PHTLS Special Trauma Considerations — Questions and Answers
Question 1: A pregnant trauma patient is in her 30th week of gestation. Which of the following positions is most appropriate during transport to minimize supine hypotension syndrome?
- Supine with legs elevated 30 degrees
- Left lateral tilt of 15-30 degrees (Correct answer)
- Right lateral decubitus position
- Trendelenburg position
Correct answer: Left lateral tilt of 15-30 degrees
Left lateral tilt of 15-30 degrees relieves uterine compression of the inferior vena cava, improving venous return and cardiac output.
Question 2: When assessing a pediatric trauma patient, which anatomical feature makes airway management more challenging compared to adults?
- Smaller tongue relative to oral cavity
- More anterior and superior larynx (Correct answer)
- Longer trachea with greater diameter
- Harder, more rigid tracheal cartilage
Correct answer: More anterior and superior larynx
The pediatric larynx is positioned more anteriorly and superiorly (at C3-C4 vs. C5-C6 in adults), making visualization during intubation more difficult.
Question 3: An elderly patient involved in a low-speed motor vehicle collision presents with altered mental status and a subdural hematoma on CT. Which age-related factor most increases this patient's susceptibility to intracranial injury?
- Decreased cardiac output reducing cerebral perfusion
- Brain atrophy with stretching of bridging veins (Correct answer)
- Reduced platelet count from bone marrow suppression
- Calcification of the dura mater
Correct answer: Brain atrophy with stretching of bridging veins
Age-related brain atrophy stretches bridging veins across a wider subdural space, making them more vulnerable to tearing even with minor trauma.
Question 4: A morbidly obese trauma patient requires needle thoracostomy for suspected tension pneumothorax. Which modification to the standard technique is most important?
- Use a shorter needle to avoid lung puncture
- Insert the needle at the 5th intercostal space mid-axillary line only
- Use a longer needle or catheter to penetrate the thicker chest wall (Correct answer)
- Avoid the procedure entirely and proceed directly to finger thoracostomy
Correct answer: Use a longer needle or catheter to penetrate the thicker chest wall
Chest wall thickness in obese patients may require a longer needle (≥8 cm) or catheter to successfully reach the pleural space.
Question 5: Which of the following best describes the primary physiological concern when managing a geriatric patient who takes beta-blockers and suffers significant hemorrhage?
- Exaggerated hypertensive response masking true volume status
- Inability to mount a compensatory tachycardia, masking shock severity (Correct answer)
- Accelerated coagulation cascade leading to DIC
- Increased sensitivity to opioid analgesics causing respiratory depression
Correct answer: Inability to mount a compensatory tachycardia, masking shock severity
Beta-blockers blunt the heart rate response to hemorrhage, so the absence of tachycardia does not rule out significant blood loss in these patients.
Question 6: A 7-year-old child is struck by a vehicle and sustains abdominal trauma. The PHTLS provider notes a visible seatbelt mark across the abdomen. Which injury pattern should be highly suspected?
- Splenic laceration and rib fractures
- Chance fracture and hollow viscus injury (Correct answer)
- Liver contusion and diaphragmatic rupture
- Pelvic ring disruption and bladder injury
Correct answer: Chance fracture and hollow viscus injury
The seatbelt sign in children is strongly associated with Chance fractures (flexion-distraction spinal injury) and hollow viscus injuries due to lap-belt mechanics.
Question 7: During a mass casualty incident involving pediatric patients, which triage tool is specifically designed and validated for use in children?
- START triage
- SALT triage
- JumpSTART triage (Correct answer)
- CESIRA triage
Correct answer: JumpSTART triage
JumpSTART was developed specifically for pediatric patients and modifies the START algorithm to account for children's different respiratory rates and inability to follow commands.
Question 8: A trauma patient is found to be 8 months pregnant and has no palpable pulse after blunt chest trauma. After 4 minutes of unsuccessful resuscitation, the most appropriate next step is:
- Continue CPR and rapid transport only
- Perform field cesarean delivery to improve maternal CPR effectiveness (Correct answer)
- Administer high-dose epinephrine and reassess in 2 minutes
- Initiate immediate transport while performing bilateral needle thoracostomy
Correct answer: Perform field cesarean delivery to improve maternal CPR effectiveness
Perimortem cesarean delivery (resuscitative hysterotomy) performed within 4-5 minutes of cardiac arrest can relieve aortocaval compression and improve maternal CPR outcomes.
Question 9: Which of the following best explains why children are at higher risk for hypothermia following trauma compared to adults?
- Children have a lower metabolic rate and produce less heat
- Children have a greater surface area-to-body mass ratio (Correct answer)
- Children's peripheral vasculature is more dilated at baseline
- Children have thicker subcutaneous fat insulating core organs
Correct answer: Children have a greater surface area-to-body mass ratio
Children's larger surface area relative to their body mass results in more rapid heat loss to the environment after trauma.
Question 10: An intoxicated trauma patient has a GCS of 12. The PHTLS provider should:
- Attribute all neurological findings to alcohol intoxication and monitor
- Assume a concurrent traumatic brain injury until proven otherwise (Correct answer)
- Administer naloxone to reverse potential opioid co-ingestion before assessment
- Delay spinal motion restriction until the patient sobers
Correct answer: Assume a concurrent traumatic brain injury until proven otherwise
Alcohol intoxication and TBI present similarly; providers must assume TBI in any intoxicated trauma patient to avoid undertreating a potentially life-threatening injury.
Question 11: When managing an obese trauma patient, which assessment finding is most likely to be UNDERESTIMATED due to body habitus?
- Respiratory rate
- Pupillary response
- Severity of abdominal tenderness and rigidity (Correct answer)
- Blood pressure by auscultation
Correct answer: Severity of abdominal tenderness and rigidity
Thick abdominal adipose tissue can mask peritoneal signs, leading to underestimation of intra-abdominal injury severity on physical exam.
Question 12: A trauma patient who is a Jehovah's Witness declines blood transfusion. The patient is conscious, alert, and has decision-making capacity. The PHTLS provider should:
- Override the refusal and administer blood given the life threat
- Document the refusal, focus on volume-sparing hemorrhage control, and transport (Correct answer)
- Administer blood only after obtaining family consent
- Delay transport until law enforcement can authorize treatment
Correct answer: Document the refusal, focus on volume-sparing hemorrhage control, and transport
A competent adult has the right to refuse treatment; the provider should respect this, document it thoroughly, optimize hemorrhage control without blood products, and transport.
Question 13: Which of the following physiological changes in pregnancy most significantly affects fluid resuscitation decisions in a trauma patient?
- Decreased maternal heart rate of 10-15 bpm
- Plasma volume increase of 40-50% with relative hemodilution (Correct answer)
- Reduced renal blood flow causing decreased urine output
- Increased systemic vascular resistance elevating blood pressure
Correct answer: Plasma volume increase of 40-50% with relative hemodilution
Plasma volume expands 40-50% during pregnancy while red cell mass increases only 20-30%, causing dilutional anemia that may mask hemorrhage severity.
Question 14: A geriatric patient on warfarin sustains a head injury with a brief loss of consciousness. CT is negative initially. The PHTLS provider should advise the receiving team that this patient:
- Requires no further neurological monitoring given negative CT
- Is at low risk for delayed intracranial hemorrhage due to anticoagulation
- Needs close observation for delayed hemorrhage despite normal initial imaging (Correct answer)
- Should receive fresh frozen plasma prophylactically in the field
Correct answer: Needs close observation for delayed hemorrhage despite normal initial imaging
Anticoagulated patients can develop delayed intracranial hemorrhage hours after injury even with an initially normal CT, requiring prolonged observation.
Question 15: A child with an isolated femur fracture is found to have bruising in multiple stages of healing across the body. What is the most appropriate PHTLS provider action?
- Treat only the acute injury and transport without documentation of findings
- Document all findings objectively and report suspicion of non-accidental trauma per protocol (Correct answer)
- Confront the caregivers about suspected abuse before transport
- Defer reporting until the emergency department physician confirms abuse
Correct answer: Document all findings objectively and report suspicion of non-accidental trauma per protocol
Prehospital providers are mandated reporters; objective documentation and notification per local protocol is required when non-accidental trauma is suspected.
Question 16: When using the Broselow tape to guide pediatric trauma care, what does the tape primarily determine?
- Injury severity score based on mechanism
- Weight-based drug dosing and equipment sizing by body length (Correct answer)
- Age-specific vital sign norms for triage classification
- Predicted blood volume based on height and weight
Correct answer: Weight-based drug dosing and equipment sizing by body length
The Broselow tape correlates body length with estimated weight to guide weight-based drug dosing and appropriate equipment sizes in pediatric emergencies.
Question 17: An elderly patient with a hip fracture following a ground-level fall is in significant pain. Regarding pain management, the PHTLS principle is:
- Withhold all analgesia to preserve accurate neurological assessment
- Provide appropriate analgesia while monitoring for respiratory depression (Correct answer)
- Avoid opioids entirely in the elderly due to absolute contraindication
- Defer pain management to the hospital to avoid masking injury severity
Correct answer: Provide appropriate analgesia while monitoring for respiratory depression
PHTLS supports humane pain management for trauma patients, with careful dose titration and monitoring in the elderly who may be more sensitive to opioids.
Question 18: During assessment of a bariatric trauma patient, pulse oximetry readings may be unreliable due to:
- Elevated hemoglobin levels from chronic hypoxia
- Poor peripheral perfusion and probe placement difficulties on thick digits (Correct answer)
- Interference from excess subcutaneous fat with signal transmission
- Increased respiratory rate producing motion artifact
Correct answer: Poor peripheral perfusion and probe placement difficulties on thick digits
In obese patients, poor peripheral perfusion and difficulty obtaining a reliable probe fit can reduce pulse oximetry accuracy.
Question 19: A 32-week pregnant trauma patient presents with vaginal bleeding and uterine rigidity after a motor vehicle collision. Which condition should be immediately suspected?
- Placenta previa from cervical dilation
- Placental abruption from direct or deceleration forces (Correct answer)
- Uterine rupture from pre-existing scar only
- Normal Braxton-Hicks contractions exacerbated by stress
Correct answer: Placental abruption from direct or deceleration forces
Placental abruption is the most common cause of fetal death in blunt abdominal trauma and presents with uterine rigidity, pain, and vaginal bleeding.
Question 20: Which of the following is TRUE regarding spinal motion restriction in elderly trauma patients with suspected cervical spine injury?
- Hard collars are always preferred over soft alternatives in elderly patients
- Kyphotic deformity may require padding modifications to maintain neutral alignment (Correct answer)
- The elderly tolerate full spinal immobilization better due to reduced range of motion
- Spinal motion restriction is contraindicated in patients over 65 years of age
Correct answer: Kyphotic deformity may require padding modifications to maintain neutral alignment
Pre-existing cervical kyphosis may require void-filling padding behind the head to maintain the patient's anatomical neutral position rather than forcing hyperextension.
Question 21: In pediatric trauma, the most common mechanism causing significant head injury without external skull fracture is:
- Direct penetrating trauma from sharp objects
- Acceleration-deceleration forces causing diffuse axonal injury (Correct answer)
- Depressed skull fractures from falls on hard surfaces
- Basilar skull fractures from lateral impact forces
Correct answer: Acceleration-deceleration forces causing diffuse axonal injury
The child's pliable skull can transmit significant acceleration-deceleration forces to brain parenchyma, causing diffuse axonal injury without fracture.
PHTLS Special Trauma Considerations
A pregnant trauma patient is in her 30th week of gestation.
Which of the following positions is most appropriate during transport to minimize supine hypotension syndrome?
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