PHTLS Thoracic Trauma 5 — Questions and Answers
Question 1: A restrained passenger has blunt chest trauma from the steering wheel and complains of pain worsening with swallowing. Which injury should this symptom prompt you to consider?
- Sternal fracture
- Esophageal rupture (Correct answer)
- Pulmonary contusion
- Diaphragmatic injury
Correct answer: Esophageal rupture
Pain on swallowing (odynophagia) following blunt chest trauma should raise suspicion for esophageal injury, which can lead to life-threatening mediastinitis.
Question 2: Which mechanism of injury is most commonly associated with traumatic diaphragmatic rupture?
- Penetrating stab wound to the upper abdomen or lower chest
- High-speed MVC with lap-belt use causing blunt abdominal compression
- Fall from height with direct impact to the lower chest
- All of the above are associated mechanisms (Correct answer)
Correct answer: All of the above are associated mechanisms
Traumatic diaphragmatic rupture occurs with both penetrating injuries to the thoracoabdominal region and blunt compression mechanisms, so all listed mechanisms are relevant.
Question 3: In managing a patient with suspected massive hemothorax, which fluid resuscitation strategy aligns with current PHTLS hemorrhagic shock guidelines?
- Aggressive crystalloid infusion to normalize systolic BP to 120 mmHg
- Permissive hypotension targeting SBP 80–90 mmHg until surgical hemorrhage control (Correct answer)
- No IV access until arrival at the ED
- Immediate 2L normal saline bolus before transport begins
Correct answer: Permissive hypotension targeting SBP 80–90 mmHg until surgical hemorrhage control
PHTLS supports hypotensive resuscitation (SBP 80–90 mmHg) in hemorrhagic shock from thoracic injury to avoid dilution coagulopathy and clot disruption before surgical control.
Question 4: A patient with a stab wound to zone III of the thorax (below the nipple line anteriorly / below the scapular tip posteriorly) should be evaluated for which additional injury?
- Brachial plexus injury
- Intra-abdominal organ injury (Correct answer)
- Spinal cord injury above T4
- Great vessel injury in the superior mediastinum
Correct answer: Intra-abdominal organ injury
The lower thoracic zone overlaps with the upper abdomen; penetrating injuries here can injure intra-abdominal organs such as the liver, spleen, and stomach.
Question 5: Which of the following correctly describes the physiologic reason why tension pneumothorax reduces cardiac output?
- Direct myocardial compression by the expanding lung
- Mediastinal shift kinks the great veins, reducing venous return to the heart (Correct answer)
- Hypoxia causes coronary artery spasm reducing contractility
- High intrathoracic pressure increases left ventricular afterload
Correct answer: Mediastinal shift kinks the great veins, reducing venous return to the heart
Mediastinal shift from a tension pneumothorax compresses and kinks the superior and inferior vena cava, dramatically reducing venous return and causing obstructive shock.
Question 6: A patient with multiple bilateral rib fractures requires positive pressure ventilation. Which complication are you most vigilant about when applying PPV in this scenario?
- Worsening of the flail segment paradoxical motion
- Conversion of a simple pneumothorax to a tension pneumothorax (Correct answer)
- Increased risk of air embolism through rib fracture sites
- Immediate gastric distension causing diaphragm elevation
Correct answer: Conversion of a simple pneumothorax to a tension pneumothorax
Positive pressure ventilation can convert an undetected simple pneumothorax into a tension pneumothorax by forcing air into the pleural space through a lung laceration.
Question 7: Which of the following findings on scene assessment would lead you to classify a thoracic trauma as immediately life-threatening requiring intervention before transport?
- Isolated rib pain with intact breath sounds bilaterally
- Open chest wound with audible air movement through the wound (Correct answer)
- Bruising over the sternum with normal SpO2 and stable vitals
- Complaint of chest tightness without objective findings
Correct answer: Open chest wound with audible air movement through the wound
An open pneumothorax (sucking chest wound) allows air to preferentially enter the pleural space and requires immediate occlusion with a vented chest seal before transport.
PHTLS Thoracic Trauma 5
A restrained passenger has blunt chest trauma from the steering wheel and complains of pain worsening with swallowing.
Which injury should this symptom prompt you to consider?