ATLS-Question and Answers-100% Verified Solutions-Complete-Newly updated 2023/2024, Exams of Nursing

Download ATLS-Question and Answers-100% Verified Solutions-Complete-Newly updated 2023/2024 and more Exams Nursing in PDF only on Docsity! ATLS-Question and Answers-100% Verified Solutions-Complete-Newly updated 2023/2024 A 22-year-old man is hypotensive and tachycardic after a shotgun wound to the left shoulder. His blood pressure is initially 80/40 mm Hg. After initial fluid resuscitation his blood pressure increases to 122/84 mm Hg. His heart rate is now 100 beats per minute and his respiratory rate is 28 breaths per minute. A tube thoracostomy is performed for decreased left chest breath sounds with the return of a small amount of blood and no air leak. After chest tube insertion, the most appropriate next step is: re-examine the chest A construction worker falls two stories from a building and sustains bilateral calcaneal fractures. In the emergency department, he is alert, vital signs are normal, and he is complaining of severe pain in both heels and his lower back. Lower extremity pulses are strong and there is no other deformity. The suspected diagnosis is most likely to be confirmed by: complete spine x-ray series What is true regarding the initial resuscitation of a trauma patient? Evidence of improved perfusion after fluid resuscitation could include improvement in Glasgow Coma Scale score on reevaluation In managing a patient with a severe traumatic brain injury, the most important initial step is to: secure the airway A previously healthy, 70-kg (154-pound) man suffers an estimated acute blood loss of 2 liters. What applies to this patient? An ABG would demonstrate a base deficit between -6 and -10 mEq/L. The physiological hypervolemia of pregnancy has clinical significance in the management of the severely injured, gravid woman by: increasing the volume of blood loss to produce maternal hypotension. The best assessment of fluid resuscitation of the adult burn patient is: urinary output of 0.5 mL/kg/hr The diagnosis of shock must include: evidence of inadequate organ perfusion A 7-year-old boy is brought to the emergency department by his parents several minutes after he fell through a window. He is bleeding profusely from a 6-cm wound of his medial right thigh. Immediate management of the wound should consist of: direct pressure on the wound For the patient with severe traumatic brain injury, profound hypocarbia should be avoided to prevent: cerebral vasoconstriction with diminished perfusion After being involved in a motor vehicle crash, a 25-year-old man is brought to a hospital that has surgery capabilities available.. Computed tomography of the chest and abdomen shows an aortic injury and splenic laceration with free abdominal fluid. His blood pressure falls to 70 mm Hg after CT. The next step is: perform an exploratory laparotomy What statements regarding abdominal trauma in the pregnant patient is TRUE? Leakage of amniotic fluid is an indication for hospital admission. The first maneuver to improve oxygenation after chest injury is: administer supplemental oxygen 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 vomitus on his face and clothing. The most appropriate step after providing supplemental oxygen and elevating his jaw is to: suction the oropharynx A 22-year-old man sustains a gunshot wound to the left chest and is transported to a small community hospital no surgical capabilities are available. In the emergency department, a chest tube is inserted and 700 mL of blood is evacuated. The trauma center accepts the patient in transfer. Just before the patient is placed in the ambulance for transfer, his blood pressure decreases to 80/68 mm Hg and his heart rate increases to 136 beats per minute. The next step should be to: repeat the primary survey and proceed with transfer A 64-year-old man involved in a high-speed car crash, is resuscitated initially in a small hospital without surgical capabilities. He has a closed head injury with a GCS score of 13. He has a widened mediastinum on chest x-ray with fractures of left ribs 2 through 4, but no pneumothorax. After initiating fluid resuscitation, his blood pressure is 110/74 mm Hg, heart rate is 100 beats per minute, and respiratory rate is 18 breaths per minute. He has gross hematuria and a pelvic fracture. You decide to transfer this patient to a facility capable of providing a higher level of care. The facility is 128 km (80 miles) away. Before transfer, you should first: call the receiving hospital and speak to the surgeon on call Hemorrhage of 20% of the patient's blood volume is associated usually with tachycardia What statement concerning intraosseous infusion is TRUE? Aspiration of bone marrow confirms appropriate positioning of the needle. A young woman sustains a severe head injury as the result of a motor vehicle crash. In the emergency department, her GCS is 6. Her blood pressure is 140/90 mm Hg and her heart rate is 80 beats per minute. She is intubated and mechanically ventilated. Her pupils are 3 mm in size and equally reactive to light. There is no other apparent injury. The most important principle to follow in the early management of her head injury is to avoid hypotension A 33-year-old woman is involved in a head-on motor vehicle crash. It took 30 minutes to extricate her from the car. Upon arrival in the emergency department, her heart rate is 120 beats per minute, BP is 90/70 mm Hg, respiratory rate is 16 breaths per minute, and her GCS score is 15. Examination reveals bilaterally equal breath sounds, anterior chest wall ecchymosis, and distended neck veins. Her abdomen is flat, soft, and not tender. Her pelvis is stable. Palpable distal pulses are found in all 4 extremities. Of the following, the most likely diagnosis is: cardiac tamponade A hemodynamically normal 10-year-old girl is hospitalized for observation after a Grade III (moderately severe) splenic injury has been confirmed by computed tomography (CT). What mandates prompt celiotomy (laparotomy)? development of peritonitis on physical exam A 40-year-old woman who was a restrained driver in a motor vehicle crash is evaluated in the emergency department. She is hemodynamically normal and found to be paraplegic at the level of T10. What precaution should be taken during evaluation and management? Log rolling using 4 people is a safe approach to restrict spinal motion when moving her. A trauma patient presents to your emergency department with inspiratory stridor and a suspected c-spine injury. Oxygen saturation is 88% on high-flow oxygen via a nonrebreathing mask. The most appropriate next step is to: restrict cervical motion and establish a definitive airway When applying the Rule of Nines to infants The head is proportionally larger in infants than in adults A healthy young male is brought to the emergency department following a motor vehicle crash. His vital signs are a blood pressure of 84/60, pulse 123, GCS 10. The patient moans when his pelvis is palpated. After initiating fluid resuscitation, the next step in management is: placement of a pelvic binder What situations requires Rh immunoglobulin administration to an injured woman? positive pregnancy test, Rh negative, and has torso trauma A 22-year-old female athlete is stabbed in her left chest at the third interspace in the anterior axillary line. On admission to the emergency department and 15 minutes after the incident, she is awake and alert. Her heart rate is 100 beats per minute, blood pressure 80/60 mm Hg, and respiratory rate 20 breaths per minute. A chest x-ray reveals a large left hemothorax. A left chest tube is placed with an immediate return of 1600 mL of blood. The next management step for this patient is: prepare for an exploratory thoracotomy A 6-year-old boy walking across the street is struck by the front bumper of a sports utility vehicle traveling at 32 kph (20 mph). What's true about this patient? A pulmonary contusion may be present in the absence of rib fractures. Adjuncts used during the primary survey ECG Pulse ox CO2 monitoringV Ventilatory rate ABGs Foleys (UOP) Gastric catheter FAST or eFAST DPL Urinary output is sensitive for Patient's volume status and renal perfusion "Golden hour" Patients with maxillofacial or head trauma should be presumed to have A cervical pine injury and cervical spine motion must be restricted PITFALL: equipment failure Test regularly Ensure spare equipment and batteries are readily available PITFALL: unsuccessful intubation Identify patients with difficult anatomy Identify the most experienced/skilled airway manager on team Ensure appropriate equipment is available Be prepared to prefer a surgical airway PITFALL: progressive airway loss Recognize the dynamic status of the airway Recognize the injuries that can result in progressive airway loss Frequently reassess the patient for signs of deterioration of the airway In a trauma patient with hypotension, what are the two most important causes to consider in order of importance? Tension pneumothorax Hemorrhage What is the best way to manage rapid external blood loss? Direct manual pressure on the wound What are the major areas of internal hemorrhage? Chest Abdomen Retroperitoneum Pelvis Long bones How should fluids be administered in trauma patients with shock? Warm IVFs If unresponsive to initial IVF, give blood transfusion immediately What are the uses for ETCO2? Detect ROSC Confirm ET intubation Help avoid hypoventilation and hyperventilation You'd like to insert a foley catheter for a trauma patient but you notice urethras injury. What test should be performed prior to the insertion of a urinary catheter? Retrograde urethrogram DDX for blood in gastric aspirate in a trauma patient Swallowed blood Traumatic gastric tube placement UGI injury What's a C/I to NGT insertion? Fracture of the cribriform/midface fracture (insert OG instead) What injuries are at high risk of compartment syndrome in trauma patients? Long bones Crush injuries Circumferential thermal burns Prolonged ischemia to the limb What's normal UOP? Adult: 0.5 ml/kg/hr Child: 1-2 ml/kg/hr MIST for obtaining info from EMS Mechanism and time of injury Injuries found and suspected Symptoms and signs Treatment initiated Retroperitoneal organs Abdominal aorta IVC Duodeum Pancreas Kidneys Ureters Posterior aspects of ascending/descending colon Bladder Rectum Reproductive organs What's the most frequently injured abdominal organ in blunt trauma? Followed by? Spleen (40-55%) Liver (35-45%) Small bowel (5-10%) Which patients should you consider transferring, and what tests should be performed prior to transfer? The patients whose injuries exceed your ability to care for them, either sue to specialize needs, or resource availably. Only perform testing that enables the referring physician to resuscitate, stabilize, and ensure the safer transfer of the patient What's a pulse oximetry measure? Oxygen saturation by relative absorption of light by oxyhemoglobin and deoxyhemoglobin Gastric catheter placement can induce vomiting Be prepared to logroll Ensure suction is immediately available Special populations that may have physiological responses that do not follow expected patterns Extremity GSW Neurovascular injury Fractures Compartment syndrome Thermal burns Eschar on extremities or chest Electrical burns Cardiac arrhythmias Myonecrosis Compartment syndrome Inhalation burns CO poisoning Upper airway swelling Pulmonary edema What is your first step when a patient condition changes? ABCDEs What's the importance of meticulous record keeping? Crucial during patient assessment and management because often more than one clinician cares for an individual patient and allows those to evaluate the patient's needs and clinical status What info should be provided to the receiving facility for a transferring patient? As much info as possible! Event of injury, patient exam, treatments done, responses of treatments, tests and results, and possible injuries What key information should prehospital providers obtain and report to the receiving hospital? Events associated with injury What patient sign can be quickly observed to assess a patient's hemodynamic status? Skin perfusion Definitive airway A tube placed in the trachea with the cuff inflated below the vocal cords, the tube connected to a form of oxygen-enriched assisted ventilation and the airway secured in place with an appropriate stabilizing method What's critical management for trauma patients, especially those with sustained head injuries? Maintaining oxygenation and printing hypercarbia Triad of largyneal fracture Hoarseness Subcutaneous emphysema Palpable fracture In a conscious trauma patient, airway adequacy can quickly be assessed by Talking to the patient-- A positive verbal response with clear voice indicated patent airways, ventilation, and brain perfusion What can conform a suspected laryngeal fracture? CT scan For a patient who is gurgling, initial assessment for ventilation should include Looking for symmetrical chest rise and listening for breath sounds Decreased or absent breath sounds over one or both hemithoraxes should alert the examiner to the presence of? Pneumothorax, hemothoax, contusion, or flail chest Adjuncts of ventilation problems Pulse ox to measure oxygen saturation and gauge peripheral perfusion Capnography to assess adequacy fo ventilation What are the symptoms of inadequate ventilation? Difficulty breathing SOB Request to sit up to breath LEMON assessment of difficult intubation Look externally Evaluate the 3-3-2 rule Mallampati Obstruction Neck mobility Types of definitive airways Orotracheal tube Nasotracheal tube Surgical airways (cricothyroidotomy and tracheostomy) Laryngeal manipulation for visualization Backward, upward, and rightward pressure on thyroid cartilage can aid in visualizing vocal cords Which surgical airway is recommended in children under 12? Needle cricothyroidotomy What're adjuncts that might be used during intubation? Suction Manual laryngealmanipulation (BURP) Elastic bougie Anesthetics, analgesics, and neuromuscular blocking agents Why is continual pulse ox monitoring necessary in critically injured patients? Because changes in oxygenation occur rapidly and are impossible to detect clinically What indicates that the endotracheal tube is in the proper position? What's the most common cause of a tension pneumothorax? Mechanical positive-pressure ventilation in patients with a visceral pleural inury Where is the ideal location for needle decompression of a tension pneumothorax? 5th intercostal space, slightly anterior to midaxillary line What do you need to remember when treating an open pneumothorax? Place a dressing on the site and only secure is on 3 sides so air can escape, then place a chest tube Massive hemothorax Accumulation of >1500 ml of blood in one side of chest Causes of PEA? Hypovolemia Hypoxia Hydrogen acidosis Hypo/hyperkalemia Hypoglycemia Hypothermia Toxins Tamponade Tension pneumo Thrombosis Indications of a thoracotomy Immediate return of > 1500 ml of blood or significant bleeding Persistent blood transfusions Penetrating anterior chest wounds medial to the nipple line Posterior wounds medial to the scapula A 26-year-old male sustained a posterior stab wound. Blood and bubbling are coming from the wound. Open pneumothorax A 46-year-old male sustained a gunshot wound to the chest Massive hemothorax A 65-year-old female who takes warfarin was involved in a MVC. She initially presented complaining of sternal pain. BP deteriorated to 90/60 after arriving to the ED Cardiac tamponade Eight life-threatening injuries during the secondary survey? Simple pneumothorax Hemothorax Flail chest Pulmonary contusion Blunt cardiac injury Traumatic aortic disruption Traumatic diaphragmatic injury Blunt esophageal rupture A patient with a simple pneumothorax May be watched for progression if pneumothorax is small (<15%) and patient is stable and does not require transfer A 38-year-old male presents to the ED after a head-on, high-speed collision. His vitals are HR 130, BP 156/90, RR 20, and O2 sat 92% on 15L of O2. His voice is raspy and he complains of chest pain that radiates to his back. A CXR shows a widened mediastinum, obliteration of the aortic notch, and depression of the left mainstream bronchus. You should Administer agents to manage his pain and lower his HR and BP (aortic disruption) What's a characteristic that is shared by all traumatic aortic disruption survivors? Contained hematoma A 36-year-old female was involved in an altercation, sustaining a knife wound to the chest, below the left nipple. She is mildly short of breath with an oxygen sat of 92%. BP is 115/80. Simple pneumothorax A 56-year-old male archer was riding a horse when it bucked and the saddle struck him in the chest wall. You note paradoxical chest wall movement on the left anterior chest. CXR is negative. Flail chest due to costochondral disruption What would confirm a diaphragmatic injury in a patient? Presence of NGT What is a common finding associated with traumatic asphyxia? Upper torso, facial, and arm plethora with petechiae secondary to acute temporary compression of SVC. Massive swelling and cerebral edema may be present. Why are rib fractures in older adults a more significant concern than in young patients? The incidence of PNA and mortality is doubled in older patients Pulmonary contusion/flail chest is best treated by? Supplemental oxygen, pain control, and recognition if the patient is unable to ventilate properly The cause of hypoxia associated with flail chest is Pulmonary contusion A patient arrives in your hospital after a fall from 20 ft landing on his right side. He has been intubated and two large-bore IVs have been started. His o2 sat is 82%, he has a good capnography waveform, and significant deformity to right chest wall. He has no breath sounds on the right. His BP is 75/30. Your next step should be to Perform a needle decompression or finger throacostomy on the right side You have completed a secondary survey on a patient who feel from a standing height. You note exquisite tenderness posterolaterally on the left chest wall at 9- 11 ribs. This should raise suspicion for what other injury? Airway appears intact. Breathing has increased rate. Circulation demonstrated hemorrhagic shock. Penetrating abdominal injury with shock is one of the indications for emergent laparotomy. In a patient with a possible pelvic fracture, how frequently should the pelvis be tested for mechanical stability? The pelvis should not be tested in a hemodynacilly unstable patient. Mechanical instability of he pelvic ring should be assumed in patients who have suspected pelvic fractures. Avoid manually manipulating the pelvis (dislodge an existing clot) Hypotension + pelvic fracture = High mortality A 12-year-old male complains of LUQ tenderness and L shoulder pain 8 hours after playing rugby. ABCDE are normal. Circulatory assessment remains normal. Abdominal exam reveals mild LUQ TTP without peritoneal signs. FAST demonstrated fluid in the hepatorenal space and the plenorenal recess. What's the appropriate next step? Observation A 29-year-old woman is the restrained driver in a head-on collision. Airbags deployed. ABCDE are normal. The patient complains of lower abd and back pain. A lower abd contusion is present and associated with tenderness. There is no evidence of diffuse peritonitis. Your institution has NOT surgical capabilities. What's the most appropriate treatment plan? The patient should be urgently transferred for surgical intervention A 50-year-old male arrives to the ED following fall of 26'. He hs gurgling respirations and is not responsive to voice. VS are BP 80/5-, RR 30, HR 138, O2 sat is undetectable. Your hospital does not have surgical capabilities. The first step in management is Application of oxygen and securing an airway A 25-year-old ale arrives at the ED following a motorcycle crash. BP is 80/60, HR 140. Airway and breathing are controlled. There are no open wounds. The abd is not distended. Both legs are externally rotated but soft. The pelvis is tender. The scrotum is swollen and ecchymotic. While vascular access is obtained, what the next most appropriate step? Application of a pelvic binder A 45-year-old male with a BMI of 48 was working in an industrial plant when 2 pieces of wood flew off a sa and struck him in the abdomen and right chest. CXR demonstrates rib fractures. What's true about this scenario? Despite multiple imaging studies, detection of intestinal and retroperitoneal injuries may be difficult Your institution does not have surgical capabilities. You have intubated a 25-year- old man who was in a rollover MVC. You have also placed bilateral chest tubes for pneumothoraxes. The patient's SBP is continually < 90 and HR > 140. Potential therapy and evaluation includes Activation of massive transfusion protocol, application of pelvic binder, and CXR What's the primary goal of treatment for patient's with suspected TBIs? To prevent secondary brain injury by ensuring adequate oxygenation and maintain BP that's sufficient to perfuse the brain Cerebral perfusion pressure (CPP) MAP - ICP A 23-year-old male fell from a bike, striking his head on the curb. He was not wearing a helmet. The patient has a 10 cm laceration to the temporal-parietal region of the left scalp. He is initially able to say hi name. VS are HR 115, BP 100/60, oxygen sat 88%, GCS initially 12. 2 hours after transfer to a local hospital, he has sonorous respirations, a HR of 120, BP 100/70, and GCS of 6. What the initial priorities in the management of this patient? Airway protection with a subglottic device Oxygenation to prevent hypoxia Maintain SBP > 100 mmHg A 23-year-old male fell from a bike, striking his head on the curb. He was not wearing a helmet. The patient has a 10 cm laceration to the temporal-parietal region of the left scalp. He is initially able to say hi name. VS are HR 115, BP 100/60, oxygen sat 88%, GCS initially 12. 2 hours after transfer to a local hospital, he has sonorous respirations, a HR of 120, BP 100/70, and GCS of 6. What are the signs that the patient's injury is progressing? Decreased GCS indicates worsening intracranial pathology with possible intracranial HTN and impending herniation A 78-year-old ale is found down in the bathroom with a large left scalp laceration from striking the corner of the sink. He arrives in the ED with a BP 180/90, HR 60, dilated, non-responsive right pupil. The most likely finding on the patient's CT scan will be Illustrtive of impending uncle hernia associated with Cushing response (high BP + bradycardia)-- associated with a large subdural hematoma with midline shift Intracranial mass effect is defined by the Monro-Kellie Doctrine A trauma patient opens her eyes, moans, and withdraws from pain. What is her GCS score? Eye opening: 2 Verbal response: 2 Best motor response: 4 Total = 8 A 48-year-old female falls from a balcony. She was witnessed striking her head on the steps after an ~8' fall. The patient briefly lost consciousness and is found confused, lying at the bottom of the steps. Her eyes are open, and she is rubbing her forehead. The most important finding related to this patient's long-term outcome is GCS score A 56-year-old male repeats questions, his eyes are open, and he moves to command GCS 14 Repair the scalp laceration What are the initial treatment options that may protect the brain from ongoing swelling? Decreasing agitation with sedation, reducing cerebral swelling with mannitol, or hypertonic saline. A neurosurgeon can drain CSF. A 22-year-old male is hit by a car while traveling downhill on a skateboard. He was found unconscious at the scene and arrives with bag-mask ventilation by the EMS crew. He only mumble incoherently, does not open his eyes, and only flexes to pain. Upon arrival in the ED, the primary goal is Intubate the patient What treatment measures is essential in maintaining cerebral perfusion pressure? Sedation, mannitol, and IVF will help decrease ICP or increase MAP A 45-year-old female is involved in a MVC and brought to a local ED with limited capabilities. She does not remember the event and has repetitive questioning. You would like to get a CT scan of the head, but the technician must be called in from home, which will take at least 30 minutes. You should Transfer the patient to a higher level of care A patient arrives after a blow to the right temporal region secondary to a tree limb striking him while chopping down a tree. He was intubated in the field for a declining mental status. His PE reveals 6 mm and non-reactive right pupil and a 4 mm L pupil with brisk reaction to 2 mm. His GCS reveals extensor posturing with no eye opening, and he is intubated. The presumed extent of his intracranial injury is most likely? Epidural hematoma causes same side pupil dilation and opposite side weakness Many patients with c-spine fractures have a second, noncontiguous vertebral column fracture A helmeted 28-year-old male fell from scaffolding. A bystander witnessed the fall and reports that the patient landed head first, causing his neck to hyperextend. His VS are BP 90/62, HR 58, RR 28, GCS 15. The patient is alert and following commands. His breathing is shallow and he is not moving his arms or legs. What injuries has this patient likely incurred? The initial assessment raises concerns for a spinal cord injury. However, complete a primary and secondary survey to rule out additional life-threatening injures. A helmeted 28-year-old male fell from scaffolding. A bystander witnessed the fall and reports that the patient landed head first, causing his neck to hyperextend. His VS are BP 90/62, HR 58, RR 28, GCS 15. The patient is alert and following commands. His breathing is shallow and he is not moving his arms or legs. What type of shock does this patient exhibit? Neurogenic Cervical spine injuries represent more than 1/2 of all spinal column injuries. What additional injuries are commonly associated with cervical fractures? 25% of all spine injuries have at least a mild brain injury and 10% with a cervical fracture have another noncontiguous spine fracture Neurogenic shock is associated with what level of spinal cord injury and causes systemic hypotension via what mechanism? T6 and higher, distributive shock from lack of vasomotor tone The patient is unable to move his legs. He can move his fingers and wrists bilaterally. He has weal triceps extension on the left. He is unable to move right elbow. He is able to feel his fingers and thumbs bilaterally, but not feel anything above his elbow. Where is the suspected spine lesion? C6 or C7 The patient is unable to move his legs. He can move his fingers and wrists bilaterally. He has weal triceps extension on the left. He is unable to move right elbow. He is able to feel his fingers and thumbs bilaterally, but not feel anything above his elbow. Why is there a difference b/t the PW findings for the UE on PE? The difference between the PE findings for the UE is likely due to initial inflammatory response, edema, and/or the presence of an incomplete spinal cord injury. Spinal cord injuries can be defined by neurologic level and severity in addition to associated syndromes and morphology. Describe Brown-Sequard syndrome lesion at T5. T5, penetrating injury to one side (partial) Which type of thoracic spinal fracture is associated with MVC with restrained passengers using lap belt, a forward flexion mechanism, likely visceral organ injury, and frequent need for internal fixation? Chance fracture What's the appropriate treatment for a C6 vertebral body fracture Spinal immobilization and IVFs, followed by vasopressors if patient remains bradycardic after fluids A patient with a known cervical spine fracture who is being transferred from a rural hospital to definitive care should be transported in which way? Semi-regid collar and head restraint Patients with cerviacl fractures above C6 require special consideration prior to transportation due to? Potential progression to respiratory failure A 35-year-oldman was ejected from a MV. On arrival, his VS are BP 80/40, HR 110,RR 24, GCS 15. Airway and breathing are intact. He complains of severe back pain, has no sensation below umbilicus, has lower thoracic tenderness, and is unable to move LE. Chest and pelvic X-rays are normal. Along with IVFs, what is most appropriate treatment for this patient's hypotension? Although this patient likely has a spinal cord injury, perform a FAST exam or DPL to r/o other etiology. An elderly female falls and sustains a hyperextension injury to her neck. Her exam demonstrated decreased strength in UE compared to LE. What is the cause of her unusual neurologic findings? Central cord syndrome What's the most common location of all spinal injuries? Swollen extremity in region of major muscle group Crush injury with impending compartment syndrome Pale or white distal extremity Lack of arterial blood flow Diagnosis of an open fracture is made based on? Physical exam and x-ray What's high risk for compartment syndrome? Ischemia repercussion injury to enclosed muscle Crush injury Tight dressing or cast How is an open joint injury confirmed? CT or saline/dye injection When does muscle necrosis begin? When there is a lack of arterial blood flow for more than 6 hours A 38-year-old female restrained driver is involved in a high-speed, head-on collision with a truck. Following a prolonged extrication, she noted to have deformity of her right thigh. On arrival, her VS are HR 120, BP 90/50, RR 22, GC 15. 2 large bore IVs are inserted in UE. VS are now HR 13- BP 80/40, RR 24, GCS 14. CXR, pelvis X-ray, and FAST are negative. You suspect the source of hypotension is a femur fracture and bilateral tibial shaft fractures. Transfer is initiated. What antibiotics and at what dose should be given tot he patient? Cefazolin 3g + ciprofloxacin or gentamicin What does splinting accomplish in patients with musculoskeletal trauma? Control blood loss, prevent further neuromuscular compromise and soft tissue injury, and reduce the patient's pain A 25-year-old male presents after a motorcycle crash. VS are BP 128/70, HR 124, GCS 15. He complains of R leg pain. On exam, the patient is found to have proximal right thigh deformity. Distal pulses intact. What's the best initial magement of this patient's symptoms? Splint the extremity and administer a small dose of an IV narcotic, like fentanyl When should IV antibiotics be given to patients with open fractures? All patients with an open fracture should receive IV antibiotics A 22-year-old female presents after jumping from the 3rd story of a building in a suicide attempt. She's stable, but GCS is 13. Both ankles are swollen. Her pulses intact. Initial chest and pelvis films are normal. Ankle films reveal bilateral calcanea fracture. What additional work-ip is important to undertake in this patient? Radiographic work-up of the spine to rule out occult injury What's true about tourniquets? It must occlude arterial inflow Musculoskeletal adjuncts to the primary survey may include? Proper application of a splint can help control blood loss, reduce pain, and prevent further neurovasculr compromise ABLS indications for early intubation Signs of airway obstruction TBSA > 40-50% Extensive and deep facial burns Burns inside the mouth Significant edema or risk for edema Difficulty swallowing Signs of respiratory compromise Decreased LOC Anticipated patient transfer of large burn with airway issue without qualified personnel to intake en route Parkland formula 2-4 ml of LR x patient's weight (kg) x % TBSA for 2nd and 3rd degree burns with 1/2 administered in the 1st 8h and the 2nd 1/2 administered during the subsequent 16h Simplest way to remove tar from trauma patient? Mineral oil Reperfusion syndrome Indicated by acidosis, hyperkalemia, and local swelling; therefore monitor the patient's cardiac status and peripheral perfusion during rewarming Immediate lifesaving measures for patients with burn injuries Stopping the burn process Recognize inhalation injury Assuring an adequate airway Oxygenation and ventilation Rapidly initiating IVF What's the most significant difference between burns and other injuries? The consequence of a burn injury are directly linked to the extent of the inflammatory response to the injury A 29-year-old M jumps from the 1st story of a burning house. His clothes are on fire. Bystanders extinguished the flames. He is conscious, agitated, and complaining of abdominal and leg pain. The patient's head and upper body appear to be extensively burned. What are the unique considerations that a burn injury adds to the initial management of this patient? Some interventions to be considered are early intubation and initiation of burn resuscitation. What is the primary difference b/t the presentation of airway injury in patients with burns compared to other forms of trauma? Airway injury can develop over time due to edema from burn injury How does hypovolemia from burn injury differ from hypovolemia from other forms of trauma? Immediate active rewarming A 35-year-old female is brought into the hospital after being lost for two days while snowmobiling in -30 C weather. She has a core body temperature of 30 C and her toes are frozen. How should the toes be thawed? Moist rewarming The most significant difference between burn and other traumatic injuries is? In a burn injury, the full extent of the injury may not be evidence immediately In an adult patient with suspected inhalation injury, it is important to? Use an ETT larger than 7.5 in an adult to enable clearance of secretions Burn shock is a result of? Interstitial loss due to inflammation The immediate treatment of electrical injury consists of? Maintaining UOP of 100 ml/hr What're the leading causes of unsuccessful resuscitation in pediatric patients with severe trauma? Failure to secure a compromised airway Failure to support breathing Failure to recognize and respond to intra-abdominal and intracranial hemorrhage A 3-year-old falls 10 meters out of an apartment window onto pavement. He does not open his eyes, moans incomprehensibly, and extending abnormally when stimulated. The patient is unresponsive on arrival to the ED, and pupils are unequal. He has blood coming from his right ear, is breathing rapidly, and is pale, with mottled extremities. VS are BP 74/57,HR 156, RR 49. What steps and maneuvers would you use to manage this patient's airway? Maintain airway with chin-lift and jaw-thrust with assisted ventilation using bag mask with placement of laryngeal mask or ETT A 3-year-old falls 10 meters out of an apartment window onto pavement. He does not open his eyes, moans incomprehensibly, and extending abnormally when stimulated. The patient is unresponsive on arrival to the ED, and pupils are unequal. He has blood coming from his right ear, is breathing rapidly, and is pale, with mottled extremities. VS are BP 74/57,HR 156, RR 49. Is this child in shock? Yes (tachycardia, mottled extremities, and hypotension) indicates significant compromise, likely due to bleeding but other etiology must be ruled out. Trauma triad of death Hypothermia Acidosis Coagulopathies A 5-year-old boy is struck by a car and brought to the ED. He is lethargic but withdraws from painful stimuli. VS are BP 90, HR 160, RR 40, and oxygen sat 85%. The best option for establishing vascular access after experienced nurses have failed to obtain PIV on two attempts is? Placement of intraosseous device into proximal tibia When treating a severely injured child, it is very important to rapidly establish the patient's weight in order to determine equipment size, drug doses, and resuscitation volumes. What are options for estimating weight quickly or determining appropriate equipment size? Asking parent or caregiver Using a length-based pediatric resuscitation tape Using the formula (2 x age in years + 10) Common causes of deterioration in intubated patients Dislodgement Obstruction Pneumothorax Equipment failures Classifications of responses of children to fluid resuscitation Responders: stabilized by crystalloid fluid OR crystalloid and blood resuscitation Transient responders: install response to crystalloid and blood, but then deteriorates Nonresponders: doesn't respond to crystalloid or blood infusion A 3-year-old falls 10 meters out of an apartment window onto pavement. He does not open his eyes, moans incomprehensibly, and extending abnormally when stimulated. The patient is unresponsive on arrival to the ED, and pupils are unequal. He has blood coming from his right ear, is breathing rapidly, and is pale, with mottled extremities. The patient is intubated and IV access is obtained. He's given crystalloid and blood with good response. HR 110 and BP 90/60. CXR shows pulmonary contusions. What are the priorities in evaluating a small child with multi system trauma? ABCDE Why do children commonly develop pulmonary contusions following trauma, even in absence of rib fractures? Ribs of children are primarily cartilaginous therefore bend and allows transmission of kinetic energy to underlying lung rather than absorbing and dissipating energy by fracturing ribs What's the most common immediately lift-threatening injury in children? Tension pneumothorax What visceral injuries are more common in children? Blunt pancreatic injuries Small bowel perforations near ligament of Treitz Mesenteric and small bowel avulsions Bladder rupture Enteric disruption Penetrating injuries to perineum Rupture of hollow viscus A 10-year-old M arrives to ED after bike accident. He's complaining of upper abdominal pain. VS HR 115 BP 100/65. CT shows large splenic laceration with contrast extravasation. He returns to ED from radiology, his HR increased to 150 BP drops to 70/45. What's the appropriate next step? COPD Ischemic heart disease DM What pitfalls may you face when intubating an elderly patient? Decreased chest wall and pulmonary compliance Decreased mucus clearance Diminished functional residual capacity Increased work of breathing A geriatric trauma patient falls from her wheelchair at a nursing home. She presents with a GCS score of 13, The patient is likely suffering from a? TBI An important immediate treatment of intracranial hemorrhage in elderly patients is? Correct all sources of coagulopathy Likely causes of elderly patient's decline in mental status? Delirium Dementia Pain medication Sedatives Increase ICP Decreased cerebral perfusion pressure Geriatric trauma patients are at greater risk of mortality from rib fractures than younger individuals because they? Are at a greater risk of developing pneumonia An elderly patient is transferred from a long-term care facility after being found down. In addition to a hip fracture, you find the patient is wearing soiled clothes and a soiled diaper, has dry mucus membranes, and tenting skin. You should evaluate the patient for? Elder maltreatment Compared to a younger patient, a geriatric trauma patient with a pelvic fracture is more likely to? Require blood transfusions The removal of spine boards early is particularly important in geriatric patients because? Patients are at increased risk of pressure ulcers The best initial treatment for pregnant trauma patients is? Resuscitate the mother and consult surgeon and obstetrician A 35-year-old woman who appears to be in the second trimester of pregnancy is brought to the ED following a MVC. She is unconscious and immobilized on a long spine board. How might the patient's pregnant affect the performance of the primary survey? The priorities are the same: ABCDE. Care must be taken to interpret VS. In addition to VS and GCS score, what information would be helpful to obtain in order to evaluate pregnant trauma patients? Additional scene information: whether/how the patient was restrained and MOI A 22-year-old female in the 3rd trimester of her pregnancy presents after MVC. Her VS are BP 100/70, HR 120,RR 22. FHR found to be 90. What statement about FHR is correct? This is abnormally low FHR likely presents impair oxygen flow to the fetus from the placental vasculature (sensitive to catecholamine surge during trauma causing increased uterine vascular resistance and decreased fetal oxygenation) What's true about hypervolemia associated with pregnancy? Cardiac output increased by 1-1.5 L/min after the 10th week of pregnancy due to the increase in plasma volume and decrease in vascular resistance Healthy pregnant patients can lose _____ ml of blood before exhibiting signs and symptoms of hypovolemia 1200-1500 ml of blood Lab values changed during pregnany Elevated WBC (12000-25000) Mildly elevated fibrinogen and other clotting factors Shortened PT and PTT (bleeding and clotting times unchanged) Decreased Hct (32-42%) While supine, vena cava compression can cause? Decrease cardiac output by 30% because of decreased venous return from the lower extremities A 35-year-old woman who appears to be in the second trimester of pregnancy is brought to the ED following a MVC. VS are RR 28, HR 130, BP 110/50, GCS 7. What are the first steps in primary survey in this patient? Establish definitive airway and stabilize cervical spine Placing a orogastric tube may be advised as it's likely to reflux gastric contents If the patient becomes hypotensive, elevate the patient's right side to displace uterus off IVC A 35-year-old woman who appears to be in the second trimester of pregnancy is brought to the ED following a MVC. VS are RR 28, HR 130, BP 110/50, GCS 7. What lab and radiologic tests should be ordered? CMP, CBC, blood gas, toxicology, coagulation, Rh status, UA (If Rh- then administer Rh immunoglobulin) Imaging to r/o brain, spine, and abdominal injuries The ability to palpate fetal extremities on the abdominal exam of a pregnant trauma patient is indicative of? Uterine rupture A 33-year-old woman who is 28 weeks pregnant by dates presents with a 4 cm stab wound to the left chest superior and lateral to the nipple. Her BP is 78/40, HR 14-, RR 30. She is awake and talking but confused, pale, and diaphoretic. Her oxygen sat is 92% on 15 L. She has markedly decreased breath sounds on left, Neck hematoma, crepitus Multiple rib fractures, flail chest, pulmonary contusion, widened mediastinum Rebound or guarding of abdomen Laceration of perineum Neurologic deficit Complex or multiple fractures, bony spine injuries Multiple comorbities, pregnancy, burns A 17-year-old male is brought to a 20 bed hospital following a snowmobile crash. Hospital has CT and ultrasound capabilities. VS are SBP 85, HR 120, GCS 15. Patient is breathing shallow. Unstable pelvis and deformity of left thigh. What's priorities of management? Perform primary survey: establish airway, obtain IV access, apply pelvic binder, and begin IVF resuscitation A 54-year-old male arrives to ED at small hospital without surgical capabilities. He was involved in MVC in which he was the driver of a car that Tboned a delivery truck at 55 mph. He has GCS of 8, decreased breath sounds on the left, abdominal tenderness. BP 95/65, HR 110. What are the priorities of management? Establish airway and insert chest tube. Resuscitate and stabilize prior to transporting patient to adequate hospital Identify the responsibilities of a referring physician in a patient transfer situation? Initiating transfer during resuscitation Consult with receiving physician Maintain familiarity with transporting agencies Select appropriate transportation Determine level of care required during transfer Stabilize the patient's confiriotn Provide patient summary Ensure adequate trained personnel accompanying patient Ensure pediatric patients are transferred to facilities with special expertise when available Airway treatments that must be established before transfer Insert airway or ETT with low GCS or the potential to deteriorate Provide suction Place gastric tube in all intubated patients and those with gastric distention Breathing treatments that must be established before transfer Determine rate and administer supplementary oxygen Provide mechanical ventilation when needed Insert chest tube Circulation treatments that must be established before transfer Control external bleeding Establish 2 large bore IVs and begin IVF Restore blood volume using crystalloid fluids and blood Insert indwelling catheter to monitor UOP Monitor cardiac rate and rhythm Transport patients late in pregnancy (tilted to the left side) Restrict spinal motion Disability treatments that must be established before transfer Assist respiration in unconscious patients Administer mannitol or hypertonic saline if needed Restrict spinal motion in spine injuries What should be done about wounds/fractures before transfers? Clean and dress wounds after external control Administer tetanus Administer antibiotics if needed Splint and tract fractures What diagnostic studies should be conducted prior to transfer? X-rays of chest, pelvis, and extremities Blood work Determine cardiac rhythm,, and hemoglobin saturation Transfer template ABC-SBAR Airway, Breathing, Circulation, Situation, Background, Assessment, Recommendation A right thigh deformity is noted and splinted. Distal pulses intact. What additional radiographic tests need to be done? Pevlic x-ray with pelvic binder to any fracture What factors would determine mode of transportation? Distance from referring to accepting facility, weather, availability of ambulance/helicopter, ability to manage intubated patient A 50-year-old male is brought to your facility, which is a small community hospital without surgical services. He was involved in a MVC in which his car sustained significant front-end damage. The patient was not wearing a seatbelt and complains of abdominal pain. He has a GCS of 13. What are the most radiographic studies should the patient have before transfer? CXR, pelvis x-ray, and FAST exam A 50-year-old female involved in a MVC is brought to your facility, a small community hospital with general surgical but no neurosurgical capability. It was reported that there was significant damage to the driver's side of the care with a starred windshield. The patient's GCS of 8, decreased breath sounds on the left, abdominal tenderness. On FAST, she clearly has fluid in her peritoneum. What are the priorities prior to sending this patient to a facility that has neurosurgical capabilities? ETT, chest tube, and exploratory laparotomy Assess basic physiology SBP < 90 RR < 10 or > 29 GCS < 14 Assess anatomy of injury Penetrating injury to head, neck, torso, and extremities Flail chest