Evaluation and Management of Traumatic Abdominal and Neurological Injuries, Exams of Nursing

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TCRN Exam 113 Questions with Verified Answers

Kehr's sign - CORRECT ANSWER Referred left shoulder pain, usually indicates a splenic injury Base deficit - CORRECT ANSWER Base deficit more than -6 indicates the need for agressive resuscitation and determination of the etiology CXR - CORRECT ANSWER Most important tool providing useful information in the early minutes. Can identify major sources of blood loss from injuries in the chest or elevated diaphragm with displacement of abdominal organs Tracheobronchial injury - CORRECT ANSWER Should be suspected if after chest tube placement a significant air leak is present Diagnostic Peritoneal Lavage - CORRECT ANSWER Alternative to FAST scan to detect abd bleeding. A urinary catheter and gastric tube should be in place prior to procedure. FAST - CORRECT ANSWER Focused Assessment with Sonography in Trauma. Used to detect free fluid in peritoneum or hemoperitoneum. Free fluid appears "black" on the screen. Has replaced DPL when available. Positive FAST scan - CORRECT ANSWER Hemodynamically unstable trauma patient with a positive fast are taken directly to the OR for laparotomy Ultrasound abd exam - CORRECT ANSWER Not useful to detect injuries to the diaphragm, intestine and pancreas. In patients with obesity, ascites and/or subQ emphysema the accuracy is reduced. CT scan - CORRECT ANSWER Hemodynamically stable patients may be taken to CT Angiography - CORRECT ANSWER Embolization is useful in treating patient with unstable pelvic fractures, liver and splenic hemorrhage. Use of hybrid OR suites to

allow for surgical and interventional radiology methods of treatment simultaneously. Diagnostic laparoscopy - CORRECT ANSWER Can be used to detect or exclude finding so f hemoperitoneum, organ injury, intestinal spillage or peritoneal penetration. Most useful in evaluating possible diaphragmatic injuries, espectially in penetrating thoracoabdominal injuries on the left site Diaphragmatic injuries - CORRECT ANSWER Usually resultant of penetrating throacoabdominal injuries on the left side, including 11-12 rib fractures on the left. Small intestine injuries - CORRECT ANSWER Result from shearing forces in MVC or direct blows that crush intestine between force and the vertebrae. Most commonly intra-abd injury in penetrating trauma. Occurs often with spinal injury. Pancreatic/solid organ injury are predictive of increased risk for hollow viscus injury. Signs of peritonitis develop. Any blow to the abd/penetrating injury to the lower chest/abd should increase suspicion of injury Treatment of small intestine injury - CORRECT ANSWER Control bleeding prior to exploration. Debridement and closure and ligation of bleeders. Resection for multiple defects. Observe for wound infection/abscess development Cause of duodenum injuries - CORRECT ANSWER Penetrating trauma most frequent cause. Usually conconcurrent mult-organ injuries. Usually found intraoperatively, commonly missed during exlap. Blunt force injury cause by vetebral compression. Duodenal injury treatment - CORRECT ANSWER Identification with CT scan. Commonly patients have midepigastric or back pain with evolving peritoneal signs 6-24 hrs after injury. Primary closure in OR, closed drainage system. Goals are to control hemorrhage, debride devitalized tissue and provide drainage. Non operative management requires close observation for expanding or ruptured hematomas causing bleeding or peritoneal contamination. Jejunum and ileum injuries - CORRECT ANSWER Jejunum lies in umbilical region, ileum lies in the hypogastric/pelvice regions. Lap belt can cause bowel to be

crushed between the vertebrae and a solid object. Incorrect wearing of seatbelt increases chance for injury Stomach injury - CORRECT ANSWER Rare, more common in children. Penetrating trauma most common cause. May find free air on cxr/fua. Pain to epigastric/abd area, tenderness, signs of peritonitis. Bloody output from gastric tube. Surgical intervention, is gastric content leakage, copious peritoneal irrigation and delayed primary closure Large intestine - CORRECT ANSWER Rectal injuries may be associated with severe pelvic fracture. Lethal due to sepsis related to fecal contamination. Most are due to penetrating trauma. Transverse colon most often injured. Most injuries are contusions. Laparotomy with primary repair and colostomy is performed when perforation to the colon or rectum is suspected. Abscesses can be percutaneously drained. Liver injuries - CORRECT ANSWER Commonly injured due to size and location. Cause of injury is blunt and penetrating trauma. MVC most common cause. Greatest mortality risk is hemorrhage. High velocity GSW cause more widespread damage that creates massive hemorrhage. Suspect liver injury in any patient with blunt injury to right side. FAST scan to rule out free fluid. CT scan in hemodynamically stable patient. Graded I to IV. Treatment of liver injuries - CORRECT ANSWER Nonoperative in select patient. OR for complex lacerations/arterial blush. Angioembolization for patients with contrast pooling or arterial blush. Pack and stabilize bleeding and return to OR 24- 36 hours later for removal of packing and definitive management of liver/possible closure. Aggressive intraoperative resuscitation to prevent hypothermia, coagulopathy and hemodynamic stability. Damage control surgery. Hemobilia - CORRECT ANSWER In patients with liver injury RUQ pain and jaundice may present days and weeks post injury so follow up care is important Splenic injuries - CORRECT ANSWER Most commonly injured intra-abd organ. 25% of all blunt visceral injuries. LUQ trauma, lower rib fractures to left. Kehr's sign is

caused by blood irritation to the phrenic nerve that causes referred pain to the left shoulder. CT scan is the imagining of choice for stable patients. Acute splenic rupture triad - CORRECT ANSWER left hemidiaphragm elevation, left lower lobe atelectasis and pleural effusion not commonly present and not a reliable sign Treatment of splenic injury - CORRECT ANSWER Nonoperative management, splenectomy/partial splenectomy, possible damage control. More focused on salvage of spleen. If patient has a splenectomy patient must receve vaccinations prior to discharge for H influenza/meningococcal/pneumococcal vaccine Overwhelming Postsplenectomy Sepsis - CORRECT ANSWER Rare, more common in children. 1-5 years after surgery. Flu like symptoms, shock from sepsis and DIC followed by death. Preventative measures include vaccinations and education. Pancreas - CORRECT ANSWER uncommon injury. If ductal tears, digestive enzymes invade. Major therapeutic challenge for clinical team. Most are associated with intra-abdominal injury and are found intraoperatively. GSW/Stab wounds are frequently the cause. Retroperitoneal injury - CORRECT ANSWER Associated with blunt trauma involving pelvic fractures Abdominal vascular injury - CORRECT ANSWER Usually occur with pelvic, thoracic or visceral injury. Retroperitoneal hematoma in conjunction with pelvic or spine trauma can contain up to 4 L of blood. Pitfalls of abdominal trauma - CORRECT ANSWER failure to suspect intra- abdominal injury from mechanism of injury, failure to fully evaluate complaints of abdominal pain following blunt abdominal injury, failure to perform timely operative intervention, failure to recognize hemodynamic compromise and delay surgery for further diagnostic tests Blood loss hypovolemia: class I - CORRECT ANSWER < 750 ml/15% of blood volume, HR < 100, normal B/P, normal PP, RR 14-20, CNS slightly anxious

Blood loss hypovolemia: class II - CORRECT ANSWER 750-1500/15-30%, >100, normal BP, decreased PP, RR 20-30, Mildly anxious Blood loss hypovolemia: class III - CORRECT ANSWER 1500-2000/30-40%, HR

129, decreased b/p, decreased PP, RR 30-40, anxious/confused Blood loss hypovolemia: class IV - CORRECT ANSWER >2000/>40%, HR > 140, decreased b/p, PP decreased, RR >35, confused and lethargic Compartment syndrome - CORRECT ANSWER Common areas for compartment syndrome include: lower leg, forearm, foot, hand, gluteal region and thigh Burn formula - CORRECT ANSWER Adult and Chemical burns > 20% TBSA resuscitate at 2 ml LR x kg x TBSA in the first 24 hrs. High voltage electrical injuries - CORRECT ANSWER 4 ml LR x kg x % TBSA in the first 24 hours Peds Burn formula (14 and under and < 40 kgs) - CORRECT ANSWER 3 ml LR x kg x % TBSA in the first 24 hours Inhalation injury - CORRECT ANSWER Do not wait to intubate, swelling will increase then increase the difficulty of placing an ETT. Stridor or horseness is a late sign. Compartment syndrome signs and symptoms - CORRECT ANSWER Pain out of proportion for the injury, weak or absent distal pulses, delayed cap refil, firmness on palpation of muscle/soft tissue in surrounding area, distal skin cool to touch, distal skin pale or cyanotic, decrase in patient sensation Hypovolemia in childresn - CORRECT ANSWER children can be hemodynamically stable up to a 40% blood loss but only have a blood volume of 7-8% of their body weight Hypovolemic shock - CORRECT ANSWER chaning mentation, tachycardia, >120 HR greatest concern, cool, clammy skin, prolonged cap refill, narrowed pulse pressure (normal 40-50), decrased urine output, hypotension

Hypotension in shock - CORRECT ANSWER Systolic blood pressure does not fall until 30% blood loss in adults SIRS - CORRECT ANSWER Systemic Inflammatory Response Syndrome. Severe physiologic reaction to injury characterized by systemic release of inflammatory cytokines and chemokines. Two or more of the following: temp > 38 or < 36, HR > 90, RR > 20 or PaCO < 32, WBC >12 or <4 or > 10% bands MODS - CORRECT ANSWER After SIRS becomes stage 3 and severe hypotension refractory to fluid and ionotropic support ischemic insult progresses. Dysfunction of at least two organ systems from inflammatory insult, trauma or sepsis. Causes of secondary brain injury - CORRECT ANSWER hypoxia, hypotension, hypocapnea or hypercapnea Secondary brain injury - CORRECT ANSWER Leads to cerebral edema, mass effect, ischemia, cellular death Optimizing oxygenation, ventilation and hemodynamics - CORRECT ANSWER Intubate with RSI, maintain O2 sat > 90%, optimally 98%, ETCO2 monitoring to keep around 35 - provides information about adequacy of circulatory flow, hyperventilation causes vasoconstriction and reduces PaCO2 and causes ischemia, PaCo2 < 30 Monroe-Kellie doctrine - CORRECT ANSWER Pressure volume relationships within the intracranial cavity, the craium is a non-expandable vault, increasing iCP is a warning that contents under pressure will try to relieve pressure by finding an exit in the area of least resistant - brain herniation Normal ICP - CORRECT ANSWER 0-15, > 20 requires intervention 8 Cranium bones - CORRECT ANSWER ethmoid, parietal, sphenoid, temporal, occipital Dura - CORRECT ANSWER Outermost layer-firmly adhered to the inner skull with fixed attachments of the cranial sutures

Arachnoid - CORRECT ANSWER Loosely adhered to the pia mater, which makes the potential arachnoid space Pia - CORRECT ANSWER closely associated with grey matter of the brain, is the innermost layer CSF circulates - CORRECT ANSWER Between the pia and the arachnoid in the subarachnoid space, cushions and protects the brain and spinal cord Middle meningeal artery - CORRECT ANSWER Key cause of epidural bleeds cerebrum - CORRECT ANSWER right and left hemispheres of the brain ventricular system - CORRECT ANSWER approx 500 ml of CSF is produced in the choroid plexus of the lateral ventricles each day third cranial nerve - CORRECT ANSWER brainstem is the origin for the CNIII - CNX and CNXII GCS 10 - CORRECT ANSWER Eye opening to voice, confused verbal response, withdraws to pain GCS < 8 - CORRECT ANSWER intubate, accepted definition of coma - categorized as severe brain injury GCS 9-12 - CORRECT ANSWER moderate brain injury GCS >12 - CORRECT ANSWER minor brain injury CPP - CORRECT ANSWER cerebral perfusion pressure, maintain 60-70 mmHg Avoid hypotension in ICH - CORRECT ANSWER Solitary and multiple episodes of hypotension have been shown to increase the morbidity and mortality associated with brain injury

Cushings Triad - CORRECT ANSWER hypertension, bradycardia and irregular respirations - ominous signs of herniation and require immediate attention and possible surgical intervention ICP monitoring - CORRECT ANSWER Placed in all salvageable head injury patients with GCS < 8 after resuscitation with an abnormal CT scan, GCS < 8 after resuscitation with a normal CT scan and at least two of the following findings: over 40 yo, systolic <90, bi or unilateral posturing CPP/brain tissue oxygenation - CORRECT ANSWER assessed through the use of devices such as the brain tissue oxygen monitoring catheter to monitor cerebral perfusion, oxygenation and oxygen carrying capacity Cerebral contusion - CORRECT ANSWER capillaries within the brain tissue are damaged and cause hemorrhage infarction or necrosis Intracerebral - CORRECT ANSWER deeper in the brain tissue, may be single or multiples, can create mass effect, increased ICP, neurologic deterioration, headache, incrased ICP, pupil changes, abn posturing, hemiparesis, hemipalegia SDH - CORRECT ANSWER Venous bleeding, acute < 72 hours old, subactue 3- days after acute injury, chronic - 21 days or older Herniation - CORRECT ANSWER Abdnormal protrusionof brain tissue through an opening when there is incrased intracranial pressue Brown-Sequard - CORRECT ANSWER Hemisectionof cord from penetrating injury, loss of motor on side of injury, loss of sensation on opposite side Temporal lobe herniation - CORRECT ANSWER oculomotor nerve runs along the edge of the tentorium and may becomme compressed against it during temporal lobe herniation, compression can cause a blown pupil Uncal herniation - CORRECT ANSWER common herniation through the tentorial notch is the medial part of the temporal lobe the motor tract crosses the opposite side of the foramen magnum and results in contralateral hemiparesis

GCS that is assymetric - CORRECT ANSWER take the highest score Neurogenic shock - CORRECT ANSWER results from impairment of the descending sympathetic pathways, results in loss of vasomotor tone and in sympathetic innervation to the heart. Rare in injury below T6. Loss of vasomotor tone cause vasodilation of lower extremities, visceral organs, blood pools in lower extremities. Bradycardia. Vasopressors are required, atropine for symptomatic bradycardia Inability to perceive pain in the spinal cord injured patient - CORRECT ANSWER can mask a potentially serious injury elsewhere in the body, such as the usual signs of an acute abd Bony level of injury - CORRECT ANSWER the veterbra at which the bones are damaged, causing injury to the spinal cord Neurologic level of injury - CORRECT ANSWER determined primarily by clinical exam. Frequently discrepancy between the bony and neurologic levels because of the nerve innervation points Central cord syndrome - CORRECT ANSWER disproportionately greater loss of motor strength in the upper extremities than in the lower extremities, with varying degress of sensory loss. Common with hyperflexion injury Anterior cord syndrome - CORRECT ANSWER parapalegia and a dissociated sensory loss with a loss of pain and temporature sensation C 1 - C 4 - CORRECT ANSWER require intubation, below C 4 consider for increased work of breathing secondary to muscle innervation changes Poikilothermic - CORRECT ANSWER Thermoregulartion is impaired and patient will take the temp of the room, adversely impacts bradycardic patients Spinal Shock - CORRECT ANSWER flaccid paralysis, loss of autonomic function, abscence of cutaneous and/or proprioceptive sensation, cessation of all reflex activity below site of injury

C2 dens fracture - CORRECT ANSWER Common in geriatric patients, hyperextension injury Compression fractures - CORRECT ANSWER axial loading injury, degree of compression affects stability, thoracic and lumbar spine usually affected Burst fracture - CORRECT ANSWER fracturing in outward pattern, may impinge cord, can have compression and cord compression Chance fracture - CORRECT ANSWER Usually L1-2, teardrop fracture, may result in paraplegia, and small bowel injury from lap belt compression and lumbar spine SCIWORA - CORRECT ANSWER spinal cord injury without radiographic abnormality, common in PEDS, dislocation with spontaneous relocation, cord injury evident, imaging negative Autonomic dysreflexia - CORRECT ANSWER uncontrolled, massive sympathetic reflex to noxious stimuli, below level of lesion Hyphema - CORRECT ANSWER blood in anterior chamber of eye, prevent rebleeding, bedrest, limited activity, HOB elevated, cycloplegic agents - atropine gtts, may need patch Open Globe - CORRECT ANSWER minimize additional damage, shield w/o pressure, eye patches contraindicated, anticipate need for OR Orbital blowout fracture - CORRECT ANSWER Diplopia, can cause eye to look upward secondary to muscle/nerve impigement, emergency surgical repair indicated, delays increase risk of vision loss LeFort I - CORRECT ANSWER transverse fx between maxillary and orbital floor, may include maxillary sinuses. Lower maxilla and teeth are mobile or floating but nose and midface stable. May have trismus, malocclusion. Check for mandible fx. Lefort II - CORRECT ANSWER includs central maxilla, nasal area, ethmoid bones, tripod shape, grasping front teeth and palate causes movement to nose and upper lip w/o movement to orbital complex, caved in appearance, edema,

subconjunctival hemorrhage and epistaxis, early intubation for airway protection. CSF presence - rhinorrhea suggests open skull fx LeFort III - CORRECT ANSWER complete craniofacial dysfunction, associated with massive soft tissue, ocular injuries, TBI, skull injuries, cribiform plate and dural tears, rocking mxillar moves the entire face Tripod fx - CORRECT ANSWER separation of all three major attachments of the zygoma to the rest of the face Orbigozygomatic fracture - CORRECT ANSWER complex fractures of zygoma and orbital floor, pain, trismus, diplopia, numbness to upper lip, lower lid and bilateral nasal area, surgical repair indicated Neck trauma - CORRECT ANSWER internal jugular vein and internal carotid artery most commonly injured Zone I neck trauma - CORRECT ANSWER highest mortality, angle of mandible to base of skull, difficult to assess, and exploration can increase mortality Zone II neck trauma - CORRECT ANSWER mid portion of neck, injuries apparent on exam, most carotid injuries occur here, manage by observation. Zone III Neck trauma - CORRECT ANSWER clavicles and sternal notch to cricoid cartilage. hard to assess surgically as so high at skull base. Diagnosis essential as infection can occur and impact mortality after 24 hours. Embolization very valuable, exploration can damage cranial nerves. Angiography to delineate site of injury S/S of emergency intervention in neck trauma - CORRECT ANSWER airway obstruction, pulsatile bleeding, expanding hematoma, unresponsive, extensive subcutaneous emphysema s/s of neck trauma needing more diagnostics - CORRECT ANSWER voice change, wide mediatstinum, hemoptysis, hematemesis, dysphonia/dysphagia, drooling, bloody sputum, horner's syndrome, pain with turning neck

Horner's syndrome - CORRECT ANSWER a contracted pupil, drooping upper eyelid, and local inability to sweat on one side of the face, caused by damage to sympathetic nerves on that side of the neck Neck trauma treatment - CORRECT ANSWER stabiltize airway, pressure control for bleeding, subclavial injury needs IV on opposite site, consider permissive hypotension, repair vs ligation, shunting, embolization, ligation, antithrombotic Neck trauma diagnostic testing - CORRECT ANSWER CXR mandated for zone I, CT most accepted, CT angiogram - excellent for laryngeal and tracheal injuries, as reliable as arteriography. Arteriogram - considered gold standard, invasive with risk of complications, contast load but embolization can happen at the same time. Associated injuries with neck trauma - CORRECT ANSWER LeFort fractures, basilar skull fracture involving carotid canal, diffuse axonal injury with GCS < 6, cervical fracture, near hanging/anxoic brain injury, seatbelt abrasion with significant swelling/altered mental status/ TBI, necrotizing infections Frontal impact - CORRECT ANSWER Suspected injuries: Capone do, anterior flail chest, myocardial contusion, pneumothorax, traumatic aortic disruption, fracturednspleennornkiver, posterior fracture/dislocation of hip and/or knee Side impact - CORRECT ANSWER Suspect injuries: contra lateral neck sprain, Capone go, lateral flail chest, pneumothorax, traumatic aortic disruption, diaphragmatic disruptive, fractured spleen liver or kidney, fix Pelvis or scetabulum Rear impact - CORRECT ANSWER Cspine injury or soft tissue to neck Pedestrian struck - CORRECT ANSWER Head injury, traumatic aortic disruption, and visceral injury, fractured lower extremity or pelvis