ATLS ADVANCED TRAUMA LIFE SUPPORT PRETEST AND PROTEST EXAM 2024, Exams of Nursing

Download ATLS ADVANCED TRAUMA LIFE SUPPORT PRETEST AND PROTEST EXAM 2024 and more Exams Nursing in PDF only on Docsity! ATLS ADVANCED TRAUMA LIFE SUPPORT PRETEST AND PROTEST EXAM 2024 AND PRACTICE EXAM TEST BANK | ACCURATE QUESTIONS AND ANSWERS WITH RATIONALES| VERIFIED FOR GUARANTEED PASS | GRADED A | BRAND NEW During an altercation, a 36-year-old man sustains a gunshot wound above the nipple line on the right, with an exit wound posteriorly above the scapula on the right. He is transported by ambulance to a community hospital. He is endotracheally intubated, close tube thoracostomy is performed, and 2 liters Ringers lactate solution are infused via 2 large-caliber IV´s. His blood pressure now is 60/0mmHg, heart rate is 160 beats per minute, and respiratory rate is 14 breaths per minute (ventilated with 100% O2). The most appropriate next step in managin this patient is: A. Laparotomy B. Diagnostic peritoneal lavage C. Arterial blood gas determination D. Administer packed red blood cells E. Chest X-ray to confirm tube placement E. Chest X-ray to confirm tube placement Abscence of breath sounds and dullness to percussion over the left hemithorax are findings best explained by: A. Left hemothorax B. Cardiac contusion C. Left simple pneumothorax D. Left diaphragmatic rupture E. Right tension pneumothorax A. Left hemothorax A 23-year-old man is brought immediately to the ED from the hospitals parking lot where he was shot in the lower abdomen. Examination reveals a single bullet wound. He is breathing and has a thready pulse. However, he is unconsious and has no detectable blood pressure. Optimale immediate management is to: A. Perform a diagnostic peritoneal lavage B. Initiate infusion of packed red blood cells C. Insert a nasogastric tube and urinary catheter D. Transfer the patient to the operating room, while initiating fluid therapy E. Initiate fluid therapy to return his blood pressure to normotensive D. Transfer the patient to the operating room, while initiating fluid therapy Which of the following is the recommended Method for trestemt frostbite? A. Vasodilators B. Anticigulants C. Warm (40 degrees) water D. Padding and elevation E. Application of heat from a hairdryer C. Warm (40 degrees) water Which of the following physical findings suggest a cause of hypotension other than spinal cord injury? A. Prispism B. Bradycardia C. Diaphragmatic breathing D. Presence of deep tendon reflexes E. Ability to flex forearms but not extend them D. Presence of deep tendon reflexes. Spinal shock refers to loss of muscle toe (flaccidty) and loss of reflexes. The primary indication for transferring A patient to a higher level trauma center is: A. Unavailibility of surgeon or operating staff B. Multiple system injuries, including severe head injury C. Resource limitations as determined by the transferring doctor D. Resource limitations as determined by the hospital administration E. Widened mediastinum on chest x-ray following blunt trauma C. Resource limitations as determined by the transferring doctor (MÅ SJEKKES) A young man sustains a rifle wound to the mid-abdomen. He is brought promptly to the ED by prehospital personnel. His skin is cool and diaphoretic, and his systolic blood pressure is 58mmHg. Warmed crystalloid fluids are initiated without improvement in his vital signs. The next, most appropriate, step is to perform: A. a laparotomy B. An abdominal CT-scan C. Diagnostic laparoscopy D. Abdominal ultrasonography E. A diagnostic peritoneal lavage A. Laparotomy because of hemodynamic abnormality A 42-year-old man is trapped from the waist down beneath his overturned tractor for several hours before medical assistance arrives. He is awake and alert until just before arriving in the ED. He is now unconscious and responds only to painful stimuli by moaning. His pupils are 3mm in diameter and symmetrically reactive to light. Prehospital personnel indicate that they have not seen the patient move either of his lower extremities. On examination in the ED, no movement of his lower extremities are detected, even in response to painful stimuli. The most likely cause for this finding is: A. An epidural hematoma B. A pelvic fracture A. His pulse pressure will be widened B. His urinary output will be at the lower limits of normal C. He will have tachycardia, but no change in systolic blood pressure D. His systolic blood pressure will be decreased with a narrowed, pulse pressure E. His systolic blood pressure will be maintained with an elevated diastolic pressure. E. His systolic blood pressure will be maintained with an elevated diastolic pressure. The physioclogic hypervolemia of pregnancy has clinical significance in the management of the severely injured gravid woman by A. Reducing the need for blood transfusion B. Increasing the risk of pulmonary edema C. Complicating the management of closed head injury D. Increasing the volume of blood loss to produce shock/maternal hypotension E. Reducing the volume of crystalloid required for resuscitation D. Increasing the volume of blood loss to produce shock A 17-year-old helmeted motorcyclist loses consciousness when he is struck broad side by an automobile at an intersection. He arrives in the ED with a blood pressure of 140/92, pulse rate 88 beats per minute, a respiratory rate of 18 breaths per minue, and a GCS of 7. Appropriate initial immobilization of this patient should include a semi-rigid cervical collar and: A. A scoop stretcher B. A long spine board C. A short spine board D. Cervical traction tongs E. Pneumatic antishock garment B. A long spine board A teen-aged bicycle rider is hit by a truck traveling at high speed. In the ED, she is actively bleeding from open fractures of her legs, and has abrasions on her chest and abdominal wall. Her blood pressure is 80/50 mmHg, heart rate is 140 beats per minute, respiratory rate is 8 breaths per minute, and GCS score is 6. The first step in managing this patient is to: A. Obtain a lateral cervical spine x-ray B. Insert av central venous pressure line C. Adminster 2 liters of crystalloid solution D. Perform endotracheal intubation and ventilation E. Apply a pneumatic antishock garment (PASG) and inflate the leg compartments. D. Perform endotracheal intubation and ventilation An 8-year-old boy falls 4,5 meters (15 feet) from a tree and is brought to the ED by his family. His vital signs are normal, but he complains of left upper quadrant pain. An abdominal CT-scan reveals a moderately severe laceration of the spleen. The receiving institution does not have 24- hour-a-day operating room capabilities. The most appropriate management of this patient would be to A. Type and crossmatch for blood B. Request consultation of a pediatrician C. Transfer the patient to a trauma center D. Admit the patient to the intensive care unit E. Prepare the patient for surgery the next day D. Admit the patient to the intensive care unit Which of the following statements regarding injury to the central nervous system in children is TRUE? A. Children suffer spinal cord injury without x-ray abnormality more commonly than adults. B. An infant with a traumatic brain injury may become hypotensive from cerebral edema C. Initial therapy for the child with traumatic brain injury includes the administration of methylprednisolone intravenously D. Children have more focal mass lesions as a result for traumatic brain injury when compared to adults. E. Young children are less tolerant of expanding intracranial mass lesions than adults A. Children suffer spinal cord injury without x-ray abnormality more commonly than adults. A 17-year-old helmeted motorcyclist is struck broadside by an automobile at an intersection. He is unconscious at the scene with a blood pressure of 140/90mmHg, heart rate of 90 beats per minute, and respiratory rate of 22 breaths per minute. His respirations are sonorous and deep. His GCS score is 6. Immobilization of the entire patient may include the use of all the following EXCEPT: A. Air splints B. Bolstering devices C. A long spine board D. A scoop-style stretcher E. A semi-rigid cervical collar A. Air splints Twenty-seven patients are seriously injured in an aircraft accident at a local airport. The basic principle of triage should be to: A. Treat the most severely injured patients first B. Establish a field triage area directed by a doctor C. Rapidly transport all patients to the nearest appropriate hospital D. Treat the greatest number of patients in the shortest period of time E. Produce the greatest number of survivors based on available resources E. Produce the greatest number of survivors based on available resources An electrician is eletrocuted by a downed power line after a thunderstorm. He apparently made contact with the wire at the level of the right mid thigh. In the ED, his vital signs are normal and no dysrythmia is noted on ECG. On examination, there is an exit wound on the bottom of the right foot. His urine is positive for blood by dipstick but not RBCs are seen microscopically. Initial management should include: A. Immediate angiography B. Aggressive fluid infusion C. Intravenous pyelography D. Debridement of necrotic muscle E. Admission to the ICU for observation B. Aggressive fluid infusion - suspected rhabdomyolyse A young woman sustains a severe head injury as the result of a motor vehicular crash. In the ED, her GCS is 6. Her blood pressure is 140/90 mmHg and her heart rate 80 beats per minute. She is intubated and is being mechanically ventilated. Her pupils are 3mm in size and equally reactive to light. There is no other apparent injury. The most important principle to follow in early management of her head injury is to: A. Administer an osmotic diuretic B. Prevent secondary brain injury C. Agressively treat systemic hypertension D. Reduce meatbolic requirements of the brain E. Distinguish between intracranial hematoma and cerebral edema. B. Prevent secondary brain injury To establish a diagnosis of shock, A. Systolic blood pressure must be below 90mmHg B. The presence of a closed head injury should be excluded C. Acidosis should be present by arterial blood gas analysis D. The patient must fail to respond to intravenous fluid infusion E. Clinical evidence of inadequate organ perfusion must be present. E. Clinical evidence of inadequate organ perfusion must be present. A 32-year-old is brought to the hospital unconscious with severe facial injuries and noisy respirations after an automobile collision. In the ED, he has no apparent injury to the anterior aspect of his neck. He suddenly becomes apneic, and attempted ventilation with a face mask is unsuccessful. Examination of his mouth reveals a large hematoma of the pharynx with loss of normal anatomic landmarks. Initial management of his airways should be consist of: A. Inserting an oropharyngeal airway B. Inserting a nasopharyngeal airway C. Performing a surgical cricothyroidotomy D. Performing fiberoptic-guided nasotracheal intubation E. Performin orotracheal intubation after obtaining a lateral c-spine x-ray A. Inserting an oropharyngeal airway B. excludes serious cervical spine injury C. Is an essential part of the primary survey D. Is not necessary for unconscious patients with penetrating cervical injuries E. Is unacceptable unless 7 cervical vertebrae and the C-7 to T-1 relationship are visualized. E. Is unacceptable unless 7 cervical vertebrae and the C-7 to T-1 relationship are visualized. A 24-year old man sustains multiple fractured ribs bilaterally as a result of being crushed in a press at a plywood factory. Examination in the ED reveals a flail segment of the patients thorax. Primary resuscitation includes high-flow oxygen administration via a nonrebreathing mask, and initiation of Ringers lactate solution. The patient exhibits progressive confusion, cyanosis and tachypnea. Management at this time should consist of: A. Intravenous sedation B. External stabilization of the chest wall C. Increasing the FIO2 in the inspired gas D. Intercostal nerve blocks for pain relief E. Endotracheal intubation and mechanical ventilation. E. Endotracheal intubation and mechanical ventilation Which of the following statements regarding patients with thoracic spine injuries is TRUE? A. Log-rolling may be destabilizing to fractures from T12 to L1 B. Adequate immobilization can be accomplished with the scoop stretcher C. Spinal cord injury below T10 usually spares bowel and bladder function D. Hyperflexion fractures in the upper thoracic spine are inherently unstable E. These patients rarely present with neurogenic shock in association with cord injury. A. Log-rolling may be destabilizing to fractures from T12 to L1 During resuscitation, which one of the following is the most reliable as a guide to volume replacement? A. Heart rate B. Hematocrit C. Blood pressure D. Urinary output E. Jugular venous pressure D. Urinary out A 24-year-old woman passenger in an automobile strikes the wind screen with her face during a head-on collision. In the ED, she is talking and has marked facial edema and crepitus. The highest priority should be given to: A. Lateral c-spine x-ray B. Upper airway protection C. Carotid pulse assessment D. Management of blod loss E. Determination of associated injuries B. Upper airway protection The driver of a single car crash is orotracheally intubated in the field by prehospital personnel after they identify a closed head injury and determine that the patient is unable to protect his airway. In the ED, the patient demonstrate decorticate posturing bilaterally. He is being ventilated with a bag-valve device, but his breath sounds are absent in the left hemithorax. His blood pressure is 160/80mmHg, heart rate is 70 beats per minute, and the pulse oximeter displays a hemoglobin oxygen saturation of 96%. The next step in assessing and managing this patient should be to: A. Determine the arterial blood gases B. Obtain a lateral cervical spine x-ray C. Assess placement of the endotracheal tube D. Perform needle decompression of the left chest E. Insert a thoracostomy in the left hemithorax. C. Assess placement of the endotracheal tube The response to catecholamines in an injured, hypovolemic pregnant woman can be expected to result in: A. Placental abruption B. Fetal hypoxia and distress C. Fetal/maternal dysrhytmia D. Improved uterine blood flow E. Increased maternal renal blood flow B. Fetal hypoxia and distress A 22-year-old man sustains a gunshot wound to the left chest and is transported to a small community hospital at which surgical capabilites are not available. In the ED, a chest tube is inserted and 700ml of blood is evacuted. The trauma center accepts the patient in transfer. Just before the patient is placed in an ambulance for transfer, his blood pressure decreases to 80/68mmHg and his heart rate increases to 136 beats per minute. The next step should be to: A. Clamp the chest tube B. Cancel the patients transfer C. Perform an ED thoracotomy D. Repeat the primary survey and proceed with transfer E. Delay the transfer until the referring doctor can contact a thoracic surgeon. D. Repeat the primary survey and proceed with transfer A young woman sustains a severe head injury as the result of a motor vehicular crash. In the ED, her GCS is 6. Her blood pressure is 140/90 mmHg and her heart rate 80 beats per minute. She is intubated and is being mechanically ventilated. Her pupils are 3mm in size and equally reactive to light. There is no other apparent injury. The most important principle to follow in early management of her head injury is to: A. Avoid hypotension B. Prevent secondary brain injury C. Agressively treat systemic hypertension D. Reduce meatbolic requirements of the brain E. Distinguish between intracranial hematoma and cerebral edema. A. Avoid hypotension A 6-year-old boy walking across the street is struck by the front bumper of a sports utility vehicle traveling at 32kph (20mph). Which one of the following statements is TRUE? A. A flail chest is probable B. A symptomatic cardiac contusion is expected C. A pulmonary contusion may be present in the absence of rib fractures D. Transection of the thoracic aorta is more likely than in an adult patient E. Rib fractures are commonly found in children with this mechanism of injury C. A pulmonary contusion may be present in the absence of rib fractures A 39-year-old man is admitted to the ED after an automobile collision. He is cyanotic, has insufficient respiratory effort, and has a GCS score of 6. His full beard makes it difficult to fit the oxygen facemask to his face. The most appropriate next step is to: A. Perform a surgical cricothyroidotomy B. Attempt nasotracheal intubation C. Ventilate him with a bag-mask device until c-spine injury can be excluded D. Attempt orotracheal intubation using 2 people and inline stabilization of the cervical spine E. Ventilate the patient with a bag-mask device until his beard can be shaved for a better mask fit. D. Attempt orotracheal intubation using 2 people and inline stabilization of the cervical spine A patient is brought to the ED 20 minutes after a motor vehicle crash. He is conscious and there is no obvious external trauma. He arrives at the hospital completely immobilized on a long spine board. His blood pressure is 60/40mmHg and his heart rate is 70 beats per minute. His skin is warm. Which one of the following statements is true? A. Vasoactive medications have no role in the patients management B. The hypotension should be managed with volume resuscitation alone C. Flexion and extension views on the c-spine should be performed early D. Occult abdominal visceral injuries can be excluded as a cause of hypotension E. Flaccidity of the lower extremities and loss of deep tendon reflexes are expected. E. Flaccidity of the lower extremities and loss of deep tendon reflexes are expected. The following are contraindications for tetanus toxoid administration: A. History of neurological reaction or severe hypersensitivity to the product B. Local side effects C. Muscular spasm D. Pregnancy E. All of the above B. Assess arterial blood gases C. Administer supplemental oxygen D. Ascertain the need for a chest tube E. Obtain a chest x-ray C. Administer supplemental oxygen A 25-year-old man, injured in a motor vehicular crash, is admitted to the ED. His pupils react sluggishly and his eyes open to painful stimuli only. He does not follow commands, but he does moan periodically. His right arm is deformed and does not respond to painful stimulus; however, his left hand reaches purposefully toward the painful stimulus. Both legs are stiffly extended. His GCS score is: A. 7 B. 8 C. 9 D. 10 E. 11 9 A 20-year-old woman, at 32 weeks gestation, is stabbed in the upper right chest. In the ED, her blood pressure is 80/60mmHg. She is gasping for breath, extremely anxious, and yelling for help. Breath sounds are diminished in the right chest. The most appropriate first step is to: A. perform tracheal intubation B. Insert an oropharyngeal airway C. Perform needle decompression of the right chest D. Manually displace the gravid uterus to the left side of the abdomen E. Initiate 2 large-caliber peripheral IV lines and crystalloid infusion C. Perform needle decompression of the right chest Which one of the following findings in an adult should prompt immediate management during primary survey? A. Distended abdomen B. GCS of 11 C. Temperature of 36,5 D. Heart rate of 120 beats per minute E. Respiratory rate of 40 breaths per minute E. Respiratory rate of 40 breaths per minute A trauma patient present to your emergency department with inspiratory stridor and a suspected C-spine injury. Oxygen saturation is 88% on high-flow oxygen via a nonrebreathing mask. The most appropriate next step is to: A. Apply cervical traction B. Perform immediate tracheostomy C. Insert bilateral thoracostomy tubes D. Maintain 100% oxygen and obtain immediate c-spine x-rays E. Maintain inline immobilization and establish a definitive airway E. Maintain inline immobilization and establish a definitive airway When apply the Rule of Nines to infants, A. It is not reliable B. The body is proportionally larger in infants than in adults C. The head is proportionally larger in infants than in adults D. The legs are proportionally larger in infants than in adults E. The arms are proportionally larger in infants than in adults C. The head is proportionally larger in infants than in adults A 60-year-old man sustains a stab wound to the right posterior flank. Witnesses state the weapon was a small knife. His heart rate is 90 beats per minute, blood pressure is 128/72mmHg and respiratory rate is 24 breaths per minute. The most appropriate action to take at this time is to: A. Perform a colonoscopy B. Perform a barium enema C. Perform an intravenous pyelogram D. Perform serial physical examinations E. Suture repair the wound and outpatient follow up D. Perform serial physical examinations The following are criteria for transfer to a burn center, EXCEPT for: A. Partial-thickness and full-thickness burns on greater than 10% of the BSA B. Any full-thickness burn C. Partial-thickness and full-thickness burn involving the face, hands, feet, genitalia, perineum and skin overlying major joints D. Elevated central venous pressure E. Inhalation injury D. Elevated central venous pressure Systolic blood pressure starts to decrease in which class of hemorrhage? A. Class 0 B. Class 1 C. Class 2 D. Class 3 E. Class 4 C. Class 2 A 7-year-old boy is brought to the ED by his parents several minutes after he fell through a window. He is bleeding profusely from a 6-cm wound of his medial right thigh. Immediate management of the wound should consist of: A. Application of a torniquet B. Direct pressure on the wound C. Packing the wound with gauze D. Direct pressure on the femoral artery at the groin E. Debridement of devitalized tissue B. Direct pressure on the wound For the patient with severe traumatic brain injury, profound hypocarbia should be avoided to prevent: A. Respiratory alkalosis B. Metabolic acidosis C. Cerebral vasoconstriction with diminished perfusion D. Neurogenic pulmonary edema E. Shift of the oxyhemoglobin dissociation curve. C. Cerebral vasoconstriction with diminished perfusion A 33-year-old woman is involved in a head-on motor vehicle crash. It took 30 minutes to extricate her from the car. Upon arrival in the ED, her heart rate is 120 beats per minute, BP is 90/70mmHg, respiratory rate is 16 breaths per minute, and GCS is 15. Examination reveals bilaterally equal breath sounds, anterior chest wall ecchymosis, and distended neck veins. Her abdomen is flat, soft, and not tender. Her pelvis is stable. Palpable distal pulses are found in all 4 extremities. Of the following, the most likely diagnosis is: A. hemorrhagic shock B. Cardiac tamponade C. Massive hemothorax D. Tension pneumothorax E. Diaphragmatic rupture. B. Cardiac tamponade A hemodynamically normal 10-year-old girls is admitted to the pediatric intensive care unit for observation after a grade III (moderately severe) splenic injury has been confirmed by CT. Which of the following mandates prompt laparotomy? A. Serum amylase of 200 B. Leukocyte count of 14,000 C. Extraperitoneal bladder rupture D. Free peritoneal air demonstrated on follow up CT E. A fall in the hemoglobin level from 12g/dl to 8g/dl over 24 hours D. Free peritoneal air demonstrated on follow up CT A 40-year-old woman restrained driver is transported to the ED in full spinal immobilization. She is hemodynamically stable and found to be paraplegic at the level of T10. Neurologic examination also determines that there is loss of pain and temperature sensation with preservation of proprioception and vibration. These finding are consistent with the diagnosis of : A. Central cord syndrome C. Breath sounds All of the following are true of the Mallampati classification EXCEPT: A. Class IV is the easiest intubation, while Class 1 is the most difficult B. It helps assess for difficult intubations C. It is part of the LEMON assessment D. It comprises a visual assessment of the distance from the tongue base to the roof of the mouth, and therefore the amount of space there is to work E. A poor Mallampati score is associated with a higher incidens of obstructive sleep apnea. A. Class IV is the easiest intubation, while Class 1 is the most difficult A 23-year-old man sustains three stab wounds to the upper right chest during an altercation and is brought by ambulance to a hospital that has full surgical capabilities. His wounds are all above the nipple. He is endotracheally intubates, closed tube thoracostomy is performed, and 2 liters of crystalloid solution are infused through 2 large-caliber IVs. His BP i 60/0mmHg, heart rate is 160 beats per minute, and respiratory rate is 14 breaths per minute (ventilated with 100% O2). 1500ml of blood has drained from the right chest. The most appropriate next step in managing this patient is to: A. Perform FAST B. Obtain a CT of the chest C. Perform angiography D. Urgently transfer the patient to the operating room E. Immediately transfer the patient to a trauma center. D. Urgently transfer the patient to the operating room Which of the following signs is LEAST reliable for diagnosing esophageal intubation? A. Symmetrical chest movement B. End-tidal CO2 presence by colorimetry C. Bilateral breath sounds D. Oxygen saturation > 92% E. ETT above carina on chest x-ray E. ETT above carina on chest x-ray Which one of the following signs necessitates a definitive airway in severe trauma patients? A. Facial lacerations B. Repeated vomiting C. Severe maxillofacial fractures D. Sternal fracture E. GCS score of 12 C. Severe maxillofacial fractures Which one of the following statements is correct? A. Cerebral contusion may coalesce to form an intracerebral hematoma B. Epidural hematomas are usually seen in frontal region C. Subdural hematomas are caused by injury to the middle meningeal artery D. Subdural hematomas typically have a lenticular shape on CTscan E. The associated brain damage is more severe in epidural hematomas. A. Cerebral contusion may coalesce to form an intracerebral hematoma An 18 year old male is brought to the ED after having been shot. He has one bullet wound just below the right clavicle and another just below the costal margin in the right posterior axillary line. His BP is 110/60, HR is 90bpm, and RR is 34bpm. After ensuring a patent airway and inserting 2 large caliber iv line, the next appropriate step is to: A. Obtain a chest x-ray B. Adminster a bolus of additional iv fluid C. Perform a laparotomy D. Obtain abdominal CT-scan E. Perform DPL A. Obtain a chest x-ray An 8 year old boy falls 4,5meters from a tree and is brought to the ED by his familiy. His vital signs are normal, but he complains of left upper quadrant pain. An abdominal CT scan reveals a moderately severe laceration of the spleen. The receiving institution does not have 24 hour a day operating room capabilities. The most appropriate management of this patient would be: A. Type and crossmatch for blood B. Request consultation of a pediatrician C. Transfer the patient to a trauma center D. Admit the patient to the ICU E. Prepare the patient for surgery the next day D. Admit the patient to the ICU A construction worker falls from a scaffold and is transferred to the ED. His HR is 124 bpm and BP is 85/60mmHg. He complains of lower abdominal pain. After assessing the airway and chest, immobilizing the c-spine and initiating fluid resuscitation, the next step is to perform A. FAST B. Detailed neurological exam C. Rectal exam D. Cervical c-spine x-ray E. Urethral catheterization. A. FAST A 22 year old male sustains a shotgun wound to the left shoulder and chest at close range. His BP is 80/40mmHg and his HR is 130bpm. After 2 liters of crystalloid solution are rapidly infused, his BP increases to 122/84, and HR decreases to 100bpm. He is tachypneic with RR of 28. On physical examination, his breath sounds are decreased at the left upper chest with dullness on percussion. A large caliber (36 french) tube thoracostomy is inserted in the fifth intercostal space with the return of 200ml of blood and no air leak. The most appropriate next step is to: A. insert a foley catheter B. Begin to transfuse o-negative blood C. Perform thoracotomy D. Obtain a CT-scan of chest and abdomen E. Repeat the physical examination of the chest E. Repeat the physical examination of the chest Which one of the following statements concerning spine and spinal cord trauma is true? A. A normal lateral c-spine film excludes injury B. A vertebral injury is unlikely in the absence of physical findings of a cord injury C. A patient with a suspected injury requires immobilization on a short spine D. Diaphragmatic breathing in an unconscious patient who has fallen is a sign of spine injury E. Determination of whether a spinal cord lesion is complete or incomplete must be made in the primary survey D. Diaphragmatic breathing in an unconscious patient who has fallen is a sign of spine injury A 20 year old athlete is involved in a motorcycle crash. When he arrives in the ED, he shouts that he cannot move his legs. On physical examination, there are noe abnormalities of the chest, abdomen or pelvis. The patient has no sensation in his legs and cannot move them, but his arms are moving. The patients RR is 28 bpm, HR is 88bpm and BP is 80/60mmHg. He is pale and sweaty. What is the most likely cause of this condition? A. Neurogenic shock B. Cardiogenic shock C. Abdominal hemorrhage D. Myocardial contusion E. Hyperthermia. A. Neurogenic shock A 28 year old male is brought to the ED. He was involved in a fight in which he was beaten with a wooden stick. His chest shows multiple severe bruises. His airway is clear, RR is 22, HR is 126 and systolic BP is 90mmHg. Which one of the following should be performed during the primary survey? A. GCS B. Cervical spine x-ray C. TT-administration D. Blood alcohol level E. Rectal exam A. GCS Which one of the following statements is true regarding access in pediatric resuscitation? A. Intraosseous access should only be considered after five percutaneous attempts A 34-year-old man is brought to the ED after being pinned to the wall of building by a cement truck. He is in obvious shock, and has deformities and marked swelling of both thighs. Although no open wound are present, his shock: A. Cannot be explained without concomitant pelvic fracture B. Signifies a loss of approximately 15% C. Is consistent with blood loss from bilateral femoral fracture D. Will likely be reversed if appropriate traction splint are applied E. Cannot be explained by his observed injuries unless a major arterial injury exist C. Is consistent with blood loss from bilateral femoral fracture Prior to passage of urinary catheter in a man, it is essential to: A. Examine the abdomen B. Determine pelvic stability C. Examine the rectum and perineum D. Perform a retrograde urethrogram E. Know the history and mechanism of injury C. Examine the rectum and perineum The best guide for adequate fluid resuscitation of the burn patient is: A. Adequate urinary output B. Reversal of systemic acidosis C. Normalization of the heart rate D. A normal central venous pressure E. 4ml/kg/percent body burn/24 hours A. Adequate urinary output A 36-year-old woman is beaten about the head and face and is brought to the local community hospital in full spinal immobilization. Her BP is 13088, HR 70/minutes, and RR 18/minute. Pulse oximetry indicated 98% while she was given 100% O2 via a non rebreather mask. Her airway is clear. She has marked swellings on her face and several lacerations of her scalp that are not actively bleeding. She does not respond to verbal stimuli, but localizes to painful stiumuli and opens her eyes. She moves all extremities equally. The remainder of her physical exam is normal. There is no neurosurgeon at the local hospital. After ensuring the patient airway, the most appropriate course of action is to: A. Admit the patient to the hospital for observation B. Obtain x-ray of her facial bones prior to transfer C. Obtain complete x-ray evaluation of the cervical spine D. Transfer the patient to a neurosurgeon without performing a CT-scan E. Perform DPL or request abdominal ultrasonography D. Transfer the patient to a neurosurgeon without performing a CT-scan For the trauma patient with cerebral edema, hypercarbia should be avoided to prevent: A. metabolic acidosis B. Respiratory acidosis C. Cerebral vasodilatation D. Neurogenic pulmonary edema E. Reciprocal high level of PaCO2 C. Cerebral vasodilatation A 29 y/o male is brought to the ED after being involved in a motor vehicular collision when his car struck a bridge abutment. He is intoxicated, has GCS 13 and complains of abdominal pain. His BP was 80mmHg systolic by palpation on admission, but rapidly increased to 110/70 with the administration of IV fluid. His heart rate is 120/minute. The chest x-ray show loss of aortic know, widening of mediastinum, no rib fracture and no hemopneumothorax. Contrast angiography: A. Is not indicated B. Should be performed after CT scan of the chest C. Is positive ofr aortic rupture in 80% of similar cases D. Is not necessary if the CT-scan of the chest is normal E. Should be performed after DPL D. Is not necessary if the CT-scan of the chest is normal Important screening x-rays to obtain in the multiple system trauma patient are: A. Skull, chest and abdomen B. Chest, abdomen and pelvis C. Skull cervical spine and pelvis D. Cervical spine, chest and pelvis E. Cervical spine, chest and abdomen D. Cervical spine, chest and pelvis All of the following statement regarding pulse oxymetry are true EXCEPT A. excessive surrounding room light can interfere with the accuracy of the reading B. Significant levels of dysfunctional hemoglobin can affect the accuracy of the reading C. It provides a continuous measurement of the partial pressure of oxygen D. It is dependent on differential light absorption by oxygenated and deoxygenated hemoglobin E. It provides a continuous, non-invasiv measurement of pulse rate that is updated with each HR C. It provides a continuous measurement of the partial pressure of oxygen Bronchial intubation at the right or left mainstem bronchus can easily occuring during infant endotracheal intubation because A. The trachea is relatively short B. The distance from the lips to the larynx is relatively short C. The use of tubes without cuffs allow the tube to slip easily D. The mainstem bronchi are less angulated in their relation to the trachea E. Do litte friction exist between endotracheal tube and the wall of the trachea. A. The trachea is relatively short A 52 y/o woman sustaining 50% total body surface burns in an explosion. She has burns around the chest and both upper arms. Adequate resuscitation is initiated. She is nasotracheally intubated and is being mechanically ventilated. Her CarboxyHb level is 10%. Her arterial blood gas reveals PaO2 of 40mmHg, PaCo2 of 60mmHg and pH of 7,25. Appropriate immediate management at the time is to A. Ensure adequate tissue perfusion B. Increase the rate of fluid resuscitation C. Add PEEP D. Reassess for the presence of pneumothorax E. Administer IV narcotics in small amounts ?A. Ensure adequate tissue perfusion All of the following suggest urethral injury EXCEPT A. scrotal hematoma B. Blood in rectal lumen C. Blod in external urethral meatus D. High riding prostate on rectal exam E. Absence of a palpable prostate on rectal exam E. Absence of a palpable prostate on rectal exam Which one of the following is recommended method for threating frostbite? A. Moist heat B. Early amputation C. Padding and elevation D. Vasodilators and heparin E. Topical application of silversulphadiazine A. Moist heat A 32-year-old mans right leg is trapped beneath his overturned car for nearly two hours before he is extricated. On arrival in the ED, both lower extremities are cool, mottled, insensate and motionless. Despite normal vital signs, pulses cannot be palpated below the femoral vessels and the muscles of the lower extremities are firm and hard. During the initial management of this patient, which of the followin is most likely to improve chances for limb salvage? A. Apply skeletal traction B. Administering anticoagulant drugs C. Administering trombolytic thearpy D. Performing lower extremity fasciotomies E. Immediately transfer the patient to a trauma care D. Performing lower extremity fasciotomies Tension pneumothorax can be caused by: A. Flail chest B. Cardiac tamponade C. Clamping of a chest tube D. All of the above Which one of the following brain stem reflexes is not assessed when assessing for brain death? A. Dolls eyes B. Oculovestibular reflex C. Gag reflex D. Argyll Robertson pupil What is the simplest way to open the airway in an unconscious patient? A. Pull out the tongue B. Tilt head and lift chin C. Lift neck from behind D. Jaw thrust What is the approximate time the brain can be anoxic before developing irreversible damage? A. 10 min B. 5 min C. 2 min D. 20 min You are treating a truama patient and attempt a definitive airway by intubation. However, the vocal cords are not visible. What tool would be the most valuable for achieving successful intubation? A. Gum elastic bougie B. Lateral cervical spine x-ray C. Nasopharyngeal airway D. Oxygen E. Laryngeal mask airway A. Gum elastic bougie A 79 year old female is involved in a motor vehicle crash and presents to the ED. She is on Coumadin and a beta blocker. Which of the following statements is true concerning her management? A. The risk of subdural hemorrhage is decreased B. Absence of tachycardia indicates that the patient is hemodynamically normal C. Non-operative management of abdominal injuries is more likely to be successful in older adults than in younger patients D. Vigorous fluid resuscitation may be associated with cardiorespiratory failure D. epinephrine should be infused immediately for hypotension D. Vigorous fluid resuscitation may be associated with cardiorespiratory failure The most common acid base disturbance encountered in injured pediatric patients is caused by: A. Hemorrhage B. Changes in ventilation C. Renal failure D. Injudicious bicarbonate administration E. Insufficient sodium chloride administration B. Changes in ventilation? A 17 year old female is brought to the ED following a 2 meter fall onto concrete. She is unresponsive and found to have a RR of 32, BP 90/60 and HR 68. The first step in treatment is: A. Adminstering vasopressors B. Establishing IV access for drug-assisted intubation C. Seeking the cause of her decreased level of consciousness D. Applying oxygen and maintaining airway E. Excluding hemorrhage as a cause of shock D. Applying oxygen and maintaining airway A 25 year old male is brought to the ED following a bar fight. He has altered consciousness, open his eyes on command, moans without forming discernible words, and localizes to painful stimuli. Which one of the following statements concerning this patient is true? A. Hyperoxia should be avoided B. CT scanning is an important part of neurological assessment C. Mandatory intubation to protect his airway is required D. His GCS suggest severe head injury E. His level of consciousness can be solely attributed to elevated blood alcohol. B. CT scanning is an important part of neurological assessment Han har GCS på 10-11, således passer det ikke med svaralternativ D som tilsvarer GCS <9. Ettersom GCS er >8 passer heller ikke svaralternativ C. E er feil da det ikke kan gi så lav GCS Which one of the following statements regarding genitourinary injuries is true? A. Urethral injuries are associated with pelvic fractures B. All patients with microscopic hematuria require evaluation of genitourinary tract C. Patient presenting with gross hematuria and shock will have a major renal injury as the source of hemorrhage D. Intraperitoneal bladder injuries are usually managed definitively with a urinary catether E. Urinary catheters should be placed in all patients with pelvic fractures during the primary survey A. Urethral injuries are associated with pelvic fractures B er feil - det er pasienter med makroskopisk hematuri og/eller pas. med mikroskopisk hematuri og sjokk som det er aktuelt å gjøre CT av. C kan være riktig, men kan ikke si det sikkert at det er nyrene som er blødningskilden. D er feil - ekstraperitoneal blæreskade behandles med kateter, og E er feil da man først må undersøke for uretraskade Cardiac tamponade: A. Requires surgical intervention B. Is defintively managed by needle pericardiocentesis C. Is easily diagnosed by discovery of Becks triad in the ED D. Is indicated by Kussmaul breathing E. Is most common with blunt thoracic trauma and anterior rib fractures A. Requires surgical intervention A 6 month old infant, being held in her mothers arms, is ejected on impact from a vehicle that is struck head on by an oncoming car traveling at 65kph. The infant arrives in the ED with multiple facial injuries, is lethargic, and is in severe respiratoy distress. Respiratory support is not effective using a bag mask device, and her oxygen saturation is falling. Repeated attempts at orotracheal intubation are unsuccessful. the most appropriate procedure to perform next is: A. perform needle cricothyroidotomy with jet insufflation B. Administer heliox and racemic epinephrine C. Perform nasotracheal intubation D. Perform surgical cricothyroidotomy E. Repeat orotracheal intubation A. perform needle cricothyroidotomy with jet insufflation Which one of the following injuries is adressed in the secondary survey? A. Bilateral femur fractures with obvious deformity B. Open fracture with bleeding C. Mid thigh amputation D. Unstable pelvic fracture E. Forearm fracture E. Forearm fracture A 22 year old male present following a motorcycle crash. He complains of the inability to move his legs. His BP is 80/50, HR 70, RR 18 and GCS 15. Oxygen saturation is 99% on 21 nasal prongs. Chest x-ray, pelvic x-ray and FAST are normal. Extremities are normal. His management should be: A: 2L of iv . crystalloid and two units of pRBCs B. 2L of iv crystalloid and vasopressors if BP does not respond C. 2L of iv. crystalloid, mannitol and iv steroids D. Vasopressors and laparotomy E. 1 unit of albumin and compression stockings B. 2L of iv crystalloid and vasopressors if BP does not respond deformity of both lower legs with bilateral open tibial fractures. Which one of the following statement concerning this patient is true? A. Pelvic injury can be ruled out based on the mechanism of injury B. Blood loss from the lower limb is most likely cause of his hypotension C. Spinal cord injury is the most likely cause of his hypotension D. X-ray of the chest and pelvis are important adjuncts in his assessment E. Aortic injury is the most likely cause of his tachycardia. D. X-ray of the chest and pelvis are important adjuncts in his assessment A 82 year old male falls down five stairs and presents to the ED. All following statements are true statements regarding his condition compared to a younger patient with similar mechanism, except: A. He is more likely to have had a contracted circulatory volume prior to his injury B. His risk of cervical spine injury is increased due to degeneration, stenosis and loss of disk compressibility C. His risk of occult fractures is increased D. His risk of bleeding may be increased E. Intracranial hemorrhage will become symptomatic more quickly E. Intracranial hemorrhage will become symptomatic more quickly A 25 year old female in the third trimester of pregnancy is brought to the ED following a high speed motor vehicle crash. She is conscious and immobilized on a long spine board. Her RR is 24 bpm, HR is 120bpm, and BP is 70/50mmHg. The lab results show a PaCO2 of 40mmHg. Which one of the following statements concerning this patient is true? A. Fetal assessment should take priority B. Log-rolling the patient to the right will decompress the vena cava C. Rh-immunoglobulin therapy should be immediately administered D. Vasopressors should be given to the patient E. The patient has likely impending respiratory failure. E. The patient has likely impending respiratory failure. Minute ventilation increases primarily due to an increase in tidal volume. Hypocapnia (PaCO2 of 30 mm Hg) is therefore common in late pregnancy. A PaCO2 of 35 to 40 mm Hg may indicate impending respiratory failure during pregnancy. Lateral cervical spine film: A. Must be performed in the primary survey B. Can exclude any significant spinal injury C. Are indicated in all trauma patients D. Should be combined with clinical exam, AP and odontoid, or CT E. Require the following films: oblique views, AP, odontoid and flexion extention views prior to spinal clearance in trauma patients D. Should be combined with clinical exam, AP and odontoid, or CT A 30 year old male is stabbed in the right chest. On arrival in the ED, he is very short of breath. His HR is 120bpm, BP is 80/50. His neck veins are flat. On auscultation of the chest, there is diminshed air entry on the right side, and there is dullness posteriorly on percussion. These findings are most consistent with: A. Hemothorax B. pericardial tamponade C. Tension pneumothorax D. Hypovolemia from the liver injury E. Spinal cord injury A. Hemothorax A specific aspect of the treatment of thermal injury is: A. Chemical burn require the immediate removal of clothing B. Patients who sustain thermal injury are at lower risk for hypothermia C. Patients with circumferential truncal burns need prompt fasciotomies D. Electrical burn are associated with extensive skin necrosis (from entry point to exit) E. The parkland formula should be used to determine adequacy of resucitation. A. Chemical burn require the immediate removal of clothing A 15 year old male is brought to the ED after being involved in a motor vehicle crash. He is unconscious and was intubated at the scene by emergency personnel. Upon arrival at the ED, the patients oxygen saturation is 92%, HR is 96 bpm and BP is 150/85 Breath sounds are decreased on the left side of the thorax. The next step is: A. Immediate needle crycothyroidotomy B. Reassess the position of the endotracheal tube C. Chest tube insertion D. Immediate needle thoracentesis E. Obtain a chest x-ray B. Reassess the position of the endotracheal tube The first priory in management of a long bone fracture is: A. Reduction of pain B. Prevention of infection in case of an open fracture C. Prevention of further soft tissue injury D. Improve long term function E. Control of hemorrhage E. Control of hemorrhage A 30 year old female is brought to the ED after being injured in a motor vehicle crash. Her initialt BP is 90/60mmHg, and her HR is 122bpm. She responds to rapid infusion of 1L crystalloid solution with a rise in her BP to 118/88 and decrease in her HR to 90bpm. Her pressure suddenly decreased to 96/66. The least likely cause of her hemodynamic change is: A. Ongoing blood loss B. Blunt cardiac injury C. Traumatic brain injury D. Inadequate resuscitation. E. Tension pneumothorax C. Traumatic brain injury Limb-threatening extremity injuries: A. Require a torniquet B. Should be defintively managed by application of a traction split. C. Are rarely present without an open wound D. Are characterized by the presence of ischemic or crushed tissue. E. Indicate a different order or priorities for the patients initial assessment and resuscitation. B. Should be defintively managed by application of a traction split. A 29 year old female arrives in the ED after being involved in a motor vehicle crash. She is 30 weeks pregnant. She was restrained with a lap and shoulder belt, and an airbag deployed. Which one of the following statement best decribes the risk of injury? A. Deployment of the airbag increased the risk of fetal loss B. The risk of premature fetal delivery and death is reduced by the use of restraints C. The use of seatbelts is associated with increased risk of maternal death. D. The mechanism of injury suggest the need for emergency ceasarean section due to the risk of impending abruptio placentae E. The deployment of the airbag increases the risk of maternal abdominal injury B. The risk of premature fetal delivery and death is reduced by the use of restraints Supraglottic airway devices: A. Are equivalent to endotracheal intubation B. Require neck extension for proper placement C. Are preferable to endotracheal intubation in a patient who cannot lie flat D. Are of value as part of a difficult or failed intubation plan E. Provide one form of definitive airway D. Are of value as part of a difficult or failed intubation plan A 25 year old male is brought to the hospital after sustaining partial and full thickness burns involving 60% of his body surface area. His right arm and hand are severely burned. There are obvious full thickness burns of the entire right hand and a circumferential burn of the right arm. Pulses are absent at the right right wrist and are not detected by doppler examination. The first step in management of the right upper extremity should be: A. Fasciotomy B. Angiography C. Escharatomy D. Heparinization E. Tangential excision B. A less pliable, calcified skeleton C. Lower incidence of bony injury with neurogenic shock D. A relatively smaller head and larger jaw E. Anterior displacement of C5 and C6 B. A less pliable, calcified skeleton A 30 year old male presents after a motor vehicle crash. Vital signs are RR 18, HR 88, BP 130/72, GCS 13. Laparotomy is indicated when A. There is distinct seat belt sign over the abdomen B. The CT-scan demonstrates a grade 4 hepatic injury C. There is evidence of extraperitoneal bladder injury D. CT demonstrates retroperitoneal air E. The abdomen is distended with localized right upper quadrant tenderness. D. CT demonstrates retroperitoneal air Indikasjoner for laparotomi: Blunt abdominal trauma with hypotension, with a positive FAST or clinical evidence of intraperitoneal bleeding, or without another source of bleeding • Hypotension with an abdominal wound that penetrates the anterior fascia • Gunshot wounds that traverse the peritoneal cavity • Evisceration • Bleeding from the stomach, rectum, or genitourinary tract following penetrating trauma • Peritonitis • Free air, retroperitoneal air, or rupture of the hemidiaphragm • Contrast-enhanced CT that demonstrates ruptured gastrointestinal tract, intraperitoneal bladder injury, renal pedicle injury, or severe visceral parenchymal injury after blunt or penetrating trauma A 20 year old male is brought to the hospital approximately 30 minutes after being stabbed in the chest. There is 3cm wound just medial to the left nipple. His BP is 70/33 and HR is 140. Neck and arm veins are distended. Breath sounds are normal. Heart sounds are diminshed, iv access has been established and warm crystalloid is infusing. The next most important aspect of immediate management is: A. CT scan of the chest B. 12 lead ECG C. Left tube thoracostomy D. Begin infusion of RBCs E. FAST exam E. FAST exam For å se etter tamponade? Normale resp.lyder bilateralt taler mot trykkpneumothorax. EKG vil ikke gi noe informasjon. Thoracostomy ikke indisert da det ikke er mistenkt pneumo/hemothorax. CT uaktuelt pga hemodynamisk ustabil A 47 year old house painter is brought to the hospital after falling 6 meters from a ladder and landing straddled on a fence. Examination of his perineum reveals extensive ecchymosis. There is blood in the external urethreal meatus. The initial diagnostic study for evaluation of the urinary tract in this patient should be: A. Cystoscopy B. Cystography C. IV pyelography D. CT scan E. Retrograde urethrography E. Retrograde urethrography Neurogenic shock has all of the following classic characteristics except which one: A. Hypotension B. Vasodilatation C. Bradycardia D. Neurologic deficit E. Narrowed pulse pressure E. Narrowed pulse pressure Which one of the following should be performed first in any patient whose injuries may include multiple closed extremity fractures? A. A thorough assessment of four limb perfusion B. Maneuvers to prevent necrosis of the skin C. Extremity compartment syndrome release D. Ensuring adequate oxygenation and ventilation E. Evaluation for occult crush syndrome D. Ensuring adequate oxygenation and ventilation A 22-year-old man is hypotensive and tachycardic after a shotgun wound to the left shoulder. His blood pressure is initially 80/40 mm Hg. After initial fluid resuscitation his blood pressure increases to 122/84 mm Hg. His heart rate is now 100 beats per minute and his respiratory rate is 28 breaths per minute. A tube thoracostomy is performed for decreased left chest breath sounds with the return of a small amount of blood and no air leak. After chest tube insertion, the most appropriate next step is: re-examine the chest A construction worker falls two stories from a building and sustains bilateral calcaneal fractures. In the emergency department, he is alert, vital signs are normal, and he is complaining of severe pain in both heels and his lower back. Lower extremity pulses are strong and there is no other deformity. The suspected diagnosis is most likely to be confirmed by: complete spine x-ray series What is true regarding the initial resuscitation of a trauma patient? Evidence of improved perfusion after fluid resuscitation could include improvement in Glasgow Coma Scale score on reevaluation In managing a patient with a severe traumatic brain injury, the most important initial step is to: secure the airway A previously healthy, 70-kg (154-pound) man suffers an estimated acute blood loss of 2 liters. What applies to this patient? An ABG would demonstrate a base deficit between -6 and -10 mEq/L. The physiological hypervolemia of pregnancy has clinical significance in the management of the severely injured, gravid woman by: increasing the volume of blood loss to produce maternal hypotension. The best assessment of fluid resuscitation of the adult burn patient is: urinary output of 0.5 mL/kg/hr The diagnosis of shock must include: evidence of inadequate organ perfusion A 7-year-old boy is brought to the emergency department by his parents several minutes after he fell through a window. He is bleeding profusely from a 6-cm wound of his medial right thigh. Immediate management of the wound should consist of: direct pressure on the wound For the patient with severe traumatic brain injury, profound hypocarbia should be avoided to prevent: cerebral vasoconstriction with diminished perfusion After being involved in a motor vehicle crash, a 25-year-old man is brought to a hospital that has surgery capabilities available.. Computed tomography of the chest and abdomen shows an aortic injury and splenic laceration with free abdominal fluid. His blood pressure falls to 70 mm Hg after CT. The next step is: perform an exploratory laparotomy What statements regarding abdominal trauma in the pregnant patient is TRUE? Leakage of amniotic fluid is an indication for hospital admission. The first maneuver to improve oxygenation after chest injury is: administer supplemental oxygen call the receiving hospital and speak to the surgeon on call Hemorrhage of 20% of the patient's blood volume is associated usually with tachycardia What statement concerning intraosseous infusion is TRUE? Aspiration of bone marrow confirms appropriate positioning of the needle. A young woman sustains a severe head injury as the result of a motor vehicle crash. In the emergency department, her GCS is 6. Her blood pressure is 140/90 mm Hg and her heart rate is 80 beats per minute. She is intubated and mechanically ventilated. Her pupils are 3 mm in size and equally reactive to light. There is no other apparent injury. The most important principle to follow in the early management of her head injury is to avoid hypotension A 33-year-old woman is involved in a head-on motor vehicle crash. It took 30 minutes to extricate her from the car. Upon arrival in the emergency department, her heart rate is 120 beats per minute, BP is 90/70 mm Hg, respiratory rate is 16 breaths per minute, and her GCS score is 15. Examination reveals bilaterally equal breath sounds, anterior chest wall ecchymosis, and distended neck veins. Her abdomen is flat, soft, and not tender. Her pelvis is stable. Palpable distal pulses are found in all 4 extremities. Of the following, the most likely diagnosis is: cardiac tamponade A hemodynamically normal 10-year-old girl is hospitalized for observation after a Grade III (moderately severe) splenic injury has been confirmed by computed tomography (CT). What mandates prompt celiotomy (laparotomy)? development of peritonitis on physical exam A 40-year-old woman who was a restrained driver in a motor vehicle crash is evaluated in the emergency department. She is hemodynamically normal and found to be paraplegic at the level of T10. What precaution should be taken during evaluation and management? Log rolling using 4 people is a safe approach to restrict spinal motion when moving her. A trauma patient presents to your emergency department with inspiratory stridor and a suspected c-spine injury. Oxygen saturation is 88% on high-flow oxygen via a nonrebreathing mask. The most appropriate next step is to: restrict cervical motion and establish a definitive airway When applying the Rule of Nines to infants The head is proportionally larger in infants than in adults A healthy young male is brought to the emergency department following a motor vehicle crash. His vital signs are a blood pressure of 84/60, pulse 123, GCS 10. The patient moans when his pelvis is palpated. After initiating fluid resuscitation, the next step in management is: placement of a pelvic binder What situations requires Rh immunoglobulin administration to an injured woman? positive pregnancy test, Rh negative, and has torso trauma A 22-year-old female athlete is stabbed in her left chest at the third interspace in the anterior axillary line. On admission to the emergency department and 15 minutes after the incident, she is awake and alert. Her heart rate is 100 beats per minute, blood pressure 80/60 mm Hg, and respiratory rate 20 breaths per minute. A chest x-ray reveals a large left hemothorax. A left chest tube is placed with an immediate return of 1600 mL of blood. The next management step for this patient is: prepare for an exploratory thoracotomy A 6-year-old boy walking across the street is struck by the front bumper of a sports utility vehicle traveling at 32 kph (20 mph). What's true about this patient? A pulmonary contusion may be present in the absence of rib fractures. Adjuncts used during the primary survey ECG Pulse ox CO2 monitoringV Ventilatory rate ABGs Foleys (UOP) Gastric catheter FAST or eFAST DPL Urinary output is sensitive for Patient's volume status and renal perfusion "Golden hour" The time from injury to definitive care, during which treatment of shock and traumatic injuries should occur because survival potential is best; also called the Golden Period. Leading cause of trauma deaths worldwide MVCs Trimodal death distribution 1st: seconds to minutes of injury (apnea) 2nd: minutes to several hours (EDH, SDH, liver lac, pelvic fractures, spleen ruptures) 3rd: several days to weeks after injury (sepsis and multi-organ failure) An 18-year-old male was the unrestrained driver in a MVC involving contact with a tree, He is being transported to the ED by ambulance after a prolonged extrication process. He is receive oxygen by mask and IVF via one large-bore IV, and he is immobilized on a long spine board. How would you prepare for arrival of this patient? Airway equipment for possible intubation IV equipment to place a second IV and get blood work Lab/Xray available Monitor equipment ready Notify blood bank and have transfusion protocol available Consider appropriate transfer AMPLE hx Allergies Medications currently used Past illnesses/Pregnancy Last meal Events/Environment related to the injury Blunt trauma MOI Seatbelt use Steering wheel deofrmation Presence/activation of airbags Direction of impact Damage to vehicle Patient position Ejection from vehicle? Penetrating trauma MOI Body region Velocity of weapon Caliber Heat loss can occur at moderated temperatures 59 to 68 F (15-20 C) Prehospital phase should include what interventions and considerations? Airway maintenance Breathing support Control of bleeding and shock Mechanism and time of injury Injuries found and suspected Symptoms and signs Treatment initiated Retroperitoneal organs Abdominal aorta IVC Duodeum Pancreas Kidneys Ureters Posterior aspects of ascending/descending colon Bladder Rectum Reproductive organs What's the most frequently injured abdominal organ in blunt trauma? Followed by? Spleen (40-55%) Liver (35-45%) Small bowel (5-10%) Which patients should you consider transferring, and what tests should be performed prior to transfer? The patients whose injuries exceed your ability to care for them, either sue to specialize needs, or resource availably. Only perform testing that enables the referring physician to resuscitate, stabilize, and ensure the safer transfer of the patient What's a pulse oximetry measure? Oxygen saturation by relative absorption of light by oxyhemoglobin and deoxyhemoglobin Gastric catheter placement can induce vomiting Be prepared to logroll Ensure suction is immediately available Special populations that may have physiological responses that do not follow expected patterns Children Pregnant females Elderly Obese individuals Athletes Why is info about mechanism of injury so important? The patient's condition is greatly influenced by MOI. It can enhance the understanding of the patient's condition and anticipated injuries Possible adjuncts to secondary survey X-rays of spine and extremities CT scans of head, chest, abdomen, spine Contrast urography and angiography TEE Bronchoscopy Esophagoscopy Frontal impact MVC Cervical spine fracture Flail chest Myocardial contusion Pneumothroax Traumatic aortic disruption Fractured spleen or liver Posterior fracture/dislocation hip/knee Head injury Facial fractures Side impact MVC Contralateral neck sprain Head injury Cervical spine fracture Flail chest Pneumothorax Traumatic aortic disrution Diaphragmatic rupture Fractured spleen/liver/kidney Fractured pelvis or acetabulum Rear impact MVC Cervical spine injury Head injury Soft tissue injury to neck MVC vs pedestrian Head injury Traumatic aortic disruption Abdominal visceral injuries Fractured lower extremities/ pelvis Fall from heigh Head injury Axial spine injury Abdominal visceral injuries Fractured pelvis or acetabulum Bilateral LE fractures Anterior stab wound Cardiac tamponade Hemothorax Pneumothorax Hemopneumothorax Left stab wound Left diaphragm injury Spleen injury Hemopneumothoax Abdomen stab wound Visceral injury Extremity GSW Neurovascular injury Fractures Compartment syndrome Thermal burns Eschar on extremities or chest Electrical burns Cardiac arrhythmias Myonecrosis Compartment syndrome Inhalation burns CO poisoning Upper airway swelling Pulmonary edema What is your first step when a patient condition changes? ABCDEs ABG or continual end-tidal carbon dioxide analysis On exam, an unrestrained driver is hoards and has minimal subcutaneous neck emphysema. This patient likely has a/an Obstructed airway In an agitated trauma patient who refuses to lay down Assessment of airway adequacy may include suctioning What's an indication for rapid sequence intubation? Patients who need airway control, have intact gag reflex, especially those who have sustained head injury A surgical airway is indicated in the presence of Edema of the glottis Fracture of larynx Severe oropharyngeal hemorrhage that obstructs airway Inability to place an endotracheal tube Possible causes of confusion after traumatic event? Hemorrhage Brain injury Stroke Intoxication What's the most common cause of shock after an injury? Hemorrhage What're the early clinical manifestations of shock? Tachycardia and cutaneous vasoconstriction What's the preferred method of vascular access for a patient involved in a MVC? 2 large bore PIVs in the antecubital veins What's the most appropriate means to restore cardiac output and end organ perfusion in hemorrhagic shock? Stopping the source of bleeding and ensuring appropriate volume repletion A 24-year-old male arrives in ED already intubated. He has significant crepitus of the right chest wall and diminished breath sounds. You place a chest tube and note a large amount of bubbling in the water seal chamber. His O2 saturation remains at 85% and he has goodCO2 return on capnography. The most likely cause of his low oxygen saturation is Tracheobronchial tree injury Most injuries to the tracheobronchial tree occur where? Within 2.5 cm from the carina Do the vast majority of thoracic injuries (blunt and penetrating) require operative intervention? No, most are treated with technical procedures Airway thoracic injuries Airway obstruction (laryngeal injury, posterior dislocation of clavicular head, or penetrating trauma) Tracheobronchial tree injury Breathing thoracic injuries Tension pneumothorax Open pneumothorax Massive hemothorax Circulation thoracic injuries Massive hemothorax Cardiac tamponade Traumatic circulatory arrest What's the most common cause of a tension pneumothorax? Mechanical positive-pressure ventilation in patients with a visceral pleural inury Where is the ideal location for needle decompression of a tension pneumothorax? 5th intercostal space, slightly anterior to midaxillary line What do you need to remember when treating an open pneumothorax? Place a dressing on the site and only secure is on 3 sides so air can escape, then place a chest tube Massive hemothorax Accumulation of >1500 ml of blood in one side of chest Causes of PEA? Hypovolemia Hypoxia Hydrogen acidosis Hypo/hyperkalemia Hypoglycemia Hypothermia Toxins Tamponade Tension pneumo Thrombosis Indications of a thoracotomy Immediate return of > 1500 ml of blood or significant bleeding Persistent blood transfusions Penetrating anterior chest wounds medial to the nipple line Posterior wounds medial to the scapula A 26-year-old male sustained a posterior stab wound. Blood and bubbling are coming from the wound. Open pneumothorax A 46-year-old male sustained a gunshot wound to the chest Massive hemothorax A 65-year-old female who takes warfarin was involved in a MVC. She initially presented complaining of sternal pain. BP deteriorated to 90/60 after arriving to the ED Cardiac tamponade Eight life-threatening injuries during the secondary survey? Simple pneumothorax Hemothorax Flail chest Pulmonary contusion Blunt cardiac injury Traumatic aortic disruption A 28-year-old male, helmeted motorcyclist was in a high speed MVC, striking head-on into the side of a vehicle. He arrives on a backboard and with a cervical collar in place via pre-hospital BLS transport. Vitals are: BP 100/75, HR 115, RR 20, GCS 15. The patient reports a brief loss of consciousness and is complaining of pain in the chest, abdomen, and pelvis. What're the priorities for management? Rapidly assess ABCs Auscultate the lungs, provide supplemental oxygen, and apply pulse ox A 28-year-old male, helmeted motorcyclist was in a high speed MVC, striking head-on into the side of a vehicle. He arrives on a backboard and with a cervical collar in place via pre-hospital BLS transport. Vitals are: BP 100/75, HR 115, RR 20, GCS 15. The patient reports a brief loss of consciousness and is complaining of pain in the chest, abdomen, and pelvis. What's the interpretation of the VS and the initial therapy? VS are consistent with hemorrhagic shock from intraabdominal or pelvic sound Maintain IV/IO access and initiate volume resuscitation, including blood transfusion if indicated Pelvic binder application may be appropriate Will retroperitoneal injuries prevent with obvious signs of peritoneal irritation? No, retroperitoneal structures are separated from anterior peritoneum by the intraperitoneal viscera, therefore no peritonitis may be present A patient was found 10' from his motorcycle, laying on his right side. He was wearing a helmet. He was going ~45 mph. He had brief LOC. He states he has no allergies, medications that he takes, no current illness. Last meal was 6 hours ago. Based on mechanism, what intra-abdominal and/or pelvic injuries is he likely to have sustained? Visceral lacerations (liver/spleen) Bowel visceral/vascular injuries Retroperitoneal visceral/vascular injuries (kidneys/adrenal) Pelvic fractures A patient was found 10' from his motorcycle, laying on his right side. He was wearing a helmet. He was going ~45 mph. He had brief LOC. He states he has no allergies, medications that he takes, no current illness. Last meal was 6 hours ago. How would the risk of intra-abdominal injury change if the patient described stroking the handlebar into the epigastrium? A direct blow to the epigastrium would raise the risk of a pancreas, duodenal, or small bowel injury A 30-year-old male presents with a 2 cm stab wound to the mid-abdomen, 3 cm to the right of the umbilicus. VS are BP 85/60, HR 130, RR 25, GCS 14. Neck veins are flat. Chest exam is CTAB. The abdomen is tender. What's the ONE BEST therapy to treat this patient's injury? Airway appears intact. Breathing has increased rate. Circulation demonstrated hemorrhagic shock. Penetrating abdominal injury with shock is one of the indications for emergent laparotomy. In a patient with a possible pelvic fracture, how frequently should the pelvis be tested for mechanical stability? The pelvis should not be tested in a hemodynacilly unstable patient. Mechanical instability of he pelvic ring should be assumed in patients who have suspected pelvic fractures. Avoid manually manipulating the pelvis (dislodge an existing clot) Hypotension + pelvic fracture = High mortality A 12-year-old male complains of LUQ tenderness and L shoulder pain 8 hours after playing rugby. ABCDE are normal. Circulatory assessment remains normal. Abdominal exam reveals mild LUQ TTP without peritoneal signs. FAST demonstrated fluid in the hepatorenal space and the plenorenal recess. What's the appropriate next step? Observation A 29-year-old woman is the restrained driver in a head-on collision. Airbags deployed. ABCDE are normal. The patient complains of lower abd and back pain. A lower abd contusion is present and associated with tenderness. There is no evidence of diffuse peritonitis. Your institution has NOT surgical capabilities. What's the most appropriate treatment plan? The patient should be urgently transferred for surgical intervention A 50-year-old male arrives to the ED following fall of 26'. He hs gurgling respirations and is not responsive to voice. VS are BP 80/5-, RR 30, HR 138, O2 sat is undetectable. Your hospital does not have surgical capabilities. The first step in management is Application of oxygen and securing an airway A 25-year-old ale arrives at the ED following a motorcycle crash. BP is 80/60, HR 140. Airway and breathing are controlled. There are no open wounds. The abd is not distended. Both legs are externally rotated but soft. The pelvis is tender. The scrotum is swollen and ecchymotic. While vascular access is obtained, what the next most appropriate step? Application of a pelvic binder A 45-year-old male with a BMI of 48 was working in an industrial plant when 2 pieces of wood flew off a sa and struck him in the abdomen and right chest. CXR demonstrates rib fractures. What's true about this scenario? Despite multiple imaging studies, detection of intestinal and retroperitoneal injuries may be difficult Your institution does not have surgical capabilities. You have intubated a 25-year-old man who was in a rollover MVC. You have also placed bilateral chest tubes for pneumothoraxes. The patient's SBP is continually < 90 and HR > 140. Potential therapy and evaluation includes Activation of massive transfusion protocol, application of pelvic binder, and CXR What's the primary goal of treatment for patient's with suspected TBIs? To prevent secondary brain injury by ensuring adequate oxygenation and maintain BP that's sufficient to perfuse the brain Cerebral perfusion pressure (CPP) MAP - ICP A 23-year-old male fell from a bike, striking his head on the curb. He was not wearing a helmet. The patient has a 10 cm laceration to the temporal-parietal region of the left scalp. He is initially able to say hi name. VS are HR 115, BP 100/60, oxygen sat 88%, GCS initially 12. 2 hours after transfer to a local hospital, he has sonorous respirations, a HR of 120, BP 100/70, and GCS of 6. What the initial priorities in the management of this patient? Airway protection with a subglottic device Oxygenation to prevent hypoxia Maintain SBP > 100 mmHg A 23-year-old male fell from a bike, striking his head on the curb. He was not wearing a helmet. The patient has a 10 cm laceration to the temporal-parietal region of the left scalp. He is initially able to say hi name. VS are HR 115, BP 100/60, oxygen sat 88%, GCS initially 12. 2 hours after transfer to a local hospital, he has sonorous respirations, a HR of 120, BP 100/70, and GCS of 6. What are the signs that the patient's injury is progressing? Decreased GCS indicates worsening intracranial pathology with possible intracranial HTN and impending herniation A 78-year-old ale is found down in the bathroom with a large left scalp laceration from striking the corner of the sink. He arrives in the ED with a BP 180/90, HR 60, dilated, non-responsive right pupil. The most likely finding on the patient's CT scan will be Illustrtive of impending uncle hernia associated with Cushing response (high BP + bradycardia)-- associated with a large subdural hematoma with midline shift Intracranial mass effect is defined by the Monro-Kellie Doctrine A trauma patient opens her eyes, moans, and withdraws from pain. What is her GCS score? Eye opening: 2 Verbal response: 2 mumble incoherently, does not open his eyes, and only flexes to pain. Upon arrival in the ED, the primary goal is Intubate the patient What treatment measures is essential in maintaining cerebral perfusion pressure? Sedation, mannitol, and IVF will help decrease ICP or increase MAP A 45-year-old female is involved in a MVC and brought to a local ED with limited capabilities. She does not remember the event and has repetitive questioning. You would like to get a CT scan of the head, but the technician must be called in from home, which will take at least 30 minutes. You should Transfer the patient to a higher level of care A patient arrives after a blow to the right temporal region secondary to a tree limb striking him while chopping down a tree. He was intubated in the field for a declining mental status. His PE reveals 6 mm and non-reactive right pupil and a 4 mm L pupil with brisk reaction to 2 mm. His GCS reveals extensor posturing with no eye opening, and he is intubated. The presumed extent of his intracranial injury is most likely? Epidural hematoma causes same side pupil dilation and opposite side weakness Many patients with c-spine fractures have a second, noncontiguous vertebral column fracture A helmeted 28-year-old male fell from scaffolding. A bystander witnessed the fall and reports that the patient landed head first, causing his neck to hyperextend. His VS are BP 90/62, HR 58, RR 28, GCS 15. The patient is alert and following commands. His breathing is shallow and he is not moving his arms or legs. What injuries has this patient likely incurred? The initial assessment raises concerns for a spinal cord injury. However, complete a primary and secondary survey to rule out additional life-threatening injures. A helmeted 28-year-old male fell from scaffolding. A bystander witnessed the fall and reports that the patient landed head first, causing his neck to hyperextend. His VS are BP 90/62, HR 58, RR 28, GCS 15. The patient is alert and following commands. His breathing is shallow and he is not moving his arms or legs. What type of shock does this patient exhibit? Neurogenic Cervical spine injuries represent more than 1/2 of all spinal column injuries. What additional injuries are commonly associated with cervical fractures? 25% of all spine injuries have at least a mild brain injury and 10% with a cervical fracture have another noncontiguous spine fracture Neurogenic shock is associated with what level of spinal cord injury and causes systemic hypotension via what mechanism? T6 and higher, distributive shock from lack of vasomotor tone The patient is unable to move his legs. He can move his fingers and wrists bilaterally. He has weal triceps extension on the left. He is unable to move right elbow. He is able to feel his fingers and thumbs bilaterally, but not feel anything above his elbow. Where is the suspected spine lesion? C6 or C7 The patient is unable to move his legs. He can move his fingers and wrists bilaterally. He has weal triceps extension on the left. He is unable to move right elbow. He is able to feel his fingers and thumbs bilaterally, but not feel anything above his elbow. Why is there a difference b/t the PW findings for the UE on PE? The difference between the PE findings for the UE is likely due to initial inflammatory response, edema, and/or the presence of an incomplete spinal cord injury. Spinal cord injuries can be defined by neurologic level and severity in addition to associated syndromes and morphology. Describe Brown-Sequard syndrome lesion at T5. T5, penetrating injury to one side (partial) Which type of thoracic spinal fracture is associated with MVC with restrained passengers using lap belt, a forward flexion mechanism, likely visceral organ injury, and frequent need for internal fixation? Chance fracture What's the appropriate treatment for a C6 vertebral body fracture Spinal immobilization and IVFs, followed by vasopressors if patient remains bradycardic after fluids A patient with a known cervical spine fracture who is being transferred from a rural hospital to definitive care should be transported in which way? Semi-regid collar and head restraint Patients with cerviacl fractures above C6 require special consideration prior to transportation due to? Potential progression to respiratory failure A 35-year-oldman was ejected from a MV. On arrival, his VS are BP 80/40, HR 110,RR 24, GCS 15. Airway and breathing are intact. He complains of severe back pain, has no sensation below umbilicus, has lower thoracic tenderness, and is unable to move LE. Chest and pelvic X- rays are normal. Along with IVFs, what is most appropriate treatment for this patient's hypotension? Although this patient likely has a spinal cord injury, perform a FAST exam or DPL to r/o other etiology. An elderly female falls and sustains a hyperextension injury to her neck. Her exam demonstrated decreased strength in UE compared to LE. What is the cause of her unusual neurologic findings? Central cord syndrome What's the most common location of all spinal injuries? C5 A 40-year-old M involved in a MVC is evaluated in a rural hospital without spine surgical capacity. The patient has a clear C-spine fracture at C4 on plain film and the inability to move any extremities and sensation limited to supraclavicular region. He is having difficulty breathing with a RR 30. BP 80/40 and HR 50. What should be performed prior to transfer? Crystalloid bolus, initiate pressers, intubate, and then transfer patient once he is hemodynamically stable Potentially life threatening extremity injuries Marjor arterial hemorrhage Bilateral femoral fractures Crush syndrome Rhabdomyolysis can lead to Metabolic acidosis Hyperkalemia Hypocalcemia Disseminated intravascular coagulation (DIC) A 38-year-old female restrained driver is involved in a high-speed, head-on collision with a truck. Following a prolonged extrication, she noted to have deformity of her right thigh. On arrival, her VS are HR 120, BP 90/50, RR 22, GC 15. 2 large bore IVs are inserted in UE. VS are now HR 13- BP 80/40, RR 24, GCS 14. CXR, pelvis X-ray, and FAST are negative. You suspect the source of hypotension is a femur fracture and bilateral tibial shaft fractures. How much blood loss would you expect from this patient's extremity injuries and what's the best way to control it? A femur fracture can result in blood loss up to 2 L and each tibial fracture can cause up to 1.5 L of blood loss. Fracture immobilization is the best control. How should femur and tibial shaft fractures be stabilized? A traction splint should NOT be used. Tibial fracture should be placed in a long leg splint. A femur and tibial fracture should be placed in a long leg posterior splint. Open fractures should be Proper application of a splint can help control blood loss, reduce pain, and prevent further neurovasculr compromise ABLS indications for early intubation Signs of airway obstruction TBSA > 40-50% Extensive and deep facial burns Burns inside the mouth Significant edema or risk for edema Difficulty swallowing Signs of respiratory compromise Decreased LOC Anticipated patient transfer of large burn with airway issue without qualified personnel to intake en route Parkland formula 2-4 ml of LR x patient's weight (kg) x % TBSA for 2nd and 3rd degree burns with 1/2 administered in the 1st 8h and the 2nd 1/2 administered during the subsequent 16h Simplest way to remove tar from trauma patient? Mineral oil Reperfusion syndrome Indicated by acidosis, hyperkalemia, and local swelling; therefore monitor the patient's cardiac status and peripheral perfusion during rewarming Immediate lifesaving measures for patients with burn injuries Stopping the burn process Recognize inhalation injury Assuring an adequate airway Oxygenation and ventilation Rapidly initiating IVF What's the most significant difference between burns and other injuries? The consequence of a burn injury are directly linked to the extent of the inflammatory response to the injury A 29-year-old M jumps from the 1st story of a burning house. His clothes are on fire. Bystanders extinguished the flames. He is conscious, agitated, and complaining of abdominal and leg pain. The patient's head and upper body appear to be extensively burned. What are the unique considerations that a burn injury adds to the initial management of this patient? Some interventions to be considered are early intubation and initiation of burn resuscitation. What is the primary difference b/t the presentation of airway injury in patients with burns compared to other forms of trauma? Airway injury can develop over time due to edema from burn injury How does hypovolemia from burn injury differ from hypovolemia from other forms of trauma? Other trauma usually result in hemorrhagic volume loss, however burn hypovolemia is due to inflammatory changes and capillary leak When do you provide burn resuscitation? Deep partial and full thickness burns larger than 20% TBSA A 29-year-old M jumps from the 1st story of a burning house. His clothes are on fire. Bystanders extinguished the flames. He is conscious, agitated, and complaining of abdominal and leg pain. The patient's head and upper body appear to be extensively burned. The patient is now intubated with IV access. A foley is placed with minimal dark urine output. The estimate of burn size is 45% TBSA. How should the patient's burn wound be managed in the initial stages? ABC management in addition to stopping the burning process, cleansing the wound, protecting it from infection, and preventing hypothermia What is the goal of burn resuscitation? To maintain end-organ perfusion in the context of ongoing intravascular fluid loss What info should be recorded on the trauma flow sheet? Depth and extent of burn Fluids given UOP Any significant interventions, including escharotomies What are the factors that contribute to the need for an escharotomy? Edema from the inflammatory response to the burn and reduced elasticity of burned skin (increased pressure in the underlying soft tissue) How cana circumferential burn injury affect muscle tissue? Can cause the pressure from burn edema to build to the point that it compromises tissue perfusion, similar to compartment syndrome How is burn resuscitation affected when the patient also has an injury causing hemorrhage? Control bleeding and resuscitate the patient per standard ATLS protocol for hemorrhagic shock before starting burn resuscitation In what situation is it not advisable to immediately wash off chemicals with irrigation? Not until airway has been assessed and secured and when the chemical is a powder (brush off before irrigation) What are two interventions for treating rhabdomyolysis? Increase IVF to target UOP of 100 ml/hr which washes out the myoglobin before it settles Administer mannitol which acts as a free radical scavenger and osmotic diuretic therefore increasing UOP and washing out myoglobin A 20-year-old is brought to ED after his shovel hits a 14,000 volt underground wire and he suffers an electrical contact injury to his arms. He is covered in powdered cement from the work site. How should be be initially treated? Establish ABCs Brush powder off before irrigating Monitor due to electrical injuries later manifesting If a burn patient's urine were reddish-brown in color, what would change in your burn resuscitation? Signifying myoglobinuria secondary to rhabdomyolysis should be treated with aggressive IVF and possible mannitol What's the difference between active and passive rewarming? Passive involves placing the patient in an environment that reduces heat loss and relies on patient's intrinsic thermoregulartory mechanisms Active involves supplying a heat source (warm IVFs, warmed packs of high vascular flow and initiating circulatory bypass) Why is the issue of iatrogenic hypothermia important? Shown to increase trauma related mortality, which is preventable A 35-year-old female is brought into the hospital after being lost for two days while snowmobiling in -30 C weather. She has a core body temperature of 30 C and her toes are frozen. How and when should rewarming start Immediate active rewarming A 35-year-old female is brought into the hospital after being lost for two days while snowmobiling in -30 C weather. She has a core body temperature of 30 C and her toes are frozen. How should the toes be thawed? Moist rewarming The most significant difference between burn and other traumatic injuries is? In a burn injury, the full extent of the injury may not be evidence immediately In an adult patient with suspected inhalation injury, it is important to? to ED from radiology, his HR increased to 150 BP drops to 70/45. What's the appropriate next step? Administer 20 ml/kg isotonic IVF bolus and 10 ml/kg pRBCs. The patient should undergo an emergent laparotomy/splenectomy. A 10-year-old male struck his head while diving into pool. On exam, he demonstrates weakness in all extremities. Cervical spine films show no fracture. Whats the next step in management.? Obtain urgent spine surgery consultation A conscious infant with bulging fontanelles or suture diastases should be assumed to have? More severe injury and requires early neurosurgical consultation ABCDEs of injury prevention Analyze injury data (local injury surveillance) Build local coalitions (hospital community partnerships) Communicate the problem (injuries are preventable) Develop prevention activities (create safer environments) Evaluate the interventions (ongoing injury surveillance) What factors are associated with progression of secondary brain injury? Hypotension and hypoxemia A 7-year-old M is struck by car while riding a bike. Upon arrival to ED, he is tachycardic, hypotension, and hypoxic. He has diminished breath sounds a large contusion of the right side. The most appropriate next step is? Perform immediate needle thoracostomy of the right chest Following the successful endotracheal intubation of an obtunded 2-year-old male involve in MVC, he is transported to CT scanner. During transport, there is a sudden deterioration of oxygen saturation. The most likely cause of this deterioration is? Dislodgment of tube A 6-month-old infant is brought to the ED after a fall onto a hard floor. She is crying and appropriately interactive. Her eyes are open. She is moving all extremities. There is a laceration on the scalp and the anterior fontanelle is firm and bulging. What is the next appropriate step? CT of the head Why are the elderly at a higher risk for TBIs? The dura is more adherent to the skull More commonly on anticoagulant/antiplatelet medication Injuries most common in the elderly population? Rib fractures TBI Pelvic fractures An 82-year-old female is brought to the ED by ambulance after she tripped while walking her dog. Her VS are RR 22 HR 64 BP 160/80 and GCS 13. What injuries would you suspect in this patient? The patient may have sustained a TBI and neck, rib, pelvis, long-bone, and/or spine fractures What unique elements of AMPLE history should you be alert to in an elderly patient? Medications (beta blockers and anticoagulation) Automatic implantable cardioverter-defibrillator, pacemaker, artificial valves/stents Last meal (they may have delayed gastric emptying) What's a likely injury for an elderly patient who sustains a standing height fall? Rub and pelvic fractures A geriatric trauma patient may be in shock despite VS that appear normal due to? Cardiovascular disease Preexisting conditions that impact morbidity and mortality of trauma patients? Cirrhosis Coagulopathy COPD Ischemic heart disease DM What pitfalls may you face when intubating an elderly patient? Decreased chest wall and pulmonary compliance Decreased mucus clearance Diminished functional residual capacity Increased work of breathing A geriatric trauma patient falls from her wheelchair at a nursing home. She presents with a GCS score of 13, The patient is likely suffering from a? TBI An important immediate treatment of intracranial hemorrhage in elderly patients is? Correct all sources of coagulopathy Likely causes of elderly patient's decline in mental status? Delirium Dementia Pain medication Sedatives Increase ICP Decreased cerebral perfusion pressure Geriatric trauma patients are at greater risk of mortality from rib fractures than younger individuals because they? Are at a greater risk of developing pneumonia An elderly patient is transferred from a long-term care facility after being found down. In addition to a hip fracture, you find the patient is wearing soiled clothes and a soiled diaper, has dry mucus membranes, and tenting skin. You should evaluate the patient for? Elder maltreatment Compared to a younger patient, a geriatric trauma patient with a pelvic fracture is more likely to? Require blood transfusions The removal of spine boards early is particularly important in geriatric patients because? Patients are at increased risk of pressure ulcers The best initial treatment for pregnant trauma patients is? Resuscitate the mother and consult surgeon and obstetrician A 35-year-old woman who appears to be in the second trimester of pregnancy is brought to the ED following a MVC. She is unconscious and immobilized on a long spine board. How might the patient's pregnant affect the performance of the primary survey? The priorities are the same: ABCDE. Care must be taken to interpret VS. In addition to VS and GCS score, what information would be helpful to obtain in order to evaluate pregnant trauma patients? Additional scene information: whether/how the patient was restrained and MOI A 22-year-old female in the 3rd trimester of her pregnancy presents after MVC. Her VS are BP 100/70, HR 120,RR 22. FHR found to be 90. What statement about FHR is correct? This is abnormally low FHR likely presents impair oxygen flow to the fetus from the placental vasculature (sensitive to catecholamine surge during trauma causing increased uterine vascular resistance and decreased fetal oxygenation) What's true about hypervolemia associated with pregnancy? A normal serum fibrinogen level late in pregnancy may indicated early disseminated intravascular coagulation A 19-year-old female stepped off a curb, tripped, and fell. Her VS are normal. She had LOC and brain CT is negative. Her only prior ED visit was for a broken arm sustained in a bike accident 5 years ago. She sees a PCP and Gyn regularly. What's true regarding intimate partner violence for this patient? Screening for intimate partner violence should be performed on all patients who present to ED Rapid triage and transport issues during primary survey Airway compromise, high risk for loss of airway Tension pneumothorax, hemothorax, open pneumothorax, hypoxia Hypotension, pelvic fracture, vascular injury, open fracture, abdominal distention/peritonitis GCS < 13, intoxicated, evidence of paralysis Rapid triage and transport issues during secondary survey Depressed skull fracture or penetrating injury Eye injury, open fractures, ongoing nasopharyngeal bleeding Neck hematoma, crepitus Multiple rib fractures, flail chest, pulmonary contusion, widened mediastinum Rebound or guarding of abdomen Laceration of perineum Neurologic deficit Complex or multiple fractures, bony spine injuries Multiple comorbities, pregnancy, burns A 17-year-old male is brought to a 20 bed hospital following a snowmobile crash. Hospital has CT and ultrasound capabilities. VS are SBP 85, HR 120, GCS 15. Patient is breathing shallow. Unstable pelvis and deformity of left thigh. What's priorities of management? Perform primary survey: establish airway, obtain IV access, apply pelvic binder, and begin IVF resuscitation A 54-year-old male arrives to ED at small hospital without surgical capabilities. He was involved in MVC in which he was the driver of a car that Tboned a delivery truck at 55 mph. He has GCS of 8, decreased breath sounds on the left, abdominal tenderness. BP 95/65, HR 110. What are the priorities of management? Establish airway and insert chest tube. Resuscitate and stabilize prior to transporting patient to adequate hospital Identify the responsibilities of a referring physician in a patient transfer situation? Initiating transfer during resuscitation Consult with receiving physician Maintain familiarity with transporting agencies Select appropriate transportation Determine level of care required during transfer Stabilize the patient's confiriotn Provide patient summary Ensure adequate trained personnel accompanying patient Ensure pediatric patients are transferred to facilities with special expertise when available Airway treatments that must be established before transfer Insert airway or ETT with low GCS or the potential to deteriorate Provide suction Place gastric tube in all intubated patients and those with gastric distention Breathing treatments that must be established before transfer Determine rate and administer supplementary oxygen Provide mechanical ventilation when needed Insert chest tube Circulation treatments that must be established before transfer Control external bleeding Establish 2 large bore IVs and begin IVF Restore blood volume using crystalloid fluids and blood Insert indwelling catheter to monitor UOP Monitor cardiac rate and rhythm Transport patients late in pregnancy (tilted to the left side) Restrict spinal motion Disability treatments that must be established before transfer Assist respiration in unconscious patients Administer mannitol or hypertonic saline if needed Restrict spinal motion in spine injuries What should be done about wounds/fractures before transfers? Clean and dress wounds after external control Administer tetanus Administer antibiotics if needed Splint and tract fractures What diagnostic studies should be conducted prior to transfer? X-rays of chest, pelvis, and extremities Blood work Determine cardiac rhythm,, and hemoglobin saturation Transfer template ABC-SBAR Airway, Breathing, Circulation, Situation, Background, Assessment, Recommendation A right thigh deformity is noted and splinted. Distal pulses intact. What additional radiographic tests need to be done? Pevlic x-ray with pelvic binder to any fracture What factors would determine mode of transportation? Distance from referring to accepting facility, weather, availability of ambulance/helicopter, ability to manage intubated patient A 50-year-old male is brought to your facility, which is a small community hospital without surgical services. He was involved in a MVC in which his car sustained significant front-end damage. The patient was not wearing a seatbelt and complains of abdominal pain. He has a GCS of 13. What are the most radiographic studies should the patient have before transfer? CXR, pelvis x-ray, and FAST exam A 50-year-old female involved in a MVC is brought to your facility, a small community hospital with general surgical but no neurosurgical capability. It was reported that there was significant damage to the driver's side of the care with a starred windshield. The patient's GCS of 8, decreased breath sounds on the left, abdominal tenderness. On FAST, she clearly has fluid in her peritoneum. What are the priorities prior to sending this patient to a facility that has neurosurgical capabilities? ETT, chest tube, and exploratory laparotomy Assess basic physiology SBP < 90 RR < 10 or > 29 GCS < 14 Assess anatomy of injury Penetrating injury to head, neck, torso, and extremities Flail chest > 1 proximal long bone fracture Crushed, degloved, or mangled extremity Amputation Pelvic fractures Open or depressed skull fracture High risk MVC Auto vs peds Special patient considerations