PHTLS Airway and Ventilation 3 — Questions and Answers
Question 1: 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 2: 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 3: 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 4: 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 5: 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 6: 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 7: 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.
PHTLS Airway and Ventilation 3
Which assessment finding best distinguishes tension pneumothorax from a simple pneumothorax in a trauma patient?