Chapter 35 Chest Trauma

13. Which of the following is NOT a sight of potential injury when the aorta is subjected to shearing forces during rapid deceleration? A) Anulus B) Coronary sinus C) Aortic hiatus D) Ligamentum arteriosum

B) Coronary sinus

28. 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) Pericardial tamponade is characterized by a marked increase in preload and flat jugular veins. D) The parietal pericardium stretches easily, so significant blood accumulation is required before signs appear.

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

48. Which of the following clinical signs may not be present in a patient with a tension pneumothorax and associated internal bleeding? A) Tachycardia B) Jugular vein distention C) Mediastinal shift D) Contralateral tracheal deviation

B) Jugular vein distention

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

B) Myocardial contusion

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

60. 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) position her on her injured side and monitor her breathing. D) apply pressure to the segment of ribs as the patient inhales.

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

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

B) associated airway obstruction.

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

B) behind the sternum or in the scapula.

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

B) damage to myocardial tissue at the cellular level.

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

B) hemoptysis.

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

B) hyperpnea.

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

B) is caused by blood accumulation in the vena cava.

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

B) left ventricular dysfunction.

19. The self-splinting effect observed in patients with chest wall trauma: A) allows the body to compensate for the injury. B) may cause atelectasis, hypoxemia, or pneumonia. C) is often accompanied by subcutaneous emphysema. D) is characterized by a markedly increased tidal volume.

B) may cause atelectasis, hypoxemia, or pneumonia.

9. The pressure within the right ventricle is: A) less than the pressure within the right atrium. B) one fourth of the pressure within the left ventricle. C) nearly equal to the pressure within the left ventricle. D) three times greater than the pressure in the left ventricle.

B) one fourth of the pressure within the left ventricle.

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

A) hyphema.

44. A patient with a small simple pneumothorax would MOST likely present with diminished breath sounds: A) in the apices of the affected lung if he or she is sitting upright. B) after more than 50% of the affected lung has been collapsed. 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.

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

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

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

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

A) decreased pulmonary function.

62. 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) frequently reassessing him for signs of clinical deterioration. B) performing a needle thoracentesis to release intrapleural tension. C) positioning him on his right side to facilitate effective breathing. D) administering a 500-mL normal saline bolus to maintain perfusion.

A) frequently reassessing him for signs of clinical deterioration.

11. 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) 4,800 mL B) 5,200 mL C) 6,000 mL D) 6,400 mL

A) 4,800 mL

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

A) ECG monitoring.

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

A) Lung

23. 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

16. A flail chest is characterized by: A) a free-floating segment of fractured ribs. B) bulging of fractured ribs during inspiration. C) excessive negative intrathoracic pressure. D) drawing in of fractured ribs during expiration.

A) a free-floating segment of fractured ribs.

20. Pneumothorax is MOST accurately defined as: A) air or gas within the pleural cavity. B) perforation of a lung by a broken rib. C) injury to the visceral or parietal pleura. D) partial or complete collapse of a lung.

A) air or gas within the pleural cavity.

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

A) are not attached anteriorly to the sternum.

61. 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) instructing the patient to hold a pillow against his chest, considering IV analgesics, and transporting to the hospital. B) stabilizing the injured area by circumferentially wrapping the chest with 3-inch tape and transporting him to a local hospital. C) encouraging the patient to take deeper breaths to maintain adequate minute volume and transporting him to the hospital. D) sedating the patient with midazolam or diazepam, assisting ventilations with a bag-mask device, and transporting at once.

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

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

A) jugular venous distention.

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

A) maintaining adequate oxygenation and ventilation, and rapid transport.

31. Traumatic injuries to the aorta are MOST commonly the result of: A) shearing forces. B) rear-end collisions. C) penetrating trauma. D) motorcycle crashes.

A) shearing forces.

49. The preferred site for performing a needle thoracentesis is: A) superior to the third rib into the intercostal space at the midclavicular line. B) just below the second rib into the intercostal space at the midaxillary line. C) just above to the fifth rib into the intercostal space at the midaxillary line. D) inferior to the third rib into the intercostal space at the midclavicular line.

A) superior to the third rib into the intercostal space at the midclavicular line.

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

A) the patient often purposely limits chest wall movement.

30. Commotio cordis is a phenomenon in which: A) ventricular fibrillation is induced following blunt trauma to the chest during the heart's repolarization period. B) excessive pressure within the pericardial sac impairs cardiac contractility as well as venous return to the heart. C) penetrating thoracic trauma perforates the atria or ventricles, causing acute rupture and massive hemorrhage. D) myocardial tissue at the cellular level is damaged by blunt or penetrating trauma, resulting in cardiac arrest.

A) ventricular fibrillation is induced following blunt trauma to the chest during the heart's repolarization period.

66. 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) ventilate the patient with a bag-mask device and transport immediately. B) perform an immediate needle thoracentesis to the right side of the chest. C) give 100% oxygen and start a large-bore IV line en route to the hospital. D) transport at once and decompress the chest if tracheal deviation is observed.

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

22. Pneumothoraces create a ventilation-perfusion mismatch when: A) concomitant myocardial injury prevents adequate pulmonary perfusion and the lung collapses. B) perfusion of the involved lung continues while the pneumothorax prevents adequate ventilation. C) the vasculature of the affected lung is not intact and intrapulmonary gas exchange is impaired. D) the affected lung continues to expand adequately despite a decrease in pulmonary perfusion.

B) perfusion of the involved lung continues while the pneumothorax prevents adequate ventilation.

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

B) right ventricle.

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

C) 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.

64. 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) Titrated IV analgesics C) IV fluid boluses D) End-tidal CO2 monitoring

C) IV fluid boluses

59. A 50-year-old man was working on his car when the jacks collapsed and the car landed on his chest. Your assessment reveals profound cyanosis and swelling to his chest and face, agonal respirations, and a weak carotid pulse. This patient will benefit MOST from: A) bilateral needle thoracenteses and 100% oxygen. B) rapid IV fluid boluses en route to a trauma center. C) aggressive airway management and rapid transport. D) prompt endotracheal intubation and hyperventilation.

C) aggressive airway management and rapid transport.

27. A pulmonary contusion following blunt chest trauma results in: A) blood leakage from injured lung tissue into the pleural space. B) decreased pulmonary shunting with rupture of the alveolar sacs. C) alveolar and capillary damage with intraparenchymal lung hemorrhage. D) pulmonary vasodilation as the body attempts to shunt blood to the injury

C) alveolar and capillary damage with intraparenchymal lung hemorrhage.

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

C) anteriorly by the sternum.

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

C) be considered unstable and reassessed every 5 minutes.

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

C) collapsed jugular veins.

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

C) converting the pneumothorax to a closed injury.

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

C) costal cartilage.

15. The diaphragm: A) is an accessory muscle used during respiratory distress. B) works in conjunction with the sternum during inspiration. C) forms a barrier between the thoracic and abdominal cavities. D) creates positive intrathoracic pressure when it increases in size.

C) forms a barrier between the thoracic and abdominal cavities.

58. 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) perform laryngoscopy to visualize his airway for an obstruction. B) administer oxygen via nonrebreathing mask and assess circulation. C) insert a nasal airway and assist ventilations with a bag-mask device. D) suction his airway and prepare for immediate orotracheal intubation.

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

21. 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) negative pressure created by inspiration draws air into the pleural space. D) the glottic opening is much larger than the open wound on the chest wall.

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

65. 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) perform a needle thoracentesis to the left side of the chest, initiate rapid transport, and administer 20-mL/kg fluid boluses en route. B) administer 100% oxygen, administer 1 to 2 L of normal saline, and transport to a trauma center for an emergency pericardiocentesis. C) provide oxygenation and ventilation support, transport at once, and maintain adequate perfusion with IV fluids while en route to a trauma center. 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.

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

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

C) second intercostal space.

40. In general, patients suspected of having a partial tracheal tear should be managed with: A) immediate endotracheal intubation. B) an oxygen-powered ventilation device. C) the least invasive airway techniques possible. D) placement of a laryngeal mask airway device.

C) the least invasive airway techniques possible.

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

D) Altered mental status

41. 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

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

D) a fractured rib injures the lung parenchyma.

2. Bony structures of the thorax include all of the following, EXCEPT the: A) ribs. B) scapulae. C) clavicles. D) acromion

D) acromion

7. The visceral pericardial layer: A) comprises the pericardial sac itself. B) is attached directly to the diaphragm. C) is the outermost layer of the pericardium. D) adheres to the heart and forms the epicardium.

D) adheres to the heart and forms the epicardium.

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

D) ascends toward the right shoulder.

57. 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) perform intubation to secure the patient's airway. B) rapidly assess the chest for signs of a sternal fracture. C) start an IV line and administer an antiarrhythmic drug. D) attach the ECG leads and be prepared to defibrillate.

D) attach the ECG leads and be prepared to defibrillate.

63. 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) performing bilateral needle thoracenteses, intubating the patient and ventilating at 10 to 12 breaths/min, and transporting him to a trauma center. B) administering oxygen via nonrebreathing mask, transporting at once, and placing an occlusive dressing over the stab wound if his oxygen saturation is low. C) 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. D) covering the stab wound with an occlusive dressing, assisting ventilations, transporting at once, and establishing large-bore IV lines en route.

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

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

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

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

D) normal lung sounds.

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

D) penetrating trauma.

47. A blood pressure of 100/70 mm Hg in the presence of clinical signs of a tension pneumothorax: A) should be treated with crystalloid fluid boluses to prevent hypotension. B) indicates that prehospital needle decompression likely will not be required. 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.

14. 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) the lung expands and fills the thoracic space. D) surface tension is lost and the lung collapses.

D) surface tension is lost and the lung collapses.

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

D) they are less protected by other bony and muscular structures.