Chest Trauma Flashcards
A patient presented to the emergency department with a flail chest after a motor vehicle accident. He has been in the trauma bay for almost 16 hours. His current vitals: O2 96%, heart rate 94, blood pressure 138/88, respiratory rate 22, temperature 37.6° C. His chest x-ray on admission showed the expected rib fractures but nothing else of concern. The patient is in pain but otherwise stable. The advanced practice registered nurse (APRN) receives a page from the RN asking if the patient could be discharged. The APRN explains that the patient still needs to be monitored for which of the following reasons?
A. Pulmonary contusions may take up to 24 hours to progress after injury.
B. The patient needs a chest CT before he can be discharged.
C. The patient’s vital signs indicate that he might have cardiac tamponade.
D. There is chance this patient has suffered from blunt aortic injury.
Correct Answer: A. Pulmonary contusions may take up to 24 hours to progress after injury.
Rationale:
Pulmonary contusions can initially be subtle or even absent on imaging and may worsen within the first 24 hours post-injury. This delayed progression is why the patient still requires monitoring, despite being hemodynamically stable and having normal initial findings on the chest x-ray. The other options either do not align with the clinical picture or are not indicated based on the patient’s current status.
Chest Trauma / Will Kill)
A 45-year-old patient arrives after a motor vehicle collision with deviated trachea, hypotension, and distended neck veins. Which diagnosis must be addressed immediately?
A. Tension pneumothorax
B. Simple rib fracture
C. Cardiac tamponade
D. Pulmonary contusion
Correct Answer: A. Tension pneumothorax
Rationale:
The clinical presentation of a deviated trachea, hypotension, and distended neck veins is highly suggestive of a tension pneumothorax—a life-threatening condition that requires immediate intervention. These signs indicate that intrathoracic pressure is building up, leading to compromised venous return and cardiovascular collapse. Other options, such as a simple rib fracture, cardiac tamponade, or pulmonary contusion, do not typically present with a deviated trachea in this context and are less immediately life-threatening in this scenario.
- (Chest Trauma / Will Harm)
In blunt chest trauma, undertreating pain can lead to which common complication?
A. Enhanced inspiratory effort
B. Atelectasis and hypoventilation
C. Improved oxygenation
D. Bronchospasm
Correct Answer: B. Atelectasis and hypoventilation
Rationale:
Undertreating pain in patients with blunt chest trauma often leads to shallow breathing due to discomfort. This reduced inspiratory effort can result in atelectasis (collapse of small areas of the lung) and hypoventilation, which in turn increases the risk for respiratory complications such as pneumonia.
Chest Trauma / Common Investigation)
Which rapid imaging modality is frequently used in trauma bays to assess for hemothorax or pericardial effusion?
A. Chest X-ray only
B. FAST ultrasound exam
C. MRI of the chest
D. Pulmonary angiography
Correct Answer: B. FAST ultrasound exam
Rationale:
The FAST (Focused Assessment with Sonography for Trauma) ultrasound exam is frequently used in trauma bays as a rapid, non-invasive imaging modality to assess for hemothorax, pericardial effusion, and other intra-abdominal injuries. This method allows for quick evaluation and helps guide urgent management decisions in the trauma setting.
- A patient presents with blunt chest trauma after a motor vehicle accident. Which complication “will kill your patient” if not rapidly diagnosed?
A. Rib fractures only
B. Cardiac tamponade due to myocardial contusion
C. Minor soft tissue injury
D. Pulmonary contusion without hypoxemia
Answer: B
o Rationale: Cardiac tamponade from trauma is life-threatening and requires immediate intervention.
- In chest trauma, what is “really common” to occur in the lung parenchyma?
A. Pulmonary embolism
B. Pulmonary contusion
C. Chronic bronchitis
D. Asthma exacerbation
o Answer: B
o Rationale: Pulmonary contusions are a common injury in blunt chest trauma.
- Which complication from chest trauma “will harm your patient” if missed?
A. Pneumothorax
B. Simple rib fracture
C. Subcutaneous emphysema
D. Mild chest wall bruising
o Answer: A
o Rationale: A pneumothorax, especially if tension develops, is life-threatening and requires prompt recognition and management.
- For a trauma patient with chest injury, which of the following is the initial ABC intervention?
A. Establishing IV access only
B. Securing the airway and ensuring adequate breathing
C. Immediate surgical intervention
D. Administering analgesics only
.
o Answer: B
o Rationale: Airway and breathing (the “A” and “B”) are the first priorities in trauma management
A 32-year-old man is brought to the emergency department after a high-speed motor vehicle collision. He is tachypneic, hypotensive, and has absent breath sounds on the right side with tracheal deviation to the left. What is the most immediate next step?
A) Obtain a STAT chest X-ray
B) Perform immediate needle decompression
C) Administer 100% oxygen and reassess
D) Order a CT scan of the chest
Answer: B
Rationale: This presentation suggests tension pneumothorax, which requires immediate needle decompression before imaging or further interventions.
A 45-year-old woman is stabbed in the left chest and arrives hypotensive and tachycardic. Her left chest wall is dull to percussion, and breath sounds are decreased. A chest tube is placed, yielding 1,600 mL of blood. What is the next step?
A) Continue chest tube drainage and observe
B) Prepare for emergent thoracotomy
C) Transfuse one unit of blood and reassess
D) Obtain a CT angiogram of the chest
Answer: B
Rationale: A massive hemothorax (>1,500 mL from a chest tube initially) indicates ongoing hemorrhage, necessitating emergent thoracotomy
A 65-year-old man falls from a ladder and presents with left-sided chest pain and tenderness over ribs 4–6. His oxygen saturation is 91% on room air. Chest X-ray shows three rib fractures without pneumothorax. What is the best next step?
A) Discharge with oral pain medications
B) Admit for pain control and pulmonary hygiene
C) Place a chest tube to prevent pneumothorax
D) Perform an emergent thoracotomy
Answer: B
Rationale: Rib fractures in elderly patients increase the risk of atelectasis and pneumonia. Pain control and pulmonary hygiene reduce complications.
A 22-year-old man is brought in after a blunt chest trauma from a motorcycle crash. He has paradoxical chest wall movement. What is the most likely diagnosis?
A) Tension pneumothorax
B) Massive hemothorax
C) Flail chest
D) Pulmonary contusion
Answer: C
Rationale: Flail chest occurs when three or more ribs are fractured in two or more places, leading to paradoxical movement.
A 50-year-old man presents after a fall. He is tachycardic, tachypneic, and has bruising over his right chest. His oxygen saturation is 90%. Chest X-ray shows no fractures, but a CT scan reveals a pulmonary contusion. What is the best initial treatment?
A) Immediate intubation
B) Supplemental oxygen and pain control
C) Prophylactic antibiotics
D) Chest tube placement
Answer: B
Rationale: Pulmonary contusion causes hypoxia due to alveolar hemorrhage. Oxygen and pain control help prevent complications
A 30-year-old man with a penetrating chest wound has a FAST exam showing pericardial fluid. He becomes hypotensive with muffled heart sounds and distended neck veins. What is the next step?
A) Perform a pericardiocentesis
B) Obtain a CT scan
C) Start broad-spectrum antibiotics
D) Place a chest tube
Answer: A
Rationale: Cardiac tamponade requires urgent pericardiocentesis to relieve pressure on the heart.
A 47-year-old woman with blunt thoracic trauma has a widened mediastinum on chest X-ray. What is the most likely diagnosis?
A) Cardiac tamponade
B) Pulmonary contusion
C) Aortic injury
D) Diaphragmatic rupture
Answer: C
Rationale: A widened mediastinum is suggestive of a thoracic aortic injury, which requires emergent evaluation with a CT angiogram.
A 55-year-old man is intubated after blunt chest trauma. He develops hypotension and increased peak inspiratory pressures. What is the most likely cause?
A) Tension pneumothorax
B) Cardiac tamponade
C) Hypovolemic shock
D) Pulmonary embolism
Answer: A
Rationale: High peak inspiratory pressures in an intubated trauma patient suggest tension pneumothorax, requiring immediate decompression.
Which of the following is the most reliable indicator of significant blunt cardiac injury?
A) ECG changes and troponin elevation
B) Hypotension unresponsive to fluids
C) Widened mediastinum on X-ray
D) Decreased breath sounds
Answer: A
Rationale: ECG changes (arrhythmias) and elevated troponin suggest myocardial contusion, which can cause hemodynamic instability.
A 60-year-old man is found to have a small pneumothorax after a minor chest trauma. He is asymptomatic. What is the best management?
A) Needle decompression
B) Immediate chest tube placement
C) Observation with repeat chest X-ray
D) Surgical intervention
Answer: C
Rationale: Small pneumothorax in a stable patient can be managed with observation and follow-up imaging.
A 29-year-old man with a stab wound to the chest is hemodynamically stable. What is the most appropriate imaging study?
A) Chest X-ray
B) CT angiogram
C) FAST ultrasound
D) Bronchoscopy
Answer: C
Rationale: FAST ultrasound quickly assesses for pericardial effusion and hemothorax in penetrating thoracic trauma.
A 33-year-old woman presents after a car accident. She has difficulty breathing, hypotension, and subcutaneous emphysema. What is the most likely diagnosis?
A) Tension pneumothorax
B) Tracheobronchial injury
C) Flail chest
D) Esophageal rupture
Answer: B
Rationale: Tracheobronchial injuries present with subcutaneous emphysema and respiratory distress.
A 45-year-old man with blunt chest trauma is hypotensive despite fluid resuscitation. What is the next best step?
A) Perform FAST ultrasound
B) Start vasopressors
C) Order a chest CT
D) Obtain arterial blood gases
Answer: A
Rationale: FAST ultrasound quickly identifies sources of bleeding in trauma patients.
Which of the following thoracic injuries is most commonly associated with blunt trauma?
A) Flail chest
B) Myocardial contusion
C) Aortic rupture
D) Esophageal perforation
Answer: B
Rationale: Myocardial contusion is common in blunt chest trauma and may cause arrhythmias or cardiac dysfunction.
A 28-year-old man with multiple rib fractures is unable to take deep breaths due to severe pain. What is the best initial management?
A) Opioid analgesia and pulmonary hygiene
B) Endotracheal intubation
C) Prophylactic antibiotics
D) Bronchoscopy
Answer: A
Rationale: Pain control and pulmonary hygiene prevent atelectasis and pneumonia in rib fractures.
A 27-year-old man is brought to the ED after being ejected from a vehicle during a high-speed collision. He is tachycardic, tachypneic, and has decreased breath sounds on the right side with dullness to percussion. Chest X-ray shows a large hemothorax. Which intervention is the most appropriate next step?
A) Immediate needle decompression
B) Chest tube placement
C) Emergent thoracotomy
D) Observation and serial hemoglobin measurements
Answer: B
Rationale: Chest tube placement is the first-line treatment for a large hemothorax. If there is massive ongoing bleeding, thoracotomy may be needed.
A 35-year-old woman sustains a stab wound to the left anterior chest. She is tachycardic and has jugular venous distension with muffled heart sounds. FAST exam confirms pericardial effusion. What is the most immediate intervention?
A) Perform pericardiocentesis
B) Obtain a CT scan of the chest
C) Start intravenous fluids and broad-spectrum antibiotics
D) Place a chest tube
Answer: A
Rationale: Beck’s triad (hypotension, muffled heart sounds, JVD) suggests cardiac tamponade, which requires urgent pericardiocentesis.
A 50-year-old man is intubated following blunt chest trauma. His blood pressure suddenly drops, and his ventilator peak pressures increase. What is the most likely diagnosis?
A) Pulmonary embolism
B) Tension pneumothorax
C) Cardiac tamponade
D) Myocardial infarction
Answer: B
Rationale: Sudden hypotension and increased ventilator pressures in a trauma patient suggest tension pneumothorax, requiring immediate needle decompression.
A 40-year-old woman presents after a motor vehicle collision with severe left-sided chest pain. Chest X-ray shows multiple rib fractures. Which of the following best reduces her risk of pneumonia?
A) High-dose corticosteroids
B) Incentive spirometry and multimodal pain control
C) Chest tube placement
D) Immediate intubation
Answer: B
Rationale: Pulmonary hygiene (e.g., incentive spirometry) and adequate pain control reduce atelectasis and pneumonia risk.
A 22-year-old male was stabbed in the chest and is hemodynamically stable. A small pneumothorax is noted on the chest X-ray. What is the best initial management?
A) Immediate chest tube placement
B) Observation with repeat chest X-ray
C) Intubation for airway protection
D) Needle decompression
Answer: B
Rationale: Small, stable pneumothoraces can be managed conservatively with serial chest X-rays to ensure no progression.
A 60-year-old man presents after a fall from a height of 15 feet. He is hemodynamically stable but has paradoxical chest wall movement. Which of the following is the most appropriate initial management?
A) Chest tube placement
B) Immediate intubation and mechanical ventilation
C) Pain control and supplemental oxygen
D) Surgical fixation of the rib fractures
Answer: C
Rationale: Flail chest is managed with pain control and oxygenation. Intubation is reserved for respiratory failure.
A 55-year-old woman presents with dyspnea after a high-speed motor vehicle crash. She has subcutaneous emphysema and a widened mediastinum on chest X-ray. What is the most concerning potential diagnosis?
A) Tracheobronchial injury
B) Pulmonary contusion
C) Esophageal perforation
D) Aortic dissection
Answer: A
Rationale: Subcutaneous emphysema and a widened mediastinum suggest tracheobronchial injury, often requiring bronchoscopy.
A 30-year-old male with blunt chest trauma presents with persistent tachycardia, hypotension, and an anterior chest wall contusion. His ECG shows sinus tachycardia with ST segment changes. Which of the following is the most likely diagnosis?
A) Myocardial contusion
B) Aortic dissection
C) Pulmonary embolism
D) Pneumothorax
Answer: A
Rationale: Myocardial contusion is common in blunt chest trauma and can present with ECG changes (e.g., ST-segment abnormalities) and persistent tachycardia.
A 48-year-old man with a history of COPD presents after a minor fall with right-sided rib fractures. He is hypoxic on room air. Which of the following is the best management approach?
A) Immediate intubation
B) Pain control and pulmonary hygiene
C) Chest tube placement
D) Broad-spectrum antibiotics
Answer: B
Rationale: Pain control and pulmonary hygiene are critical in preventing respiratory complications in rib fractures.
A 25-year-old male is brought to the ED after a gunshot wound to the right chest. He is hemodynamically stable, but the initial chest X-ray shows a pneumothorax and moderate hemothorax. What is the best initial management?
A) Observation
B) Immediate thoracotomy
C) Chest tube placement
D) Bronchoscopy
Answer: C
Rationale: Pneumothorax and hemothorax from penetrating trauma require immediate chest tube placement to prevent deterioration.
Tension pneumothorax →
Immediate needle decompression
Massive hemothorax →
→ Chest tube + consider thoracotomy (>1,500 mL output
Cardiac tamponade
look for tamponade (Beck’s triad: hypotension, muffled heart sounds, JVD) → treat with Pericardiocentesis
Flail chest →
Pain control + pulmonary hygiene (intubate only if respiratory failure)
Tracheobronchial injury
look for → Subcutaneous emphysema + mediastinal air → treat with Bronchoscopy
Pulmonary contusion
Peaks at 48-72 hrs, worsens over time treat with → Oxygen + fluid restriction
Blunt cardiac injury
look for ECG changes, tachycardia → Monitor for arrhythmias
