PHTLS Thoracic Trauma 4 — Questions and Answers
Question 1: 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 2: 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 3: 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 4: 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 5: 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 6: 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 7: 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 4
A trauma patient has no breath sounds on the left after intubation.
The most immediate action is to: