ATLS Test Real Exam Questions with 100% Correct Answers Latest Update 2024/2025, Exams of Nursing

Download ATLS Test Real Exam Questions with 100% Correct Answers Latest Update 2024/2025 and more Exams Nursing in PDF only on Docsity! A 22-year-old man is hypotensive and tachycardic a5er a shotgun wound to the le5 shoulder. His blood pressure is ini<ally 80/40 mm Hg. A5er ini<al fluid resuscita<on 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 le5 chest breath sounds with the return of a small amount of blood and no air leak. A5er chest tube inser<on, 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 construc<on worker falls two stories from a building and sustains bilateral calcaneal fractures. In the emergency department, he is alert, vital signs are ATLS TEST REAL EXAM QUESTIONS WITH 100% CORRECT ANSWERS LATEST UPDATE 2024 /2025 |RATED A 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 e. Complete spine x-ray series E) Complete spine x-ray series Which of the following is true regarding the ini<al resuscita<on of a trauma pa<ent? Select one: a. A pa<ent that presents with a torso gunshot wound and is hypotensive should receive crystalloid fluid resuscita<on un<l the blood pressure is normal b. Evidence of improved perfusion a5er fluid resuscita<on could include improvement in Glasgow coma scale score on reevalua<on c. Massive transfusion is defined as transfusion of more than >10 of packed red blood cells and plasma in 24 hours Reducing the volume of crystalloid required for resuscita<on e. Increasing the volume of blood loss to produce maternal hypotension E. Increasing the volume of blood loss to produce maternal hypotension The best assessment of fluid resuscita<on of the adult burn pa<ent is: Select one: a. Urine output of 0.5 ml/kg/hr b. Normaliza<on of blood pressure c. Normaliza<on of the heart rate d. Measuring a normal central venous pressure e. Providing 4 ml/kg/percent body burn/24 hours of crystalloid fluid A. Urine output of 0.5 ml/kg/hr The diagnosis of shock must include: Select one: a. Hypoxemia b. Acidosis c. Hypotension d. Increased vascular resistance e. Evidence of inadequate organ perfusion E. Evidence of inadequate organ perfusion A 7-year-old boy is brought to the emergency department by his parents several minutes a5er 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: Select one: a. Applica<on of a tourniquet 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 <ssue B. Direct pressure on the wound For the pa<ent with severe trauma<c brain injury, profound hypocarbia should be avoided to prevent: Select one: a. Respiratory acidosis b. Metabolic acidosis c. Cerebral vasoconstric<on with diminished perfusion d. Neurogenic pulmonary edema e. Shi5 of the oxyhemoglobin dissocia<on curve C. Cerebral vasoconstric<on with diminished perfusion A5er being involved in a motor vehicle crash, a 25-year-old man is brought to a hospital that has surgery capabili<es available.. Computed tomography of the chest and abdomen shows an aor<c injury and splenic lacera<on with free abdominal fluid. His blood pressure falls to 70 mm Hg a5er CT. The next step is: Select one: a. Obtain contrast angiography b. Transfer to a higher level trauma center c. Perform an exploratory laparotomy d. Infuse addi<onal crystalloid fluids e. Obtain transesophageal echocardiography 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 gesta<on , 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 intuba<on b. Insert an oropharyngeal airway c. Perform needle or finger decompression of the right chest d. Manually displace the gravid uterus to the le5 side of the abdomen e. Ini<ate 2, large-caliber peripheral IV lines and crystalloid infusion C. Perform needle or finger decompression of the right chest An important, immediate step in the management of an open pneumothorax is: Select one: a. Endotracheal intuba<on b. Opera<on to close the wound c. Placing a chest tube through the chest wound d. Placement of an occlusive dressing over the wound secured on three sides e. Ini<a<on of 2, large-caliber ivs and infusing crystalloid solu<on D. Placement of an occlusive dressing over the wound secured on three sides Which of the following is a contraindica<on for tetanus toxoid administra<on? Select one: a. History of neurological reac<on or severe hypersensi<vity to the product b. Local side effects c. Muscular spasms d. Pregnancy e. All of the above A. History of neurological reac<on or severe hypersensi<vity to the product A 56-year-old man is thrown violently against the steering wheel of his truck during a motor vehicle crash. On arrival to the emergency department he is diaphore<c and complaining of chest pain. His blood pressure is 60/40 mm Hg and his respiratory rate is 40 breaths per minute. Which of the following best differen<ates cardiac tamponade from tension pneumothorax as the cause of his hypotension? Select one: a. Tachycardia b. Pulse volume c. Breath sounds d. Pulse pressure e. Jugular venous pressure C. Breath sounds Bronchial intuba<on of the right or le5 mainstem bronchus can easily occur during infant endotracheal intuba<on because: Select one: a. The trachea is rela<vely short. B. The distance from the lips to the larynx is rela<vely short. C. Restrict cervical mo<on and agempt orotracheal intuba<on using 2 people e. Ven<late the pa<ent with a bag-mask device un<l his beard can be shaved for beger mask fit D. Restrict cervical mo<on and agempt orotracheal intuba<on using 2 people A pa<ent is brought to the emergency department a5er 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. Vasoac<ve medica<ons have no role in this pa<ent's management. B. The hypotension should be managed with volume resuscita<on 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 extremi<es and loss of deep tendon reflexes are expected. E. Flaccidity of the lower extremi<es and loss of deep tendon reflexes are expected Which one of the following is the most effec<ve method for ini<ally trea<ng frostbite? Select one: a. Moist heat b. Early amputa<on c. Padding and eleva<on d. Vasodilators and heparin e. Topical applica<on 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, mogled, insensate, and mo<onless. 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 pa<ent, which of the following is most likely to improve the chances for limb salvage? Select one: a. Applying skeletal trac<on b. Administering an<coagulant drugs c. Administering thromboly<c therapy d. Surgical consulta<on for right lower extremity fasciotomy e. Transferring the pa<ent to the trauma center 120 km away D. Surgical consulta<on for right lower extremity fasciotomy A pa<ent arrives in the emergency department a5er 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 ecchymo<c. He has gurgling respira<ons and vomitus on his face and clothing. The most appropriate step a5er providing supplemental oxygen and eleva<ng his jaw is to: Select one: a. Request a CT scan b. Insert a gastric tube c. Suc<on the oropharynx d. Obtain a lateral cervical spine x-ray e. Ven<late the pa<ent with a bag-mask C. Suc<on the oropharynx A 22-year-old man sustains a gunshot wound to the le5 chest and is transported to a small community hospital; no surgical capabili<es are available. In the emergency department, a chest tube is inserted and 700 ml of Which one of the following statements concerning intraosseous infusion is TRUE? Select one: a. Only crystalloid solu<ons may be safely infused through the needle. B. Aspira<on of bone marrow confirms appropriate posi<oning of the needle. C. Intraosseous infusion is the preferred route for volume resuscita<on in small children. D. Intraosseous infusion may be u<lized indefinitely. E. Swelling in the so5 <ssues around the intraosseous site is not a reason to discon<nue infusion. B. Aspira<on of bone marrow confirms appropriate posi<oning 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 ven<lated. Her pupils are 3 mm in size and equally reac<ve 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 osmo<c diure<c c. Aggressively treat systemic hypertension d. Reduce metabolic requirements of the brain e. Dis<nguish 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. Examina<on reveals bilaterally equal breath sounds, anterior chest wall ecchymosis, and distended neck veins. Her abdomen is flat, so5, and not tender. Her pelvis is stable. Palpable distal pulses are found in all 4 extremi<es. Of the following, the most likely diagnosis is: Select one: a. Hemorrhagic shock b. Cardiac tamponade c. Massive hemothorax d. Tension pneumothorax e. Diaphragma<c rupture B. Cardiac tamponade A hemodynamically normal 10-year-old girl is hospitalized for observa<on a5er 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 peritoni<s on physical exam e. A fall in the hemoglobin level from 12 g/dl to 8 g/dl over 24 hours D. Development of peritoni<s 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. Which of the following are true regarding her evalua<on and management? Select one: a. d. Insert urinary catheter e. Repeat examina<on of pelvis A. Placement of a pelvic binder Which situa<on requires Rh immunoglobulin administra<on to an injured female? Select one: a. Nega<ve pregnancy test, Rh nega<ve, and has torso trauma b. Posi<ve pregnancy test, Rh posi<ve, and has torso trauma c. Posi<ve pregnancy test, Rh nega<ve, and has torso trauma d. Posi<ve pregnancy test, Rh posi<ve, and has an isolated wrist fracture e. Posi<ve pregnancy test, Rh nega<ve, and has an isolated wrist fracture C. Posi<ve pregnancy test, Rh nega<ve, and has torso trauma A 22-year-old female athlete is stabbed in her le5 chest at the third interspace in the anterior axillary line. On admission to the ED and 15 minutes a5er the incident, she is awake and alert. Her heart rate is 100 beats per minute, blood pressure is 80/60 mm Hg, and respiratory rate is 20 breaths per minute. A chest x-ray reveals a large le5 hemothorax. A le5 chest tube is placed with an immediate return of 1600 ml of blood. The next management step for this pa<ent is to: Select one: a. Perform a thoracoscopy b. Perform an arch aortogram c. Insert a second le5 chest tube d. Prepare for an exploratory thoracotomy e. Perform a chest CT D. Prepare for an exploratory thoracotomy A 6-year-old boy walking across the street is struck by the front bumper of a sports u<lity vehicle traveling at 32 kph (20 mph). Which one of the following statements is TRUE about this pa<ent? Select one: a. A flail chest is probable. B. A symptoma<c blunt cardiac injury is expected. C. A pulmonary contusion may be present in the absence of rib fractures. D. Transec<on of the thoracic aorta is more likely than in an adult pa<ent. 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 When something crashes in secondary survey, you... GO BACK TO PRIAMRY SURVEY If the ques<on says you do not have capabili<es, you will most likely PREPARE FOR AND DO NOT DELAY TRANSPORT How much blood can femur lose 2L What is always going to be the shock type to pick Hemorrhagic What are the classes of hemorrhagic shock 0-15% is class 1 15-30 is class 2 30-40% is class 3 >40% is class 4 What is the EARLIEST predictor of shock at what class Narrowed pulse pressure in class 2 What will be base deficit for class 2 shock? -2 to -6 meq What will be the deficit for class 4? -10 or less When will urine output start to decrease in shock? Class 3 and 4 When does BP start to fall in shock Class 3 How do you determine difference between PTX and tamponade? BREATH SOUNDS Blowing air leak on chest tube is sign of? TRACHEOBRONCHIAL RUPTURE Bowel sounds on chest ausculta<on are reflec<ve of Diaphragm injury Apical capping and widened medias<num are reflec<ve of what? Aor<c trauma Circumferen<al burn? Escharotomy What is main goal of priamry brain injury? Preven<ng secondary brain injury 2 big causes of secondary brain injury? HYPOVOLEMIA and HYPOXEMIA Girl falls on her head, loses consciousness, and is now unstable. What kind of hematoma is this? EPIDURAL, lucid interval is common between <me of injury and presenta<on What is more common, subdural or epidural Subdural What is considered mid TBI? 13-15 T/o secondary management of mild TBI? CT repeat if first is abnormal OR GCS persists at under 15. Serial exams Ini<al management of TBI? Elevate head NS (3%) Indica<ons of transport to higher Level of care with TBI? Worsening GCS, GCS <8. Lesions on CT Above what level can you get neurogenic shock T6 Descrip<on of neurogenic shock pa<ent? What is bulbovesicular reflex indica<ve of? NOT qualify as sacral sparing. If there is ANY motor or sensory func<on below level of injury, cons<tutes as incomplete injury and should be documented appropriately T/F: Stridor is LATE finding of airway damage in burn pt? TRUE Ini<al management of burn? DRY dressing. NOT moist! Transfer indica<ons for burn? Par<al thickness >40% BSA What is dark urine reflec<ve of in burn pt? RHABDO What do you constantly need to replenish burn pt? Cellular losses 2/2 inflamma<on What is GOAL urine output in burn? 3-50ml per hour, BEST assessment of hydra<on What do you need to monitor for with rewarming in hypothermia ARRYTHMIA MCC of cardiac arrest in kids? HYPOXIA If you fail an IV in a kid what is next step? IO What is crystalloid infusion unit for kids 20/kg Two MCC of geriatric injuries? FALL, MVC True or false? Although the mechanism of injury may be similar to those for the younger popula<on, data shows increased mortality with similar severity of injury in older adults. True In the elderly popula<on, what is decreased physiological reserve? Aging is characterized by impaired adap<ve and homeosta<c mechanisms that caused an increased suscep<bility to the stress of injury. Insults tolerated by the younger popula<on can lead to devasta<ng results in elderly pa<ents. Pre-exis<ng condi<ons 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 popula<on, what are risk factors for falls? Advanced age, physical impairment, history of previous fall, medica<on use, demen<a, unsteady gait, and visual, cogni<ve impairment Most of elderly traffic fatali<es occur in the day<me 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 reac<on <me, a larger blind spot, limited cervical mobility, decreased hearing, and cogni<ve impairment. truly reflect a hypotensive state. A systolic BP of 110 is to be u<lized as the threshold for iden<fying hypotension in pa<ents 65 and older. Do no equate blood pressure with shock in older pa<ents BP in older pa<ents may look normal due to the medica<ons they are on. Use lactate and base deficit to evaluate for evidence of shock What 2 factors place elderly pa<ents at risk for intracranial hemorrhage? Aging causes dura to become more adherent to the skull increasing risk of injury and older pa<ents are on an<coagulant and an<platelet medica<ons. Loss of subcutaneous fat, nutri<onal deficiencies, chronic medical condi<ons place elderly pa<ents as risk for hypothermia and complica<ons for immobility. Rapid evalua<on and when possible early libera<on from spine boards and cervical collars will minimize complica<ons. True or False: Fall preven<on is the mainstay of reducing the mortality associated with pelvic fractures. True Poor hygiene, dehydra<on, oral injury, contusions affec<ng the inner arms, inner thighs, palms, soles, scalp, ear, nasal bridge and temple injury from being struck while wearing glasses, contact burns and scalds. These are all signs of.......? Elder maltreatment. The presence of physical findings of maltreatment should prompt a detailed history. If history conflicts with findings, immediately report findings to authori<es. True of false: early ac<va<on of the trauma team may be required for elderly pa<ents who do not meet tradi<onal criteria for ac<va<on True. A simple injury such as an open <bia fracture in a frail elderly pa<ent may become life threatening. Common mechanisms of injury include falls, MVC, burns, and penetra<ng injuries Common injuries in the elderly include rib fractures, TBI, pelvic fractures The best ini<al treatment for the fetus is to provide op<mal resuscita<on of the mother. True or False? True. Also if xray examina<on is indicated during the pregnant pa<ent's treatment, it should not be withheld because of the pregnancy. What happens as the uterus enlarged and the bowel is pushed cephalad. When the uterus enlarges it pushes the bowel cephalad and the uterus lies in the upper abdomen. As a result, the bowel is somewhat protected from blunt abdominal trauma, whereas the uterus and its contents (fetus and placenta) become more vulnerable. Uterus remains intrapelvic un<l 12 weeks and then at 20 weeks it is at the umbilicus, and at 34-36 weeks it reaches the costal margin. Amnio<c fluid can cause amnio<c fluid embolism and disseminated intravascular coagula<on following trauma if fluid enters maternal intravascular space. True or False True By the third trimester, what is the complica<on of trauma to the pelvis of the mother? By the third trimester, the uterus is large and thin walled. In vertex presenta<on, fetal head is usually in the pelvis and the remainder of the fetus is exposed above the pelvic brim. Pelvic fractures in late gesta<on can result in skull fracture or intracranial injury to the fetus. Also we can have a placental abrup<on due to its ligle elas<city and vulnerability to sheer forces. An abrupt decrease in maternal intravascular volume can result in a profound increase in uterine vascular resistance reducing fetal oxygena<on despite reasonably normal maternal vital signs. This is true Physiological anemia of pregnancy A smaller increase in red blood cell volume can occur resul<ng in a decreased hematocrit level. Thus, in late pregnancy a hematocrit of 31-33% is normal. Healthy pregnancy pa<ents can lose 1200-1500 ml of blood before exhibi<ng 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 cloung factors are mildly elevated and PT and pg are shortened, but bleeding <me and cloung <me are unchanged. A5er 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 pa<ent's cardiac output during the 3rd trimester. In supine posi<on, vena cava compression can decrease cardiac output by 30% because of decreased venous return from lower extremi<es. 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 interpre<ng 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. injury to other viscera. However, fetal outcome is generally poor with penetra<ng injury to uterus. Carefully observe pregnant pa<ents with even minor injuries since occasionally minor injuries are associated with placental abrup<on and fetal loss. True. AND to op<mize outcomes for mother and baby, clinicians must assess and resuscitate the mother first and then assess the fetus before conduc<ng second survey of the mother. Failure to displace the uterus to the le5 side in a hypotensive pregnant pa<ent Logroll all pa<ents appearing clinically pregnant (second and third trimester) to the le5 15-30 degrees and elevate the right side 4-6 inches and support with a bolstering device to maintain spinal mo<on restric<on and decompression of the vena cava. Due to increases intravascular volume, pregnant pa<ents 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 pa<ent indicate about the fetus? The fetus may be in distress and the placenta deprived of vital perfusion while the mother's condi<on and vital signs appear stable. Administer crystalloid fluid resuscita<on and blood to support the physiological hypervolemia of pregnancy. Vasopressers should be an absolute last resort in restoring maternal blood pressure as they further reduce uterine blood flow, resul<ng in fetal hypoxia. What does a normal fibrinogen level indicate in a pregnant pa<ent? Fibrinogen level may double in late pregnancy and a normal level may indicate early disseminated intravascular coagula<on Most common cause of fetal death? Maternal shock and maternal death. Placental abrup<on is second. Placental abrup<on is suggested by vaginal bleeding, uterine tenderness, frequent uterine contrac<ons, uterine tetany, and uterine irritability (uterus contracts when touched). In 30% of cases of abrup<on, bleeding may not occur. Uterine ultrasound may be helpful in diagnosis, but is NOT defini<ve. Signs of uterine rupture Abdominal tenderness, guarding, rigidity, or rebound tenderness. Signs of peritoni<s are hard to tell due to expansion and agenua<on of the abdominal wall musculature. Other findings include abdominal fetal lie (oblique or transverse lie), easy palpa<on of the fetal parts because of their extrauterine loca<on and inability to readily palpate the uterine fundus when there is fundal rupture. Xray evidence of rupture include extended fetal extremi<es, abnormal fetal posi<on, and free intraperitoneal air. Perform con<nuous fetal monitoring with a tocodynamometer beyond 20-24 weeks of gesta<on. Pa<ents with no risk factors for fetal loss should have con<nuous monitoring for 6 hours, whereas, pa<ents with risk factors for fetal loss or placental abrup<on should be monitored for 24 hours. RISK FACTORS ARE: heart rate > 110, an injury severity score >9, evidence of placental abrup<on, fetal heart rate >160 or less than 120, ejec<on during MV, and motorcycle or pedestrian collisions REMEMBER: maternal bicarbonate is low during pregnancy to compensate for respiratory alkalosis. 17-22 in pregnant pa<ent. (non pregnant pa<ent is 22-28) Fetal heart rate is a sensi<ve indicator of maternal blood volume status and fetal well being. Normal range for fetus is 120-160. Abnormal heart rate, repe<<ve decelera<ons, absence of accelera<ons or beat to beat variability and frequent uterine ac<vity can be signs of impending maternal and or fetal decompensa<on (hypoxia or acidosis) and should prompt immediate obstetrical consulta<on. If a DPL is to be placed in a pregnant trauma pa<ent, place the catheter above the umbilicus using the open technique. Be alert to uterine contrac<ons which suggest early labor and tetanic contrac<ons which suggest placental abrup<on. Evidence of ruptured chorioamnio<c membranes include amnio<c fluid in vagina evidenced by a ph of 4.5 Bleeding in 3rd trimester may indicate placental abrup<on and impending death of the fetus, a vaginal exam is vital However, avoid repea<ng vaginal examina<on, CT abdominal imaging can be done and radia<on doses less than 50mgy are not associated with fetal anomalies or higher risk of fetal loss. Admission to hospital for pregnant pa<ents: Vaginal bleeding, uterine irritability, abdominal tenderness, pain or cramping, evidence of hypovolemia, changes in or absence of fetal heart tones and or leakage of amnio<c fluid With extensive placental separa<on or amnio<c fluid emboliza<on, widespread consump<ve coagulopathy can emerge rapidly causing deple<on of fibrinogen, other cloung factors, and platelets. Immediately perform uterine evacua<on and replace platelets, fibrinogen, and other cloung factors. As ligle as 0.01ml of RH+ blood will sensi<ze 70% of Rh- women. Measurements of arterial pao2 do not reliably predict CO poisoning b/c a par<al 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 dis<nguish oxyhemoglobin from carboxyhemoglobin. A discrepancy between pulse ox and arterial blood gas may be explained by presence of carboxyhemoglobin. Cyanide inhala<on poisoning can occur in confined spaces and sign of poten<al toxicity is persistent profound unexplained metabolic acidosis. THERE IS NO ROLE for hyperbaric oxygen therapy in the primary resuscita<on of a pa<ent with cri<cal burn injury. American Burn Associa<on states 2 requirements for diagnosis of smoke inhala<on injury: 1. Exposure to combus<ble 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 pa<ent with smoke inhala<on injury, but normal values on admission DO NOT exclude an inhala<on injury. The treatment of smoke inhala<on injury is suppor<ve. Any pa<ent with smoke inhala<on injury and significant burns greater than 20% TBSA should be intubated. IF the pa<ent's hemodynamic condi<on permits and spinal injury has been excluded, elevate the pa<ent's head and chest 30 degrees to help reduce neck and chest wall edema. True or false: Clinicians should provide burn resuscita<on fluids for deep par<al 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 resuscita<on In a burn pa<ent, cardiac dysrhytmias may be the first sign of hypoxia and electrolyte or acid base abnormali<es. Therefore an ECG should be performed for cardiac rhythm disturbances. Persistent acidemia in pa<ents with burn injuries may be due to under resuscita<on or infusion of large volumes of saline. Tachycardia is a poor indica<on for resuscita<on in the burn pa<ent. Adjust the fluid rate up or down based on the urine output and recognize that factors such as inhala<on injury, age of pa<ent, renal failure, diure<cs, and alcohol can affect the volume of resuscita<on and urine output. True of false: Burn pa<ents should get tetanus. True Par<al thickness burns Are characterized as either superficial par<al thickness (moist, painfully hypersensi<ve, , poten<ally blistered, homogenously pink, and blanch to touch) or deep par<al thickness ( drier, less painful, poten<ally blistered, red or mogled 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 pa<ents: 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 condi<on results from a combina<on of decreased skin elas<city and increased edema in the so5 <ssue. 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 propor<on to the injury pain on passive stretch of the affected muscle tense swelling of the affected compartment paresthesias or altered sensa<on distal to the affected compartment Compartment syndrome may be present with circumferen<al chest and abdominal burns Chest and abdominal escharotomies performed along the anterior axillary lines with cross incision at the clavicular line and the junc<on of the thorax and abdomen usually relieve this problem. Relieve circulatory compromise in a circumferen<ally burned limb by eschartomy and these escharo<mies are not needed within the first 6 hours. Par<al thickness burns are painful when air currents pass over the burned surface. Gently cover the burn with clean sheets will decrease the pain and deflect air currents. Do not break blisters or apply an an<sep<c and applica<on of cold compress can cause hypothermia. DO not apply cold water to a burn pa<ent. Electrical burns are more serious than they appear on the body surface and extremi<es, par<cularly the digits. Current can travel inside blood vessels and nerves and can cause local thrombosis and nerve injury. So a severe electrical injury usually results in contracture of the affected extremity. A clenched hand with a small electrical entrance wound should alert the clinician that a deep so5 <ssue injury is likely much more extensive than is visable to the naked eye Opera<ve revasculariza<on 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 splin<ng the injured extremity. This maneuver can restore the blood flow High risk ac<vi<es 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 <mes 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 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 <ssue or denervated wounds True or false? On page 162. To exclude occult disloca<on and concomitant injury, x ray films must include the joints above and below the suspected fracture site True. Unless life threatening, splin<ng of extremity injuries should be done during the secondary survey. Do not apply trac<on to pa<ents with an ipsilateral <bia sha5 fracture. True Laryngeal Trauma presents as hoarseness, subcutaneous emphysema, and palpable fracture True. Sounds of airway obstruc<on and include snoring, gurgling, stridor, hoarseness, cyanosis, agita<on LEMON assessment for difficult airway Look, evaluate 3-3-2 rule, mallampa<, obstruc<on, neck mobility Do not give a nasopharyngeal airway to someone suspected of having a cribriform plate fracture. Also do not give nasotracheal intuba<on to pa<ents 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 ven<la<on and airway secured in place. Defini<ve airway Pa<ents use the gum elas<c bougie when vocal cords cannot be visualized on direct laryngoscopy. Using the GEB has allowed for rapid intuba<on of nearly 80% of prehospital pa<ents in whom laryngoscopy was difficult. A GEB inserted into the esophagus will pass its full length without resistance Reliable ways to detect proper intuba<on Proper placement of the tube is suggested but not confirmed: 1. Hearing equal breath sounds bilaterally 2. Detec<ng no borborygmi (rumbling or gurgling noises) in the epigastrium. The presence of this with inspira<on sugges<on esophageal intuba<on 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 intuba<on has occurred. 4. Proper posi<on of the tube is best confirmed via chest xray Defini<ve control of hemorrhage and restora<on of adequate circula<ng volume are the goals of trea<ng hemorrhagic shock. Never give vasopressors as the first line treatment as they worsen <ssue perfusion. Most injured pa<ents who are in hemorrhagic shock require early surgical interven<on or angioemboliza<on to reverse the shock state. The presence of shock in a trauma pa<ent warrants the immediate involvement of a surgeon. An injured pa<ent who is cool to the touch and is tachycardic should be considered to be in shock un<l 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 recogni<on of the condi<on b/c compensatory mechanisms can prevent measurable fall in systolic pressure un<l up to 30% of the pa<ent's blood volume is loss. A Massive fluid resuscita<on with the resultant dilu<on of platelets and cloung factors (severe hemorrhage and injury results in consump<on of coagula<on factors and early coagulopathy) contributes to coagulopathy in injured pa<ents. The response of elderly pa<ents, athletes, pregnant pa<ents, pa<ents on medica<ons, hypothermic pa<ents, and pa<ents with pacemakers or implantable devices may have different set of vitals in response to shock. Older pa<ents are unable to increase their HR when stressed by blood volume loss. A systolic BP of 100 may represent shock in an elderly pa<ent. Due to medica<ons, HR may not increase in the elderly popula<on when in shock. Blood volumes may increase 15-20% in athletes, cardiac output can increase 6 fold and the rest HR can be 50. Trained athletes have a remarkable ability to compensate for blood loss and they may not manifest the usual way to hypovolemia, even with significant blood loss. Pa<ents suffering from hypothermia and hemorrhagic shock do not respond as expected to the administra<on of blood products and fluid resuscita<on. IN hypothermia, coagulopathy may develop and worsen. When a pa<ent fails to respond to fluid therapy one or more of these causes may be: tension pneumothorax, cardiac tamponade, undiagnosed bleeding, unrecognized fluid loss, acute gastric disten<on, MI, diabe<c acidosis, neurogenic shock Tracheobronchial injury will present with hemoptysis, cervical subcutaenous emphysema, tension pneumothorax, and/or cyanosis. A bronchoscopy can confirm the diagnosis, but these pa<ents require immediate surgical consulta<on. Intuba<on of these pa<ents may be difficult, so they may need fiber op<c assisted ET What are these signs and symptoms describing? Chest pain, air hunger, tachypnea, respiratory distress, tachycardia, hypotension, tracheal devia<on away from side of injury, unilateral absence of breath sounds, neck vein disten<on, cyanosis (late manifesta<on), hyperresonance on percussion Tension pneumothorax. Ini<ally, you can do a needle decompression or finger thoracostomy. Place tube in a5erwards 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 Ac<vity Hypovolemia, hypokalemia, hyperkalemia, hypoglycemia, hypothermia, toxins, cardiac tamponade, tension pneumothorax, thrombosis Massive hemothorax is suggested when a pa<ent 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 fi5h intercostal space at the midaxillary line and you get a return of 1500ml or 1/3 or more of the pa<ent's blood in the chest, that indicated the need for urgent thoracotomy. Persistent need for blood is an indica<on 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 inspira<on 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 iden<fy cardiac tamponade. If FAST is unavailable, use echo or pericardial window. Defini<ve treatment is surgery so thoracotomy or sternotomy. Poten<ally life threatening injuries that should be iden<fied on secondary survey Simple pneumothorax, hemothorax, flail chest, pulmonary contusion, blunt cardiac injury, trauma<c aor<c disrup<on, trauma<c diaphragma<c injury, esophageal rupture Pulmonary contusion can occur with rib fractures and flail chest (two or more adjacent ribs fractured in two or more places). Ini<al treatment includes humidified oxygen, adequate ven<la<on, and cau<ous fluid resuscita<on. Defini<ve treatment includes pain control, adequate oxygena<on Blunt cardiac injury can present with hypotension, dysrhythmias, EKG changes, premature ventricular contrac<ons, unexplained sinus tachycardia, afib, bundle branch block, elevated central venous pressure without any obvious cause may indicate right ventricular dysfunc<on secondary to contusion. Cardiac troponins can be diagnos<c in an MI but have ligle role in diagnosing blunt cardiac injury. Pa<ents with a blunt injury to the heart diagnosed by conduc<on abnormali<es are at increased risk for sudden dysrhythmias and need to be monitored for 24 hours. Trauma<c aor<c disrup<on- most survive if they have an incomplete lacera<on near the ligmentum arteriosum. Commonly caused by vehicle collision or fall from a great height. Have a high index of suspicion if history has decelera<ng force. Look for widened medias<num on chest xray, oblitera<on of the aor<c knob, devia<on of the trachea to the right, depression of the L mainstem bronchus, eleva<on of R mainstem bronchus, devia<on of the esophagus to the right, le5 Blunt abdominal trauma with hypotension, posi<ve FAST hypotension with an abdominal wound that penetrates anterior fascia gunshot wounds that traverse the peritoneal cavity eviscera<on bleeding from stomach, rectum, or GU tract peritoni<s free air of hemidiaphragm contrast CT showing rupture GI tract, bladder injury Aspira<on of gastrointes<nal contents, vegetable fibers, or bile through the lavage mandate laparotomy. Aspira<on of 10cc or more of blood in hemodynamically abnormal pa<ents requires laparotomy. Diaphragm injuries Eleva<on or blurring of the hemidiaphragm, hemothorax, an abnormal gas shadow that obscures the hemidiaphragm, or a gastric tube in the chest Duodenal injuries- a bloody gastric aspirate or retroperitoneal air on abdominal CT or radiograph should raise suspicion Classically seen in unrestrained drives involved in frontal-impact MVC and pa<ents who sustain direct blows to the abdomen from bicycle handlebars. Any early normal serum amylase level or an elevated amylase level does not conclude pancreas injury Uncal herina<on Ipsilateral pupillary dila<on associated w/contralateral hemiparesis and loss of pupillary response to light ICP Normal is 10. > 22 has poor outcomes. Increased ICP decreases cerebral perfusion pressure. Monroe kellie doctrine states that total volume of intracranial contents must remain constant because cranium is a rigid container incapable of expanding. CPP= MAP -ICP A MAP of 50-150 is autoregulated to maintain a constant cerebral blood flow. GCS of 8 or less= severe brain injury GCS of 9-12= moderate GCS of 13-15= mild Indica<ons for CT scanning GCS < 15 at 2 hours a5er injury suspected open or depressed skull fracture any sign of basilar skull fracture emesis more than 2 episodes age > 65 an<coagulant use LOC > 5 minutes amnesia before impact Goals of treatment of brain injury Systolic BP > 100 temp 36-38 Glucose 80-180 Hgb > 7 paco2 35-45 ICP 5-15 pulse ox > 95 NA 135-145 TBI treatment IV fluids & hypertonic saline (do not give hypotonic fluids or glucose containing fluids because this can harm the injured brain) Avoid hyponatremia reversal of an<coagulants Hyperven<la<on to keep paco2 at 35-temporizing measure Mannitol-do not give to pa<ents with hypotension Reversal agents: Aspirin/plavix: platelets warfarin: FFP, vitamin K, Prothrombin Complex Heparin or LMWH: Protamine Sulfate Direct thrombin inhibitors: Idarucizumab Rivaroxaban: N/A Neurogenic shock Loss of vasomotor tone and sympathe<c innerva<on to the heart. Injury T6 and above can cause impairment of the sympathe<c pathways. We get hypotension and bradycardia. Neurogenic shock is not reversed with fluid resuscita<on alone. Vasopressors may be required. Spinal shock refers to the loss of muscle tone (flaccid) and reflexes immediately a5er injury Central cord syndrome