PHTLS Shock and Hemorrhage Control — Questions and Answers

Question 1: A trauma patient has a BP of 80/60 mmHg, HR of 128 bpm, and cool, clammy skin. Which class of hemorrhagic shock does this best represent?

Class I
Class II
Class III (Correct answer)
Class IV

Correct answer: Class III

Class III hemorrhagic shock involves 30–40% blood volume loss and presents with hypotension, tachycardia >120, and altered mental status.

Question 2: Which of the following is the MOST appropriate initial intervention for a suspected pelvic fracture causing hemodynamic instability in the prehospital setting?

Apply a pelvic binder or sheet wrap (Correct answer)
Perform external cardiac compression
Initiate IV fluid bolus of 2L normal saline
Place the patient in Trendelenburg position

Correct answer: Apply a pelvic binder or sheet wrap

A pelvic binder or sheet wrap reduces pelvic volume and tamponades internal hemorrhage in unstable pelvic fractures.

Question 3: When using a windlass tourniquet on a lower extremity, how far proximal to the wound should it be placed?

Directly over the wound
1–2 inches proximal to the wound
2–3 inches proximal to the wound (Correct answer)
At the groin crease regardless of wound location

Correct answer: 2–3 inches proximal to the wound

PHTLS guidelines recommend placing a tourniquet 2–3 inches proximal to the wound to ensure adequate compression of the vessel.

Question 4: A patient in hemorrhagic shock has received 1L of blood products en route. On reassessment, BP is 88/60 and HR is 110. This response is best described as:

Nonresponder
Responder
Transient responder (Correct answer)
Delayed responder

Correct answer: Transient responder

A transient responder improves initially but then deteriorates, suggesting ongoing hemorrhage that may require surgical control.

Question 5: Which acid-base disturbance is most commonly seen in severe hemorrhagic shock?

Metabolic alkalosis
Respiratory alkalosis
Metabolic acidosis (Correct answer)
Respiratory acidosis

Correct answer: Metabolic acidosis

Anaerobic metabolism from inadequate tissue perfusion produces lactic acid, causing metabolic acidosis in hemorrhagic shock.

Question 6: In the PHTLS model, 'permissive hypotension' targets a systolic BP of approximately how much in penetrating trauma without TBI?

60–70 mmHg
80–90 mmHg (Correct answer)
100–110 mmHg
120 mmHg

Correct answer: 80–90 mmHg

Permissive hypotension targets a systolic BP of 80–90 mmHg to maintain cerebral perfusion while avoiding dilution of clotting factors and clot disruption.

Question 7: Which finding is the EARLIEST clinical indicator of hemorrhagic shock in an otherwise healthy adult?

Hypotension
Tachycardia (Correct answer)
Altered mental status
Decreased pulse pressure

Correct answer: Tachycardia

Tachycardia is the earliest compensatory response as the body attempts to maintain cardiac output despite falling blood volume.

Question 8: Tranexamic acid (TXA) is most effective when administered within what time frame after traumatic injury?

Within 30 minutes
Within 1 hour
Within 3 hours (Correct answer)
Within 6 hours

Correct answer: Within 3 hours

The CRASH-2 trial demonstrated TXA is most effective when given within 3 hours of injury; after this window it may increase mortality.

Question 9: A patient has an arterial bleed from the axilla that cannot be controlled with a standard tourniquet. What is the BEST hemorrhage control option?

Pack the wound with hemostatic gauze and apply direct pressure (Correct answer)
Apply a second tourniquet distally
Elevate the extremity above the level of the heart
Wrap the entire torso with an abdominal binder

Correct answer: Pack the wound with hemostatic gauze and apply direct pressure

Junctional wounds like the axilla cannot be controlled with a standard tourniquet, so wound packing with hemostatic gauze and sustained direct pressure is the appropriate technique.

Question 10: What is the primary mechanism by which hypothermia worsens hemorrhagic shock?

It increases cardiac output
It impairs coagulation enzyme function (Correct answer)
It causes vasodilation
It increases red blood cell production

Correct answer: It impairs coagulation enzyme function

Clotting enzymes are temperature-dependent; hypothermia slows their activity, impairing coagulation and worsening the lethal triad.

Question 11: Which component of Damage Control Resuscitation (DCR) directly addresses dilutional coagulopathy?

Early surgical hemorrhage control
High-ratio packed red blood cells to FFP (Correct answer)
Large-volume crystalloid infusion
Permissive normotension

Correct answer: High-ratio packed red blood cells to FFP

DCR uses a balanced 1:1:1 ratio of PRBCs to FFP to platelets to replace all lost blood components and prevent dilutional coagulopathy.

Question 12: A motorcyclist ejected at high speed has distended neck veins, absent breath sounds on the left, and hypotension. After needle decompression fails to improve vitals, what condition should you consider?

Hemorrhagic shock from splenic laceration
Cardiac tamponade (Correct answer)
Massive hemothorax
Neurogenic shock

Correct answer: Cardiac tamponade

Persistent hypotension with distended neck veins after ruling out tension pneumothorax suggests cardiac tamponade (Beck's triad), which requires pericardiocentesis or thoracotomy.

Question 13: In the context of PHTLS, the term 'lethal triad' refers to which combination of conditions?

Hypotension, tachycardia, and altered mental status
Hypothermia, acidosis, and coagulopathy (Correct answer)
Hemorrhage, hypoxia, and hypovolemia
Pain, hypoxia, and hyperthermia

Correct answer: Hypothermia, acidosis, and coagulopathy

The lethal triad of hypothermia, acidosis, and coagulopathy creates a vicious cycle that dramatically increases mortality in trauma patients.

Question 14: When packing a wound for junctional hemorrhage control, approximately how long should direct pressure be maintained after packing?

30 seconds
1 minute
3 minutes (Correct answer)
5 minutes

Correct answer: 3 minutes

PHTLS and TCCC guidelines recommend at least 3 minutes of direct pressure after wound packing to allow clot formation with hemostatic agents.

Question 15: A 45-year-old patient with blunt abdominal trauma presents with rigidity, guarding, and a BP of 90/70. Estimated blood loss is 1.5L. What is the PRIORITY prehospital action?

Establish two large-bore IV lines and infuse 2L of NS
Rapid transport to a trauma center with hemostatic resuscitation (Correct answer)
Apply an abdominal binder and administer morphine for pain
Place a Foley catheter to monitor urine output

Correct answer: Rapid transport to a trauma center with hemostatic resuscitation

Internal abdominal hemorrhage cannot be controlled prehospitally; rapid transport and hemostatic resuscitation are the priorities to minimize time to definitive surgical care.

Question 16: Which physiologic parameter is MOST reliable for detecting early compensated shock in a young, fit trauma patient?

Systolic blood pressure
Heart rate
Shock index (HR/SBP) (Correct answer)
Mean arterial pressure

Correct answer: Shock index (HR/SBP)

The shock index (HR divided by SBP) is more sensitive than either parameter alone in detecting early compensated shock, with values >1.0 indicating significant hemodynamic compromise.

Question 17: A patient has a tourniquet applied to the right thigh. How should time of application be documented?

Verbally communicated to receiving hospital only
Written directly on the tourniquet or patient's skin with the time (Correct answer)
Entered in the patient care report at the end of transport
Estimated based on arrival time at the ED

Correct answer: Written directly on the tourniquet or patient's skin with the time

The time of tourniquet application must be written directly on the tourniquet or patient's forehead/skin to prevent accidental removal and inform definitive care providers of ischemia duration.

Question 18: Which type of shock results from a mismatch between oxygen supply and demand due to cellular inability to utilize oxygen, despite adequate delivery?

Hypovolemic shock
Distributive shock
Obstructive shock
Cellular/metabolic shock (Correct answer)

Correct answer: Cellular/metabolic shock

Cellular or metabolic shock (e.g., from cyanide poisoning) occurs when cells cannot use delivered oxygen, leading to anaerobic metabolism despite normal or high oxygen supply.

Question 19: In neurogenic shock following spinal cord injury, which hemodynamic profile is MOST characteristic?

High BP, low HR, cold extremities
Low BP, tachycardia, diaphoresis
Low BP, bradycardia, warm extremities (Correct answer)
Low BP, bradycardia, cool extremities

Correct answer: Low BP, bradycardia, warm extremities

Neurogenic shock from sympathetic disruption causes vasodilation (warm extremities) and loss of cardiac acceleration (bradycardia) alongside hypotension.

Question 20: A PHTLS provider applies a Combat Application Tourniquet (CAT) to a bleeding arm. Upon reassessment 5 minutes later, the wound is still oozing significantly. What is the MOST appropriate next step?

Remove the tourniquet and apply direct pressure instead
Tighten the windlass until bleeding stops and recheck distal pulse (Correct answer)
Apply a second tourniquet proximal to the first
Pack the wound above the tourniquet with hemostatic gauze

Correct answer: Tighten the windlass until bleeding stops and recheck distal pulse

If a tourniquet is not controlling hemorrhage, it should be tightened further until bleeding stops, as an undertightened tourniquet provides inadequate occlusion and may worsen venous engorgement.

Question 21: What is the primary goal of administering blood products rather than crystalloids in hemorrhagic shock resuscitation?

Lower the viscosity of blood to improve flow
Restore oxygen-carrying capacity and coagulation factors simultaneously (Correct answer)
Rapidly expand intravascular volume with minimal cost
Prevent electrolyte imbalances from large-volume resuscitation

Correct answer: Restore oxygen-carrying capacity and coagulation factors simultaneously

Blood products restore both oxygen-carrying capacity (via RBCs) and coagulation factors (via FFP/platelets), addressing the root causes of hemorrhagic shock without the dilutional effects of crystalloids.

PHTLS Shock and Hemorrhage Control

A trauma patient has a BP of 80/60 mmHg, HR of 128 bpm, and cool, clammy skin.
Which class of hemorrhagic shock does this best represent?

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