PHTLS - Prehospital Trauma Life Support Prehospital Trauma Life Support Special Trauma Considerations 1 — Questions and Answers
Question 1: A pediatric trauma patient presents with rapid respiratory rate, normal blood pressure, and mottled skin after a motor vehicle crash. Which statement BEST explains why hypotension is a late and ominous sign in pediatric trauma?
- Children have lower circulating blood volumes, so any loss is immediately critical
- Children compensate through increased heart rate and vasoconstriction before blood pressure drops (Correct answer)
- Children's vasculature is more rigid, preventing pressure changes until complete decompensation
- Children lose blood faster due to higher metabolic demands
Correct answer: Children compensate through increased heart rate and vasoconstriction before blood pressure drops
Pediatric patients have robust compensatory mechanisms — they vasoconstrict aggressively and increase heart rate to maintain blood pressure. By the time BP drops, the child may have lost 30–45% of circulating volume, making hypotension an immediate pre-arrest warning in pediatric trauma.
Question 2: During a rescue operation, a patient is extricated after being pinned under heavy machinery for 2 hours. PHTLS guidelines caution that reperfusion following prolonged crush injury can cause which life-threatening complication?
- Anaphylactic shock from histamine release
- Tension pneumothorax from mediastinal shift
- Hyperkalemia and myoglobinuria leading to cardiac dysrhythmia and renal failure (Correct answer)
- Massive internal hemorrhage from aortic shear stress
Correct answer: Hyperkalemia and myoglobinuria leading to cardiac dysrhythmia and renal failure
Crush syndrome (traumatic rhabdomyolysis) causes release of intracellular potassium and myoglobin upon reperfusion. Hyperkalemia can trigger fatal dysrhythmias, while myoglobin precipitates in renal tubules, causing acute kidney injury. Early aggressive IV fluid resuscitation is the prehospital priority.
Question 3: A 78-year-old patient on warfarin therapy sustains a seemingly minor head impact after a ground-level fall. PHTLS emphasizes which assessment priority for this patient?
- Spinal immobilization takes precedence over all other interventions due to osteoporosis risk
- Even minor mechanisms warrant high suspicion for intracranial hemorrhage; expedite transport to a trauma center (Correct answer)
- Field reversal of anticoagulation with oral vitamin K is recommended before transport
- Neurological examination findings reliably exclude significant intracranial injury in anticoagulated patients
Correct answer: Even minor mechanisms warrant high suspicion for intracranial hemorrhage; expedite transport to a trauma center
Anticoagulated patients — especially elderly patients on warfarin — have dramatically increased risk of intracranial hemorrhage even from low-energy mechanisms. Normal mental status and absence of focal deficits do NOT rule out significant bleeding. Rapid transport for CT imaging and possible reversal is the PHTLS priority.
Question 4: According to PHTLS, which component of the 'lethal triad' is specifically exacerbated by prolonged scene time, wet clothing, and inadequate patient packaging in trauma patients?
- Coagulopathy
- Hypothermia (Correct answer)
- Acidosis
- Hypoxia
Correct answer: Hypothermia
The lethal triad of trauma — hypothermia, coagulopathy, and acidosis — are mutually reinforcing. Hypothermia is the component most directly preventable in prehospital care through rapid packaging, removing wet clothing, and applying warming measures. Hypothermia worsens coagulopathy by impairing clotting enzyme function, accelerating the triad.
Question 5: PHTLS providers respond to a patient with a known pre-existing complete spinal cord injury at C6 who was involved in a vehicle collision. The patient has a BP of 80/50 and bradycardia. What is the MOST likely cause of this hemodynamic pattern?
- Tension pneumothorax causing obstructive shock
- Neurogenic shock from a new spinal injury at a higher level (Correct answer)
- Hemorrhagic shock masked by baseline hypotension
- Cardiogenic shock from pre-existing cardiac disease
Correct answer: Neurogenic shock from a new spinal injury at a higher level
Neurogenic shock results from loss of sympathetic tone below the level of a spinal cord injury, causing vasodilation and bradycardia (the sympathetic accelerator to the heart is also lost). In a patient with a pre-existing spinal injury, a new injury at a higher cervical level — or spinal cord concussion — should be suspected when hypotension accompanies bradycardia without obvious hemorrhage.
Question 6: A trauma patient with severe burns to 40% total body surface area (TBSA) also has signs of airway involvement — singed nasal hairs, hoarseness, and carbonaceous sputum. According to PHTLS, what is the MOST critical prehospital airway intervention?
- Apply a non-rebreather mask and reassess at the hospital
- Delay airway management until fluid resuscitation is established
- Secure a definitive airway early, before progressive edema makes intubation impossible (Correct answer)
- Perform nasotracheal intubation to avoid stimulating the burn-injured oropharynx
Correct answer: Secure a definitive airway early, before progressive edema makes intubation impossible
Inhalation injury causes progressive airway edema that can render intubation impossible within minutes to hours. PHTLS stresses early definitive airway management — orotracheal intubation — before edema distorts anatomy. Waiting until respiratory distress worsens significantly reduces the chance of successful airway control.
PHTLS - Prehospital Trauma Life Support Prehospital Trauma Life Support Special Trauma Considerations 1
A pediatric trauma patient presents with rapid respiratory rate, normal blood pressure, and mottled skin after a motor vehicle crash.
Which statement BEST explains why hypotension is a late and ominous sign in pediatric trauma?