PHTLS - Prehospital Trauma Life Support Prehospital Trauma Life Support Abdominal and Pelvic Trauma 1 — Questions and Answers
Question 1: A patient with a suspected open book pelvic fracture is in hemorrhagic shock. Which prehospital intervention is most appropriate to reduce pelvic volume and control hemorrhage?
- Apply a pelvic binder or sheet wrap at the level of the greater trochanters (Correct answer)
- Pack the pelvic wound with sterile gauze and apply direct pressure
- Elevate both legs to 45 degrees to tamponade pelvic vessels
- Administer high-flow oxygen and defer all interventions until hospital arrival
Correct answer: Apply a pelvic binder or sheet wrap at the level of the greater trochanters
An open book pelvic fracture disrupts the pelvic ring, dramatically increasing pelvic volume and allowing massive hemorrhage. Applying a circumferential pelvic binder or improvised sheet wrap at the greater trochanters closes the pelvic ring, reduces volume, and provides tamponade of venous bleeding — the key prehospital hemorrhage control maneuver.
Question 2: Kehr's sign, defined as referred pain to the left shoulder, is a classic indicator of which abdominal injury?
- Hollow viscus perforation
- Splenic laceration with diaphragmatic irritation (Correct answer)
- Retroperitoneal hematoma
- Mesenteric tear with bowel ischemia
Correct answer: Splenic laceration with diaphragmatic irritation
Kehr's sign occurs when blood from a splenic laceration tracks beneath the left hemidiaphragm, irritating the phrenic nerve (C3–C5). Because these nerve roots also supply the left shoulder, the patient perceives pain there. It is a classic — though not always present — indicator of splenic injury.
Question 3: Which mechanism of injury is most associated with a hollow organ (bowel) rupture in blunt abdominal trauma?
- Lateral impact motor vehicle collision
- Lap belt restraint in a high-speed frontal collision (Correct answer)
- Unrestrained driver striking the steering wheel
- Direct blow to the right upper quadrant
Correct answer: Lap belt restraint in a high-speed frontal collision
A lap belt without a shoulder harness concentrates deceleration force across the lower abdomen. This compresses and shears the small bowel against the lumbar spine, making bowel perforation — along with Chance fractures of the lumbar vertebrae — a hallmark injury pattern of lap-belt–only restraint in frontal crashes.
Question 4: A restrained passenger after a high-speed collision has periumbilical bruising (Cullen's sign). This finding is associated with which type of abdominal injury?
- Splenic rupture with immediate hemorrhage
- Retroperitoneal or intraperitoneal hemorrhage tracking to the umbilicus (Correct answer)
- Bladder rupture with urine extravasation
- Mesenteric vascular injury with venous engorgement
Correct answer: Retroperitoneal or intraperitoneal hemorrhage tracking to the umbilicus
Cullen's sign (periumbilical ecchymosis) results from blood dissecting through fascial planes and pooling around the umbilicus. It indicates significant retroperitoneal or intraperitoneal hemorrhage. Because it takes hours to develop, its absence in the prehospital setting does not rule out serious injury.
Question 5: When assessing a patient for abdominal trauma in the prehospital setting, which finding is the MOST reliable early indicator of significant intra-abdominal injury?
- Rigid or involuntary guarding on abdominal palpation (Correct answer)
- Bowel sounds absent on auscultation
- Patient report of nausea and vomiting
- Normal vital signs ruling out hemorrhage
Correct answer: Rigid or involuntary guarding on abdominal palpation
Involuntary guarding or rigidity on palpation reflects peritoneal irritation from blood or bowel contents and is the most reliable early physical sign of significant intra-abdominal injury. Bowel sound assessment is unreliable in the field, nausea is nonspecific, and normal vitals can persist even with significant hemorrhage due to compensatory mechanisms.
Question 6: A patient struck by a vehicle has a suspected pelvic fracture and is hemodynamically unstable. After applying a pelvic binder, the MOST important next prehospital priority is:
- Perform a secondary survey and document all injuries before transport
- Establish large-bore IV access en route and initiate permissive hypotension fluid strategy (Correct answer)
- Immobilize both lower extremities with traction splints to reduce blood loss
- Obtain a 12-lead ECG to rule out traumatic cardiac contusion
Correct answer: Establish large-bore IV access en route and initiate permissive hypotension fluid strategy
After mechanical hemorrhage control with a pelvic binder, large-bore IV access should be established en route (not delaying transport) with fluid resuscitation targeted to a permissive hypotensive SBP of ~90 mmHg in trauma patients without TBI. Over-aggressive fluid administration dilutes clotting factors and raises pressure before surgical hemorrhage control is achieved.
PHTLS - Prehospital Trauma Life Support Prehospital Trauma Life Support Abdominal and Pelvic Trauma 1
A patient with a suspected open book pelvic fracture is in hemorrhagic shock.
Which prehospital intervention is most appropriate to reduce pelvic volume and control hemorrhage?