PHTLS - Prehospital Trauma Life Support Prehospital Trauma Life Support Thoracic Trauma 1 — Questions and Answers
Question 1: A patient sustains a gunshot wound to the left chest and presents with a large open chest wound, audible air movement through the wound, and increasing respiratory distress. What is the immediate PHTLS-recommended prehospital intervention?
- Apply an occlusive dressing sealed on three sides (Correct answer)
- Apply a fully occlusive dressing sealed on all four sides
- Perform immediate needle decompression at the second intercostal space
- Pack the wound with hemostatic gauze and apply direct pressure
Correct answer: Apply an occlusive dressing sealed on three sides
PHTLS recommends a three-sided (vented) occlusive dressing for open chest wounds (sucking chest wounds). The open side acts as a flutter valve, allowing air to escape during exhalation while preventing air entrainment during inhalation. A fully occlusive seal risks converting the open pneumothorax into a tension pneumothorax.
Question 2: Which of the following clinical findings is most consistent with cardiac tamponade in a trauma patient?
- Unilateral absent breath sounds, tracheal deviation, and hypotension
- Hypotension, distended neck veins, and muffled heart sounds (Correct answer)
- Paradoxical chest wall movement and severe respiratory distress
- Massive subcutaneous emphysema with oxygen saturation below 80%
Correct answer: Hypotension, distended neck veins, and muffled heart sounds
Beck's Triad — hypotension, distended jugular veins (JVD), and muffled heart sounds — classically describes cardiac tamponade. Blood accumulating in the pericardial sac compresses the heart, reducing cardiac output while venous pressure rises. This distinguishes it from tension pneumothorax, which also causes JVD and hypotension but includes absent breath sounds and tracheal deviation.
Question 3: A restrained driver is involved in a high-speed frontal collision. He is conscious but has severe chest pain, tachycardia, and a blood pressure of 80/50 mmHg. Breath sounds are equal bilaterally and neck veins are flat. Which injury should be highest on the differential?
- Tension pneumothorax
- Cardiac tamponade
- Massive hemothorax (Correct answer)
- Traumatic aortic disruption
Correct answer: Massive hemothorax
Flat neck veins with shock and equal breath sounds point to massive hemothorax, where large-volume blood loss into the pleural space causes hypovolemic shock without venous congestion. Tension pneumothorax and tamponade both elevate venous pressure (distended neck veins). The high-speed deceleration mechanism is consistent with massive hemothorax from great vessel or pulmonary hilar injury.
Question 4: When assessing a trauma patient for pulmonary contusion, which statement best reflects PHTLS guidance on this injury?
- Pulmonary contusion is immediately apparent on physical exam and produces visible bruising over the chest wall
- Signs and symptoms may be subtle initially and worsen over hours as alveolar hemorrhage and edema develop (Correct answer)
- Pulmonary contusion only occurs in patients who also have rib fractures on the same side
- High-flow oxygen is contraindicated because it worsens alveolar damage in contused lung tissue
Correct answer: Signs and symptoms may be subtle initially and worsen over hours as alveolar hemorrhage and edema develop
Pulmonary contusion is deceptive: the injury to alveolar-capillary membranes causes progressive hemorrhage and edema that worsens over the first 24–48 hours. Initial presentation may show only mild tachypnea and hypoxia that deteriorates significantly. External chest wall appearance can be misleading — the force transfers to the lung parenchyma even without dramatic surface findings.
Question 5: During rapid assessment of a multi-system trauma patient, you note paradoxical inward movement of a segment of the right chest wall during inspiration. Oxygen saturation is 88% on room air. After applying high-flow oxygen, what is the next priority in managing this patient's thoracic injury?
- Immediate needle decompression to relieve underlying pneumothorax
- Stabilize the flail segment with sandbags or manual pressure before transport
- Provide positive-pressure ventilation if the patient cannot maintain adequate tidal volume (Correct answer)
- Apply a circumferential chest wrap to immobilize all rib fractures
Correct answer: Provide positive-pressure ventilation if the patient cannot maintain adequate tidal volume
While the paradoxical movement of a flail chest is visually dramatic, the real physiologic threat is the underlying pulmonary contusion and the patient's inability to generate adequate tidal volume. PHTLS emphasizes that if the patient cannot maintain adequate ventilation and oxygenation despite supplemental oxygen, positive-pressure ventilation (BVM or advanced airway) is the intervention that addresses the underlying pathophysiology — not external splinting.
Question 6: A patient who was struck by a vehicle presents with left-sided chest pain, decreased breath sounds on the left, bowel sounds auscultated over the left lower chest, and an oxygen saturation of 91%. What injury does this presentation suggest?
- Left-sided tension pneumothorax requiring immediate needle decompression
- Traumatic diaphragmatic rupture with herniation of abdominal contents (Correct answer)
- Massive left hemothorax requiring aggressive IV fluid resuscitation
- Left pulmonary contusion with associated pleural effusion
Correct answer: Traumatic diaphragmatic rupture with herniation of abdominal contents
Bowel sounds heard within the thoracic cavity are pathognomonic for diaphragmatic rupture with herniation of abdominal organs into the chest. This injury compresses the lung and can cause significant respiratory compromise. It is more common on the left side because the liver tends to protect the right hemidiaphragm. Prehospital management focuses on airway support and rapid transport; positive-pressure ventilation may worsen herniation.
PHTLS - Prehospital Trauma Life Support Prehospital Trauma Life Support Thoracic Trauma 1
A patient sustains a gunshot wound to the left chest and presents with a large open chest wound, audible air movement through the wound, and increasing respiratory distress.
What is the immediate PHTLS-recommended prehospital intervention?