ATLS Written Exam — Questions and Answers

Question 1: A trauma patient has been stabilized after the primary survey and initial resuscitation. When does the ATLS protocol indicate the secondary survey should begin?

After the primary survey is completed, resuscitation is underway, and vital signs are normalizing. (Correct answer)
After all imaging studies, including CT scans, have been completed.
Immediately after assessing 'E' for Exposure.
Once the patient is transferred to the intensive care unit.

Correct answer: After the primary survey is completed, resuscitation is underway, and vital signs are normalizing.

The secondary survey is a head-to-toe evaluation that should only begin after the primary survey (ABCDEs) is complete, resuscitation efforts are in progress, and the patient is demonstrating normalization of vital functions. If the patient becomes unstable at any point during the secondary survey, the provider must return to the primary survey.

Question 2: Which injury must be identified and treated during the primary survey?

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

Correct answer: Massive hemothorax

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

Question 3: What is the role of vasopressors in initial hemorrhagic shock management?

Contraindicated
Used only after adequate volume resuscitation and hemorrhage control (Correct answer)
First-line treatment
Preferred over blood products

Correct answer: Used only after adequate volume resuscitation and hemorrhage control

Vasopressors are used only after adequate volume and hemorrhage control, as vasoconstrictors in hypovolemia worsen tissue ischemia.

Question 4: A hemodynamically stable patient with a Grade III splenic laceration on CT is best managed with which approach?

Nonoperative management with observation (Correct answer)
Splenic artery embolization only
Diagnostic peritoneal lavage
Emergent splenectomy

Correct answer: Nonoperative management with observation

Hemodynamically stable patients with Grade I-III splenic injuries are typically managed nonoperatively with serial abdominal exams, hemoglobin monitoring, and bed rest, achieving success rates of over 90%.

Question 5: Permissive hypotension targets what systolic BP in a patient without TBI?

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

Correct answer: 80-90 mmHg

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

Question 6: What is the preferred initial study for suspected blunt cardiac injury in a stable patient?

Transesophageal echo
Cardiac catheterization
12-lead ECG (Correct answer)
Cardiac MRI

Correct answer: 12-lead ECG

ECG detects arrhythmias, ST changes, and conduction abnormalities indicating myocardial damage.

Question 7: In the initial management of a patient with an open tibial fracture, which of the following is the most appropriate sequence of actions in the emergency department according to ATLS guidelines?

Remove gross contaminants, cover with a sterile saline-moistened dressing, realign the limb, splint, and administer IV antibiotics. (Correct answer)
Take multiple x-rays from various angles before touching the wound, then apply a compressive dressing.
Aggressively scrub the wound with povidone-iodine, apply a tourniquet, and await surgical consultation.
Perform a bedside fracture reduction, apply a cast, and administer oral antibiotics.

Correct answer: Remove gross contaminants, cover with a sterile saline-moistened dressing, realign the limb, splint, and administer IV antibiotics.

The correct initial management for an open fracture involves controlling any life-threatening hemorrhage, removing visible gross contaminants, covering the wound with a sterile dressing to prevent further contamination, gently realigning the limb to a more anatomic position to restore perfusion and relieve pressure on soft tissues, immobilizing it with a splint, and administering prompt intravenous antibiotics and tetanus prophylaxis. [1, 6, 19] Aggressive scrubbing in the ED is not recommended, and tourniquets are only for life-threatening hemorrhage unresponsive to other means. [1]

Question 8: In a patient with a pelvic fracture and hemodynamic instability, what is the most appropriate initial intervention to control hemorrhage?

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

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 9: A diving accident patient has bilateral motor loss and pain/temperature loss but preserved proprioception and light touch. Which syndrome?

Brown-Sequard syndrome
Central cord syndrome
Anterior cord syndrome (Correct answer)
Posterior cord syndrome

Correct answer: Anterior cord syndrome

Anterior cord syndrome affects motor (corticospinal tracts) and pain/temperature (spinothalamic tracts) while sparing posterior columns.

Question 10: During the 'E' (Exposure and Environment) phase of the primary survey, what is a critical management principle?

Performing a log roll to inspect the back before assessing the anterior body.
Leaving clothing in place over injured areas to act as a sterile dressing.
Limiting fluid resuscitation to prevent dilutional coagulopathy.
Applying warm blankets and external warming devices to prevent hypothermia. (Correct answer)

Correct answer: Applying warm blankets and external warming devices to prevent hypothermia.

In the 'E' phase, the patient must be fully undressed to allow for a thorough examination for injuries. However, this exposes them to the risk of hypothermia, a component of the 'triad of death' in trauma. Therefore, a critical step is to prevent heat loss by covering the patient with warm blankets, using external warming devices, and warming intravenous fluids.

Question 11: What is the recommended method to confirm correct endotracheal tube placement in the trauma setting?

End-tidal CO2 detection combined with clinical assessment (Correct answer)
Chest X-ray as the sole method
Auscultation of bilateral breath sounds alone
Pulse oximetry response within 2 minutes

Correct answer: End-tidal CO2 detection combined with clinical assessment

End-tidal CO2 combined with clinical assessment is the most reliable method to confirm tracheal placement.

Question 12: A patient has a positive FAST but is hemodynamically stable after a motor vehicle collision. CT reveals a Grade II liver laceration with no active extravasation. What is the recommended management?

Exploratory laparotomy with packing
Nonoperative management with serial monitoring (Correct answer)
Emergent hepatic lobectomy
Hepatic artery embolization

Correct answer: Nonoperative management with serial monitoring

Hemodynamically stable patients with low-grade liver injuries and no active bleeding are best managed nonoperatively with close monitoring.

Question 13: What modification to the primary survey is needed for pregnant patients beyond 20 weeks?

Skip airway assessment
Circulation before breathing
Reduce IV fluids
Add fetal heart tone assessment after maternal stabilization (Correct answer)

Correct answer: Add fetal heart tone assessment after maternal stabilization

After standard ABCDE and maternal stabilization, fetal assessment is added.

Question 14: A 6-year-old child involved in a fall has a GCS of 10, is breathing spontaneously but noisily (stridor), and has significant bruising over the anterior neck. Which statement regarding airway management in this pediatric patient is most accurate based on ATLS principles?

Oral airways should be inserted with a 180-degree rotation, similar to adults.
Surgical cricothyroidotomy is the preferred initial surgical airway.
The jaw-thrust maneuver should be used instead of the head-tilt/chin-lift to open the airway. (Correct answer)
A nasopharyngeal airway is contraindicated due to potential facial fractures.

Correct answer: The jaw-thrust maneuver should be used instead of the head-tilt/chin-lift to open the airway.

In all trauma patients, especially those with potential neck injuries, a cervical spine injury should be assumed. Therefore, the jaw-thrust maneuver is the appropriate technique to open the airway without extending the neck. Surgical cricothyroidotomy is generally avoided in young children (under 12) due to anatomical differences. Oral airways in children are inserted using a tongue depressor, not with a rotational motion.

Question 15: Which of the following is the most reliable method for confirming correct endotracheal tube placement in a trauma patient immediately after intubation?

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

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 16: During the primary survey of a trauma patient, what is the immediate priority after establishing a patent airway?

Completely exposing the patient to check for injuries.
Performing a rapid neurological assessment.
Controlling external hemorrhage.
Assessing for adequate breathing and ventilation. (Correct answer)

Correct answer: Assessing for adequate breathing and ventilation.

The ATLS protocol follows the ABCDE mnemonic. After ensuring the Airway (A) is patent, the next immediate step is to assess Breathing (B) to ensure adequate ventilation and oxygenation. Life-threatening issues with breathing, such as a tension pneumothorax or open chest wound, must be addressed before moving to Circulation (C).

Question 17: Hyperventilation to a PaCO2 of 30-35 mmHg in severe TBI should be used in which situation?

Only after ICP above 40 mmHg
As a temporizing measure for acute signs of herniation (Correct answer)
Routinely to prevent intracranial hypertension
Continuously for the first 48 hours

Correct answer: As a temporizing measure for acute signs of herniation

Brief hyperventilation is a temporizing measure for acute herniation signs, as cerebral vasoconstriction reduces ICP rapidly but can cause ischemia if prolonged.

Question 18: 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?

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

Correct answer: Right mainstem bronchus intubation

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

Question 19: 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?

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

Correct answer: Acute compartment syndrome; emergent fasciotomy

Classic compartment syndrome presentation requires emergent fasciotomy within 6 hours.

Question 20: 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
Only colloids in pregnancy
Need less fluid due to decreased blood volume

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 21: A 30-year-old female presents 36 hours after being kicked in the abdomen during an altercation. She initially declined medical care but now has a fever, tachycardia, and diffuse abdominal tenderness with rigidity. Which of the following injuries is most likely responsible for her delayed presentation and current signs of peritonitis?

Small bowel perforation. (Correct answer)
Renal artery thrombosis.
Hepatic contusion.
Splenic laceration with a subcapsular hematoma.

Correct answer: Small bowel perforation.

Injuries to hollow viscera, such as a small bowel perforation, often have a delayed presentation. The initial injury may be small, but the subsequent leakage of enteric contents leads to chemical and then bacterial peritonitis over hours to days, causing fever, tachycardia, and a rigid abdomen. Solid organ injuries (spleen, liver, kidney) typically present more acutely with signs of hemorrhage.

Question 22: What documentation must accompany a trauma patient during transfer?

Only insurance information
Verbal report is sufficient
Transfer summary with assessment, interventions, imaging, labs, and response to treatment (Correct answer)
Only imaging on CD

Correct answer: Transfer summary with assessment, interventions, imaging, labs, and response to treatment

Complete written documentation including all findings, interventions, imaging, labs, and response must accompany the patient.

Question 23: What is the recommended head-of-bed elevation for a patient with severe TBI and elevated ICP?

45 degrees
30 degrees (Correct answer)
Flat (0 degrees)
15-20 degrees

Correct answer: 30 degrees

Head-of-bed elevation to 30 degrees promotes venous drainage from the brain, reducing ICP.

Question 24: 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?

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

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 25: In the START triage system, what is the first assessment step performed?

Check respiratory rate of all patients first
Control all bleeding before categorizing patients
Instruct all ambulatory patients to move to a designated area, tagging them as Minor (Green) (Correct answer)
Assess mental status of all patients first

Correct answer: Instruct all ambulatory patients to move to a designated area, tagging them as Minor (Green)

The first step in START triage is to call out for ambulatory patients to walk to a designated area, immediately categorizing them as Minor (Green) and clearing the scene for more critical assessment.

Question 26: What is the appropriate chest tube size for an adult hemothorax?

36-40 French (Correct answer)
44-48 French
16-20 French
24-28 French

Correct answer: 36-40 French

Large-bore 36-40 Fr is required for hemothorax to adequately drain blood and clots.

Question 27: At what rib level should a chest tube for hemopneumothorax be inserted?

2nd intercostal space, midclavicular
4th-5th intercostal space, anterior axillary line (Correct answer)
6th intercostal space, midaxillary
7th intercostal space, posterior axillary

Correct answer: 4th-5th intercostal space, anterior axillary line

ATLS recommends 4th-5th ICS (nipple level), anterior axillary line, in the safe triangle.

Question 28: A chest tube initially drains 1,800 mL of blood. According to ATLS, next step?

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

Correct answer: Prepare for emergent thoracotomy

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

Question 29: 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?

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

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.

Question 30: 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?

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

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 31: A 25-year-old with a left chest stab wound develops PEA in the trauma bay. What is the most appropriate intervention?

Emergency department thoracotomy (Correct answer)
Start CPR and epinephrine
Pericardiocentesis
Bilateral needle decompression

Correct answer: Emergency department thoracotomy

PEA from penetrating thoracic trauma is an indication for ED thoracotomy.

Question 32: A patient has periorbital swelling and ecchymosis after trauma. On exam, there is enophthalmos and limitation of upward gaze. What injury does this suggest?

Open globe injury
Zygomaticomaxillary complex fracture only
Orbital floor (blowout) fracture with inferior rectus entrapment (Correct answer)
Retrobulbar hematoma

Correct answer: Orbital floor (blowout) fracture with inferior rectus entrapment

Blowout fractures of the orbital floor can trap the inferior rectus muscle, causing restricted upward gaze and enophthalmos from loss of orbital volume support.

Question 33: Which of the following is an appropriate, temporary measure for a patient with an acute traumatic brain injury who is demonstrating signs of active brain herniation, such as a unilaterally blown pupil?

Immediate placement of a ventricular drain in the emergency department
Brief, controlled hyperventilation to a target PaCO2 of 30-35 mmHg (Correct answer)
Prophylactic hyperventilation to a PaCO2 below 25 mmHg for several hours
Administration of high-dose corticosteroids

Correct answer: Brief, controlled hyperventilation to a target PaCO2 of 30-35 mmHg

For a patient with acute neurological deterioration suggestive of herniation, brief and controlled hyperventilation is a recognized temporizing measure. It causes cerebral vasoconstriction, reducing cerebral blood flow and thereby acutely lowering intracranial pressure. Prolonged or aggressive hyperventilation (PaCO2 < 25 mmHg) is harmful as it can cause cerebral ischemia. Corticosteroids are not indicated for TBI.

Question 34: An electrician sustains high-voltage (>1000V) electrical injury with minimal skin burns. What internal injuries should be suspected?

Thermal injury at entry/exit points only
Isolated nerve damage
Only superficial damage
Deep muscle necrosis, cardiac arrhythmias, and rhabdomyolysis (Correct answer)

Correct answer: Deep muscle necrosis, cardiac arrhythmias, and rhabdomyolysis

High-voltage injuries cause extensive deep tissue damage disproportionate to visible burns.

Question 35: In the ATLS 10th edition, which mnemonic prioritizes hemorrhage control?

SAMPLE
ABCDE
MARCH (Correct answer)
FAST

Correct answer: MARCH

MARCH (Massive hemorrhage, Airway, Respirations, Circulation, Hypothermia) places hemorrhage first.

Question 36: A patient presents with a circumferential, full-thickness burn to the right lower leg. The limb is tense and swollen. Which of the following is the most definitive indication for an immediate escharotomy?

A capillary refill time of 4 seconds in the toes.
The presence of a third-degree burn around the entire limb.
Severe pain reported by the patient in the affected limb.
Loss of a previously audible distal pulse signal on Doppler ultrasound. (Correct answer)

Correct answer: Loss of a previously audible distal pulse signal on Doppler ultrasound.

The primary purpose of an escharotomy is to relieve the constricting effect of a circumferential burn eschar, which can cause compartment syndrome and compromise distal blood flow. The most critical and definitive sign of severe vascular compromise necessitating immediate intervention is the loss of distal pulses, confirmed by Doppler if not palpable. While delayed capillary refill is a concerning sign, the absence of a pulse indicates that limb-threatening ischemia is already occurring.

Question 37: Which shock type is characterized by hypotension, bradycardia, and warm flushed skin below the injury?

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

Correct answer: Neurogenic shock

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

Question 38: An elderly patient falls and develops upper extremity weakness greater than lower. Most likely diagnosis?

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

Correct answer: Central cord syndrome

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

Question 39: 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?

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

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

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

Correct answer: Posterior knee dislocation

Posterior knee dislocation carries a 20-40% risk of popliteal artery 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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These practice questions were written with AI tools. They are not real exam questions. Exam facts are checked against the official sources listed below. Not reviewed by a subject-matter expert. Editorial policy

Sources & references

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