Advanced Trauma Life Support (ATLS) Cases Scenarios

Preface

The Advanced Trauma Life Support (ATLS®) course provides an essential, systematic framework universally recognized for the initial assessment and management of injured patients. Its principles form the bedrock of effective trauma care globally. However, translating this structured knowledge into confident, competent action during the high-stress reality of a critical trauma resuscitation remains a perpetual challenge. Reading the manual and participating in the course are foundational; truly mastering the application of these concepts under pressure requires deliberate practice and exposure to the diverse clinical situations encountered in real-world trauma care.

Recognizing this persistent gap between theoretical learning and practical application, and drawing from my years of experience in trauma surgery, medical education, and as an international ATLS® instructor, I, Dr. Atef Ahmed, developed this collection, Advanced Trauma Life Support (ATLS®) Cases Scenarios. It is designed as a practical, engaging tool for healthcare professionals seeking to deepen their understanding and refine their clinical application of ATLS® principles.

Aligning meticulously with the structure of the core chapters of the ATLS® 10th Edition Student Course Manual  . this resource presents 100 unique scenarios. Each case has been crafted with realistic clinical detail, reflecting the broad spectrum of injuries encountered in emergency departments and trauma bays worldwide. Following each detailed narrative, five targeted clinical questions challenge the reader to analyze the evolving situation, establish management priorities, identify procedural indications, and apply critical ATLS® concepts—mirroring the cognitive demands of an actual resuscitation. Detailed answers and explanations provide immediate feedback, clarify reasoning, and reinforce key learning objectives tied directly to the ATLS® curriculum.

This resource is intended as an invaluable study and review tool for physicians, residents, and medical students preparing for the ATLS® course or seeking recertification. It is equally beneficial for Trauma Nurses, Paramedics, Physician Assistants, Nurse Practitioners, and other healthcare professionals involved in the demanding field of acute trauma care. Furthermore, it may serve ATLS® instructors seeking realistic teaching materials or scenarios adaptable for high-fidelity simulation training.

It is my sincere hope that diligently working through these case scenarios will not only enhance performance within the ATLS® course structure but, more importantly, translate into improved clinical decision-making, increased confidence when faced with complex injuries, and ultimately, contribute to better care and improved outcomes for the injured patients entrusted to our care.

With my best

Dr.atef ahmed

Chapter 1: Initial Assessment and Management

Case 1

Case Title: High-Speed MVC with Hemodynamic Instability and Chest Trauma

Case Narrative: A 28-year-old male unrestrained driver is brought in by EMS after a high-speed (estimated 70 mph) head-on collision with a tree. Extrication time was 15 minutes. Prehospital vital signs were BP 90/60 mmHg, HR 130 bpm, RR 30/min, GCS 9 (E2V2M5). Upon arrival in the trauma bay, he is moaning incomprehensibly. Vital signs are: BP 85/50 mmHg, HR 140 bpm, RR 34/min and shallow, SpO2 86% on a non-rebreather mask. Physical exam reveals significant facial trauma with crepitus, unstable chest wall with paradoxical movement on the left, markedly decreased breath sounds on the left, and tracheal deviation to the right. His abdomen is soft, pelvis is stable, and extremities show no gross deformities.

Five Clinical Questions:

Based on ATLS principles, what is the immediate first priority in managing this patient?

Given the physical exam findings (decreased left breath sounds, tracheal deviation to the right, hypotension, tachypnea), what life-threatening condition must be immediately addressed during the breathing assessment?

What intervention is required immediately for the condition identified in question 2, even before obtaining a chest x-ray?

After addressing Airway and Breathing, what is the next step according to the primary survey, and what specific concerns should be addressed given the mechanism and vitals?

Which adjuncts should be initiated during the primary survey and resuscitation phase?

Answers and Explanations:

Answer: A – Airway maintenance with restriction of cervical spine motion. Explanation: The ATLS protocol dictates a sequential ABCDE approach. Although breathing is severely compromised, securing a patent airway while protecting the c-spine is the initial step. The facial trauma and decreased GCS (now likely <8) suggest an inability to protect the airway, necessitating immediate airway management.

Answer: Tension pneumothorax (left-sided). Explanation: The combination of respiratory distress, hypotension, unilateral decreased breath sounds, and tracheal deviation away from the affected side are classic signs of tension pneumothorax, a critical emergency requiring immediate intervention.

Answer: Immediate needle decompression followed by chest tube thoracostomy. Explanation: Tension pneumothorax is a clinical diagnosis. Treatment (decompression) should not be delayed for radiographic confirmation. Needle or finger decompression provides immediate relief, followed by definitive chest tube placement.

Answer: C – Circulation with hemorrhage control. Explanation: Following the ABC sequence, circulation is next. Given the high-energy mechanism, hypotension, and tachycardia, significant internal hemorrhage must be suspected (chest, abdomen, pelvis, long bones) even if not immediately obvious externally. Control of any external bleeding and establishing large-bore IV access for fluid resuscitation are priorities.

Answer: Continuous ECG monitoring, pulse oximetry, end-tidal CO2 monitoring (if intubated), insertion of large-bore IVs, drawing baseline labs (including type & crossmatch), consideration for FAST exam/chest/pelvic X-rays once appropriate. Explanation: These adjuncts provide vital ongoing information about the patient's physiological status during resuscitation. FAST/X-rays help identify sources of hemorrhage or other injuries but shouldn't delay resuscitation or transfer if unstable. A urinary catheter should be placed after examining the perineum/rectum.

Case 2

Case Title: Penetrating Abdominal Trauma with Shock

Case Narrative: A 22-year-old female presents after sustaining a single gunshot wound (GSW) to the right upper quadrant (RUQ) of the abdomen approximately 30 minutes prior. She is awake, anxious, and complaining of severe abdominal pain. Vital signs on arrival: BP 90/70 mmHg, HR 125 bpm, RR 24/min, SpO2 98% on room air, GCS 15. Physical exam reveals a single GSW entry wound in the RUQ with no exit wound found. The abdomen is distended, rigid, and markedly tender throughout. Bowel sounds are absent. Pelvis is stable.

Five Clinical Questions:

This patient is in shock. What class of hemorrhagic shock is most likely based on her vital signs and presentation?

What is the most likely source of her shock?

What immediate steps should be taken during the Circulation assessment?

Which diagnostic adjunct, if any, is indicated during the primary survey for this patient?

What is the definitive management plan for this patient?

Answers and Explanations:

Answer: Class III Hemorrhagic Shock. Explanation: She demonstrates significant tachycardia (>120 bpm), tachypnea (RR 24), and hypotension (SBP 90) with signs of significant intra-abdominal injury, consistent with ~30-40% blood volume loss (Class III).

Answer: Intra-abdominal hemorrhage. Explanation: A penetrating injury (GSW) to the RUQ places the liver, kidney, colon, duodenum, and major vascular structures at high risk. Peritoneal signs (distension, rigidity, tenderness) strongly suggest significant intra-abdominal bleeding.

Answer: Establish two large-bore IVs, initiate warmed crystalloid infusion (e.g., Lactated Ringer's), draw blood for type and crossmatch and baseline labs, control any external bleeding (though none is described here), and assess peripheral perfusion. Explanation: These are standard steps for managing presumed hemorrhagic shock in the primary survey's circulation phase.

Answer: None are strictly required during the primary survey given the clear indication for surgery. FAST might be rapidly performed during resuscitation if readily available but should not delay definitive care. Explanation: This patient presents with hemodynamic instability and peritonitis after penetrating abdominal trauma, which are clear indications for immediate laparotomy. Diagnostic adjuncts like CT are contraindicated in unstable patients, and DPL/FAST are generally unnecessary when surgical exploration is already mandated by clinical findings.

Answer: Immediate exploratory laparotomy. Explanation: Penetrating abdominal trauma with hemodynamic instability and/or peritonitis requires urgent surgical exploration to identify and control hemorrhage and visceral injury.

Case 3

Case Title: Elderly Patient after Ground-Level Fall

Case Narrative: An 81-year-old female with a history of atrial fibrillation (on warfarin) and hypertension (on a beta-blocker) presents after tripping on a rug and falling at home. She did not lose consciousness but complains of left hip pain. On arrival, she is alert and oriented. Vital signs: BP 120/75 mmHg, HR 68 bpm, RR 18/min, SpO2 97% on room air, GCS 15. Physical exam reveals her left leg is shortened and externally rotated. The left hip region is tender to palpation. Chest is clear, abdomen is soft, and there is no head trauma.

Five Clinical Questions:

Despite the seemingly normal vital signs (HR 68, BP 120/75), why might this patient still be inadequately compensating for blood loss from a hip fracture?

What immediate management priority relates to her medication history?

During the secondary survey, what specific examinations are crucial given the mechanism and injury?

Besides the obvious hip injury, what other potential injury should have a high index of suspicion in elderly fall patients?

What is the appropriate disposition for this patient?

Answers and Explanations:

Answer: Her baseline blood pressure may be higher due to hypertension, and her beta-blocker prevents the expected tachycardic response to hypovolemia or pain. Explanation: Elderly patients have reduced physiological reserve and often have blunted responses to shock, especially when on beta-blockers. A heart rate of 68 bpm may be inappropriately low, and a BP of 120/75 mmHg could represent relative hypotension for her.

Answer: Assess anticoagulation status (obtain INR) and consider reversal. Explanation: Patients on warfarin are at high risk for hemorrhage even with relatively minor trauma. Prompt assessment and potential reversal of anticoagulation (e.g., with Vitamin K, PCC) are critical, especially if surgery is contemplated.

Answer: Thorough assessment of distal neurovascular status (pulses, sensation, motor function) of the affected leg and assessment for associated injuries (e.g., wrist fracture from trying to break the fall, head injury if she hit her head). Explanation: Hip fractures/dislocations can compromise neurovascular supply to the leg. Elderly falls often involve associated injuries.

Answer: Head injury (specifically intracranial hemorrhage, e.g., subdural hematoma). Explanation: Even without reported loss of consciousness or obvious head trauma, elderly patients (especially if anticoagulated) are at high risk for intracranial bleeding after falls.

Answer: Admission for orthopedic consultation/management, potential anticoagulation reversal, and management of comorbidities. Transfer may be needed if orthopedic services are unavailable. Explanation: This patient requires admission for management of her hip fracture and careful monitoring given her age, comorbidities, and anticoagulation status.

Case 4

Case Title: Mass Casualty Incident - Initial Scene Triage

Case Narrative: You are the first physician arriving at the scene of a building collapse. There are approximately 15-20 known victims scattered amongst the debris. EMS resources are en route but limited. You hear people screaming. You quickly assess the scene for safety hazards (unstable debris, gas leaks). Your task is initial triage. Victim 1: Adult male, trapped by legs under concrete, awake, moaning, RR 28/min, radial pulse present but rapid (est >120). Victim 2: Young child, not moving, apneic, no pulse palpable. Victim 3: Adult female, walking around, appears dazed, has minor scalp laceration. Victim 4: Adult male, penetrating rebar injury to chest, severe respiratory distress, RR 40/min, absent radial pulse, carotid pulse weak and rapid.

Five Clinical Questions:

According to mass casualty triage principles, what is the immediate priority category for Victim 1 (Trapped, moaning, RR 28, HR >120)?

What is the triage category for Victim 2 (Child, apneic, pulseless)?

What is the triage category for Victim 3 (Walking wounded, dazed, scalp lac)?

What is the triage category for Victim 4 (Penetrating chest, RR 40, absent radial pulse)?

What overriding principle guides resource allocation in this scenario?

Answers and Explanations:

Answer: Delayed (Yellow). Explanation: Although likely seriously injured (potential crush injury, possible fractures), he is conscious, breathing spontaneously with a patent airway (implied by moaning), and has a radial pulse (indicating SBP likely >80-90). His care can be delayed slightly while more immediately critical patients are assessed/treated. Extrication will require significant resources.

Answer: Deceased/Expectant (Black). Explanation: In a mass casualty setting with limited resources, patients who are found apneic and pulseless are generally triaged as deceased/expectant, as the resources required for resuscitation are extensive with a very low likelihood of survival. (Some protocols allow brief repositioning/airway opening).

Answer: Minimal (Green). Explanation: Patients who are able to walk are typically assigned to the minimal category, requiring delayed or no immediate treatment. They are often directed to a