ATLS Written Exam — Questions and Answers

Question 1: Which finding on clinical examination is the earliest sign of uncal herniation?

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

Correct answer: Ipsilateral pupillary dilation

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

Question 2: A 30-year-old trauma patient is alert (GCS 15), not intoxicated, and has no focal neurological deficits. According to the NEXUS low-risk criteria for clinical clearance of the cervical spine, which of the following findings would mandate radiographic imaging?

History of a brief loss of consciousness
Patient is over 60 years of age
Presence of a painful wrist fracture (Correct answer)
Complaint of minor anterior neck pain

Correct answer: Presence of a painful wrist fracture

The NEXUS criteria require five conditions to be met for clinical clearance: no posterior midline cervical tenderness, no evidence of intoxication, a normal level of alertness, no focal neurologic deficit, and no painful distracting injury. A painful wrist fracture is considered a distracting injury that could mask the pain from a significant cervical spine injury, thus requiring imaging.

Question 3: A patient has an L1 burst fracture with 60% canal compromise but intact neurological function. What determines need for surgery?

Canal compromise alone mandates surgery
Only neurological deficit warrants surgery
Kyphosis degree and posterior ligamentous complex integrity (Correct answer)
All burst fractures require surgery

Correct answer: Kyphosis degree and posterior ligamentous complex integrity

Surgical decision depends on spinal stability: kyphotic deformity degree and PLC integrity, not canal compromise alone.

Question 4: Widened mediastinum on CXR after high-speed deceleration suggests which injury?

Tracheobronchial disruption
Traumatic aortic injury (Correct answer)
Myocardial contusion
Esophageal rupture

Correct answer: Traumatic aortic injury

Widened mediastinum (>8 cm) after deceleration is the most common finding suggesting traumatic aortic injury at the isthmus.

Question 5: 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 6: Which type of chemical burn causes more severe ocular injury — alkali or acid?

Alkali burns, because they cause liquefactive necrosis and penetrate deeper into ocular structures (Correct answer)
Acid burns, because they cause coagulative necrosis that penetrates further
Neither penetrates beyond the conjunctiva
Both cause equal damage

Correct answer: Alkali burns, because they cause liquefactive necrosis and penetrate deeper into ocular structures

Alkalis (e.g., lye, lime) cause liquefactive necrosis, which allows continued deep penetration into the anterior chamber, making them more destructive than acids.

Question 7: The presence of ecchymosis across the lower abdomen in the distribution of a lap belt (a "seat belt sign") following a motor vehicle collision should raise the highest suspicion for which combination of injuries?

Diaphragmatic rupture and splenic laceration.
Hollow viscus injury and lumbar spine fracture. (Correct answer)
Hepatic laceration and rib fractures.
Aortic dissection and renal contusion.

Correct answer: Hollow viscus injury and lumbar spine fracture.

The "seat belt sign" indicates a significant transfer of energy to the abdominal wall and its underlying structures. This mechanism is strongly associated with compression injuries to the bowel (hollow viscus injury) and flexion-distraction injuries to the lumbar spine (e.g., a Chance fracture).

Question 8: 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?

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

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 9: What is the emergency bedside treatment for retrobulbar hematoma with impending vision loss?

Lateral canthotomy and cantholysis (Correct answer)
Immediate surgical decompression in the OR only
IV mannitol alone
Ice packs and head elevation

Correct answer: Lateral canthotomy and cantholysis

Lateral canthotomy and inferior cantholysis releases orbital compartment pressure rapidly and is a time-critical bedside procedure to save vision.

Question 10: Which of the following patients with thermal burns requires initiation of formal intravenous fluid resuscitation according to ATLS guidelines?

An 8-year-old with partial-thickness burns covering the entire back. (Correct answer)
A 50-year-old with full-thickness burns on the back of the left hand and fingers.
A 30-year-old with superficial (first-degree) burns covering 30% TBSA.
A 40-year-old with partial-thickness burns to the entire anterior aspect of both arms.

Correct answer: An 8-year-old with partial-thickness burns covering the entire back.

Formal fluid resuscitation is generally indicated for adults with burns >20% TBSA and children with burns >10-15% TBSA. The 8-year-old with burns to the entire back (18% TBSA) meets the pediatric criteria. The adult with burns to the anterior arms has a 9% TBSA burn (4.5% for each anterior arm), which is below the threshold. Superficial burns are not included in TBSA calculations for resuscitation. Isolated hand burns, while serious, do not typically meet the TBSA requirement for formal resuscitation.

Question 11: Which of the following is the most reliable method for confirming correct endotracheal tube placement in a trauma patient immediately after intubation?

Continuous waveform capnography showing a consistent CO2 waveform. (Correct answer)
Auscultation of bilateral breath sounds and absence of epigastric sounds.
Condensation seen inside the endotracheal tube.
Observation of symmetric chest rise with ventilation.

Correct answer: Continuous waveform capnography showing a consistent CO2 waveform.

While auscultation, chest rise, and tube condensation are all used as part of the assessment, continuous waveform capnography is considered the gold standard for confirming tracheal placement of an endotracheal tube. It provides a real-time, objective measure of CO2 in exhaled air, which is the most reliable indicator that the tube is in the trachea and not the esophagus.

Question 12: Perimortem cesarean delivery should be initiated within what time frame of maternal cardiac arrest?

Only after 30 minutes of unsuccessful CPR
10 minutes
4 minutes of arrest, delivery by 5 minutes (Correct answer)
15 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 13: A patient with a suspected basilar skull fracture requires emergency airway management. Which approach is contraindicated?

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

Correct answer: Nasotracheal intubation

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

Question 14: 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?

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

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 15: Tranexamic acid in trauma is most effective within what time frame?

3 hours (Correct answer)
1 hour
6 hours
12 hours

Correct answer: 3 hours

Per the CRASH-2 trial, TXA reduces mortality when given within 3 hours. After 3 hours, it may increase mortality.

Question 16: Which type of pelvic fracture is most commonly associated with life-threatening hemorrhage?

Anterior-posterior compression (open book) type III (Correct answer)
Lateral compression type I
Vertical shear
Lateral compression type II

Correct answer: Anterior-posterior compression (open book) type III

AP compression type III fractures create the greatest pelvic volume expansion, disrupting the posterior pelvic ring and major vascular structures.

Question 17: A chest tube initially drains 1,800 mL of blood. According to ATLS, next step?

Continue observation
Prepare for emergent thoracotomy (Correct answer)
Autotransfuse and observe
Clamp tube and reassess

Correct answer: Prepare for emergent thoracotomy

Initial drainage >1,500 mL indicates massive hemothorax requiring emergent thoracotomy.

Question 18: A precordial stab wound patient in shock with pericardial effusion on FAST. Pericardiocentesis removes 20 mL with transient improvement. Definitive management?

Observation with repeat FAST
Serial pericardiocentesis
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 19: Which shock type is characterized by hypotension, bradycardia, and warm flushed skin below the injury?

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

Correct answer: Neurogenic shock

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

Question 20: A patient with a nasal fracture has complete obstruction of both nostrils after manipulation. What immediate concern must be addressed?

Nasal bone osteomyelitis
Le Fort I fracture
Bilateral choanal atresia
Septal hematoma requiring drainage to prevent avascular necrosis (Correct answer)

Correct answer: Septal hematoma requiring drainage to prevent avascular necrosis

Septal hematomas must be drained promptly because the elevated perichondrium disrupts cartilage blood supply, causing avascular necrosis and saddle-nose deformity.

Question 21: A 22-year-old patient has a suspected cervical spine injury after a diving accident. He is hypotensive (BP 80/40 mmHg) with a heart rate of 50 bpm. His skin is warm and dry. What type of shock is most likely present?

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

Correct answer: Neurogenic Shock

The combination of hypotension and bradycardia (paradoxical in shock), along with warm, dry skin, is the classic presentation of neurogenic shock. This results from a loss of sympathetic tone due to a high spinal cord injury, leading to vasodilation and pooling of blood.

Question 22: Which factor is MOST important in determining transport mode for interfacility transfer?

Weather only
Patient preference
Cost
Time to definitive care balanced against patient acuity (Correct answer)

Correct answer: Time to definitive care balanced against patient acuity

Transport mode should be determined by time needed to reach definitive care weighed against clinical acuity.

Question 23: 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?

Tension pneumothorax.
Tracheobronchial injury.
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 24: 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?

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

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

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

Correct answer: Posterior knee dislocation

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

Question 26: According to ATLS 10th edition guidelines, what is the minimum target systolic blood pressure (SBP) that should be maintained in a 60-year-old patient with a traumatic brain injury to prevent secondary injury from hypotension?

≥100 mmHg (Correct answer)
≥120 mmHg
≥110 mmHg
≥90 mmHg

Correct answer: ≥100 mmHg

The ATLS 10th edition guidelines emphasize avoiding hypotension to prevent secondary brain injury. For patients aged 50 to 69 years, the target systolic blood pressure (SBP) should be maintained at or above 100 mmHg. For other age groups (15-49 or >70), the target is ≥110 mmHg. A single hypotensive episode can significantly worsen outcomes.

Question 27: Which type of traumatic brain injury carries the highest overall mortality rate?

Diffuse axonal injury
Epidural hematoma
Acute subdural hematoma (Correct answer)
Depressed skull fracture

Correct answer: Acute subdural hematoma

Acute subdural hematoma carries the highest mortality (50-90%) because it usually results from severe primary brain injury.

Question 28: A patient with an unstable pelvic ring fracture and hemodynamic instability should initially receive:

Greater than 2 liters of crystalloid to restore blood pressure before any intervention
Pelvic binder or circumferential sheet wrap for provisional stabilization (Correct answer)
Immediate surgical exploration of the retroperitoneum
CT pelvis with contrast prior to any mechanical intervention

Correct answer: Pelvic binder or circumferential sheet wrap for provisional stabilization

A pelvic binder or sheet wrap reduces pelvic volume, tamponades venous bleeding, and stabilizes the fracture as the critical first step before imaging or surgery.

Question 29: Which of the following patients would be most appropriate for needle cricothyroidotomy rather than surgical cricothyroidotomy?

A 45-year-old with massive facial trauma
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

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 30: A trauma patient presents with a GCS of 7, copious oral bleeding, and suspected cervical spine injury. What is the most appropriate airway management approach?

Rapid sequence intubation with in-line cervical stabilization (Correct answer)
Nasotracheal intubation
Surgical cricothyroidotomy
Bag-valve-mask ventilation until CT clears the spine

Correct answer: Rapid sequence intubation with in-line cervical stabilization

RSI with manual in-line stabilization is the standard approach for securing the airway in trauma patients with potential cervical spine injuries and a GCS less than 8.

Question 31: A crush injury victim trapped for 4 hours. What complication should be anticipated upon extrication?

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

Correct answer: Hyperkalemia from rhabdomyolysis

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

Question 32: A chronic alcoholic patient is involved in an MVC. Most important assessment consideration?

Alcoholics need less analgesia
Alcohol may mask head injury and shock signs, requiring lower imaging threshold (Correct answer)
Wait until sober to assess
Alcohol protects against hypothermia

Correct answer: Alcohol may mask head injury and shock signs, requiring lower imaging threshold

Intoxication masks pain and alters mental status, requiring liberal CT imaging and high suspicion for occult injuries.

Question 33: A trauma patient has HR 130, BP 70/50, RR 30, and altered mental status. What class of hemorrhagic shock?

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

Correct answer: Class IV

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

Question 34: In a hospital MCI response, what is the role of the Incident Command System (ICS)?

Direct clinical care at the bedside
Coordinate media communications only
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 35: A 30-year-old male is brought to the trauma bay after a high-speed motor vehicle collision. His vital signs are: HR 130 bpm, BP 90/60 mmHg, RR 35 breaths/min. He is anxious and confused. His skin is cool and clammy. Based on the ATLS classification of hemorrhagic shock, what is the estimated percentage of blood volume loss?

15-30% (Class II)
30-40% (Class III) (Correct answer)
Up to 15% (Class I)
>40% (Class IV)

Correct answer: 30-40% (Class III)

The patient's clinical presentation, including significant tachycardia (>120 bpm), hypotension, tachypnea, and altered mental status (anxious, confused), is consistent with Class III hemorrhagic shock. This class corresponds to an estimated blood volume loss of 30-40%.

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

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

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: An elderly patient falls and develops upper extremity weakness greater than lower. Most likely diagnosis?

Anterior cord syndrome
Cauda equina syndrome
Brown-Sequard syndrome
Central cord syndrome (Correct answer)

Correct answer: Central cord syndrome

Central cord syndrome characteristically affects upper extremities more due to somatotopic organization of corticospinal tracts.

Question 38: A patient sustains a high-pressure injection injury to the hand. Initial exam shows only a small puncture wound. What is the correct management?

Observe for 4 hours and discharge if stable
Apply a splint and elevate the hand only
Local wound care and discharge with antibiotics
Emergency surgical consultation for operative decompression and debridement (Correct answer)

Correct answer: Emergency surgical consultation for operative decompression and debridement

High-pressure injection injuries appear deceptively minor externally but cause extensive deep tissue destruction, requiring urgent surgical decompression to prevent limb loss.

Question 39: Following the insertion of a large-bore chest tube for a hemothorax in a trauma patient, the initial drainage is 1,600 mL of blood. According to ATLS guidelines, what is the most appropriate next step in management?

Clamping the chest tube to prevent further blood loss.
Preparing for an urgent thoracotomy. (Correct answer)
Monitoring chest tube output for the next hour.
Administering a second 2-liter bolus of crystalloid.

Correct answer: Preparing for an urgent thoracotomy.

A massive hemothorax is defined by an initial chest tube output of greater than 1,500 mL of blood, or ongoing blood loss of more than 200 mL per hour for 2 to 4 hours. An initial output of 1,600 mL meets the criteria for a massive hemothorax and is an indication for urgent surgical intervention (thoracotomy) to control the source of bleeding.

Question 40: A trauma patient has hypotension, distended neck veins, and muffled heart sounds. Most likely diagnosis?

Massive hemothorax
Myocardial contusion
Tension pneumothorax
Cardiac tamponade (Correct answer)

Correct answer: Cardiac tamponade

Beck's triad: hypotension, JVD, and muffled heart sounds is the classic presentation of cardiac tamponade.

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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