Hypovolemic shock

Correct answer: Neurogenic shock

Neurogenic shock results from loss of sympathetic tone after spinal cord injury, causing vasodilation and bradycardia.

Question 16: A 45-year-old restrained driver involved in a frontal collision has a normal FAST exam. A chest x-ray is obtained, and the nasogastric tube is visualized coiled in the left hemithorax. What is the most likely diagnosis?

Tracheobronchial injury.
Tension pneumothorax.
Traumatic diaphragmatic rupture. (Correct answer)
Esophageal perforation.

Correct answer: Traumatic diaphragmatic rupture.

The visualization of an abdominal organ, such as the stomach (indicated by the coiled nasogastric tube), within the thoracic cavity on a chest x-ray is a pathognomonic sign of a traumatic diaphragmatic rupture. This occurs when a tear in the diaphragm allows abdominal contents to herniate into the chest.

Question 17: Le Fort I fractures involve which anatomical level?

Fracture through the nasal bones and orbital floors
Fracture of the frontal sinus only
Horizontal fracture at the base of the maxilla above the tooth apices, separating the palate from the upper face (Correct answer)
Fracture through the zygomatic arches and lateral orbital walls

Correct answer: Horizontal fracture at the base of the maxilla above the tooth apices, separating the palate from the upper face

Le Fort I is a horizontal fracture separating the tooth-bearing maxilla (hard palate and alveolar ridge) from the rest of the facial skeleton.

Question 18: Which of the following is an absolute indication for an immediate exploratory laparotomy in a patient with a penetrating abdominal wound?

A stab wound to the anterior abdomen without peritoneal signs.
A gunshot wound to the right upper quadrant in a stable patient.
Hematuria following a stab wound to the flank.
Evisceration of omentum. (Correct answer)

Correct answer: Evisceration of omentum.

Evisceration of any intra-abdominal content (such as omentum or bowel) through a penetrating wound is a definitive sign of peritoneal violation and mandates immediate exploratory laparotomy. The other options are relative indications that may be managed with further evaluation (e.g., CT scan) or observation in a hemodynamically stable patient.

Question 19: A patient has an unstable pelvis on manual compression. What is the correct immediate action?

Apply a pelvic binder and avoid further manipulation (Correct answer)
Repeat compression to confirm
Log roll for rectal exam
Obtain AP pelvis X-ray first

Correct answer: Apply a pelvic binder and avoid further manipulation

Once instability is identified, apply a pelvic binder immediately. Never repeat the test.

Question 20: A 22-year-old male is brought to the emergency department after being struck on the side of the head with a bat. He briefly lost consciousness at the scene but was awake and talking upon arrival, complaining only of a headache. Thirty minutes later, he becomes drowsy, his right pupil becomes fixed and dilated, and he develops left-sided weakness. What is the most likely diagnosis?

Subarachnoid hemorrhage
Diffuse axonal injury
Acute subdural hematoma
Epidural hematoma (Correct answer)

Correct answer: Epidural hematoma

The classic presentation of an epidural hematoma involves trauma to the temporal area, a brief loss of consciousness, followed by a 'lucid interval' where the patient seems relatively well, and then rapid neurological deterioration. This decline is due to arterial bleeding, most commonly from the middle meningeal artery, which causes rapid expansion of the hematoma and compression of the brain, leading to signs of uncal herniation like an ipsilateral fixed and dilated pupil.

Question 21: A patient with a tibial fracture develops severe pain disproportionate to injury, pain with passive toe extension, and a tense compartment. What is the diagnosis and treatment?

Acute compartment syndrome; emergent fasciotomy (Correct answer)
Deep vein thrombosis; anticoagulation
Fat embolism syndrome; supportive care
Fracture malreduction; re-splint

Correct answer: Acute compartment syndrome; emergent fasciotomy

Classic compartment syndrome presentation requires emergent fasciotomy within 6 hours.

Question 22: A patient with left diaphragmatic rupture may present with which CXR finding?

Elevated right hemidiaphragm
Left pleural calcifications
Right mediastinal shift
Bowel loops or NG tube visible in the left chest (Correct answer)

Correct answer: Bowel loops or NG tube visible in the left chest

Abdominal contents herniate through the torn diaphragm, visible in the chest on X-ray.

Question 23: Permissive hypotension targets what systolic BP in a patient without TBI?

60-70 mmHg
100-110 mmHg
80-90 mmHg (Correct answer)
120-130 mmHg

Correct answer: 80-90 mmHg

Target SBP 80-90 mmHg to avoid disrupting clot formation while maintaining organ perfusion.

Question 24: A 50-year-old female involved in a high-speed collision is noted to have a blood pressure of 190/110 mmHg, a heart rate of 48 bpm, and an irregular respiratory pattern. This set of vital signs is known as Cushing's triad and is a late sign of what critical condition?

Spinal shock
Hemorrhagic shock Class IV
Fat embolism syndrome
Impending brainstem herniation (Correct answer)

Correct answer: Impending brainstem herniation

Cushing's triad consists of hypertension (with a widening pulse pressure), bradycardia, and irregular respirations. It is a late and ominous physiological response to severely increased intracranial pressure (ICP) and indicates that the brainstem is being compressed, signaling impending herniation.

Question 25: What is the most reliable indicator of intra-abdominal hemorrhage requiring surgical intervention in an unstable trauma patient?

Base deficit greater than 6
Elevated serum lactate
Positive FAST exam (Correct answer)
Falling hemoglobin on serial labs

Correct answer: Positive FAST exam

A positive FAST exam in a hemodynamically unstable patient is the most reliable bedside indicator of significant intra-abdominal hemorrhage requiring emergent surgical exploration.

Question 26: A trauma patient develops progressive hoarseness, stridor, and subcutaneous emphysema in the neck. Which injury should be most strongly suspected?

Laryngeal fracture (Correct answer)
Tension pneumothorax
Esophageal perforation
Carotid artery dissection

Correct answer: Laryngeal fracture

The triad of hoarseness, stridor, and subcutaneous emphysema in the neck is highly suggestive of laryngeal fracture.

Question 27: A T4 complete SCI patient is at risk for which respiratory complication?

No respiratory compromise expected
Upper airway obstruction only
Loss of diaphragm function requiring ventilation
Loss of intercostal and abdominal muscle function with preserved diaphragm (Correct answer)

Correct answer: Loss of intercostal and abdominal muscle function with preserved diaphragm

At T4, the diaphragm (C3-C5) is preserved but intercostals and abdominal muscles are paralyzed.

Question 28: In a patient with a pelvic fracture and hemodynamic instability, what is the most appropriate initial intervention to control hemorrhage?

Application of a pelvic binder (Correct answer)
Internal iliac artery ligation
Angiographic embolization
Emergent laparotomy

Correct answer: Application of a pelvic binder

A pelvic binder reduces pelvic volume and provides tamponade effect, serving as the first-line intervention for hemorrhage control in unstable pelvic fractures.

Question 29: Which mechanism most commonly causes tracheobronchial disruption?

Blast injury
Sudden chest compression against a closed glottis (Correct answer)
Penetrating neck trauma
Rapid deceleration

Correct answer: Sudden chest compression against a closed glottis

Sudden AP chest compression against a closed glottis increases intraluminal pressure, causing rupture near the carina.

Question 30: A trauma patient has narrow pulse pressure, tachycardia, and flat neck veins. Which shock type?

Neurogenic shock
Hypovolemic shock (Correct answer)
Cardiac tamponade
Tension pneumothorax

Correct answer: Hypovolemic shock

Narrow pulse pressure, tachycardia, and flat neck veins indicate hypovolemic shock.

Question 31: Which clinical sign most reliably indicates tension pneumothorax requiring immediate intervention?

Paradoxical chest wall movement
Subcutaneous emphysema
Unilateral absent breath sounds with hypotension and tracheal deviation (Correct answer)
Oxygen saturation below 90%

Correct answer: Unilateral absent breath sounds with hypotension and tracheal deviation

The classic presentation of tension pneumothorax includes absent breath sounds on the affected side, hypotension, and contralateral tracheal deviation.

Question 32: Which injury has the highest risk of associated vascular injury requiring evaluation?

Ankle fracture-dislocation
Posterior knee dislocation (Correct answer)
Humeral shaft fracture
Femoral shaft fracture

Correct answer: Posterior knee dislocation

Posterior knee dislocation carries a 20-40% risk of popliteal artery injury.

Question 33: An open pneumothorax (sucking chest wound) is initially managed with which intervention?

Chest tube through the wound
Positive pressure ventilation alone
Four-sided occlusive dressing
Three-sided occlusive dressing (Correct answer)

Correct answer: Three-sided occlusive dressing

Three-sided dressing creates a flutter-valve: sealed during inspiration, open during expiration to prevent tension.

Question 34: A 34-year-old patient presents with a deep penetrating wound to the right chest following an assault. On inspiration, a distinct 'sucking' sound is heard from the wound. The patient is tachypneic and anxious. What is the most appropriate immediate field management for this injury?

Immediately inserting a chest tube through the wound.
Applying an occlusive dressing taped on three sides. (Correct answer)
Packing the wound with sterile gauze.
Performing endotracheal intubation and positive pressure ventilation.

Correct answer: Applying an occlusive dressing taped on three sides.

This patient has an open pneumothorax, or 'sucking chest wound.' The immediate priority is to place an occlusive dressing taped on only three sides. This creates a one-way valve effect, allowing air to escape from the pleural space during exhalation but preventing air from entering during inhalation, thus preventing the development of a tension pneumothorax. A chest tube will be required later but is not the first step.

Question 35: A patient on warfarin presents with a GCS of 10 after a fall. CT reveals an acute subdural hematoma. What is the most critical initial pharmacologic intervention?

Start heparin infusion
Administer tranexamic acid
Give desmopressin
Reverse anticoagulation with prothrombin complex concentrate and vitamin K (Correct answer)

Correct answer: Reverse anticoagulation with prothrombin complex concentrate and vitamin K

Immediate reversal with PCC and IV vitamin K is critical to prevent hematoma expansion in anticoagulated patients.

Question 36: What is the initial treatment for carbon monoxide poisoning in a burn patient?

100% oxygen via non-rebreather mask (Correct answer)
Hyperbaric oxygen immediately
Room air and observation
Intubation with 50% FiO2

Correct answer: 100% oxygen via non-rebreather mask

100% O2 reduces COHb half-life from 4-6 hours to 60-90 minutes. Start before COHb levels are available.

Question 37: Which burn type is characterized by white/waxy appearance, no pain, and no capillary refill?

Superficial partial-thickness
Deep partial-thickness
Superficial (first-degree)
Full-thickness (third-degree) (Correct answer)

Correct answer: Full-thickness (third-degree)

Full-thickness burns destroy all skin layers including nerve endings, resulting in insensate, white/waxy wounds requiring grafting.

Question 38: Which of the following components is assessed during the 'D' (Disability) part of the ATLS primary survey?

The patient's AMPLE history.
Glasgow Coma Scale (GCS) score. (Correct answer)
Capillary refill time.
A detailed sensory and motor examination of the extremities.

Correct answer: Glasgow Coma Scale (GCS) score.

The 'D' for Disability in the primary survey is a rapid neurological evaluation. Its core components are the Glasgow Coma Scale (GCS) to assess the level of consciousness, and pupillary size and reaction. A detailed neurological exam is part of the secondary survey. AMPLE history is also taken during the secondary survey, and capillary refill is part of the 'C' (Circulation) assessment.

Question 39: What is the most common level of cervical spine injury in adults?

C5-C6 (Correct answer)
C7-T1
C3-C4
C1-C2

Correct answer: C5-C6

C5-C6 is most common because it has the greatest cervical spine mobility.

Question 40: During the secondary survey of a patient with paraplegia following a severe fall, the examiner assesses for sacral sparing. Which of the following findings indicates an incomplete spinal cord injury?

Voluntary anal contraction (Correct answer)
Presence of priapism
Absence of deep tendon reflexes in the lower extremities
Flaccid paralysis below the lesion

Correct answer: Voluntary anal contraction

Sacral sparing refers to the preservation of sensory or motor function in the lowest sacral segments (S4-S5). Evidence of this, such as voluntary anal contraction, perianal sensation, or great toe flexion, indicates that the spinal cord injury is incomplete and carries a better prognosis for recovery. The other options are signs associated with spinal shock or a complete injury.

ATLS Written Exam

The ATLS written exam assesses physicians on systematic trauma assessment and management, covering the 10th Edition curriculum from initial assessment through definitive care.

Questions

75 min

Time Limit

75%

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