PHTLS - Prehospital Trauma Life Support Abdominal and Pelvic Trauma — Questions and Answers
Question 1: Which organ is the most commonly injured solid organ in blunt abdominal trauma?
- Liver
- Spleen (Correct answer)
- Kidneys
- Pancreas
Correct answer: Spleen
The spleen is the most commonly injured solid organ in blunt abdominal trauma due to its location, vascularity, and relatively fragile capsule.
The spleen accounts for approximately 40-55% of solid organ injuries in blunt abdominal trauma. Its location beneath the left lower ribs, high vascularity, and thin capsule make it vulnerable to both direct and deceleration forces.
Question 2: What is the primary prehospital concern with penetrating abdominal trauma?
- Infection at the wound site
- Internal hemorrhage and hollow organ injury (Correct answer)
- Cosmetic damage to the abdominal wall
- Need for tetanus prophylaxis
Correct answer: Internal hemorrhage and hollow organ injury
Penetrating abdominal trauma can cause significant internal hemorrhage from solid organ or vascular injury and peritonitis from hollow organ perforation.
Solid organ injuries cause hemorrhage, while hollow organ injuries release contents that cause peritonitis. Major vascular injuries can produce rapid exsanguination. PHTLS teaches that external wound appearance does not predict internal injury severity.
Question 3: How should eviscerated abdominal organs be managed in the prehospital setting?
- Push the organs back into the abdomen
- Cover with moist sterile dressings and protect from further injury (Correct answer)
- Apply direct pressure to the eviscerated organs
- Leave completely uncovered for continuous monitoring
Correct answer: Cover with moist sterile dressings and protect from further injury
Eviscerated organs should be covered with moist sterile dressings moistened with saline to prevent drying and contamination.
The exposed organs should be covered with sterile dressings moistened with warm normal saline, then covered with an occlusive material to retain moisture and warmth. The organs should NEVER be pushed back into the abdomen as this can introduce contamination and worsen injury.
Question 4: A patient involved in a motorcycle crash complains of left flank pain and has signs of shock. Which injury should be suspected?
- Ruptured appendix
- Bladder rupture
- Splenic laceration with hemorrhage (Correct answer)
- Small bowel obstruction
Correct answer: Splenic laceration with hemorrhage
Left flank pain with signs of shock after blunt trauma strongly suggests splenic injury with significant hemorrhage.
The spleen receives approximately 5% of cardiac output, so laceration can produce rapid hemorrhage. Associated findings may include left shoulder pain (Kehr's sign), left lower rib fractures, and progressive abdominal distension.
Question 5: What is the significance of pelvic instability found during physical assessment of a trauma patient?
- It confirms a simple pelvic fracture only
- It suggests potential life-threatening pelvic hemorrhage (Correct answer)
- It indicates the patient has osteoporosis
- It means the sacroiliac joint is dislocated
Correct answer: It suggests potential life-threatening pelvic hemorrhage
Pelvic instability suggests a significant pelvic fracture with high risk of life-threatening hemorrhage from the rich pelvic vascular network.
An unstable pelvis can accommodate several liters of blood. PHTLS emphasizes that the pelvis should only be tested ONCE to avoid disrupting clots. A pelvic binder should be applied immediately at the greater trochanter level.
Question 6: Which of the following findings during abdominal assessment is most suggestive of peritoneal irritation?
- Soft, non-tender abdomen
- Involuntary guarding and rigidity (Correct answer)
- Hyperactive bowel sounds
- Umbilical bruising only
Correct answer: Involuntary guarding and rigidity
Involuntary guarding and rigidity indicate peritoneal irritation, often from blood or intestinal contents irritating the peritoneal lining.
Involuntary guarding is a reflexive contraction of the abdominal musculature in response to peritoneal irritation. Unlike voluntary guarding, involuntary guarding persists regardless of distraction and indicates true peritonitis. In trauma, this results from blood or intestinal contents.
Question 7: In PHTLS, what is the recommended prehospital assessment approach for suspected intra-abdominal hemorrhage?
- Detailed abdominal palpation with deep pressure in all four quadrants
- Serial abdominal assessments combined with monitoring for signs of shock (Correct answer)
- Diagnostic peritoneal lavage in the field
- Focused ultrasound examination by paramedics
Correct answer: Serial abdominal assessments combined with monitoring for signs of shock
Since prehospital providers cannot definitively diagnose intra-abdominal hemorrhage, serial assessments monitoring for worsening tenderness, distension, and shock signs guide management.
PHTLS teaches that the prehospital abdominal exam has significant limitations. Initial findings may be normal despite significant internal injury. Progressive abdominal distension, increasing tenderness, developing rigidity, and worsening hemodynamic status all suggest ongoing hemorrhage.
Question 8: A restrained driver in a frontal collision presents with a seatbelt sign across the lower abdomen. What injuries should be suspected?
- Only superficial skin bruising
- Lumbar spine fracture, mesenteric tear, and hollow organ injury (Correct answer)
- Isolated liver laceration
- Thoracic vertebral fracture only
Correct answer: Lumbar spine fracture, mesenteric tear, and hollow organ injury
The seatbelt sign is associated with a triad of injuries: lumbar spine fractures (Chance fractures), mesenteric tears, and hollow organ perforation.
The classic 'seatbelt syndrome' includes Chance fractures from flexion over the belt, mesenteric tears from shearing forces, and hollow organ rupture from compression against the spine. Patients with seatbelt signs have a 4-8 times increased risk of intra-abdominal injury.
Question 9: What is the role of the FAST exam in relation to PHTLS prehospital assessment?
- It replaces the physical exam for all abdominal trauma
- It can supplement clinical assessment when available but does not change prehospital transport decisions for unstable patients (Correct answer)
- It is the definitive diagnostic tool for pelvic fractures
- It must be performed before any fluid resuscitation
Correct answer: It can supplement clinical assessment when available but does not change prehospital transport decisions for unstable patients
While FAST ultrasound can detect free fluid in the abdomen, hemodynamically unstable trauma patients still require rapid transport regardless of FAST results.
PHTLS emphasizes that FAST does not change management for hemodynamically unstable patients. A negative FAST does not rule out significant injury. FAST is most useful for stable patients where positive findings increase suspicion and may influence destination decisions.
Question 10: How does PHTLS recommend managing a patient with suspected bladder rupture following blunt pelvic trauma?
- Catheterize immediately to decompress the bladder
- Monitor for signs of peritonitis and shock, apply pelvic binder, and transport rapidly (Correct answer)
- Apply ice packs to the suprapubic region
- Perform suprapubic needle aspiration
Correct answer: Monitor for signs of peritonitis and shock, apply pelvic binder, and transport rapidly
Prehospital management focuses on treating associated pelvic fracture hemorrhage with a pelvic binder, monitoring for peritonitis and shock, and rapid transport.
Bladder rupture occurs in approximately 10% of pelvic fractures. In the prehospital setting, specific diagnosis is impossible. Management addresses the most life-threatening component: pelvic hemorrhage. Urethral catheterization is generally avoided when pelvic fracture is suspected.
Question 11: Which physical finding in a trauma patient suggests retroperitoneal hemorrhage?
- Distended abdomen with shifting dullness
- Grey Turner's sign, flank ecchymosis (Correct answer)
- Hyperactive bowel sounds
- Periumbilical tenderness only
Correct answer: Grey Turner's sign, flank ecchymosis
Grey Turner's sign (ecchymosis of the flanks) suggests retroperitoneal hemorrhage, though it typically takes hours to develop.
Grey Turner's sign is flank ecchymosis caused by blood dissecting along retroperitoneal tissue planes. It classically indicates retroperitoneal hemorrhage from injuries to the kidneys, pancreas, duodenum, aorta, or vena cava. Both Grey Turner's sign and Cullen's sign typically take 6-12 hours to appear.
Question 12: A trauma patient presents with abdominal distension, tachycardia, and dropping blood pressure 20 minutes after a stabbing. What is the most likely cause?
- Gastric dilation from air swallowing
- Intraperitoneal hemorrhage from injured abdominal vessels or organs (Correct answer)
- Constipation from opioid administration
- Bladder distension from urinary retention
Correct answer: Intraperitoneal hemorrhage from injured abdominal vessels or organs
Progressive abdominal distension with hemodynamic instability after penetrating trauma indicates active intraperitoneal hemorrhage.
A stab wound can injure the liver, spleen, mesenteric vessels, aorta, or vena cava. The abdomen can accommodate several liters of blood. Prehospital management requires aggressive hemorrhage control, permissive hypotension, and immediate transport. This is the quintessential 'load and go' scenario.
PHTLS - Prehospital Trauma Life Support Abdominal and Pelvic Trauma
Which organ is the most commonly injured solid organ in blunt abdominal trauma?
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