Trauma Assessment and Management, Exams of Nursing

Download Trauma Assessment and Management and more Exams Nursing in PDF only on Docsity! ATLS Practice Questions And Answers Graded A+ 2022 Patients with a GSC of less than ___ usually require intubation. Correct Answer: 8 The "A" in ABCD stands for _______. Correct Answer: Airway maintenance with CERVICAL SPINE PROTECTION You should assume that any patient in a multisystem trauma with an altered level of consciousness or blunt injury above the clavicle has what type of injury? Correct Answer: Cervical spine injury Flail chest is invariably accompanied by ______ which can interfere with blood oxygenation. Correct Answer: pulmonary contusion - do NOT over fluid resuscitate these patients! Hypotension is caused by _____ until proven otherwise. Correct Answer: hypovolemia When you don't have/can't get a blood pressure, what are three things to look for when evaluating perfusion. Correct Answer: 1. Level of consciousness (brain perfusion), 2. Skin color (ashen face/grey extremities) 3. Pulse (bilateral femoral - thready/tachy) Elderly patients have a limited ability to ______ to compensate for blood loss. Correct Answer: increase heart rate Resuscitation fluids should be warmed 39 degrees Celsius (102.2 F). Can you use a microwave to do this? Correct Answer: YES - for CRYSTALLOID ONLY (but NOT for blood products). Urinary catheters are good for assessing renal perfusion and volume status. List 5 signs of urethral injury that might prevent you from inserting one. Correct Answer: Blood at urethral meatus, perineal ecchymosis, blood in scrotum, high-riding/non-palpable prostate, pelvic fracture Which arm should you NOT put a pulse-ox on? Correct Answer: The arm with a blood pressure cuff on it Name two anatomical things that can interfere with doing a FAST scan. Correct Answer: Obesity & intraluminal bowel gas When should radiographs be obtained? Correct Answer: During the SECONDARY survey. How do you get an ample patient history? Correct Answer: A=Allergies, M=Medications, P=PMH/Pregnancy, L=Last meal, E=Events/Environment of injury Why might you want a Bair Hugger for a patient who smells of alcohol? Correct Answer: Vasodilation can lead to hypothermia What things are you looking for when you do a DRE in a trauma? Correct Answer: Blood, high-riding prostate (in males), and sphincter tone What should you do for every female patient? Correct Answer: Pregnancy test (females of childbearing age) Adult patients should maintain UOP of at least ___ mL/kg/hr. Kids should have at least ___ mL/kg/hr. Correct Answer: Adults 0.5 mL/kg/hr, Kids 1.0 ml/kg/hr Preventing hypercarbia is critical in patients who have sustained a _____ injury. Correct Answer: head What two places would you LOOK at a patient if you suspect hypoxemia? Correct Answer: Lips and fingernail beds Patients may be abusive and belligerent because of _____, so don't just assume it's due to drugs, alcohol, or the fact that they are just inherently a jerk. Correct Answer: hypoxia Can a patient breathe on their own after complete cervical cord transection? Correct Answer: Yes, if the phrenic nerves (C3-C5) are spared. This will result in "abdominal" breathing. The intercostal muscles will be paralyzed though. Can you use an OPA (Guedel) in a conscious patient? Correct Answer: No, it could make them vomit. An NPA (trumpet) would be okay. Bougies are typically inserted blindly, how do you know you are in the trachea and not the esophagus? Correct Answer: You can feel the "clicks" as the distal tip rubs against the cartilaginous tracheal rings, or it will deviate right or left when entering either bronchus (usually at 50 cm). What do you NOT want to hear if you ascultate a patient after placement of an ET tube? Correct Answer: Borborygmi - rumbling or gurgling noises suggesting esophageal insertion. What is the RSI dose for etomidate? Correct Answer: 0.3 mg/kg (usually 20 mg) What is the RSI dose for sux? Correct Answer: 1-2 mg/kg (usually 100 mg) How does etomidate affect blood pressure? Correct Answer: It doesn't - at least it SHOULDN'T have any significant effect on BP. Ketamine will increase BP, and propofol and thiopental will both drop BP. A RSI dose of sux usually lasts about ___ minutes. Correct Answer: 5 What hypnotic/sedative/induction agent do you NOT want to use for a severely burned patient? Correct Answer: SUX - patients with severe burns, crush injuries, hyperkalemia, or chronic paralytic/neuromuscular diseases should NOT get sux because of hyperkalemia risk. Oxygen should flow at 15L for needle cricothyroidotomy, and have a Y-connector for insufflation if possible. What size needle do you use for adults? Kids? Correct Answer: Adults 12-14 gauge, kids 16-18 gauge Cricoid cartilage is the only circumferential support for the upper trachea in kids, therefore surgical cricothyroidotomy is not recommended in kids under the age of ___. Correct Answer: 12 In a "normal" patient without significant chest wall injury or lung disease, needle cricothyroidotomy can provide adequate oxygenation for approximately ____ minutes. Correct Answer: 30-45 Answer: III or IV - These patients almost always require a blood transfusion, which depends on their response to initial fluid resuscitation. The first priority is stopping the hemorrhage. Loss of more than ___% of blood volume results in loss of consciousness. Correct Answer: 50 How much blood volume is lost with Class IV Hemorrhage? Correct Answer: More than 40%. Unless very aggressive measures are taken the patient will die within minutes. A Class ___ Hemorrhage represents the smallest volume of blood loss that is consistently associated wiht a drop in systolic blood pressure. Correct Answer: III Up to ______ mL of blood loss is commonly associated with femur fractures. Correct Answer: 1500 Unexplained hypotension or cardiac dysrhythmias (usually bradycardia from excessive vagal stimulation) are often caused by ______, especially in children. Correct Answer: gastric distention How much crystalloid should you give an adult for an initial fluid resuscitation bolus? For kids? Correct Answer: Adults: 2 liters, Kids: 20 mL/kg (may repeat and give as much as 60 mL/kg but with high reserve in kids, if they're in shock they should get blood sooner rather than later. Each mL of blood loss whould be replaced with ___ mL of crystalloid, thus allowing for replacement of plasma volume lost into interstitial and intracellular spaces. Correct Answer: 3 Blood on the floor x four more is a mnemonic for occult blood loss where? Correct Answer: Chest, pelvis, retroperitoneum, and thigh For children UNDER 1 year of age, UOP should be ___ mL/kg/hr. Correct Answer: 2 Would patients in EARLY hypovolemic shock be acidodic or alkalotic? Correct Answer: Alkalotic - respiratory alkalosis from tachypnea....followed later by mild metabolic acidosis in the early phase of shock. "Rapid responders" whose vital signs return to normal (and stay there) after fluid resuscitation likely have/had a Class ___ Hemorrhage. Correct Answer: I or II "Transient responders" are associated with Class ___ Hemorrhage. Correct Answer: II or III What differential diagnoses should you always consider for "non-responders" following fluid resuscitation? Correct Answer: NON-HEMORRHAGIC causes, e.g. tension pneumothorax, tamponade, blunt cardiac injury, MI, acute gastric distention, neurogenic shock... Most patients receiving blood transfusions ____ need calcium replacement. Correct Answer: don't How should you position the patient before placing a subclavian or IJ line? Correct Answer: SUPINE, head down 15 degrees to distend neck veins and prevent embolism, only turn head away if C-SPINE HAS BEEN CLEARED FIRST. How long can you keep an IO line in? Correct Answer: Intraosseous infusion should be limited to emergency resuscitation and shoudl be discontinued as soon as other venous access is obtained. Where do you want to make an incision for a saphenous vein cutdown and how long should your incision be? Correct Answer: The saphenous vein can be accessed approximately 1 cm anterior and 1 cm superior to the medial malleolus. Make a 2.5 cm transverse incision through the skin and SQ tissue, careful not to injure the vessel. A patient arrives to the trauma bay intubated and there are absent breath sounds over the left hemithorax, where should you place your decompression needle? Correct Answer: This may NOT be a pneumothorax, for intubated patients always suspect a right main-stem before attempting needle decompression. Where would you insert a large caliber needle to decompress a tension pnuemothorax? Correct Answer: Into the 2nd intercostal space in the midclavicular line of the affected hemithorax. For an open pneumothorax, (sucking chest wound) air passes preferentially through the chest wall defect (least resistance) if the diameter of the defect is at least ___ the diameter of the trachea. Correct Answer: 2/3 Flail chest results from multiple rib fractures - by definition this would be ___ or more ribs, fractured in ___ or more places. Correct Answer: 2 or more ribs fractured in 2 or more places Both tension pneumothorax and massive hemothorax are associated with decreased breath sounds on auscultation, so you can tell which it is by _______. Correct Answer: Percussion - hyperresonant with pnuemo, dull with hemothorax. If a patient doesn't have JVD, does this mean they don't have a tension pneumo or tamponade? Correct Answer: No, they might have a massive internal hemorrhage and be hypovolemic. By definition, how much blood is in the chest cavity to call it a "massive hemothorax"? Correct Answer: 1500 mL or 1/3 or more of the patient's total blood volume. (Some also define it as continued blood loss of 200 mL/hr for 2-4 hours- but ATLS does NOT use this rate for any mandatory treatment decisions). What size chest tube might you use to evacuate a massive hemothorax? Correct Answer: #38 French - inserted at the 4th or 5th intercostal space, just anterior to the midaxillary line. What is Kussmaul's sign? Correct Answer: A rise in venous pressure with inspiration while breathing spontaneously, and is a true paradoxical venous pressure abnormality associated with cardiac tamponade. How well do CPR compressions work on someone with a penetrating chest injury and hypovolemia? Correct Answer: "Closed heart massage for cardiac arrest or PEA is INEFFECTIVE in patients with hypovolemia." Patients with PENETRATING thoracic injuries who arrive pulseless, but with myocardial electrial activity, may be candidates for an ED thoacotomy. Are patients with PEA who have sustained blunt thoracic injuries candidates for an ED thoracotomy? Correct Answer: NO - Only PEA with PENETRATING thoracic injuries should get an ED thoracotomy. An ED thoracotomy can allow you to do what? Correct Answer: Evacuate pericardial blood, direcly control hemorrhage, cardiac massage, cross-clamp the descending aorta to slow blood loss below the diaphragm and increase perfusion to the heart and brain. For a patient with a traumatic simple pneumothorax, what should you do BEFORE you start positive pressure ventilation or take them to surgery for a GA? Correct Answer: CHEST TUBE - positive pressure ventilation can turn a simple pneumo into a tension pneumo, so put in a chest tube first. Should you evacuate a simple hemothorax if it is not causing any respiratory problems? Correct Answer: YES - A simple hemothorax, if not fully evacuated, may result in a retained, clotted hemothroax with lung entrapment or, if infected, develop into an empyema. A pneumothorax associated with a persistent large air leak after tube thoracostomy suggests a _______ injury. Correct Answer: tracheobronchial - Use bronchoscopy to confirm, you may need more than one chest tube before definitive operative management. What radiographic findings are suggestive of traumatic aortic disruption? Correct Answer: Widened mediastinum, obliteration of aortic knob, deviation of trachea to the right, depression of left mainstem bronchus, deviation of esophagus (NG tube) to right, widened paratracheal stripe, fx'd 1st/2nd ribs or scapula. A deceleration injury victim with a left pnuemothorax or hemothorax without rib fractures, is in pain or shock out of proportion to the apparent injury, and has particulate matter in their chest tube may have _________. Correct Answer: an ESOPHAGEAL RUPTURE - a forceful blow causes expulsion of gastric contents into the esophagus, producing a linear tear in the lower esophagus allowing leakage into the mediastinum. Fractures for the lower ribs (10-12) should increase suspicion for _____ injury. Correct Answer: hepatosplenic Why are upper torso, facial, and arm plethora with petechiae associated with crush injuries to the chest? Correct Answer: Temporary compression of the superior vena cava. How does ATLS suggest you should review a chest radiograph? Correct Answer: Trachea & bronchi, pleural spaces and parenchyma, mediastinum, diaphragm, bones, soft tissues, tubes & lines. You should use a size 16 or 18 gauge 6" needle for pericardiocentesis. How do you insert it? Correct Answer: Puncture the skin 1-2 cm inferior to the left xiphohondral junction at a 45 degree angle to the skin towards the heart, aiming toward the top of the left scapula. What's a good way to know if you've advanced your needle too far during pericardiocentesis and have entered ventricular muscle? Correct Answer: ECG Changes - extreme ST-changes, widened QRS, PVCs, etc... Withdrawl needle until ECG returns to baseline. What should you do with your needle after you successfully evacuate blood during pericardiocentesis? Correct Answer: Lock the stopcock and leave the catheter in place in case it needs to be reevacuated. If possible, use the Seldinger technique to pass a 14 gauge flexible catheter over the guidewire. This is NOT a definitive treatment. For patients with facial fractures or basillar skull fractures, gastric tubes should be inserted ____ before doing a DPL. Correct Answer: through the mouth minutes? Correct Answer: CT scan - Everything but the 30 min amnesia makes them HIGH risk for neurosurgical intervention (as would a basillar skull fx). What 2 things do you need to do first for everyone with a MODERATE brain injury (according to ATLS algorithm)? Correct Answer: CT scan, admit to faciolity capable of definitive neurosurgical care (Moderate = GCS 9-12) High levels of CO2 will cause cerebral vasculature to _____. Correct Answer: Dilate (to increase blood flow) - so you might want to HYPERventilate people with brain injuries. Ideally, you want to wait to perform a GCS on a person with SEVERE brain injury until what? Correct Answer: BP is normalized A FAST scan, DPL, or ex-lap should take priority over a CT scan if you can't get the brain injured patient's BP up to ____ mm Hg. Correct Answer: 100 If a patient has a systolic over 100 with evidence of intracranial mass (blown pupil, unequal motor exam) THEN a CT would take first priority. A midline shift of greater than ___ often indicates the need for neurosurgical evacuation of the mass/blood. Correct Answer: 5mm Your patient has a dilated pupil and you want to give mannitol on the way to the CT scanner or OR. What is the correct dose? Correct Answer: 0.25-1.0 g/kg via rapid bolus A cast cutter should be removed to remove a trauma victim's helmet if there is evidence of a c-spine injury or if _____. Correct Answer: the patient experiences pain or paresthesias during an initial attempt to remove the helmet. What are the signs of neurogenic shock? Correct Answer: Vasodilation of lower extremity blood vessels - resulting in pooling of blood and hypotension. This loss of sympathetic tone may cause bradycardia or inhibit the tachycardic response to hypovolemia. How do you treat neurogenic shock? Correct Answer: Judicious use of pressors and MODERATE fluid resuscitation. Too much fluid may result in overload and pulmonary edema. What is the most common type of C1 fracture? Correct Answer: Burst fractures (Jefferson fracture) What's the difference between types I, II, and III odontoid process fractures? Correct Answer: I=tip of odontoid, II=fx at base, III=base of odontoid and extends obliquely into body of axis. (Odontoid process = dens). What are the indications for c-spine radiographs in a trauma patient? Which x-ray views should be obtained? Correct Answer: Midline neck pain, tenderness on palpation, neurological deficits related to c-spine injuries, altered LOC or intoxication. 1) Lateral, 2) AP, 3) Open mouth odontoid view With the proper views of the c-spine, and a qualified radiologist - what is the sensitivity for finding unstable cervical spine injuries? Correct Answer: >97% (CT with 3mm slices >99%). Ten percent of all patients with a c-spine fracture have what? Correct Answer: A second, noncontiguous vertebral column fracture. (So scan the rest of their spine). Attempts to align the spine for the purpose of immobilization on the backboard are not recommended if they _______. Correct Answer: cause pain Can you clear a c-spine without films? Correct Answer: Yes, if they are awake, alert, sober, neurological normal, have NO pain, and can flex, extend, and move their head to both sides without pain - you don't need films. Should a quadriplegic or paraplegic patient be put on a hard board? Correct Answer: Not for more than 2 hours - get them off ASAP. What's a big difference in a physical finding between hypovolemic and neurogenic shock? Correct Answer: Hypovolemic = usually TACHY, Neurogenic = usually BRADY Partial or total loss of respiratory function may be seen in a patient with a cervical spine injury above ___. Correct Answer: C6 Why might someone not be able to breathe if they have a long bone fracture? Correct Answer: Fat embolism - uncommon though Abnormal arterial blood flow is indicated by an ABI of ____. Correct Answer: <0.9 By LOOKING at the patient, what findings might suggest pelvic injury? Correct Answer: Leg-length discrepancy, rotation (usually external) Crush injuries may result in rhabdomyolysis - casts block flow, also iron is released which forms ROS which then damage cells and impair ability to regulate K+ etc... What can you do to prevent this? Correct Answer: Volume expansion, and alkalization of urine with bicarb will reduce intratubular precipitation of myoglobin. UOP should be 100 mL/hr until myoglobinuria is cleared. Muscle does not tolerate lack of arterial flow (tourniquet) for more than ___ hours before necrosis begins. Correct Answer: 6 What things increase the risk for tetanus? Correct Answer: Wounds >6 hours old, wounds contused or abraded, >1 cm deep, from high velocity missiles, due to burns or cold, and significantly contaminated wounds. Should legs be completely straight when splinting? Correct Answer: No, flexion of 10 degrees recommended to take pressure off neurovascular structures. Any patient with burns covering more than ___% of BSA require fluid resuscitation. Correct Answer: 20 The palmer surface of a patient's hand represents approximately ___% of their BSA. Correct Answer: 1% A high index of suspicion for inhalation injury must be maintained, because patients may not display clinical evidence for up to ___ hours, by this time edema may prevent non-surgical intubation. Correct Answer: 24 Carbon monoxide has ____ times the affinity for oxygen as hemoglobin. Correct Answer: 240 Patients with CO levels less than ___% usually don't have any physical symptoms. Correct Answer: 20% Adult head BSA = ___%. Correct Answer: 9 (ENTIRE head front and back = 9) Baby head BSA = __% Correct Answer: 18 (9 front, 9 back) What is the main difference between adult and baby BSA determination for burns? Correct Answer: Entire head on baby is 18, whereas it's 9 for adults. This difference of 9 is made up by the fact that each side (front/back) on adult = 9, but only 7 for kids. (36 vs 28). Chest BSA = ___%. Correct Answer: 18 Back BSA = ___%. Correct Answer: 18 Arm BSA = ___%. Correct Answer: 9 TOTAL (front AND back). Leg BSA for adult = ___%. Correct Answer: 18 TOTAL (9 front, 9 back). Baby front or back of leg BSA =___%. Correct Answer: 7 (TOTAL leg = 14%) If you add up BSA head, chest, back, arms, and legs you get 99% of BSA. What is the remaining 1%? Correct Answer: Perineum Partial/2nd degree burns extend into the _____ whereas full thickness/3rd degree burns ______. Correct Answer: Partial - go into dermis, FULL go all the way through dermis and into/beyond SQ tissue. For patients with CO poisoning, the ½ life is ___ when breathing room air and ___ breathing 100% oxygen Correct Answer: 4 hours on RA, 40 min on 100% O2 How do you calculate the Parkland formula? Correct Answer: 4 * weight (kg) * percent BSA burned = volume in 24 hours (1st half in 8 hrs, 2nd half over 16 hrs).4*70kg*25 percent = 7 liters in 24 hours. ***Use 25, NOT 0.25)*** Partial or full thickness burns of ___% in patients less than 10 or older than 50 warrants transfer to a burn center. Correct Answer: 10% What percent partial/full thickness burns would qualify a 25 year old for a burn center transfer? Correct Answer: 20% What anatomical positions with partial/full thickness burns warrant burn center transfer? Correct Answer: Face, eyes, ears, hands, genitalia, perineum, feet, skin overlying joints. Does an inhalation injury warrant transfer to a burn center? Correct Answer: YES!!!!! Should you treat frostbite by soaking body part in water or not? Correct Answer: YES, 40 degree (104F) for 20-30 min should suffice. Don't warm if there is risk of REFREEZING.