Blunt and Penetrating Abdominal Trauma, Exams of Nursing

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TCRN Review - Trunk What is a collection of excess fluid between the visceral pericardium and the parietal pericardium? - Answer -Pericardial Tamponade What are the classic signs and symptoms of a pericardial tamponade? - Answer -Beck's Triad What are the 3 findings in Beck's Triad? - Answer -Muffled heart tones Systemic Hypotension Distended Neck Veins (may not be present with hypovolemia) What are the cardiovascular effects of Pericardial Tamponade? - Answer -Elevated CVP Narrowed Pulse Pressure Rapidly falling cardiac output Tachycardia Pulsus alternans Blunting of the QRS complex Pulseless Electrical Activity Pulsus paradoxus or paradoxical pulse What is Pulsus Alternans? - Answer -Alternating morphology of the QRS complex What is pulsus paradoxus or paradoxical pulse? - Answer -A change of more than 10 mmHg in arterial pressure during inspiration How is pulsus paradoxus or paradoxical pulse found? - Answer -Usually seen as a decreased amplitude on the arterial waveform, but may also be palpated as a reduction in the strength of the radial pulse during inspiration. What are the non-cardiac indications of a pericardial tamponade? - Answer -Grey, death-like appearance Extreme anxiety Inability to lie supine Dyspnea Cyanosis How is pericardial tamponade diagnosed? - Answer -Clinically or via FAST exam What is the treatment for pericardial tamponade? - Answer -Pericardiocentesis Observe monitor for ventricular irritation during insertion How do you determine if blood aspirated from a pericardiocentesis is pericardial blood or ventricular blood? - Answer -Pericardial blood WILL NOT clot Ventricular blood WILL clot In blunt cardiac injury, what part of the heart is most likely to be injured? - Answer -Right ventricle (anterior chest) Blunt cardiac injury is frequently associated with _____ and _____. - Answer -External chest wall trauma Fractures of the sternum or ribs overlying the heart What are the symptoms of blunt cardiac injury? - Answer -Electrical disturbances Chest Pain Describe fractures of upper ribs (1st and 2nd). - Answer -Protected by surrounding tissue and requires great force to fracture. Fractures of 1st and 2nd ribs are usually associated with what other injuries? - Answer -Lungs, trachea, aortic arch, great vessels, vertebral column Describe fractures of ribs 3 through 9. - Answer -Challenges include pain management, ineffective ventilation and secretion retention. What injures are frequently associated with fractures of ribs 3 through 9? - Answer -Pulmonary contusions Pneumothorax What injuries are commonly associated with sternum fractures? - Answer -Blunt cardiac injury and great vessel injury What injuries are commonly associated with left sided ribs 9-12 fractures? - Answer -Pulmonary injury, splenic injury, left kidney injury What injuries are commonly associated with right sided ribs 9-12 fractures? - Answer -Pulmonary injury, liver injury, right kidney injury Define a flail chest segment - Answer -Three or more rib fractures in two or more locations causing a free floating segment of the rib cage Define paradoxical chest wall movement. - Answer -Sinking of the flail segment during inspiration when the remainder of the chest bulges; bulging of the flail segment during exhalation when the remainder of the chest sinks. List some common symptoms of flail chest. - Answer -Paradoxical chest wall movement Decreased tidal volume Increased respiratory effort Verying degrees of hypoxia What types of pain management are used in flail chest? - Answer -IV analgesia Epidural anesthesia (for 3 or more rib fractures) Intercostal nerve block Intrapleural anesthesia TENS List the treatments for flail chest. - Answer -Pain management Judicious use of crystalloids (goal of euvolemia) Appropriate ventilator support (adjusted to insure normal blood gases, pulse ox and respiratory effort) Aggressive chest physiotherapy (postural drainage, percussion, vibration) Suctioning Early mobilization Position to insure optimal ventilation, oxygenation and chest wall stability What should be considered with rib fractures in children? - Answer -Rib fractures in children are often associated with abuse What should be considered with rib fractures in the older population? - Answer -Rib fractures occur frequently in the elderly and often lead to respiratory complications, therefore, admission with aggressive pain control may be necessary. After trauma, symptoms of pulmonary contusions evolve when? - Answer -6-48 hours after the trauma List the symptoms of pulmonary contusions - Answer -Reduction of PaO2 (below 60 mmHg on room air) Signs of respiratory distress (increased HR and RR) Pleuritic chest pain Crackles on auscultation Severe hypoxemia and respiratory acidosis Cough/inability to clear secretions Local areas of wheezing Increasing plateau pressures What are the treatment goals of pulmonary contusions? - Answer -Pain relief Maintain euvolemia Adequate respiratory gas exchange (application of oxygen and non-invasive or invasive ventilation if needed) What are the long term treatments for pulmonary contusions? - Answer -Mobilize and clear blood and secretions (chest physiotherapy, postural drainage, mobilization) What is the term for excess air in the pleural space? - Answer -Pneumotherax What are the sources of pneumothorax and their frequency? - Answer -Pulmonary laceration (71%) Tracheobronchial Injury (13%) Esophagus (7%) External wound or open pneumothorax (7%) What are the symptoms of an open pneumothorax? - Answer -Sucking sound on inhalation Bubbling on exhalation May cause subcutaneous emphysema Emergent treatment is a three-sided occlusive dressing What are the symptoms of a tension pneumothorax? - Answer -Severe respiratory distress Significantly diminished or absent breath sounds on the affected side Signs of obstructive shock What are the treatments for a patient with indications of instability in a hemothorax? - Answer -Support oxygenation/ventilation Chest Tube Placement Consider Thoracotomy Treat hypovolemic shock Blood loss replacement / autotransfusion List the factors of care for the chest drainage set. - Answer -Maintain the drainage set below the level of the chest. Keep the unit upright Prevent dependent loops Describe bubbling in a patent system. - Answer -Bubbling should be noted in the suction control chamber with intermittent bubbling in the water seal chamber. There should be no bubbling in the collection chamber. If the fluctuation or bubbling in the water seal chamber suddenly ceases, what are the likely causes? - Answer -Tubing is kinked Obstruction (clot in the tubing) Pneumothorax has re-expanded What is the pneumonic FOCA and what is it used for? - Answer -FOCA is used for problem solving for chest tubes. F - presnece of fluctuation O - Output C - Color A - Presence of Air Leak Chest Tube drainage of more than 1000 mL initially or 200 mL/hour over 2-4 hours will likely need _____. - Answer -Thoracotomy Sudden increase in bright red blood may indicate _____. - Answer -New arterial bleeding Continuous bubbling noted in water seal chamber is indicative of _____. - Answer -Presence of air leak What are the possible causes of a chest tube air leak? - Answer -Expected in an unexpanded lung Check for air leak at insertion site Check for hole in tubing Change out the chest drainage set Consider large internal leak What is ARDS? - Answer -Acute Respiratory Distress Syndrome: non-cardiogenic pulmonary edema What are the symptoms of ARDS? - Answer -Hypoxemia Non-cardiogenic pulmonary edema Pulmonary hypertension Intrapulmonary shunting ARDS mneumonic symptoms: - Answer -A - Acute in onset R - Ratio of PaO2 to FiO2 (P/F ratio) less than 20 regardless of PEEP D - Diffuse bilateral pulmonary infiltrates on CXR S - Swan-Ganz pulmonary artery wedge pressure less than 18 mmHg or no clinical evidence of left atrial hypertension Describe ARDS related to the PF ratio. (PaO2 to FiO2). - Answer -Healthy adult: >400 Mild ARDS: 200-300 Moderate ARDS: 100-200 Severe ARDS: < 100 List the risk factors for ARDS: - Answer -Occurs more frequently in patients with any type of shock Multi-system trauma with extensive tissue destruction Pulmonary contusion Multiple orthopedic injuries (especially pelvic or long bone fractures) Massive transfusions Thoracic trauma Bacterial Pneumonia Sepsis Near-Drowning Gastric aspiration Major head injuries What are some physiological symptoms of impending insufficiency in ARDS? - Answer -Physical assessment normal initially Dyspnea (although relatively normal PaO2) Decreased PaCO2 and respiratory alkalosis CXR may be normal In ARDS, impending insufficiency usually leads to clinical insufficiency which includes symptoms like_____. - Answer -Usually starts within 24 hours Markedly decreased oxygenation Significant dyspnea Hyperdynamic state with elevated Cl Patchy infiltrates on CXR Physiological deadspace increases High levels of PEEP required for oxygenation What are the late symptoms of ARDS? - Answer -Frequently irreversible with fibrosis, atelectasis and recurrent pneumonia Hypoxemia is refractory to increased oxygenation _____% of gunshot wounds penetrate the peritoneum. - Answer -85% _____% of gunshot wounds result in significant abdominal trauma. - Answer -68-94% Penetration below the nipple line may cause _____. - Answer -Abdominal or chest trauma or both _____ carries a higher rate of infection than other penetrating trauma. - Answer -Impalement Shoulder restraints cause _____ in the driver and _____ in the passenger. - Answer -Right-sided rib fractures with underlying visceral trauma Left-sided rib fractures Underarm usage of shoulder restraints _____. - Answer -Increases abdominal compressive forces, especially in front-end crashes. What is the term for contusions or bruising along the lower abdomen from the lap belt? - Answer -Seat- Belt Sign 33% of patients with seat-belt sign will have _____. - Answer -Associated small bowel injury Mesenteric tears Fractures of the lumbar spine Accuracy of abdominal assessment may be diminished with: - Answer -distracting injuries spinal cord injuries neuropathies from diabetes alcohol or drug use head injuries psychiatric problems In the exam of a patient with abdominal trauma, nausea and vomiting are suspect for what injuries? - Answer -Peritoneal irritation, hypovolemia and obstructions In the exam of a patient with abdominal trauma, dyspnea is suspect for what injuries? - Answer -Gastric distension, diaphragmatic irritation, or diaphragmatic tear with visceral herniation In the exam of a patient with abdominal trauma, a distended abdomen is suspect for what injuries? - Answer -pneumoperitoneum, gastric dilation, ileus and hemoperitoneum In the exam of a patient with abdominal trauma, brusising in the flanks or around the umbilicus is suspect for what injuries? - Answer -Retroperitoneal injuries (delayed by 12 hours or more) In the exam of a patient with abdominal trauma, decreased bowel sounds are suspect for what injuries? - Answer -Fluid or blood irritating the peritoneum, ileus from spinal cord injury, or peritonitis In the exam of a patient with abdominal trauma, RUQ tenderness is suspect for what injuries? - Answer - Liver, gallbladder, duodenum injuries In the exam of a patient with abdominal trauma, LUQ tenderness is suspect for what injuries? - Answer - Spleen, Stomach or pancreatic trauma In the exam of a patient with abdominal trauma, lower abdominal tenderness is suspect for what injuries? - Answer -Colonic, bladder or urethral injuries In the exam of a patient with abdominal trauma, rebound tenderness is suspect for what injuries? - Answer -Blood in the peritoneum, chemical peritonitis (leakage of gastric contents) enzyme spillage (from pancreas) or bacterial contaminants from bowel contents In the exam of a patient with abdominal trauma, dullness over hollow organs is suspect for what injuries? - Answer -Free fluid in the perineum, solid mass In the exam of a patient with abdominal trauma, hyper-resonance over solid organs is suspect for what injuries? - Answer -Free air in the abdomen or rupture of a hollow organ In the exam of a patient with abdominal trauma, fixed areas of dullness is suspect for what injuries? - Answer -Bleeding from a specific organ (dullness in the LUQ caused by splenic bleeding) In the exam of a patient with abdominal trauma, dullness that does not change position is suspect for what injuries? - Answer -Retroperitoneal hematoma Focused Abdominal Sonography for Trauma is _____. - Answer -a FAST exam Name 4 things a FAST exam can be used to detect. - Answer -Hemoperitoneum (as little as 100 mL of blood) Pericardial Fluid Pneumothorax Hemothorax List two drawbacks of the FAST exam. - Answer -It does not identify or grade solid organ injury It has lower accuracy for retroperitoneal bleeding and for small bowel or diaphragm injuries _____ or _____ is rarely used today because of other diagnostic options, but remains 95% accurate for hemoperitoneum. - Answer -Diagnostic Peritoneal Aspiration (DPA) or Diagnostic Peritoneal Lavage (DPL) What should be placed prior to performing a DPL? - Answer -Catheter and Gastric Tubes Discuss the procedure of DPL. - Answer -Aspiration of 10mL or more of blood, bile, food particles or GI contents is an indication for laparotomy. If DPL is negative, instill one liter of crystalloid into the abdomen and drain, send to lab for analysis. List the symptoms of abdominal trauma that are an indication for surgical intervention. (8) - Answer - Signs of hypovolemia with persistent hypotension in a patient for whom there is no other reasonable explanation for blood loss, or intra-abdominal injury is strongly suspected. Ongoing hemodynamic instability To measure APP: - Answer -Subtract the patient's IAP (intra-abdominal pressure) from their MAP (mean arterial pressure) APP = MAP-IAP Ideally, APP should always be above _____. - Answer -50 mmHg What are the treatments for abdominal compartment syndrome? - Answer -Avoid elevating HOB Maintain MAP but avoid over-resuscitation (especially with isotonic crystalloids) Consider diuresis Percutaneous catheter decompression for patients with intraperitoneal fluid, abscess or blood Bedside or operative decompression Describe the symptoms of pain in peritonitis. - Answer -Diffuse, Guarding, Rebound Tenderness, Worse with movement or pain, Relieved by flexion of the knees, positive Markle test Describe a Markle Test. - Answer -Have a patient stand on their tiptoes and drop onto their heels. This will elicit abdominal pain in the patient with peritonitis. In the stretcher patient, strike the bottom of the heel with a fist. If this maneuver elicits abdominal pain, it is a possible indication of peritonitis. What are the symptoms of peritonitis? - Answer -Pain Rigid washboard abdomen Fluid shifting with dehydration, electrolyte imbalances and respiratory difficulties What is the treatment for peritonitis? - Answer -Aggressive fluid resuscitation Correction of electrolyte and coagulation imbalances Prompt initiation of systemic broad-spectrum antibiotics Adequate drainage of abscesses Describe pain in pancreatitis. - Answer -Sudden onset LUQ or epigastric (radiates through the back) Pain decreased in the sitting or fetal position Describe the signs and symptoms of pancreatitis. - Answer -Pain Abdominal tenderness and guarding Nausea, vomiting and anorexia Fever and tachycardia What is the term for bruising in the flanks? - Answer -Gray-Turner Sign What is the term for bruising around the umbilicus? - Answer -Cullen Sign List some characteristics of Pancreatitis: - Answer -Bruising in the flank (Gray-Turner sign), bruising around the umbilicus (Cullen Sign), Hypocalcemia (may include signs such as tetany, prolonged QT interval, muscle cramping), pleural effusion, acute respiratory distress syndrome, sepsis Describe the laboratory findings associated with pancreatitis. (5) - Answer -Serum amylase rises quickly but returns to normal in 24-72 hours. Serum lipase rises slowly, but may remain elevated for up to 2 weeks. Hypocalcemia Decreased H/H Elevated serum glucose What is the treatment for pancreatitis? - Answer -IV fluid resuscitation as needed Analgesia (morphine should be avoided) Antiemetics IV calcium PRN Antibiotics for abscess or sepsis What medication should be avoided in pancreatitis and why? - Answer -Morphine. It can cause spasms of the sphincter of Oddi What should an ongoing monitoring of pancreatitis consist of? - Answer -Monitor for worsening hemorrhage Monitor for respiratory failure Monitor for hyperglycemia Monitor for Hypocalcemia Monitor for signs of sepsis The _____ is rarely injured and is rarely a single system injury. - Answer -Esophagus Where do most esophagus injuries occur? - Answer -In the cervical region (the abdominal region is rarely injured) Is esophageal trauma more common in blunt or penetrating trauma? - Answer -More common in penetrating Esophageal trauma may result in _____ leading to respiratory distress. - Answer -Significant fluid losses in the thorax and abdomen What are the symptoms of esophageal trauma? - Answer -Pain in the neck, chest, shoulders and throughout the abdomen Dysphagia Fever (delayed finding) Signs of peritonitis Dyspnea and pleural pain What are the treatments for esophageal trauma? - Answer -Gastric decompression Antibiotic therapy What are the symptoms of splenic injury? - Answer -Surface trauma to the LUQ Indications of intraperitoneal bleeding (abdominal distension, asymmetry, abnormal contour, tight abdomen) Tenderness, guarding and rigidity in the LUQ Pain What are the indications for operative repair of the spleen? - Answer -Surgical packing and repair Splenorrhaphy Splenectomy (reserved for unstable patients or patients with a grade IV or V injury). What are the common inpatient complications of spleen injuries? - Answer -Gastric perforation Recurrent bleeding Acute gastric dilation Pancreatitis Post op elevations of _____ and _____ are normal after splenectomy, but should return to normal about _____ days post-op. - Answer -WBC Platelet Count 4 Continued elevation of WBC's and platelet count more than 4 days post-op of a splenectomy indicate _____. - Answer -Sepsis Spleen may rupture more than _____ after trauma. The patient may have been asymptomatic on presentation. - Answer -48 Hours Splenectomy leaves a patient vulnerable to infections by _____, therefore patients should be _____ post-operatively after a splenectomy and every _____ years thereafter. - Answer -encapsulated bacteria vaccinated 5 List some encapsulated bacteria. - Answer -Pneumococcus Meningococcus Exherichia Coli Haemophilus Influenza Staphylococcus Streptococcus Patient's should be taught to report to a health care provider for any _____ such as _____. - Answer - Flu-like symptoms Nausea and Vomiting, progressing rapidly to confusion, high fever or shock The liver contains approximately _____% of the body's blood at any given time. - Answer -13 Liver lies under ribs _____ on the right, then crosses the midline and lies under ribs _____ on the left. - Answer -6-10 7-8 The _____ is the largest abdominal organ and weighs _____. - Answer -Liver 3-4 pounds What grade of liver injury has a subcapsular, non expanding hematoma with <10 cm surface area? - Answer -Grade 1 What grade of liver injury has a capsular nonbleeding laceration that is <1 cm parenchymal bleeding? - Answer -Grade 1 What grade of liver injury has a subcapsular, non-expanding hematoma that is 10-50% surface area or intraparenchymal nonexpanding hematoma <10 cm in diameter? - Answer -Grade 2 What grade of liver injury has a capsular laceration with active bleeding and is 1-3 cm parenchymal depth and <10cm in length? - Answer -Grade 2 What grade of liver injury has a subcapsular hematoma that is >50% surface area or expanding, a ruptured subcapsular hematoma with active bleeding or an intraparenchymal hematoma > 10cm or expanding? - Answer -Grade 3 What grade of liver injury has a laceration >3 cm parenchymal depth? - Answer -Grade 3 Describe a hematoma in a Grade 4 liver injury? - Answer -Ruptured intraparenchymal hematoma with active bleeding. Describe a laceration in a Grade 4 liver injury. - Answer -Parenchymal disrupion involving 25-75% of hepatic lobe. Describe a laceration in a Grade 5 liver injury. - Answer -Parenchymal disruption involving >75% of hepatic lobe A liver injury with a justahepatic venous injury is considered what grade? - Answer -Grade 4 What is another name for a justahepatic venous injury? - Answer -Retrohepatic vena cava Describe a Grade 6 liver injury. - Answer -Vascular avulsion What are the symptoms of liver injuries? - Answer -Tenderness, guarding, rigidity in RUQ Elevated LFTs Ecchymosis around the umbilicus or RUQ Distended abdomen Which is more common for liver injuries: non-operative or operative? - Answer -Non-operative Duodenal hematomas typically become evident _____ days after trauma, presenting as a vague _____. - Answer -5-7 days Abdominal pain and vomiting _____ _____ usually have acute pain and tenderness immediately after trauma. - Answer -Duodenal perforations Content of small bowel has _____ pH and is _____; therefore, clinical findings of injury may be delayed. - Answer -Neutral Relatively sterile What are the common points of injury in the small bowel? - Answer -Ligament of Trietz Ileocecal Valve Hematomas from small bowel injuries may cause _____. - Answer -Bowel obstructions _____, i.e. Chance Fractures, may mask clinical findings of bowel injuries. - Answer -Spinal cord injuries List the symptoms of small bowel injuries. - Answer -Muscle spasm or rigidity in the epigastric or RUQ Elevated WBC, amylase or metabolic acidosis Rebound tenderness and guarding Free air on x-ray or CT Seatbelt sign Tachycardia and Hypotension Presnece of bile or food fibers in DPL Discuss non-operative treatment in small bowel injuries. - Answer -Non-operative = stable patient with no signs of peritonitis Requires serial abdominal examinations Which small bowel injury patients require operative management? - Answer -Those that show signs of peritonitis Those with hemodynamic instability List the complications of small bowel injuries. - Answer -Wound infection / abscess Fistula formation Small-bowel obstruction Ischemic bowel Suture line leakage Short gut syndrome What part of the large bowel is mot likely to be affected in trauma? - Answer -Transverse colon _____% of penetrating trauma affects the large bowel - Answer -17% The large bowel contains _____, which when released into the peritoneum, increases the risk of sepsis. - Answer -Anaerobic Bacteria _____, caused by penetrating trauma to the back, may take up to 24 hours or more to manifest as abdominal tenderness or show signs of infection. - Answer -Retroperitoneal colon injuries What are the symptoms of large bowel trauma? - Answer -Evisceration Peritoneal Irritation Hypovolemic Shock What are the symptoms of rectal trauma? - Answer -Bleeding from/around the rectum Scrotal hematoma Immediate signs of peritonitis with anterior/lateral wall injuries, delayed signs with posterior wall injuries What is the goal of treatment for large bowel and rectal trauma? - Answer -Early recognition of injury and control of fecal contamination What are the treatments for significant large bowel trauma? - Answer -Irrigation to remove fecal material Primary bowel repair (resection and anastomosis) Diverting colostomy (may be closed within weeks with uncomplicated healing) Pre-operative antibiotic therapy _____. - Answer -Reduces sepsis from enteric contamination What is the treatment for significant rectal trauma? - Answer -Colostomy and distal rectal washout What are some complications of large bowel and rectal trauma? - Answer -Incisional infection (delayed skin closure considered for major fecal contamination) Intra-abdominal abscess Fecal fistula List the 3 types of pelvic fractures. - Answer -Lateral compression Anterior-posterior compression Vertical Shear What is the common mechanism and frequency of a lateral compression pelvic fracture? - Answer -MVC 60-70% What is the common mechanism and frequency of a anterior-posterior compression pelvic fracture? - Answer -Auto vs. Ped 15-20% What is the common mechanism and frequency of a vertical shear pelvic fracture? - Answer -Fall from height Can cause a partial tear to become a complete tear In urethral tears, if the patient can void spontaneously, the tear is likely _____. - Answer -Partial If there is a heightened suspicion for urethral trauma, a _____ should be considered. - Answer - Retrograde urethrogram In cases of suspected/confirmed urethral damage, _____ is recommended. - Answer -suprapubic catheter What are the complications of urethral trauma? - Answer -Necrotizing infections and sepsis Incontinence Fistulas Dyspareunia Strictures Recurrent urethritis or cystitis In the bladder, the _____ is the weakest part and most likely to rupture. - Answer -Dome The fuller the bladder, the _____. - Answer -Higher the risk on injury _____ is commonly associated with pelvic fractures and a _____ at the time of trauma. - Answer - Bladder trauma Full bladder Children under _____ are more vulnerable to bladder trauma because _____. - Answer -6 the bladder is an abdominal organ What are the common co-existing injuries with bladder trauma? - Answer -bowel lacerations lacerations of the vena cava mesenteric and renal iliac arteries and veins List the symptoms of bladder trauma. - Answer -Abdominal distension, guarding or rebound tenderness Inability to void Suprapubic pain that may radiate to the shoulder Ecchymosis around the bladder and thighs Hematuria (87-98%). Microscopic hematuria is more likely with a _____. Frank blood with a _____. - Answer -Contusion Bladder rupture What type of bladder rupture is most common? - Answer -extraperitoneal bladder rupture _____ bladder rupture is related to injuries related to a distended bladder. - Answer -Intraperitoneal With an intraperitoneal bladder rupture, cystography will reveal contrast material _____. - Answer - Around bowel loops and between mesenteric folds With an extraperitoneal bladder rupture, cystography will reveal contrast _____. - Answer -in a variable path. _____ bladder rupture is often associated with pelvic fractures. - Answer -Extraperitoneal _____ injuries are more likely to have peritoneal signs such as rebound tenderness and require surgical repair. - Answer -Intraperitoneal _____ injuries may be treated with bladder drainage and allowed to heal over 7-14 days. - Answer - extraperitoneal _____ are required for bladder ruptures due to a high rate of UTI's due to catheters and hematomas - Answer -Antibiotics In bladder rupture, catheterization is used to _____. - Answer -Monitor for clots Reabsorbed extravasated urine can result in: - Answer -Hyperkalemia Hypernatremia Uremia Acidosis Extravasation of urine into the peritoneum may cause: - Answer -Peritonitis Fistula/abscess Uroascites with respiratory compromise Sepsis What are the common mechanisms of renal trauma? - Answer -Blunt injury to the flank Deceleration forces Fall from significant heights Renal trauma occurs in _____% of patients with abdominal trauma. - Answer -10% The majority of renal trauma is _____. - Answer -Contusions Penetrating trauma to the _____, _____, and _____ also raise the index of suspicion for renal trauma. - Answer -Flank Pelvis Lower Chest Except for the _____, the kidney is fairly mobile. - Answer -Renal Pedicle What are the prevention techniques for renal failure? - Answer -Maintain adequate intravascular volume Avoid nephrotoxic agents (or ensure adequate intravascular volume loading before administration) Actively treat myoglobinuria What is the term for poor blood flow to the kidneys (hypovolemia, vasodilation, cardiac dysfunction)? - Answer -Pre-renal failure What is the term for nephrotoxins (antibiotics, x-ray contrast media), or ischemic sources (prolonged hypotension, sepsis, transfusion reactions, direct parenchymal damage) of renal failure? - Answer -Intra- renal failure What is the term for injury to the urinary collection system, such as a ruptured bladder, urethral or ureteral trauma, neurogenic bladder? - Answer -Post-renal failure What is the expected specific gravity for pre-renal, intra-renal and post-renal failure? - Answer -Pre = 1.020 or greater Intra = 1.010 Post = Normal What is the expected Urine Sodium for pre-renal, intra-renal and post-renal failure? - Answer -Pre = Low Intra = High (Greater than 30 meq/L) Post = Normal What is the expected Sediment for pre-renal, intra-renal and post-renal failure? - Answer -Pre = Normal Intra = Renal tubule cells and cell casts Post = Normal What is the expected Protein content for pre-renal, intra-renal and post-renal failure? - Answer -Less than 1g/24 hours for all. What is the exptected RBC count for pre-renal, intra-renal and post-renal failure? - Answer -Microscopic for all What is the expected WBC count for pre-renal, intra-renal and post-renal failure? - Answer -Few for all What is the hallmark sign of renal failure? - Answer -Decreased urinary output _____ is considered a more accurate reflection of renal function than creatinine levels. - Answer - Creatinine Clearance Overall, a doubling of creatinine levels equates to _____. - Answer -Halving glomerular filtration Why is BUN not an accurate test for renal failure? - Answer -BUN can be affected by gastrointestinal bleeding, hypovolemia or hypercatabolism Simultaneous elevation in BUN and Creatinine at a ratio of _____ is strongly suggestive of renal failure. - Answer -10:1 Elevated serum _____ is indicative of renal failure. - Answer -Potassium Describe 2 additional symptoms of renal failure. - Answer -Delated decreasing H/H Hypertension What are the initial treatments for renal failure? - Answer -Fluid administration Inotropes, Vasopressors, Diuretics If the initial treatments of renal failure (fluids and inotropes, vasopressors, diuretics) are unsuccessful, consider _____, _____ or _____. - Answer -Renal artery thrombosis Myoglobinuria Increased intra-abdominal pressure What are the advantages of peritoneal dialysis? - Answer -Simple and inexpensive What are the disadvantages of peritoneal dialysis? - Answer -May be ineffectual in critical illness. Contraindicated in patients with intraperitoneal trauma. Increases intra-abdominal pressures and may diminish respiratory status. Increased risk for peritonitis. What are the advantages to hemodialysis? - Answer -Treatments are brief (3-4 hours) Highly efficient to remove fluid and balance electrolytes Requires less anticoagulation than CCRT (continuous renal replacement therapy) What are the disadvantages of hemodialysis? - Answer -Rapid shift in electrolytes can cause disequilibrium syndrome (LOC, weakness, hypotension) Intermittent therapy leads to periods of normal electrolytes/fluids alternated with gradual increases. Requires personnel with highly specialized competencies. What are the symptoms of disequilibrium syndrome that can occur with rapid shifts in electrolytes? - Answer -LOC Weakness Hypotension What are the advantages of continuous renal replacement therapy? - Answer -Hemodynamic control may be achieved by slower blood flow rates and fluid removal Slower fluid corrections cause less shifts in ICP Create a greater dialysis dose per day What are the disadvantages of continuous renal replacement therapy? - Answer -Requires anticoagulation. Additional devices minimize mobility 1st = 4.5 2nd = 6 3rd = 6 Compare CVP in pre-pregnancy, first, second and third trimesters. - Answer -Pre = 9.0 1st = 7.5 2nd = 4.0 3rd = 3.8 Compare hematocrit without iron (%) and hematocrit with iron (%) in pre-pregnancy, first, second and third trimesters. - Answer -Pre = W/O - 40 W - 40 1st = W/O - 36 W - 36 2nd = W/O - 33 W - 34 3rd = W/O - 34 W - 36 Compare WBC count in pre-pregnancy, 1st, 2nd and 3rd trimesters. - Answer -Pre = 7200 1st = 9100 2nd = 9700 3rd = 9800 What is the term for compression of the vena cava against the vertebral column when the pregnant woman lies supine that can cause vasovagal like symptoms? - Answer -Venocaval Compression Syndrome Describe the GI changes that occur during pregnancy. - Answer -Decreased gastric motility and emptying Relaxation of the gastroesophageal sphincter Compartmentalization of the small intestine into the upper abdomen Stretched abdominal wall _____ and _____ are more common in pregnancy, but _____ is less common. - Answer -Splenic Liver Small Bowel In pregnancy, urinary frequency changes due to _____. - Answer -Increased glomerular filtration rate and pressure of the fetus on the bladder Later in pregnancy, the bladder is elevated anteriorly out of the _____ and into the abdomen. - Answer - Protective ring of the pelvis What are the maternal and fetal mortality rates with pelvic fractures? - Answer -Maternal (9% of the time) Fetal (35% of the time) _____ of severe trauma results in abruption - Answer -40% _____ of minor trauma results in abruption. - Answer -1-5% _____ of fetal death from MVC is secondary to abruption. - Answer -50-70% What are the symptoms of placental abruption? - Answer -Abdominal pain and cramping Vaginal bleeding Uterine tenderness on palpation Increasing uterine fundal height Premature labor Signs of hypovolemia Describe the diagnostics for placental abruption. - Answer -Ultrasound 50% sensitive Continuous fetal monitoring (fetal distress) WBC > 20 is suggestive of abruption, but may be delayed What are the treatments for placental abruption? - Answer -Treatment ranges from observation to C- section Uterine rupture is a _____ injury which results in fetal death nearly _____% of the time and maternal death _____% of the time. - Answer -Rare 100% 10% What are the symptoms of a uterine rupture? - Answer -Abdominal pain Uterine tenderness Difficulty identifying fundal height Change or loss of normal contour of uterus Palpable mass outside the uterus Vaginal bleeding Signs of hypovolemic shock In uterine rupture, a previous C-section rupture anteriorly is _____ while a non-previous c-section rupture posteriorly is _____. - Answer -More obvious More difficult to detect _____ is a condition where the umbilical cord precedes the infant out of the vaginal canal. - Answer - Prolapsed cord The weight of the fetal head against the cord can result in _____. - Answer -Fetal hypoxia What is the treatment for a prolapsed cord? - Answer -A gloved hand should be placed inside the vaginal canal to push the fetal head off of the pelvic bones until a C-Section can be performed. Fetal injury/death with trauma is more likely _____ in pregnancy. - Answer -Late Tip backboard _____% in all patients who are more than _____ weeks pregnant to prevent Venocaval Compression Syndrome. - Answer -20% 20 Weeks In the pregnant trauma patient, the abdomen is less sensitive to palpation and a ____ should be considered. - Answer -FAST exam In the pregnant trauma patient, why should the fundus be checked and marked? - Answer -Usually elevated fundus may indicate concealed uterine bleeding. In the pregnant trauma patient, clear fluid in the vaginal vault should be tested with _____. - Answer - Nitrazine paper What is the pH of amniotic fluid? - Answer -7.5 What is the pH of Urine? - Answer -4.6-8.0 What are the possible sources of vaginal bleeding in the pregnant trauma patient? - Answer -Abruption Uterine Rupture Pelvic Fracture Reproductive Organ Damage When is cardiotocographic monitoring initiated? - Answer -As soon as the secondary survey is done. All pregnant trauma patients greater than 20 weeks gestation should be monitored for 2-6 hours if they have ____, _____ or _____. - Answer -Contractions, abdominal pain or significant injury What test identifies fetal blood cells in the maternal circulation? - Answer -Kleihauer-Betke test A positive Kleihauer-Betke test may indicate _____. - Answer -Fetal or placental injury A positive Kleihauer-Betke test in an Rh negative woman may indicate _____. - Answer -Sensitization and the need for Rho-Gam The best outcomes for a peri-mortem C-Section are within _____. - Answer -5 minutes In a peri-mortem C-Section, fetal and maternal survival rates are _____ & _____ respectively when performed within _____. - Answer -45% 72% 4 minutes A peri-mortem C-Section is not attempted beyond _____ except to improve maternal cardiac output. - Answer -20 minutes For peri-mortem C-Section, the fetal age must be greater than _____. - Answer -23-28 weeks.