Thoracic Trauma

The eleventh and twelfth ribs are known as the floating ribs because they: A. do not have a posterior point of attachment. B. are not connected to any bony structures. C. are not attached anteriorly to the sternum. D. are attached to the sternum only by cartilage.

C. are not attached anteriorly to the sternum.

When performing a needle decompression of the chest, you should insert the needle: A. on the side of the chest that has audible breath sounds. B. on the inferior rib border to avoid vasculature and nerves. C. at a 90-degree angle and listen for the release of air. D. at a 45-degree angle until you hear a sudden release of air.

C. at a 90-degree angle and listen for the release of air.

A 16-year-old man collapsed after being struck in the center of the chest by a line drive during a high school baseball game. Your assessment reveals that he is pulseless and apneic. As your partner initiates one-rescuer CPR, your MOST important action should be to: A. start an IV line and administer an antiarrhythmic drug. B. perform intubation to secure the patient's airway. C. attach the ECG leads and be prepared to defibrillate. D. rapidly assess the chest for signs of a sternal fracture.

C. attach the ECG leads and be prepared to defibrillate.

Any patient with a presumptive diagnosis of a pneumothorax should: A. be transported to a trauma center via air medical transport. B. be intubated and ventilated at a rate of 15 breaths/min. C. be considered unstable and reassessed every 5 minutes. D. receive a prophylactic needle thoracentesis.

C. be considered unstable and reassessed every 5 minutes.

Most patients with an aortic injury will complain of pain: A. that radiates from the chest to the flank. B. in the region of the posterior pharynx. C. behind the sternum or in the scapula. D. while taking a shallow breath.

C. behind the sternum or in the scapula.

You are transporting a conscious and alert man who experienced an isolated blunt injury to the right anterolateral chest. His vital signs are stable, but he is dyspneic and his breath sounds are diminished over the apex of his right lung. In addition to administering high-flow oxygen, the MOST critical intervention for this patient involves: A. performing a needle thoracentesis to release intrapleural tension. B. positioning him on his right side to facilitate effective breathing. C. frequently reassessing him for signs of clinical deterioration. D. administering a 500-mL normal saline bolus to maintain perfusion.

C. frequently reassessing him for signs of clinical deterioration.

Increased intravenous pressure commonly manifests as: A. a widened pulse pressure. B. bounding peripheral pulses. C. jugular venous distention. D. a pulsating abdominal mass.

C. jugular venous distention.

If the pleural space becomes filled with air or blood: A. increased surface tension ruptures the lung. B. surface tension forces the pleurae together. C. surface tension is lost and the lung collapses. D. the lung expands and fills the thoracic space.

C. surface tension is lost and the lung collapses.

Ribs 4 through 9 are the most commonly fractured because: A. they are not anteriorly attached to any portion of the sternum. B. the person's height predisposes him or her to injury in this area. C. they are less protected by other bony and muscular structures. D. these particular ribs are inherently weak compared to other ribs.

C. they are less protected by other bony and muscular structures.

Most hemothoraces occur when: A. a penetrating injury perforates the lung. B. the intercostal arteries are lacerated. C. a fractured rib injures the lung parenchyma. D. severe barotrauma ruptures one of the lungs.

C. a fractured rib injures the lung parenchyma.

Which of the following clinical findings is MOST suggestive of inadequate oxygenation? A. Altered mental status B. Irregular tachycardia C. Blood pressure of 90/50 mm Hg D. Accessory muscle use

A. Altered mental status

Which of the following statements regarding diaphragmatic injury is correct? A. Because the diaphragm is protected by the liver on the right side, most diaphragmatic injuries caused by blunt force trauma occur on the left side. B. During the latent phase of a diaphragmatic injury, abdominal contents herniate through the defect, cutting off their blood supply. C. Once the diaphragm has been injured, the healing process is facilitated by the natural pressure differences between the abdominal and thoracic cavities. D. The spleen provides significant protection to the diaphragm on the left side, resulting in a higher incidence of right-sided diaphragmatic injuries.

A. Because the diaphragm is protected by the liver on the right side, most diaphragmatic injuries caused by blunt force trauma occur on the left side.

Which of the following is NOT a mediastinal structure? A. Lung B. Mainstem bronchi C. Esophagus D. Trachea

A. Lung

What type of chest injury is characterized by air accumulation in the pleural space when a perforation in the lung parenchyma acts as a one-way valve? A. Tension pneumothorax B. Simple pneumothorax C. Massive hemothorax D. Spontaneous pneumothorax

A. Tension pneumothorax

As soon as the aorta exits the left ventricle, it: A. ascends toward the right shoulder. B. becomes the brachiocephalic artery. C. descends toward the abdomen. D. branches into the femoral arteries.

A. ascends toward the right shoulder.

Immediate treatment for an open pneumothorax involves: A. converting the pneumothorax to a closed injury. B. administering oxygen via nonrebreathing mask. C. assisting ventilations with a bag-mask device. D. covering the open wound with a porous dressing.

A. converting the pneumothorax to a closed injury.

The eighth, ninth, and tenth ribs are indirectly attached to the sternum by the: A. costal cartilage. B. suprasternal notch. C. manubrium. D. angle of Louis.

A. costal cartilage.

A convenience store clerk was stabbed during a robbery attempt. He is semiconscious with shallow breathing and weak radial pulses. During the rapid assessment, you find a single stab wound to his left anterior chest. His jugular veins are distended and his breath sounds are bilaterally diminished but equal. The MOST appropriate treatment for this patient involves: A. covering the stab wound with an occlusive dressing, assisting ventilations, transporting at once, and establishing large-bore IV lines en route. B. assisting his ventilations, initiating transport, starting a large-bore IV line en route, and administering fluids to maintain a systolic blood pressure of 100 mm Hg. C. performing bilateral needle thoracenteses, intubating the patient and ventilating at 10 to 12 breaths/min, and transporting him to a trauma center. D. administering oxygen via nonrebreathing mask, transporting at once, and placing an occlusive dressing over the stab wound if his oxygen saturation is low.

A. covering the stab wound with an occlusive dressing, assisting ventilations, transporting at once, and establishing large-bore IV lines en route.

Due to intrapulmonary hemorrhage, patients with a pulmonary contusion may present with: A. hemoptysis. B. hypocarbia. C. hematochezia. D. hematemesis.

A. hemoptysis.

Crackles or rales in the lungs following a myocardial contusion would MOST likely result from: A. left ventricular dysfunction. B. intrapulmonary hemorrhage. C. pulmonary vein disruption. D. decreased right atrial preload.

A. left ventricular dysfunction.

You should be MOST suspicious that your patient has a pericardial tamponade if he or she presents with hypotension, jugular vein distention, and: A. normal lung sounds. B. respiratory distress. C. loud heart tones. D. a bounding pulse.

A. normal lung sounds.

With the exception of the aorta, great vessel injury is MOST likely to occur following: A. penetrating trauma. B. shearing forces. C. blunt trauma. D. rotational injury.

A. penetrating trauma.

Following blunt trauma to the anterior chest, a 44-year-old man presents with restlessness, respiratory distress, perioral cyanosis, and tachycardia. Further assessment reveals a midline trachea, engorged jugular veins, and absent breath sounds on the right side of his chest. You should: A. perform an immediate needle thoracentesis to the right side of the chest. B. ventilate the patient with a bag-mask device and transport immediately. C. transport at once and decompress the chest if tracheal deviation is observed. D. give 100% oxygen and start a large-bore IV line en route to the hospital.

A. perform an immediate needle thoracentesis to the right side of the chest.

The anterior-most portion of the heart is the: A. right ventricle. B. left atrium. C. left ventricle. D. right atrium.

A. right ventricle.

Most of the heart is protected: A. by the tough pericardium. B. by the sternal manubrium. C. anteriorly by the sternum. D. by the anterior rib cage.

C. anteriorly by the sternum.

What is the cardiac output for an 80-kg man who has a heart rate of 80 beats/min and a stroke volume of 60 mL? A. 6,000 mL B. 4,800 mL C. 6,400 mL D. 5,200 mL

B. 4,800 mL

Any normotensive patient with a sternal fracture should receive: A. antiarrhythmic drugs. B. ECG monitoring. C. IV fluid boluses. D. ventilation assistance.

B. ECG monitoring.

You are dispatched to a residence for an injured person. The scene has been secured by law. The patient, a young female, tells you that her boyfriend kicked her in the chest yesterday during an argument. Your assessment reveals that the patient is in significant pain, is dyspneic, has a strong heart rate of 98 beats/min, and has an area of ecchymosis over her left lower rib cage. Auscultation to the left side of her chest reveals coarse crackles. Which of the following treatment interventions is likely NOT indicated for this patient? A. Cardiac monitoring B. IV fluid boluses C. Titrated IV analgesics D. End-tidal CO2 monitoring

B. IV fluid boluses

Which of the following statements regarding a pericardial tamponade is correct? A. Most pericardial tamponades are caused by blunt chest trauma during an automobile crash. B. In a pericardial tamponade, blood collects between the visceral and parietal pericardium. C. The parietal pericardium stretches easily, so significant blood accumulation is required before signs appear. D. Pericardial tamponade is characterized by a marked increase in preload and flat jugular veins.

B. In a pericardial tamponade, blood collects between the visceral and parietal pericardium.

Which of the following statements regarding the thorax is correct? A. The dimensions of the thorax are defined anteriorly by the thoracic vertebrae. B. The diaphragm inserts into the anterior thoracic cage below the fifth rib. C. The thoracic cavity extends to the ninth or tenth rib posteriorly. D. The dimensions of the thorax are defined inferiorly by the thoracic inlet.

B. The diaphragm inserts into the anterior thoracic cage below the fifth rib.

A 26-year-old unrestrained woman struck her chest on the steering wheel when her car collided with another vehicle. After performing your primary assessment and administering high-flow oxygen, you assess her chest and note a segment of obviously fractured ribs that bulges outward during exhalation. You should: A. increase intrathoracic pressure with a demand valve. B. apply a bulky dressing to the segment of fractured ribs. C. apply pressure to the segment of ribs as the patient inhales. D. position her on her injured side and monitor her breathing.

B. apply a bulky dressing to the segment of fractured ribs.

As air accumulates in the pleural space, the FIRST thing to occur is: A. compression of the great vessels. B. decreased pulmonary function. C. contralateral tracheal deviation. D. marked decrease in venous return.

B. decreased pulmonary function.

Common clinical findings associated with a traumatic asphyxia include all of the following, EXCEPT: A. exopthalmos. B. hyphema. C. tongue swelling. D. facial cyanosis.

B. hyphema.

A patient with a small simple pneumothorax would MOST likely present with diminished breath sounds: A. after more than 50% of the affected lung has been collapsed. B. in the apices of the affected lung if he or she is sitting upright. C. in the posterior bases of the affected lung if he or she is sitting. D. on the contralateral side as the mediastinum begins to shift.

B. in the apices of the affected lung if he or she is sitting upright.

You are assessing a 39-year-old man who experienced blunt chest trauma. He is semiconscious and has poor respiratory effort with stridor. You should: A. suction his airway and prepare for immediate orotracheal intubation. B. insert a nasal airway and assist ventilations with a bag-mask device. C. administer oxygen via nonrebreathing mask and assess circulation. D. perform laryngoscopy to visualize his airway for an obstruction.

B. insert a nasal airway and assist ventilations with a bag-mask device.

Management of a diaphragmatic injury focuses on: A. inserting a nasogastric tube to decompress the gastrointestinal organs. B. maintaining adequate oxygenation and ventilation, and rapid transport. C. applying the pneumatic antishock garment to stabilize the diaphragm. D. intubation and hyperventilation with 100% supplemental oxygen.

B. maintaining adequate oxygenation and ventilation, and rapid transport.

By definition, a massive hemothorax is characterized by: A. 10% of circulating blood volume within the pleural space. B. more than 1,500 mL of blood within the pleural space. C. pulmonary injury with secondary myocardial injury. D. cardiac arrest secondary to severe intrapleural bleeding.

B. more than 1,500 mL of blood within the pleural space.

A robbery suspect was shot once in the left anterior chest by law enforcement personnel when he pulled a gun on them. The patient is exhibiting obvious signs of shock, is in significant respiratory distress, and is coughing up blood. Further assessment reveals collapsed jugular veins and absent breath sounds over the left hemithorax. After covering the gunshot wound with the appropriate dressing, you should: A. administer 100% oxygen, administer 1 to 2 L of normal saline, and transport to a trauma center for an emergency pericardiocentesis. B. provide oxygenation and ventilation support, transport at once, and maintain adequate perfusion with IV fluids while en route to a trauma center. C. perform a needle thoracentesis to the left side of the chest, initiate rapid transport, and administer 20-mL/kg fluid boluses en route. D. ventilate the patient with a demand valve, transport to a trauma center, and run two large-bore IV lines wide open while en route to the hospital.

B. provide oxygenation and ventilation support, transport at once, and maintain adequate perfusion with IV fluids while en route to a trauma center.

The space between the second and third ribs is called the: A. third intercostal space. B. second intercostal space. C. second subcostal margin. D. intrathoracic margin.

B. second intercostal space.

Isolated rib fractures may result in inadequate ventilation because: A. preferential use of the intercostal muscles reduces tidal volume. B. the patient often purposely limits chest wall movement. C. the pain associated with the fracture causes hyperventilation. D. most rib fractures cause paradoxical chest wall movement.

B. the patient often purposely limits chest wall movement.

Which of the following thoracic injuries would you LEAST likely discover in the primary assessment? A. Flail chest B. Open pneumothorax C. Myocardial contusion D. Bronchial disruption

C. Myocardial contusion

Dysrhythmias following a myocardial contusion are usually secondary to: A. excess tachycardia that accompanies the injury. B. aneurysm formation caused by vascular damage. C. direct damage to the vasculature of the epicardium. D. damage to myocardial tissue at the cellular level.

D. damage to myocardial tissue at the cellular level.

Which of the following thoracic injuries generally does NOT require immediate treatment? A. Flail chest B. Open pneumothorax C. Tension pneumothorax D. Myocardial contusion

D. Myocardial contusion

Tracheobronchial injuries have a high mortality due to: A. perforation of the esophagus. B. concomitant spinal cord injury. C. massive internal hemorrhage. D. associated airway obstruction.

D. associated airway obstruction.

Unlike a tension pneumothorax, a massive hemothorax would MOST likely present with: A. signs of shock. B. tracheal deviation. C. severe respiratory distress. D. collapsed jugular veins.

D. collapsed jugular veins.

You would NOT expect a patient with a flail chest to present with: A. decreased breath sounds. B. shallow breathing. C. cyanosis. D. hyperpnea.

D. hyperpnea.

A 30-year-old man felt a snap in his chest when he abruptly twisted his torso. He is conscious and alert, and complains of severe pain during inhalation. Your assessment reveals palpable tenderness over the fifth and sixth ribs on the left side. His vital signs are stable and he denies other injuries. In addition to administering supplemental oxygen, the MOST appropriate treatment for this patient involves: A. stabilizing the injured area by circumferentially wrapping the chest with 3-inch tape and transporting him to a local hospital. B. encouraging the patient to take deeper breaths to maintain adequate minute volume and transporting him to the hospital. C. sedating the patient with midazolam or diazepam, assisting ventilations with a bag-mask device, and transporting at once. D. instructing the patient to hold a pillow against his chest, considering IV analgesics, and transporting to the hospital.

D. instructing the patient to hold a pillow against his chest, considering IV analgesics, and transporting to the hospital.

Jugular venous distention during a tension pneumothorax: A. indicates a significant increase in atrial preload. B. occurs before a unilateral absence of breath sounds. C. manifests early as air accumulates in the pleural space. D. is caused by blood accumulation in the vena cava.

D. is caused by blood accumulation in the vena cava.

An open pneumothorax causes ventilatory inadequacy when: A. positive pressure created by expiration forces air into the pleural space. B. the heart stops perfusing the lung on the side of the open chest injury. C. the glottic opening is much larger than the open wound on the chest wall. D. negative pressure created by inspiration draws air into the pleural space.

D. negative pressure created by inspiration draws air into the pleural space.

A blood pressure of 100/70 mm Hg in the presence of clinical signs of a tension pneumothorax: A. indicates that prehospital needle decompression likely will not be required. B. should be treated with crystalloid fluid boluses to prevent hypotension. C. is likely the result of systemic vasodilation in an attempt to reduce preload. D. suggests adequate cardiac compensation for the diminished venous return.

D. suggests adequate cardiac compensation for the diminished venous return.