PHTLS Thoracic Trauma 3 — Questions and Answers
Question 1: 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 2: 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 3: 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 4: 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 5: 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 6: 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 7: 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.
PHTLS Thoracic Trauma 3
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?