TCRN Review: Trunk Trauma - Thoracic, Abdominal, Genitourinary, Obstetrical, Exams of Traumatology

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TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) What is a collection of excess fluid between the visceral pericardium and the parietal pericardium? - correct answer Pericardial Tamponade What are the classic signs and symptoms of a pericardial tamponade? - correct answer Beck's Triad What are the 3 findings in Beck's Triad? - correct answer Muffled heart tones Systemic Hypotension Distended Neck Veins (may not be present with hypovolemia) What are the cardiovascular effects of Pericardial Tamponade? - correct 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 TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) What is Pulsus Alternans? - correct answer Alternating morphology of the QRS complex What is pulsus paradoxus or paradoxical pulse? - correct answer A change of more than 10 mmHg in arterial pressure during inspiration How is pulsus paradoxus or paradoxical pulse found? - correct 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? - correct answer Grey, death-like appearance Extreme anxiety Inability to lie supine Dyspnea Cyanosis How is pericardial tamponade diagnosed? - correct answer Clinically or via FAST exam TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) Inotropic drugs List the Great Vessels - correct answer Aorta 3 branches of the aorta: brachiocephalic, left common carotid, left subclavian Pulmonary artery and veins Superior Vena Cava What percentage of aortic injuries die on scene? - correct answer 80% Of the patients with aortic injuries that make it to the hospital, how many will die within 6 hours? - correct answer 30% Of the patients with aortic injuries that make it to the hospital, how many will die with 24 hours? - correct answer 40% What is the mortality rate in patients with pulmonary vascular trauma? - correct answer 60% TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) Of patients with great vessel injuries, what percentage are asymptomatic? - correct answer 30-50% What are the subjective symptoms of great vessel injuries? - correct answer Chest pain (ripping or tearing) Radiates through to the back Difficulty breathing Vagal complaints Dysphagia What are the objective symptoms of great vessel injuries? - correct answer Signs of hemorrhagic shock Dyspnea Asymmetric pulse pressure (stronger upper extremity pulses as opposed to femoral pulses) Vascular bruits over precordium or intrascapular region Focal neurological findings Hoarseness TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) What injury does asymmetric pulse pressure indicate? - correct answer Vascular injury to the descending aorta What are the treatments for great vessel injuries? - correct answer Keep the patient calm and quiet Type and cross 10 units of blood (assure blood is readily available) Beta-blockade with a goal of: SBP: 80-100 and HR 60-80 Operative management Describe fractures of upper ribs (1st and 2nd). - correct answer Protected by surrounding tissue and requires great force to fracture. Fractures of 1st and 2nd ribs are usually associated with what other injuries? - correct answer Lungs, trachea, aortic arch, great vessels, vertebral column Describe fractures of ribs 3 through 9. - correct answer Challenges include pain management, ineffective ventilation and secretion retention. TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) 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? - correct answer Rib fractures in children are often associated with abuse What should be considered with rib fractures in the older population? - correct 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? - correct answer 6-48 hours after the trauma List the symptoms of pulmonary contusions - correct answer Reduction of PaO2 (below 60 mmHg on room air) Signs of respiratory distress (increased HR and RR) TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) 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? - correct 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? - correct answer Mobilize and clear blood and secretions (chest physiotherapy, postural drainage, mobilization) What is the term for excess air in the pleural space? - correct answer Pneumotherax TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) What are the sources of pneumothorax and their frequency? - correct answer Pulmonary laceration (71%) Tracheobronchial Injury (13%) Esophagus (7%) External wound or open pneumothorax (7%) What are the symptoms of an open pneumothorax? - correct 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? - correct answer Severe respiratory distress Significantly diminished or absent breath sounds on the affected side Signs of obstructive shock What are the signs of obstructive shock associated with a tension pneumothorax? - correct answer anxiety or severe restlessness hypotension TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) Pneumothorax - sharp pain which may radiate to the shoulder on the side of the pneumothorax Describe the differences in fremitus of a hemothorax and pneumothorax - correct answer Hemothorax - fremitus is absent over fluid Pneumothorax - fremitus is decreased over air Describe the differences in breath sounds between a hemothorax and pneumothroax. - correct answer Breath sounds are decreased over both. Describe the differences in percussion of a hemothorax and percussion of a pneumothorax. - correct answer Hemothorax - hypo-resonance Pneumothorax - hyper-resonance How are treatments of hemothorax and pneumothroax determined? - correct answer Based on size, symptoms and patient stability What is the treatment for an asymptomatic and stable pneumothorax? - correct answer Supplemental oxygen (promotes reabsorption of pleural air) TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) Observe for deterioration What is the treatment for an asymptomatic and stable hemothorax? - correct answer IV Encourage deep breathing Observe for deterioration What are the treatments for a patient with indications of instability in a pneumothorax? - correct answer Support oxygenation / ventilation (oxygen administration) Chest Tube placement Consider Thoracotomy What are the treatments for a patient with indications of instability in a hemothorax? - correct answer Support oxygenation/ventilation Chest Tube Placement Consider Thoracotomy Treat hypovolemic shock Blood loss replacement / autotransfusion TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) List the factors of care for the chest drainage set. - correct answer Maintain the drainage set below the level of the chest. Keep the unit upright Prevent dependent loops Describe bubbling in a patent system. - correct 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? - correct answer Tubing is kinked Obstruction (clot in the tubing) Pneumothorax has re-expanded What is the pneumonic FOCA and what is it used for? - correct answer FOCA is used for problem solving for chest tubes. F - presnece of fluctuation O - Output C - Color A - Presence of Air Leak TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) 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? - correct 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_____. - correct answer Usually starts within 24 hours Markedly decreased oxygenation TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) 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? - correct answer Frequently irreversible with fibrosis, atelectasis and recurrent pneumonia Hypoxemia is refractory to increased oxygenation Decreased lung compliance Patient often dies within two weeks with multi-organ dysfunction syndrome Many ARDS survivors have _____. - correct answer Lasting lung damage In treatment of ARDS, vent settings: Tidal volume should be_____. - correct answer 6-10 mL/kg Permissive hypercapnia PaCO2 65-85 tolerated unless there is increased ICP TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) In treatment of ARDS, vent settings for end-expiratory plateau pressure should be _____. - correct answer <30 cm H2O Barotrauma and air leaks above this limit In the treatment of ARDS, vent settings for PEEP (positive end- expiratory pressure) should be _____. - correct answer 10-15 cm H2O Consider early prone positioning In treatment of ARDS, vent settings for RR should be _____. - correct answer 18-24 breaths per minute Higher than normal limits, hypercapnia In treatment of ARDS, vent settings inspiratory:expiratory ratio should be _____ - correct answer 1:2 to 1:1 Check for inadvertent PEEP In treatment of ARDS, vent settings FiO2 should be _____. - correct answer <60-80% Goal PaO2 40-60 TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) 50-75% _____% of gunshot wounds penetrate the peritoneum. - correct answer 85% _____% of gunshot wounds result in significant abdominal trauma. - correct answer 68-94% Penetration below the nipple line may cause _____. - correct answer Abdominal or chest trauma or both _____ carries a higher rate of infection than other penetrating trauma. - correct answer Impalement Shoulder restraints cause _____ in the driver and _____ in the passenger. - correct answer Right-sided rib fractures with underlying visceral trauma Left-sided rib fractures TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) Underarm usage of shoulder restraints _____. - correct 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? - correct answer Seat-Belt Sign 33% of patients with seat-belt sign will have _____. - correct answer Associated small bowel injury Mesenteric tears Fractures of the lumbar spine Accuracy of abdominal assessment may be diminished with: - correct answer distracting injuries spinal cord injuries neuropathies from diabetes alcohol or drug use head injuries psychiatric problems TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) In the exam of a patient with abdominal trauma, nausea and vomiting are suspect for what injuries? - correct answer Peritoneal irritation, hypovolemia and obstructions In the exam of a patient with abdominal trauma, dyspnea is suspect for what injuries? - correct 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? - correct 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? - correct 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? - correct answer Fluid or blood irritating the peritoneum, ileus from spinal cord injury, or peritonitis TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) List two drawbacks of the FAST exam. - correct 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. - correct answer Diagnostic Peritoneal Aspiration (DPA) or Diagnostic Peritoneal Lavage (DPL) What should be placed prior to performing a DPL? - correct answer Catheter and Gastric Tubes Discuss the procedure of DPL. - correct 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) - correct answer Signs of hypovolemia with persistent hypotension in a patient for whom there is no other TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) reasonable explanation for blood loss, or intra-abdominal injury is strongly suspected. Ongoing hemodynamic instability More than 2 units of blood required to maintain hemodynamic stability Clear and persistent signs of peritoneal irritation Radiological evidence of pneumoperitoneum consistent with viscus rupture. Persistent, significant gastrointestinal bleeding seen in the gastric tube return, vomitus, or gross blood per rectum. Evisceration List some symptoms of abdominal trauma that are indications for non- operative management. - correct answer Solid organ injuries are less likely to require surgical intervention when compared to hollow organ injuries. Hymodynamically stable Stable hemoglobin levels during the first 12-48 hours. Less than 2 units of PRBC's Less than 55 years old Alert and able to interact during abdominal examination. TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) List three important factors in post-operative abdominal surgical monitoring. - correct answer Progressive anemia Hypotension / Tachycardia Failure to correct base defecit despite volume resuscitation. List the signs of abdominal compartment syndrome. - correct answer Decreased urinary output Increased central venous pressures Increased pulmonary artery wedge pressures Increased systemic vascular resistance Decreased blood pressure Decreased tidal volume Respiratory Acidosis What is usually the initial indication of abdominal compartment syndrome? - correct answer Decreased urinary output What are the effects of intra-abdominal pressure above 20 mmHg? - correct answer Increased ICP TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) Consider diuresis Percutaneous catheter decompression for patients with intraperitoneal fluid, abscess or blood Bedside or operative decompression Describe the symptoms of pain in peritonitis. - correct answer Diffuse, Guarding, Rebound Tenderness, Worse with movement or pain, Relieved by flexion of the knees, positive Markle test Describe a Markle Test. - correct 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? - correct answer Pain Rigid washboard abdomen Fluid shifting with dehydration, electrolyte imbalances and respiratory difficulties TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) What is the treatment for peritonitis? - correct 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. - correct 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. - correct answer Pain Abdominal tenderness and guarding Nausea, vomiting and anorexia Fever and tachycardia What is the term for bruising in the flanks? - correct answer Gray- Turner Sign What is the term for bruising around the umbilicus? - correct answer Cullen Sign TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) List some characteristics of Pancreatitis: - correct 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) - correct 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? - correct answer IV fluid resuscitation as needed Analgesia (morphine should be avoided) Antiemetics IV calcium PRN Antibiotics for abscess or sepsis TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) Esophageal strictures A stomach injury is more common in _____ trauma (20%) versus _____ trauma (1%). - correct answer penetrating blunt Stomach injury is _____ an isolated injury in blunt trauma. - correct answer Rarely Due to _____, the stomach has low bacterial growth. - correct answer Acidity List the symptoms of a stomach injury. - correct answer Bloody drainage from gastric tube Tenderness (primarily epigastric) Free air on the x-ray initial pain due to chemical irritation, later pain due to bacterial peritonitis What are some common complications of a stomach injury? - correct answer Peritonitis TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) Intra-abdominal abscess formation Gastric fistulas What is the encapsulated, dense organ with little elasticity and flexibility, making it the most frequently injured organ from blunt trauma? - correct answer Spleen The spleen stores _____ of blood, which can be released in a significant injury, and another _____ of blood circulates through the spleen each minute. - correct answer 200-300 mL 250 mL Subcapsular hematoma <10% and a capsular laceration <1 cm parenchymal depth describe what grade of splenic injury? - correct answer Grade 1 Subcapsular hematoma 10%-50% surface area, intraparenchymal , <5cm in diameter describes what grade of splenic injury? - correct answer Grade 2 TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) Capsular tear, 1-3 cm parenchymal depth that does not involve a trabecular vessel describes what grade of splenic injury? - correct answer Grade 2 Subcapsular hematoma >50% surface area or expanding/ ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma > 5cm or expanding, describe what grade of splenic injury? - correct answer Grade 3 A laceration >3 cm parenchymal depth or involving trabecular vessels describes what grade of splenic injury? - correct answer Grade 3 A spleen laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen) describes what grade of splenic injury? - correct answer Grade 4 A completely shattered spleen or laceration to hilar vascular injury devascularizing the spleen describes what grade of splenic injury? - correct answer Grade 5 In regard to spleen injuries, if splenic blood remains capsular it is known as a _____. - correct answer Hematoma TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) splenectomy and every _____ years thereafter. - correct answer encapsulated bacteria vaccinated 5 List some encapsulated bacteria. - correct 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 _____. - correct 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. - correct answer 13 TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) Liver lies under ribs _____ on the right, then crosses the midline and lies under ribs _____ on the left. - correct answer 6-10 7-8 The _____ is the largest abdominal organ and weighs _____. - correct answer Liver 3-4 pounds What grade of liver injury has a subcapsular, non expanding hematoma with <10 cm surface area? - correct answer Grade 1 What grade of liver injury has a capsular nonbleeding laceration that is <1 cm parenchymal bleeding? - correct 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? - correct 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? - correct answer Grade 2 TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) 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? - correct answer Grade 3 What grade of liver injury has a laceration >3 cm parenchymal depth? - correct answer Grade 3 Describe a hematoma in a Grade 4 liver injury? - correct answer Ruptured intraparenchymal hematoma with active bleeding. Describe a laceration in a Grade 4 liver injury. - correct answer Parenchymal disrupion involving 25-75% of hepatic lobe. Describe a laceration in a Grade 5 liver injury. - correct answer Parenchymal disruption involving >75% of hepatic lobe A liver injury with a justahepatic venous injury is considered what grade? - correct answer Grade 4 TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) High Is a pancreatic injury more common in penetrating or blunt trauma? - correct answer Penetrating What are the symptoms of pancreatic trauma? - correct answer Elevated amylase levels (delayed and does not always occur) Abdominal tenderness to deep palpation Pain often radiates through to the back May be pain-free initially, with increasing epigastric pain within 48 hours of injury What are the non-operative treatments for pancreatic trauma? - correct answer Complete bowel rest Nutritional Support Serial CT scans with observation How are pancreatic pseudocysts treated? - correct answer Percutaneous drainage TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) How are pancreatic ductal injuries treated? - correct answer Distal pancreatectomy What are some inpatient complications associated with a pancreatic injury? - correct answer Secondary Hemorrhage Pancreatic Fistula Abdominal Abscess Pancreatitis Infection Infection is most common _____ days after pancreatic injury. Infection presents as _____. (3) - correct answer 7-10 days Fever Elevated WBC Nausea and Vomiting _____ injuries are commonly associated with pancreatic, bile duct and vena cava trauma. - correct answer Duodenal TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) The duodenum is in the _____, therefore, injuries frequently lack peritoneal signs. - correct answer Retroperitoneum Duodenal hematomas typically become evident _____ days after trauma, presenting as a vague _____. - correct answer 5-7 days Abdominal pain and vomiting _____ _____ usually have acute pain and tenderness immediately after trauma. - correct answer Duodenal perforations Content of small bowel has _____ pH and is _____; therefore, clinical findings of injury may be delayed. - correct answer Neutral Relatively sterile What are the common points of injury in the small bowel? - correct answer Ligament of Trietz Ileocecal Valve Hematomas from small bowel injuries may cause _____. - correct answer Bowel obstructions TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) What are the symptoms of large bowel trauma? - correct answer Evisceration Peritoneal Irritation Hypovolemic Shock What are the symptoms of rectal trauma? - correct 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? - correct answer Early recognition of injury and control of fecal contamination What are the treatments for significant large bowel trauma? - correct answer Irrigation to remove fecal material Primary bowel repair (resection and anastomosis) Diverting colostomy (may be closed within weeks with uncomplicated healing) TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) Pre-operative antibiotic therapy _____. - correct answer Reduces sepsis from enteric contamination What is the treatment for significant rectal trauma? - correct answer Colostomy and distal rectal washout What are some complications of large bowel and rectal trauma? - correct answer Incisional infection (delayed skin closure considered for major fecal contamination) Intra-abdominal abscess Fecal fistula List the 3 types of pelvic fractures. - correct answer Lateral compression Anterior-posterior compression Vertical Shear What is the common mechanism and frequency of a lateral compression pelvic fracture? - correct answer MVC 60-70% TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) What is the common mechanism and frequency of a anterior-posterior compression pelvic fracture? - correct answer Auto vs. Ped 15-20% What is the common mechanism and frequency of a vertical shear pelvic fracture? - correct answer Fall from height 5-15% Define an open pelvic fracture. - correct answer Laceration or puncture of the skin OR opening into the rectum or vaginal vault Describe a stable pelvic fracture. - correct answer Weight bearing ligaments intact Less likely to have associated injuries Describe an unstable pelvic fracture. - correct answer Weight bearing ligaments affected. Two or more fractures of the pelvic ring with outward rotational displacement TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) Urethra often tears away from _____. In this case consider pelvic fracture or vaginal trauma with urethral trauma. - correct answer Head of the bladder What are the symptoms of urethral trauma? - correct answer Rebound tenderness in the suprapubic area Urge to urinate with an inability to void Blood in the urinary meatus High-riding prostate Pelvic, perineal, or scrotal hematoma (butterfly ecchymotic area) What is the main goal of treatment in urethral trauma? - correct answer Maintain patency of urethra and continence If urethral trauma is suspected, DO NOT _____. Why? - correct answer Catheterize Can cause a partial tear to become a complete tear In urethral tears, if the patient can void spontaneously, the tear is likely _____. - correct answer Partial TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) If there is a heightened suspicion for urethral trauma, a _____ should be considered. - correct answer Retrograde urethrogram In cases of suspected/confirmed urethral damage, _____ is recommended. - correct answer suprapubic catheter What are the complications of urethral trauma? - correct 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. - correct answer Dome The fuller the bladder, the _____. - correct answer Higher the risk on injury TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) _____ is commonly associated with pelvic fractures and a _____ at the time of trauma. - correct answer Bladder trauma Full bladder Children under _____ are more vulnerable to bladder trauma because _____. - correct answer 6 the bladder is an abdominal organ What are the common co-existing injuries with bladder trauma? - correct answer bowel lacerations lacerations of the vena cava mesenteric and renal iliac arteries and veins List the symptoms of bladder trauma. - correct answer Abdominal distension, guarding or rebound tenderness Inability to void Suprapubic pain that may radiate to the shoulder Ecchymosis around the bladder and thighs TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) Fistula/abscess Uroascites with respiratory compromise Sepsis What are the common mechanisms of renal trauma? - correct answer Blunt injury to the flank Deceleration forces Fall from significant heights Renal trauma occurs in _____% of patients with abdominal trauma. - correct answer 10% The majority of renal trauma is _____. - correct answer Contusions Penetrating trauma to the _____, _____, and _____ also raise the index of suspicion for renal trauma. - correct answer Flank Pelvis Lower Chest TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) Except for the _____, the kidney is fairly mobile. - correct answer Renal Pedicle Describe a Grade 1 Renal Injury. - correct answer Contusion / Subcapsular hematoma with no parenchymal laceration What grade of renal trauma has a laceration <1 cm depth of renal cortex and no urinary extravasation? - correct answer Grade 2 Describe a Grade 3 renal injury. - correct answer Laceration > 1 cm depth of renal cortex with no urinary extravasation. What grade of renal trauma has a laceration extending through the renal cortex, medulla and into the collection system? Associated with minor renal artery or vein injury with contained hematoma. - correct answer Grade 4 Describe a Grade 5 Renal Injury. - correct answer Shattered kidney Devascularized kidney, hilar avulsion TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) What are the symptoms of renal injuries? - correct answer Flank tenderness Costovertebral angle tenderness Frank or microscopic hematuria Palpable flank mass Ecchymosis over the flank at the level of the 11th and 12th ribs Abnormal blood urea nitrogen and creatinine levels What diagnostic test is used in stable patients with renal injuries? - correct answer IVP Introvenous pyelogram What diagnostic test is used in patients with hematuria? Why? - correct answer CT Contrast media can cause damage to an already compromised kidney Renal trauma treatment is similar to _____ for non-operative treatment and monitoring. - correct answer splenic/hepatic trauma TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) 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? - correct 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? - correct answer Post-renal failure What is the expected specific gravity for pre-renal, intra-renal and post- renal failure? - correct 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? - correct 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? - correct answer Pre = Normal TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) Intra = Renal tubule cells and cell casts Post = Normal What is the expected Protein content for pre-renal, intra-renal and post- renal failure? - correct answer Less than 1g/24 hours for all. What is the exptected RBC count for pre-renal, intra-renal and post- renal failure? - correct answer Microscopic for all What is the expected WBC count for pre-renal, intra-renal and post- renal failure? - correct answer Few for all What is the hallmark sign of renal failure? - correct answer Decreased urinary output _____ is considered a more accurate reflection of renal function than creatinine levels. - correct answer Creatinine Clearance Overall, a doubling of creatinine levels equates to _____. - correct answer Halving glomerular filtration TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) Why is BUN not an accurate test for renal failure? - correct 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. - correct answer 10:1 Elevated serum _____ is indicative of renal failure. - correct answer Potassium Describe 2 additional symptoms of renal failure. - correct answer Delated decreasing H/H Hypertension What are the initial treatments for renal failure? - correct answer Fluid administration Inotropes, Vasopressors, Diuretics If the initial treatments of renal failure (fluids and inotropes, vasopressors, diuretics) are unsuccessful, consider _____, _____ or _____. - correct answer Renal artery thrombosis TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) OB trauma during the first trimester carries a _____ % chance of maternal or fetal injury. - correct answer 10-15% OB trauma during the second trimester carries a _____% chance of maternal or fetal injury. - correct answer 32-40% OB trauma during the third trimester carries a _____% chance of maternal or fetal injury. - correct answer 50-54% During pregnancy, maternal oxygen consumption does what? - correct answer Increases 15-20% During pregnancy, respiratory rate increases causing: - correct answer PCO2 to be 27-32 (respiratory alkalosis) Bicarbonate to be 18-22 Slight respiratory alkalosis is normal During pregnancy, tidal volume and minute ventilation do what? - correct answer Increase by about 40% TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) During pregnancy, the diaphragm elevates _____, contributing to a _____ in functional residual capacity. - correct answer 4 cm 20-25% decrease In pregnancy, having an elevated diaphragm makes _____ more difficult. - correct answer bag-mask ventilation During pregnancy, the fetus will oxygenate from maternal circulation until maternal PaO2 drops below _____, then fetal oxygenation _____. - correct answer 60 mmHg Drops precipitously During pregnancy, blood volume increases by _____. - correct answer 50% In regard to the 50% blood volume increase during pregnancy, the main increase is _____. - correct answer Plasma During pregnancy, RBC's increase only by _____. - correct answer 30% TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) What is the blood volume in pre-pregnancy, the first trimester, second trimester and third trimester? - correct answer Pre-pregnant = 4000 mL First trimester = 4200 mL Second trimester = 5000 mL Third trimester = 5600 mL Because of increased blood volume during pregnancy, signs of shock may not be evident until _____ of blood is lost. - correct answer 2L In OB trauma, the mother's condition rapidly deteriorates when blood loss exceeds _____. - correct answer 3500 mL Compare heart rates in pre-pregnancy, first trimester, second trimester and third trimester. - correct answer Pre = 70 1st = 78 2nd = 82 3rd = 85 Compare SBP and DBP in pre-pregnancy, first trimester, second trimester and third trimester. - correct answer Pre = 115/70 TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) _____ and _____ are more common in pregnancy, but _____ is less common. - correct answer Splenic Liver Small Bowel In pregnancy, urinary frequency changes due to _____. - correct 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. - correct answer Protective ring of the pelvis What are the maternal and fetal mortality rates with pelvic fractures? - correct answer Maternal (9% of the time) Fetal (35% of the time) _____ of severe trauma results in abruption - correct answer 40% _____ of minor trauma results in abruption. - correct answer 1-5% TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) _____ of fetal death from MVC is secondary to abruption. - correct answer 50-70% What are the symptoms of placental abruption? - correct 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. - correct 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? - correct answer Treatment ranges from observation to C-section TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) Uterine rupture is a _____ injury which results in fetal death nearly _____% of the time and maternal death _____% of the time. - correct answer Rare 100% 10% What are the symptoms of a uterine rupture? - correct 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 _____. - correct answer More obvious More difficult to detect TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) At 12 weeks gestation, where is the fundal height? - correct answer Symphysis Pubis At 20 weeks gestation, where is the fundal height? - correct answer Umbilicus At 40 weeks gestation, where is the fundal height? - correct answer Xyphoid process In emergent care of the pregnant trauma patient, what are the airway considerations? - correct answer Increased risk of aspiration Protect the cervical spine In intubation with RSI, consider fetal respiratory depression if delivery is imminent In the emergent care of the pregnant trauma patient, what are the breathing considerations? - correct answer Normal blood gas = slight respiratory alkalosis Slight tachypnea is normal Poor respiratory reserve - apply oxygen and consider intubation early TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) Chest tube placed 1-2 intercostal spaces higher to prevent diaphragmatic injury In the pregnant trauma patient, because of _____, fetus may show distress before alteration in maternal blood pressure. - correct answer selective uterine vasoconstriction In the pregnant trauma patient, because of _____, maternal distress may not show up until hemorrhage of _____, and the fetus can be severely distressed by then. - correct answer increased serum 1500-2000 mL Uterine flow comprises _____% of cardiac output, therefore the uterus is a potential source of significant blood loss. - correct answer 20% What are the 5th vital sign of pregnancy? - correct answer FHT (fetal heart tones) In FHT, normal is _____. Early distress = _____. Late distress = _____. - correct answer 120-160 bpm TCRN Review - Trunk (Thoracic Trauma, Abdominal Trauma, Genitourinary Trauma, Obstetrical Trauma) (questions and answers ) fetal tachycardia fetal bradycardia Tip backboard _____% in all patients who are more than _____ weeks pregnant to prevent Venocaval Compression Syndrome. - correct answer 20% 20 Weeks In the pregnant trauma patient, the abdomen is less sensitive to palpation and a ____ should be considered. - correct answer FAST exam In the pregnant trauma patient, why should the fundus be checked and marked? - correct answer Usually elevated fundus may indicate concealed uterine bleeding. In the pregnant trauma patient, clear fluid in the vaginal vault should be tested with _____. - correct answer Nitrazine paper What is the pH of amniotic fluid? - correct answer 7.5