ATLS Written Exam — Questions and Answers

Question 1: According to ATLS, what is the preferred method for log-rolling a patient with suspected spinal injury?

Minimum four-person team with one maintaining cervical stabilization (Correct answer)
Two-person roll
Mechanical lift
Single-person roll with collar

Correct answer: Minimum four-person team with one maintaining cervical stabilization

ATLS recommends minimum four people: one for cervical stabilization, three for coordinated body roll.

Question 2: Which of the following patients would be most appropriate for needle cricothyroidotomy rather than surgical cricothyroidotomy?

An 8-year-old with a failed intubation attempt (Correct answer)
A 60-year-old with known tracheal stenosis
A 30-year-old with laryngeal fracture
A 45-year-old with massive facial trauma

Correct answer: An 8-year-old with a failed intubation attempt

Needle cricothyroidotomy with transtracheal jet ventilation is the preferred emergency surgical airway in children under 12 because the cricothyroid membrane is small.

Question 3: Which injury must be identified and treated during the primary survey?

Small pneumothorax
Massive hemothorax (Correct answer)
Stable pelvic fracture
Simple rib fracture

Correct answer: Massive hemothorax

Massive hemothorax (>1500 mL) is an immediately life-threatening condition that must be treated during the primary survey.

Question 4: What is the most common cause of death in hospitalized burn patients?

Sepsis and multi-organ failure (Correct answer)
Hypovolemic shock
Carbon monoxide poisoning
Renal failure

Correct answer: Sepsis and multi-organ failure

Sepsis is the leading cause due to loss of the skin barrier, immune suppression, and prolonged ICU stay.

Question 5: Which finding on diagnostic peritoneal lavage (DPL) is considered positive for significant intra-abdominal injury?

RBC count >100,000/mm3 in blunt trauma (Correct answer)
WBC count >100/mm3
Amylase level >100 IU/dL
RBC count >50,000/mm3

Correct answer: RBC count >100,000/mm3 in blunt trauma

A red blood cell count exceeding 100,000/mm3 in the DPL effluent is the standard threshold for a positive result in blunt trauma.

Question 6: A crush injury victim trapped for 4 hours. What complication should be anticipated upon extrication?

Hyperkalemia from rhabdomyolysis (Correct answer)
Esophageal rupture
Tension pneumothorax
Epidural hematoma

Correct answer: Hyperkalemia from rhabdomyolysis

Crushed muscle releases potassium, myoglobin, and phosphate upon reperfusion. Hyperkalemia can cause cardiac arrest.

Question 7: 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)
Medical management with mannitol and hyperventilation
Serial CT scans every 6 hours

Correct answer: Emergent craniotomy for evacuation

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

Question 8: A 25-year-old male arrives after a motorcycle crash. He is agitated, his skin is cool and clammy, heart rate is 130 bpm, and blood pressure is 90/60 mmHg. During the primary survey, which of the following is the MOST appropriate initial step for managing his circulation?

Obtain a CT scan to identify the source of bleeding.
Immediately transfuse two units of O-negative packed red blood cells.
Administer a vasopressor to increase blood pressure.
Control any obvious external hemorrhage and establish two large-bore IV lines. (Correct answer)

Correct answer: Control any obvious external hemorrhage and establish two large-bore IV lines.

In the 'C' (Circulation) phase of the primary survey, the priority is to control hemorrhage and restore circulating volume. The patient's signs are consistent with hemorrhagic shock. The first steps are to stop any visible bleeding and secure intravenous access for fluid resuscitation. While blood transfusion may be necessary, it follows securing IV access. A CT scan is an adjunct to the secondary survey and should not delay resuscitation. Vasopressors are generally a later consideration after volume has been addressed.

Question 9: What is the GCS score for a patient who opens eyes to pain, makes incomprehensible sounds, and exhibits flexion withdrawal to pain?

GCS 9
GCS 10
GCS 8 (Correct answer)
GCS 7

Correct answer: GCS 8

Eye opening to pain (E2) + incomprehensible sounds (V2) + flexion withdrawal (M4) = GCS 8.

Question 10: Which finding differentiates vascular injury from neurological injury in a fractured extremity?

Absent distal pulses with pale, cool extremity (Correct answer)
Swelling of the compartment
Pain on passive stretch
Numbness in a dermatomal pattern

Correct answer: Absent distal pulses with pale, cool extremity

Absent pulses with a pale, cool extremity indicates vascular compromise; neurological injury causes sensory/motor deficits without perfusion changes.

Question 11: A precordial stab wound patient in shock with pericardial effusion on FAST. Pericardiocentesis removes 20 mL with transient improvement. Definitive management?

Serial pericardiocentesis
Observation with repeat FAST
Emergent OR thoracotomy for repair (Correct answer)
CT chest

Correct answer: Emergent OR thoracotomy for repair

Pericardiocentesis is a temporizing measure only. Definitive management requires surgical repair.

Question 12: A patient with a suspected basilar skull fracture requires emergency airway management. Which approach is contraindicated?

Orotracheal intubation with RSI
Nasotracheal intubation (Correct answer)
Video-assisted laryngoscopy
Surgical cricothyroidotomy

Correct answer: Nasotracheal intubation

Nasotracheal intubation is contraindicated in patients with suspected basilar skull fractures due to the risk of intracranial placement.

Question 13: A patient suffers a penetrating stab wound to the right side of the neck, resulting in a Brown-Séquard syndrome at the C7 level. Which pattern of neurological deficits would be expected below the injury?

Bilateral loss of pain and temperature sensation with preserved motor function
Paralysis and loss of proprioception on the right; loss of pain and temperature on the left (Correct answer)
Bilateral loss of motor function with preserved sensation
Paralysis and loss of proprioception on the left; loss of pain and temperature on the right

Correct answer: Paralysis and loss of proprioception on the right; loss of pain and temperature on the left

Brown-Séquard syndrome is caused by hemisection of the spinal cord. This damages the ipsilateral (same side) corticospinal tracts (motor) and posterior columns (proprioception/vibration). It also damages the spinothalamic tracts, which cross over; therefore, the loss of pain and temperature sensation occurs on the contralateral (opposite) side.

Question 14: During the primary survey, a patient has oxygen saturation of 85% despite high-flow oxygen. Breath sounds are present bilaterally. What should be evaluated next?

Order a CT angiogram for pulmonary embolism
Begin continuous positive airway pressure
Check for flail chest or pulmonary contusion (Correct answer)
Perform bilateral chest tube insertion

Correct answer: Check for flail chest or pulmonary contusion

Persistent hypoxemia despite supplemental oxygen with bilateral breath sounds suggests underlying pulmonary pathology such as pulmonary contusion or flail chest.

Question 15: Which unique consideration affects fluid resuscitation in pregnant trauma patients?

30-50% hypervolemia means significant blood loss occurs before shock signs appear (Correct answer)
Fluid restriction for fetal edema
Need less fluid due to decreased blood volume
Only colloids in pregnancy

Correct answer: 30-50% hypervolemia means significant blood loss occurs before shock signs appear

Pregnancy increases blood volume 30-50%, masking hemorrhage. The fetus may become hypoperfused before maternal shock signs appear.

Question 16: In a patient with a pelvic fracture and hemodynamic instability, what is the most appropriate initial intervention to control hemorrhage?

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

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 17: 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?

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

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 18: According to ATLS guidelines and general medical-legal principles, when does the responsibility of the referring physician for the care of a transferred trauma patient officially end?

Once the accepting physician at the receiving facility has agreed to the transfer over the phone.
When the patient physically leaves the premises of the referring hospital.
When the transport team arrives at the bedside to assume care.
When the patient has been safely delivered to the receiving facility and care has been formally assumed by the accepting physician. (Correct answer)

Correct answer: When the patient has been safely delivered to the receiving facility and care has been formally assumed by the accepting physician.

The referring physician and their institution retain full responsibility for the patient's care throughout the transfer process. This responsibility only ceases once the patient has arrived at the receiving institution and the medical staff there has formally accepted and assumed care of the patient.

Question 19: A C5 SCI patient has hypotension with HR 52 and warm extremities. After fluids, BP remains low. Best pharmacologic intervention?

Atropine alone
Epinephrine infusion
Norepinephrine or phenylephrine infusion (Correct answer)
Dopamine bolus only

Correct answer: Norepinephrine or phenylephrine infusion

Neurogenic shock requires vasopressors after volume resuscitation fails. Norepinephrine provides combined alpha and beta effects.

Question 20: What is the primary mechanism of death in untreated hemorrhagic shock?

Respiratory failure from ARDS
Cardiac arrhythmia
Disseminated intravascular coagulation
Irreversible cellular ischemia and multi-organ failure (Correct answer)

Correct answer: Irreversible cellular ischemia and multi-organ failure

Prolonged hypoperfusion causes irreversible cellular ischemia and multi-organ failure.

Question 21: Which medication combination is most commonly used for rapid sequence intubation in the trauma setting?

Ketamine and vecuronium
Propofol and rocuronium
Etomidate and succinylcholine (Correct answer)
Midazolam and succinylcholine

Correct answer: Etomidate and succinylcholine

Etomidate provides rapid onset sedation with minimal hemodynamic effects, and succinylcholine provides rapid-onset, short-duration paralysis.

Question 22: A trauma patient has narrow pulse pressure, tachycardia, and flat neck veins. Which shock type?

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

Correct answer: Hypovolemic shock

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

Question 23: What is the earliest and most reliable clinical indicator of adequate resuscitation?

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

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 24: A stab wound to the left lower chest at the 7th intercostal space should raise suspicion for injury to which abdominal organ?

Spleen (Correct answer)
Pancreas
Right kidney
Bladder

Correct answer: Spleen

The thoracoabdominal region contains the upper abdominal organs beneath the diaphragm, and left-sided wounds in this zone frequently injure the spleen.

Question 25: 12. Which of the following statements about PTX treatment is correct?

Current ATLS recommendations state that selected patients with a small, occult PTX can be safely transported by air without a chest tube.
The needle should be placed in the 2nd intercostal space in the midclavicular line during needle decompression of tension PTX, according to current ATLS recommendations.
The needle should be placed in the 5th intercostal space, just anterior to the mid axillary line, during needle decompression of tension PTX, according to current ATLS recommendations. (Correct answer)
The needle should not be longer than 6cm during needle decompression of tension PTX, according to current ATLS recommendations, to avoid potential damage to vessels and other structures.

Correct answer: The needle should be placed in the 5th intercostal space, just anterior to the mid axillary line, during needle decompression of tension PTX, according to current ATLS recommendations.

According to current ATLS guidelines, the recommended site for needle decompression of a tension pneumothorax is the 5th intercostal space, just anterior to the mid-axillary line. This location is preferred over the previously recommended 2nd intercostal space in the midclavicular line due to a lower risk of injury to underlying structures and a higher success rate in reaching the pleural space.

Question 26: A blast injury victim presents with tympanic membrane rupture, pulmonary contusions, and bowel injury. Which mechanism causes bowel injury in blast victims?

Quaternary blast injury from burns
Secondary blast injury from shrapnel
Tertiary blast injury from being thrown by the blast wind
Primary blast injury — overpressure wave disrupting air-fluid interfaces in hollow viscera (Correct answer)

Correct answer: Primary blast injury — overpressure wave disrupting air-fluid interfaces in hollow viscera

Primary blast injury results from the high-pressure shock wave acting on air-filled organs (lungs, bowel, middle ear) at tissue-air interfaces, causing barotrauma.

Question 27: When assessing a trauma patient for a potentially difficult airway, the ATLS course recommends using the LEMON mnemonic. What does the 'E' in LEMON stand for?

Emergency Profile
End-tidal CO2
Evaluate the 3-3-2 Rule (Correct answer)
External Injury

Correct answer: Evaluate the 3-3-2 Rule

The LEMON mnemonic is a tool for assessing a difficult airway. The 'L' stands for Look externally, 'E' for Evaluate the 3-3-2 rule (incisor distance, hyoid-mental distance, and thyroid-to-mouth distance), 'M' for Mallampati score, 'O' for Obstruction/Obesity, and 'N' for Neck mobility.

Question 28: A patient responds to the initial 1-liter crystalloid bolus with transient improvement then drops again. This is classified as what type of responder?

Transient responder (Correct answer)
Rapid responder
Nonresponder
Delayed responder

Correct answer: Transient responder

A transient responder shows initial improvement then deteriorates, indicating ongoing blood loss of 25-40%.

Question 29: A 22-year-old male presents after being crushed between two vehicles. He has an unstable pelvic fracture and, on physical examination, blood is noted at the urethral meatus. What is the most appropriate initial diagnostic step to evaluate the urinary tract?

Perform a CT cystogram.
Immediately attempt to place a Foley catheter.
Obtain an urgent urology consultation for suprapubic catheter placement.
Perform a retrograde urethrogram (RUG). (Correct answer)

Correct answer: Perform a retrograde urethrogram (RUG).

The presence of blood at the urethral meatus, especially in the context of a significant pelvic fracture, is highly suspicious for a urethral injury. Attempting to blindly pass a Foley catheter is contraindicated as it can convert a partial urethral tear into a complete transection. The correct first step is to perform a retrograde urethrogram (RUG) to assess the integrity of the urethra before any catheterization is attempted.

Question 30: A patient with blunt chest trauma has paradoxical chest wall movement. What is the primary cause of hypoxia?

Rib fracture pain
Diaphragmatic paralysis
Underlying pulmonary contusion (Correct answer)
Paradoxical movement alone

Correct answer: Underlying pulmonary contusion

The underlying pulmonary contusion, not the mechanical wall defect, is the primary driver of respiratory failure.

Question 31: Which finding on clinical examination is the earliest sign of uncal herniation?

Decerebrate posturing
Contralateral hemiplegia
Ipsilateral pupillary dilation (Correct answer)
Bilateral fixed dilated pupils

Correct answer: Ipsilateral pupillary dilation

Ipsilateral pupillary dilation from CN III compression against the tentorial edge is the earliest sign of uncal herniation.

Question 32: Permissive hypotension targets what systolic BP in a patient without TBI?

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

Correct answer: 80-90 mmHg

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

Question 33: A patient with a GCS of 14 and brief loss of consciousness undergoes CT showing a small subdural hematoma with no midline shift. What is the most appropriate management?

Emergent craniotomy
Discharge with return precautions
Neurological observation with repeat CT in 6-8 hours (Correct answer)
Immediate burr hole placement

Correct answer: Neurological observation with repeat CT in 6-8 hours

A small subdural hematoma without significant mass effect in an alert patient is managed with neurological observation and repeat imaging.

Question 34: Which of the following is the primary goal of 'permissive hypotension' or 'hypotensive resuscitation' in the initial management of a trauma patient with uncontrolled hemorrhage?

To limit disruption of newly formed clots and avoid re-bleeding. (Correct answer)
To minimize crystalloid administration to prevent hemodilution.
To preferentially perfuse the kidneys and maintain urine output.
To rapidly normalize systolic blood pressure to >120 mmHg.

Correct answer: To limit disruption of newly formed clots and avoid re-bleeding.

Permissive hypotension is a strategy used in damage control resuscitation for patients with uncontrolled hemorrhage. The goal is to maintain a blood pressure just high enough for essential organ perfusion (e.g., systolic BP of 80-90 mmHg) without aggressively raising it, which could dislodge fragile clots and worsen bleeding before definitive surgical control is achieved.

Question 35: 6. Two assailants beat a 49 year-old man with a wooden bat in his home during a robbery. He is taken to the emergency department, hemodynamically stable, with hemoptysis and cervical subQ emphysema. Which of the following statements is true?

Bronchoscopy should be avoided because it may aggravate the injury.
Insert a gastric tube immediately to prevent aspiration.
Immediately begin needle decompression.
Fiber optic assisted intubation could be used. (Correct answer)

Correct answer: Fiber optic assisted intubation could be used.

The presence of hemoptysis and cervical subcutaneous emphysema following blunt trauma strongly suggests a potential airway injury, such as a tracheal or bronchial laceration. In such scenarios, fiber optic assisted intubation is the preferred method for securing the airway. This technique allows for direct visualization of the airway, minimizing the risk of exacerbating the injury during intubation and ensuring a safer procedure.

Question 36: 11. Coagulationopathy is a serious risk in a severely injured patient. Which of the following statements is true?

After the initial bolus, tranexamic acid should not be redosed.
Resuscitation procedures may increase the risk of coagulopathy. (Correct answer)
Tranexamic acid can be prescribed within the first four hours of injury.
To reduce the risk of coagulopathy, keep the patient cool.

Correct answer: Resuscitation procedures may increase the risk of coagulopathy.

Resuscitation procedures, especially the administration of large volumes of intravenous crystalloids, can significantly contribute to the development or worsening of coagulopathy in severely injured patients. This occurs through mechanisms such as dilutional coagulopathy, hypothermia induced by cold fluids, and acidosis, all of which impair the clotting cascade. Maintaining normothermia and judicious fluid administration are crucial to mitigate this risk.

Question 37: 24 hours after femoral fixation, a patient develops sudden dyspnea, petechial rash on chest, and confusion. Most likely diagnosis?

Pulmonary embolism
Compartment syndrome
Hospital-acquired pneumonia
Fat embolism syndrome (Correct answer)

Correct answer: Fat embolism syndrome

The triad of respiratory distress, petechial rash, and neurological changes 24-72 hours after long bone fracture is classic for fat embolism syndrome.

Question 38: During the primary survey of a 26-year-old female who is 24 weeks pregnant and immobilized on a backboard, she suddenly becomes hypotensive and lightheaded. Which of the following is the most critical immediate intervention?

Prepare for an emergency cesarean section.
Obtain a STAT chest x-ray to rule out tension pneumothorax.
Administer a 2-liter bolus of warm crystalloid.
Manually displace the uterus to the left side. (Correct answer)

Correct answer: Manually displace the uterus to the left side.

After 20 weeks of gestation, the gravid uterus can compress the inferior vena cava when the patient is in the supine position, leading to decreased venous return and subsequent hypotension (supine hypotensive syndrome). The most important immediate intervention is to relieve this compression by manually displacing the uterus to the left or tilting the entire backboard 15-30 degrees to the left.

Question 39: An ECG shows electrical alternans and low voltage with hypotension and JVD. Diagnosis?

Tension pneumothorax
Cardiac tamponade (Correct answer)
Acute MI
Aortic dissection

Correct answer: Cardiac tamponade

Electrical alternans (alternating QRS amplitude) with low voltage, hypotension, and JVD is diagnostic of cardiac tamponade.

Question 40: A patient with circumferential full-thickness burns of both legs develops tense compartments and diminished pulses. Treatment?

Increase IV fluid rate
Apply compression bandages
Elevate and observe
Perform escharotomy (Correct answer)

Correct answer: Perform escharotomy

Circumferential full-thickness burns create rigid eschar acting as a tourniquet; escharotomy restores perfusion.

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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Sources & references

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facs.org — Renewal, test delivery · verified Oct 2026
learning.facs.org — Eligibility, exam format · verified Oct 2026
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