Comprehensive Prehospital Trauma Life
Support and PHTLS Practice Exam –
Updated 2026 (Graded A+)
Subject: Prehospital Trauma Life Support (PHTLS)
Subtopic: Kinematics of Trauma and Primary Assessment
Question 1: In a high-speed frontal collision, a patient is found unrestrained with significant
deformity to the steering column. Which of the following secondary impact patterns should the
paramedic prioritize during the assessment of the chest and abdomen?
A) Compression injury to the anterior chest wall and potential deceleration injury to the thoracic
aorta.
B) Seatbelt-related abdominal evisceration and lumbar spine fracture.
C) Whiplash-type cervical spine injury and facial fractures.
D) Traumatic brain injury and bilateral femur fractures.
Correct Answer: A - Compression injury to the anterior chest wall and potential
deceleration injury to the thoracic aorta.
Rationale: The steering wheel impact commonly results in anterior chest wall compression (flail
chest, cardiac contusion). Furthermore, the rapid deceleration of the torso causes the heart and
great vessels to continue moving forward, which frequently results in shearing or transection of
the thoracic aorta at the ligamentum arteriosum. While B and C are possible in other collision
types (rear-end or unrestrained), A is the classic, high-mortality sequela of steering column
impact.
Question 2: During the primary assessment of a trauma patient, you identify a patent airway, but
the patient exhibits paradoxical chest wall movement and severe respiratory distress. According
to PHTLS, what is the immediate intervention?
A) Endotracheal intubation with rapid sequence induction.
B) Application of a non-rebreather mask at 15 L/min and rapid transport.
C) Positive pressure ventilation using a bag-valve-mask (BVM) and consideration of fluid
resuscitation.
D) Administration of nebulized bronchodilators to improve alveolar ventilation.
,Correct Answer: C - Positive pressure ventilation using a bag-valve-mask (BVM) and
consideration of fluid resuscitation.
Rationale: Paradoxical chest movement is the hallmark of a flail chest. This creates a
mechanical breathing deficit. Simply providing oxygen (B) does not correct the underlying
ventilatory failure. Positive pressure ventilation (C) acts as an "internal splint" to move the flail
segment with the rest of the chest wall. While intubation (A) may be necessary later, BVM is the
immediate, life-saving intervention. Fluid resuscitation must be used judiciously to avoid over-
hydrating the potentially contused heart.
Question 3: Which physiologic parameter is considered a "late" sign of hemorrhagic shock in the
trauma patient?
A) Tachycardia
B) Narrowing pulse pressure
C) Hypotension
D) Altered mental status
Correct Answer: C - Hypotension
Rationale: The body utilizes compensatory mechanisms, primarily sympathetic nervous system
activation, to maintain blood pressure despite significant blood loss. Tachycardia (A) and
narrow pulse pressure (B) are early markers of compensation. Altered mental status (D) is a sign
of decreased cerebral perfusion. Hypotension is a decompensated state; by the time the patient is
hypotensive, they have likely lost 30% or more of their total blood volume, making it a late sign.
Question 4: In the assessment of a patient with a suspected tension pneumothorax, which clinical
finding represents the most definitive need for immediate decompression?
A) Distended neck veins and tracheal deviation.
B) Decreased breath sounds on the affected side and signs of shock.
C) Subcutaneous emphysema and hyper-resonance to percussion.
D) Pleuritic chest pain and anxiety.
Correct Answer: B - Decreased breath sounds on the affected side and signs of shock.
Rationale: Tension pneumothorax is a clinical diagnosis. While tracheal deviation and JVD (A)
are classic textbook signs, they are late and often absent. The PHTLS philosophy emphasizes
recognizing the condition based on the presence of respiratory distress, absent breath sounds,
and hemodynamic instability (signs of shock). Waiting for tracheal deviation can be fatal.
,https://encrypted-tbn0.gstatic.com/licensed-
image?q=tbn:ANd9GcQDgsxCjIwakB__wis6q7w3MR1CzQ8e0uQH_mX_TvF_3W_VYqQZa5
dSGtX4w95Uaml7VBeGEpeph9korFQy5EtN9V_SxDUk4jYEUAzH8wDd7IfnoVw
Question 5: A patient involved in a motorcycle crash is found with a GCS of 10. The patient is
combative and refuses care. What is the most appropriate management approach?
A) Honor the patient's refusal, as they are conscious.
B) Assume implied consent due to the patient's altered mental status and potential for life-
threatening injury.
C) Contact medical control to request a psychiatric hold.
D) Administer a sedative to allow for a safe transport.
Correct Answer: B - Assume implied consent due to the patient's altered mental status and
potential for life-threatening injury.
Rationale: A GCS of 10 indicates a significant traumatic brain injury (TBI) and confirms the
patient is not alert and oriented. A patient with a head injury and potential life-threatening
trauma does not have the capacity to refuse care. PHTLS supports the use of implied consent to
provide necessary, life-saving intervention.
Subtopic: Hemorrhage Control and Fluid Resuscitation
Question 6: When managing a patient with massive external hemorrhage from a extremity
wound, what is the evidence-based sequence of interventions according to current PHTLS
guidelines?
A) Direct pressure, elevation, pressure points, and tourniquet.
B) Tourniquet application, direct pressure, and wound packing.
C) Direct pressure, wound packing (if appropriate), and tourniquet application.
D) Immediate application of a tourniquet if direct pressure fails or the wound is catastrophic.
Correct Answer: C - Direct pressure, wound packing (if appropriate), and tourniquet
application.
Rationale: PHTLS emphasizes "Stop the Bleed" concepts. For junctional or deep wounds,
packing with hemostatic or standard gauze followed by pressure is the standard. If hemorrhage
remains uncontrolled, or if the initial assessment indicates catastrophic limb hemorrhage, a
tourniquet is the definitive tool. A is outdated (elevation and pressure points are ineffective for
major trauma).
, Question 7: What is the primary clinical goal of fluid resuscitation in the hypotensive trauma
patient with active hemorrhage?
A) Maintain a mean arterial pressure of 100 mmHg.
B) Normalize the systolic blood pressure to 120 mmHg.
C) Permissive hypotension, maintaining a radial pulse or a systolic pressure of 80–90 mmHg
until surgical control is reached.
D) Fluid resuscitation to achieve a heart rate of 80 bpm.
Correct Answer: C - Permissive hypotension, maintaining a radial pulse or a systolic
pressure of 80–90 mmHg until surgical control is reached.
Rationale: "Aggressive" fluid resuscitation can "pop the clot" by raising pressure too quickly,
diluting clotting factors, and decreasing core temperature. Permissive hypotension focuses on
maintaining just enough perfusion to vital organs (systolic 80–90 mmHg) to prevent end-organ
damage while minimizing hemodilution and hemorrhage until surgical intervention.
Question 8: A patient has an impaled object in the chest. What is the standard management for
this patient?
A) Remove the object immediately to allow for chest expansion.
B) Stabilize the object in place, unless it interferes with airway management or BVM.
C) Shorten the object to make it easier to transport.
D) Cover the site with a plastic, occlusive dressing.
Correct Answer: B - Stabilize the object in place, unless it interferes with airway
management or BVM.
Rationale: Removal of an impaled object can cause further internal injury and release the "plug"
that may be slowing internal hemorrhage. The only exceptions are if the object physically
prevents airway control or the provision of effective positive pressure ventilation. Occlusive
dressings (D) are used for open chest wounds, not necessarily impaled objects.
Question 9: Which of the following is the most significant concern when using a tourniquet for
prolonged transport times?
A) Nerve damage is inevitable regardless of technique.
B) Potential for crush syndrome and systemic acidosis upon release.
Support and PHTLS Practice Exam –
Updated 2026 (Graded A+)
Subject: Prehospital Trauma Life Support (PHTLS)
Subtopic: Kinematics of Trauma and Primary Assessment
Question 1: In a high-speed frontal collision, a patient is found unrestrained with significant
deformity to the steering column. Which of the following secondary impact patterns should the
paramedic prioritize during the assessment of the chest and abdomen?
A) Compression injury to the anterior chest wall and potential deceleration injury to the thoracic
aorta.
B) Seatbelt-related abdominal evisceration and lumbar spine fracture.
C) Whiplash-type cervical spine injury and facial fractures.
D) Traumatic brain injury and bilateral femur fractures.
Correct Answer: A - Compression injury to the anterior chest wall and potential
deceleration injury to the thoracic aorta.
Rationale: The steering wheel impact commonly results in anterior chest wall compression (flail
chest, cardiac contusion). Furthermore, the rapid deceleration of the torso causes the heart and
great vessels to continue moving forward, which frequently results in shearing or transection of
the thoracic aorta at the ligamentum arteriosum. While B and C are possible in other collision
types (rear-end or unrestrained), A is the classic, high-mortality sequela of steering column
impact.
Question 2: During the primary assessment of a trauma patient, you identify a patent airway, but
the patient exhibits paradoxical chest wall movement and severe respiratory distress. According
to PHTLS, what is the immediate intervention?
A) Endotracheal intubation with rapid sequence induction.
B) Application of a non-rebreather mask at 15 L/min and rapid transport.
C) Positive pressure ventilation using a bag-valve-mask (BVM) and consideration of fluid
resuscitation.
D) Administration of nebulized bronchodilators to improve alveolar ventilation.
,Correct Answer: C - Positive pressure ventilation using a bag-valve-mask (BVM) and
consideration of fluid resuscitation.
Rationale: Paradoxical chest movement is the hallmark of a flail chest. This creates a
mechanical breathing deficit. Simply providing oxygen (B) does not correct the underlying
ventilatory failure. Positive pressure ventilation (C) acts as an "internal splint" to move the flail
segment with the rest of the chest wall. While intubation (A) may be necessary later, BVM is the
immediate, life-saving intervention. Fluid resuscitation must be used judiciously to avoid over-
hydrating the potentially contused heart.
Question 3: Which physiologic parameter is considered a "late" sign of hemorrhagic shock in the
trauma patient?
A) Tachycardia
B) Narrowing pulse pressure
C) Hypotension
D) Altered mental status
Correct Answer: C - Hypotension
Rationale: The body utilizes compensatory mechanisms, primarily sympathetic nervous system
activation, to maintain blood pressure despite significant blood loss. Tachycardia (A) and
narrow pulse pressure (B) are early markers of compensation. Altered mental status (D) is a sign
of decreased cerebral perfusion. Hypotension is a decompensated state; by the time the patient is
hypotensive, they have likely lost 30% or more of their total blood volume, making it a late sign.
Question 4: In the assessment of a patient with a suspected tension pneumothorax, which clinical
finding represents the most definitive need for immediate decompression?
A) Distended neck veins and tracheal deviation.
B) Decreased breath sounds on the affected side and signs of shock.
C) Subcutaneous emphysema and hyper-resonance to percussion.
D) Pleuritic chest pain and anxiety.
Correct Answer: B - Decreased breath sounds on the affected side and signs of shock.
Rationale: Tension pneumothorax is a clinical diagnosis. While tracheal deviation and JVD (A)
are classic textbook signs, they are late and often absent. The PHTLS philosophy emphasizes
recognizing the condition based on the presence of respiratory distress, absent breath sounds,
and hemodynamic instability (signs of shock). Waiting for tracheal deviation can be fatal.
,https://encrypted-tbn0.gstatic.com/licensed-
image?q=tbn:ANd9GcQDgsxCjIwakB__wis6q7w3MR1CzQ8e0uQH_mX_TvF_3W_VYqQZa5
dSGtX4w95Uaml7VBeGEpeph9korFQy5EtN9V_SxDUk4jYEUAzH8wDd7IfnoVw
Question 5: A patient involved in a motorcycle crash is found with a GCS of 10. The patient is
combative and refuses care. What is the most appropriate management approach?
A) Honor the patient's refusal, as they are conscious.
B) Assume implied consent due to the patient's altered mental status and potential for life-
threatening injury.
C) Contact medical control to request a psychiatric hold.
D) Administer a sedative to allow for a safe transport.
Correct Answer: B - Assume implied consent due to the patient's altered mental status and
potential for life-threatening injury.
Rationale: A GCS of 10 indicates a significant traumatic brain injury (TBI) and confirms the
patient is not alert and oriented. A patient with a head injury and potential life-threatening
trauma does not have the capacity to refuse care. PHTLS supports the use of implied consent to
provide necessary, life-saving intervention.
Subtopic: Hemorrhage Control and Fluid Resuscitation
Question 6: When managing a patient with massive external hemorrhage from a extremity
wound, what is the evidence-based sequence of interventions according to current PHTLS
guidelines?
A) Direct pressure, elevation, pressure points, and tourniquet.
B) Tourniquet application, direct pressure, and wound packing.
C) Direct pressure, wound packing (if appropriate), and tourniquet application.
D) Immediate application of a tourniquet if direct pressure fails or the wound is catastrophic.
Correct Answer: C - Direct pressure, wound packing (if appropriate), and tourniquet
application.
Rationale: PHTLS emphasizes "Stop the Bleed" concepts. For junctional or deep wounds,
packing with hemostatic or standard gauze followed by pressure is the standard. If hemorrhage
remains uncontrolled, or if the initial assessment indicates catastrophic limb hemorrhage, a
tourniquet is the definitive tool. A is outdated (elevation and pressure points are ineffective for
major trauma).
, Question 7: What is the primary clinical goal of fluid resuscitation in the hypotensive trauma
patient with active hemorrhage?
A) Maintain a mean arterial pressure of 100 mmHg.
B) Normalize the systolic blood pressure to 120 mmHg.
C) Permissive hypotension, maintaining a radial pulse or a systolic pressure of 80–90 mmHg
until surgical control is reached.
D) Fluid resuscitation to achieve a heart rate of 80 bpm.
Correct Answer: C - Permissive hypotension, maintaining a radial pulse or a systolic
pressure of 80–90 mmHg until surgical control is reached.
Rationale: "Aggressive" fluid resuscitation can "pop the clot" by raising pressure too quickly,
diluting clotting factors, and decreasing core temperature. Permissive hypotension focuses on
maintaining just enough perfusion to vital organs (systolic 80–90 mmHg) to prevent end-organ
damage while minimizing hemodilution and hemorrhage until surgical intervention.
Question 8: A patient has an impaled object in the chest. What is the standard management for
this patient?
A) Remove the object immediately to allow for chest expansion.
B) Stabilize the object in place, unless it interferes with airway management or BVM.
C) Shorten the object to make it easier to transport.
D) Cover the site with a plastic, occlusive dressing.
Correct Answer: B - Stabilize the object in place, unless it interferes with airway
management or BVM.
Rationale: Removal of an impaled object can cause further internal injury and release the "plug"
that may be slowing internal hemorrhage. The only exceptions are if the object physically
prevents airway control or the provision of effective positive pressure ventilation. Occlusive
dressings (D) are used for open chest wounds, not necessarily impaled objects.
Question 9: Which of the following is the most significant concern when using a tourniquet for
prolonged transport times?
A) Nerve damage is inevitable regardless of technique.
B) Potential for crush syndrome and systemic acidosis upon release.
