ATLS Thoracic Trauma 2 — Questions and Answers
Question 1: A patient with blunt chest trauma has paradoxical chest wall movement. What is the primary cause of hypoxia?
- Paradoxical movement alone
- Underlying pulmonary contusion (Correct answer)
- Rib fracture pain
- Diaphragmatic paralysis
Correct answer: Underlying pulmonary contusion
The underlying pulmonary contusion, not the mechanical wall defect, is the primary driver of respiratory failure.
Pulmonary contusion causes intrapulmonary shunting and may worsen over 24-48 hours. Management: analgesia, pulmonary toilet, oxygen, positive pressure ventilation if needed.
Question 2: A chest tube initially drains 1,800 mL of blood. According to ATLS, next step?
- Continue observation
- Clamp tube and reassess
- Prepare for emergent thoracotomy (Correct answer)
- Autotransfuse and observe
Correct answer: Prepare for emergent thoracotomy
Initial drainage >1,500 mL indicates massive hemothorax requiring emergent thoracotomy.
ATLS thoracotomy indications: initial >1,500 mL, ongoing >200 mL/hr for 2-4 hours, continued transfusion need. Never clamp a draining chest tube.
Question 3: An open pneumothorax (sucking chest wound) is initially managed with which intervention?
- Chest tube through the wound
- Three-sided occlusive dressing (Correct answer)
- Four-sided occlusive dressing
- Positive pressure ventilation alone
Correct answer: Three-sided occlusive dressing
Three-sided dressing creates a flutter-valve: sealed during inspiration, open during expiration to prevent tension.
A chest tube should then be placed at a SEPARATE site. If a four-sided dressing is applied and the patient deteriorates, lift one corner.
Question 4: Widened mediastinum on CXR after high-speed deceleration suggests which injury?
- Esophageal rupture
- Traumatic aortic injury (Correct answer)
- Tracheobronchial disruption
- Myocardial contusion
Correct answer: Traumatic aortic injury
Widened mediastinum (>8 cm) after deceleration is the most common finding suggesting traumatic aortic injury at the isthmus.
85% of patients die at the scene. CT angiography is diagnostic. Treatment: endovascular stent graft preferred, BP control (SBP <100) as bridge.
Question 5: A chest tube is in place but there is continuous air leak with the lung not re-expanding. Diagnosis?
- Chest tube malposition
- Tracheobronchial disruption (Correct answer)
- Simple converting to tension
- Esophageal perforation
Correct answer: Tracheobronchial disruption
Persistent large air leak with failure to re-expand suggests tracheobronchial disruption.
Typically occurs within 2.5 cm of the carina. Diagnosis confirmed by bronchoscopy. May need additional chest tubes while awaiting surgical repair.
Question 6: What is the preferred initial study for suspected blunt cardiac injury in a stable patient?
- Cardiac catheterization
- 12-lead ECG (Correct answer)
- Cardiac MRI
- Transesophageal echo
Correct answer: 12-lead ECG
ECG detects arrhythmias, ST changes, and conduction abnormalities indicating myocardial damage.
If ECG normal AND troponin normal at 4-6 hours, clinically significant BCI is essentially excluded. Abnormal ECG warrants telemetry for 24-48 hours and echocardiography.
ATLS Thoracic Trauma 2
A patient with blunt chest trauma has paradoxical chest wall movement.
What is the primary cause of hypoxia?