PHTLS - Prehospital Trauma Life Support Shock and Hemorrhage Control Questions and Answers — Questions and Answers
Question 1: A 25-year-old male has sustained a gunshot wound to the upper right thigh. Bright red blood is spurting from the wound. Direct pressure is ineffective. What is the MOST appropriate next step in managing this hemorrhage?
- Apply a hemostatic dressing and continue direct pressure.
- Immediately apply a tourniquet high and tight on the extremity. (Correct answer)
- Administer a rapid bolus of 1 liter of normal saline.
- Package the patient for immediate transport without further intervention.
Correct answer: Immediately apply a tourniquet high and tight on the extremity.
PHTLS guidelines prioritize immediate control of life-threatening external hemorrhage. For massive extremity bleeding that is not controlled by direct pressure, the application of a tourniquet is the indicated life-saving intervention. It should be placed proximal to the wound, often 'high and tight' on the limb, to effectively stop arterial blood flow.
Question 2: Which of the following is a primary goal of 'permissive hypotension' in the management of a trauma patient with suspected non-compressible torso hemorrhage?
- To rapidly normalize blood pressure to 120/80 mmHg.
- To increase urine output and confirm adequate renal perfusion.
- To prevent clot dislodgement by avoiding aggressive fluid resuscitation. (Correct answer)
- To aggressively administer crystalloids until the radial pulse is bounding.
Correct answer: To prevent clot dislodgement by avoiding aggressive fluid resuscitation.
Permissive hypotension is a strategy used in trauma patients with suspected internal bleeding to maintain a blood pressure that is just high enough for vital organ perfusion (e.g., SBP of 80-90 mmHg) without being so high that it dislodges newly formed clots or dilutes clotting factors. The goal is to avoid 'popping the clot' before the patient can get to definitive surgical care.
Question 3: According to PHTLS principles, Tranexamic Acid (TXA) is most effective when administered to a trauma patient with significant hemorrhage under which condition?
- Anytime within 24 hours of the injury.
- Only after 2 liters of crystalloid have been administered.
- For isolated, compressible extremity hemorrhage.
- Within 3 hours of the injury. (Correct answer)
Correct answer: Within 3 hours of the injury.
Clinical evidence, such as the CRASH-2 trial, has shown that TXA provides the greatest mortality benefit when administered as early as possible, specifically within the first 3 hours following the injury. Administration after this window may not be beneficial and could potentially be harmful.
Question 4: You are treating a patient with a suspected unstable pelvic fracture after a high-speed MVC. The patient is tachycardic and hypotensive. Besides IV access and fluid administration, which intervention is critical for controlling internal hemorrhage?
- Log rolling the patient to assess their back.
- Application of a pelvic binder or sheet. (Correct answer)
- Placing the patient in a prone position.
- Applying bilateral traction splints.
Correct answer: Application of a pelvic binder or sheet.
An unstable pelvic fracture can lead to massive internal hemorrhage by increasing the pelvic volume and damaging blood vessels. Applying a pelvic binder or a circumferential sheet wrap is a critical intervention to stabilize the pelvis, reduce its volume, and help tamponade the bleeding source.
Question 5: In the PHTLS patient assessment sequence (XABCDE), what does the 'X' represent and why is it addressed first?
- X-factor, for considering unknown variables in the mechanism of injury.
- eXamine, for a detailed head-to-toe examination before other steps.
- eXsanguinating Hemorrhage, because it is the most immediate threat to life. (Correct answer)
- Xiphoid process, as a landmark for chest compressions if needed.
Correct answer: eXsanguinating Hemorrhage, because it is the most immediate threat to life.
The PHTLS assessment model uses XABCDE to prioritize care. The 'X' stands for eXsanguinating Hemorrhage. This step was placed before the traditional 'ABC's to emphasize that catastrophic external bleeding must be controlled immediately, as a patient can bleed to death in minutes, making airway and breathing interventions futile if circulation is lost.
Question 6: When applying a commercial windlass-style tourniquet to an upper arm, which of the following actions is correct?
- Place the tourniquet directly over the elbow joint to compress the brachial artery.
- Tighten the windlass only until venous bleeding stops.
- Position the tourniquet 2-3 inches proximal to the wound, but not over a joint. (Correct answer)
- Loosen the tourniquet for 30 seconds every 15 minutes to allow for distal perfusion.
Correct answer: Position the tourniquet 2-3 inches proximal to the wound, but not over a joint.
Proper tourniquet application requires placing it 2-3 inches proximal to the wound on uninjured skin. It should never be placed directly over a joint (like an elbow or knee) because the bones can prevent effective arterial compression. The windlass must be tightened until all bleeding (arterial and venous) stops and the distal pulse is absent, and it should not be loosened in the prehospital setting.
PHTLS - Prehospital Trauma Life Support Shock and Hemorrhage Control Questions and Answers
A 25-year-old male has sustained a gunshot wound to the upper right thigh.
Bright red blood is spurting from the wound.
Direct pressure is ineffective.
What is the MOST appropriate next step in managing this hemorrhage?