PHTLS Airway and Ventilation — Questions and Answers
Question 1: A trauma patient has a GCS of 8 and is breathing with an irregular pattern. What is the most appropriate airway intervention?
- Nasopharyngeal airway only
- Oropharyngeal airway and BVM ventilation
- Definitive airway management via endotracheal intubation or supraglottic device (Correct answer)
- High-flow oxygen via non-rebreather mask
Correct answer: Definitive airway management via endotracheal intubation or supraglottic device
A GCS ≤8 with inadequate breathing indicates the need for a definitive airway to protect and control ventilation.
Question 2: Which finding during airway assessment indicates immediate life-threatening airway obstruction?
- Mild stridor during exertion
- Complete absence of breath sounds bilaterally with no chest rise (Correct answer)
- Expiratory wheeze in both lung fields
- SpO2 of 94% on room air
Correct answer: Complete absence of breath sounds bilaterally with no chest rise
No breath sounds and no chest rise with ventilation attempts signals complete airway obstruction requiring immediate action.
Question 3: When performing bag-valve-mask ventilation on a trauma patient, what tidal volume and rate are recommended to avoid iatrogenic harm?
- Large tidal volumes at 20 breaths/min
- Tidal volumes causing visible chest rise at 10-12 breaths/min (Correct answer)
- Minimal volumes at 6 breaths/min
- Forceful ventilation at 24 breaths/min to maximize oxygenation
Correct answer: Tidal volumes causing visible chest rise at 10-12 breaths/min
PHTLS recommends ventilations sufficient to produce visible chest rise at 10-12/min to prevent hyperventilation and gastric insufflation.
Question 4: A patient with suspected cervical spine injury needs airway management. Which approach is preferred?
- Hyperextend the neck to open the airway fully
- Use jaw thrust maneuver with in-line spinal stabilization (Correct answer)
- Avoid all airway maneuvers until imaging confirms injury
- Perform immediate cricothyrotomy
Correct answer: Use jaw thrust maneuver with in-line spinal stabilization
Jaw thrust with manual in-line stabilization opens the airway while minimizing cervical spine movement.
Question 5: Which supraglottic airway device is considered acceptable for definitive airway management when endotracheal intubation is not feasible in PHTLS?
- Simple face mask
- Laryngeal mask airway (LMA) or King LT (Correct answer)
- Nasopharyngeal airway
- Oropharyngeal airway
Correct answer: Laryngeal mask airway (LMA) or King LT
Supraglottic devices like the LMA or King LT are acceptable rescue airways when intubation cannot be performed.
Question 6: During rapid sequence intubation (RSI) of a trauma patient, which complication most directly results from excessive ventilation rate?
- Hypoxia from oxygen consumption
- Reduced venous return and decreased cardiac output (Correct answer)
- Esophageal intubation
- Laryngospasm
Correct answer: Reduced venous return and decreased cardiac output
Hyperventilation raises intrathoracic pressure, reducing venous return and can cause or worsen hypotension in trauma patients.
Question 7: A patient with a penetrating neck injury is maintaining their own airway but has progressive swelling and voice changes. What is the most appropriate prehospital action?
- Wait and reassess in 5 minutes
- Apply a cervical collar tightly to tamponade swelling
- Initiate early definitive airway before complete obstruction occurs (Correct answer)
- Administer albuterol for swelling
Correct answer: Initiate early definitive airway before complete obstruction occurs
Progressive airway compromise from expanding hematoma requires early airway intervention before complete obstruction makes it impossible.
Question 8: Which assessment finding best distinguishes tension pneumothorax from a simple pneumothorax in a trauma patient?
- Absent breath sounds on affected side
- Absent breath sounds plus hypotension and tracheal deviation (Correct answer)
- Pain with inspiration
- Subcutaneous emphysema alone
Correct answer: Absent breath sounds plus hypotension and tracheal deviation
Tension pneumothorax produces absent breath sounds combined with hemodynamic compromise (hypotension) and possibly tracheal deviation.
Question 9: When is a needle decompression indicated in the prehospital setting?
- Any patient with a chest wound
- Suspected tension pneumothorax with deteriorating hemodynamics (Correct answer)
- Confirmed simple pneumothorax on palpation
- SpO2 below 95% after oxygen application
Correct answer: Suspected tension pneumothorax with deteriorating hemodynamics
Needle decompression is indicated for suspected tension pneumothorax causing hemodynamic or respiratory deterioration.
Question 10: What is the preferred site for needle decompression according to current PHTLS guidelines?
- 2nd intercostal space, midclavicular line
- 4th or 5th intercostal space, anterior axillary line (Correct answer)
- 7th intercostal space, midaxillary line
- 1st intercostal space, midclavicular line
Correct answer: 4th or 5th intercostal space, anterior axillary line
PHTLS and TCCC guidelines now recommend the 4th or 5th ICS at the anterior axillary line due to higher success rates in muscular patients.
Question 11: A patient with an open chest wound is becoming hypoxic. What is the immediate intervention?
- Apply a fully occlusive dressing on all four sides
- Apply a vented (3-sided) chest seal or commercial vented device (Correct answer)
- Pack the wound with gauze and apply pressure
- Perform immediate needle decompression
Correct answer: Apply a vented (3-sided) chest seal or commercial vented device
A vented chest seal allows air to escape on exhalation, preventing conversion to tension pneumothorax while sealing the wound.
Question 12: Which of the following is a contraindication to nasopharyngeal airway (NPA) insertion in a trauma patient?
- Active gag reflex
- Suspected basilar skull fracture (Correct answer)
- Nasal hair present
- Patient over age 60
Correct answer: Suspected basilar skull fracture
Suspected basilar skull fracture is a relative contraindication to NPA because of the theoretical risk of intracranial placement.
Question 13: End-tidal CO2 (ETCO2) monitoring after intubation in a trauma patient should target which range to avoid secondary brain injury?
- 20-25 mmHg
- 35-45 mmHg (Correct answer)
- 50-60 mmHg
- 60-70 mmHg
Correct answer: 35-45 mmHg
Normal ETCO2 (35-45 mmHg) prevents both hypercapnia (increases ICP) and hypocapnia (causes cerebral vasoconstriction and ischemia).
Question 14: Which clinical sign is the most reliable indicator of adequate ventilation in a prehospital trauma patient?
- Pink skin color
- Symmetric chest rise with each breath (Correct answer)
- SpO2 reading above 90%
- Patient can speak
Correct answer: Symmetric chest rise with each breath
Symmetric chest rise with each ventilation confirms bilateral lung inflation and is the most direct assessment of adequate ventilation.
Question 15: A trauma patient with severe facial injuries has an unsecurable airway via orotracheal intubation. What is the next definitive option?
- Continue BVM ventilation indefinitely
- Surgical cricothyrotomy (Correct answer)
- Nasal intubation without medications
- Increase oxygen flow rate
Correct answer: Surgical cricothyrotomy
Surgical cricothyrotomy is the definitive rescue airway when oral and nasal intubation are not possible due to facial trauma.
Question 16: In PHTLS, what does the mnemonic 'MOANS' help assess?
- Severity of traumatic brain injury
- Anticipated difficulty of bag-valve-mask ventilation (Correct answer)
- Likelihood of hemorrhagic shock
- Spinal cord injury level
Correct answer: Anticipated difficulty of bag-valve-mask ventilation
MOANS (Mask seal, Obesity/Obstruction, Age, No teeth, Stiff) predicts difficulty with BVM ventilation before intubation.
Question 17: What physiologic effect does hyperventilation cause in a trauma patient with TBI that makes it harmful?
- Increases cerebral blood flow leading to herniation
- Causes cerebral vasoconstriction reducing blood flow and oxygen delivery (Correct answer)
- Raises blood pressure causing rebleeding
- Causes metabolic alkalosis worsening coagulopathy
Correct answer: Causes cerebral vasoconstriction reducing blood flow and oxygen delivery
Hyperventilation lowers CO2, causing cerebral vasoconstriction that reduces cerebral blood flow and worsens ischemia in the injured brain.
Question 18: A patient has diminished breath sounds on the left with a deviated trachea to the right and a BP of 70/40. Which condition does this represent?
- Left-sided hemothorax
- Left-sided tension pneumothorax (Correct answer)
- Right-sided simple pneumothorax
- Pericardial tamponade
Correct answer: Left-sided tension pneumothorax
Left-sided absent breath sounds, rightward tracheal deviation, and shock are classic signs of left-sided tension pneumothorax.
Question 19: When using a two-handed BVM technique during trauma resuscitation, why is it preferred over single-handed technique?
- It delivers higher oxygen concentrations
- It achieves a better mask seal and reduces leak, improving ventilation (Correct answer)
- It allows faster compression rates
- It prevents regurgitation
Correct answer: It achieves a better mask seal and reduces leak, improving ventilation
A two-person technique with two hands on the mask creates a superior seal, ensuring more consistent tidal volume delivery.
Question 20: Which patient presentation is MOST consistent with a hemothorax requiring prehospital intervention?
- Bilateral crackles with JVD
- Unilateral absent breath sounds, dull percussion, normal BP (Correct answer)
- Absent breath sounds with tracheal deviation and hypotension
- Subcutaneous emphysema with normal vitals
Correct answer: Unilateral absent breath sounds, dull percussion, normal BP
Hemothorax produces absent or diminished breath sounds with dullness to percussion on the affected side, though BP may be maintained initially.
Question 21: Pulseoximetry (SpO2) may give falsely normal readings in which trauma scenario?
- Hypoxia from tension pneumothorax
- Carbon monoxide poisoning from smoke inhalation (Correct answer)
- Airway obstruction from tongue
- Hemorrhagic shock with hemoglobin drop
Correct answer: Carbon monoxide poisoning from smoke inhalation
Pulse oximetry cannot distinguish carboxyhemoglobin from oxyhemoglobin, so CO poisoning can produce falsely normal SpO2 readings.
PHTLS Airway and Ventilation
A trauma patient has a GCS of 8 and is breathing with an irregular pattern.
What is the most appropriate airway intervention?
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