ATLS EXAM QUESTIONS WITH
VERIFIED SOLUTIONS 2025
UPDATES
By definition, how much blood is in the chest cavity to call it a "massive hemothorax"? -
Answer-1500 mL or 1/3 or more of the patient's total blood volume. (Some also define it
as continued blood loss of 200 mL/hr for 2-4 hours- but ATLS does NOT use this rate
for any mandatory treatment decisions).
What size chest tube might you use to evacuate a massive hemothorax? - Answer-#38
French - inserted at the 4th or 5th intercostal space, just anterior to the midaxillary line.
What is Kussmaul's sign? - Answer-A rise in venous pressure with inspiration while
breathing spontaneously, and is a true paradoxical venous pressure abnormality
associated with cardiac tamponade.
How well do CPR compressions work on someone with a penetrating chest injury and
hypovolemia? - Answer-"Closed heart massage for cardiac arrest or PEA is
INEFFECTIVE in patients with hypovolemia." Patients with PENETRATING thoracic
injuries who arrive pulseless, but with myocardial electrial activity, may be candidates
for an ED thoacotomy.
Are patients with PEA who have sustained blunt thoracic injuries candidates for an ED
thoracotomy? - Answer-NO - Only PEA with PENETRATING thoracic injuries should get
an ED thoracotomy.
An ED thoracotomy can allow you to do what? - Answer-Evacuate pericardial blood,
direcly control hemorrhage, cardiac massage, cross-clamp the descending aorta to slow
blood loss below the diaphragm and increase perfusion to the heart and brain.
For a patient with a traumatic simple pneumothorax, what should you do BEFORE you
start positive pressure ventilation or take them to surgery for a GA? - Answer-CHEST
TUBE - positive pressure ventilation can turn a simple pneumo into a tension pneumo,
so put in a chest tube first.
Should you evacuate a simple hemothorax if it is not causing any respiratory problems?
- Answer-YES - A simple hemothorax, if not fully evacuated, may result in a retained,
clotted hemothroax with lung entrapment or, if infected, develop into an empyema.
,A pneumothorax associated with a persistent large air leak after tube thoracostomy
suggests a _______ injury. - Answer-tracheobronchial - Use bronchoscopy to confirm,
you may need more than one chest tube before definitive operative management.
What radiographic findings are suggestive of traumatic aortic disruption? - Answer-
Widened mediastinum, obliteration of aortic knob, deviation of trachea to the right,
depression of left mainstem bronchus, deviation of esophagus (NG tube) to right,
widened paratracheal stripe, fx'd 1st/2nd ribs or scapula.
A deceleration injury victim with a left pnuemothorax or hemothorax without rib
fractures, is in pain or shock out of proportion to the apparent injury, and has particulate
matter in their chest tube may have _________. - Answer-an ESOPHAGEAL
RUPTURE - a forceful blow causes expulsion of gastric contents into the esophagus,
producing a linear tear in the lower esophagus allowing leakage into the mediastinum.
Fractures for the lower ribs (10-12) should increase suspicion for _____ injury. -
Answer-hepatosplenic
Why are upper torso, facial, and arm plethora with petechiae associated with crush
injuries to the chest? - Answer-Temporary compression of the superior vena cava.
How does ATLS suggest you should review a chest radiograph? - Answer-Trachea &
bronchi, pleural spaces and parenchyma, mediastinum, diaphragm, bones, soft tissues,
tubes & lines.
You should use a size 16 or 18 gauge 6" needle for pericardiocentesis. How do you
insert it? - Answer-Puncture the skin 1-2 cm inferior to the left xiphohondral junction at a
45 degree angle to the skin towards the heart, aiming toward the top of the left scapula.
What's a good way to know if you've advanced your needle too far during
pericardiocentesis and have entered ventricular muscle? - Answer-ECG Changes -
extreme ST-changes, widened QRS, PVCs, etc... Withdrawl needle until ECG returns to
baseline.
What should you do with your needle after you successfully evacuate blood during
pericardiocentesis? - Answer-Lock the stopcock and leave the catheter in place in case
it needs to be reevacuated. If possible, use the Seldinger technique to pass a 14 gauge
flexible catheter over the guidewire. This is NOT a definitive treatment.
For patients with facial fractures or basillar skull fractures, gastric tubes should be
inserted ____ before doing a DPL. - Answer-through the mouth
You need to do retrograde urethrography PRIOR to foley placement if _____. - Answer-
inability to void, unstable pelvic fracture, blood at urethral meatus, scrotal hematoma,
perineal ecchymoses, or high-riding prostate.
, DPL is considered to be __% sensitive for detecting intraperitoneal bleeding. - Answer-
98
What are the four places you should look first when doing a FAST scan? - Answer-
Mediastinum, hepatorenal fossa, splenorenal fossa, pouch of Douglas.
DPL is indicated when a patient with multiple blunt injuries is hemodynamically
unstable, especially when they have _____. - Answer-Change in sensorium (brain
injury/EtOH or drug intoxication), change in sensation (spinal cord injury), injury to
adjacent structures (pelvis, lumbar spine), lap-belt sign (from seatbelt), or if patient is
going for long studies (CT, ortho surgery...).
What is the only ABSOLUTE contraindication to DPL? - Answer-An existing indication
for laparotomy.
What are some RELATIVE contraindications to DPL? - Answer-Morbid obesity,
advanced cirrhosis, preexisting coagulopathy, and previous abdominal operations
(adhesions).
When should you use an open SUPRAUMBILICAL approach for a DPL? - Answer-
PELVIC FRACTURES (don't want to enter pelvic hematoma) and ADVANCED
PREGNANCY (don't want to damage enlarged uterus).
When doing a DPL, what INITIAL findings (not from lab) would mandate a laparotomy? -
Answer-Free blood (>10 mL) or GI contents (vegetable fiber, bile).
If you don't get gross blood upon initial DPL aspiration, what do you do next for an
adult? For a child? - Answer-Adult - 1,000 mL warm isotonic crystalloid. Kid - 10 mL/kg
You've just put a bunch of fluid in the belly and aspirated more fluid for your DPL. No
gross GI contents or anything alarming are present, what QUANTATIVE things would
make the DPL positive? - Answer->100,000 red cells/mm^3, 500 white cells/mm^3, or
BACTERIA (on gram stain).
Your trauma patient needs an urgent laparotomy, can you take them to the CT scanner
first to evaluate injuries? - Answer-No, if they need an emergent laparotomy they are
unstable - unstable patients should NOT go to the CT scanner!
What are some indications for laparotomy in patients with penetrating abdominal
wounds? - Answer-Unstable, GSW, peritoneal irritation, fascial penetration
What percentage of stab wounds to the anterior abdomen do NOT penetrate the
peritoneum? - Answer-25-33%
Does an early normal serum amylase level exclude major pancreatic trauma? - Answer-
NO
VERIFIED SOLUTIONS 2025
UPDATES
By definition, how much blood is in the chest cavity to call it a "massive hemothorax"? -
Answer-1500 mL or 1/3 or more of the patient's total blood volume. (Some also define it
as continued blood loss of 200 mL/hr for 2-4 hours- but ATLS does NOT use this rate
for any mandatory treatment decisions).
What size chest tube might you use to evacuate a massive hemothorax? - Answer-#38
French - inserted at the 4th or 5th intercostal space, just anterior to the midaxillary line.
What is Kussmaul's sign? - Answer-A rise in venous pressure with inspiration while
breathing spontaneously, and is a true paradoxical venous pressure abnormality
associated with cardiac tamponade.
How well do CPR compressions work on someone with a penetrating chest injury and
hypovolemia? - Answer-"Closed heart massage for cardiac arrest or PEA is
INEFFECTIVE in patients with hypovolemia." Patients with PENETRATING thoracic
injuries who arrive pulseless, but with myocardial electrial activity, may be candidates
for an ED thoacotomy.
Are patients with PEA who have sustained blunt thoracic injuries candidates for an ED
thoracotomy? - Answer-NO - Only PEA with PENETRATING thoracic injuries should get
an ED thoracotomy.
An ED thoracotomy can allow you to do what? - Answer-Evacuate pericardial blood,
direcly control hemorrhage, cardiac massage, cross-clamp the descending aorta to slow
blood loss below the diaphragm and increase perfusion to the heart and brain.
For a patient with a traumatic simple pneumothorax, what should you do BEFORE you
start positive pressure ventilation or take them to surgery for a GA? - Answer-CHEST
TUBE - positive pressure ventilation can turn a simple pneumo into a tension pneumo,
so put in a chest tube first.
Should you evacuate a simple hemothorax if it is not causing any respiratory problems?
- Answer-YES - A simple hemothorax, if not fully evacuated, may result in a retained,
clotted hemothroax with lung entrapment or, if infected, develop into an empyema.
,A pneumothorax associated with a persistent large air leak after tube thoracostomy
suggests a _______ injury. - Answer-tracheobronchial - Use bronchoscopy to confirm,
you may need more than one chest tube before definitive operative management.
What radiographic findings are suggestive of traumatic aortic disruption? - Answer-
Widened mediastinum, obliteration of aortic knob, deviation of trachea to the right,
depression of left mainstem bronchus, deviation of esophagus (NG tube) to right,
widened paratracheal stripe, fx'd 1st/2nd ribs or scapula.
A deceleration injury victim with a left pnuemothorax or hemothorax without rib
fractures, is in pain or shock out of proportion to the apparent injury, and has particulate
matter in their chest tube may have _________. - Answer-an ESOPHAGEAL
RUPTURE - a forceful blow causes expulsion of gastric contents into the esophagus,
producing a linear tear in the lower esophagus allowing leakage into the mediastinum.
Fractures for the lower ribs (10-12) should increase suspicion for _____ injury. -
Answer-hepatosplenic
Why are upper torso, facial, and arm plethora with petechiae associated with crush
injuries to the chest? - Answer-Temporary compression of the superior vena cava.
How does ATLS suggest you should review a chest radiograph? - Answer-Trachea &
bronchi, pleural spaces and parenchyma, mediastinum, diaphragm, bones, soft tissues,
tubes & lines.
You should use a size 16 or 18 gauge 6" needle for pericardiocentesis. How do you
insert it? - Answer-Puncture the skin 1-2 cm inferior to the left xiphohondral junction at a
45 degree angle to the skin towards the heart, aiming toward the top of the left scapula.
What's a good way to know if you've advanced your needle too far during
pericardiocentesis and have entered ventricular muscle? - Answer-ECG Changes -
extreme ST-changes, widened QRS, PVCs, etc... Withdrawl needle until ECG returns to
baseline.
What should you do with your needle after you successfully evacuate blood during
pericardiocentesis? - Answer-Lock the stopcock and leave the catheter in place in case
it needs to be reevacuated. If possible, use the Seldinger technique to pass a 14 gauge
flexible catheter over the guidewire. This is NOT a definitive treatment.
For patients with facial fractures or basillar skull fractures, gastric tubes should be
inserted ____ before doing a DPL. - Answer-through the mouth
You need to do retrograde urethrography PRIOR to foley placement if _____. - Answer-
inability to void, unstable pelvic fracture, blood at urethral meatus, scrotal hematoma,
perineal ecchymoses, or high-riding prostate.
, DPL is considered to be __% sensitive for detecting intraperitoneal bleeding. - Answer-
98
What are the four places you should look first when doing a FAST scan? - Answer-
Mediastinum, hepatorenal fossa, splenorenal fossa, pouch of Douglas.
DPL is indicated when a patient with multiple blunt injuries is hemodynamically
unstable, especially when they have _____. - Answer-Change in sensorium (brain
injury/EtOH or drug intoxication), change in sensation (spinal cord injury), injury to
adjacent structures (pelvis, lumbar spine), lap-belt sign (from seatbelt), or if patient is
going for long studies (CT, ortho surgery...).
What is the only ABSOLUTE contraindication to DPL? - Answer-An existing indication
for laparotomy.
What are some RELATIVE contraindications to DPL? - Answer-Morbid obesity,
advanced cirrhosis, preexisting coagulopathy, and previous abdominal operations
(adhesions).
When should you use an open SUPRAUMBILICAL approach for a DPL? - Answer-
PELVIC FRACTURES (don't want to enter pelvic hematoma) and ADVANCED
PREGNANCY (don't want to damage enlarged uterus).
When doing a DPL, what INITIAL findings (not from lab) would mandate a laparotomy? -
Answer-Free blood (>10 mL) or GI contents (vegetable fiber, bile).
If you don't get gross blood upon initial DPL aspiration, what do you do next for an
adult? For a child? - Answer-Adult - 1,000 mL warm isotonic crystalloid. Kid - 10 mL/kg
You've just put a bunch of fluid in the belly and aspirated more fluid for your DPL. No
gross GI contents or anything alarming are present, what QUANTATIVE things would
make the DPL positive? - Answer->100,000 red cells/mm^3, 500 white cells/mm^3, or
BACTERIA (on gram stain).
Your trauma patient needs an urgent laparotomy, can you take them to the CT scanner
first to evaluate injuries? - Answer-No, if they need an emergent laparotomy they are
unstable - unstable patients should NOT go to the CT scanner!
What are some indications for laparotomy in patients with penetrating abdominal
wounds? - Answer-Unstable, GSW, peritoneal irritation, fascial penetration
What percentage of stab wounds to the anterior abdomen do NOT penetrate the
peritoneum? - Answer-25-33%
Does an early normal serum amylase level exclude major pancreatic trauma? - Answer-
NO
