Trauma Assessment and Management, Exams of Nursing

Download Trauma Assessment and Management and more Exams Nursing in PDF only on Docsity! NURS TNCC Final Exam Test 2024/2025 COMPLETE 8TH EDITION Open Book WITH VERIFIED Questions and 100% Correct Answers A+ A+ Expedite transfer to the closest trauma center - ANSWER>>>A 56 y/o M pt involved in a motor vehicle crash is brought to the ED of a rural critical access facility. He complains of neck pain, SOB, and diffuse abd pain. His GCS is 15. His VS: BP 98/71, HR 125, RR 26, SpO2 94% on high-flow O2 via NRB mask. Which of the following is the priority intervention for this patient? a pertinent medical hx is crucial - ANSWER>>>Which of the following considerations is the most important when caring for a geriatric trauma pt? Mitigation - ANSWER>>>Following a review of recent drills and a real disaster event, a hospital has identified deficiencies and is taking steps to minimize the impact of a future disaster . Which phase of the disaster life cycle does this describe? Alcohol All tools and guidelines require the patient to be awake, alert, not under the influence of any substances, and without neurologic abnormalities - ANSWER>>>EMS brings a pt who fell while riding his bicycle. Using the American College of Surgeons screening guidelines, which assessment finding would prompt the RN to prepare the pt for a radiologic spine clearance? hemoglobin does not readily release O2 for use by the tissues - ANSWER>>>What is the effect of hypothermia on the oxyhemoglobin dissociation curve? acidosis - ANSWER>>>Which of the following is a component of the trauma triad of death? Complete - ANSWER>>>EMS brings a pt from MVC. VS: BP 90/49, HR 48, RR 12, temp 97.2F (36.2 C). The pt exhibits urinary incontinence and priapism. These assessment findings are most consistent with which of the following types of spinal cord injury? flucuation in the water seal chamber - ANSWER>>>Which of the following is an expected finding in a pt with a tube thoracstomy connected to a chest drainage system? insert an oropharyngeal airway if there is no gag reflex - ANSWER>>>During the primary survey of an unconscious pt with multi-system trauma, the nurse notes snoring respirations. What priority nursing interventions should be preformed next? globe rupture - ANSWER>>>A 35 y/o M presents with facial trauma after being struck in the face with a baseball. A teardrop-shaped left pupil is noted on exam. What type of injury is suspected? compensated - ANSWER>>>A trauma pt is restless and repeatedly asking "where am i?" VS upon arrival: BP 110/60, HR96, RR 24. Her skin is cool and dry. Current VS are BP 104/84, HR 108, RR 28. The pt is demonstrating s/sx of which stage of shock? ventilate with a bag mask device - ANSWER>>>An unresponsive trauma pt has an oropharygeal airway in place, shallow and labored respirations, and dusky skin. The trauma team has administered medications for drug-assisted intubation and attempted intubation but was unsuccessful. What is the most appropriate immediate next step? within 24 hrs of trauma - ANSWER>>>When is the tertiary survey completed fora trauma pt? pressure - ANSWER>>>An intubated and sedated pt in the ED has multiple extremity injuries with the potential for causing compartment syndrome. What is the most reliable indication of compartment syndrome in a patient who is unconscious? worsening pneumothorax - ANSWER>>>Which of the following is possible complication of positive- pressure ventilation? pelvic stability - ANSWER>>>the most reassuring finding for a male pt with hip pain after a fall is which of the following? narrowed - ANSWER>>>Which of the following pulse pressures indicate early hypovolemic shock? dysrhythmias - ANSWER>>>Patients with a crush injury should be monitored for which of the following conditions? subdural hematoma - ANSWER>>>Tearing of the bridging veins is most frequently associated with which brain injury? straight cath for urine sample - ANSWER>>>A 20 y/o M presents to the ED complaining of severe lower abd pain after landing hard on the bicycle cross bars while preforming an aerial BMX maneuver. Secondary assessment reveals lower abd tenderness and scrotal ecchymosis. Which of the following orders would the RN question? placental abruption - ANSWER>>>You are caring for a pt who was involved in a MVC and is 32 weeks pregnant. Findings of your secondary survey include abd pain on palpation, fundal ht at the costal after a physical examination if the pt has no radiologic abnormalities on CT - ANSWER>>>EMS arrives with the intoxicated driver of a car involved in a MVC. EMS reports significant damage to the drivers side of the car. The pt is asking to have the cervical collar removed. When it is appropriate to remove the cervical collar? MARCH - ANSWER>>>Which of the following mnemonics can help the nurse prioritize care for a trauma patient with massive uncontrolled hemorrhage? What is kinematics? - ANSWER>>>A branch of mechanics (energy transfer) that refers to motion and does not consider the concepts of force and mass of the object or body. What is Newton's First Law? - ANSWER>>>A body at rest will remain at rest. A body in motion will remain in motion until acted on by an outside force. What is the Law of Conservation of Energy? - ANSWER>>>Energy can neither be created nor destroyed. It is only changed from one form to another. What is Newton's Second Law? - ANSWER>>>Force equals mass multiplied by acceleration of deceleration. What is kinetic energy (KE)? - ANSWER>>>KE equals 1/2 the mass (M) multiplied by the velocity squared. What is the Mnemonic for the Initial Assessment? - ANSWER>>>A = Airway with simultaneous cervical spine protection B = Breathing C = Circulation D = Disability (neurologic status) E = Expose/Environmental controls (remove clothing and keep the patient warm) What is the Mnemonic for the Secondary Assessment? - ANSWER>>>F = Full set of VS/Focused adjuncts (includes cardiac monitor, urinary catheter, and gastric tube)/Family presence G = Give comfort measures (verbal reassurance, touch, and pharmacologic and nonpharmacologic management of pain). H = Hx and Head-to-toe assessment I = Inspect posterior surfaces Where do you listen to auscultate breath sounds? - ANSWER>>>Auscultate the lungs bilaterally at the second intercostal space midclavicular line and at the fifth intercostal space at the anterior axillary line. What are the late signs of breathing compromise? - ANSWER>>>- Tracheal deviation - JVD What are signs of ineffective breathing? - ANSWER>>>- AMS - Cyanosis, especially around the mouth - Asymmetric expansion of chest wall - Paradoxical movement of the chest wall during inspiration and expiration - Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing - Sucking chest wounds - Absent or diminished breath sounds - Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated - Anticipate definitive airway management to support ventilation. Upon initial assessment, what type of oxygen should be used for a pt breathing effectively? - ANSWER>>>A tight-fitting nonrebreather mask at 12-15 lpm. What intervention should be done if a pt presents with effective circulation? - ANSWER>>>- Insert 2 large caliber IV's - Administer warmed isotonic crystalloid solution at an appropriate rate What are signs of ineffective circulation? - ANSWER>>>- Tachycardia - AMS - Uncontrolled external bleeding - Pale, cool, moist skin - Distended or abnormally flattened external jugular veins - Distant heart sounds What are the interventions for Effective/Ineffective Circulation? - ANSWER>>>- Control any uncontrolled external bleeding by: - Applying direct pressure over bleeding site - Elevating bleeding extremity - Applying pressure over arterial pressure points - Using tourniquet (last resort). - Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution - Use warmed solution - Use pressure bags to increase speed of IVF infusion - Use blood administration tubing for possible administration of blood - Use rapid infusion device based on protocol - Use NS 0.9% in same tubing as blood product - IV = surgical cut-down, central line, or both. - Blood sample to determine ABO and Rh group - IO in sternum, legs, arms or pelvis - Administer blood products - PASG (without interfering with fluid resuscitation) How do you assess Mnemonic "D"? - ANSWER>>>DISABILITY A = Alert V = Verbal P = Pain U = Unresponsive - GCS - PERRL? - Determine presence of lateralizing signs including: - Unilateral deterioration in motor movements or unequal pupils - Symptoms that help to locate area of injury in brain What are the interventions for Disability? - ANSWER>>>- If assessment indicates a decreased LOC, conduct further investigation during secondary focused assessments - If pt is not alert or verbal, continue to monitor for any compromise to ABC's - If pt demonstrates signs of herniation or neurologic deterioration, consider hyperventilation. What is assessed and intervened for Expose/Environmental Controls? - ANSWER>>>- Remove clothing - Ensure appropriate decontamination if exposed to hazardous material - Keep pt warm - Keep clothing for evidence What is the first thing assessed under the Secondary Assessment? - ANSWER>>>FULL SET VS / FOCUSED ADJUNCTS / FAMILY PRESENCE - ABCDE should be completed - Labs, X-rays, CT, Foley, - Family Presence What is the second thing assessed under the Secondary Assessment? - ANSWER>>>GIVE COMFORT MEASURES What is a Combitube? - ANSWER>>>A dual-lumen, dual-cuff airway that can be placed blindly into the esophagus to establish an airway. If inadvertently placed into trachea, it can be used as a temporary ET tube. There are only two sizes: small adult and larger adult. What is a Laryngeal Mask Airway? - ANSWER>>>Looks like an ET tube but is equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to cover the supraglottic area. ILMA, does not require laryngoscopy and visualization of the chords. What is Needle Cricothyrotomy - ANSWER>>>Percutaneous transtracheal ventilation. (temporary) Complications include: - inadequate ventilation causing hypoxia - hematoma formation - esophageal perforation - aspiration - thyroid perforation - subcutaneous emphysema What is Surgical Cricothyrotomy? - ANSWER>>>Making an incision in cricothyroid membrane and placing a cuffed endo or trach tube into trachea. This is indicated when other methods of airway management have failed and pt cannot be adequately ventilated and oxygenated. Complications include: - Aspiration - Hemorrhage or hematoma formation or both - Lac to trachea or esophagus - Creation of a false passage - Laryngeal stenosis How do you confirm ET Tube/Alternative Airway Placement? - ANSWER>>>- Visualization of the chords - Using bronchoscope to confirm placement - Listening to breath sounds over the epigastrum and chest walls while ventilating the pt - CO2 detector - Esophageal detection device - Chest x-ray How do you inspect the chest for adequate ventilation? - ANSWER>>>Observe: - mental status - RR and pattern - chest wall symmetry - any injuries - patient's skin color (cyanosis?) - JVD or tracheal deviation? (Tension pneumothorax) What are you looking for when auscultating lung sounds? - ANSWER>>>Absence of BS: - Pneumothorax - Hemothorax - Airway Obstruction Diminished BS: - Splinting or shallow BS may be a result of pain What are you looking for when percussing the chest? - ANSWER>>>Dullness: - hemothorax Hyperresonance - Pneumothorax What are you looking for when palpating the chest wall, clavicles and neck? - ANSWER>>>- Tenderness - Swelling - subcutaneous emphysema - step-off deformities = These may indicate: esophageal, pleural, tracheal or bronchial injuries. Palpate trachea above suprasternal notch. Tracheal deviation may indicate a tension pneumothorax or massive hemothorax. What is the DOPE mnemonic? - ANSWER>>>D - Displaced tube O - Obstruction: Check secretions or pt biting tube P - Pneumothorax: Condition may occur from original trauma or barotrauma from ventilator E - Equipment failure: pt may have become detached from equipment or there's a kink in the tubing Explain Hypovolemic Shock. - ANSWER>>>Most common to affect a trauma pt cause by hypovolemia.. Hypovolemia, a decrease in amount of circulating blood volume, may result from significant loss of whole blood because of hemorrhage or from loss of semipermeable integrity of cellular membrane leading to leakage of plasma and protein from intravascular space to the interstitial space (as in a burn). Some causes: - Blood loss - Burns, etc. Explain Cardiogenic Shock. - ANSWER>>>Syndrome that results from ineffective perfusion caused by ineffective perfusion caused by inadequate contractility of cardiac muscle. Some causes: - MI - Blunt cardiac injury - Mitral valve insufficiency - dysrhythmias - Cardiac Failure Explain Obstructive Shock. - ANSWER>>>Results from inadequate circulating blood volume because of an obstruction or compression of great veins, aorta, pulmonary arteries, or heart itself. Some causes: - Cardiac tamponade (may compress the heart during diastole to such and extent that atria cannot adequately fill, leading to decreased stroke volume). - Tension pneumothorax may lead to inadequate stroke volume by displacing inferior vena cava and obstructing venous return to right atrium. - Air embolus may lead to obstruction of pulmonary artery and subsequent obstruction to right ventricular outflow during systole, with resulting obstructive shock Explain Distributive Shock. - ANSWER>>>Results from disruption in SNS control of the tone of blood vessels, which leads to vasodilation and maldistribution of blood volume and flow. (Neurogenic and Septic Shock). Neurogenic shock may result from injury to spinal cord in cervical or upper thoracic region. - Assess jugular veins and peripheral veins Auscultate: - BP - Pulse pressure - Breath sounds - Heart sounds - Bowel sounds Percuss: - Chest and abdomen Palpate: - Central pulse (carotid or femoral) - Positive inotropic effect (force of contraction) may be evidence by a bounding central pulse - Palpate peripheral pulses - Palpate skin temp and moisture Diagnostic Procedures: - Xrays and other studies - Labs Planning and Implementation - Oxygen - IV's with warmed replacement fluids - Control external bleeding with direct pressure - Elevate LE's - NGT - Foley - Monitor and pulse oximeter - Monitor for development of coagulopathies - Surgery? ICP is a reflection of what three volumes? What happens when one increases? - ANSWER>>>1. Brain 2. CSF 3. Blood within the nonexpansible cranial vault As volume of one increases, the volume of another decreases to maintain ICP within normal range. As ICP rises, CPP decreases, leading to cerebral ischemia and potential for hypoxia and lethal secondary insult. Hypotensive pt w/marginally elevated ICP can be harmful. Slightly elevated BP could protect against brain ischemia in a pt with high ICP. Cerebral ischemia can lead to increased concentration of CO2 and decreased concentration of O2 in cerebral vessels. CO2 dilates cerebral blood vessels = increase blood volume and ICP. What are the early signs and symptoms of increased ICP? - ANSWER>>>- Headache - N/V - Amnesia regarding events around the injury - Altered LOC - Restlessness, drowsiness, changes in speech, or loss of judgement What are the late observable signs of symptoms of increased ICP? - ANSWER>>>- Dilated, nonreactive pupil - Unresponsiveness to verbal or painful stimuli - Abnormal motor posturing patterns - Widening pulse pressure - Increased systolic blood pressure - Changes in RR and pattern - Bradycardia What is Cushing's phenomenon or Cushing's Reflex? - ANSWER>>>Triad of progressive HTN, bradycardia and diminished respiratory effort. What are the two types of herniation that occurs with ICP? - ANSWER>>>1. Uncal herniation 2. Central or transtentorial herniation Why does herniation occur? What are the symptoms? - ANSWER>>>Because of uncontrolled increases in ICP. S/E's - Unilateral or bilateral pupillary dilation - AsyDimmetric pupillary reactivity - Abnormal motor posturing - Other evidence of neurologic deterioration Define uncal herniation. - ANSWER>>>The uncus (medial aspect of the temporal lobe) is displaced over the tentorium into the posterior fossa. This herniation is the more common of the two types of herniation syndromes. Define central or transtentorial herniation. - ANSWER>>>A downward movement of the cerebral hemispheres with herniation of the diencephalon and midbrain through the elongated gap of the tentorium. Disruptions of the bony structures of the skull can result in what? - ANSWER>>>Displaced or nondisplaced fx's causing CSF leakage b/c of lac to the dura mater, creating a passage for CSF. CSF leaks through the nose (rhinorrhea) or the ears (otorrhea). A potential entrance for invading bacteria. Also: meningitis or encephalitis or brain abscess Define Minor Head Trauma. - ANSWER>>>GCS 13-15 Define Moderate Head Trauma - ANSWER>>>Postresuscitative state with GCS 9-13. Define Severe Head Trauma. - ANSWER>>>Postresuscitative state with GCS score of 8 or less. What is a concussion and its signs and symptoms? - ANSWER>>>A temporary change in neurologic function that may occur as a result of minor head trauma. S/S: - Transient LOC - H/A - Confusion and disorientation - Dizziness - N/V - Loss of memory - Difficulty with concentration - Irritability - Fatigue Chronic pt's " " up to 2 wks post injury - H/A - Progressive decrease in LOC - Ataxia - Incontinence - Sz's What are intracerebral hematoma's and its S/S? - ANSWER>>>Occur deep within brain tissue, may be single or multiple and commonly associated with contusions (frontal & temporal lobes). They result in significant mass effect, leading to increased ICP and neurologic deterioration. S/S: - Progressive and often rapid decline in LOC - H/A - Signs of increasing ICP - Pupil abnormalities - Contralateral hemiplegia What are the S/S of a linear skull fx? - ANSWER>>>- H/A - Possible decreased LOC What are the S/S of a depressed skull fx? - ANSWER>>>- H/A - Possible decreased LOC - Possible open fx - Palpable depression of skull over the fx site What are the S/S of a basilar skull fx? - ANSWER>>>- H/A - Altered LOC - Periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle's sign), or blood behind tympanic membrane (hemotympanum) - Facial nerve (VII) palsy - CSF rhinorrhea or otorrhea How would you assess a pt with a cranial injury? - ANSWER>>>(Initial assessment) INSPECTION: - Assess airway - RR, pattern and effort - Assess pupil size and response to light - Unilateral fixed and dilated pupil = oculomotor nerve compression from increased ICP + herniation syndrome - Bilateral fixed and pinpoint pupils indicate a pontine lesion or effects of opiates - Mildly dilated pupil w/sluggish response may be early sign of herniation syndrome - Widely dilated pupil occasionally occurs w/direct trauma to globe of eye - Determine if pt uses eye meds - Abnormal posturing? - Inspect craniofacial area for ecchymosis/contusions - Periorbital ecchymosis - Mastoid's process ecchymosis - Blood behind tympanic membrane - Inspect nose and ears for drainage - Drng present w/out blood, test drng w/chemical reagant strip. Presence of glucose indicated drng of CSF - If drng present and mixed with blood, test by placing drop of fluid on linen or gauze. If a light outer ring forms around dark inner ring, drng contains CSF - Assess extraocular eye movement (Tests cranial nerves, III, IV, VI) - Performing extraocular eye movements indicates functioning brainstem - Limitation indicates orbital rim fx w/entrapment or paralysis of either a cranial nerve or ocular muscle - Determine LOC with GCS PALPATION - Palpate cranial area for: - Point tenderness - Depressions or deformities - Hematomas - Assess all 4 extremities for: - Motor function, muscle strength and abnormal motor posturing - Sensory function DIAGNOSTIC PROCEDURES - Lab Studies PLANNING AND IMPLEMENTATION - (Initial assessment) - Clear airway (stimulation of gag reflex can produce transient increase in ICP or vomiting with subsequent aspiration. - Administer O2 via NRB - Assist with early ET intubation - Administer sedative/neuromuscular blocking agent - Consider hyperventilation - PaCO2 above 45 What are signs of a serious eye injury? - ANSWER>>>- Visual disturbances - Pain - Redness and ecchymosis of the eye - Periorbital ecchymosis - Increased intraocular pressure What is hyphema and its S/S? - ANSWER>>>Accumulation of blood, mainly RBC's that disperse and layer within the anterior chamber. A severe hymphema obscures entire anterior chamber + will diminish visual acuity severely or completely. Injuries are graded on amount of blood in chamber (Grades I-IV). S/S: - Blood in anterior chamber - Deep, aching pain - Mild to severe diminished visual acuity - Increased intraocular pressure What are s/s of chemical burns to the eye? - ANSWER>>>Chemical injuries require immediate intervention if it is to be preserved. S/S: - Pain - Corneal Opacification - Coexisting chemical burn and swelling of lids - Dysphonia (hoarseness) - Dysphagia (difficulty swallowing) How would you assess a patient with ocular, maxillofacial and neck trauma? - ANSWER>>>(Initial assessment) HISTORY - MOI? - Acceleration/Deceleration? - What was it caused by? - Pt restrained? Airbags deployed? Etc. - What are the pt's complaints? - Pt normally wear glasses or contacts? - Pt have hx of eye problems? - Pt ever have eye surgery? - Pt have visual or ocular changes associated with chronic illness? PHYSICAL INSPECTION: - Inspect eye, orbits, face and neck - Check for symmetry, edema, ecchymosis, ptosis, lacerations and hematomas - Inspect globe for lacerations, large corneal abrasions, hyphema, and extrusion or prolapse of intraocular contents - Determine whether lid lac's - Assess pupil's (PERRL) - Unilateral fixed and dilated pupil may indicate oculomotor nerve compression as a result of ICP + herniation syndrome - Bilateral fixed and pinpoint pupils = pontine lesion or drugs - Mildly dilated pupil w/sluggish response may early sign of herniation syndrome - Widely dilated pupil occasionally occurs w/direct trauma to globe of eye - Assess for consensual response - Assess redness, eye watering, blepharospasm - Assess extraocular movement, except when an open globe injury is known or suspected. - Limitation range of ocular motion may indicate orbital rim fx w/entrapment or paralysis of cranial nerve or ocular muscle - Perform visual acuity exam - Use Snellen or handheld chart. Check uninjured eye first - Assess for blurred or double vision with injured eye and then with both eyes open - Inspect for rhinorrhea or otorrhea - If drng present, may indicate CSF leak - Observe for impaled objects - Assess occlusion of mandible and maxilla - Malocclusion or inability to open + close mouth is highly indicative of maxillary or mandibular fx - Observe for uncontrolled bleeding PALPATION - Palpate periorbital area, face and neck for: - Tenderness - Edema - Step-off de What are the nursing interventions for a pt with an ocular injury? - ANSWER>>>- Assess visual acuity & reassess - Elevate HOB to minimize intraocular pressure - Instruct pt not to bend forward, cough or perform Valsalva maneuver b/c these actions may raise intraocular pressure - Assist w/removal of foreign bodies as indicated; stabilize impaled objects - Apply cool packs to decrease pain + periorbital swelling - Admin medications - Instill prescribed topical anesthetic drops for pain - Instill NS drops or artificial tears to keep corneas moist. Cover eyelids w/sterile, moist saline dsg to prevent drying and ulceration - Antibiotics topically or systemically - Admin tetanus prophylactically - Use an eye patch to affected eye - Patch or shield both eyes to reduce movement + photophobia in pt's w/retinal injuries - Patch, shield or cover w/cool pack - Do NOT patch injured eye of pt w/suspected open or ruptured globe or impaled object, patch unaffected eye. Use metal or plastic and do not put pressure on the globe. - Provide psychosocial support - Obtain an ophthalmology consultation - Provide d/c instructions: - Importance of protective eyewear - No driving w/eye patch on - Wear sunglasses to prevent tearing, aid photophobia - Prepare for admission, OR or transfer What are the nursing interventions for a patient with a maxillofacial or neck injury? - ANSWER>>>- Administer oxygen - For facial trauma, place pt in high-fowler's position if no spinal injury is present. - Insert OG or NGT. OGT should be used if basilar skull fx or severe midface fx's are suspected - Monitor for progressive airway assessment - Prepare for intubation, PRN. - Cannulate 2 large IV's, initiate isotonic crystalloid IV solution - Control external bleeding w/direct pressure - Monitor for continued bleeding + expanding hematomas - Apply cold compresses to face to minimize edema - Assist w/repair of oral lac's, PRN - Admin antibiotics - Stabilize impaled objects - Admin analgesic meds With any eye injury, what should the evaluation and ongoing assessments be? - ANSWER>>>- Reassessing visual acuity at reasonable intervals - Reassessing pain, including response to nonpharmacologic + pharmacologic interventions - Monitoring appearance, position, movements of globe and pupillary responses - Monitoring airway patency, respiratory effort and ABG's - Respiratory compromise b/c impaired lung capacity + displacement of normal tissue. - Mediastinal structures may shift to opposite side of injury What are S/S of a ruptured diaphragm? - ANSWER>>>(Anything below the nipple line and should be evaluated for potential diaphragmatic injury). - Dyspnea or orthopnea - Dysphagia - Abdominal pain - Sharp epigastric or chest pain radiating to left shoulder (Kehr's sign) - Bowel sounds heard in lower middle chest - Decreased breath sounds on injured side What are S/S with tracheobronchial injury? - ANSWER>>>Blunt trauma. "Clothesline-type" injuries. - Dyspnea, tachypnea - Hoarseness - Hemoptysis - Subcutaneous emphysema in neck, face, or suprasternal area - Decreased or absent breath sounds - S/S of airway obstruction What are S/S with blunt cardiac injury? - ANSWER>>>"Cardiac contusion" or "concussion." Common with MVC or falls from heights. - ECG (sinus tach, PVC's, AV blocks) - Chest pain - Chest wall ecchymosis What are the S/S of pericardial tamponade? - ANSWER>>>A collection of blood in pericardial sac. As blood accumulates, it exerts pressure on the heart, inhibiting or compromising ventricular filling. - Hyotension - Tachycardia or PEA - Dyspnea - Cyanosis - Beck's Triad (hypotension, distended neck veins + muffled heart sounds) - Progressive decreased voltage of conduction complexes on ECG What are aortic injuries S/S? - ANSWER>>>- Hypotension - Decreased LOC - Hypertension in UE's - Decreased quality (amplitude) of femoral pulses compared to UE pulses - Loud systolic murmur in parascapular region - Chest pain - Chest wall ecchymosis - Widened mediastinum on chest xray - Paraplegia How would you assess a pt with a thoracic injury? - ANSWER>>>(Initial assessment) Obtain Hx. PHYSICAL: Inspection: - Observe chest wall - Assess breathing effort and RR - Symmetry - Inspect jugular veins (Distended = increased intrathoracic pressure as result of tension pneumothorax or pericardial tamponade. Flat = external jugular veins may reflect hypovolemia) - Inspect upper abdominal region for injury Percussion: - Percuss the chest (Dullness = hemothorax, Hyperresonance = pneumothorax) Palpation: - Palpate chest wall, clavicles and neck for: - Tenderness - Swelling or hematoma - Subcutaneous emphysema - Note presence of bony crepitus - Palpate central and peripheral pulses and compare quality between: - Right and left extremities - Upper and lower extremities - Palpate the trachea (above suprasternal notch. Trach shift may indicate late sign of tension pneumothorax or massive hemothorax) - Palpate extremities for motor and sensory function (lower extremitiy paresis or paralysis may indicate aortic injury). Auscultation: - Auscultate compare BP in both UE's and LE's - Auscultate breath sounds (decreased or absent breath = pneumo or hemothorax. Diminshed BS = splinting. Shallow = b/c of pain). - Auscultate chest for presence of BS (diaphragmatic rupture) - Auscultate Heart sounds (muffled = pericardial tamponade) - Auscultate neck vessels for bruits (vascular injury) Diagnostic Procedures: - Xrays - Arteriography - Bronchoscopy and laryngoscopy - CT's - FAST - Labs (cardiac enzymes) - ECG, CVP What is the planning and implementation for thoracic injury? - ANSWER>>>p. 142 What is kinematics? - ANSWER>>>A branch of mechanics (energy transfer) that refers to motion and does not consider the concepts of force and mass of the object or body. What is Newton's First Law? - ANSWER>>>A body at rest will remain at rest. A body in motion will remain in motion until acted on by an outside force. What is the Law of Conservation of Energy? - ANSWER>>>Energy can neither be created nor destroyed. It is only changed from one form to another. What is Newton's Second Law? - ANSWER>>>Force equals mass multiplied by acceleration of deceleration. What is kinetic energy (KE)? - ANSWER>>>KE equals 1/2 the mass (M) multiplied by the velocity squared. What is the Mnemonic for the Initial Assessment? - ANSWER>>>A = Airway with simultaneous cervical spine protection - Unilateral deterioration in motor movements or unequal pupils - Symptoms that help to locate area of injury in brain What are the interventions for Disability? - ANSWER>>>- If assessment indicates a decreased LOC, conduct further investigation during secondary focused assessments - If pt is not alert or verbal, continue to monitor for any compromise to ABC's - If pt demonstrates signs of herniation or neurologic deterioration, consider hyperventilation. What is assessed and intervened for Expose/Environmental Controls? - ANSWER>>>- Remove clothing - Ensure appropriate decontamination if exposed to hazardous material - Keep pt warm - Keep clothing for evidence What is the first thing assessed under the Secondary Assessment? - ANSWER>>>FULL SET VS / FOCUSED ADJUNCTS / FAMILY PRESENCE - ABCDE should be completed - Labs, X-rays, CT, Foley, - Family Presence What is the second thing assessed under the Secondary Assessment? - ANSWER>>>GIVE COMFORT MEASURES - Talking to pt - Pharmacologic/Nonpharmacologic pain management - Observe for physical signs of pain What is assessed under the Mnemonic "H"? - ANSWER>>>HISTORY / HEAD-TO-TOE ASSESSMENT - MIVT - M = Mechanism of injury - I = Injuries sustained - V = Vital Signs - T = Treatment - Pt generated information - PMH - Head-to-toe assessment What is assessed under the Mnemonic "I"? - ANSWER>>>INSPECT POSTERIOR SURFACES - While maintaining C-spine, logroll pt with assistance to inspect back, flanks, buttocks and posterior thighs. - Palpate vertebral column for deformity and areas of tenderness - Assess rectum for presence/absence of tone, presence of blood What she be done after the Secondary Assessment? - ANSWER>>>Reassess: - Primary survey, - VS - Pain - Any injuries What are factors that contribute to ineffective ventilation? - ANSWER>>>- AMS - LOC - Neurologic injury - Spinal Cord Injury - Intracranial Injury - Blunt trauma - Pain caused by rib fractures - Penetrating Trauma - Preexisting hx of respiratory diseases - Increased age What medications are used during intubation? - ANSWER>>>LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents What are the Rapid Sequence Intubation Steps? - ANSWER>>>PREPARATION: - gather equipment, staffing, etc. PREOXYGENATION: - Use 100% O2 (prevent risk of aspiration). PRETREATMENT: - Decrease S/E's of intubation PARALYSIS WITH INDUCTION: - Pt has LOC, then administer neuromuscular blocking agent PROTECTION AND POSITIONING: - Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration PLACEMENT WITH PROOF - Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30-60 seconds between attempts. - After intubation, inflate the cuff - Confirm tube placement w/exhaled CO2 detector. POSTINTUBATION MANAGEMENT: - Secure ET tube - Set ventilator settings - Obtain Chest x-ray - Continue to medicate - Recheck VS and pulse oxtimetry What is a Combitube? - ANSWER>>>A dual-lumen, dual-cuff airway that can be placed blindly into the esophagus to establish an airway. If inadvertently placed into trachea, it can be used as a temporary ET tube. There are only two sizes: small adult and larger adult. What is a Laryngeal Mask Airway? - ANSWER>>>Looks like an ET tube but is equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to cover the supraglottic area. ILMA, does not require laryngoscopy and visualization of the chords. What is Needle Cricothyrotomy - ANSWER>>>Percutaneous transtracheal ventilation. (temporary) Complications include: - inadequate ventilation causing hypoxia - hematoma formation - esophageal perforation - aspiration - Blunt cardiac injury - Mitral valve insufficiency - dysrhythmias - Cardiac Failure Explain Obstructive Shock. - ANSWER>>>Results from inadequate circulating blood volume because of an obstruction or compression of great veins, aorta, pulmonary arteries, or heart itself. Some causes: - Cardiac tamponade (may compress the heart during diastole to such and extent that atria cannot adequately fill, leading to decreased stroke volume). - Tension pneumothorax may lead to inadequate stroke volume by displacing inferior vena cava and obstructing venous return to right atrium. - Air embolus may lead to obstruction of pulmonary artery and subsequent obstruction to right ventricular outflow during systole, with resulting obstructive shock Explain Distributive Shock. - ANSWER>>>Results from disruption in SNS control of the tone of blood vessels, which leads to vasodilation and maldistribution of blood volume and flow. (Neurogenic and Septic Shock). Neurogenic shock may result from injury to spinal cord in cervical or upper thoracic region. Spinal shock = areflexia and flaccidity associated with lower motor neuron involvement in complete cord injuries; reflexes return with resolution of spinal shock. Septic shock from bacteremia is distributive shock. Endotoxins and other inflammatory mediators cause vasodilation, shunting of blood in microcirculation, and other perfusion abnormalities. What is vascular response? - ANSWER>>>As blood volume decreases, peripheral blood vessels vasoconstrict as a result of sympathetic stimulation via inhibition of baroreceptors. Arterioles constrict to increase TPR and BP. What is renal response? - ANSWER>>>Renal ischemia activates release of renin. Kidneys do not receive adequate blood supply, renin is release into circulation. Renin causes angiotensinogen, normal plasma protein, to release angiotensin I. Angiotensin-converting enzyme from the lungs converts into angiotensin II. Angiotensin II causes: - Vasoconstriction of arterioles and some veins - Stimulation of sympathetic nervous system - Retention of water by kidneys - Stimulation of release of aldosterone from the adrenal cortex (sodium retention hormone) *Decreased urinary output = early sign renal hypoperfusion and an indicator that there's systemic hypoperfusion. Explain adrenal gland response. - ANSWER>>>When adrenal glands are stimulated by SNS, release of catecholamines (epinephrine and norepinephrine) from adrenal medulla will increase. Epi stimulates receptors in heart to increase force of cardiac contraction (positive inotropy) and increase HR (positive chronotropy) to improve cardiac output, BP and tissue perfusion. Shock stimulates hypothalamus to release corticotropin-releasing hormone that stimulates pituitary to release ACTH that stimulates adrenal gland to release cortisol. Effect of cortisol release is elevation in blood sugar and increased insulin resistance and gluconeogenesis, hepatic process to produce more sugar. Cortisol also causes renal retention of water and sodium, a compensatory mechanism to conserve body water. Explain Hepatic Response. - ANSWER>>>Liver can store excess glucose as glycogen. As shock progresses, glycogenolysis is activated by epi to break down glycogen into glucose. In a compensatory response to shock, hepatic vessels constrict to redirect blood flow to other vital areas. Explain Pulmonary Response. - ANSWER>>>Tachypnea happens for 2 reasons: 1. Maintain acid-base balance 2. Maintain increased supply of oxygen * Metabolic acidosis from anaerobic metabolism will be a stimulus for the lungs to increase rate of ventilation. Increased RR is an attempt to correct acidosis + augments oxygen supply to maximize oxygen delivery to alveoli. Explain Irreversible Shock. - ANSWER>>>Shock uncompensated or irreversible stages will cause compromises to most body systems. - Inadequate venous return - inadequate cardiac filling - decreased coronary artery perfusion - Membranes of lysosomes breakdown within cells and release digestive enzymes that cause intracellular damage. How would you assess someone in hypovolemic shock? - ANSWER>>>(Use Initial Assessment) and then: Inspect: - LOC - Rate and quality of respirations - External bleeding? - Skin color and moisture - Assess jugular veins and peripheral veins Auscultate: - BP - Pulse pressure - Breath sounds - Heart sounds - Bowel sounds Percuss: - Chest and abdomen Palpate: - Central pulse (carotid or femoral) - Positive inotropic effect (force of contraction) may be evidence by a bounding central pulse CSF leaks through the nose (rhinorrhea) or the ears (otorrhea). A potential entrance for invading bacteria. Also: meningitis or encephalitis or brain abscess Define Minor Head Trauma. - ANSWER>>>GCS 13-15 Define Moderate Head Trauma - ANSWER>>>Postresuscitative state with GCS 9-13. Define Severe Head Trauma. - ANSWER>>>Postresuscitative state with GCS score of 8 or less. What is a concussion and its signs and symptoms? - ANSWER>>>A temporary change in neurologic function that may occur as a result of minor head trauma. S/S: - Transient LOC - H/A - Confusion and disorientation - Dizziness - N/V - Loss of memory - Difficulty with concentration - Irritability - Fatigue What are the signs and symptoms of postconcussive syndrome? - ANSWER>>>- Persistent H/A - Dizziness - Nausea - Memory impairment - Attention deficit - Irritability - Insomnia - Impaired judgement - Loss of libido - Anxiety - Depression What is diffuse axonal injury and its signs and symptoms? - ANSWER>>>(DAI) is widespread, rather than localized, through the brain. Diffuse shearing, tearing and compressive stresses from rotational or accerleration/deceleration forces resulting in microscopic damage primarily to axons within the brain. S/S: - Immediate unconsciousness - mild DAI, coma = 6-24 hrs - severe DAI, coma = weeks/months or persistent vegetative state - Elevated ICP - Abnormal posturing - HTN - Hyperthermia - Excessive sweating because of autonomic dysfunction - Mild to severe memory impairment, cognitive, behavioral, and intellectual deficits What is a cerebral contusion and its S/S? - ANSWER>>>A common focal brain injury in which brain tissue is bruised and damaged in a local area. Mainly located in frontal and temporal lobes. May cause hemorrhage, infarction, necrosis and edema. Max effects of bleeding & edema peak 18-36 post injury. S/S: - Alteration in LOC - Behavior, motor or speech deficits - Abnormal motor posturing - Signs of increased ICP What is an epidural hematoma and its S/S? - ANSWER>>>Results when a collection of blood forms between the skull and the dura mater. Bleeding is arterial=blood accumulates rapidly: - Compression of underlying brain - rapid increase in ICP - Decreased CBF - Secondary brain injury * Usually requires surgical intervention S/S: - Transient LOC - Lucid period lasting a few minutes to several hours - Rapid deterioration in neurologic status - Severe H/A - Sleepiness - Dizziness - N/V - Hemiparesis or hemiplegia on opposite side of hematoma - Unilateral fixed and dilated pupil on same side of hematoma What is a subdural hematoma and its S/S? - ANSWER>>>A focal brain injury beneath the dura mater that results from acceleration/deceleration. Usually venous, and not necessarily from a fx. Formation may be acute or chronic. Acute pt's hematoma manifest 48 hrs post injury S/S: - Altered LOC or steady decline in LOC - S/S of increased ICP - Hemiparesis or hemiplegia on opposite side of hematoma - Unilateral fixed and dilated pupil on same side of hematoma Chronic pt's " " up to 2 wks post injury - H/A - Progressive decrease in LOC - Ataxia - Incontinence - Sz's What are intracerebral hematoma's and its S/S? - ANSWER>>>Occur deep within brain tissue, may be single or multiple and commonly associated with contusions (frontal & temporal lobes). They result in significant mass effect, leading to increased ICP and neurologic deterioration. S/S: - Progressive and often rapid decline in LOC - PaCO2 above 45 What are signs of a serious eye injury? - ANSWER>>>- Visual disturbances - Pain - Redness and ecchymosis of the eye - Periorbital ecchymosis - Increased intraocular pressure What is hyphema and its S/S? - ANSWER>>>Accumulation of blood, mainly RBC's that disperse and layer within the anterior chamber. A severe hymphema obscures entire anterior chamber + will diminish visual acuity severely or completely. Injuries are graded on amount of blood in chamber (Grades I-IV). S/S: - Blood in anterior chamber - Deep, aching pain - Mild to severe diminished visual acuity - Increased intraocular pressure What are s/s of chemical burns to the eye? - ANSWER>>>Chemical injuries require immediate intervention if it is to be preserved. S/S: - Pain - Corneal Opacification - Coexisting chemical burn and swelling of lids What are S/S of penetrating trauma/open or ruptured globe? - ANSWER>>>- Marked visual impairments - Extrusion of intraocular contents - Flattened or shallow anterior chamber - Subconjunctival hemorrhage, hyphema - Decreased intraocular pressure - Restriction of extraocular movements What are the S/S of orbital fracture (orbital blowout fracture)? - ANSWER>>>- Diplopia (double vision) - Loss of vision - Altered extraocular eye movements - Enophthalmos (displacement of the eye backward into the socket) - Subconjunctival hemorrhage or ecchymosis of the eyelid - Infraorbital pain or loss of sensation - Orbital bony deformity What is LeFort I fracture and its S/S? - ANSWER>>>Transverse maxillary fx that occurs above level of teeth and results in separation of teeth from rest of maxilla. S/S: - Slight swelling of maxillary area - Possible lip lac's or fractured teeth - Independent movement of the maxilla from rest of face - Malocclusion What is LeFort II fracture and its S/S? - ANSWER>>>Pyramidal maxillary fx=middle facial area. Apex of fx transverses bridge of nose. Two lateral fx's of pyramid extend through the lacrimal bone of the face and ethmoid bone of skull into the median portion of both orbits. Base of the fx extends above level of the upper teeth into maxilla. CSF leak is possible. S/S: - Massive facial edema - Nasal swelling w/obvious fx of nasal bones - Malocclusion - CSF rhinorrhea What is LeFort III fracture and its S/S? - ANSWER>>>Complete craniofacial separation involving maxilla, zygoma and bones of cranial base. This fx is frequently associated w/leakage of CSF and fx mandible. S/S: - Massive facial edema - Mobility and depression of zygomatic bones - Ecchymosis - Anesthesia of the cheek - Diplopia - Open bite or malocclusion - CSF rhinorrhea What are the mandibular fracture S/S? - ANSWER>>>- Malocclusion - Inability to open the mouth (trismus) - Pain, especially on movement - Facial asymmetry and a palpable step-off deformity - Edema or hematoma formation at the fracture site - Blood behind, ruptured, tympanic membrane - Anesthesia of the lower lip What are neck injury S/S? - ANSWER>>>- Dyspnea - Hemoptysis (coughing up blood) - Subcutaneous emphysema in neck, face, or suprasternal area - Decreased or absent breath sounds - Penetrating wounds or impaled objects - Pulsatile or expanding hematoma - Loss of normal anatomic prominence of the laryngeal region - Bruits - Active external bleeding - Neurologic deficit, such as aphasia or hemiplegia - Cranial nerve deficits - Facial sensory or motor nerve deficits - Dysphonia (hoarseness) - Dysphagia (difficulty swallowing) How would you assess a patient with ocular, maxillofacial and neck trauma? - ANSWER>>>(Initial assessment) HISTORY - MOI? - Acceleration/Deceleration? - What was it caused by? - Pt restrained? Airbags deployed? Etc. - What are the pt's complaints? - Pt normally wear glasses or contacts? What are the nursing interventions for a patient with a maxillofacial or neck injury? - ANSWER>>>- Administer oxygen - For facial trauma, place pt in high-fowler's position if no spinal injury is present. - Insert OG or NGT. OGT should be used if basilar skull fx or severe midface fx's are suspected - Monitor for progressive airway assessment - Prepare for intubation, PRN. - Cannulate 2 large IV's, initiate isotonic crystalloid IV solution - Control external bleeding w/direct pressure - Monitor for continued bleeding + expanding hematomas - Apply cold compresses to face to minimize edema - Assist w/repair of oral lac's, PRN - Admin antibiotics - Stabilize impaled objects - Admin analgesic meds With any eye injury, what should the evaluation and ongoing assessments be? - ANSWER>>>- Reassessing visual acuity at reasonable intervals - Reassessing pain, including response to nonpharmacologic + pharmacologic interventions - Monitoring appearance, position, movements of globe and pupillary responses - Monitoring airway patency, respiratory effort and ABG's What are the most common type of injury associated with chest trauma? - ANSWER>>>blunt; MVC's. Penetrating; firarm injuries or stabbings What are S/S of a rib fracture? - ANSWER>>>- Dyspnea - Localized pain on movement, palpation, or inspiration - Pt assumes position intended to splint chest wall to reduce pain - Chest wall ecchymosis or sternal contusion - Bony crepitus or deformity What is a flail chest? - ANSWER>>>A fracture of two or more sites on two or more adjacent ribs, or when rib fractures produce a free-floating sternum. Flail segments may not be clinically evident in the first several hours after injury b/c of muscle spasms that cause splinting. After positive pressure intiated, paradoxical chest wall movement ceases. What could a flail chest be associated with? - ANSWER>>>- Ineffective ventilation - Pulmonary contusion - Lacerated lung parenchyma What are the S/S of flail chest? - ANSWER>>>- Dyspnea - Chest wall pain - Paradoxical chest wall movement - the flail segment moves in during inspiration and out during expiration. Define Pneumothorax. - ANSWER>>>Results when an injury to lung leads to accumulation of air in pleural space w/subsequent loss of negative intrapleural pressure. Partial or total collapse of lung may ensue. An open pneumothorax results from wound through chest wall. Air enters pleural space both through the wound and trachea. What are the S/S of a pneumothorax? - ANSWER>>>- Dyspnea, tachypnea - Tachycardia - Hyerresonance (increased echo produced by percussion over the lung field) on the injured side - Decreased or absent breath sounds on the injured side - Chest pain - Open, sucking wound on inspiration (open pneumothorax) Define tension pneumothorax. - ANSWER>>>Life-threatening injury. Air enters pleural space on inspiration, but air cannot escape on expiration. Rising intrathoracic pressure collapses lung on side of injury causing a mediastinal shift that compresses the heart, great vessels, trachea and uninjured lung. Venous return impeded, cardiac output falls, hypotension results. Immediate decompression should be performed. Treatment should not be delayed. What are the S/S of a tension pneumothorax? - ANSWER>>>- Severe respiratory distress - Markedly diminished or absent breath sounds on affected side - hypotension - Distended neck, head and upper extremity veins-may not be clinically appreciated if significant blood loss present - Tracheal deviation - shift toward uninjured side (LATE sign) - Cyanosis (LATE sign) Define Hemothorax. - ANSWER>>>Accumulation of blood in the pleural space. What are the S/S of Hemothorax? - ANSWER>>>- Dyspnea, tachypnea - Chest pain - Signs of shock - Decreased breath sounds on injured side - Dullness to percussion on the injured side What is a pulmonary contusion? - ANSWER>>>They occur as a result of direct impact, deceleration or high-velocity bullet wounds. It develops when blood leaks into lung parenchyma, causing edema + hemorrhage. This usually develops overtime and not immediately. What are the S/S of pulmonary contusion? - ANSWER>>>- Dyspnea - Ineffective cough - Hemoptysis - Hypoxia - Chest pain - Chest wall contusion or abrasions What happens to a ruptured diaphragm? - ANSWER>>>Potentially life-threatening, results from forces that penetrate the body. Left hemidiaphragm is more susceptible to injury because the right side is protected by the liver. - Herniation of abdominal contents - Respiratory compromise b/c impaired lung capacity + displacement of normal tissue. - Mediastinal structures may shift to opposite side of injury What are S/S of a ruptured diaphragm? - ANSWER>>>(Anything below the nipple line and should be evaluated for potential diaphragmatic injury). - Dyspnea or orthopnea - Dysphagia - Abdominal pain - Sharp epigastric or chest pain radiating to left shoulder (Kehr's sign) - Bowel sounds heard in lower middle chest - Auscultate chest for presence of BS (diaphragmatic rupture) - Auscultate Heart sounds (muffled = pericardial tamponade) - Auscultate neck vessels for bruits (vascular injury) Diagnostic Procedures: - Xrays - Arteriography - Bronchoscopy and laryngoscopy - CT's - FAST - Labs (cardiac enzymes) - ECG, CVP What is the planning and implementation for thoracic injury? - ANSWER>>>p. 142 Kinematics - ANSWER>>>Is the study of energy transfer as it applies to identifying actual or potential injuries. Biomechanics - ANSWER>>>Is the general study of forces and their effects. Mechanism of Injury - ANSWER>>>Is how external forces are transferred to the body, resulting in injury Newton's First Law of Motion - ANSWER>>>an object in motion will remain in motion unless acted upon by another force Newton's Second Law of Motion - ANSWER>>>The acceleration of an object depends on the mass of the object and the amount of force applied. Newton's Third Law of Motion - ANSWER>>>For every action there is an equal and opposite reaction Law of Conservation of Energy - ANSWER>>>Matter is neither created nor destroyed (but may change form) What are the five forms in which energy exist? - ANSWER>>>1. Mechanical 2. Thermal 3. Chemical 4. Electrical 5. Radiant Describe the 3 types of Internal forces of energy transfer in the context of trauma. - ANSWER>>>Compression: The ability of the tissue to resist crush injury or force Tension: The ability to resist being pulled apart when stretched Shear: The ability to resist a force applied parallel to the tissue Describe the 3 types of external forces of energy transfer in the context of trauma. - ANSWER>>>Deceleration: Force from a sudden stop in the body's motion Acceleration: Force from a sudden onset in the body's motion Compression: Force from being crushed between objects List the four main types of traumatic injury and give an example of each - ANSWER>>>Blunt: The result of a broad energy impact across a large surface area. Penetrating: The What 4 environmental and pathophysiologic factors are considered when the mechanism of injury is a fall? - ANSWER>>> Describe the three impacts in the motor vehicle impact sequence - ANSWER>>>1. First Impact: Vehicle hits another object 2. Second Impact: Occupant hits the interior of the vehicle 3. Third Impact: Organcs hit other internal structures Define the five mechanisms of injury in blast trauma. - ANSWER>>>1. Primary: Found in patients who were closest to the blast. Injuries are most commonly associated with air-filled organs 2. Secondary: Include fragment injuries, puncture wounds, lacerations, and impaled objects. Generally, these cause the most casualties 3. Tertiary: Result from the patient being blown into a large object. Injuries include pelvic or femur fractures an thoracic injuries. 4. Quaternary: Result from heat, flame, gas, and smoke and cause burn injuries. 5. Quinary: Injuries associated with radioactive, biological or chemical elements that may be present in the explosion. Describe the usefulness of the Haddon Matrix in prevention and reduction of injury - ANSWER>>>Looks at 3 phases of the event: Pre-event, event, and post-event. Looks at 4 factors involved in the event: The host (patient), the agent (cause), the physical evironment, and the socioeconomic environment. Countermeasures can be applied at each phase to help reduce injury. What assessment findings differentiate a placental abruption from a uterine rupture? - ANSWER>>> What intervention is used to treat hypotension from aortocaval compression? - ANSWER>>> Describe the activities and associated factors related to low-energy trauma in the older adult. - ANSWER>>> List common injuries from falls in the older adult population. - ANSWER>>> What condition is associated with a fall from which the older adult cannot rise? What complications result from this condition? - ANSWER>>> Review the age-related anatomic and physiologic change of the older adult in relation to the components of the initial assessment. - ANSWER>>> Describe the fluid resuscitation of an older adult patient related to fluid overload, when to administer red blood cells, and the use of anticoagulant medication. - ANSWER>>> Describe effects of common medications in relation to the older adult trauma patient. - ANSWER>>> Describe common patterns and severity of injuries in the bariatric trauma patient. - ANSWER>>> Which comorbid conditions factor into the risks of the bariatric trauma patient? And how? - ANSWER>>> Describe the pathophysiologic changes of the systems of the bariatric patient and the effects on trauma resuscitation efforts. - ANSWER>>> Describe techniques to improve the intubation process for the bariatric trauma patient. - ANSWER>>> Discuss the use and insertion of nasogastric tubes in the bariatric patient. - ANSWER>>> Differentiate family and intimate partner violence from community violence. - ANSWER>>> List the populations at higher risk for interpersonal violence. - ANSWER>>> Describe the types of abuse and the associated signs of each. - ANSWER>>> What cues to abuse may be obtained during the history portion of the initial assessment? - ANSWER>>> Describe specific injuries associated with interpersonal violence and abuse. - ANSWER>>> List the basic components of evidence collection. - ANSWER>>> Describe steps to maintain the forensic chain of custody. - ANSWER>>> 1. Preparation and Triage 2. Primary Survery (ABCDE) with resuscitation adjuncts (F,G) 3. Reevaluation (consideration of transfer) 3. Maxillary fractures 4. Evidence of inhalation injury (facial burns) 5. Laryngeal or tracheal injury or neck hematoma 6. High risk of aspiration and patients inability to protect the airway 7. Compromised or ineffective ventilation - ANSWER>>>Following conditions might require a definitive airway Breathing: To assess breathing expose the chest: 1. Inspect for a. spontaneous breathing b. symmetrical rise and fall c. depth, pattern, and rate of respiration d. signs of difficulty breathing such as accessory muscle use e. skin color (normal, pale, flushed, cyanotic) f. contusions, abrasions, deformities (flail chest) g. open pneumothoraces (sucking chest wounds) h. JVD i. signs of inhalation injury (singed nasal hairs, carbonaceous sputum) - ANSWER>>>B tracheal deviation and jvd - ANSWER>>>Late signs of tension pneumo: 1. equal breath sounds bilaterally at the second intercostal space midclavicular line and the bases for fifth intercostal space at the axillary line - ANSWER>>>Auscultate the chest for: 1. bony fractures and possible rib fractures, which may impact ventilation 2. palpate for crepitus 3. subcutaneous emphysema which may be a sign for a pneumothorax 4. soft tissue injury - ANSWER>>>Palpate the chest for 1. open the airway, use jaw thrust 2. insert an oral airway 3. assist ventilations with a bag mask 4. prepare for definitive airway - ANSWER>>>If breathing is absent.. trauma its need early supplemental oxygen, start with 15 mL O2 and titrate oxygen delivery. - ANSWER>>>Oxygen on trauma patients Circulation and Control of Hemorrhage Inspect first for any uncontrolled bleeding Skin color palpate for central pulses - carotid and femoral - rate, rhythm, and strength Skin temp: cool, diaphoretic, or warm and dry - ANSWER>>>C apply direct pressure to bleeding elevate extremity apply pressure over arterial sites Consider a pelvic binder for pelvic fractures consider a tourniquet cannulate two veins with large caliber IV - if unable to gain assess consider IO a. obtain labs, type and cross b. infuse warm isotonic fluids c. consider balanced resuscitation d. use rapid infusion device - ANSWER>>>C Interventions: Disability - Neurologic Status 1. Assess pupils for equality, shape, and reactivity (PERRL) 2. Assess GCS (eye opening, verbal response, and motor response) - ANSWER>>>D 1. Get a CT 2. Consider ABG 's if decreased LOC 3. Consider glucose check - ANSWER>>>D Interventions Exposure and Environmental Control Remove all clothes and assess for any obvious injuries and uncontrolled bleeding - ANSWER>>>E IF clothing is needed for evidence preserve in paper bag. Maintain body temp - cover the pt, turn up heat in room, administer warm fluids - ANSWER>>>E Interventions: Full set of vitals and family presence - ANSWER>>>F Get Resuscitation Adjuncts L - Labs (maybe a lactic acid), a b g 's, blood type M - monitors N - naso or oro gastric tubes O Oxygen and ETC02 monitors P - pain assessment and management - ANSWER>>>G Reevaluation and Consider the need to Transfer - ANSWER>>>Final step in primary survey H,I - ANSWER>>>Secondary Survery History and Head to toe MIST - prehospital report MOI Injuries sustained S s/s in the field T treatment in the field if patients family present get a better hx on them - ANSWER>>>H Sample is part of history S symptoms associated with injury A allergies and tetanus status M meds currently on including anticoagulant therapy P past medical hx L last oral intake 5. Protecting and positioning - v 6. Placement of proof - secure the tube 7. Post intubation - secure ETT Tube, get X-ray for placement - ANSWER>>>Steps of Rapid Sequence Intubation from hemorrhage is leading cause. Hypovolemia is caused by decrease in the amount of circulating volume. Goal is to replace volume. - ANSWER>>>Hypovolemic Shock results from hypo perfusion to the tissue due to an obstruction in either vasculature or heart. Goal is to relieve obstruction and improve perfusion. Ex: tension pneumo or cardiac tamponade are two classic examples that may result from trauma. - ANSWER>>>Obstructive Shock Results from pump failure in the presence of adequate intravascular volume. There is a lack of cardiac output and end organ perfusion secondary to a decrease in myocardial contractility and/or valvular insufficiency. Ex: MI's or dysrhythmia are common causes - ANSWER>>>Cariogenic Shock occurs as a result of maldistribution of an adequate circulating blood volume with the loss of vascular tone or increased permeability. Ex: Anaphylactic - release of antihistamines Septic Shock - systemic release of bacterial endotoxins, resulting in increased vascular permeability and vasodilation. Neurogenic shock - spinal cord injury results of loss in sympathetic nervous system control of vascular tone. Goal: Volume replacement and vasoconstriction - ANSWER>>>Distributive Shock A breath every 5 to 6 seconds: 10-12 ventilations per minute - ANSWER>>>Bag mask ventilation Stroke Volume X HR - ANSWER>>>Cardiac Output = .. activation: .... are found in the carotid sinus and along the aortic arch, are sensitive to the degree of stretch in the arterial wall. When the receptors sense a decrease in stretch, they stimulate the sympathetic nervous system to release Epi, norepi, causing stimulation of cardiac activity and constriction of blood vessels, which causes a rise in heart rate and diastolic blood pressure - ANSWER>>>Baroreceptors: activation: consist of carotid and aortic bodies. ... detect changes in blood oxygen and Co2 and pH. When Co2 rises or oxygen level of pH falls these receptors are activated and information is relayed to the CNS and the cardiorespiratory centers in the medulla , which increases respiratory rage and depth and BP - ANSWER>>>Chemoreceptors: 50 to 150 - ANSWER>>>MAP Range the decrease coagulopathy .. you will you bleed more - ANSWER>>>The colder you are the more acidic you are.. in massive transfusion protocol... responsible for dissolving clots - ANSWER>>>TXA stabilized vital signs, improved mental status, improved urine output - ANSWER>>>What are indicators of increased perfusion? - ANSWER>>>Prehospital shock index pg. 85 Flail chest - ANSWER>>>Paradoxical chest wall movement can be caused by blunt trauma. air escapes from injured lung to pleural space and negative intrapleural pressure is lost causing partial or collapsed lung - ANSWER>>>Simple Pneumothorax 1. Dyspnea 2. Tachycardia 3. Decreased or absent breath sounds on the injured side 4. CP - ANSWER>>>Simple Pneumo assessment: Tx is based on size, presence of sx, and stability. For those are aysmpomatic and stable. Observation with or without oxygen. Larger pneumo who are unstable or likely to deteriorate a chest tube is placed. - ANSWER>>>Simple pneumo interventions: can result from penetrating wound through chest wall causing air to be trapped in to the intrapleural place. Might hear "sucking" Tx: nonporous dressing tapes on 3 sided, then Chest tube and would closure surgical repair. - ANSWER>>>Open Pneumo: Air cannot escape intrapleural space.. can begin to compress heart. pt will have sever resp distress, hypotension, JVD. - ANSWER>>>Tension pneumo A 14 gauge needle that is inserted into the 2nd intercostal space in the midclavicular line on the affected side over the top of the rib to avoid neuromuscular bundle that runs under the rib. Prepare for chest tube placement. - ANSWER>>>Tension pneumo intervention Caused by blood in the intrapleural space/ May also occur from lac to live or spleen combined with injury to the diaphragm. Ensure two large bore IVS are placed. Prepare for thoracentesis and chest tube insertion. If open thoracotomy is done chest tube is deferred. - ANSWER>>>Hemothorax: 1. Hypotension 2. JVD 3. Muffled heart sounds - ANSWER>>>Becks Triad: Needle pericardiocentesis, but it is a temp solution. Requires surgical evaluation. (Ultrasound guided) - ANSWER>>>Cardiac Tamponade Intervention: Aortic Dissection - ANSWER>>>Unequal extremity pulse strength possibility of.. 1. pain - hallmark sign, early sign 2. pressure - early sign 3. pallor, pules, paresthesia, paralysis - late sign - ANSWER>>>Six P's of compartment syndrome: Pediatric Assessment Triangle 1. General appearance - muscle tone, interactiveness, consoloability, poor or gaze, speech or cry 2. Work of breathing - inadequate or excessive, accessory muscle use, retractions, tripod position, abnormal upper airway sounds 3. Circulation of the skin - color, mottling or central or peripheral cyanosis, diaphoresis - ANSWER>>>PAT brachial pulse - ANSWER>>>Under age of 1 where do you find a pulse What are the greatest risks for transport? - ANSWER>>>Loss of airway patency, displaced obstructive tubes lines or catheters, dislodge splinting devices, need to replace or reinforce dressings, deterioration in patient status change in vital signs or level of consciousness, injury to the patient and/or team members According to newtons law which of these two force is greater: size or force? - ANSWER>>>Neither. For each force there is an equal and opposite reaction. What is the relationship between mass and velocity to kinetic energy? - ANSWER>>>Kinetic energy is equal to 1/2 the mass multiplied the square of its velocity therefore when mass is doubled so is the net energy, however, when velocity is doubled energy is quadrupled. What is tension? - ANSWER>>>stretching force by pulling at opposite ends What is compression? - ANSWER>>>Crushing by squeezing together What is the trauma triad of death? - ANSWER>>>hypothermia, acidosis, coagulopathy Describe the characteristics of obstructive shock - ANSWER>>>Obstructive shock is it mechanical problem that results from hypoperfusion of the tissue due to an obstruction in either the vasculature or the heart resulting in decreased cardiac output. Some causes include a tension pneumothorax, cardiac tamponade, or venous air embolism on the right side of the heart during systole in the pulmonary artery.Signs include anxiety, muffled heart sounds, JVD, hypertension, chest pain, difficulty breathing, or pulses paradoxes. Describe the characteristics of cardiogenic shock - ANSWER>>>Cardiogenic shock results from pump failure in the presence of adequate intravascular volume. Lack of cardiac output and an organ perfusion occurs secondary to a decrease in myocardial contractility and or valvular insufficiency. This can happen with blunt cardiac trauma or an MI. Symptoms can include low blood pressure increase heart rate and respiratory rate chest pain shortness of breath dysrhythmias increase troponin and pale cool moist skin Describe the characteristics of distributive shock. - ANSWER>>>Distributive shock occurs as a result of Mel distribution of an adequate circulating blood volume with the loss of vascular tone or increased permeability. This can occur with spinal cord injuries, sepsis, or anaphylaxis. Symptoms include low blood pressure heart rate respiratory rate preload and afterload, spinal tenderness, difficulty breathing, warm pink and dry skin with a cool core temperature. Describe the characteristics of hypovolemic shock - ANSWER>>>Hypovolemia is caused by a decrease in the amount of circulating volume usually caused by massive bleeding, but also can be from vomiting and diarrhea. Characteristics include low blood pressure and preload, increase heart rate respiratory rate and afterload, with contractility unchanged. Signs include obvious bleeding, weak peripheral pulses, pale cool and moist skin, distended abdomen, pelvic fracture, or bruise swollen and deformed extremities especially long bones. What is the recommended fluid bolus for a trauma? - ANSWER>>>500 ML's of warmed isotonic crystalloid. Ongoing fluid boluses of 500 ML's should be given judiciously with constant reassessments after administration. What is the minimum permissive hypertension and a trauma patient? - ANSWER>>>A systolic of greater than or equal to 90 MMHG What is the minimum permissive oxygenation level of a trauma patient? - ANSWER>>>Greater than or equal to 94% What is Cullen's sign and its significance? - ANSWER>>>Cullens sign is periumbilical bruising and is indicative of intraperitoneal bleeding Define Cushing's triad - ANSWER>>>Bradycardia, progressive hypertension (widening pulse pressure), and decreased respiratory effort What are the early signs of increased Intracranial pressure - ANSWER>>>headache, vomiting, behavioral changes that begin with restlessness and may progress to confusion, drowsiness, or impaired judgment What are the late signs of Increased intracranial pressure - ANSWER>>>dilated, non-reactive pupil(s); abnormal motor posturing (flexion, extension, flaccidity); Cushing's triad, Unresponsive to per verbal and painful stimuli, bradycardia and decreased respiratory effort What are the symptoms of a subdural hematoma? - ANSWER>>>Decreased LOC, nausea vomiting headache and ipsilateral pupillary changes What is a trademark symptom of an epidural hematoma - ANSWER>>>Loss of consciousness then awake and alert then loss of consciousness Define the characteristics of neurogenic shock - ANSWER>>>Distributive shock with a T6 or higher injury results and vasodilation, bradycardia, flushed warm dry skin. Risk for temperature instability. Nursing interventions include maintaining warmth and spinal stabilization. Define the characteristics of spinal shock - ANSWER>>>Transient loss of function can include loss of reflexes and muscle tone below the level of industry with possible vascular response. Describe the four types of spinal cord injury - ANSWER>>>Central cord injury results in greater weakness distally, anterior injury includes motor loss or weakness below the cord level of injury yet sensory is intact, Brown-Sequard (hemicord) is weak on one side with sensory deficit on opposite side, posterior cord syndrome although rare is when the patient is unable to use sense vibration in proprioception Describe one fat embolism syndrome is most likely to occur in its characteristics - ANSWER>>>With longform fractures. Tachycardia, Thrombocytopenia, and petechiae rash. What is the Munro-Kellie doctrine? - ANSWER>>>Within the skull 80% his brain, 10% is blood, and 10% is CSF. Any increase of any of the products results in increased intracranial pressure. What are the treatment goals for a TBI? - ANSWER>>>O2 saturation > or equal to 95%, systolic blood pressure > or equal to 100 MMHG, ICP < 15 MMHG, CPP > or equal to 60 MMHG, normal glycemia, hemoglobin > or equal to 7 g/DL, sodium 135-145, osmotic diuretics, anti-emetics, sedatives, anticonvulsants, head of bed at 30°, and neck at midline A 56 y/o M involved in a MVC is brought to the ED. He complains of neck pain, SOB, and diffuse abdominal pain. His GCS is 15, VS: BP 98/71, HR 125, RR 26, SpO2 94% on high-flow O2 via NRB mask. Which is the priority intervention for this patient? - ANSWER>>>Expedite transfer to the closest trauma center Which of the following considerations is the most important when caring for a geriatric trauma pt? - ANSWER>>>a pertinent medical hx is crucial Following a review of recent drills and a real disaster event, a hospital has identified deficiencies and is taking steps to minimize the impact of a future disaster . Which phase of the disaster life cycle does this describe? - ANSWER>>>Mitigation EMS brings a pt who fell while riding his bicycle. Using the American College of Surgeobs screening guidelines, which assessment finding would prompt the RN to prepare the pt for a radiologic spine clearance? - ANSWER>>>smell of alcohol on breath What is the effect of hypothermia on the oxyhemoglobin dissociation curve? - ANSWER>>>hemoglobin does not readily release O2 for use by the tissues Which of the following is a component of the trauma triad of death? - ANSWER>>>acidosis EMS brings a pt from MVC. VS: BP 90/49, HR 48, RR 12, temp 97.2F (36.2 C). The pt exhibits urinary incontinence and priapism. These assessment findings are most consistent with which of the following types of spinal cord injury? - ANSWER>>>Complete Which of the following is an expected finding in a pt with a tube thoracstomy connected to a chest drainage system? - ANSWER>>>flucuation in the water seal chamber During the primary survey of an unconscious pt with multi-system trauma, the nurse notes snoring respirations. What priority nursing interventions should be preformed next? - ANSWER>>>insert an oropharyngeal airway if there is no gag reflex A 35 y/o M presents with facial trauma after being struck in the face with a baseball. A teardrop-shaped left pupil is noted on exam. What type of injury is suspected? - ANSWER>>>globe rupture A trauma pt is restless and repeatedly asking "where am i?" VS upon arrival: BP 110/60, HR96, RR 24. Her skin is cool and dry. Current VS are BP 104/84, HR 108, RR 28. The pt is demonstrating s/sx of which stage of shock? - ANSWER>>>compensated An unresponsive trauma pt has an oropharygeal airway in place, shallow and labored respirations, and dusky skin. The trauma team has administered medications for drug-assisted intubation and attempted intubation but was unsuccessful. What is the most appropriate immediate next step? - ANSWER>>>ventilate with a bag mask device When is the tertiary survey completed fora trauma pt? - ANSWER>>>within 24 hrs of trauma An intubated and sedated pt in the ED has multiple extremity injuries with the potential for causing compartment syndrome. What is the most reliable indication of compartment syndrome in a patient who is unconscious? - ANSWER>>>pressure Which of the following is possible complication of positive-pressure ventilation? - ANSWER>>>worsening pneumothorax the most reassuring finding for a male pt with hip pain after a fall is which of the following? - ANSWER>>>pelvic stability Which of the following pulse pressures indicate early hypovolemic shock? - ANSWER>>>narrowed Patients with a crush injury should be monitored for which of the following conditions? - ANSWER>>>dysrhythmias Tearing of the bridging veins is most frequently associated with which brain injury? - ANSWER>>>subdural hematoma A 20 y/o M presents to the ED complaining of severe lower abd pain after landing hard on the bicycle cross bars while preforming an aerial BMX maneuver. Secondary assessment reveals lower abd A patient arrives with a large open chest wound after being assaulted with a machete. Prehospital providers placed a nonporous dressing over the chest wound and taped it on three sides. he is now showing signs of anxiety, restlessness, severe respiratory distress, cyanosis and decreasing blood pressure. Which of the following is the MOST appropriate immediate intervention? - ANSWER>>>dressing removal (This is the fastest effective intervention for this decompensating patient. A nonporous dressing taped on three sides is temporary and has variable effectiveness. If signs and symptoms of tension pneumothorax develop after the application of the dressing) EMS arrives with the intoxicated driver of a car involved in a MVC. EMS reports significant damage to the drivers side of the car. The pt is asking to have the cervical collar removed. When it is appropriate to remove the cervical collar? - ANSWER>>>after a physical examination if the pt has no radiologic abnormalities on CT Which of the following mnemonics can help the nurse prioritize care for a trauma patient with massive uncontrolled hemorrhage? - ANSWER>>>MARCH (The MARCH mnemonic stands for massive hemorrhage, airway, respiration, circulation, and head injury/hypothermia. The MARCH mnemonic recognizes uncontrolled hemorrhage as the major cause of preventable death after injury.) A patient is thrown against a car during a tornado and presents with obvious bilateral femoral fractures. The patient is pale, alert, disoriented, and has delayed capillary refill. Which of the following interventions would be most appropriate for this patient based on the disaster triage principles? - ANSWER>>>Initiate two large-caliber IVs for LR administration What finding raises suspicion of a complete spinal cord injury? - ANSWER>>>Priapism A trauma patient is en route to a rural emergency department. Radiology notifies the charge nurse that the computerized tomography (CT) scanner will be out of service for several hours. The team gathers to plan accordingly. Which of the following terms best describes this trauma teams communication? - ANSWER>>>huddle? An intubated trauma patient is being transferred to a tertiary care center. After moving the patient to the stretcher for transport, a drop in pulse oximetry to 85% is noted. Which of the following is the priority intervention? - ANSWER>>>Confirm ETT placement The nurse is caring for a 120 kg male brought in after a warehouse fire and is calculating the patients fluid resuscitation needs. He has painful red blistering to the entire surface of both upper extremities and superficial burns to the anterior chest. Using the modified Lund and Browder chart to calculate the total body surface area burned, how much IV fluid would be administered in the first 8 hours? - ANSWER>>>2280 ml (Both upper arms = 8%, both lower arms = 6%, and both hands = 5%, yielding 19 * 2 * 120 = 4560 mL. Half of the total is equal to 2280 mL. Superficial burns are not included in the TBSA calculation for fluid resuscitation.) Associated with significant geriatric morbidity and mortality. - ANSWER>>>Which of is TRUE about rib fractures? -Immediate treatment is 3-sided dressing -Definitive treatment is Chest Tube - ANSWER>>>For Open Pneumothorax treatments are - will cause obstructive shock - If Chest Tube placement is not ready available, needs Needle Decompression with 14-gauge needle, longer is better over the 2nd Intercostal space, midclavicular line OR 5th intercostal space, anterior axillary line - ANSWER>>>During Tension Pneumothorax -Decrease/Absent breath sounds ipsilaterally -JVD -Hypotension -Hyper-resonance ipsilaterally -Tracheal Deviation (late sign) -Severe Respiratory distress, Anxiety, agitation -Can lead to PEA - ANSWER>>>S/S of Tension Pneumothorax -Persistent Blood lost following chest tube insertion -Hemorrhagic shock: pallor, tachycardia, hypotension, cool peripheries -External thoracic injury -Decrease Breath sounds and decrease chest movement - dullness ipsilaterally -Anxiety/ Agitation. - ANSWER>>>Hemothorax: Blood in the pleural space. Assessment Finding What is the best measure of the adequacy of cellular perfusion and helps predict the outcome of resuscitation? - ANSWER>>>Base deficit used in conjunction with serum lactate Will hypocapnia cause vasoconstriction or vasodilation, especially in the cerebral vasculature? - ANSWER>>>Vasoconstriction What results from tissue hypo perfusion and oxygen deficit? - ANSWER>>>Metabolic acidosis What type of shock results in generalized vasodilation? - ANSWER>>>Neurogenic shock Spinal cord injuries at C3-C5 causes loss of what nerves function, resulting in what? - ANSWER>>>Phrenic nerve; paralyzed diaphragm and inability to breath Extremity elevation AT the level of the heart is beneficial for what type of injury? - ANSWER>>>Compartment Syndrome What is a high risk of frostbite? - ANSWER>>>Thrombus formation What two medications can be administered to maintain perfusion after a frostbite injury along with rewarming? - ANSWER>>>Tissue plasminogen activator or non steroidal anti-inflammatory medication (NSAIDS) An rise in diastolic blood pressures is a sign of increasing what? - ANSWER>>>Peripheral resistance What position will benefit the airway and work of breathing for the bariatric patient? - ANSWER>>>Reverse Trendelenburg Which phase of a blast results from flying debris, projectiles, and bomb fragments causing lacerations or penetrating injuries? - ANSWER>>>Secondary Phase What phase of a blast results from any explosion-related illness or injury including hyperglycemia, hypertension, angina, asthma, COPD, or sepsis? - ANSWER>>>Quaternary Phase What phase of a blast results from individuals being thrown by the blast and impacting walls, ground, or any hard object? - ANSWER>>>Tertiary Phase What phase of a blast results from impact of the over and under pressurization wave with body surfaces. Injuries include blast lung, tympanic membrane rupture, abdominal hemorrhage, globe rupture, and mild traumatic brain injury? - ANSWER>>>Primary Phase Signs of what include muscle pain or weakness, dark red or brown urine, general weakness or malaise, and elevated creatinine kinase levels? - ANSWER>>>Rhabdomyolosis Signs of what include anxiety, pleuritic chest pain, dyspnea, hypoxemia, hemoptysis, cough, orthopnea, adventitious lung sounds, decreased lung sounds, jugular vein distention, or hypotension? - ANSWER>>>Pulmonary Embolus Signs of what include headache, nausea and vomiting, amnesia, behavioral changes, altered level of consciousness? - ANSWER>>>Increased intracranial pressure Signs of what include asymmetric pupillary reactivity, unilateral dilation, widening pulse pressure, abnormal motor posturing, bradycardia, and decreased respiratory effort? - ANSWER>>>Late signs of increased ICP with Herniation Syndrome What is caused by the tear of the bridging veins or middle meningeal artery? - ANSWER>>>Subdural and Epidural Hematoma Affect concentration, memory, sleep, mode, and libido. Causes headaches, dizziness and nausea. - ANSWER>>>Postconcussive Syndrome/ Mild Traumatic Brain Injury Signs and symptoms similar to early signs of increased ICP but do not worsen. - ANSWER>>>Postconcussive Syndrome/ Mild Traumatic Brain Injury Cerebral Perfusion Pressure = ______-______ - ANSWER>>>MAP - ICP What is the range for CO2 to maximize perfusion? - ANSWER>>>35-45 Does hypoventilation cause dilation or constriction? Increase or decrease ICP? - ANSWER>>>Dilation and increase in ICP due to high CO2 Hyperventilation cause dilation or constriction? - ANSWER>>>Constriction d/t low CO2 Pupils with pressure on cranial nerve - ANSWER>>>Fixed and dilated Pupils with opiates vs stimulants - ANSWER>>>small; large Mitigation - ANSWER>>>A foundation to limit the potential impact of a disaster Triage colors and meanings: - ANSWER>>>Green - minor, walking wounded Yellow - delayed Red - immediate Black - expectant, deceased When should the decision to transfer be made? - ANSWER>>>When the patient's needs outweigh the capabilities of your facility Tertiary care facility, teaching hospital, comprehensive care from resuscitation or rehabilitation, research, injury prevention. - ANSWER>>>Level 1 Trauma Center Trauma rescucitation and definitive trauma care. Specialty and rehabilitation care may not be as comprehensive, may not conduct research. - ANSWER>>>Level 2 Trauma Center Provides ATLS assessment, intervention, resuscitation and emergency surgery. Generally does not accept transfers. - ANSWER>>>Level 3 Trauma Center Provides ATLS assessment, intervention, and resuscitation. May be in a remote area, has 24 hour physician and NP coverage. - ANSWER>>>Level 4 Trauma Center Greatest risk to the patient during interfaculty transfer/transport? - ANSWER>>>Loss of airway and respiratory compromise What survey is a complete exam within 24 hours of arrival and identified injuries missed during primary assessment, reviews radiology studies, orders more studies, and assesses for hidden injuries? - ANSWER>>>Tertiary Survey Stages of shock - ANSWER>>>1. Compensatory Shock 2. Decompensatory Shock (progressive, hypotensive) 3. Irreversible Shock Anxiety, confusion, restlessness, narrowing pulse pressure, tachycardia, bounding pulse, and decreasing urinary output are signs of what? - ANSWER>>>Compensated Shock Decreased level of consciousness, hypotension, narrowed pulse pressure, tachycardia with weak pulse, tachypnea, and cool, clammy, cyanotic skin are signs of what? - ANSWER>>>Decompensated/Progressive shock Obtunded/comatose, profound hypotension, bradycardia, dysrhythmias, slow shallow respirations, petechiae/purpura are signs of what? - ANSWER>>>Irreversible shock Benefits of the trauma nursing process - ANSWER>>>Systematic approach to the evaluation of each trauma patient. Identifies life-threatening conditions, determines priorities of care. Efficient production of ATP, which maintains cellular metabolic function, is seen with what type of metabolism? - ANSWER>>>Aerobic metabolism Inefficient production of ATP, byproduct is lactic acid, leads to metabolic acidosis, cellular dysfunction leads to cell death with what type of metabolism? - ANSWER>>>Anaerobic metabolism The cellular process in which oxygen is used to metabolize glucose. Energy is produced in an efficient manner with minimal waste products. - ANSWER>>>Aerobic metabolism The cellular process in which glucose is metabolized into energy without oxygen. Energy is produced in an inefficient manner with many waste products. - ANSWER>>>Anaerobic metabolism What is included in the Trauma Triad of Death? - ANSWER>>>Coagulopathy Acidosis Hypothermia Pump failure, caused by blunt cardiac injury, dysrhythmias, or myocardial infarction is what type of shock? - ANSWER>>>Cardiogenic Shock What type of shock is caused by cardiac tamponade or tension pneumothorax? Ventricular failure is seen. - ANSWER>>>Obstructive Shock Reservoir depletion and hemorrhage cause which type of shock? - ANSWER>>>Hypovolemic Shock Vasodilation, anaphylaxis, sepsis, and spinal cord injuries cause which type of shock? - ANSWER>>>Distributive Shock Options for hemorrhage - ANSWER>>>Pressure at site, tourniquet, hemostatic dressings, Massive Transfusion Protocol, Tranexamic Acid (clotting promoter) Treatment for cariogenic shock - ANSWER>>>inotropic support, anti-dysrhythmic medications, treat myocardial infarction or other underlying cause Treatment for obstructive shock - ANSWER>>>pericardiocentesis, cardiac window, needle decompression, position pregnant patient on L side Treatment for distributive shock - ANSWER>>>Support ventilations, vasopressors, pain management, apply warming methods Treatment for hypovolemic shock - ANSWER>>>Tourniquet, 1:1:1 blood products, massive transfusion protocol, TXA, surgical repair Subdural hematoma is caused by tearing of the ______ veins and symptoms usually present within ____ hours of the accident. - ANSWER>>>Bridging; 72 Epidural hematoma is caused by an arterial or venous bleed? Sx are transient LOC followed by a lucid period. - ANSWER>>>Arterial Hyperventilation causes cerebral blood vessels to do what? - ANSWER>>>Constrict Why is a measure of serum lactate obtained in the initial assessment of the trauma patient? Answer: c - ANSWER>>>a) to measure oxygenation and ventilation b) to quantify the base deficit for the adequacy of cellular perfusion c) *to gauge end-organ perfusion and tissue hypoxia ** d) to determine the underlying cause of shock A trauma patient is restless and repeatedly asking "where am I?" vital signs upon arrival were BP 100/60 mm Hg, HR 96 beats/min, and RR 24 breaths/min. Her skin is cool and dry. Current vital signs are BP 104/84mm Hg, HR 108, RR 28 breaths/min. The patient is demonstrating signs and symptoms of which stage of shock? Answer: A - ANSWER>>>A) compensated ** B) Progressive C) irreversible D) decompensated An elderly patient with a history of anticoagulant use presents after a fall at home that day. she denies any loss of consciousness. She has a hematoma to her forehead and complains of headache, dizziness, and nausea. Which is a most likely cause of her symptoms? Answer: D - ANSWER>>>A) epidural hematoma B) diffuse axonal injury C) post-concussive syndrome D) subdural hematoma *** EMS brings a patient who fell riding his bicycle. Using the American College of Surgeons screening guidelines, which assessment finding would prompt the nurse to prepare the patient for radiologic spine clearance? Answer: D - ANSWER>>>A) Alert with no neurologic deficits B) Multiple abrasions to the extremities C) Multiple requests of water D) Smell of alcohol on breath *** Which of the following occurs during the third impact of a motor vehicle crash? D) apply a splint and elevate the extremity to the level of the heart. Which of the following is a late sign of increased intracranial pressure? Answer: C Cushing Response Widening pulse pressure Reflex bradycardia Decreased RR - ANSWER>>>A) Restlessness or drowsiness B) Nausea and vomiting C) Decreased respiratory effort** D) amnesia and anxiety Which of the following mnemonics can help the nurse prioritize care for a trauma patient with massive uncontrolled hemorrhage? Answer: B - ANSWER>>>A) ABC B) MARCH*** C) AVPU D) VIPP A patient is thrown against a car during a tornado and presents with obvious bilateral femoral fractures. The patient is pale, alert, disoriented, and has delayed cap refill. Which of the following interventions would be most appropriate for this patient based on the disaster triage principle? Answer: A - ANSWER>>>A) initiate two large caliber intravenous lines for Ringers lactate solution administration *** B) Administer Dilaudid for pain control and provide comfort care C) Place the patient in an observation area for care within the next few hours D) Contact the command center for the personnel to notify next of kin. A patient arrives with a large open chest wound after being assault ed with a machete, Prehospital providers placed a nonporous dressing over the chest wound and tapes it on 3 sides. He is now showing signs of anxiety, restlessness, severe respiratory distress, cyanosis, and decreasing blood pressure. Which of the following is the MOST appropriate interventions? Answer: C - ANSWER>>>A) needle decompression B) tube thoracostomy C) dressing removal ** D) surgical repair A patient is found lying on the floor after falling 13 hours ago. Which of the following lab values is expected with a musculoskeletal complication associated with this presentation? Answer: A - ANSWER>>>A) elevated creatine kinase *** B) decreased potassium level C) decreased WBC D) elevated GFR A 56-year- male patient involved in a MVC is brought to the ED of a rural critical access facility. He c/o neck pain, SOB, and diffuse abd pain. His GCS is 15. His vitals are as follows: BP 98/71 HR 125 beats/min RR 26 breaths/min SpO2 94% on high flow O2 via NRB mask which of the following is the priority intervention for this patient? Answer: C - ANSWER>>>A) Expedite transport to the CT scanner B) prepare the patient for spinal radiographs C) expedite transfer to the closest trauma center *** D) notify the patients family Caregivers carry a 2-year old into the ED who fell out of 2nd story window. The patient is awake and crying with increased work of breathing and pale skin. which of the following interventions has the highest priority? Answer: A - ANSWER>>>A) padding the upper back while stabilizing the cervical spine *** B) applying a tight-fitting NRB mask with an attached resevior C) establishing intravenous access and administering a 20mL/kg bolus D) preparing for drug assisted intubation Which of the following is a component of the trauma triad of death? Answer: A hypothermia, metabolic acidosis, coagulopathy - ANSWER>>>A) Acidosis ** B) hyperthermia C) hemorrhage D) sepsis A 35-year old male presents with facial trauma after bring struck inthe face with a baseball. a tear-drop shaped left pupil is noted on exam. What type of injury is suspected? Answer: B - ANSWER>>>A) oculomotor nerve palsy B) globe rupture *** C) uncal herniation D) retinal detachment Which of the following is true about the log roll maneuver? Answer: C - ANSWER>>>A) it causes less spinal motion than the lift and slide manuever B) it is recommended for patients with unstable pelvic fractures C) it can worsen cord damage from an unstable spinal injury *** D) it does not increases the risk of life threatening hemorrhage from unstable injuries EMS arrives with the intoxicated driver of a car involved in a MVC. EMS reports significant damage to the drivers side of the car. The patient is asking to have the cervical color removed. when is it appropriate to remove the cervical collar? An intubated trauma patient is being transferred to a tertiary care center. After moving the patient to the stretcher for transport, a drop in pulse oximetry to 85% is noted. Which of the following is the priority interventions? Answer: D - ANSWER>>>A) call for a portable CXR stat B) chest to make sure the ventilator is plugged in C) suction the ET tube D) confirm ET tube placement What factor contributes most the kinetic energy of a body in motion? answer: C - ANSWER>>>A) acceleration B) mass C) velocity *** D) inertia During the primary survey of an unconscious patient with multi-system trauma, the nurse notes snoring respirations. Which priority nursing interventions should be performed next? Answer: D - ANSWER>>>A) open the airway with the head-tilt/chin lift maneuver B) auscultate bilateral breath sounds to assess ventilatory status C) assist respirations using a BVM D) insert an oropharyngeal airway if there is no gag reflex *** Following a review of recent drills and a real disaster event, a hospital has identified deficiencies and is taking steps to minimize the impact of future disaster. Which phase of the disaster life cycle does this describe? Answer: A - ANSWER>>>A) mitigation *** B) preparedness C) response D) recovery Which pulse pressure description is an indication of early hypovolemic shock? Answer: B - ANSWER>>>A) widened B) narrowed *** C) bounding D) weak The most reassuring finding for a male patient with hop pain after a fall is which of the following? Answer: D - ANSWER>>>A) a normal prostate exam B) absence of abdominal distension C) a normal fast exam D) pelvic stability *** A 49-year old restrained driver involved in a MVC presents to the trauma center c/o abd, pelvic, and bil lower extremity pain Vitals signs are stable. The nurse can anticipate all of these negative fast exam except which of the following? Answer: A The FAST exam is done at the bedside to identify pathological fluid in the abdominal and pelvic cavities. FAST exams reduce the use of more invasive diagnostic peritoneal lavage and can be repeated if clinical changes or hemodynamic changes occur. A negative FAST study does not rule out injury and may warrant a follow-up computed tomography scan. Serial FAST exams can identify increasing abdominal fluid collections from hemorrhage. Diagnostic peritoneal lavage/diagnostic peritoneal aspiration is performed by the surgical team to rapidly identify the presence of hemorrhage in patients who are hemodynamically unstable after trauma. - ANSWER>>>A) diagnostic peritoneal lavage *** B) serial fast exams C) abdominal and pelvic CT scans D) serial abdominal assessments Which of the following is an expected finding in a patient with a thoracostomy connected to a chest drainage system? Answer: D - ANSWER>>>A) output of 200 mL/hr B) tubing clamp closed for transport C) dependent loops in the tubing to promote drainage D) fluctuations in the water serial chamber *** Which of the following patients warrants referral to a burn center? Answer: C - ANSWER>>>A) a 21- year old female with a partial thickness burn to the right forearm B) a 40-year old hypertensive male with a superficial burn to the back C) a 52-year old diabetic male with partial thickness burn to the left lower leg *** D) a 35-year old hyperlipidemic female with superficial burns to the anterior thorax. A patient has been in the ED for several hours waiting to be admitted. He sustained multiple rib fractures and a femur fracture after a fall. He has been awake, alert, and c/o leg pain. His wife reported suddenly becoming anxious and confused. Upon reassessment, the patient is restless, with respiratory distress and petechiae to his neck. the patient is exhibiting signs of symptoms commonly associated with which of the following conditions? Answer: B - ANSWER>>>A) acute lung injury B) fat embolism *** C) PTX D) pulmonary contusion Which is the effect of hypothermia on the oxyhemoglobin dissociation curve? Answer: A - ANSWER>>>A) Hemoglobin does not readily release oxygen for use by the tissues *** B) The amount of oxygen available to the tissues increases C) Tissue oxygenation (PaO2) increases D) Hemoglobin molecule saturation (SaO2) decreases A 20-year old male presents to the ED c/o severe lower abd pain after landing hard on the bicycle cross bars which performing an aerial BMX maneuver. Secondary assessment reveals lower abd tenderness and scrotal ecchymosis. Which of the following orders would the nurse questions? Answer: C - ANSWER>>>A) Fast exam