Tracheobronchial, Diaphragmatic, and Esophageal Injuries and Traumatic Asphyxia Practice Questions

25 multiple-choice questions on Tracheobronchial, diaphragmatic, and esophageal injuries and traumatic asphyxia for paramedic and EMT students, from Chapter 36 (Chest Trauma). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. Most tracheobronchial injuries from blunt trauma occur:

   1. A. At the level of the cricoid cartilage
   2. B. In the terminal bronchioles of the lung bases
   3. C. Within about 2.5 cm (1 inch) of the carina
   4. D. At the thyroid cartilage in the neck
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   Answer: C. Within about 2.5 cm (1 inch) of the carina

   The carina and mainstem bronchi are relatively fixed, so shearing forces tear them near the bifurcation. Terminal bronchioles are small and peripheral and are not the typical site of major airway disruption.

2. After needle decompression, a patient has a continuous rush of air from the catheter, rapidly spreading subcutaneous emphysema of the neck, and hemoptysis. The lung does not re-expand. The most likely injury is:

   1. A. Tracheobronchial injury
   2. B. A kinked decompression catheter
   3. C. Esophageal rupture
   4. D. Pulmonary contusion
   Show answer

   Answer: A. Tracheobronchial injury

   A large, persistent air leak that keeps refilling the pleural space, with hemoptysis and spreading air in the tissues, suggests a torn bronchus. A kinked catheter would stop the air flow rather than produce a continuous leak.

3. When ventilating a patient with a suspected tracheobronchial injury, you should:

   1. A. Ventilate rapidly to overcome the size of the air leak
   2. B. Ventilate gently with the lowest effective pressure
   3. C. Hold ventilations until the leak seals over
   4. D. Use large tidal volumes to open the bronchus
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   Answer: B. Ventilate gently with the lowest effective pressure

   High pressures force more air through the tear into the pleura and mediastinum, worsening tension and subcutaneous emphysema. Rapid or large breaths increase the leak without improving oxygenation.

4. Traumatic diaphragmatic rupture occurs more often on the:

   1. A. Right, because the liver is heavy and tears it
   2. B. Left, because the heart pushes down on it
   3. C. Left, because the liver shields the right
   4. D. Right, because the stomach lies on the right
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   Answer: C. Left, because the liver shields the right

   The liver acts as a buffer under the right hemidiaphragm, so most ruptures from blunt trauma are on the left. The stomach lies on the left, which is why it is often the organ that herniates.

5. After a lap-belt crash, a patient has dyspnea, diminished breath sounds on the left, bowel sounds heard in the left chest, and a sunken abdomen. The most likely injury is:

   1. A. Diaphragmatic rupture
   2. B. Tension pneumothorax
   3. C. Massive hemothorax
   4. D. Esophageal rupture
   Show answer

   Answer: A. Diaphragmatic rupture

   Bowel sounds in the chest and a scaphoid abdomen mean abdominal organs have moved up through a torn diaphragm. Tension pneumothorax also diminishes breath sounds but would not produce bowel sounds in the chest.

6. Blunt diaphragmatic rupture is usually caused by:

   1. A. Penetrating injury above the nipple line
   2. B. Hyperextension of the cervical spine
   3. C. Prolonged coughing after a cold
   4. D. A sudden rise in abdominal pressure
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   Answer: D. A sudden rise in abdominal pressure

   A forceful blow or lap belt compresses the abdomen, and the pressure spike bursts the diaphragm. Wounds above the nipple line are usually above the diaphragm, even at full exhalation.

7. A patient with a suspected diaphragmatic hernia becomes more dyspneic when laid flat. The most likely reason is that:

   1. A. Pleural blood spreads over more of the lung surface
   2. B. The supine position triggers bronchospasm
   3. C. The flat position lowers venous return
   4. D. Abdominal organs shift farther into the chest
   Show answer

   Answer: D. Abdominal organs shift farther into the chest

   Lying flat lets the abdominal contents slide up through the defect and compress the lung. Bronchospasm is not a feature of diaphragmatic injury, venous return rises rather than falls when a patient lies flat, and the worsening points to herniated organs, not to blood layering in the pleural space.

8. The most dangerous delayed complication of an esophageal perforation is:

   1. A. Aspiration pneumonia from gastric reflux
   2. B. Mediastinitis from leaking contents
   3. C. Esophageal varices with bleeding
   4. D. Tracheal stenosis from scarring
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   Answer: B. Mediastinitis from leaking contents

   Saliva, food, and gastric contents leak into the mediastinum and cause a severe infection with high mortality. Varices are dilated veins from portal hypertension, not a result of perforation.

9. A crunching sound heard with each heartbeat on auscultation (Hamman sign) suggests:

   1. A. Air in the mediastinum
   2. B. Fluid in the pericardium
   3. C. Blood in the pleural space
   4. D. Air in the abdomen
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   Answer: A. Air in the mediastinum

   Hamman sign is the crackle of mediastinal air moving with the heart, seen with tracheobronchial or esophageal injury. Pericardial fluid muffles heart sounds rather than adding a crunching noise.

10. A 25-year-old has a gunshot wound that crosses the mediastinum. He reports pain on swallowing and has subcutaneous emphysema in the neck. Breath sounds are equal, and the BP is 118/74 mmHg. The most likely injury is:

    1. A. Diaphragmatic rupture
    2. B. Pulmonary contusion
    3. C. Esophageal injury
    4. D. Commotio cordis
    Show answer

    Answer: C. Esophageal injury

    A transmediastinal wound with painful swallowing and air in the neck tissues points to the esophagus. A diaphragmatic rupture would not cause air in the neck or painful swallowing.

11. A patient with a suspected esophageal injury asks for a drink of water. You should:

    1. A. Give small sips of cool water
    2. B. Give ice chips to suck on
    3. C. Withhold anything by mouth
    4. D. Give a little milk to coat it
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    Answer: C. Withhold anything by mouth

    Anything swallowed can leak through the perforation into the mediastinum and worsen infection. Small sips, ice chips, and coating liquids such as milk seem harmless but still pass through the injury.

12. Traumatic asphyxia is caused by:

    1. A. A sudden chest crush that backs blood into the head
    2. B. Strangulation that blocks arterial blood flow to the brain
    3. C. Smoke inhalation that poisons the hemoglobin
    4. D. Aspiration of blood that obstructs the airway
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    Answer: A. A sudden chest crush that backs blood into the head

    Sudden severe compression of the chest forces blood backward out of the heart and into the veins of the head and neck. Despite the name, it is not an airway obstruction or a strangulation injury.

13. In traumatic asphyxia, the discoloration is limited to the head, neck, and upper chest because:

    1. A. Those arteries go into spasm under pressure
    2. B. Those tissues have a thinner layer of skin
    3. C. Those capillaries leak because of hypoxia
    4. D. Those veins lack valves to block backflow
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    Answer: D. Those veins lack valves to block backflow

    The jugular and other upper-body veins have no valves, so the pressure wave transmits straight into the head and neck. The lower-body veins have valves that block the backflow.

14. A 40-year-old was crushed between a forklift and a wall. His head and neck are deep purple, his eyes show subconjunctival hemorrhages, and his skin below the chest is normal in color. The most likely condition is:

    1. A. Carbon monoxide poisoning
    2. B. Traumatic asphyxia
    3. C. Basilar skull fracture
    4. D. Anaphylactic reaction
    Show answer

    Answer: B. Traumatic asphyxia

    A purple head and neck with eye hemorrhages above a line of crush compression is classic for traumatic asphyxia. Carbon monoxide causes no line of demarcation and is rarely associated with a crush.

15. A worker has been pinned for several minutes with a steel beam across his chest. His face is purple, and his breathing is shallow and labored. The crew is ready to lift the beam. The best approach is to:

    1. A. Delay lifting it until two IV lines are running
    2. B. Give sodium bicarbonate before lifting it
    3. C. Lift it now, ready to treat sudden hypotension
    4. D. Ease it off gradually over 20 minutes
    Show answer

    Answer: C. Lift it now, ready to treat sudden hypotension

    While the beam stays on his chest he cannot ventilate and blood cannot return to the heart, and survival in traumatic asphyxia depends mainly on how long the compression lasts. The weight comes off as soon as it is safe, with suction, a BVM, the monitor, and resuscitation equipment ready, because release can bring sudden hypotension, dysrhythmia, or arrest. Delaying the lift to start IVs prolongs the compression; that pre-release step belongs to prolonged limb crush, not to a chest that cannot breathe, and IV access can be gained right after or during extrication. Sodium bicarbonate before release is likewise a limb-crush measure in some protocols, and easing the weight off over many minutes only prolongs the compression. (PHTLS 10th ed.; Richards & Wallis, Emerg Med J 1997; Sertaridou et al. 2012.)

16. The prognosis in traumatic asphyxia depends mostly on:

    1. A. Associated injuries and duration of compression
    2. B. The degree of facial discoloration that is present
    3. C. Whether subconjunctival bleeding is seen
    4. D. How quickly the facial color returns
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    Answer: A. Associated injuries and duration of compression

    The discoloration itself is harmless and fades, so outcome depends on underlying injuries and how long the chest was compressed. A very purple face looks alarming but does not predict survival.

17. With a suspected partial laryngotracheal disruption, a major risk of intubation is:

    1. A. Causing bronchospasm from the inflated ET cuff
    2. B. Converting a partial tear into a full one
    3. C. Pushing air into the stomach
    4. D. Triggering a vagal reflex and asystole
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    Answer: B. Converting a partial tear into a full one

    Passing a tube through a torn airway can complete the tear or create a false passage, losing the airway entirely. Gastric insufflation is a problem with BVM ventilation, not a specific risk of airway disruption.

18. Diaphragmatic injuries are often missed early because:

    1. A. Small tears tend to heal on their own
    2. B. Most result from low-energy blows
    3. C. Most involve the right hemidiaphragm
    4. D. Signs are often subtle or delayed
    Show answer

    Answer: D. Signs are often subtle or delayed

    Small tears may cause few signs until abdominal organs herniate, sometimes days or years later. Untreated defects tend to enlarge rather than heal, most tears follow high-energy blunt or penetrating trauma rather than minor blows, and most involve the left hemidiaphragm, not the right.

19. Most esophageal injuries result from:

    1. A. Penetrating wounds to the chest or neck
    2. B. Blunt high-speed frontal vehicle crashes
    3. C. Steering wheel blows to the sternum
    4. D. Mild blows to the lateral chest wall
    Show answer

    Answer: A. Penetrating wounds to the chest or neck

    The esophagus lies deep and protected, so it is injured mostly by stab and gunshot wounds; blunt rupture, even in high-speed crashes or from a steering wheel blow, is rare. Low-energy blows almost never reach it.

20. In a patient with a suspected left diaphragmatic hernia, a low lateral needle decompression risks:

    1. A. Puncturing the right lobe of the liver
    2. B. Lacerating the subclavian artery
    3. C. Injuring the brachial plexus
    4. D. Puncturing a herniated stomach or bowel
    Show answer

    Answer: D. Puncturing a herniated stomach or bowel

    Herniated abdominal organs can lie in the lower left chest, right where a low lateral needle might enter. The liver is on the right, so it is not the risk on the left side.

21. A patient with a tracheal injury in the neck may present with:

    1. A. Bowel sounds in the chest and dyspnea
    2. B. Hoarseness, stridor, and subcutaneous air
    3. C. Muffled heart tones and a narrow pulse pressure
    4. D. Facial plethora and eye hemorrhages
    Show answer

    Answer: B. Hoarseness, stridor, and subcutaneous air

    Air leaking from the trachea spreads into the neck tissues, and damage to the larynx or nerves changes the voice. Facial plethora and eye hemorrhages describe traumatic asphyxia.

22. A 50-year-old with a suspected left diaphragmatic hernia after a crash is struggling to breathe. The hernia compromises breathing mainly by:

    1. A. Paralysis of the intercostal muscles
    2. B. Bronchospasm caused by gastric acid
    3. C. Lung compression from herniated organs
    4. D. Blockage of the trachea by the stomach
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    Answer: C. Lung compression from herniated organs

    Abdominal organs in the chest take up space and collapse the lung on that side, and the torn diaphragm cannot contract effectively. The intercostal muscles are not affected by a diaphragmatic tear.

23. Blunt tracheobronchial injury typically results from:

    1. A. Low-energy blows to the lower ribs
    2. B. Rupture of distal alveoli from overpressure
    3. C. Shearing at the mobile lung bases
    4. D. Shearing forces near the fixed carina
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    Answer: D. Shearing forces near the fixed carina

    Sudden deceleration or compression against a closed glottis shears the airway where it is anchored near the carina. Overpressure ruptures alveoli and causes pneumothorax rather than an airway tear, the lung bases are mobile rather than anchored, and low-energy blows to the lower ribs do not generate these forces.

24. A patient with traumatic asphyxia may also have:

    1. A. Purple discoloration of the legs and feet
    2. B. Flat neck veins with facial pallor
    3. C. Visual disturbances and altered mental status
    4. D. Pinpoint pupils with slow, shallow respirations
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    Answer: C. Visual disturbances and altered mental status

    Venous congestion of the brain and eyes can cause confusion, seizures, and blurred vision. The congestion stays above the level of the crush, so the face is plethoric with full neck veins while the legs keep normal color. Pinpoint pupils with slow breathing suggest opioid toxicity, not a crush injury.

25. In an intubated patient with a suspected left diaphragmatic rupture, placing an orogastric tube can help by:

    1. A. Draining blood from the left chest
    2. B. Decompressing the herniated stomach
    3. C. Stopping bleeding from the spleen
    4. D. Pulling the stomach back into the abdomen
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    Answer: B. Decompressing the herniated stomach

    A distended stomach in the chest compresses the lung and heart, so venting it improves ventilation. Gastric suction cannot pull the stomach back through the defect or drain blood from the pleural space, and it has no effect on splenic bleeding; the defect requires surgery.