ATLS EXAM WITH COMPLETE SOLUTIONS RATED A+ 2024 LATEST UPDATE, Exams of Nursing

Download ATLS EXAM WITH COMPLETE SOLUTIONS RATED A+ 2024 LATEST UPDATE and more Exams Nursing in PDF only on Docsity! ATLS EXAM WITH COMPLETE SOLUTIONS RATED A+ 2024 LATEST UPDATE field triage scheme step 1: when to transport to level 1 trauma center? GCS - systolic BP - RR - - answerGCS <13 systolic BP <90 RR <10 or >29 [ <20 in infants <1 yr] (OR need for ventilatory support) when adults fall > feet or meters (2 stories) you should transport to trauma center - answer>20 feet or 6 meters (2 stories) when children fall > feet or meters you should transport to trauma center - answer>10 feet or 3 meters (2-3x height of child) high risk mvc qualities - answer- intrusion, including roof: >12 inches (30cm) occupants side - intrusion >18 inches (45cm) on any side - ejection - death in same passenger compartment - vehicle telemetry data consistent with high risk of injury stop the bleed - answer1. direct pressure to wound 2.pressure dressing 3.compression of artery proximal to injury 4.tourniquet Tranexamic Acid (TXA) - answerclot promoter. given in patients who are severely injured in the field in some jurisdictions. Studies demonstrate survival improved with TXA when given within 3 hrs of injury. If given, follow up infusion is given over 8 hrs in the hospital. What part of GCS correlates best with outcome? - answermotor score. methods to prevent hypothermia - answer- increase temperature of resuscitation area to minimize the loss of body heat - the use of a high flow fluid warmer to heat crystalloid fluids to 39*C (102.2) is recommended. When fluid warmers are not available, a microwave can be used to warm crystalloid fluids but it should never be used to warm blood products. When urethral injury is suspected, confirm urethral integrity by performing a before the catheter is inserted. - answerretrograde urethrogram How do you monitor the adequacy of a patient's respirations? - answerVentilatory rate, capnography, (end tidal carbon dioxide levels), ABG measurements. End tidal CO2 can be detected using ? - answercolorimetry, capnometry, or capnography— a noninvasive monitoring technique that provides insight into the patient's ventilation, circulation, and metabolism. End tidal CO2 can also be used for tight control of ventilation to avoid hypoventilation and hyperventilation. It reflects and is used to predict - hypercarbia - answerhypoventilation - too much CO2 an agitated pt can suggest .. - answerhypoxia take away: abusive and belligerent pt may be hypoxic. do not assume intoxication! an obtunded pt can suggest - answerhypercarbia Cervical spinal cord injury can result in respiratory muscle paresis or paralysis. The more the injury, the more likely there will be respiratory impairment. - answerproximal Injuries below the C3 level result in maintenance of the but loss of the intercostal and abdominal muscle contribution to respiration. - answerdiaphragmatic function Typically these patients display a seesaw pattern of breathing in which the abdomen is pushed out with inspiration, while the lower ribcage is pulled in. This presentation is referred to as "abdominal breathing" or "diaphragmatic breathing." This pattern of respiration is inefficient and results in rapid, shallow breaths that lead to atelectasis and ventilation perfusion mismatching and ultimately respiratory failure What nerves innervate the diaphragm? - answerC3,4,5 (phrenic nerve) When do you give O2 when managing an airway? - answerHigh-flow oxygen is required both before and immediately after instituting airway management measures. LEMON assessment for difficult intubation - answerL = Look Externally: Look for characteristics that are known to cause difficult intubation or ventilation (e.g., small mouth or jaw, large overbite, or facial trauma). E = Evaluate the 3-3-2 Rule: To allow for alignment of the pharyngeal, laryngeal, and oral axes and therefore simple intubation, observe the following relationships: What is the preferred technique for Oropharyngeal airway insertion? - answerThe preferred technique is to insert the oral airway upside down, with its curved part directed upward, until it touches the soft palate. At that point, rotate the device 180 degrees, so the curve faces downward, and slip it into place over the tongue patients who tolerate an oropharyngeal airway are - answerlikely to need intubation is an LMA a definitive airway? - answerthe LMA does not provide a definitive airway, and proper placement of this device is difficult without appropriate training. What are the 3 types of definitive airway? - answer1. orotracheal tube, 2. nasotracheal tube 3. surgical airway (cricothyroidotomy and tracheostomy). If clinicians decide to perform orotracheal intubation, what technique is preferred? - answerthe three-person technique with restriction of cervical spinal motion is recommended what is the preferred route taken to protect the airway? - answerorotracheal intubation What can reduce thee risk of aspiration during intubation? - answercricoid pressure. - this maneuver may also reduce the view of the larynx What can aid in visualizing the vocal cords during intubation? - answerBURP! Laryngeal manipulation by backward, upward, and rightward pressure (BURP) on the thyroid cartilage can aid in visualizing the vocal cords. - when the addition of cricoid pressure compromises the view of the larynx, this maneuver should be discontinued or readjusted. Additional hands are required for administering drugs and performing the BURP maneuver. Problematic airway, what can you use to assist intubation? - answerEschmann tracheal tube introducer (aka gum elastic bougie ; GEB) When do clinicians use GEB? - answerwhen vocal cords cannot be visualized on direct laryngoscopy How do you confirm tracheal position with GEB placement? - answerby feeling clicks as the distal tip rubs along the cartilaginous tracheal rings. A GEB inserted into the esophagus will pass its full. length without resistance. After confirming position of GEB, pass a lubricated endotracheal tube over the bougie beyond the vocal cords. Proper placement of an endotracheal tube is suggested—but not confirmed—by - answer- hearing equal breath sounds bilaterally and requires less time to perform than an emergency tracheostomy. Oxygenated inspired air is best provided via .... - answera tight-fitting oxygen reservoir face mask with a flow rate of at least 10 L/min. PaO2 level of 90 corresponds with what O2 saturation? - answer100% PaO2 level of 60 corresponds with what O2 saturation? - answer90% PaO2 level of 30 corresponds with what O2 saturation? - answer60% PaO2 level of 27 corresponds with what O2 saturation? - answer50% Tachycardia is diagnosed when the heart rate is greater than 160 BPM in an - answerinfant Tachycardia is diagnosed when the heart rate is greater than 140 BPM in - answera preschool-aged child Tachycardia is diagnosed when the heart rate is greater than 120 BPM in - answerchildren from school age to puberty Tachycardia is diagnosed when the heart rate is greater than 100 BPM in - answeradults Elderly patients may not exhibit tachycardia with shock because they - answerhave a limited cardiac response to catecholamine stimulation or they have concurrent use of medications, such as ß-adrenergic blocking agents. A narrowed pulse pressure suggests significant blood loss and involvement of compensatory mechanisms. The release of increases peripheral vascular resistance, which in turn increases diastolic blood pressure and reduces pulse pressure. - answerendogenous catecholamines The classic presentation of neurogenic shock is - answerhypotension without tachycardia or cutaneous vasoconstriction. Although it can vary considerably, adult blood volume is approximately % of body weight - answer7% ex) a 70kg male has a circulating blood volume of approximately 5L. Although it can vary considerably, child blood volume is approximately % of body weight - answer8-9% Name that class of hemorrhage! Base deficit: -2 to -6 mEq/L - answerClass II MILD Name that class of hemorrhage! Base deficit: -10 or less mEq/L - answerClass IV SEVERE Name that class of hemorrhage - HR: normal - BP: normal - Pulse pressure: normal - RR: normal - Urine output: normal - GCS: normal - Base deficit: 0 to -2 mEq/L - answerClass I Name that class of hemorrhage - HR: tachycardic - BP: normal - Pulse pressure: decreased - RR: normal - Urine output: normal - GCS: normal - Base deficit: -2 to -6 mEq/L - answerClass II MILD Name that class of hemorrhage - HR: VERY tachycardic - BP: decreased - Pulse pressure: decreased - RR: increased - Urine output: decreased/none - GCS: decreased - Base deficit: -10 mEq/L or less - answerClass IV SEVERE Name that class of hemorrhage - EBL 15-30% - answerClass II longer thinner catheters. The usual dose for fluid therapy in adults - answer1 L for adults The usual dose for fluid therapy in peds** - answer20mL/kg ** peds weighing less than 40kg The volume of urinary output is a reasonably sensitive indicator of normal urine; volumes generally imply adequate renal blood flow, if not modified by underlying kidney injury, marked hyperglycemia or the administration of diuretic agents. For this reason, urinary output is one of the prime indicators of resuscitation and patient response. Within certain limits, urinary output is used to monitor renal blood flow. - answerrenal perfusion Adequate volume replacement during resuscitation should produce a urinary output of in adults - answerapproximately 0.5 mL/kg/hr Adequate volume replacement during resuscitation should produce a urinary output of in pediatric patients. - answer1 mL/kg/hr Adequate volume replacement during resuscitation should produce a urinary output of in children under 1 year of age. - answer2 mL/kg/hr should be If crossmatched blood is unavailable, pRBCs are indicated for patients with exsanguinating hemorrhage. - answertype O pRBCs type plasma is given when uncrossmatched plasma is needed. - answerAB To avoid sensitization and future complications, Rh- pRBCs are preferred for females of childbearing age. - answernegative Blood products cannot be stored in a warmer but they can be heated by - answerpassage through an IV warmer Define MTP - answerdefined as > 10 units of pRBCs within the first 24 hours of admission or more than 4 units in 1 hour. Massive fluid resuscitation with the resultant dilution of platelets and clotting factors, as well as the adverse effect of hypothermia on platelet aggregation and the clotting cascade, contributes to in injured patients. - answercoagulopathy PT, PTT. and PLT count are valuable baseline studies to obtain withinespecially in those with history of coagulation disorders or those who take medications that alter coagulation - answerfirst hour Equating Blood pressure to Cardiac Output - answeris a big no-no. Ohm's law (V = I × R). (BP = CO x SVR/afterload) sucking chest wound - answer How to treat open pneumothorax - answerFor initial management of an open pneumothorax, promptly close the defect with a sterile dressing large enough to overlap the wound's edges. Any occlusive dressing (e.g. plastic wrap or petrolatum gauze) may be used as temporary measure to enable rapid assessment to continue. Tape it securely on only three sides to provide a flutter-valve effect. Define Massive Hemothorax - answerrapid accumulation of more than 1500 mL of blood or one-third or more of the patient's blood volume in the chest cavity. Hemothorax: The immediate return of 1500 mL or more of blood generally indicates the need for - answerurgent thoracotomy/ exploratory thoracotomy. Note: Patients who have an initial output of less than 1500 mL of fluid, but continue to bleed, may also require thoracotomy. This decision is based on the rate of continuing blood loss (200 mL/hr for 2 to 4 hours), as well as the patient's physiologic status and whether the chest is completely evacuated of blood. Again, the persistent need for blood transfusion is an indication for thoracotomy. Tension pneumothorax on the left side can mimic - answercardiac tamponade. Define simple hemothorax - answertype of pleural effusion in which blood. <1500mL. accumulates in pleural cavity. Why might children have pulmonary contusions without overlying rib fractures? - answertheir bones are more pliable. they have far more compliant chest walls. What is the most common potentially lethal chest injury in adults? - answerpulmonary contusion with rib fractures Blunt cardiac injury should be monitored with EKG for how long? - answerfor the first 24 hours Radiographic signs of blunt aortic injury include: - answer- Widened mediastinum - Obliteration of the aortic knob - Deviation of the trachea to the right - Depression of the left mainstem bronchus - Elevation of the right mainstem bronchus - Obliteration of the space between the pulmonary artery and the aorta (obscuration of the aortopulmonary window) - Deviation of the esophagus (nasogastric tube) to the right - Widened paratracheal stripe Fractures to lower ribs (10-12) should raise suspicion for injury - answerhepatosplenic What is in the retroperitoneal space - answer- abdominal aorta - inferior vena cava - most of the duodenum - pancreas - kidneys and ureters - the posterior aspects of the ascending colon and descending colon - the retroperitoneal components of the pelvic cavity. Injuries to the retroperitoneal visceral structures are difficult to recognize because they occur deep within the abdomen and may not initially present with signs or symptoms of peritonitis. In patients who sustain blunt trauma, the organs most frequently injured are .... - answerthe spleen (40% to 55%) the liver (35% to 45%) the small bowel (5% to 10%). Stab wounds and low-energy gunshot wounds cause tissue damage by . - answerlacerating and tearing. High-energy gunshot wounds transfer more kinetic energy, causing increased damage surrounding the track of the missile due to ... - answertemporary cavitation. In the case of shotguns, what determines the severity of injuries incurred? - answerthe distance between the shotgun and the patient determines the severity of injuries incurred. Physical exam findings suggestive of pelvic fracture include evidence of - answer- ruptured urethra (scrotal hematoma or blood at the urethral meatus) - discrepancy in limb length - rotational deformity of a leg without obvious fracture. When obtaining a supine abdominal x-ray in hemodynamically normal penetrating trauma patient to demonstrate the path of the missile and determine the presence of retroperitoneal air, should be placed. - answerRadiopaque markers or clips applied to all entrance and exit wounds Relative contraindications to DPL - answer- previous abdominal operations - morbid obesity - advanced cirrhosis - preexisting coagulopathy. A sheet, pelvic binder, or other device can produce sufficient temporary. fixation for the unstable pelvis when applied at the level of - answerthe greater trochanters of the femur. The primary goal of treatment for all patients with suspected TBI is - answerto prevent 2ndary brain injury. How do we prevent 2ndary brain injury in a patient with suspected TBI - answerensure adequate oxygenation and maintain blood pressure at a level that is sufficient to perfuse the brain What side hemisphere contains the language centers in virtually all right handed people and ~85% of left handed people? - answerthe left hemisphere. What does the frontal lobe control? - answerexecutive function, emotions, motor function, and on the dominant side, expression of speech (motor speech areas) What does the parietal lobe control? - answerdirects sensory function and spatial orientation What does the temporal lobe do? - answerregulates certain memory functions what does the occipital lobe do? - answerprocesses visual information What is included in the brain stem? - answerThe brainstem is composed of the midbrain, pons, and medulla. The midbrain and upper pons contain the reticular activating system, which is responsible for - answerthe state of alertness. Vital cardiorespiratory centers reside in what part of the brain stem? - answerthe medulla what does the cerebellum do? - answerresponsible mainly for coordination and balance what divides the intracranial cavity into supra and infratentorial compartments? - answerThe Tentorium cerebelli. The midbrain passes through the supra and infratentorial compartments through an opening called the . - answertentorial hiatus or notch. What causes a blown pupil? - answerThe oculomotor nerve (cranial nerve III) runs along the edge of the tentorium and may become compressed against the tentorium during temporal lobe herniation. Parasympathetic fibers that constrict the pupils lie on the surface of the third cranial nerve; compression of the superficial parasympathetic fibers during herniation causes pupillary dilation due to unopposed sympathetic activity, often referred to as a "blown" pupil. With regards to CPP, what may occur if the MAP is too low? - answerinfarction and/or ischemia With regards to CPP, what may occur if the MAP is too high? - answermarked brain swelling and elevated ICP Glasgow Coma Scale - answereyes - 1 no response 2to pain 3to sound/speech 4spontaneous blinks verbal - 1 no response 2moans, groans, sounds 3inappropriate words 4confused conversation 5alert & oriented motor - 1 no response 2extensor response 3flexor response 4flexion withdrawal from pain 5localizes pain 6 obeys commands Who needs a head CT? - answer- Obtain a CT scan in all patients with suspected brain injury who have a clinically suspected open skull fracture, any sign of basilar skull fracture, and more than two episodes of vomiting. - Patients who are older than 65 years CT should also be considered if the patient had a loss of consciousness for longer than 5 minutes, retrograde amnesia for longer than 30 minutes, a dangerous mechanism of injury, severe headaches, seizures, short term memory deficit, alcohol or drug intoxication, coagulopathy or a focal neurological deficit attributable to the brain. What ventilation parameters should occur in a patient with TBI? - answer- Ventilate the patient with 100% oxygen until blood gas measurements are obtained, and then make appropriate adjustments to the fraction of inspired oxygen (FIO2). - Pulse oximetry is a useful adjunct, and oxygen saturations of > 98% are desirable. - Patients should maintain a PCO2 of approximately 35mm Hg. (Normocarbia) - Reserve hyperventilation acutely in patients with severe brain injury to those with acute neurologic deterioration or signs of herniation. - Absence of confounding factors such as alcohol or drug intoxication or hypothermia Ancillary studies that may be used to confirm the diagnosis of brain death include: - Electroencephalography: No activity at high gain - CBF studies: No CBF (e.g., isotope studies, Doppler studies, xenon CBF studies) - Cerebral angiography In adults, where does the spinal cord end? - answerusually near the L1 bony level as the conus medullaris. Below this level is the cauda equina, which is somewhat more resilient to injury. What is the function of the corticospinal tract? - answerControls motor power on the same side of the body How do you assess the corticospinal tract? - answerBy voluntary muscle contractions or involuntary response to painful stimuli What is the function of the spinothalmic tract? - answerTransmits pain and temperature sensation from the opposite side of the body How do you assess the spinothalmic tract? - answerpin prick What is the function of the dorsal columns? - answerCarries position sense (proprioception), vibration sense, and some light-touch sensation from the same side of the body How do you assess the dorsal columns? - answerBy position sense in the toes and fingers or vibration sense using a tuning fork Neurogenic shock results in the loss of and innervation to the heart - answervasomotor tone and sympathetic innervation to the heart. Neurogenic shock is characterized by - answerhypotension and bradycardia - The physiologic effects of neurogenic shock are not reversed with fluid resuscitation alone, and massive resuscitation can result in fluid overload and/ or pulmonary edema. Judicious use of vasopressors may be required after moderate volume replacement, and atropine may be used to counteract hemodynamically significant bradycardia. Spinal shock refers - answerto the flaccidity (loss of muscle tone) and loss of reflexes that occur immediately after spinal cord injury. After a period of time, spasticity ensues. When a patient's spine is injured, the primary concern should be potential respiratory failure. Hypoventilation in a spinal cord injury can occur from paralysis of - answerthe intercostal muscles (ie: lower cervical or upper thoracic spinal injury) or the diaphragm (ie: c3-c5) temperature sensation beginning one to two levels below the level of injury (spinothalamic tract). Even when the syndrome is caused by a direct penetrating injury to the cord, some recovery is usually achieved. What is the MCC of death in shaken baby syndrome? - answerAtlanto-occipital dislocation is a common cause of death in cases of shaken baby syndrome. The most common C1 fracture is - answera burst fracture (Jefferson fracture). What is the mechanism of a C1 fracture? - answerThe typical mechanism of injury is axial loading, which occurs when a large load falls vertically on the head or a patient lands on the top of his or her head in a relatively neutral position. Jefferson fractures involve disruption of the anterior and posterior rings of C1 with lateral displacement of the lateral masses. Best imaging for C1 fracture? - answerThe fracture is best seen on an open- mouth view of the C1 to C2 region and axial computed tomography (CT) scan C1 rotary subluxation is most often seen in who? - answerchildren How does a C1 rotary subluxation present? - answerpersistent rotation of the head (torticollis) MC type of axis fractures - answerodontoid fractures (dens) or hangman's (posterior element fracture) What is the odontoid process? - answera peg-shaped bony protuberance that projects upward and is normally positioned in contact with the anterior arch of C1. The odontoid process is held in place primarily by - answerthe transverse ligament. Type I odontoid fractures: - answertypically involve the tip of the odontoid and are relatively uncommon Type II odontoid fractures: - answeroccur through the base of the dens and are the most common odontoid fracture. In children younger than 6 years of age, the epiphysis may be prominent and resemble a fracture at this level. Type III odontoid fractures: - answeroccur at the base of the dens and extend obliquely into the body of the axis. Posterior element fracture - answerAKA hangman's fracture - involves the posterior elements of C2—the pars interarticularis - This type of fracture is usually caused by an extension-type injury. - Ensure that patients with this fracture are maintained in properly sized rigid cervical collar until specialized care is available. chance fracture - answer Patients with thoracolumbar fractures are particularly vulnerable to rotational movement, so be extremely careful when - answerlogrolling them. Canadian C spine Rule - answerCanadian C-Spine Rule: 1) Any high-risk factor that mandates radiography? Age ≥ 65 years, OR Dangerous mechanism, OR Paresthesias in extremities Dangerous mechanism = fall from elevation ≥ 3 ft or 5 stairs, axial load to head, MVA at high speed or with rollover or ejection - If YES to any of these, then RADIOGRAPH - If NO, go to #2 below 2)Any low-risk factor that allows safe assessment of range of motion? Simple rear-end MVA, OR Sitting position in ED, OR Ambulatory at any time, OR Delayed onset of neck pain, OR Absence of midline c-spine tenderness If NO to any of these, then RADIOGRAPH - If YES, go to #3 below 3)Able to actively rotate neck 45° left and right? If UNABLE, then RADIOGRAPH If ABLE, then NO RADIOGRAPH NEXUS CRITERIA - answer- Absence of tenderness in posterior midline - No evidence of intoxication - Normal mental status - Absence of a neurological deficit - No painful distracting injuries If ALL met = no radiography Hemorrhage from long-bone fractures can be significant, and femoral fractures in particular often result in significant blood loss into the thigh. What do we do? and if the fracture is OPEN? - answerAppropriate splinting of fractures can significantly decrease bleeding by reducing motion and enhancing the tamponade effect of the muscle and fascia. If the fracture is open, application of a sterile pressure dressing typically controls hemorrhage.The ankle/brachial index is determined by taking the systolic blood pressure value at the ankle of the injured leg and dividing it by the systolic blood pressure of the uninjured arm. hours Which injuries are at higher risk for compartment syndrome? - answer- forearm - tibia - burns - immobilization in tight dressings or casts - crush injuries - excessive exercise - increased capillary permeability secondary to reperfusion of ischemic muscle - localized, prolonged external pressure to an extremity Measurement of intracompartmental pressure can be helpful in diagnosing suspected compartment syndrome. Tissue pressures of greater than suggest. .? - answerTissue pressures of greater than 30 mm Hg suggest decreased capillary blood flow, which can result in muscle and nerve damage from anoxia. Blood pressure is also important: The lower the systemic pressure, the lower the compartment pressure that causes a compartment syndrome. S&S of compartment syndrome - answer- Pain greater than expected and out of proportion to the stimulus or injury - Pain on passive stretch of the affected muscle - Tense swelling of the affected compartment - Paresthesias or altered sensation distal to the affected compartment peripheral nerve assessment of upper extremities - answer peripheral nerve assessment of lower extremities - answer Pitfall: Application of traction to an extremity with a tibia/ fibula fracture can result in a neurovascular injury. Prevention: - answer- Avoid use of traction in extremities with combined femur and tibia/fibula fractures. - Use a long-leg posterior splint with an additional sugar-tong splint for the lower leg. With knee injuries, you should not immobilize the knee in complete extension but with degrees of flexion to reduce tension on the neurovascular structures - answer10 The airway of a patient who has been severely burned can become obstructed from direct injury but also.... - answermassive edema. CO dissociates very slowly, and its half-life is approximately hrs when the patient is breathing room air. - answer4 hours Because the half-life of HbCO can be reduced to 40 minutes by breathing 100% oxygen, any patient in whom CO exposure could have occurred should receive high-flow (100%) oxygen via a non-rebreathing mask. If a carboxyhemoglobin level is not available and the patient has been involved in a closed-space fire, empiric treatment with 100% oxygen for hrs is reasonable as an effective treatment for CO poisoning and has few disadvantages. - answer4 to 6 hours what persistent profound unexplained acid base disorder is a sign of potential cyanide poisoning ? - answermetabolic acidosis A patient with a high likelihood of smoke inhalation injury associated with a significant burn (i.e., greater than 20% total body surface area [TBSA] in an adult, or greater than 10% TBSA in patients less than 10 or greater than 50 years of age) should - answerbe intubated. In contrast to resuscitation for other types of trauma in which fluid deficit is typically secondary to hemorrhagic losses, burn resuscitation is required to replace the ongoing losses from ..... - answercapillary leak due to inflammation. Patients with burns require resuscitation with Ringer's lactate solution starting at mL per kilogram of body weight per percentage BSA of partial-thickness and full- thickness burns during the first 24 hours to maintain adequate perfusion, titrated hourly. - answer2mL One-half of the total fluid is provided in the first 8 hours after the burn injury (for example, a 100-kg man with 80% TBSA burns requires 2 × 80 × 100 = 16,000 mL in 24 hours). One-half of that volume (8,000 mL) should be provided in the first 8 hours, so the patient should be started at a rate of 1000 mL/hr. The remaining one-half of the total fluid is administered during the subsequent 16 hours. It is important to understand that formulas provide a starting target rate; subsequently, the amount of fluids provided should be adjusted based on a urine output target of 0.5 mL/kg/hr for adults and 1 mL/kg/hr for children weighing less than 30 kg. In adults, urine output should be maintained between 30 and 50 cc/ hr to minimize potential over-resuscitation If the initial resuscitation rate fails to produce the target urine output... what should you do? - answerincrease the fluid rate until the urine output goal is met. - However, do not precipitously decrease the IV rate by one-half at 8 hours; rather, base the reduction in IV fluid rate on urine output and titrate to the lower urine output rate. - Fluid boluses should be avoided unless the patient is hypotensive. - Low urine output is best treated with titration of the fluid rate Rule of 9s: adult leg - answerfront and back =18 Rule of 9s: infant leg - answer7% each Rule of 9s: adult head - answer4.5% front, 4.5 back Rule of 9s: infant head - answer18% total Partial-thickness burns are characterized as either or - answersuperficial partial thickness or deep partial thickness. these burns are moist, painfully hypersensitive (even to air current), potentially blistered, homogeneously pink, and blanch to touch - answerSuperficial partial-thickness burns these burns are drier, less painful, potentially blistered, red or mottled in appearance, and do not blanch to touch - answerDeep partial-thickness burns these burns appear leathery. The skin may appear translucent or waxy white. The surface is painless to light touch or pinprick and generally dry. Once the epidermis is removed, the underlying dermis may be red initially, but it does not blanch with pressure. This dermis is also usually dry and does not weep - answerFull-thickness burns gastric tubes & burns: Insert a gastric tube and attach it to a suction setup if the patient experiences nausea, vomiting, or abdomin- al distention, or when a patient's burns involve more than % total BSA - answer20% total BSA. How to manage chemical burn? - answerwash for at least 20-30 min with large amounts of warm water how to manage electrical burn injury? - answerABA consensus formula guidelines are to start resuscitation for electrical burn injury at 4 mL/kg/%TBSA to ensure a urinary output of 100 mL/hr in adults and 1-1.5 mL/kg/hr in children weighing less than 30 kg. - Once the urine is clear of pigmentation, titrate the IV fluid down to ensure a standard urine output of 0.5cc/kg/hr. - Consult a local burn unit before initiating a bicarbonate infusion or using mannitol. What degree frost bite: Hyperemia and edema are present without skin necrosis. - answerfirst What degree frost bite: Large, clear vesicle formation accompanies the hyperemia and edema with partial-thickness skin necrosis. - answersecond What degree frost bite: Full-thickness and subcutaneous tissue necrosis occurs, commonly with hemorrhagic vesicle formation. - answerthird NOTE: the use of cuffed ETTs, even in toddlers and small children, provides the benefit of improving ventilation and CO2 management, resulting in improved cerebral blood flow. Previous concerns about cuffed endotracheal tubes causing tracheal necrosis are no longer relevant due to improvements in the design of the cuffs. Ideally, cuff pressure should be measured as soon as is feasible, and <30 mm Hg is considered safe. A simple technique to gauge the ETT size needed for a specific patient (peds) is to approximate - answerthe diameter of the child's external nares or the tip of the child's smallest finger and use a tube with a similar diameter. Length- based pediatric resuscitation tapes also list appropriate tube sizes. Infants have a more pronounced vagal response to endotracheal intubation than do children and adults, and they may experience bradycardia with direct laryngeal stimulation. Bradycardia in infants is much more likely to be due to hypoxia. pretreatment should be considered for infants requiring drug-assisted intubation, but it is not required for children. - answerAtropine sulfate - Atropine also dries oral secretions, enabling visualization of landmarks for intubation. The mnemonic, "Don't be a DOPE" may be a useful reminder of the common causes of deterioration in intubated patients. What is DOPE - answerD for dislodgment, O for obstruction, P for pneumothorax, E for equipment failure At what age is the cricoid membrane easily palpable which can help facilitate surgical circothyroidotomy? - answer12 yo Hypoxia is the most common cause of pediatric cardiac arrest. However, before cardiac arrest occurs, causes , which is the most common acid-base abnormality encountered during the resuscitation of injured children. With adequate ventilation and perfusion, a child should be able to maintain relatively normal pH - answerhypoventilation causes respiratory acidosis The mean normal systolic blood pressure for children` - answeris 90 mm Hg plus twice the child's age in years. The lower limit of normal systolic blood pressure in children is 70 mm Hg plus twice the child's age in years. - The diastolic pressure should be about two-thirds of the systolic blood pressure. method for estimating weight in kilograms is the formula .... - answer([2 × age in years] + 10) An infant's blood volume can be estimated at mL/kg, and a child age 1-3 years at mL/kg, and children over age 3 years at mL/kg. - answerinfant - 80 mL/kg child 1-3yo - 75mL/kg child over 3 - 70mL/kg The presence of intraperitoneal blood on CT or FAST, the grade of injury, and/or the presence of a paO2 in pregnancy - answerincreased 100-108 In pregnancy, minute ventilation increases primarily due to an increase in tidal volume. is therefore common in late pregnancy. - answerHypocapnia (PaCO2 of 30 mm Hg) [HYPERVENTILATION] A PaCO2 of 35 to 40 mm Hg may indicate impending respiratory failure during pregnancy. SO ANYTHING >35 IN PREGNANCY --> WORRY!! In patients with advanced pregnancy, when chest tube placement is required it should be positioned - answerhigher to avoid intraabdominal placement given the elevation of the diaphragm. Uterine compression of the vena cava may reduce venous return to the heart, thus decreasing cardiac output and aggravating the shock state. Manually displace the uterus to the side to relieve pressure on the inferior vena cava. - answerleft - If the patient requires spinal motion restriction in the supine position, logroll her to the left 15- 30 degrees (i.e., elevate the right side 4-6 inches), and support with a bolstering device, thus maintaining spinal motion restriction and decompress- ing the vena cava Initial fetal heart tones can be auscultated with Doppler ultrasound by 10 weeks of gestation. - answer Perform continuous fetal monitoring with a tocodynamometer beyond to weeks of gestation - answer20 to 24 weeks of gestation. - Patients with no risk factors for fetal loss should have continuous monitoring for 6 hours, whereas patients with risk factors for fetal loss or placental abruption should be monitored for 24 hours. The risk factors are - maternal heart rate > 110 - an Injury Severity Score (ISS) > 9 - evidence of placental abruption - fetal heart rate > 160 or < 120 - ejection during a motor vehicle crash - motorcycle or pedestrian collisions. The presence of amniotic fluid in the vagina, evidenced by a pH of , suggests ruptured chorioamniotic membranes. - answergreater than 4.5 A- assessment of airway adequacy may include suctioning B- sedation is indicated C- patient restraints are needed D- intoxication should be assumed - answerA - assessment of airway adequacy may include suctioning Which of the following is an indication for RSI? A- patients for whjom endotracheal intubation is safe and successful B- patients with a history of difficult intubation C- patients with precipitous drop in o2 saturation D- patients who need airway control, have intact gag reflexes especially who sustained head injuries. - answerD - patients who need airway control, have intact gag reflexes especially who sustained head injuries. A surgical airway is indicated in the presence of: A- edema of the glottis B- facial trauma C- small mouth or jaw D - inability to place a nasopharyngeal airway - answerA - edema of the glottis Which of the following signs is characteristic of class 3 shock? A- pulse rate <100 B- increased pulse pressure C- urine output >30mL/hr D- decreased systolic blood pressure - answerD- decreased systolic blood pressure Hypoxia associated with flail chest is due to A- paradoxical motion of chest wall due to rib fractures B- soft tissue crepitus with escape of oxygen into the tissues C- associated cartilage disruption D- pulmonary contusion - answerD - pulmonary contusion A patient arrives in your hospital after a fall from 20 feet. He has been intubated, and two large bore IVs have been started. Oxygen is 83%. He has good capnogaphy waveform and significant deformity of his right chest wall. He has no breath sounds on the right. His BP is 75/30. Your next step should be to: A- replace the ETT B- readjust the ETT C- perform a needle decompression or finger thoracostomy on the right side