Thoracic Trauma

You have arrived on the scene of a paramedic who was shot as she approached a residence on a call. The scene has since been secured. Your patient is a 38-year-old female with one gunshot wound to the left side of the chest at the fifth intercostal space in the midaxillary line. She is pale, cool, and awake but agitated. She is diaphoretic and complaining of pain in her left side and difficulty breathing. The patient's EMT partner has applied oxygen by nonrebreathing mask and an occlusive dressing over the entry wound before your arrival. As you continue your assessment, the patient's level of consciousness decreases. She responds to verbal stimuli. Her airway is clear, her respiratory rate is 38 per minute and shallow, her neck veins are flat, and her breath sounds are absent on the left side. The patient lacks a radial pulse, and the abdomen is nonguarded and nontender. Which of the following should you do first? a. Assist ventilations with a bag-valve-mask device b. Start a large-bore IV of isotonic crystalloid solution c. Do an immediate needle chest decompression d. Do a rapid trauma assessment

a. Assist ventilations with a bag-valve-mask device

Your patient is a 15-year-old male who was struck in the chest with a baseball. He is unresponsive, pulseless, and apneic. The monitor shows ventricular fibrillation. This condition is most accurately described as: a. Commotio cordis b. Pericardial tamponade c. Blunt cardiac injury d. Traumatic asphyxia

a. Commotio cordis

Which of the following is the correct description of a wound that is below the fifth rib, directly in line with the armpit? a. Fifth intercostal space, midaxillary line b. Sixth intercostal space, midclavicular c. Sixth intercostal space, midaxillary line d. Fifth intercostal space, midclavicular line

a. Fifth intercostal space, midaxillary line

Which of the following is the primary prehospital concern with a simple, isolated fracture of the fifth rib in the right posterior-axillary line? a. Hypoventilation b. Pneumonia c. Liver contusion d. Hemorrhage

a. Hypoventilation

Which of the following guidelines applies to prehospital fluid resuscitation of hypotensive patients with intraabdominal hemorrhage? a. In most cases fluid administration should be limited to 3 liters. b. IV access should be obtained using a salien lock, but fluid resuscitation is contraindicated in the prehospital setting c. Fluid administration rate should be titrated to maintina systlic blood pressure of 60 mmHg. d. IV access is only necessary if the use of PASG fails to improve the patient's clinical condition.

a. In most cases fluid administration should be limited to 3 liters.

Your patient is an 80-year-old female who fracture a vertebrae while coughing. This type of fracture is best described as a(n) ________ fracture a. Pathological b. Greenstick c. Epiphyseal d. Communicated

a. Pathological

An individual is struck in the left ventricle with a high-velocity projectile. As compared to low-velocity penetrating trauma, you should have a higher index of suspicion for: a. Pericardial tamponade b. Ventricular rupture c. Blunt cardiac injury d. Simple penetrating injury

a. Pericardial tamponade

Which of the following is a complication of positive-pressure ventilation in the patient with significant chest trauma? a. Reduced cardiac output b. Pulmonary contusion c. Atelectasis d. Exacerbation of flail chest

a. Reduced cardiac output

You have just inserted a large-bore catheter into the chest of a patient with a tension pneumothorax and received a return of air. Which of the following should NOT be done? a. Remove the catheter. b. Leave the catheter in place, and create a flutter valve. c. Leave the catheter in place and open to air. d. Insert a second, or even a third, catheter if the patient is symptomatic, despite the release of air.

a. Remove the catheter.

Which of the following is TRUE of pulmonary contusion? a. Signs and symptoms generally develop gradually. b. The primary pathophysiology is that the alveoli are filled with blood. c. Pulmonary contusion is typically an isolated injury. d. Pulmonary contusion results in paradoxical motion of the chest wall.

a. Signs and symptoms generally develop gradually.

Which of the following statements is NOT true of pericardial tamponade? a. The systolic blood pressure increases significantly on inspiration. b. It is most often associated with penetrating trauma. c. As little as 150 ml of blood can cause pericardial tamponade. d. The pathophysiology results in increased venous pressure and decreased cardiac output.

a. The systolic blood pressure increases significantly on inspiration.

Which of the following are the most commonly fractured ribs? a. 5 to 10 b. 4 to 8 c. 1 to 3 d. 7 to 12

b. 4 to 8

On maximal expiration the diaphragm may be: a. As low as the ninth intercostal space anteriorly b. As high as the fourth intercostal space anteriorly c. As low as the eleventh intercostal space anteriorly d. As high as the second intercostal space anteriorly

b. As high as the fourth intercostal space anteriorly

Which of the following is NOT part of the prehospital examination or the patient with suspectedabdominal trauma? a. Asking the patient about abdominal pain first, then palpating the abdomen in all four quadrants b. Auscultating bowel sounds c. Checking for stability of the pelvis d. Assessment of the thorax for injury

b. Auscultating bowel sounds

Which of the following statements concerning blunt thoracic trauma in the pediatric population is most accurate? a. Children are less likely than adults to suffer either rib fractures or organ injury. b. Children are less likely than adults to suffer rib fractures but more likely to have significant organ injury. c. Children are more likely than adults to suffer both rib fracture and organ injury. d. Children are more likely than adults to suffer rib fractures but less likely to suffer significant organ injury.

b. Children are less likely than adults to suffer rib fractures but more likely to have significant organ injury.

Traumatic asphyxia is a(n) ________ type of injury. a. Acceleration b. Compression c. Deceleration d. Decompression

b. Compression

Which of the following best describes the threat to life associated with traumatic rupture of the esophagus? a. Hypoxia b. Entry of gastric contents into the mediastinum c. Massive hemorrhage d. Decreased cardiac output

b. Entry of gastric contents into the mediastinum

Which of the following occurs during the onset of inspiration? a. Intrathoracic pressure increases and venous return to the heart is facilitated. b. Intrathoracic pressure decreases and venous return to the heart is facilitated. c. Intrathoracic pressure increases and venous return to the heart is impeded. d. Intrathoracic pressure decreases and venous return to the heart is impeded.

b. Intrathoracic pressure decreases and venous return to the heart is facilitated.

Which of the following is LEAST likely to be a sign of an open pneumothorax? a. Large, open thoracic wound. b. Jugular vein distention c. Frothy blood around the opening d. Dyspnea

b. Jugular vein distention

The central area in the thorax that contains the heart, great vessels, trachea, and esophagus is the: a. Pulmonary hilum b. Mediastinum c. Carina d. Hemothorax

b. Mediastinum

Which of the following has the greatest likelihood of resulting in an open pneumothorax? a. Open defects that are one-quarter the size of the trachea or larger b. Open defects that are two-thirds the size of the trachea or larger c. Any opening between the pleural cavity and the atmosphere d. Open defects that are larger in diameter than the trachea

b. Open defects that are two-thirds the size of the trachea or larger

Your patient is a 27-year-old male with one stab wound at the fifth intercostal space posteriorly, on the right. He is ambulatory at the scene but dyspneic and has air movement at the site of the injury. Which of the following should you do first? a. Cover the wound with your gloved hand. b. Prepare an occlusive dressing. c. Perform a needle thoracostomy. d. Apply oxygen by nonrebreather.

b. Prepare an occlusive dressing.

The angle of Louis serves as a landmark for performing needle thoracostomy at which of the following locations? a. Fourth intercostal space laterally b. Second intercostal space anteriorly c. Second intercostal space laterally d. Fourth intercostal space anteriorly

b. Second intercostal space anteriorly

Your patient is a 38-year-old male who was pinned beneath the frame of a vehicle when it slipped off the makeshift jacks he was using to elevate it. The patient's brother thinks he may have been trapped for up to 20 minutes. The rescue unit is preparing to use airbags to lift the vehicle off the patient. Which of the following medications could you consider giving this patient? a. Potassium chloride b. Sodium bicarbonate c. Magnesium sulfate d. Calcium chloride

b. Sodium bicarbonate

Your patient is a 38-year-old male who was pinned beneath the frame of a vehicle when it slipped off the makeshift jacks he was using to elevate it. The patient's brother thinks he may have been trapped for up to 20 minutes. The rescue unit is preparing to use airbags to lift the vehicle off the patient. Which of the following medications could you consider giving this patient? Select one: a. Magnesium sulfate b. Sodium bicarbonate c. Potassium chloride d. Calcium chloride

b. Sodium bicarbonate

Your patient received a blow to the left lateral chest at the level of the sixth and seventh ribs. You should suspect fractures at: Select one: a. The point of impact on both ribs b. The point of impact and the posterior axillary line of both ribs c. The point of impact of the sixth rib only d. The point of impact and the posterior axillary line of the sixth rib only

b. The point of impact and the posterior axillary line of both ribs

Thoracic trauma accounts for approximately ________ percent of mortality from trauma? a. 45 to 50 b. 75 to 80 c. 20 to 25 d. 10 to 15

c. 20 to 25

The trachea divides into the right and left mainstem bronchi at the: a. Hilum b. Thoracic inlet c. Carina d. Lingual

c. Carina

Which of the following best describes the mechanism of blunt thoracic trauma associated with blast injuries? a. Compression and decompression b. Compression c. Deceleration d. Acceleration

c. Deceleration

Abdominal trauma should be suspected with penetrating thoracic wounds below the ________ rib anteriorly and the ________ rib posteriorly. a. Second, tenth b. Second, fifth c. Fourth, sixth d. Fourth, ninth

c. Fourth, sixth

The finding of jugular venous distension in the patient with thoracic trauma is LEAST likely to be associated with which of the following? a. Pericardial tamponade b. Tension pneumothorax c. Hemothorax d. Traumatic asphyxia

c. Hemothorax

Your patient is a 24-year-old male who was struck just below the left scapula with a 3-inch-diameter metal pipe. He is awake but having difficulty breathing. His pulse is 112 at the radial artery, and his respiratory rate is 28 per minute and shallow. His breath sounds are present bilaterally but diminished on the left. He has a blood pressure of 108/68. The patient is coughing up some bloody sputum. He has no other complaints, and a rapid trauma survey reveals no additional life-threatening injuries. Which of the following represents the best sequence of intervention for this patient? a. Begin transport immediately, positive pressure ventilation, a large-bore IV of isotonic solution to maintain a systolic blood pressure of 120 mmHg or greater b. Positive-pressure ventilation, a large-bore IV of normal saline solution at a keep-open rate, transport c. High-concentration oxygen by nonrebreathing mask, begin transport, a 16-gauge IV at a keep-open rate d. High-concentration oxygen by nonrebreathing mask, begin transport, two 14-gauge IVs of 50 percent dextrose solution wide open

c. High-concentration oxygen by nonrebreathing mask, begin transport, a 16-gauge IV at a keep-open rate

The location of the neurovascular bundles containing the intercostal arteries is best described as the bundle that runs along the: a. Intercostal space equally distant from both associated ribs b. Posterior surface of the associated rib c. Inferior margin of the associated rib d. Superior margin of the associated rib

c. Inferior margin of the associated rib

Your patient is an 80-year-old male who was the unrestrained driver of a vehicle without airbags that was involved in a frontal collision with a parked car. Your assessment reveals that he is dyspneic, tachypneic, and tachycardic. He is awake but unable to respond to questions. There are no obvious signs of injury to the head or neck. The patient has paradoxical movement of the sternum with breathing, along with crepitus and subcutaneous air noted on palpation. Chest excursion is limited, and the patient has cyanosis of his lips, ears, and nail beds. Which of the following is MOST needed in this patient? a. Being placed in a prone position to stabilize the chest wall b. Application of bulky dressings over the site of paradoxical motion c. Intubation and positive-pressure ventilation d. Infusion of isotonic crystalloid solution using a large-bore IV

c. Intubation and positive-pressure ventilation

Which of the following most accurately characterizes simple pneumothorax? a. Untreated, it will lead to mediastinal shift and compression of the contralateral lung. b. It results from the creation of a one-way valve that continues to allow air into, but not out of, the pleural cavity. c. It is a problem of ventilation/perfusion mismatch. d. It results from air entering the pleural cavity through a defect in the chest wall.

c. It is a problem of ventilation/perfusion mismatch.

Which of the following best describes the incidence of pericardial tamponade? a. It occurs in 2 percent of all trauma patients. b. It occurs in 10 to 15 percent of patients with serious chest trauma. c. It occurs in less than 2 percent of all patients with serious chest trauma. d. It occurs in 10 to 15 percent of all trauma patients.

c. It occurs in less than 2 percent of all patients with serious chest trauma.

Which of the following best describes the epidemiology of sternal fracture? a. High incidence, high mortality b. High incidence, low mortality c. Low incidence, high mortality d. Low incidence, low mortality

c. Low incidence, high mortality

Which of the following may improve breathing in the patient with isolated rib fractures? a. Nitrous oxide b. Taping circumferentially around the chest c. Morphine sulfate d. None of the above

c. Morphine sulfate

You are treating a patient whose open chest wound has been sealed by EMTs on the scene before your arrival. During transport the patient becomes more dyspneic, tachycardic, and hypotensive. There are no breath sounds on the affected side, and the patient has JVD. Which of the following is the best action? a. Perform a needle thoracostomy at the fourth intercostal space in the midaxillary line. b. Perform a needle thoracostomy at the second intercostal space in the midclavicular line. c. Remove the dressing, and see if the patient's clinical status improves, then replace the dressing. d. Reinforce the dressing with additional tape, using tincture of benzoin, if necessary, to improve the seal

c. Remove the dressing, and see if the patient's clinical status improves, then replace the dressing.

Your patient was the unrestrained driver of a motor vehicle without airbags. The vehicle struck a large utility pole at about 45 miles per hour. Your patient has a contusion over his chest and upper abdomen consistent with the shape of the steering wheel. You should suspect which of the following types of injury in this patient? a. Deceleration b. Compression and acceleration c. Compression d. Compression and deceleration

d. Compression and deceleration

Your patient is a 21-year-old male with a single, small-caliber gunshot wound to the left anterior chest, just lateral to the sternum at the fourth intercostal space. Bleeding from the wound is minimal. The patient is initially anxious, combative, and diaphoretic. Initial vital signs include a heart rate of 100, respirations of 20, and a blood pressure of 110/80. Breath sounds are clear bilaterally and equal. En route the patient becomes quieter but still restless. The heart rate increases to 120, respirations are 24, blood pressure 106/88, and breath sounds remain clear and equal. The patient has also developed significant JVD. You are 15 minutes from a Level I trauma center and 5 minutes away from a large community hospital. You should: a. Immediately decompress the left chest and divert to the community hospital for chest tube insertion. b. Immediately decompress the left chest and continue to the trauma center for chest tube insertion. c. Continue to the Level I trauma center for pericardiocentesis. d. Divert to the community hospital for pericardiocentesis.

d. Divert to the community hospital for pericardiocentesis.

Which of the following findings differentiates a simple pneumothorax from a tension pneumothorax? a. Absent breath sounds on the affected side b. An open defect in the chest wall c. Decreased breath sounds on the affected side d. Hemodynamic compromise

d. Hemodynamic compromise

You have arrived on the scene of a paramedic who was shot as she approached a residence on a call. The scene has since been secured. Your patient is a 38-year-old female with one gunshot wound to the left side of the chest at the fifth intercostal space in the midaxillary line. She is pale, cool, and awake but agitated. She is diaphoretic and complaining of pain in her left side and difficulty breathing. The patient's EMT partner has applied oxygen by nonrebreathing mask and an occlusive dressing over the entry wound before your arrival. As you continue your assessment, the patient's level of consciousness decreases. She responds to verbal stimuli. Her airway is clear, her respiratory rate is 38 per minute and shallow, her neck veins are flat, and her breath sounds are absent on the left side. The patient lacks a radial pulse, and her abdomen is nonguarded and nontender. Which of the following best explains the presentation of this patient? a. Pericardial tamponade b. Tension pneumothorax c. Simple pneumothorax d. Hemothorax

d. Hemothorax

Which of the following is the primary concern in the patient with a hemothorax? a. Increased intrathoracic pressure b. Mediastinal shift c. Atelectasis d. Hypovolemia

d. Hypovolemia

Which of the following best describes the finding of tracheal deviation in the trauma patient? a. It is a contraindication to needle thoracostomy in tension pneumothorax. b. Its absence rules out tension pneumothorax. c. It is the earliest sign of tension pneumothorax. d. It is not reliably present in patients with tension pneumothorax.

d. It is not reliably present in patients with tension pneumothorax.

Which of the following best describes the incidence of pericardial tamponade? a. It occurs in 10 to 15 percent of all trauma patients. b. It occurs in less than 2 percent of all patients with serious chest trauma. c. It occurs in 10 to 15 percent of patients with serious chest trauma. Incorrect d. It occurs in 2 percent of all trauma patients.

d. It occurs in 2 percent of all trauma patients.

Another name for an open pneumothorax is: a. Tension pneumothorax b. Hemopneumothorax c. Flail chest d. Sucking chest wound

d. Sucking chest wound

The morbidity associated with simple pneumothorax is primarily due to which of the following? a. Loss of chest wall integrity b. Increased intrathoracic pressure c. Occlusion of pulmonary circulation d. Ventilation/perfusion mismatch

d. Ventilation/perfusion mismatch