ATLS POST TEST 4 LATEST VERSIONS, EXAM QUESTIONS & ANSWERS, A+ GUIDE, Exams of Nursing

Download ATLS POST TEST 4 LATEST VERSIONS, EXAM QUESTIONS & ANSWERS, A+ GUIDE and more Exams Nursing in PDF only on Docsity! 1 ATLS POST TEST 4 LATEST VERSIONS, EXAM QUESTIONS & ANSWERS, A+ GUIDE 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: Select one: a. reexamine the chest b. perform an aortogram c. obtain a CT scan of the chest d. obtain arterial blood gas analyses e. perform transesophageal echocardiography - A) Reexamine 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: Select one: a. angiography b. compartment pressures c. retrograde urethrogram d. Doppler ultrasound studies 2 e. complete spine x-ray series - e) Complete spine x-ray series Which of the following is true regarding the initial resuscitation of a trauma patient? Select one: a. A patient that presents with a torso gunshot wound and is hypotensive should receive crystalloid fluid resuscitation until the blood pressure is normal b. Evidence of improved perfusion after fluid resuscitation could include improvement in Glasgow coma scale score on reevaluation c. Massive transfusion is defined as transfusion of more than >10 of packed red blood cells and plasma in 24 hours d. When tranexamic acid is administered by pre-hospital providers a second dose is required within 24 hours e. Fluid resuscitation is far more important than bleeding control in trauma patients - b. 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: Select one: a. Secure the airway b. obtain a c-spine film c. support the circulation d. control scalp hemorrhage e. 5 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: Select one: a. respiratory acidosis 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 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: Select one: a. obtain contrast angiography b. transfer to a higher level trauma center c. perform an exploratory laparotomy 6 d. infuse additional crystalloid fluids e. Obtain transesophageal echocardiography - c. perform an exploratory laparotomy Which one of the following statements regarding abdominal trauma in the pregnant patient is TRUE? Select one: a. The fetus is in jeopardy only with major maternal abdominal trauma. b. Leakage of amniotic fluid is an indication for hospital admission. c. Indications for peritoneal lavage are different from those in the nonpregnant patient. d. With penetrating trauma, injury to the mother's abdominal hollow viscus is more common in late than in early pregnancy. e. The secondary survey follows a different pattern from that of the nonpregnant patient. - b. Leakage of amniotic fluid is an indication for hospital admission. The first maneuver to improve oxygenation after chest injury is to: Select one: a. intubate the patient b. assess arterial blood gases c. administer supplemental oxygen d. ascertain the need for a chest tube e. obtain a chest x-ray - c. 7 administer supplemental oxygen A 25-year-old man, injured in a motor vehicular crash, is admitted to the emergency department. His pupils react sluggishly and his eyes open to pressure. He does not follow commands, but he does moan periodically. His right arm is deformed and does not respond to pressure; however, his left hand reaches purposefully toward the stimulus. Both legs are stiffly extended. His GCS score is: Select one: a: 2 b: 4 c: 6 d: 9 e: 12 - d: 9 Which one of the following findings in an adult is most likely to require immediate management during the primary survey? Select one: a. distended abdomen b. Glasgow Coma Scale score of 11 c. temperature of 36.5°C (97.8°F) d. deformity of the right thigh e. respiratory rate of 40 breaths per minute - e. respiratory rate of 40 breaths per minute A 20-year-old woman that is 32 weeks gestation , is stabbed in the upper right chest. In the emergency department, her blood pressure is 80/60 mm Hg. 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: Select one: a. perform tracheal intubation 10 A 23-year-old man sustains 4 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 intubated, closed tube thoracostomy is performed, fluid resuscitation is initiated through 2 large-caliber IVs. FAST exam does not reveal intraabdominal injuries. His blood pressure now is 60/0 mm Hg, heart rate is 160 beats per minute, and respiratory rate is 14 breaths per minute (ventilated with 100% O2). 1500 mL of blood has drained from the right chest. The most appropriate next step in managing this patient is to Select one: a. perform diagnostic peritoneal lavage b. obtain a CT of the chest c. perform an 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 A 39-year-old man is admitted to the emergency department 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 Select one: 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. restrict cervical motion and attempt orotracheal intubation using 2 people 11 e. ventilate the patient with a bag-mask device until his beard can be shaved for better mask fit 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. restrict cervical motion and attempt orotracheal intubation using 2 people e. ventilate the patient with a bag-mask device until his beard can be shaved for better mask fit - d. restrict cervical motion and attempt orotracheal intubation using 2 people A patient is brought to the emergency department after a motor vehicle crash. He is conscious and there is no obvious external trauma. His blood pressure is 60/40 mm Hg and his heart rate is 70 beats per minute. His skin is warm. Which one of the following statements is TRUE? Select one: a. Vasoactive medications have no role in this patient's management. b. The hypotension should be managed with volume resuscitation alone. c. Flexion and extension views of the c-spine should be performed early. d. 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 Which one of the following is the most effective method for initially treating frostbite? 12 Select one: a. moist heat b. early amputation c. padding and elevation d. vasodilators and heparin e. topical application of silver sulfadiazine - a. moist heat A 32-year-old man's right leg is trapped beneath his overturned car for nearly 2 hours before he is extricated. On arrival to the emergency department, his right lower extremity is cool, mottled, insensate, and motionless. Despite normal vital signs, a pulse cannot be palpated below the right femoral artery and the muscles of the lower extremity are firm and hard. During the management of this patient, which of the following is most likely to improve the chances for limb salvage? Select one: a. applying skeletal traction b. administering anticoagulant drugs c. administering thrombolytic therapy d. surgical consultation for right lower extremity fasciotomy e. transferring the patient to the trauma center 120 km away - d. surgical consultation for right lower extremity fasciotomy A patient arrives in the emergency department after being beaten about the head and face with a wooden club. He is comatose and has a palpable depressed skull fracture. His face is swollen and ecchymotic. He has gurgling respirations and 15 Only crystalloid solutions may be safely infused through the needle. b. Aspiration of bone marrow confirms appropriate positioning of the needle. c. Intraosseous infusion is the preferred route for volume resuscitation in small children. d. Intraosseous infusion may be utilized indefinitely. e. Swelling in the soft tissues around the intraosseous site is not a reason to discontinue infusion. - b. Aspiration of bone marrow confirms appropriate positioning of the needle. A young female sustains a severe head injury as the result of a motor vehicle crash. In the emergency department, her GCS is 6, 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: Select one: a. avoid hypotension b. administer an osmotic diuretic c. aggressively treat systemic hypertension d. reduce metabolic requirements of the brain e. distinguish between intracranial hematoma and cerebral edema - a. avoid hypotension A 33-year-old female 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. 16 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: Select one: a. hemorrhagic shock b. cardiac tamponade c. massive hemothorax d. tension pneumothorax e. diaphragmatic rupture - b. 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). Which of the following mandates prompt celiotomy (laparotomy)? Select one: a. a serum amylase of 200 b. a leukocyte count of 14,000 c. evidence of retroperitoneal hematoma on CT scan d. development of peritonitis on physical exam e. a fall in the hemoglobin level from 12 g/dL to 8 g/dL over 24 hours - d. 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 17 to be paraplegic at the level of T10. Which of the following are true regarding her evaluation and management? Select one: a. Neurogenic shock is likely to develop b. Imaging of her complete spine is required prior to transfer to a trauma center c. Given the injury level knee extension would be expected d. log rolling using 4 people is a safe approach to limit spinal motion when moving her e. Presence of bulbocarvenous reflex indicates a better prognosis - d. log rolling using 4 people is a safe approach to limit 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: Select one: 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. restrict cervical motion and establish a definitive airway - e. restrict cervical motion and establish a definitive airway When applying the Rule of Nines to infants: Select one: a. 20 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 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 FAST 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 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: 1L of iv . crystalloid and two units of pRBCs B. 1L of iv. crystalloid, mannitol and iv steroids C. 1 unit of albumin and compression stockings D. Vasopressors and laparotomy E. 1 L of cystalloid and vasopressors if blood pressure does not respond - E. 1 L of cystalloid and vasopressors if blood pressure does not respond Which of the following is MOST RELIABLE to confirm endotracheal intubation? a. presence of breath sounds bilaterally b. absence of borborygmi in the epigatrium on ascultation c. presence of CO2 in exhaled air via capnography d. appearance of fog in the endotracheal tube e. chest xray with endotracheal tube tip appearing above the carina - e. chest xray with endotracheal tube tip appearing above the carina 21 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 64kph. 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.Administer heliox and racemic epinephrine B. Perform nasotracheal intubation C. Perform surgical cricothyroidotomy D. Repeat orotracheal intubation E. Perform needle cricothyroidotomy with jet insufflation - E. Perform needle cricothyroidotomy with jet insufflation A 28 year olf male is brought to the ED. He was involved in a fight, during which he was beaten with a wooden stick. His chest shows multiple severe bruises. His arway is clear, resp rate is 22, hear rate 126, and systolic blood pressure is 90 mmHG. Which of the following should be performed during the primary survey a. glasgow coma b. tetanus status c. cervical spine xray d. blood alcohol level e. rectal exam - a. glasgow coma an 18yo male is brought to the emergency department after being dumped by a large wave while surfing. He landed head first on the firm beach sand. His vital signs are blood pressure 85/60 mmHg, heart rate 60, and respiratory rate 18; he is unable to move his lower extremities. He appears calm and asks if he will ever walk again. The most appropriate next step is to: a. reassure patient that he will walk again b. proceed to a more detailed neuro exam c. obtain c spin xrays d. begin infusion of vasopressors e. begin bolus of warm IV crystalloid - e. begin bolus of warm IV crystalloid Whic one of the following statements is true regarding access in pediatric resuscitation? 22 a. intraosseous access should be considered only after 5 percutaneous attempts b. cutdown at teh ankle is the preferred initial access technique c. internal jugular cannulation is the next preferred option when percutaneous venous access fails d. intraosseous cannulation should be the first choice e. blood transfusion can be delivered through intraosseous access - e. blood transfusion can be delivered through intraosseous access a 35 year old female ustains multiple linjuries in a MVA and is transported to a small hospital. She has a GCS of V2E2M2. Spinal motion restrictions are in place. ET is performed, IV and wamred fluids are administered. She remains hemodynamically normal, and preparations are made to transfer to another facility for definitive neuro care. Which of the following tests or treatment should occur before transport? a. ct abdomen and chest b. chest xray c. lateral cervical spine xray d. admin of methlyprednisolone e. transfusion of 2 units packed RBCs - b. chest xray 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. Fluid resusciation is initiated, 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 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. measure blood pressure again b. begin transfuse O negative blood c. wait until the chest xray is completed d. obtain a CT scan of the chest and abdomen e. repeat the physical exam of the chest - e. repeat the physical exam of the chest A 22 yo male is brought to the ED after being assaulted in a bar. On intial exam, his vital signs are normal and his Glasgow Coma scale is V5E4M6. A definite indication for a head CT is 25 d. In a unresponsive patient, mannitol should be the first line therapy to treat increased ICP - b. prescence of hypoxia and hypotension significantly increase the risk of mortality The first priority in the management of a long bone fracture is a. reduction of pain b. prevention of infection in cause of open fracture c. prevention of further ST injury d. reduction of blood loss e. improvement of long term function - d. reduction of blood loss a 40 yo obese patient with a GCD of V2E2M4 requires a CT scan. Before transfer to the scanner, you should a. give more sedative drugs b. insert a multi lumen esophageal airway c. obtain a definitive airway d. request cervical spine film e. insert a NG tube - c. obtain a definitive airway Which of the following patient require imaging .... ? a. 28 yo who fell from a 3 meter balcony and sustained a fracture. The patient does not have spine pain, motor or sensory deficits and has an otherwise normal PE. b. 40 yo patient who sustained a severe closed head injury and has a GCS of 8 V2M3E3 c. 6month old who fell from the couch to the carpted floor and has a GCS of 15 d. 10 yo who was hit in the head with a bat and has a right frontal hematoma without history of LOC and does not have neck pain or tenderness e. 30 yp man who after a MVA, briefly LOC but was ambulating at teh scene and does not have neck or back pain - b. 40 yo patient who sustained a severe closed head injury and has a GCS of 8 V2M3E3 A 30 year old male is brought toe the hospital after falling 6 meters. Inspection reveals an obvious flail chest on the right. Breath sounds on the right are slightly increased. Twelve hours later, the patient is in severe respiratory distress. Arterial blood gas obtained while the patient recieves oxygen by face mask are: pH of 7,47, 26 PaO2 of 45mmHg (6Kpa), PaCO2 of 28mmHg (3,7 Kpa). The component of injury that most likely responsible for abnormalities in this patients blood gas is: a. pain b. hypovolemia c. PTX d. pulmonary contusion e. chest wall instability - c. pulmonary contusion A 82 year old male falls down five stairs and presents to the ED. Which of the following statements IS NOT CORRECT: 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. Internal hemorrhage will become symptomatic more quickly d. His risk of occult fractures is increased e. His risk of bleeding may be increased - c. Internal hemorrhage will become symptomatic more quickly A 14 year old female is brought to the ED after falling from a horse. Cervical spinal motion is restricted wit ha hard collar and cervical blocks and she is immobilized on a long spine board. Which of the following IS TRUE REGARDING Cervical spine x-ray: A. More than 20% of these patients will have cervical spine injury B. Cervical spine injury is excluded if no abnormalities are found on lateral cervical spine xray C. Are not needed if she is awake, alert, neurologically normal, and has no neck pain or midline tenderness D. Should be performed before adressing potential breating or circulatory problems E. She should reamin on teh long spine board until imaging excluded injuries - C. Are not needed if she is awake, alert, neurologically normal, and has no neck pain or midline tenderness The most specific test to evaluate for injuries of solid abdominal organs is a. Abd xray b. Abd ultrasonography c. Diagnostic peritoneal lavage 27 d. Frequent abdominal examinations e. CT of abdomen and pelvis - e. CT of abdomen and pelvis The most important consequence of inadequate organ perfusion is a. multiple organ failure b. decreased base deficit c. acute glomerulonephritis d. increased cellular ATP production e. Vasodilation - a. multiple organ failure A patient is brought to the hospital with no surgical capabilities following head trauma. He is intubated due to compromised mental status. His BP on arrival is 155/82, heart rate 100. Shortly after arrival his BP is found to be 220/120 with a heart rate of 53. Which of the following is TRUE regarding this patient's condition? a. The bradycardia is a sign of neurogenic shock b. The change in BP and HR may indicate imminent herniations from critically high ICP c. The change in BP is reflective of worsening pre existing HTN d. The change in vital signs should prompt burr hole drainage of potential subdural hematoms - b. The change in BP and HR may indicate imminent herniations from critically high ICP Initial treatment of frostbite injuries involve a. application of dry heat b. rapid rewarming of body part c. debridement of hemorrhagic blisters d. early amputation to prevent septic complications e. application of bulk dressing to rewarm the part - b. rapid rewarming of body part Signs and symptoms of airway compromise include all of the following, EXCEPT: A. change in voice B. Stridor C. Tachypnea D. Dyspnea and agitation E. Decreased pulse pressure - E. Decreased pulse pressure 30 30 year old male present with a stab wound to the abdomen. BP is 60/34, HR 130, RR 25 and GCS 13 E3V4M6. Neck veins are flat and chest examination is clear with bilateral breath sounds. Optimal resuscitation should include: A. Transfusion of FFP and platelets B. 500ml of hypertonic saline and transfusion of pRBCs C. Resuscitation with crystalloid and pRBC until base excess is normal D. Fluid resuscitation and angioembolization E. Preparation for laparotomy while initiating fluid resuscitation - E. Preparation for laparotomy while initiating fluid resuscitation Which of the following statement are true regarding crystalloid fluid resuscitation of a patient with penetrating torso trauma? a. It can produce dilutional coagulopathy b. It is the fluid of choice for the patient presenting in Class IV hemorrhagic shock c. It should be infused until a normal BP is achieved d. Hypotonic fluids are preferred e. Crystalloid fluids are the only fluids that should be given through an intraosseous needle - a. It can produce dilutional coagulopathy A 25 year old male is brought to the ED of a trauma center 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. He requies immediate intubation to protect his airway B. The GCS score suggests a severe traumatic brain injury C. His level of consciousness can be attributed to alcohol D. CT scanning is an important part of the neuro assessment E. Hyperoxia should be avoided - D. CT scanning is an important part of the neuro assessment Which one of the following statements regarding patients with genitourinary trauma is true? a. Hematuria is present in all patients with significant genitourniary injury b. injuries to the urethra are more common in females than in males c. evaluation of injuries to the urethra always require a CT scan 31 d. blunt renal injuries should always have surgical intervention e. hypotension can be caused by renal injury - e. hypotension can be caused by renal injury Patients with a GSC of less than usually require intubation. - 8 The "A" in ABCD stands for . - Airway maintenance with CERVICAL SPINE PROTECTION You should assume that any patient in a multisystem trauma with an altered level of consciousness or blunt injury above the clavicle has what type of injury? - Cervical spine injury Flail chest is invariably accompanied by which can interfere with blood oxygenation. - pulmonary contusion - do NOT over fluid resuscitate these patients! Hypotension is caused by until proven otherwise. - hypovolemia When you don't have/can't get a blood pressure, what are three things to look for when evaluating perfusion. - 1. Level of consciousness (brain perfusion), 2. Skin color (ashen face/grey extremities) 3. Pulse (bilateral femoral - thready/tachy) Elderly patients have a limited ability to to compensate for blood loss. - increase heart rate Resuscitation fluids should be warmed 39 degrees Celsius (102.2 F). Can you use a microwave to do this? - YES - for CRYSTALLOID ONLY (but NOT for blood products). Urinary catheters are good for assessing renal perfusion and volume status. List 5 signs of urethral injury that might prevent you from inserting one. - Blood at urethral meatus, perineal ecchymosis, blood in scrotum, high-riding/non-palpable prostate, pelvic fracture Which arm should you NOT put a pulse-ox on? - The arm with a blood pressure cuff on it 32 Name two anatomical things that can interfere with doing a FAST scan. - Obesity & intraluminal bowel gas When should radiographs be obtained? - During the SECONDARY survey. How do you get an ample patient history? - A=Allergies, M=Medications, P=PMH/Pregnancy, L=Last meal, E=Events/Environment of injury Why might you want a Bair Hugger for a patient who smells of alcohol? - Vasodilation can lead to hypothermia What things are you looking for when you do a DRE in a trauma? - Blood, high- riding prostate (in males), and sphincter tone What should you do for every female patient? - Pregnancy test (females of childbearing age) Adult patients should maintain UOP of at least mL/kg/hr. Kids should have at least mL/kg/hr. - Adults 0.5 mL/kg/hr, Kids 1.0 ml/kg/hr Preventing hypercarbia is critical in patients who have sustained a injury. - head What two places would you LOOK at a patient if you suspect hypoxemia? - Lips and fingernail beds Patients may be abusive and belligerent because of , so don't just assume it's due to drugs, alcohol, or the fact that they are just inherently a jerk. - hypoxia Can a patient breathe on their own after complete cervical cord transection? - Yes, if the phrenic nerves (C3-C5) are spared. This will result in "abdominal" breathing. The intercostal muscles will be paralyzed though. Can you use an OPA (Guedel) in a conscious patient? - No, it could make them vomit. An NPA (trumpet) would be okay. 35 Why does shock actually reduce the total volume of circulating blood? - Anaerobic metabolism --> can't make more ATP --> Endoplasmic then mitochondrial damage --> lysosomes rupture --> sodium and WATER enter the cell, which SWELLS and dies. Which vasopressors should you use to treat hemorrhagic shock? What are the drug doses? - NEVER use pressors for hypovolemic shock - use VOLUME replacement. Pressors will worsen tissue perfusion in hemorrhagic shock. Compensatory mechanisms may preclude a measurable fall in systolic blood pressure until up to % of the patient's blood volume is lost. - 30 Any patient who is cool and is tachycardic is considered to be until proven otherwise. - in shock The definition of tachycardia depends on the patient's age. What heart rate is considered tachycardic for infants, toddlers/preschoolers, school age/prebuscent, and adults? - Infants >160, toddlers/preschoolers >140, school age/prebuscent >120, adults >100 Elderly patients may not exhibit tachycardia in response to hypovolemia because of limited cardiac response to catecholamines. Why else might not they get tachy? - They might be on a beta-blocker or have a pacemaker. A FAST scan is an excellent way to diagnose cardiac tamponade. What signs suggest tamponade? - Becks's Triad: JVD, muffled heart sounds, and hypotension (will be resistant to fluid therapy). Will also likely be tachycardic. Patients with a tension pneumo and patients with cardiac tamponade may present with many of the same signs. What findings will you see with a tension pneumo that you will NOT see with tamponade? - Absent breath sounds and hyperresonance to percussion over the affected hemithorax. Immediate thoracic decompression is warranted for anyone with absent breath sounds, hyperresonance to percussion, tracheal deviation, , and . - Acute respiratory distress & subcutaneous emphysema 36 Can isolated intracranial injuries cause neurogenic shock? - NO How do you calculate total blood volume in an adult? - 70 mL per kg body weight. A 70 kg person has about 5 liters of circulating blood. (70*70=4900) How do you calculate total blood volume in an child? - Body weight in kg x 80-90 mL The blood volume of an obese person is calculated based upon their weight. - ideal Fluid replacement should be guided by , not simply by the initial classification (Class I-IV). - The patient's response to initial replacment How much blood volume is lost with Class I Hemorrhage? - Up to 15% Donating 1 pint, or ~500 mL of blood is about a 10% volume loss and would qualify as Class I Hemorrhage! How do you treat a Class I Hemorrhage? - You don't (usually). Transcapillary refill and other compensatory mechanisms usually restore blood volume within 24 hours. How much blood volume is lost with Class II Hemorrhage? - 15-30% (750-1500 mL in a 70 kg adult) How do you treat a Class II Hemorrhage? - Usually just crystalloid resuscitation Subtle CNS changes such as anxiety, fright, and hostility would be expected in a patient with a Class Hemorrhage. - II How much blood volume is lost with Class III Hemorrhage? - 30-40% (2000 mL in a 70 kg adult) A patient with inadequate perfusion, marked tachycardia and tachypnea, significant mental status change, and a measurable fall in systolic blood pressure likely has a 37 Class Hemorrhage. - III or IV - These patients almost always require a blood transfusion, which depends on their response to initial fluid resuscitation. The first priority is stopping the hemorrhage. Loss of more than % of blood volume results in loss of consciousness. - 50 How much blood volume is lost with Class IV Hemorrhage? - More than 40%. Unless very aggressive measures are taken the patient will die within minutes. A Class Hemorrhage represents the smallest volume of blood loss that is consistently associated wiht a drop in systolic blood pressure. - III Up to mL of blood loss is commonly associated with femur fractures. - 1500 Unexplained hypotension or cardiac dysrhythmias (usually bradycardia from excessive vagal stimulation) are often caused by , especially in children. - gastric distention How much crystalloid should you give an adult for an initial fluid resuscitation bolus? For kids? - Adults: 2 liters, Kids: 20 mL/kg (may repeat and give as much as 60 mL/kg but with high reserve in kids, if they're in shock they should get blood sooner rather than later. Each mL of blood loss whould be replaced with mL of crystalloid, thus allowing for replacement of plasma volume lost into interstitial and intracellular spaces. - 3 Blood on the floor x four more is a mnemonic for occult blood loss where? - Chest, pelvis, retroperitoneum, and thigh For children UNDER 1 year of age, UOP should be mL/kg/hr. - 2 Would patients in EARLY hypovolemic shock be acidodic or alkalotic? - Alkalotic - respiratory alkalosis from tachypnea. .. followed later by mild metabolic acidosis in the early phase of shock. 40 Are patients with PEA who have sustained blunt thoracic injuries candidates for an ED thoracotomy? - NO - Only PEA with PENETRATING thoracic injuries should get an ED thoracotomy. An ED thoracotomy can allow you to do what? - Evacuate pericardial blood, direcly control hemorrhage, cardiac massage, cross-clamp the descending aorta to slow blood loss below the diaphragm and increase perfusion to the heart and brain. For a patient with a traumatic simple pneumothorax, what should you do BEFORE you start positive pressure ventilation or take them to surgery for a GA? - CHEST TUBE - positive pressure ventilation can turn a simple pneumo into a tension pneumo, so put in a chest tube first. Should you evacuate a simple hemothorax if it is not causing any respiratory problems? - YES - A simple hemothorax, if not fully evacuated, may result in a retained, clotted hemothroax with lung entrapment or, if infected, develop into an empyema. A pneumothorax associated with a persistent large air leak after tube thoracostomy suggests a injury. - tracheobronchial - Use bronchoscopy to confirm, you may need more than one chest tube before definitive operative management. What radiographic findings are suggestive of traumatic aortic disruption? - Widened mediastinum, obliteration of aortic knob, deviation of trachea to the right, depression of left mainstem bronchus, deviation of esophagus (NG tube) to right, widened paratracheal stripe, fx'd 1st/2nd ribs or scapula. A deceleration injury victim with a left pnuemothorax or hemothorax without rib fractures, is in pain or shock out of proportion to the apparent injury, and has particulate matter in their chest tube may have . - an ESOPHAGEAL RUPTURE - a forceful blow causes expulsion of gastric contents into the esophagus, producing a linear tear in the lower esophagus allowing leakage into the mediastinum. Fractures for the lower ribs (10-12) should increase suspicion for injury. - hepatosplenic 41 Why are upper torso, facial, and arm plethora with petechiae associated with crush injuries to the chest? - Temporary compression of the superior vena cava. How does ATLS suggest you should review a chest radiograph? - Trachea & bronchi, pleural spaces and parenchyma, mediastinum, diaphragm, bones, soft tissues, tubes & lines. You should use a size 16 or 18 gauge 6" needle for pericardiocentesis. How do you insert it? - Puncture the skin 1-2 cm inferior to the left xiphohondral junction at a 45 degree angle to the skin towards the heart, aiming toward the top of the left scapula. What's a good way to know if you've advanced your needle too far during pericardiocentesis and have entered ventricular muscle? - ECG Changes - extreme ST-changes, widened QRS, PVCs, etc... Withdrawl needle until ECG returns to baseline. What should you do with your needle after you successfully evacuate blood during pericardiocentesis? - Lock the stopcock and leave the catheter in place in case it needs to be reevacuated. If possible, use the Seldinger technique to pass a 14 gauge flexible catheter over the guidewire. This is NOT a definitive treatment. For patients with facial fractures or basillar skull fractures, gastric tubes should be inserted before doing a DPL. - through the mouth You need to do retrograde urethrography PRIOR to foley placement if . - inability to void, unstable pelvic fracture, blood at urethral meatus, scrotal hematoma, perineal ecchymoses, or high-riding prostate. DPL is considered to be % sensitive for detecting intraperitoneal bleeding. - 98 What are the four places you should look first when doing a FAST scan? - Mediastinum, hepatorenal fossa, splenorenal fossa, pouch of Douglas. 42 DPL is indicated when a patient with multiple blunt injuries is hemodynamically unstable, especially when they have . - Change in sensorium (brain injury/EtOH or drug intoxication), change in sensation (spinal cord injury), injury to adjacent structures (pelvis, lumbar spine), lap-belt sign (from seatbelt), or if patient is going for long studies (CT, ortho surgery...). What is the only ABSOLUTE contraindication to DPL? - An existing indication for laparotomy. What are some RELATIVE contraindications to DPL? - Morbid obesity, advanced cirrhosis, preexisting coagulopathy, and previous abdominal operations (adhesions). When should you use an open SUPRAUMBILICAL approach for a DPL? - PELVIC FRACTURES (don't want to enter pelvic hematoma) and ADVANCED PREGNANCY (don't want to damage enlarged uterus). When doing a DPL, what INITIAL findings (not from lab) would mandate a laparotomy? - Free blood (>10 mL) or GI contents (vegetable fiber, bile). If you don't get gross blood upon initial DPL aspiration, what do you do next for an adult? For a child? - Adult - 1,000 mL warm isotonic crystalloid. Kid - 10 mL/kg You've just put a bunch of fluid in the belly and aspirated more fluid for your DPL. No gross GI contents or anything alarming are present, what QUANTATIVE things would make the DPL positive? - >100,000 red cells/mm^3, 500 white cells/mm^3, or BACTERIA (on gram stain). Your trauma patient needs an urgent laparotomy, can you take them to the CT scanner first to evaluate injuries? - No, if they need an emergent laparotomy they are unstable - unstable patients should NOT go to the CT scanner! What are some indications for laparotomy in patients with penetrating abdominal wounds? - Unstable, GSW, peritoneal irritation, fascial penetration 45 High levels of CO2 will cause cerebral vasculature to . - Dilate (to increase blood flow) - so you might want to HYPERventilate people with brain injuries. Ideally, you want to wait to perform a GCS on a person with SEVERE brain injury until what? - BP is normalized A FAST scan, DPL, or ex-lap should take priority over a CT scan if you can't get the brain injured patient's BP up to mm Hg. - 100 If a patient has a systolic over 100 with evidence of intracranial mass (blown pupil, unequal motor exam) THEN a CT would take first priority. A midline shift of greater than often indicates the need for neurosurgical evacuation of the mass/blood. - 5mm Your patient has a dilated pupil and you want to give mannitol on the way to the CT scanner or OR. What is the correct dose? - 0.25-1.0 g/kg via rapid bolus A cast cutter should be removed to remove a trauma victim's helmet if there is evidence of a c-spine injury or if . - the patient experiences pain or paresthesias during an initial attempt to remove the helmet. What are the signs of neurogenic shock? - Vasodilation of lower extremity blood vessels - resulting in pooling of blood and hypotension. This loss of sympathetic tone may cause bradycardia or inhibit the tachycardic response to hypovolemia. How do you treat neurogenic shock? - Judicious use of pressors and MODERATE fluid resuscitation. Too much fluid may result in overload and pulmonary edema. What is the most common type of C1 fracture? - Burst fractures (Jefferson fracture) What's the difference between types I, II, and III odontoid process fractures? - I=tip of odontoid, II=fx at base, III=base of odontoid and extends obliquely into body of axis. (Odontoid process = dens). 46 What are the indications for c-spine radiographs in a trauma patient? Which x-ray views should be obtained? - Midline neck pain, tenderness on palpation, neurological deficits related to c-spine injuries, altered LOC or intoxication. 1) Lateral, 2) AP, 3) Open mouth odontoid view With the proper views of the c-spine, and a qualified radiologist - what is the sensitivity for finding unstable cervical spine injuries? - >97% (CT with 3mm slices >99%). Ten percent of all patients with a c-spine fracture have what? - A second, noncontiguous vertebral column fracture. (So scan the rest of their spine). Attempts to align the spine for the purpose of immobilization on the backboard are not recommended if they . - cause pain Can you clear a c-spine without films? - Yes, if they are awake, alert, sober, neurological normal, have NO pain, and can flex, extend, and move their head to both sides without pain - you don't need films. Should a quadriplegic or paraplegic patient be put on a hard board? - Not for more than 2 hours - get them off ASAP. What's a big difference in a physical finding between hypovolemic and neurogenic shock? - Hypovolemic = usually TACHY, Neurogenic = usually BRADY Partial or total loss of respiratory function may be seen in a patient with a cervical spine injury above . - C6 Why might someone not be able to breathe if they have a long bone fracture? - Fat embolism - uncommon though Abnormal arterial blood flow is indicated by an ABI of . - <0.9 By LOOKING at the patient, what findings might suggest pelvic injury? - Leg- length discrepancy, rotation (usually external) 47 Crush injuries may result in rhabdomyolysis - casts block flow, also iron is released which forms ROS which then damage cells and impair ability to regulate K+ etc... What can you do to prevent this? - Volume expansion, and alkalization of urine with bicarb will reduce intratubular precipitation of myoglobin. UOP should be 100 mL/hr until myoglobinuria is cleared. Muscle does not tolerate lack of arterial flow (tourniquet) for more than hours before necrosis begins. - 6 What things increase the risk for tetanus? - Wounds >6 hours old, wounds contused or abraded, >1 cm deep, from high velocity missiles, due to burns or cold, and significantly contaminated wounds. Should legs be completely straight when splinting? - No, flexion of 10 degrees recommended to take pressure off neurovascular structures. Any patient with burns covering more than % of BSA require fluid resuscitation. - 20 The palmer surface of a patient's hand represents approximately % of their BSA. - 1% A high index of suspicion for inhalation injury must be maintained, because patients may not display clinical evidence for up to hours, by this time edema may prevent non-surgical intubation. - 24 Carbon monoxide has times the affinity for oxygen as hemoglobin. - 240 Patients with CO levels less than % usually don't have any physical symptoms. - 20% Adult head BSA = %. - 9 (ENTIRE head front and back = 9) Baby head BSA = % - 18 (9 front, 9 back) 50 What would you see in an infant that would make you suspect very severe brain injury despite normal LOC? - Bulging fontanelles - these allow tolerance for expanding masses/swelling... What is a possible mistake about a blood pressure of 120/80 in a 87 year old man? - Assuming that normal blood pressure = normovolemia. Many geriatric patients have uncontrolled hypertension, and if their normal systolic is 180, then 120/80 is relative HYPOtension for them. How well do geriatric patients do with non-operative management of abdominal injuries compared to younger people? - Not as well - the risks of non-operative management are often worse than the risks of surgery. Why would geriatric patients be MORE susceptible to head bleeds when there is increased space around a shrinking brain to protect them from contusion? - Atrophic brains = stretching of the parasagittal bridging veins, making them more prone to rupture upon impact. Plasma volume increases during pregnancy, what happens to hematocrit? - Decreases - dilution by plasma (31-35% is normal in pregnancy) What would you think of a WBC of 15,000 in a pregnant woman? - Normal, it can go up to 25,000 during labor! What should you always assume about a pregnant patient's stomach? - That it is always full. (Gastric emptying time increases during pregnancy). Early NG tube placement recommended. A PaCO2 of 35 to 40 in a pregnant patient may indicate what? - Impending respiratory failure. It is usually around 30 due to hyperventilation due to increased levels of progesterone. True or False: All Rh negative pregnant trauma patients should get Rhogam? - True, unless the injury is remote from the uterus (distal extremity injury only). This therapy should be initiated within 72 hours of injury. 51 When worn correctly, seatbelts reduce fatalities by %. - 65-70%, with a 10-fold reduction in serious injury. True or false? Although the mechanism of injury may be similar to those for the younger population, data shows increased mortality with similar severity of injury in older adults. - True In the elderly population, what is decreased physiological reserve? - aging is characterized by impaired adaptive and homeostatic mechanisms that caused an increased susceptibility to the stress of injury. Insults tolerated by the younger population can lead to devastating results in elderly patients. Pre-existing conditions that affect morbidity and mortality include: - cirrhosis, coagulopathy, COPD, ischemic heart disease, DM What is the most common mechanism of injury in the elderly? - Fall. Nonfatal falls are common in women and fractures are common in women who fall. Falls are the most common cause of TBI. In the elderly population, what are risk factors for falls? - advanced age, physical impairment, history of previous fall, medication use, dementia, unsteady gait, and visual, cognitive impairment Most of elderly traffic fatalities occur in the daytime and on weekends and typically involve other vehicles. Why? - Older people drive on more familiar roads and at lower speeds and tend to drive during the day. Older people have slower reaction time, a larger blind spot, limited cervical mobility, decreased hearing, and cognitive impairment. True or False? Mortality associated with small to moderate sized burns in older adults remains high - True Spilled hot liquids on the leg, which in younger patients may re-epithelialize due to an adequate number of hair follicles, will result in a full thickness burn in older patients. - this is true 52 Airway-patients may have dentures that may loosen or obstruct the airway. If dentures are not obstructing the airway, leave them in place for what? - bag mask ventilation, as it improves mask fitting. When preforming rapid sequence intubation, the dose of benzos, barbiturates, and other sedatives should be reduced to what percentage to minimize the risk of cardiovascular depression? - 20-40% Functional changes in cardiac system include declining function, decreased sensitivity to catecholamines, atherosclerosis of coronary vessels, increased afterload, fixed heart rate (beta blockers) - this results in lack of classic response to hypovolemia, risk for cardiac ischemia, elevated BP at baseline, and increased risk of dysrythmias. Functional changes in pulmonary system include decreased elastic recoil, reduced residual capacity, decreased gas exchange and decreased cough reflex - thus they are at increased risk for respiratory failure, increased risk for pneumonia, and poor tolerance to rib fractures Functional changes in renal system include loss of renal mass, decreased GFR, and decreased sensitivity to ADH and aldosterone - resulting in drug dosing for renal insufficiency, decreased ability to concentrate urine, increased risk for AKI and urine flow may be normal with hypovolemia Functional changes to MSK include loss of lean body mass, osteoporosis, changes in joints and cartilage, c spine degenerative changes and loss of skin elastin and subcutaneous fat - resulting in increased risk for fractures, decreased mobility, difficulty for oral intubation, risk of skin injury, increased risk for hypothermia, challenges in rehabiliation Functional changes in Endocrine system include decreased production and response to thyroxin and decreased dehydroepiandrosterone (DHEA) - resulting in occult hypothyroidism, relative hypercortisone states and increased risk of infection 55 An abrupt decrease in maternal intravascular volume can result in a profound increase in uterine vascular resistance reducing fetal oxygenation despite reasonably normal maternal vital signs. - this is true Physiological anemia of pregnancy - A smaller increase in red blood cell volume can occur resulting in a decreased hematocrit level. Thus, in late pregnancy a hematocrit of 31-33% is normal. Healthy pregnancy patients can lose 1200-1500 mL of blood before exhibiting signs and symptoms of hypovolemia. How can this manifest? - this amount of hemorrhage may be reflected by fetal distress as evidenced by an abnormal fetal heart rate. What are some of the lab changes in pregnancy? - WBC increases to 12000 and during labor can be 25000. Fibrinogen and other clotting factors are mildly elevated and PT and pTT are shortened, but bleeding time and clotting time are unchanged. After the 10th week of pregnancy, cardiac output can increase 1.0-1.5 L/min because of the increase in plasma volume and decrease in vascular resistance of the uterus and placenta. - The placenta receives 20% of the patient's cardiac output during the 3rd trimester. In supine position, vena cava compression can decrease cardiac output by 30% because of decreased venous return from lower extremities. During pregnancy the heart rate increases to a maximum of 10-15 beats per minute over baseline by the third trimester. - this heart rate must be considered when interpreting a tachycardic response to hypovolemia. Blood pressure falls 5-15 mm Hg in systolic and diastolic pressures during second trimester, although it returns to near normal levels at term. - some women experience hypotension when placed in the supine position due to the compression of teh inferior vena cava. hypertension in the pregnant if accompanied by proteinuria may represent what? - pre-eclampsia. 56 EKG findings in pregnant patient - Flatted or inverted T waves in leads III and AVF and the precordial leads may be normal. Ectopic beats are increased during pregnancy. Minute ventilation increases primarily due to an increase in tidal volume. Hypocapnia (30 mm Hg) is common in late pregnancy - Monitor ventilation in late pregnancy with arterial blood gas values. A PaCO2 of 35-40 mm Hg may indicate impending respiratory failure during pregnancy. Pregnant patients should be hypocapneic. Anatomical alterations in the thoracic cavity seem to account for the decreased residual volume associated with diphragmatic elevation and chest x ray reveals increased lung marking and prominence of the pulmonary vessels. - oxygen consumption increases during pregnancy and its important when resuscitating injured pregnant patients to maintain adequate oxygenation above 95% In patients with advanced pregnancy, those that require a chest tube placement, where should the test tube be placed? - it should be positioned higher to avoid intra-abdominal placement given the elevation of the diaphragm. Urinary system: what happens to the GFR, serum creatinine and urea nitrogen levels? - GFR and renal blood increases during pregnancy, whereas levels of the serum creatinine and urea nitrogen fall to one half of the normal pre pregnancy levels. Glycosuria is common in pregnancy. When interpreting x ray films of the pelvis in a pregnant patient, the symphysis pubis widens 4-8 mm and the sacroiliac joint spaces increase by the 7th month - keep this in mind Eclampsia - Maintain a high index of suspicion for eclampsia when seizures are accompanied by HTN, proteinuria, hyperreflexia, and peripheral edema in pregnant trauma patients. This can mimic head injury. External contusions and abrasions of the abdominal wall are signs of blunt uterine trauma. - true. Fetal injuries can occur when the abdominal wall strikes an object, 57 such as the dashboard or steering wheel, or when a pregnant patient is struck by a blunt instrument. Using a shoulder restraints in conjunction with a lap belt reduces the likelihood of direct and indirect fetal injury, presumably because the shoulder belt dissipates deceleration forces over a great surface area and helps prevent the mother from flexing forward over the gravid uterus. - the deployment of air bags in vehicles does not appear to increase pregnancy specific risks. Using lap belt alone allows for forward flexion and uterine compression with possible uterine rupture or placental abruption. Lap belt worn too high over uterus may produce uterine rupture. Penetrating injury to pregnant women - As uterus grows larger, other viscera are protected from penetrating injury. Dense uterine musculature in early pregnancy can absorb significant amount of energy from penetrating objects decreasing their velocity and lowering risk of injury to other viscera. However, fetal outcome is generally poor with penetrating injury to uterus. carefully observe pregnant patients with even minor injuries since occasionally minor injuries are associated with placental abruption and fetal loss. - True. AND to optimize outcomes for mother and baby, clinicians must assess and resuscitate the mother first and then assess the fetus before conducting second survey of the mother. Failure to displace the uterus to the left side in a hypotensive pregnant patient - logroll all patients appearing clinically pregnant (second and third trimester) to the left 15-30 degrees and elevate the right side 4-6 inches and support with a bolstering device to maintain spinal motion restriction and decompression of the vena cava. Due to increases intravascular volume, pregnant patients can lose a significant amount of blood before tachycardia, hypotension, and other signs of hypovolemia occur. Thus, what do stable vital signs in a pregnant patient indicate about the fetus? - The fetus may be in distress and the placenta deprived of vital perfusion while the mother's condition and vital signs appear stable. Administer crystalloid fluid resuscitation and blood to support the physiological hypervolemia of 60 Flame injury is more evident than most chemical injuries. - Monitor IV lines closely to ensure they do not become dislodged as the patient becomes more edematous. Regularly check ties securing ET or NG to ensure they are not too tight. Factors that increase the risk of upper airway obstruction are: - increasing burn size and depth, burns to the head and face, inhalation injury, associated trauma, and burns inside the mouth. Airway can become obstructed form direct injury such as inhalation injury, but also from massive edema resulting from burn injury. How do you decontaminate burn areas? - Completely remove the patient's clothing to stop burning process, but do not peel off adherent clothing. Synthetic fabrics can ignite, burn rapidly at high temps and melt into hot residue that continues to burn the patient. brush any dry chemical powder from wound. rinse with copious amounts of warm saline irrigation or rinsing in a warm shower. once the burning process has been stopped, cover the patient with warm, clean, dry linens to prevent hypothermia. hoarseness, stridor, accessory respiratory muscle use, sternal retraction are signs of what? - airway obstruction. Clinical manifestations of inhalation injury may be subtle and may not show up within the first 24 hours. do not wait for the xray to show evidence of pulmonary injury or changes in blood gas because airway edema can preclude intubation and a surgical airway will be required. A carboxyhemoglobin level greater than what percentage indicates a patient was involved in a fire and has inhalation injury? - 10% Indications for early intubation in burn patients: - full thickness circumferential neck burns, signs of airway obstruction, extent of the burn > 40%, burns inside the mouth, difficulty clearing secretions or swallowing, decreased level of consciousness, Patient with inhalation injury are at risk for bronchial obstruction from secretions and debris and they may require bronchoscopy. - Make sure to place an adequately sized airway tube 61 Direct thermal injury to the lower airway is very rare and essentially occurs only after exposure to superheated steam or ignition of inhaled inflammable gases. Breathing concerns arise from what 3 general causes: - hypoxia, carbon monoxide poisoning, and smoke inhalation injury. Always assume CO exposure in patients who were burned in enclosed areas. Patients with CO levels less than 20% may not show any symptoms - HA and nausea (20-30%), confusion (30-40%), coma (40-60%) and death (>60%). Cherry red skin color in patients may only be seen in moribund patients. Measurements of arterial PaO2 do not reliably predict CO poisoning b/c a partial pressure of only 1 mm Hg results in an HbCO level of 40% or greater. Pulse ox cannot be relied on to rule out carbon monoxide poisoning b/c we cant distinguish oxyhemoglobin from carboxyhemoglobin. A discrepancy between pulse ox and arterial blood gas may be explained by presence of carboxyhemoglobin. Cyanide inhalation poisoning can occur in confined spaces and sign of potential toxicity is persistent profound unexplained metabolic acidosis. - THERE IS NO ROLE for hyperbaric oxygen therapy in the primary resuscitation of a patient with critical burn injury. American Burn Association states 2 requirements for diagnosis of smoke inhalation injury: - 1. exposure to combustible agent 2. signs of exposure to smoke in the lower airway, below the vocal cords, seen on bronchoscopy. A chest Xray and arterial blood gases should be ordered to evaluate the pulmonary status of a patient with smoke inhalation injury, but normal values on admission DO NOT exclude an inhalation injury. The treatment of smoke inhalation injury is supportive. - Any patient with smoke inhalation injury and significant burns greater than 20% TBSA should be intubated. IF the patient's hemodynamic condition permits and spinal injury has been excluded, elevate the patient's head and chest 30 degrees to help reduce neck and chest wall edema. 62 True or false: Clinicians should provide burn resuscitation fluids for deep partial and full thickness burns larger than 20% TBSA - True. urine output monitoring is 0.5mL/kg/hr in adults and should be maintained at 30-50cc/hr to minimize over resuscitation in a burn patient, cardiac dysrhytmias may be the first sign of hypoxia and electrolyte or acid base abnormalities. - therefore an ECG should be performed for cardiac rhythm disturbances. Persistent acidemia in patients with burn injuries may be due to under resuscitation or infusion of large volumes of saline. Tachycardia is a poor indication for resuscitation in the burn patient. - Adjust the fluid rate up or down based on the urine output and recognize that factors such as inhalation injury, age of patient, renal failure, diuretics, and alcohol can affect the volume of resuscitation and urine output. True of false: Burn patients should get tetanus. - true Partial thickness burns - are characterized as either superficial partial thickness (moist, painfully hypersensitive, , potentially blistered, homogenously pink, and blanch to touch) or deep partial thickness ( drier, less painful, potentially blistered, red or mottled in appearance, and do not blanch to touch) Full thickness burns - appear leathery and skin may be white or translucent or waxy white. surface area is painless to light touch or pinprick and generally dry Compartment syndrome in burn patients: - Compartment syndrome can result from an increase in pressure inside the compartment that interferes with perfusion to the structures within that compartment. In burns, this condition results from a combination of decreased skin elasticity and increased edema in the soft tissue. A pressure > 30 mm Hg within the compartment can lead to muscle necrosis and once the pulse is gone it may be TOO LATE to save the muscle. so recognize the signs early: pain greater than expected and out of proportion to the injury pain on passive stretch of the affected muscle tense swelling of the affected compartment 65 Blanched skin associated with fractures and dislocations can lead to soft tissue necrosis. The purpose of promptly reducing this injury is to prevent pressure necrosis of the lateral left ankle soft tissue - the only reason to forgo an xray exam before treating a dislocation or fracture is the presence of vascular compromise or impending skin breakdown, often seen with fracture dislocations of the ankle Treat all patients with open fractures as soon as possible with iv antibiotics - cephalosporins are necessary for all open fractures operative revascularization to an avascular extremity is important to treat emergently. - muscle necrosis begins where there is a lack of blood flow for 6 hours. is there is an associated fracture deformity, correct it by gently pulling the limb out to length, realigning the fracture and splinting the injured extremity. This maneuver can restore the blood flow High risk activities that can cause compartment syndrome include: - excessive exercise burns severe crush injury to muscle localized prolonged external pressure to an extremity increased capillary permeability secondary to reperfusion of ischemic muscle. Compartment syndrome is a clinical diagnosis and pressure measurements are only an adjunct to aid in its diagnosis. a pressure greater than 30 can cause anoxia. - the absence of a palpable distal pulse is an uncommon or late finding and is not necessary to diagnose compartment syndrome. Capillary refill times are also unreliable weakness or paralysis of the involved muscle is a late sign and indicates nerve or muscle damage the lower the systemic pressure, the lower the compartment pressure that causes compartment syndrome 66 risk of tetanus: - wounds that are more than 6 hours old contused or abraded more than 1cm in depth from high velocity missiles due to burns or cold significantly contaminated ischemic tissue or denervated wounds True or false? on page 162. To exclude occult dislocation and concomitant injury, x ray films must include the joints above and below the suspected fracture site - true. unless life threatening, splinting of extremity injuries should be done during the secondary survey. do not apply traction to patients with an ipsilateral tibia shaft fracture. - true Laryngeal Trauma presents as hoarseness, subcutaneous emphysema, and palpable fracture - true. sounds of airway obstruction and include snoring, gurgling, stridor, hoarseness, cyanosis, agitation LEMON assessment for difficult airway - Look, evaluate 3-3-2 rule, mallampati, obstruction, neck mobility Do not give a nasopharyngeal airway to someone suspected of having a cribriform plate fracture. - also do not give nasotracheal intubation to patients with basillar skull fracture A tube placed in the trachea with the cuff inflated below the vocal cords and the tube connected to oxygen enriched assisted ventilation and airway secured in place. - definitive airway patients use the gum elastic bougie when vocal cords cannot be visualized on direct laryngoscopy. - using the GEB has allowed for rapid intubation of nearly 80% of prehospital patients in whom laryngoscopy was difficult. A GEB inserted into the esophagus will pass its full length without resistance 67 Reliable ways to detect proper intubation - proper placement of the tube is suggested but not confirmed: 1. hearing equal breath sounds bilaterally 2. detecting no borborygmi (rumbling or gurgling noises) in the epigastrium. the presence of this with inspiration suggestion esophageal intubation and warrants removal of tube 3. A CO2 detector ideally capnograph or colorimetric CO2 monitoring device. If CO2 is not detected in exhaled air, then esophageal intubation has occurred. 4. Proper position of the tube is best confirmed via chest xray definitive control of hemorrhage and restoration of adequate circulating volume are the goals of treating hemorrhagic shock. - never give vasopressors as the first line treatment as they worsen tissue perfusion. most injured patients who are in hemorrhagic shock require early surgical intervention or angioembolization to reverse the shock state. The presence of shock in a trauma patient warrants the immediate involvement of a surgeon. An injured patient who is cool to the touch and is tachycardic should be considered to be in shock until proven otherwise. Massive blood loss may only produce a slight decrease in HCT/Hgb. - relying solely on BP as an indicator of shock can delay recognition of the condition b/c compensatory mechanisms can prevent measurable fall in systolic pressure until up to 30% of the patient's blood volume is loss. A narrowed pulse pressure suggests significant blood loss and involvement in compensatory mechanisms. tachycardia is diagnosed as > 100 in adults > 160 in infants >140 in preschool aged children >120 in children from school age to puberty. Tachycardia, muffled heart sounds, dilated engorged neck veins, hypotension and insufficient response to fluid therapy is what? - cardiac tamponade, which is commonly caused by penetrating thoracic trauma, but can result from blunt injury to the thorax. Definitive treatment is operative intervention as pericardiocentesis is temporary measure. 70 you can do a needle decompression or finger thoracostomy. place tube in afterwards pain, difficulty breathing, tachypnea, decreased breath sounds on affected side, and noisy movement of air through chest wall injury - these are signs and symptoms of an open pneumothorax. sterile occlusive dressing large enough to overlap the wound's edges and tap it securely on 3 sides Causes of Pulseless Electrical Activity - hypovolemia, hypokalemia, hyperkalemia, hypoglycemia, hypothermia, toxins, cardiac tamponade, tension pneumothorax, thrombosis Massive hemothorax is suggested when a patient is in shock and has decreased breath sounds or dullness to percussion on one side of the chest with collapsed neck veins - chest tube at the fifth intercostal space at the midaxillary line and you get a return of 1500mL or 1/3 or more of the patient's blood in the chest, that indicated the need for urgent thoracotomy. persistent need for blood is an indication for a thoracotomy. color of the blood is a poor indicator of the necessity for thoracotomy. muffled heart sounds, hypotension, and distended necks veins may not always be present in cardiac tamponade. Kussmaul's sign (rise in venous pressure with inspiration when breathing spontaneously) is a true paradoxical venous pressure abnormality that is associated with tamponade - The presence of hyperresonance on percussion indicated tension pneumothorax whereas presence of bilateral breath sounds is cardiac tamponade. FAST can identify cardiac tamponade. if FAST is unavailable, use echo or pericardial window. definitive treatment is surgery so thoracotomy or sternotomy. potentially life threatening injuries that should be identified on secondary survey - simple pneumothorax, hemothorax, flail chest, pulmonary contusion, blunt cardiac injury, traumatic aortic disruption, traumatic diaphragmatic injury, esophageal rupture pulmonary contusion can occur with rib fractures and flail chest (two or more adjacent ribs fractured in two or more places). - initial treatment includes 71 humidified oxygen, adequate ventilation, and cautious fluid resuscitation. definitive treatment includes pain control, adequate oxygenation Blunt cardiac injury can present with hypotension, dysrhythmias, EKG changes, premature ventricular contractions, unexplained sinus tachycardia, AFib, bundle branch block, elevated central venous pressure without any obvious cause may indicate right ventricular dysfunction secondary to contusion. - cardiac troponins can be diagnostic in an MI but have little role in diagnosing blunt cardiac injury. patients with a blunt injury to the heart diagnosed by conduction abnormalities are at increased risk for sudden dysrhythmias and need to be monitored for 24 hours. Traumatic aortic disruption- most survive if they have an incomplete laceration near the ligmentum arteriosum. commonly caused by vehicle collision or fall from a great height. have a high index of suspicion if history has decelerating force. - Look for widened mediastinum on chest xray, obliteration of the aortic knob, deviation of the trachea to the right, depression of the L mainstem bronchus, elevation of R mainstem bronchus, deviation of the esophagus to the right, left hemothorax, presence of the pleural or apical cap, fractures of the first or second rib or scapula, widened paraspinal interface, widened paratracheal stripe. In a traumatic aortic rupture, heart rate and blood pressure control can decrease the likelihood of rupture. - definitive treatment is surgery. Diaphragmatic injury-displaced bowel, stomach, and nasogastric tube on left side. - The appearance of peritoneal lavage fluid in the chest tube also confirms diagnosis esophageal injury- clinical picture is a patient with a left pneumothorax or hemothorax without a rib fracture who has received a severe blow to the lower sternum or epigastrum and is in pain or shock out of proportion to the apparent injury - presence of mediastinal air also suggests diagnosis and definitive treatment is direct repair of the injury. injuries to the retroperitoneal structures are difficult to recognize because they occur deep within the abdomen and may not initially present with signs or symptoms of peritonitis. - the retroperitoneal space is NOT sampled by DPL or FAST 72 physical exam findings suggestive of a pelvic fracture include: - ruptured urethra, scrotal hematoma or blood at the urethral meatus, discrepancy in limb length and rotational deformity of a leg w/o obvious fracture. use pelvic binder that is centered at the greater trochanters rather than over the iliac crests. signs of urethral injury include: - blood at the uretheral meatus, ecchymosis or hematoma of the scrotum and perineum. Palpation of the prostate gland is NOT a reliable sign of urethral injury. a retrograde urethorgram is mandatory when the patient is unable to void, requires a pelvic binder, or has blood at the meatus, scrotal hematoma, or perineal ecchymosis. confirm an intact urethra before inserting a urinary catheter. DPL: Aspiration of gastrointestinal contents, vegetable fibers, or bile through the lavage mandate laparotomy. Aspiration of 10cc or more of blood in hemodynamically abnormal patients requires laporotomy. - performed rapidly, invasive procedure sensitive for detecting intraperitoneal hemorrhage low specificity requires gastric and urinary decompression not repeatable a positive DPL is an indication for laparotomy contraindications include previous abdominal operations, morbid obesity, advanced cirrhosis, pre-existing coagulopathy. FAST - noninvas and can be done rapidly repeatable does not assess retroperitoneal structures. obesity can degrade images obtained by FAST indications for a laparotomy: - Blunt abdominal trauma with hypotension, positive FAST hypotension with an abdominal wound that penetrates anterior fascia gunshot wounds that traverse the peritoneal cavity 75 Neurogenic shock - loss of vasomotor tone and sympathetic innervation to the heart. Injury T6 and above can cause impairment of the sympathetic pathways. We get hypotension and bradycardia. Neurogenic shock is not reversed with fluid resuscitation alone. Vasopressors may be required. spinal shock refers to the loss of muscle tone (flaccid) and reflexes immediately after injury Central cord syndrome - loss of function in upper extremities > lower extremities occurring after a hyperextension injury, forward fall resulting in facial impact. Anterior Cord Syndrome - injury to the motor and sensory pathways in the anterior part of cord. paraplegia and bilateral loss of pain and temp. However, position, vibration, and deep pressure sense are preserved (sensations from dorsal columns). commonly due to cord ischemia Brown-Sequard Syndrome - results from hemisection of the spinal cord. Ipsilateral motor loss and loss of position sense and contralateral loss of pain and temp Atlanto Occipital Dislocation - this is commonly seen in shaken baby syndrome due to severe traumatic flexion and distraction. Most patients with this injury die of brainstem destruction and apnea or have profound neurological impairments. Jefferson Fracture - Burst fracture of C1 due to axial loading, which occurs when a large load falls vertically on the head in a relatively neutral position. Disruption of anterior and posterior rings of C1 Fracture best seen on an open mouth view of the C1-C2 region on CT Hangman Fracture - this involves the posterior elements of C2, the pars interarticularis and this type of fracture is caused by an extension type injury Chance Fracture - transverse fractures through the vertebral body seen after MVC where patient was restrained by only an improperly placed lap belt. 76 Chance fractures can be associated with retroperitoneal and abdominal visceral injuries. these are unstable and require internal fixation NEXUS - Neurological deficit ethanol intoxication distracting injury unable to provide history spinal tenderness midline Signs of blood loss in a child - progressive weakening of peripheral pulses, narrowing pulse pressure less than 20, skin mottling (clammy skin), cool extremities compared with torso skin, decrease in level of consciousness with dulled response to pain. often times tachycardia may be the only sign of shock in a kid hypotension in child - systolic BP for kid is 90 + twice the child's age in years. hypotension represents a state of decompensated shock and can indicated blood loss of > 45%.