PHTLS 10TH EDITION: EXAM QUESTIONS,

ANSWERS & DETAILED RATIONALES

Page Range Section / Trauma Domain

Pages 1–4 Kinematics & Scene Assessment

Pages 5–8 Airway & Ventilation

Pages 9–13 Shock & Resusciation

Pages 14–17 Thoracic & Abdominal Trauma

Pages 18–22 CNS & Spinal Injuries

Pages 23–25 Special Populations & Answers

The PHTLS (Prehospital Trauma Life Support) 10th Edition Pre/Post-Test Study Guide
is a 25-page comprehensive educational assessment tool. It consists of 50 multi-part and
multiple-choice questions complete with verified answer keys.

The primary purpose of this document is to reinforce critical thinking, evidence-based trauma
care principles, and rapid patient evaluation protocols established by the National Association
of Emergency Medical Technicians (NAEMT) in cooperation with the American College of
Surgeons Committee on Trauma (ACS-COT). It serves as a diagnostic tool for EMS
professionals, paramedics, and nurses to assess their competency before and after undergoing
formal PHTLS certification.
1. Spontaneous Ventilation Assessment

Which of the following represents adequate spontaneous ventilation in an adult?

A. Tidal volume 100 mL, ventilatory rate 40/minute

B. Tidal volume 500 mL, ventilatory rate 8/minute

C. Tidal volume 300 mL, ventilatory rate 16/minute

D. Tidal volume 600 mL, ventilatory rate 12/minute

Correct Answer: D Detailed Rationale: Adequate ventilation depends on both rate and depth (tidal
volume). Minute volume is calculated as $\text{Tidal Volume} \times \text{Ventilatory Rate}$. In an
adult, an average tidal volume of 500–600 mL and a standard rate of 12 breaths per minute provides
sufficient alveolar ventilation to satisfy the body's metabolic demands. Options with exceptionally
low tidal volumes (like 100 mL or 300 mL) fail to clear the anatomic dead space (approximately 150
mL), resulting in severe hypoxia and hypercarbia, regardless of how fast the patient breathes.

2. Verification of Endotracheal Tube Placement

Which of the following is 100% accurate in verifying endotracheal tube placement?

A. Pulse oximetry

B. End-tidal capnometry

C. Syringe aspiration

D. None of the above

Correct Answer: D Detailed Rationale: No single prehospital confirmation method is 100% foolproof
in every single clinical scenario. While waveform end-tidal capnography ($\text{ETCO}_2$) is
universally recognized as the gold standard for verifying correct placement in patients with a
perfusing rhythm, it can yield false negatives during prolonged cardiac arrest due to zero or minimal
pulmonary blood flow. Because every mechanical device or assessment technique can fail or be
misread under extreme conditions, clinicians must always utilize a combination of clinical
assessment (bilateral breath sounds, chest rise) and objective technology rather than relying on one
solitary factor.

3. Percutaneous Transtracheal Ventilation

When utilizing percutaneous transtracheal ventilation, the correct ratio of lung inflation to lung
deflation time, in seconds, is:

A. 1:4

B. 1:5

C. 1:2

D. 2:2

Correct Answer: A Detailed Rationale: Percutaneous transtracheal jet ventilation utilizes high
pressure to force oxygen into the lungs through a narrow catheter. Because exhalation occurs
passively via the upper airway, it takes significantly longer for the lungs to deflate than to inflate. A

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strict 1:4 ratio (1 second of active inflation followed by 4 seconds of passive deflation) is mandatory
to prevent air trapping, barotrauma, and the development of a deadly tension pneumothorax.

4. Oxygen-Powered Ventilation Device Complications

Which of the following is a possible complication of using a manually triggered oxygen-powered

device for ventilation?

A. Gastric distention

B. Pneumothorax

C. Inability to feel lung compliance

D. All of the above

Correct Answer: D Detailed Rationale: Manually triggered oxygen-powered ventilation devices

deliver oxygen under high pressure. Because the gas flows at a fixed high velocity, if the airway is not
perfectly aligned, the pressure easily forces open the esophagus, leading to rapid gastric distention
and an increased risk of vomiting and aspiration. Furthermore, the high pressures can rupture
alveoli, causing a pneumothorax. Because the operator simply presses a button rather than
squeezing a bag, they are entirely unable to feel any changes in lung compliance, increasing the risk
of airway injury.

5. Essential Airway Skills

Which of the following procedures is considered an essential airway skill?

A. Needle cricothyroidotomy

B. Endotracheal intubation

C. Insertion of an oropharyngeal airway

D. Retrograde endotracheal intubation

Correct Answer: C Detailed Rationale: PHTLS heavily emphasizes that simple, non-invasive
maneuvers form the true foundation of effective airway management. Manual maneuvers,
suctioning, and the insertion of basic airway adjuncts—like an oropharyngeal airway (OPA)—are
classified as essential skills because they are highly effective, rapidly executed, and present a very
low risk of worsening a patient's injury. Advanced invasive techniques like intubation and surgical
airways are considered optional or secondary skills reserved for specific scenarios.

6. Pericardial Tamponade Presentation

Pericardial tamponade is most likely to occur in which of the following situations?

A. Stab wound to the chest

B. Fall from a height

C. Frontal impact vehicle crash

D. Gunshot wound to the chest

Correct Answer: A Detailed Rationale: Pericardial tamponade requires a specific type of anatomical
injury where the tough, fibrous pericardial sac is damaged but remains largely sealed, trapping blood

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inside. Low-velocity penetrating trauma, such as a sharp knife stab wound to the central chest, is the
classic mechanism. Gunshot wounds typically create larger exit paths in the pericardium that allow
blood to escape into the pleural space rather than trapping it around the heart. Blunt trauma (like
crashes or falls) more commonly results in myocardial contusion or a aortic tear rather than isolated
tamponade.

7. Needle Decompression Landmarks

Which of the following is the preferred site for needle decompression of a tension pneumothorax?

A. 4th intercostal space, midclavicular line, just over the top of the 5th rib

B. 4th intercostal space, midclavicular line, just below the 4th rib

C. 2nd intercostal space, midclavicular line, just over top of the 3rd rib

D. 2nd intercostal space, midclavicular line, just below the 2nd rib

Correct Answer: C Detailed Rationale: The classic, globally accepted anatomical site for needle
thoracostomy is the second intercostal space at the midclavicular line. The needle must be advanced
directly over the top of the third rib. This specific path is vital because the intercostal neurovascular
bundle (comprising primary arteries, veins, and nerves) runs along the lower border of each rib.
Inserting a needle below a rib risks causing massive internal hemorrhage or severe nerve damage.

8. Pulmonary Contusion Pathophysiology

Which of the following is the mechanism by which pulmonary contusion interferes with
oxygenation?

A. Inability to generate negative intrapleural pressure

B. Decrease in vital capacity due to collapse of the flail segment

C. Increased intrathoracic pressure

D. Blood and fluid in the alveoli and interstitial spaces of the lung

Correct Answer: D Detailed Rationale: A pulmonary contusion is essentially a bruise of the lung tissue
caused by blunt trauma. This impact ruptures the delicate capillaries within the lung parenchyma,
causing blood, localized inflammatory plasma, and fluid to flood directly into the alveoli and the
surrounding interstitial spaces. This fluid creates a barrier that prevents oxygen from diffusing across
the alveolar-capillary membrane, leading to severe ventilation-perfusion ($V/Q$) mismatch and
systemic hypoxemia.

9. Chest Trauma Assessment Case

Your patient is a 55-year-old male who was struck in the right side of the chest with a piece of steel
pipe. He presents with uncooperative behavior, pale/moist skin, a ventilatory rate of 32, a weak
radial pulse of 112, and decreased breath sounds on the right side. The trachea is midline and
jugular veins are flat while supine. Crepitus is isolated over the 4th and 5th ribs. What is the most
likely cause?

A. Tension pneumothorax

B. Simple pneumothorax

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C. Pulmonary contusion

D. Hemothorax

Correct Answer: D Detailed Rationale: This clinical picture points clearly to massive internal blood
loss within the chest cavity (hemothorax). The patient is showing advanced signs of hemorrhagic
shock: uncooperative behavior due to cerebral hypoxia, pale/moist skin, tachycardia (112), and
tachypnea (32). The key differentiators are the flat jugular veins while in a supine position. In a
tension pneumothorax or cardiac tamponade, systemic venous return is blocked, which causes the
neck veins to distend significantly. Flat neck veins in the presence of decreased breath sounds and
profound shock indicate that the missing blood is pooling inside the right pleural space.

10. PASG Inflation and Diaphragmatic Rupture

Deterioration of ventilation and oxygenation after inflation of a PASG (Pneumatic Anti-Shock

Garment) in a patient who has sustained a high-pressure compression injury of the abdomen most
likely represents which of the following injuries?

A. Abdominal aortic aneurysm

B. Ruptured diaphragm

C. Ruptured esophagus

D. "Paper bag" syndrome of the lungs

Correct Answer: B Detailed Rationale: When an individual sustains a high-pressure abdominal

compression injury (such as a lap belt worn improperly high during a sudden deceleration crash), the
pressure within the abdominal cavity spikes instantly. If the diaphragm tears or ruptures, inflating a
PASG will compress the abdomen further, forcing the stomach, intestines, and other abdominal
organs upward through the tear into the chest cavity. These displaced organs physically compress
the lungs, severely restricting tidal volume and leading to an immediate, noticeable drop in
oxygenation and ventilation.

11. The Fick Principle Components

Which of the following is NOT a component of the Fick Principle?

A. Adequate number of platelets in the blood

B. Oxygenation of red blood cells

C. Transportation of red blood cells to the tissues of the body

D. Off-loading oxygen from the red blood cells to the tissues

Correct Answer: A Detailed Rationale: The Fick Principle models the essential steps required for
systemic tissue perfusion and cellular oxygenation. It relies on three main components: 1. Adequate
loading of oxygen onto red blood cells via the lungs. 2. Adequate transport of those red blood cells
to peripheral tissues (requiring a functional heart, sufficient blood volume, and vascular tone). 3.
Successful off-loading of that oxygen at the cellular level. While platelets are vital for clotting and
hemorrhage control, they do not play a direct role in the mechanical binding, transport, or release of
oxygen molecules to tissues.

12. Early Signs of Shock

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One of the earliest signs of hypovolemic shock is:

A. Hypotension

B. Bradycardia

C. Anxiety

D. Reduced urine output

Correct Answer: C Detailed Rationale: As blood volume drops, the sympathetic nervous system fires
an immediate compensatory response, releasing epinephrine and norepinephrine to maintain
perfusion. This surge causes subtle early central nervous system changes, typically presenting as
unexplained anxiety, restlessness, or mild agitation. Hypotension is a late, decompensated sign
indicating that the body’s compensatory mechanisms have failed.

13. Washout Phase of Shock

Which of the following characterizes the washout phase of shock?

A. Systemic acidosis

B. Localized tissue acidosis

C. Edema

D. Reduced capillary blood flow

Correct Answer: A Detailed Rationale: During prolonged shock, prolonged vasoconstriction causes
peripheral capillary beds to undergo anaerobic metabolism, building up large amounts of localized
lactic acid and toxic metabolic wastes. When the precapillary and postcapillary sphincters finally
relax completely (the washout phase), this trapped pool of acidic, metabolic waste is suddenly
flushed out into the central circulation. This shifts the patient from a state of localized tissue acidosis
to profound, life-threatening systemic metabolic acidosis.

14. Neurogenic vs. Hypovolemic Shock Presentation

A trauma patient who fell 20 feet is alert with warm, dry, pink skin and normal capillary refilling in
the lower extremities, but is hypotensive. The upper extremities are cool, pale, and diaphoretic.
Which injury should be suspected?

A. Aortic dissection

B. Liver laceration

C. Fractured pelvis

D. Spinal cord injury

Correct Answer: D Detailed Rationale: This presentation describes neurogenic shock secondary to a
spinal cord injury. A severe injury to the cord disrupts the sympathetic nervous system pathways
below the level of the lesion, eliminating vascular tone and causing massive, uncontrolled
vasodilation. This presents below the injury as warm, dry, flushed skin despite low systemic blood
pressure. Above the level of the injury, the brain attempts to compensate normally via intact
sympathetic pathways, making the upper extremities cool, pale, and diaphoretic in an effort to raise
blood pressure.

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15. Limitations of Crystalloid Fluid Resuscitation

Which of the following is a limitation of prehospital fluid resuscitation of the patient in hemorrhagic
shock?

A. Inability of fluids to carry oxygen

B. Pulmonary edema

C. Increased hemorrhage

D. All of the above

Correct Answer: D Detailed Rationale: Standard IV fluids like Lactated Ringer's or Normal Saline are
temporary volume expanders, but they carry significant physiological limitations. They contain zero
hemoglobin and cannot transport oxygen to hypoxic tissues. Pumping large volumes of clear fluids
into the system dilutes clotting factors and lowers blood viscosity. This can elevate blood pressure
enough to mechanically pop freshly formed blood clots, causing a recurrence of internal bleeding.
Additionally, excessive volume shifts can increase hydrostatic pressure, leading to fluid backup and
pulmonary edema.

16. Intraabdominal Injury Signs

Which of the following statements regarding signs of intraabdominal injury is NOT true?

A. Fresh blood in the abdominal cavity does not cause signs of peritonitis

B. A significant amount of blood loss occurs before abdominal distention can be noticed

C. Substantial intraabdominal hemorrhage always causes tenderness and abdominal rigidity

D. Signs and symptoms of shock greater than can be explained by other injuries is a reliable indicator
of intraabdominal injury

Correct Answer: C Detailed Rationale: The abdomen can hide a massive amount of blood before
showing obvious clinical signs. Fresh, uninfected blood is relatively non-irritating to the peritoneal
lining initially, meaning a patient can bleed internally without experiencing immediate, severe
tenderness or involuntary abdominal rigidity. This makes statement C entirely false. Prehospital
providers must maintain a high index of suspicion based on the mechanism of injury and
unexplained systemic signs of shock.

17. Abdominal Trauma Assessment Techniques

Which of the following assessment techniques is least useful in the prehospital assessment of the
patient with suspected intraabdominal trauma?

A. Palpation

B. Auscultation

C. Inspection

D. Scene assessment

Correct Answer: B Detailed Rationale: Auscultation of bowel sounds provides almost no actionable
value in the chaotic, high-noise environment of prehospital trauma care. Determining whether
bowel sounds are absent or hypoactive requires several minutes of silence and does not change

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immediate emergency field treatments. In contrast, evaluating the mechanism via scene
assessment, inspecting for bruising or seatbelt signs, and gently palpating for structural instability
are vital, rapid assessments.

18. Positioning the Pregnant Trauma Patient

Pregnant trauma patients should be placed on the left side because:

A. This prevents seizures due to eclampsia

B. This prevents abruption of the placenta

C. This prevents compression of the vena cava

D. This is the best way to auscultate fetal heart tones

[ MATERNAL SPINE ]

[ INFERIOR VENA CAVA ] ◄─── │ ◄─── [ HEAVY PREGNANT UTERUS ]

(Compressed if Supine: │ (Shifts LEFT when tilted

Causes Hypotension) │ to restore blood flow)

Correct Answer: C Detailed Rationale: When a late-term pregnant patient lies completely flat on her
back (supine), the heavy weight of the enlarged uterus and fetus presses directly down onto the
inferior vena cava (IVC). This compression severely restricts venous blood flow back to the mother's
heart, precipitating supine hypotensive syndrome. This drop in maternal cardiac output directly
compromises placental blood flow. Tilting or placing the patient onto her left side shifts the uterine
mass off the vena cava, restoring maternal blood pressure and protecting the fetus.

19. Fetal Survival in Trauma

Survival of the fetus in a trauma situation is most dependent upon which of the following factors?

A. Gestational age of the fetus

B. Prenatal care

C. Immediate cesarean section

D. Good resuscitation of the mother

Correct Answer: D Detailed Rationale: The fetus relies entirely on the mother’s circulatory system for
oxygenation and perfusion. If the mother's blood volume falls into jeopardy, her body will naturally
compensate by constricting the uterine arteries to divert blood away from the fetus to protect her
own vital organs. Therefore, the absolute best way to ensure the survival of the fetus is to provide
aggressive, high-quality assessment and resuscitation directly to the mother.

20. Cerebral Contusion (Coupe vs. Contrecoup)

A patient struck in the back of the head with a baseball bat may sustain a cerebral contusion to
which area of the brain?

A. Frontal and occipital

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B. Occipital

C. Parietal

D. Frontal

Correct Answer: B Detailed Rationale: A direct blow from a blunt object like a baseball bat
concentrated on the back of the head delivers localized energy directly to the point of impact,
causing an isolated coup injury to the occipital lobe. High-velocity mechanisms (such as high-speed
vehicle crashes or long falls) are typically required to cause the brain to slosh back and forth inside
the skull, which produces a classic counter-injury (contrecoup) on the opposite side.

21. Hyperventilation Rates in Traumatic Brain Injury (TBI)

In the context of caring for an adult patient with a traumatic brain injury who is actively
deteriorating and exhibiting clear signs of herniation, hyperventilation means ventilating with a BVM
and 100% oxygen at a rate of:

A. 12 to 16 per minute

B. 32 to 40 per minute

C. 8 to 12 per minute

D. 20 per minute

Correct Answer: D Detailed Rationale: While routine hyperventilation is strictly discouraged in head
injuries because it causes vasoconstriction and brain ischemia, controlled mild hyperventilation is
indicated as a last resort when a patient is actively herniating (e.g., demonstrating decerebrate
posturing, a blown pupil). In an adult, this targeted rate is exactly 20 breaths per minute (or 1 breath
every 3 seconds). For pediatric patients, the target rate under the same emergency conditions is 25–
30 breaths per minute.

22. Spinal Cord Injury Etiology

In the United States, which of the following mechanisms most frequently causes spinal cord injury in
adults?

A. Shallow water diving

B. Vehicle crashes

C. Falls

D. Pedestrian struck by a vehicle

Correct Answer: B Detailed Rationale: Statistical data across the United States consistently shows
that motor vehicle collisions (MVCs) are the leading cause of acute spinal cord injuries in adult
populations, accounting for a large percentage of all recorded cases annually. Falls represent the
second most common cause, especially among elderly demographics.

23. Spinal Cord Injury Syndromes

Which of the following presentations indicate spinal cord injury?

A. Complete loss of sensory and motor function below the site of injury

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B. Weakness and paresthesia in the upper extremities, but normal function in the lower extremities

C. Complete loss of function on one side of the body and loss of pain/temperature sensation on the
opposite side

D. All of the above

Correct Answer: D Detailed Rationale: Spinal cord injuries can present through a variety of complete
or incomplete neurological syndromes. Choice A describes a complete transection of the cord.
Choice B outlines Central Cord Syndrome, a classic presentation where hyperextension causes more
pronounced impairment in the upper extremities than the lower ones. Choice C describes Brown-
Séquard Syndrome, an incomplete cord injury resulting from lateral hemisection that produces
ipsilateral motor loss and contralateral loss of pain and temperature sensation.

24. Compartment Syndrome Recognition

Of the following, which is the earliest indication of compartment syndrome?

A. Paralysis of the affected muscles

B. Loss of pulses

C. Loss of feeling in the web spaces

D. Tense swelling of the involved area

Correct Answer: D Detailed Rationale: As pressure climbs within an enclosed muscle compartment,
the very first physical finding is a tense, firm swelling of the area accompanied by severe pain that is
entirely disproportionate to the visible injury. Neurological changes (paresthesia) and structural
deficits (paralysis) develop later as nerves become ischemic. The loss of a distal pulse is a very late,
dangerous sign indicating complete arterial occlusion and impending limb death.

25. Traction Splint Indications

A traction splint may be used for which of the following injuries?

A. Knee dislocation

B. Pelvic fractures

C. Femur fractures

D. All of the above

Correct Answer: C Detailed Rationale: Traction splints are strictly designed and indicated for isolated,
mid-shaft femur fractures. They work by pulling mechanical traction along the long axis of the leg,
which re-aligns the bone ends, reduces muscle spasms, and helps control severe internal thigh
bleeding. Applying a traction splint to a knee dislocation or a pelvic fracture is highly contraindicated
and can cause severe vascular and nerve damage.

26. Burn Center Transfer Criteria

Which of the following descriptions meets the criteria for transport to a facility with a burn unit?

A. A 49-year-old female with a partial thickness burn from her elbow to her shoulder

B. A 25-year-old male with an electrical burn across his chest

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C. A 9-year-old male with superficial burns on the backs of both legs

D. A 32-year-old female with a partial thickness burn about twice the size of her hand on her back

Correct Answer: B Detailed Rationale: According to American Burn Association guidelines adopted by
PHTLS, all electrical burns (including lightning injuries) require direct transfer to a specialized burn
center. Electrical currents travel along internal paths through deep tissue, nerves, and blood vessels,
often causing severe internal injuries and cardiac arrhythmias that cannot be accurately evaluated
by looking at the surface skin alone.

27. Prehospital Burn Dressings

The preferred method of dressing burns in the prehospital setting is:

A. Dry sterile dressing

B. Moist sterile dressing

C. Wet dressings

D. Petroleum gauze

Correct Answer: A Detailed Rationale: For transport from the field, burns should be covered with a
clean, dry sterile dressing. Using large wet or moist dressings over significant burn areas is
dangerous because injured skin loses its ability to regulate temperature. Wet dressings cause rapid
cooling, putting the patient at a high risk of developing severe hypothermia. Wet applications are
only acceptable for cooling very small, localized burns for less than one to two minutes immediately
after the injury occurs.

28. Hypothermia Assessment

In assessing the hypothermic patient in the prehospital setting, the most reliable indicator of the
severity of hypothermia is:

A. Rectal temperature

B. Oral temperature

C. Heart rate < 60

D. Presence or absence of shivering

Correct Answer: A Detailed Rationale: Core body temperature is the gold standard for measuring
hypothermia. Axillary and oral temperatures fluctuate too easily based on environmental air
exposure and breathing, making them unreliable in the field. A core rectal temperature provides a
steady, accurate assessment of internal heat levels, guiding choices around rewarming procedures
and resuscitation protocols.

29. Pediatric vs. Adult Vital Signs

In the normal child, which general statement is most accurate in comparison with the adult patient?

A. Blood pressure is higher, heart rate is higher, and ventilatory rate is higher

B. Blood pressure is lower, heart rate is lower, and ventilatory rate is higher

C. Blood pressure is lower, heart rate is higher, and ventilatory rate is higher

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D. Blood pressure is lower, heart rate is higher, and ventilatory rate is lower

Correct Answer: C Detailed Rationale: Due to a smaller cardiovascular structure and higher
metabolic rates, pediatric patients naturally maintain a lower baseline blood pressure alongside
significantly higher resting heart rates and respiratory rates compared to healthy adults.

30. Glasgow Coma Scale (GCS) with Intubation

A patient who withdraws from painful stimuli, opens eyes on verbal command, and cannot speak
because of intubation has a Glasgow Coma Scale of:

A. 8

B. 8T

C. 7

D. 7T

Correct Answer: B Detailed Rationale: The standard components are scored as follows: Eye Opening
= 3 (responds to voice); Motor Response = 4 (withdraws from pain). Because the advanced
endotracheal airway prevents the patient from physically speaking, the verbal component cannot be
assigned a standard numerical value. It is designated with a "T" for intubated patients, making the
final documented score 8T.

31. Intraosseous (IO) Infusion Site Landmarks

The preferred site for intraosseous infusion is:

A. Anterior tibia, just above the tibial tuberosity

B. Anterior fibula

C. Anterior tibia, just below the tibial tuberosity

D. Posterior fibula

Correct Answer: C Detailed Rationale: The proximal tibia provides an excellent, dependable site for
immediate vascular access via intraosseous infusion. The needle is placed on the flat, anteromedial
aspect of the bone, approximately 1–2 cm below the tibial tuberosity. This landmark avoids the
growth plate (epiphyseal plate) in pediatric patients and provides direct access to the rich, non-
collapsible venous sinusoids within the bone marrow cavity.

32. Geriatric Cognitive Assessment

Which of the following behaviors is the most reliable indication of confusion in the elderly trauma
patient?

A. Inability to recall his/her name

B. Inability to recall the day of the week

C. Inability to identify his/her present location when out of his/her normal residence

D. Focus on repeated retelling of events that occurred years ago

Correct Answer: A Detailed Rationale: Forgetting the day of the week or feeling disoriented after
being moved from a familiar environment can happen to elderly patients without indicating an acute

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traumatic brain injury. However, losing track of core identity details—such as forgetting one's own
name—represents a profound neurological deficit that points directly to acute confusion or a
significant head injury.

33. Geriatric Shock Thresholds

In the elderly trauma patient, a high index of suspicion for shock should occur beginning when the
systolic blood pressure is less than:

A. 90 mmHg

B. 150 mmHg

C. 120 mmHg

Correct Answer: C Detailed Rationale: Because many elderly adults have pre-existing hypertension
and stiffer blood vessels, their baseline normal blood pressure is often higher than a younger adult's.
A systolic reading below 120 mmHg, which looks normal in a younger patient, can actually represent
early, serious hypovolemic shock in a geriatric patient. Waiting for their blood pressure to drop
below 90 mmHg before treating means missing the window for early compensation.

34. Femur Fracture Internal Hemorrhage Volume

In an adult patient, blood loss into the tissue from a fractured femur may be as much as which of the
following?

A. 150 to 500 mL

B. 500 to 1000 mL

C. 1000 to 2000 mL

D. 2500 to 5000 mL

Correct Answer: C Detailed Rationale: The thigh has a large soft-tissue compartment that can hold a
significant amount of fluid before pressure slows the bleeding down. A single closed femur fracture
can easily bleed 1,000 to 2,000 mL directly into the thigh. This internal volume loss can push a
patient into severe hypovolemic shock without showing any visible external blood loss.

35. Pathophysiology of Delayed Trauma Death

Delayed death due to trauma is usually a result of:

A. Biochemical and pathophysiological effects of inadequate initial resuscitation

B. Acute circulatory failure

C. Brain injury

D. Acute hypoxia

Correct Answer: A Detailed Rationale: While immediate trauma deaths are usually caused by
massive brain destruction or rapid bleeding, delayed deaths occurring days or weeks later are
typically driven by systemic complications. Inadequate or delayed early fluid and oxygen
resuscitation allows systemic cellular hypoxia to persist. This triggers an inflammatory cascade that
can lead to multi-organ dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS),
or systemic sepsis.

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36. Trauma Center Designations

A regional resource center with a full spectrum of trauma services from prevention to rehabilitation
which serves as the leader in trauma care for a geographical region is a:

A. Level IV trauma center

B. Level III trauma center

C. Level II trauma center

D. Level I trauma center

Correct Answer: D Detailed Rationale: A Level I trauma center is a comprehensive regional center
that handles the highest volume of critical cases. It provides continuous, 24-hour surgical coverage
and leads initiatives across trauma prevention, academic research, medical education, and full-
spectrum rehabilitation.

37. Selective Spinal Immobilization Criteria

Which of the following patients is not indicated for spinal immobilization?

A. Intoxicated patient in a MVC

B. Patient who fell 8 feet and lost consciousness

C. Patient complaining of pain on palpation of the neck

D. Patient with a knife wound to the chest and a GCS of 15

Correct Answer: D Detailed Rationale: Modern PHTLS guidelines show that routine spinal
immobilization for isolated penetrating trauma (such as knife or gunshot wounds) without
neurological deficits does not help the patient and can delay definitive care. Patients who are
intoxicated, have a history of losing consciousness, or report midline neck pain fail standard clearing
protocols and must be immobilized.

38. Core Premise of PHTLS

The premise of PHTLS is that:

A. EMTs must treat all trauma patients based on protocols

B. EMTs are capable of sound patient care judgment, given an adequate knowledge base

C. EMTs must work only under on-line medical direction when caring for trauma patients

D. EMTs are capable of working independently of medical direction

Correct Answer: B Detailed Rationale: PHTLS is built on the philosophy that prehospital providers are
thinking clinicians rather than individuals who simply follow cookbook protocols. Equipped with a
deep understanding of anatomy and trauma pathophysiology, providers are expected to use critical
thinking to adapt their care to the unique challenges of each field situation.

39. Critical Trauma Classification

Which of the following warrants classification of a patient as a critical trauma patient?

A. An extremity fracture

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B. Preexisting major medical problem

C. Bleeding from the nose

D. Deployment of air bags in a motor vehicle crash

Correct Answer: B Detailed Rationale: A patient with severe pre-existing medical conditions (such as
advanced cardiovascular disease, severe COPD, or dependence on blood thinners) has very little
physiological reserve. Minor trauma that a healthy individual could tolerate can quickly become life-
threatening for these patients, clearing the threshold for a critical trauma classification.

40. Foundation of Effective Trauma Care

Which of the following is the foundation of effective trauma care?

A. Protocols permitting invasive airway procedures

B. The ability to administer large amounts of crystalloid fluids

C. The ability to quickly locate and manage life-threatening and potentially life-threatening injuries

D. Effective spinal immobilization skills

Correct Answer: C Detailed Rationale: The core foundation of trauma care relies on a rapid primary
survey designed to quickly locate and manage immediate life threats while minimizing scene delays.
Advanced invasive airway skills or large fluid infusions are secondary interventions that do not
replace rapid assessment and transport.

41. Kinematics and Energy Exchange

You arrive at the scene of a motor vehicle collision in which a vehicle struck a tree. Which is the best
indicator of potential injury?

A. Circumference of the vehicle

B. Diameter of the tree

C. Mass of the vehicle

D. Speed of the vehicle

Correct Answer: D Detailed Rationale: Kinematics relies heavily on the kinetic energy formula.
Because velocity is squared, any increase in speed exponentially multiplies the kinetic energy
transferred to the vehicle and the human body during a collision, making velocity the single most
important factor in predicting injury potential.

42. Vehicle Collision Mechanics

The potential for death or serious injury is greatest in which of the following motor vehicle
collisions?

A) Down and under

B) Ejection from vehicle

C) Lateral compression

D) Up and over

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Correct Answer: B Detailed Rationale: Being ejected from a vehicle exposes a patient to multiple
violent impacts: hitting the interior structure, breaking through the glass, and striking the external
ground or oncoming vehicles. Statistically, patients ejected during a crash face a significantly higher
risk of severe disability or death compared to those who remain inside the protective cabin
structure.

43. Motorcycle Impact Kinematics

Bilateral femur fractures are most often associated with which type of motorcycle crash?

A) Angular impact

B) Bike-road impact

C) Head-on impact

D) Rear impact

Correct Answer: C Detailed Rationale: In a head-on motorcycle crash, the vehicle stops instantly. The
rider's momentum carries them forward, causing their thighs to strike the handlebars at high
velocity. This direct transfer of kinetic energy regularly results in bilateral mid-shaft femur fractures
before the rider is thrown clear of the bike.

44. Fluid Resuscitation in Hemorrhagic Shock

Which is the preferred fluid for resuscitation of hemorrhagic shock in the prehospital setting?

A) 5% dextrose in water

B) 7.5% hypertonic saline

C) Hetastarch

D) Lactated Ringer's

Correct Answer: D Detailed Rationale: Isotonic crystalloids, specifically Lactated Ringer's, are the
standard choice for prehospital volume expansion when blood products are unavailable. They
balance electrolyte concentrations and remain within the intravascular space significantly longer
than hypotonic solutions like D5W, which quickly shift out into cellular tissue.

45. Upper Airway Obstruction Causes

Which is the most common cause of upper airway obstruction in the trauma patient?

A) Blood

B) Teeth

C) Tongue

D) Vomitus

Correct Answer: C Detailed Rationale: When a trauma patient loses consciousness, the muscles of
the jaw and hypopharynx relax completely. This allows the tongue to drop backward against the
posterior pharyngeal wall, acting as a physical valve that blocks the upper airway. This displacement
can be corrected using basic manual airway maneuvers like the jaw-thrust.

46. Mechanical Resuscitation Interventions

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Your patient is an unresponsive male who crashed his motorcycle, presenting with a respiratory rate
of 6 and absent breath sounds on the left side. What is the most appropriate next intervention?

A) Apply a non-rebreather mask

B) Begin ventilation with a BVM

C) Insert an endotracheal tube

D) Perform a needle decompression

Correct Answer: B Detailed Rationale: A respiratory rate of 6 breaths per minute represents
imminent respiratory failure that cannot sustain life. The immediate priority is to support ventilation
manually using a Bag-Valve-Mask (BVM) with high-flow oxygen. While the absent breath sounds on
the left side could point to a pneumothorax or hemothorax, you must address the immediate threat
of respiratory arrest before attempting invasive procedures like needle decompression or intubation.

47. Shock Definition

Which best describes shock?

A) Decreased Glasgow Coma Scale (GCS)

B) Flushed, dry, hot skin combined with bradycardia

C) Generalized inadequate tissue perfusion

D) Low blood pressure combined with tachycardia

Correct Answer: C Detailed Rationale: At its fundamental physiological level, shock is defined as
generalized inadequate tissue perfusion. It represents a state where the circulatory system fails to
deliver enough oxygen and nutrients to capillary beds to meet basic cellular metabolic demands,
forcing cells to shift into anaerobic metabolism.

48. Primary Survey Ordering (XABCDE)

When using the XABCDE assessment, which of the following takes precedence over all other actions?

A. Controlling severe bleeding from a limb or other compressible site

B. Airway stabilization and assessing circulatory status

C. Exposing the body to allow a thorough evaluation

D. Ensuring adequate breathing

[ STEP X ] ◄─── CRITICAL EXSANGUINATING HEMORRHAGE (Stop within seconds)

[ STEP A ] ◄─── Airway Maintenance & C-Spine Control

[ STEP B ] ◄─── Breathing and Ventilation

[ STEP C ] ◄─── Circulation (Internal Bleeding/Pulses)

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Correct Answer: A Detailed Rationale: The "X" stands for exsanguinating external hemorrhage.
Severe arterial bleeding can deplete a patient's total blood volume within minutes. PHTLS places this
step before airway management because an open airway provides no benefit if the patient pumps
out their entire circulating blood volume onto the ground while the airway is being secured.

49. The Critical Thinking Process

Which of the following requires you to develop a plan of action, initiate the plan, reassess the plan as
care for the patient moves forward, and adjust the plan as the patient's condition or circumstances
change?

A. Principles of PHTLS

B. The Golden Period

C. The XABCDE assessment

D. Critical thinking process

Correct Answer: D Detailed Rationale: This describes the critical thinking process in medicine. It is an
ongoing, dynamic loop where the clinician constantly observes the patient, processes new data,
applies interventions, evaluates the patient's response, and refines the care plan in real time.

50. The Golden Period Goals

Which of the following is a goal of the Golden Period?

A. Provide written documentation from field care to receiving hospital.

B. Expedite the field care and transport of the patient.

C. Use a team approach for optimal patient care.

D. Use the XABCDE approach to patient assessment.

Correct Answer: B Detailed Rationale: The primary goal of the Golden Period is to minimize scene
time and safely speed up transport to definitive surgical care. Because internal traumatic bleeding
cannot be stopped in the field, reducing the time between the initial injury and surgical intervention
is a key factor in patient survival.

51. First Priority on a Mass Casualty Scene

You are called to the scene of a possible mass casualty motor vehicle collision on the highway. Once
you arrive on scene, what is your first priority?

A. Immediately begin triaging patients.

B. Treat the patient with the most visible blood loss.

C. Determine the need for additional resources.

D. Assess the scene and ensure it is safe.

Correct Answer: D Detailed Rationale: Responders must always ensure scene safety before
approaching any patient. Entering an unsecured highway scene risks injury from passing traffic, fire,
or hazardous materials. If a provider becomes injured, they can no longer help others and add to the
patient count, further straining emergency resources.

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52. Management of Venous Hemorrhage

A trauma patient is holding her arm, and you note a significant amount of dark red blood steadily
flowing from a long gash. What type of hemorrhage is this, and what is the best way to control it?

A) Capillary bleeding; Tourniquet

B) Venous bleeding; Direct pressure

C) Arterial bleeding; Elevation

D) Road rash; Occlusive dressing

Correct Answer: B Detailed Rationale: A steady flow of dark red blood indicates a venous bleed.
Because veins operate under lower pressure than arteries, applying firm, direct pressure to the
wound site is typically highly effective for stopping the bleeding and allowing clots to form.

53. Visualizing Traumatic Wounds

The patient is wearing long sleeves, and you are having trouble visualizing the wound. What should
you do?

A. Cut the cloth away from the site until the entire wound site is visible.

B. Leave the clothing in place. Put gauze over the wound.

C. Remove the patient's shirt.

D. Cut through the sleeve and use it as a makeshift tourniquet.

Correct Answer: A Detailed Rationale: A core tenet of trauma management states: "You cannot treat
what you cannot see." Providers should quickly cut clothing away from injury sites to accurately
assess the wound's size, check for underlying fractures, and ensure that hemorrhage control
measures are applied directly to the bleeding vessels.

54. Airway Control with Cervical Spine Concerns

An explosion casualty is found unconscious with gurgling respirations. Why should you use the
trauma jaw-thrust maneuver first?

A. It's an easy technique that always works to open the airway.

B. It allows you to open the airway with little or no movement of the head and cervical spine.

C. Other techniques and interventions don't work as well.

D. It can relieve a variety of anatomic airway obstructions.

Correct Answer: B Detailed Rationale: In any severe blast or blunt trauma scenario, a cervical spine
injury must be suspected. The trauma jaw-thrust maneuver allows providers to pull the mandible
forward to clear the tongue from the airway while keeping the neck in a neutral, in-line position,
minimizing the risk of worsening a spinal cord injury.

55. Pediatric Airway Anatomical Differences

Why might it be more difficult to deal with an airway obstruction in a child?

A. Children have longer tracheas.

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B. Children have larger heads and tongues so there is a greater potential for airway obstruction.

C. Children have smaller heads, so there is less room to clear the obstruction.

D. A child's epiglottis is smaller and stiffer than an adult's.

Correct Answer: B Detailed Rationale: Proportionally, children have a much larger tongue and a
more prominent occiput (the back of the head) compared to adults. When a child lies flat on their
back, the large back of the head naturally forces the neck into slight flexion, which can easily cause
the large tongue to slide back and block the narrow airway.

56. Geriatric Airway and Physiological Reserve

Why might you consider early mechanical ventilation via bag-mask device in a geriatric patient?

A. Shorter tracheas in geriatric patients create the need for ventilation assistance.

B. Laxity of the rib cage makes hyperventilation more likely.

C. Geriatric patients have greatly limited physiologic reserve.

D. Geriatric patients have a greater alveolar surface area of the lungs.

Correct Answer: C Detailed Rationale: Older adults have a significantly reduced physiologic reserve
across their respiratory and cardiovascular systems. They tire much faster under stress, and their
bodies cannot tolerate prolonged hypoxemia or hypercarbia. Assisting their ventilations early
prevents rapid respiratory failure and subsequent cardiac arrest.

57. Electronic Monitoring Discrepancies

En route to the trauma center, your electronic monitors start to differ from your thoracic trauma
patient's current clinical condition each time you reassess. How should you handle this situation?

A. Treat the patient's condition, not the monitor results.

B. Continue to reassess the patient and record the results.

C. Treat your patient based on the test results.

D. Stop testing and wait until you arrive at the trauma center.

Correct Answer: A Detailed Rationale: In prehospital care, providers must always treat the patient,
not the monitor. Electronic devices can malfunction or lose calibration due to ambulance movement,
poor peripheral perfusion, or artifact interference. Physical findings—such as changing mental
status, skin condition, and breath sounds—are the most dependable indicators of a patient's status.

58. Intubation Preparation Protocols

You need to perform orotracheal intubation on a critically injured trauma patient due to a prolonged
transport time. What do you need to do first?

A. Pre-oxygenate to maximize oxygen saturation.

B. Place the patient in a "sniffing" position.

C. Clear the mouth of any obstructions.

D. Prepare the patient for immediate transport.

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Correct Answer: A Detailed Rationale: Inserting an invasive airway carries a risk of inducing hypoxia
during the procedure. It is essential to pre-oxygenate the patient with 100% oxygen using a non-
rebreather mask or manual ventilations beforehand. This step fills the functional residual capacity of
the lungs with pure oxygen, providing a vital buffer window to safely complete the intubation
without a dangerous drop in oxygen levels.

59. Quantitative Capnography Targets

When oxygenating a pediatric patient using a bag-mask device, you check your end-tidal $\
text{CO}_2$ ($\text{ETCO}_2$) monitoring, aiming to maintain what level?

A. Between 40 and 45 mm Hg

B. Between 30 and 35 mm Hg

C. Between 35 and 40 mm Hg

D. The level is irrelevant because capnography is inaccurate in pediatric patients.

Correct Answer: C Detailed Rationale: A normal, healthy $\text{ETCO}_2$ target for both adult and
pediatric patients is 35 to 40 mm Hg. Keeping the carbon dioxide output within this narrow range
ensures adequate ventilation while preventing hyperventilation or hypoventilation, both of which
can alter cerebral blood flow.

60. Tension Pneumothorax Intervention Rationale

A male patient with multiple stab wounds to the left chest becomes pale, rapid-breathing, and
combative, stating he "can't breathe." What is your next move?

A. Start assisted ventilation.

B. Give high-flow oxygen.

C. Decompress the left chest.

D. Give a 250-mL fluid bolus.

Correct Answer: C Detailed Rationale: Penetrating chest wounds combined with worsening dyspnea,
agitative behavior, and poor perfusion point directly to a tension pneumothorax. In this state, air is
trapped inside the pleural space and cannot escape, building up pressure that collapses the lung and
shifts the mediastinum. This pressure compresses the vena cava, blocking blood return to the heart
and causing rapid circulatory collapse. Performing an immediate needle decompression is the fastest
way to relieve this pressure, restore venous return, and treat obstructive shock.

61. Balance of Hemorrhage Control and Transport Priority

The patient's respiration improves after decompression, but he remains confused with an absent
radial pulse and a fast, thready carotid pulse. Your partner asks if he can stop applying pressure to
the chest wound to start an IV. How should you respond?

A. "Oh yes, that's a great idea!"

B. "Yes, but we have to immobilize him first"

C. "Take a blood pressure first to see if he needs an IV."

D. "No, keep the pressure and let's get out of here!"

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Correct Answer: D Detailed Rationale: This patient is in decompensated shock, likely from internal
bleeding. The highest priority is rapid transport to an operating room. Releasing pressure on an
external wound risks restarting severe bleeding, which would worsen the patient's condition. Direct
pressure must be maintained continuously while moving quickly toward the hospital.

62. Permissive Hypotension Principles

You manage to place an IV while en route, but the patient remains confused with no radial pulse.
How should you manage fluid resuscitation?

A. Give 1-L fluid bolus.

B. Give one 250-mL fluid bolus, and then stop.

C. Give fluid until you get a radial pulse.

D. Administer TXA.

Correct Answer: C Detailed Rationale: Resuscitation for internal bleeding without a traumatic brain
injury follows the principle of permissive hypotension. Fluids should be carefully titrated until a weak
radial pulse returns, which indicates a systolic blood pressure of around 80–90 mmHg. Administering
large fluid boluses can raise blood pressure too much, diluting clotting factors and popping freshly
formed clots, which can cause severe re-bleeding.

63. Antiplatelet Therapy Complications in Trauma

A patient mentions during the secondary survey that he takes oral Clopidogrel (Plavix). Why is this
information highly critical?

A. No, he should stop talking and breathe.

B. Yes, he should see a cardiologist once in the local hospital.

C. Yes, he will need platelets and a heart surgeon ASAP.

D. Yes, you should raise his blood pressure up to 130 mm Hg systolic.

Correct Answer: C Detailed Rationale: Clopidogrel is an antiplatelet medication that irreversibly

blocks platelets for their entire lifespan (about 5–7 days). This significantly impairs the body's ability
to form stable blood clots after trauma. Alerting the receiving trauma center early is vital so they can
prepare for an immediate platelet transfusion and rapid surgical intervention.

64. Intracranial Hematoma Identification

A 72-year-old woman taking Warfarin presents with a severe headache and worsening confusion
after a fall earlier in the week. Her vital signs show: BP 110/90, HR 118 (irregular), RR 20, and $\
text{SpO}_2$ 93%. Which injury should you suspect?

A. Cerebral contusion

B. Epidural hematoma

C. Subarachnoid hemorrhage

D. Subdural hematoma

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Correct Answer: D Detailed Rationale: The slow, gradual onset of neurological symptoms over days
following a minor fall is a classic presentation of a subdural hematoma. This injury involves tearing of
the bridging veins between the dura and the brain. In elderly patients, normal brain shrinkage leaves
more room in the skull, allowing blood to collect slowly before causing symptoms. This risk is
significantly increased by her use of Warfarin, a major anticoagulant.

65. Traumatic Brain Injury Severity Classification

The patient's GCS score is calculated as 12 (Eyes: 4, Verbal: 4, Motor: 4). What does this score
indicate?

A. Mild TBI

B. Moderate TBI

C. Severe TBI

D. No TBI

Correct Answer: B Detailed Rationale: Traumatic brain injuries are categorized by GCS scores: a score
of 13 to 15 indicates a mild injury, 9 to 12 indicates a moderate injury, and 3 to 8 points to a severe
head injury requiring intensive airway management.

66. Uncal Herniation Pathophysiology

The patient's right pupil becomes dilated and her motor response on the left side is delayed. What
does this suggest?

A. Coup-countercoup injury

B. Hyphema

C. Hypoxia

D. Uncal herniation

Correct Answer: D Detailed Rationale: This presentation describes uncal herniation. As pressure
builds on one side of the brain, the inner edge of the temporal lobe (the uncus) is forced downward
across the tentorial notch. This puts direct pressure on the oculomotor nerve (CN III) on that side,
causing the pupil to dilate. It also compresses the nearby corticospinal tract, which crosses over in
the brainstem, leading to weakness or delayed motor responses on the opposite side of the body.

67. Monro-Kellie Doctrine in Compensated States

According to the Monro-Kellie doctrine, what happens to the brain when it is still in a compensated
state after a TBI?

A. CSF, ICP, heart rate, and blood pressure are still within normal range.

B. CSF increases, ICP decreases, heart rate increases, and blood pressure decreases.

C. CSF and blood volume decrease, while heart rate and blood pressure are still within normal range.

D. CSF decreases, ICP increases, heart rate decreases, and blood pressure increases.

Correct Answer: C Detailed Rationale: The Monro-Kellie doctrine states that the skull is a rigid, fixed
container filled with three components: brain tissue, blood, and cerebrospinal fluid (CSF). If a new

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mass, like a blood clot, begins to grow, the body compensates to keep intracranial pressure (ICP)
normal by pushing out some CSF and venous blood volume. During this early compensated phase,
vital signs like heart rate and blood pressure remain within normal ranges.

68. Adult Spinal Immobilization Padding

When securing an adult patient with a potential spinal injury to a backboard, how should you secure
and pad them?

A. Secure head first; use compressible padding under the shoulders to prevent hyperflexion.

B. Secure torso first; use firm padding between the back of the head and the backboard to prevent
hyperextension.

C. Secure legs first; do not use any padding whatsoever to avoid extension.

D. Secure pelvis first; leave unpadded but tip backboard immediately to a left lateral position.

Correct Answer: B Detailed Rationale: When immobilizing a patient, the torso must be secured to
the board first, followed by the head, legs, and pelvis. This order ensures that any movement of the
body during strapping does not pull or twist the neck. For adult patients, the back of the head
naturally sits slightly forward relative to the shoulders when lying flat. Firm padding should be placed
behind the head to fill this gap and prevent hyperextension of the cervical spine.

69. Modifications for Respiratory Distress During Restraint

While attempting to lay a patient with a fractured clavicle and ribs supine for spinal restriction, she
becomes increasingly distressed and short of breath. What should you do?

A. Tip the backboard to a left lateral position.

B. Raise the back of the stretcher.

C. Let her sit up completely in a position of comfort without restriction.

D. Administer morphine.

Correct Answer: B Detailed Rationale: Forcing a trauma patient with rib fractures and a clavicle injury
into a completely flat, supine position can severely restrict their chest wall movement and
compromise their breathing. In these situations, elevating the head of the stretcher slightly helps
relieve respiratory distress while keeping the spine aligned and protected.

70. Pediatric Burn Evaluation and Inadvertent Harm

A 2-year-old child presents with a wet, red burn with blisters on his left hand. The babysitter is
applying ice to the wound, and the child is shivering. What type of burn is this, and what is your next
immediate step?

A) Superficial; Administer strong pain analgesia immediately.

B) Partial thickness; Stop the burning process and remove the ice pack.

C) Full thickness; Start an IV line for large fluid resuscitation.

D) Subdermal; Lance the blisters immediately to drain the fluid.

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Correct Answer: B Detailed Rationale: A wet, red burn with blisters is classified as a partial thickness
(second-degree) burn. Applying ice or ice packs directly to a burn is highly discouraged because it
causes severe vasoconstriction. This cold exposure reduces blood flow to the injured area,
converting a temporary zone of stasis into permanent tissue loss. It also quickly triggers shivering
and hypothermia in small children. The correct intervention is to remove the ice and cover the area
with a clean, dry dressing.

71. Burn Blister Field Management

How should you manage the intact blisters that have formed on this pediatric patient's burned
hand?

A. Lance the blisters to drain the fluid and relieve the pressure.

B. Cover the injury with a dry, loose, sterile dressing, being sure to leave the blisters intact.

C. Use a topical antibiotic ointment and firmly wrap the burn injury.

D. Establish an IV for fluid resuscitation.

Correct Answer: B Detailed Rationale: In prehospital care, intact burn blisters should be left
completely alone. The intact skin serves as a sterile, natural barrier that protects the delicate raw
tissue underneath from contamination and infection. Breaking them open increases the risk of local
infection.

72. Field Analgesia Selection

A motorcycle crash patient has an isolated femur fracture and reports severe pain during a 20-
minute transport window. Which pain medication is the best choice?

A. NSAIDs

B. Acetaminophen

C. Fentanyl

D. Morphine

Correct Answer: C Detailed Rationale: Fentanyl is preferred for acute severe trauma pain because it
has a rapid onset, a short duration of action, and minimal impact on blood pressure. Morphine
carries a higher risk of inducing vasodilation and hypotension, making it less ideal for patients who
may have underlying internal bleeding from a high-energy mechanism.

73. Tourniquet Application Protocol

A male patient has a deep laceration on his thigh with bright red blood spurting from the wound.
Direct pressure is not controlling the bleeding. What is the most appropriate next step?

A) Apply a topical hemostatic agent and transport

B) Apply a tourniquet and tighten it until bleeding stops

C) Elevate the leg and apply pressure to the femoral artery

D) Maintain direct pressure and transport immediately

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Correct Answer: B Detailed Rationale: Spurting bright red blood indicates a severe arterial injury. If
direct pressure fails to stop the bleeding, a combat tourniquet must be applied immediately
proximal to the injury and tightened until the bleeding stops and the distal pulse disappears.
Delaying this step to try elevation or pressure points can lead to fatal volume loss.

74. Distracting Injuries and Spinal Immobilization

An 18-year-old female was struck by a car and has a clear left femur fracture. She only speaks a
foreign language, hampering communication. Which finding, by itself, does not mandate spinal
immobilization?

A) Fracture of the femur

B) Inability to communicate

C) Mechanism of injury

D) Tenderness over the cervical spine

Correct Answer: C Detailed Rationale: Under modern PHTLS clinical guidelines, a high-energy
mechanism of injury alone does not automatically require spinal immobilization. Immobilization is
required if the mechanism is accompanied by clinical findings, such as a severe distracting injury (the
femur fracture), a communication barrier that prevents an accurate exam, or direct midline spinal
tenderness.

75. Altered Mental Status in Trauma

During the primary survey, you note that a patient is agitated, confused, and has multiple injuries
from an altercation. Which of the following choices is the most appropriate first treatment priority?

A) Blood glucose determination

B) Correction of possible hypoxia

C) Full immobilization to a backboard

D) Obtain intravenous access

Correct Answer: B Detailed Rationale: In any trauma patient, acute agitation, confusion, or altered
mental status must be assumed to be caused by hypoxia until proven otherwise. Ensuring a
functional airway and providing high-flow oxygen takes absolute priority during the primary survey
over blood draws or secondary testing.

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