PHTLS Thoracic Trauma — Questions and Answers
Question 1: A patient with blunt chest trauma presents with absent breath sounds on the right, tracheal deviation to the left, and JVD. Which condition does this most likely represent?
- Massive hemothorax
- Tension pneumothorax (Correct answer)
- Open pneumothorax
- Cardiac tamponade
Correct answer: Tension pneumothorax
Tension pneumothorax classically presents with absent breath sounds, tracheal deviation away from the affected side, and JVD due to mediastinal shift.
Question 2: During assessment of a chest trauma patient, you note paradoxical chest wall movement over a section of ribs. What minimum number of consecutive rib fractures in two places typically produces this finding?
- 2 ribs in 1 place
- 3 or more ribs in 2 places (Correct answer)
- 1 rib in 2 places
- 4 or more ribs in 1 place
Correct answer: 3 or more ribs in 2 places
A flail segment requires three or more adjacent ribs fractured in at least two places, creating a free-floating segment that moves paradoxically.
Question 3: Which of the following best describes the pathophysiology of paradoxical motion seen in flail chest?
- The flail segment moves inward on inspiration and outward on expiration (Correct answer)
- The flail segment moves outward on inspiration and inward on expiration
- The flail segment remains stationary due to muscle splinting
- The flail segment collapses only during forced expiration
Correct answer: The flail segment moves inward on inspiration and outward on expiration
The flail segment moves paradoxically — inward during inspiration (when pleural pressure drops) and outward during expiration.
Question 4: A construction worker falls from scaffolding and complains of severe chest pain. Palpation reveals crepitus along the left lateral chest wall. Which immediate life threat should be highest on your differential?
- Pulmonary contusion
- Rib fractures with potential hemothorax or pneumothorax (Correct answer)
- Esophageal rupture
- Diaphragmatic tear
Correct answer: Rib fractures with potential hemothorax or pneumothorax
Crepitus over the chest wall indicates rib fractures, which carry significant risk of associated hemothorax or pneumothorax requiring rapid assessment.
Question 5: In prehospital management of a sucking chest wound, after applying a vented chest seal, the patient deteriorates with increasing respiratory distress and decreasing SpO2. What is the next step?
- Apply a second vented seal over the first
- Remove the seal to release potential tension buildup (Correct answer)
- Increase oxygen flow rate
- Perform needle decompression on the opposite side
Correct answer: Remove the seal to release potential tension buildup
If a patient with a vented chest seal deteriorates, the seal should be lifted or removed to relieve a developing tension pneumothorax.
Question 6: Which hemodynamic pattern is most consistent with massive hemothorax in a trauma patient?
- Hypertension, bradycardia, JVD
- Hypotension, tachycardia, absent breath sounds, flat neck veins (Correct answer)
- Hypotension, bradycardia, JVD, muffled heart sounds
- Hypertension, tachycardia, tracheal deviation
Correct answer: Hypotension, tachycardia, absent breath sounds, flat neck veins
Massive hemothorax presents with hemorrhagic shock signs (hypotension, tachycardia) and absent breath sounds on the affected side, with flat neck veins from blood loss.
Question 7: Which anatomic structure is at greatest risk of injury in a deceleration mechanism causing thoracic aortic disruption?
- Ascending aorta at the aortic valve
- Aortic isthmus just distal to the left subclavian artery (Correct answer)
- Descending thoracic aorta at the diaphragm
- Aortic arch between the brachiocephalic vessels
Correct answer: Aortic isthmus just distal to the left subclavian artery
The aortic isthmus, fixed by the ligamentum arteriosum just distal to the left subclavian, is the most common site of traumatic aortic disruption due to shear forces.
Question 8: A trauma patient has muffled heart sounds, hypotension, and distended neck veins after a stab wound to the chest. Which intervention is indicated in the prehospital setting for suspected cardiac tamponade?
- Immediate needle thoracostomy bilaterally
- Rapid transport with IV access and fluid resuscitation en route (Correct answer)
- Pericardiocentesis on scene
- Application of a chest seal over the wound
Correct answer: Rapid transport with IV access and fluid resuscitation en route
Prehospital management of cardiac tamponade is rapid transport with IV fluid support; pericardiocentesis is a hospital-level intervention.
Question 9: A 45-year-old restrained driver involved in a high-speed MVC has chest pain and shortening of breath. ECG shows sinus tachycardia with frequent PVCs. Lung sounds are clear bilaterally. What should you suspect?
- Tension pneumothorax
- Myocardial contusion (Correct answer)
- Aortic disruption
- Pulmonary embolism
Correct answer: Myocardial contusion
Blunt cardiac injury (myocardial contusion) commonly presents with dysrhythmias after significant chest wall impact and should be suspected with sternal or significant anterior chest trauma.
Question 10: When performing needle thoracostomy for suspected tension pneumothorax, what is the preferred anatomic landmark using the anterior approach?
- 2nd intercostal space, midclavicular line, inferior rib border
- 4th intercostal space, anterior axillary line
- 2nd intercostal space, midclavicular line, superior border of the 3rd rib (Correct answer)
- 5th intercostal space, midaxillary line
Correct answer: 2nd intercostal space, midclavicular line, superior border of the 3rd rib
The needle is inserted at the 2nd ICS midclavicular line over the superior border of the 3rd rib to avoid the neurovascular bundle running beneath each rib.
Question 11: Following needle decompression for tension pneumothorax, a rush of air is heard but the patient does not improve clinically. What is the most likely explanation?
- Diagnosis was incorrect; consider hemothorax
- Needle was too short to reach the pleural space (Correct answer)
- The patient has bilateral tension pneumothorax
- A second needle decompression is never indicated
Correct answer: Needle was too short to reach the pleural space
A needle that is too short may not penetrate the pleural space in patients with a thick chest wall, resulting in failure of decompression despite air sound from subcutaneous tissue.
Question 12: A patient with multiple rib fractures is breathing at 28 breaths/min and is hypoxic. High-flow oxygen is applied. What additional prehospital intervention most directly addresses ventilatory failure from flail chest?
- External chest wall stabilization with sandbags
- Positive pressure ventilation via BVM (Correct answer)
- Placing the patient on the unaffected side
- Tight circumferential bandaging of the chest
Correct answer: Positive pressure ventilation via BVM
Positive pressure ventilation internally splints the flail segment and supports ventilation, directly addressing the underlying mechanism of failure.
Question 13: Which of the following injuries is most likely to cause immediate exsanguination and death before hospital arrival in thoracic trauma?
- Simple pneumothorax
- Tension pneumothorax
- Traumatic aortic disruption with full transection (Correct answer)
- Pulmonary contusion
Correct answer: Traumatic aortic disruption with full transection
Complete transection of the thoracic aorta causes massive hemorrhage and is nearly universally fatal at the scene; survivors typically have a contained pseudoaneurysm.
Question 14: A 30-year-old motorcyclist has a penetrating chest wound that produces a loud sucking noise with each breath. After sealing the wound, what should be monitored to detect a developing complication?
- Level of consciousness only
- Signs of tension pneumothorax: worsening dyspnea, absent breath sounds, hypotension (Correct answer)
- Core body temperature
- Skin color at the wound margins
Correct answer: Signs of tension pneumothorax: worsening dyspnea, absent breath sounds, hypotension
After sealing an open pneumothorax, continued monitoring for tension pneumothorax is essential as the seal can trap air and convert a simple to a tension pneumothorax.
Question 15: A trauma patient has no breath sounds on the left after intubation. The most immediate action is to:
- Order a chest X-ray
- Withdraw the ETT 2 cm and reassess breath sounds (Correct answer)
- Perform bilateral needle decompression
- Increase ventilator tidal volume
Correct answer: Withdraw the ETT 2 cm and reassess breath sounds
Absent unilateral breath sounds after intubation most commonly indicate right mainstem intubation; withdrawing the ETT slightly and reassessing is the first corrective action.
Question 16: Which of the following best explains why pulmonary contusion causes hypoxemia?
- Alveolar collapse from surfactant destruction increases dead space
- Hemorrhage into alveoli creates an intrapulmonary shunt (Correct answer)
- Bronchospasm reduces oxygen delivery to alveoli
- Pleural fluid compresses adjacent lung tissue
Correct answer: Hemorrhage into alveoli creates an intrapulmonary shunt
Blood-filled alveoli are perfused but not ventilated, creating an intrapulmonary shunt that results in hypoxemia refractory to supplemental oxygen.
Question 17: In the PHTLS approach, which of the following thoracic injuries is managed primarily by rapid transport rather than scene intervention?
- Open pneumothorax
- Tension pneumothorax
- Cardiac tamponade (Correct answer)
- Simple pneumothorax with hemodynamic compromise
Correct answer: Cardiac tamponade
Cardiac tamponade requires pericardiocentesis or surgical drainage, which are hospital-level interventions; prehospital care focuses on rapid transport and supportive care.
Question 18: A 55-year-old is ejected from a vehicle and presents with subcutaneous emphysema across the entire chest and neck. What thoracic injury should be highest on the differential?
- Esophageal perforation only
- Tracheobronchial injury (Correct answer)
- Myocardial contusion
- Diaphragmatic rupture
Correct answer: Tracheobronchial injury
Widespread subcutaneous emphysema following blunt thoracic trauma is a hallmark of tracheobronchial disruption, allowing large volumes of air to escape into soft tissues.
Question 19: Which of the following is the most reliable clinical sign distinguishing tension pneumothorax from massive hemothorax in the field?
- Degree of respiratory distress
- Tracheal deviation and neck vein status (Correct answer)
- Oxygen saturation reading
- Skin color and capillary refill
Correct answer: Tracheal deviation and neck vein status
Tension pneumothorax causes JVD and tracheal deviation from increased intrathoracic pressure, while massive hemothorax produces flat neck veins due to hemorrhagic shock.
Question 20: According to PHTLS principles, what is the primary indication for performing needle decompression in the prehospital environment?
- Unilateral absent breath sounds alone
- Clinical suspicion of tension pneumothorax with hemodynamic instability (Correct answer)
- Any penetrating chest trauma with dyspnea
- Oxygen saturation below 94% in a chest trauma patient
Correct answer: Clinical suspicion of tension pneumothorax with hemodynamic instability
PHTLS indicates needle decompression when tension pneumothorax is clinically suspected with hemodynamic compromise; absent sounds alone are insufficient in the field.
Question 21: A trauma patient with known left-sided rib fractures deteriorates 20 minutes after hospital departure. Breath sounds are suddenly absent on the right. What is the most likely explanation?
- Right-sided tension pneumothorax from unsuspected contralateral injury (Correct answer)
- ETT has migrated into the left mainstem bronchus
- Patient has developed a tension pneumothorax on the injured left side
- Increased secretions are occluding the right bronchus
Correct answer: Right-sided tension pneumothorax from unsuspected contralateral injury
Delayed tension pneumothorax on the contralateral (right) side is possible from previously unrecognized injury; reassess both sides whenever a patient deteriorates.
PHTLS Thoracic Trauma
A patient with blunt chest trauma presents with absent breath sounds on the right, tracheal deviation to the left, and JVD.
Which condition does this most likely represent?
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