Download TCAR-POST TEST REAL EXAM and more Exams Nursing in PDF only on Docsity!
TCAR-POST TEST REAL EXAM WITH 100% VERIFIED QUESTIONS
AND CORRECT ANSWERS ALREADY GRADED A+ NEWEST 2024-
bruise on the lungs - pulmonary contusion causes of pulmonary contusions - high speed blunt or penetrating injury what happens to the lungs in pulmonary contusions - big boggy bruise on the lungs diffusion problems when it becomes contused & edematous, it becomes difficult for oxygen to move from the alveoli into the capillaries where on the tissue oxygenation cascade do pulmonary contusions cause their problems - diffusion all contusions over time - all contusions "blossom" over time. the full extent of the injury is not initially apparent important thing to remember when you are evaluating a patient for pulmonary contusions - 70% of pulmonary contusions aren't initial on the initial CXR what should you monitor when a pt has trauma to the throax - closely monitor for pulmonary contustiobs = 70% not present on the initial CXR and "blossom" over time -monitor for progress e deterioration in hours/days post injury *might look ok in ER best parameter of serial monitoring for pt's who have risk factors for pulmonary contusions - anticipate "blossoming" over time b/c 70% of pulmonary contusions aren't present on the initial CXR P:F ratio problem of using CXR as a definitive clinical dx tool - CXR may lag behind clinical status *b/c 70% of pulmonary contusions aren't present on initial CXR. they "blossom" over time tear in lung tissue - pulmonary laceration problem of pulmonary lacerations - risk of massive hemothoax b/c those vessels are very vascular simple v. tension v. open v. closed. v. hemothorax v. hemopneumothorax -
what is a simple pneumothorax - any air that enters the pleural cavity can also leave at the same rate. lungs deflated but no increase in intrathroacic pressure. air in/out exits at the same rate. pt might be able to tolerate a simple pneumothraox causes a problem at the ventilation point at the tissue oxygen cascade intrathroacic pressure in simple pneumothorax - air that enters the pleural cavity leaves at the same rate lungs are deflated but no increase in pressure air in/out at the same rate where is the problem in the tissue oxygenation cascade in simple pneumothroax - ventilation what happens in penumothorax - lungs are collapsed/deflated aire enters space between the visceral & parietal two layers of the lungs - visceral & parietal Q - in a pneumothorax, no ligaments attach the lung to the wall. so what holds it up? - A
- a thin layer of pleural fluid & negative pressure. the liquid helps it stick like how a spilled liquid forms a seal between a glass and a smooth table top difference between a simple and tension pneumo - aka chest tube - chest thoacotomy purpose of using a chest tube in simple pneumothorax - to allow for negative pressure to reestablish. tension pnumothorax - air enters under pressure but doesn't exit at the same rate. = accumulation of air under pressure example of tension pneumothorax - like using a bicycle pump to put more and more air into the lungs over time. no escape *pressure means no lung function on the side of the injury and compromises function on the un injured heart and great vessel compression (decreases preload/CO increases afterload effect of tension pneumothorax on heart function - increases intrathoracic pressure decreases preload/CO increases afterload normal pressure in the vena cavas - normally is low similar to the central venous pressure which is similar to right atrial pressure (2-8mm hg) so very little increase in pressure to impede venous return to the heart
what is the significance of posterior rib fractures - unusual direction of injury shorter stubby ribs good muscle profection **posterior rib fractures have a lot of force so need a high dose. ***PRF need a lot of force so high dose of energy. big red flag for t-spine injury indication of c-spine injury - to injure c-spine, you don't need a big energy blow. all it takes is shaking around. c spine versus t spine fractures - c-spine doesn't need a big energy blow. just some shaking around t-spine needs a great strong direct blow (not just a shock_ treatment for rib fractures - largely supportive nursing care like pulmonary toilet CXR and rib fractures - simple rib fractures are difficult to see on CXR and can be commonly missed (1/2 of all rib fractures aren't identified at the POI CXR) identify a previous rib fracture on CXR - once healed, rib fractures form bony callouses and become more visible on CXR how to tell a pt has a pneumonia from a CXR - dark spot that is not equal to the opposite side consider if a pt has a lower rib fracture - liver & spleen injury acts like BBQ/marshmellow skewers how high does the diaphragm rise on inspiration - level of 4th ICS risk of rib fractures - can puncture liver, spleen,, diaphragm pop lungs +2 adjacent rib fractures - flail chest free floating sternum - flail chest definition of flail chest - +2 adjacent rib fracture free floating sternum why is flail chest a problem - b/c breathing is a mechanical process paradoxical chest movements - in flail chest s/s of flail chest - paradoxical chest wall movement
where on the tissue oxygenation cascade is thoracic cage fractures a problem - ventilation parameters to assess ventilation - ETCO2, PaCO2, clinical assessment what are considered "great vessels" - thorax - what type of injuries occur when the lungs are subjected to force? - bruise = contusion tear = lacerations pop = punctures inhalation injury what part on the tissue oxygenation cascade is affected by tension pneumothorax - ventilation r/t collapsed lung CO b/c pressure why is tension pneumothorax more life threatening than simple pneumothorax - tension pneuma is more life threatening than simple b/c of the pressure it puts on the great vessels so decreased CO considerations of chest trauma - pneumonia, great vessel trauma, pressure so low CO when is a hospitalized chest patient the most likely to develop tension pneumothrax - when we initiate positive pressure ventilation what can rapidly convert a simple pneumothorax to a tension pneumothraox - positive pressure can rapidly convert a simple pneumothorax to a tension pneumothorax (BVM or m. ventilation) or if a chest tube is kinked/clamped/occluded chest pain w/breathign - pleuritic pleuritic chest pain - pain with breathing assessment of t. pneumothraox - pleuritic chest pain (hurts to breathe) respiratory distress increased HR hyppoxemia agitation decreased LS chest dyspmetry hyperresonance
% blood loss that is tolerable versus not tolerable - most people can tolerate a 10% blood volume loss but most can't tolerate 40% how to tell if something is blood or air on a CXR - blood = white black = air intervention if hemothorax - needs CT later will need intrapleura tPA or VATS VATS - video-assisted thoracic surgery empyema - added to blood products that may cause low Ca - citrate. purpose of citrate in blood products - w/o citrate, blood will clot keeps blood in blood products from clotting - citrate priority in bleeding episodes - stop bleeding CABC leading cause of early mortality in trauma - hemorrhage cause of 30 - 40% of all patients who die of trauma - hemorrhage why is it important to keep a hemorrhage pt warm - keep a trauma pt warm helps stop bleeding b/c you can't clot well if cold coagulopathy control in hemorrhage - can't clot if we only give RBC/crystallids needs plasma, cry, plt definitive bleeding management - OR field care for bleeding management - helping blood loss > replacing fludis IVF in hemorrhage - IVF is not a substitution for aggressive hemorrhage control and can be harmful benefit of chest tube in trauam - autotransufsion benefits of autotransfusion in massive hemorrhage - perfect cross-match fresh blood k levels lower room temp
no communicable disease many clotting factors no anticoagulation needed warm versus cold blood - warm blood pleases oxygen better problems with autotrausncusion - contained (GSW) coagulaopathies enhanced inflammatory response benefits of any trauma intervention.... - often depends on the circumstance how long does it take to cross-match - 1 hour what type of blood is always preferred - fully cross-matched universal donor - O- blood types by US population % - AB neg = 0.6% A+ = 36% B+ = 8.5% O+ =34% O- = 6.6% 3/4 of US has A+ or O+ blood 85% are Rh+ Rh negative patients who receive Rh_ - Rh neg patients who receive Rh+ blood can develop antibodies to the Rh antigen reservation of type O neg RBC's - type O negative RBC's are reserved for anyone who could potentially become pregnant in the future including little girls. if you give a little girl who is Rh- blood that is O+ then later she gets pregnant and her spouse/baby are Rh+. then the Rh negative mom may have antibodies against the Rh + fetus and attack it Rh factor in hemorrhage - onsieration but not a contraindication in a massive hemorrhage. untyped female needs blood and Only O+ iOS available Rh- patient receives Rh+ blood mixing - needs Rhogam within 72hrs. passive immunization to prevent Rh sensitization and actual Rh formation universal plasma donr - type AB considered massive transfusion - 10 units air in soft tissue - Subcutaneous emphysema
modality - hemopericardium - blood in the pericardial sac blood in the pericardial sac - hemopericaridum s/s of cardiac tamponade - muffled HS high HR low bp high RR narrow PP JVD low voltage ECG waveform muffled heart sounds - consider cardiac tamponade EKG of cardiac tamponade - low voltage Electrical alternans (alternating amplitude on EKG) - where on the tissue oxygenation cascade does cardiac tamponade effect - prob lem f CO (obstruction issue not hypovolemia) interventions for cardiac tamponade - echo or FAST what can be lifesaving in cardiac tamponade - removing as little of 30ml you can leave in the needle w/a stockcock for later repeat drainage. frequently the blood is clotted an can't be removed. helps w/ s/s only but doens t actually fix the problem and helps until definitive care top 3 causes of death at the scene of traumatic injury - massive head trauma aortic care high spinal cord injury assessment findings that indicate great vessel injury - massive hemothroax shock inability to resuscitate patient method of treatment - modality mesenteric injuries - 3 layers of blood vessels - endothelium (tunica intima)
tunica media tunica adventitia what happens when the aorta is stretched - the most delicate/weakest layers tear first screening needed for thoracic trauma - decrease great vess3l injury bilateral bp why should you do bilateral bp to screen for aortic tear - b/c blood normally flows in a forward direction but in a dissection blood flows downwards w/ a little backwards. it doesn't take much backward dissection to start obstructing flow to the L subclavian what happens in a dissection - retrograde flow and potential obstruction of any vessel that branches off the aorta importance of the aorta - everything branches off the aorta problem of femoral artery occlusion - compromises flow of lower extremities classic CXR findings in aortic injury - widened mediastium what are you looking for on the CXR if you suspect a dissection - widened mediastium widened mediastinum on CXR - dissection cause of the widened mediastinum on CXR in a dissection - shadow of the hematoma as it balloons out from the aorta heparin in truma - never a good idea in a trauma pt TVAR - thoracic endovascular aortic repair REBOA - resuscitative endovaqscular balloon occlusion of the aorta treatment of aortic injury - stent through the femoral artery to the occlusion of the tear and channel blood back into the true lumen ECMO - extracorporeal membrane oxygenation type of cardiac bypass - ECMO = extracorporeal membrane oxygenation bleed out - exsanguination interventions prior to aortic repair - deliberately keep BP low (esmolol) to decrease stress on artery (exception to the goal of high Bp in most trauma)
freeze dried plasma - military are testing. lyophilized plasma what is a "unit" of blood - 1 unit is the amount donated by one donor only blood product that carries oxygen - _PRBC hematocrit of PRBC - 55-70% so it thickness is prone to lysis lifespan of RBC's - up to 120 days in the body lifespan of RBC's on a shelf - 42 days shelf life of plt - 5 days. needs to be continuously agitated in lab at room temperatue indication fo platelet transufsion - under 50K what is the most important thing with consideration of plt transfusion - plt is not solely about the total number dysfunction is more important when are plt transfusions indicated - for non-specific coagulation deficiencies and volume resuscitation shelf life of plasma - 7 years how long does it take to thaw FFP - 15 - 30 minutes what is taken out of cryoprecipitate - water and albumin what do you use to make cryoprecipitate - FFP ROTEM - method of measuring hemostasis quality via the visoelastic properties of a blood clot and is designed for patient blood management -rapid assessment of clot development (clot formation, clot firmness, and clot fibrinolysis) metabolic derangement - what do hemophilias need - clotting factors what type of blood products do burn pt need - plasma coagulopathies -
what do we do if we don't have whole blood for trauma patientsq - we can remake it 1:1:1 damage control resuscitation RBC:FFP:plt components of damage control resuscitation - 1:1: RBC:FFP:plt 2 problems in traumatic bvleeding - anatomica problem = mechanical bleeding. stop/plug holes then replace volume coagulpathy bleeding: physicaologica bleeding. can't fix int eh OR. needs goal directed treatment Trauma Induced Coagulopathy - developed r/t factors released from damaged cells, tissue hypo perfusion (shock), hypothermia, acidosis, inflammation accelerates fibrinolysis = dissolves clots machine used to evaluate bloods ability to clot - ROTEM how do we stop bleeding in a patient with trauma induced coagulpathies - directed replacement. needs to identify where in the coagulation cascade the problem is happening (ROTEM or TEG *provides us a visual representation of clot formation and lysis can recommend specific interveionts rx for hemorrhage patients - TXA, Riastap, Novoseven stimulates clot formation or inhibits clot breakdown Cullen's sign - ecchymosis in umbilical area, seen with pancreatitis bruising around the umbilicus - cullen s sign indication of Cullen's sign - pancreatitis Kehr's sign - Referred pain down the left shoulder; indicative of a ruptured spleen. referred pain to left shoulder - Kehr's xigbn indication of a ruptured spleen - Kehr's sign equivocal - ambiguous ambiguous - equivolcal
calculate pulse pressure - SBP (CO) - DBP (how much the body has to resist to maintain CO) what is pulse pressure - the relationships between CO and the body's compensatory vasoC response SBP - DBP minimally acceptable pulse pressure - 30 - 40 mm hg or 25% SBP indication of narrow pulse pressure - hemorrhage pulse pressure in hemorrhage - narrow pulse pressure calculate MAP - (SBP + 2DBP)/ pressure felt by organs monitor trends too detect decreased organ transfusion - trending MAP calculate shock index - HR/SBP HR divided by SBP - shock index why is HR high in a trauma pt - compensatory tachycardia HR > SBP - "that's backwards" so compensation CO. pt's is telling us that he's only maintaining CO by increasing HR why can't we use shock index for kdis - SI dons't normally apply to small kids b/c their HR is normally increased SBP but by 8yo septic workup - consider MPAP, PULSE PRESSURE, SHOCK INDEX what is considered a "narrow pulse pressure" - less than 40mm hg what does a narrow pulse pressure indicate - decreased cardiac output hemorrhage, heart failure what is considered a high pulse pressure - anything over 60 mm hg normal pulse pressure - 40 - 60 mm hg narrow - normal - wide what lab studies does a trauma patient need to gauge end points of resuscitation -
markers of hemostasis - hct/hgb, coagulation studies, ROTEM, lactate in shock - over 4. no universal conssensus base deficit - how much extra buffers are needed to soak up excessive acid VO2 - volume of oxygen consumed per minute oxygen consumption per minute - VO normal base deficit - +2 to - base deficit where you would suspect shock - - calculate VO2 - (SpO2 - SvO2) x hemoglobin x 1.36 x CO x *tells us opportunities for intervention to reverse oxygen debt. multiple places for us to provide interventions *example = PRBC/plamsa SvO2 - mixed venous oxygen saturation normal is 60 - 80% mixed venous oxygen saturation - SvO normal is 60 - 80% what happens if the body is relying on vasodilation to maintain vital signs - if rely on vasodilation to maintain vital signs and we give morphine, we are taking away the means to maintain BP. so we should give IVF then pain. medications what happens when a patients' bp drops after we give opioids - those patients are tell us that we took away their means to keep their bp high. was Vasoconstriction as a strategy so needs volume replacement. give us good info about how the body was compensating pain medications less likely to cause low bp - fentanyl and ketamine pain methods for thoracic trauma - nerve block epidural tyolenol lidocaine patch ambulation and mechanical ventilation - yes you can q's to ask if shot - self-inflicted, accidental, intential is the assailant still at lage consider pt safety
how to perform FAST - onus - burden burden or obligation - onus solid encapsulated abdominal structures - spleen liver kidneys abdominal injury most common in truma - spleen s/s of a spleen injury - left flank bruise LUQ tender rigidity/abd tension blood loss s/s blood loss s/s in a spleen injury - Kehr's tachycardia lw bp Kehr's sign - Referred pain down the left shoulder; indicative of a ruptured spleen. cause of Kehr's sign - pain form diaphragm irritation that refers to shoulder typically a result of blood under the left hemidraiphram common in spleen injuruies goals of FAST - rapidly identify free flowing blood which is usually what injuries can't a FAST detect - bowel or retroperitoneal injury what happens too bleeding in spleen/liver/kidney - all are encapsulated organs so the blood stays in the capsule and causes a sub capsular hematoma if a laceration = will bleed repair of the spleen - splenorrhaphy management of spleen injury - can manage noninvasively angioembolization, remove the spleen, splehorrharpy - repair -harpy - surgical repair how to gauge how long a person with a spleen injury needs to stay in the hospital - grade the spleen injury 1-VI each grade = 10 + 1 day 6 is not survivablew
contact sports precautions post spleen injury - severity grade (convert to weeks) + 2 weeks retroperitoneal steructures - kidney pancreas vena ava spine aortA indications for MRI, CT, US, CXR - ` consideration if a pt bends over in a car accident - jackknife injuries transsection - process of cutting across cutting actross - transsection worse case scenario for shock - if the tank is empty what often happens in retroperitoneal bleeding - retroperitoneal bleeding often tamponades itself so non-operative is an option labs in pancreatic injury - serial amylase and lipase delayed onset burning epigastria pain - pancreqase diffuse tender rigid abodmen - solid organ injury air filled structures of the abd - lugns, stomach, intestines most common bunt abdominal trauma injury versus penetrating - blunt = spleen penetrating = bowel important to remember about contusions anywhere - "blossom" over time monitor if bowel injury - s/s of infection fever & leukocytosis high WBC - leukocytosis leukocytossi - high WBC when aren't s/s of infection easy to detect - elderly or immunosuppressed
