PHTLS - Prehospital Trauma Life Support Abdominal and Pelvic Trauma Questions and Answers — Questions and Answers
Question 1: A patient involved in a high-speed motor vehicle collision is found to have an unstable pelvis on assessment. The patient is tachycardic and hypotensive. Which intervention is the highest priority for managing life-threatening hemorrhage from this injury?
- Rapid infusion of two liters of crystalloid solution.
- Application of a pelvic binder or circumferential sheet. (Correct answer)
- Careful log rolling onto a long spine board for transport.
- Administration of high-flow oxygen via non-rebreather mask.
Correct answer: Application of a pelvic binder or circumferential sheet.
An unstable pelvic fracture can disrupt the pelvic ring, dramatically increasing its volume and leading to massive, life-threatening hemorrhage from venous plexuses and arteries. The most critical immediate intervention is to apply a pelvic binder or sheet circumferentially at the level of the greater trochanters to 'close the book,' which reduces the pelvic volume, stabilizes fracture ends, and promotes tamponade of the bleeding. [26, 28, 30]
Question 2: A patient with blunt abdominal trauma complains of acute pain in the tip of their left shoulder. This finding, known as Kehr's sign, is most commonly associated with irritation of which structure?
- The left kidney
- The descending colon
- The diaphragm (Correct answer)
- The stomach
Correct answer: The diaphragm
Kehr's sign is referred pain to the left shoulder caused by irritation of the diaphragm from blood in the peritoneal cavity. [5, 7, 8] This is a classic sign of a splenic rupture, as the spleen lies just inferior to the diaphragm in the left upper quadrant. [6, 12] The phrenic nerve, which innervates the diaphragm, shares the same nerve roots (C3-C5) as the nerves that provide sensation to the shoulder. [8]
Question 3: You are treating a patient with a stab wound to the abdomen resulting in an evisceration of the small intestine. What is the most appropriate prehospital management for the exposed organ?
- Gently reinsert the intestine and cover the wound with a dry dressing.
- Cover the intestine with a moist, sterile dressing, then an occlusive dressing. (Correct answer)
- Apply a dry sterile dressing directly over the intestine to absorb blood.
- Pack the wound tightly with sterile gauze to prevent further evisceration.
Correct answer: Cover the intestine with a moist, sterile dressing, then an occlusive dressing.
The proper management for an abdominal evisceration is to cover the exposed organs with a saline-moistened sterile dressing to prevent the tissue from drying out. [17, 18, 22] This should then be covered with an occlusive dressing to minimize heat and fluid loss. Organs should never be pushed back into the abdomen in the field, and dry dressings can adhere to the tissue and cause damage. [22, 24]
Question 4: Which of the following physical exam findings is the strongest contraindication to inserting a urinary catheter in a male trauma patient with a suspected pelvic fracture?
- Suprapubic tenderness and guarding.
- A large hematoma over the iliac crest.
- Instability on gentle palpation of the pelvis.
- Blood at the urethral meatus. (Correct answer)
Correct answer: Blood at the urethral meatus.
Blood at the urethral meatus is a cardinal sign of urethral injury. [1, 4, 10] Attempting to insert a catheter in this situation can convert a partial urethral tear into a complete transection, causing significant further damage. Other signs include a scrotal hematoma or a high-riding prostate. [4, 9]
Question 5: A 17-year-old bicyclist struck a fixed post, impacting his left upper abdomen and flank on the handlebar. He is pale and tachycardic with a BP of 88/58 mmHg. Based on the mechanism and location of injury, which organ is most likely the source of his hypovolemia?
- Spleen (Correct answer)
- Liver
- Stomach
- Appendix
Correct answer: Spleen
The spleen is a highly vascular, solid organ located in the left upper quadrant (LUQ) of the abdomen. [15, 16] It is the most commonly injured organ in blunt abdominal trauma. [19] A direct blow to the LUQ, such as from a handlebar, is a classic mechanism for splenic injury, which can lead to rapid and severe internal hemorrhage. [16, 21]
Question 6: When performing a secondary survey on a conscious patient with a painful, deformed femur fracture following a fall, what is the most significant limitation of the abdominal physical exam?
- Palpation is likely to dislodge blood clots, worsening hemorrhage.
- The presence of a painful distracting injury can make abdominal findings unreliable. (Correct answer)
- Bowel sounds are always absent after significant trauma, limiting their utility.
- The exam cannot differentiate between retroperitoneal and intraperitoneal bleeding.
Correct answer: The presence of a painful distracting injury can make abdominal findings unreliable.
A severe, painful injury, such as a femur fracture, is considered a 'distracting injury.' It can mask the pain and tenderness associated with a concurrent abdominal injury because the patient's perception of pain is focused on the more obvious injury. [11] This can lead to a falsely reassuring abdominal exam. Therefore, a high index of suspicion based on the mechanism of injury is crucial, even with a seemingly benign abdominal exam.
PHTLS - Prehospital Trauma Life Support Abdominal and Pelvic Trauma Questions and Answers
A patient involved in a high-speed motor vehicle collision is found to have an unstable pelvis on assessment.
The patient is tachycardic and hypotensive.
Which intervention is the highest priority for managing life-threatening hemorrhage from this injury?