Trauma Management: Identifying and Treating Critical Injuries, Exams of Nursing

Download Trauma Management: Identifying and Treating Critical Injuries and more Exams Nursing in PDF only on Docsity! ATLS PRACTICE EXAM Questions with 100% Verified Answers Latest Updates 2024 TOP RATED A+ Patients with a GSC of less than usually require intubation. - answer8 The "A" in ABCD stands for . - answerAirway 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? - answerCervical spine injury Flail chest is invariably accompanied by which can interfere with blood oxygenation. - answerpulmonary contusion - do NOT over fluid resuscitate these patients! Hypotension is caused by until proven otherwise. - answerhypovolemia When you don't have/can't get a blood pressure, what are three things to look for when evaluating perfusion. - answer1. 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. - answerincrease heart rate Resuscitation fluids should be warmed 39 degrees Celsius (102.2 F). Can you use a microwave to do this? - answerYES - 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. - answerBlood 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? - answerThe arm with a blood pressure cuff on it Name two anatomical things that can interfere with doing a FAST scan. - answerObesity & intraluminal bowel gas When should radiographs be obtained? - answerDuring the SECONDARY survey. How do you get an ample patient history? - answerA=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? - answerVasodilation can lead to hypothermia What things are you looking for when you do a DRE in a trauma? - answerBlood, high-riding prostate (in males), and sphincter tone What should you do for every female patient? - answerPregnancy test (females of childbearing age) Adult patients should maintain UOP of at least mL/kg/hr. Kids should have at least mL/kg/hr. - answerAdults 0.5 mL/kg/hr, Kids 1.0 ml/kg/hr Preventing hypercarbia is critical in patients who have sustained a injury. - answerhead What two places would you LOOK at a patient if you suspect hypoxemia? - answerLips 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. - answerhypoxia Shock is defined as an abnormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation. What are the 4 different types? - answerNeurogenic, cardiogenic, hypovolemic, septic The most common cause of shock in the injured trauma patient is . - answerhemorrhage Approximately % of the body's total blood volume is located in the venous circuit. - answer70 Why does shock actually reduce the total volume of circulating blood? - answerAnaerobic metabolism --> can't make more ATP --> Endoplasmic then mitochondrial damage --> lysosomes rupture --> sodium and WATER enter the cell, which SWELLS and dies. Which vasopressors should you use to treat hemorrhagic shock? What are the drug doses? - answerNEVER use pressors for hypovolemic shock - use VOLUME replacement. Pressors will worsen tissue perfusion in hemorrhagic shock. Compensatory mechanisms may preclude a measurable fall in systolic blood pressure until up to % of the patient's blood volume is lost. - answer30 Any patient who is cool and is tachycardic is considered to be until proven otherwise. - answerin shock The definition of tachycardia depends on the patient's age. What heart rate is considered tachycardic for infants, toddlers/preschoolers, school age/prebuscent, and adults? - answerInfants >160, toddlers/preschoolers >140, school age/prebuscent >120, adults >100 Elderly patients may not exhibit tachycardia in response to hypovolemia because of limited cardiac response to catecholamines. Why else might not they get tachy? - answerThey might be on a beta-blocker or have a pacemaker. A FAST scan is an excellent way to diagnose cardiac tamponade. What signs suggest tamponade? - answerBecks's Triad: JVD, muffled heart sounds, and hypotension (will be resistant to fluid therapy). Will also likely be tachycardic. Patients with a tension pneumo and patients with cardiac tamponade may present with many of the same signs. What findings will you see with a tension pneumo that you will NOT see with tamponade? - answerAbsent breath sounds and hyperresonance to percussion over the affected hemithorax. Immediate thoracic decompression is warranted for anyone with absent breath sounds, hyperresonance to percussion, tracheal deviation, , and . - answerAcute respiratory distress & subcutaneous emphysema Can isolated intracranial injuries cause neurogenic shock? - answerNO How do you calculate total blood volume in an adult? - answer70 mL per kg body weight. A 70 kg person has about 5 liters of circulating blood. (70*70=4900) How do you calculate total blood volume in an child? - answerBody weight in kg x 80-90 mL The blood volume of an obese person is calculated based upon their weight. - answerideal Fluid replacement should be guided by , not simply by the initial classification (Class I-IV). - answerThe patient's response to initial replacment How much blood volume is lost with Class I Hemorrhage? - answerUp to 15% Donating 1 pint, or ~500 mL of blood is about a 10% volume loss and would qualify as Class I Hemorrhage! How do you treat a Class I Hemorrhage? - answerYou don't (usually). Transcapillary refill and other compensatory mechanisms usually restore blood volume within 24 hours. How much blood volume is lost with Class II Hemorrhage? - answer15-30% (750-1500 mL in a 70 kg adult) How do you treat a Class II Hemorrhage? - answerUsually just crystalloid resuscitation Subtle CNS changes such as anxiety, fright, and hostility would be expected in a patient with a Class Hemorrhage. - answerII How much blood volume is lost with Class III Hemorrhage? - answer30-40% (2000 mL in a 70 kg adult) A patient with inadequate perfusion, marked tachycardia and tachypnea, significant mental status change, and a measurable fall in systolic blood pressure likely has a Class Hemorrhage. - answerIII 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. - answer50 How much blood volume is lost with Class IV Hemorrhage? - answerMore 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. - answerIII Up to mL of blood loss is commonly associated with femur fractures. - answer1500 Unexplained hypotension or cardiac dysrhythmias (usually bradycardia from excessive vagal stimulation) are often caused by , especially in children. - answergastric distention answer1500 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? - answer#38 French - inserted at the 4th or 5th intercostal space, just anterior to the midaxillary line. What is Kussmaul's sign? - answerA 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? - 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? - answerNO - Only PEA with PENETRATING thoracic injuries should get an ED thoracotomy. An ED thoracotomy can allow you to do what? - answerEvacuate 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? - answerCHEST 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? - answerYES - 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. - answertracheobronchial - 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? - answerWidened 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 . - answeran 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. - answerhepatosplenic Why are upper torso, facial, and arm plethora with petechiae associated with crush injuries to the chest? - answerTemporary compression of the superior vena cava. How does ATLS suggest you should review a chest radiograph? - answerTrachea & 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? - answerPuncture 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? - answerECG 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? - answerLock 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. - answerthrough the mouth You need to do retrograde urethrography PRIOR to foley placement if . - answerinability to void, unstable pelvic fracture, blood at urethral meatus, scrotal hematoma, perineal ecchymoses, or high-riding prostate. DPL is considered to be % sensitive for detecting intraperitoneal bleeding. - answer98 What are the four places you should look first when doing a FAST scan? - answerMediastinum, hepatorenal fossa, splenorenal fossa, pouch of Douglas. DPL is indicated when a patient with multiple blunt injuries is hemodynamically unstable, especially when they have . - answerChange in sensorium (brain injury/EtOH or drug intoxication), change in sensation (spinal cord injury), injury to adjacent structures (pelvis, lumbar spine), lap-belt sign (from seatbelt), or if patient is going for long studies (CT, ortho surgery...). What is the only ABSOLUTE contraindication to DPL? - answerAn existing indication for laparotomy. What are some RELATIVE contraindications to DPL? - answerMorbid obesity, advanced cirrhosis, preexisting coagulopathy, and previous abdominal operations (adhesions). When should you use an open SUPRAUMBILICAL approach for a DPL? - answerPELVIC FRACTURES (don't want to enter pelvic hematoma) and ADVANCED PREGNANCY (don't want to damage enlarged uterus). use? - answerThe "BEST" response. (Better predictor than worst response) What signs might you see if a patient has a basillar skull fracture? - answerPERIORBITAL ECCHYMOSIS (raccoon eyes), RETROAURICULAR ECCHYMOSIS (Battle sign), and otorrhea/rhinorrhea. What do you need to know about the GCS? - answerEVERYTHING - Know it COLD! What things might require a person with MINOR brain injury get admitted? - answerAbnormal CT (or no scan available), penetrating head injury, prolonged LOC, worsening LOC, moderate to severe HA, significant drug/alcohol intoxication, skull fx, oto/rhinorrhea, nobody at home to watch, GCS stays <15, focal neuro deficits. What would you want to do if a patient with a minor brain injury fails to reach a GCS of 15 within 2 hour post injury, had LOC >5 min, are older than 65, emesis x 2, or had retrograde amnesia >30 minutes? - answerCT 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)? - answerCT scan, admit to faciolity capable of definitive neurosurgical care (Moderate = GCS 9-12) High levels of CO2 will cause cerebral vasculature to . - answerDilate (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? - answerBP 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. - answer100 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. - answer5mm 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? - answer0.25-1.0 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 . - answerthe patient experiences pain or paresthesias during an initial attempt to remove the helmet. What are the signs of neurogenic shock? - answerVasodilation 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? - answerJudicious 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? - answerBurst fractures (Jefferson fracture) What's the difference between types I, II, and III odontoid process fractures? - answerI=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? - answerMidline 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? - answer>97% (CT with 3mm slices >99%). Ten percent of all patients with a c-spine fracture have what? - answerA 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 . - answercause pain Can you clear a c-spine without films? - answerYes, 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? - answerNot for more than 2 hours - get them off ASAP. What's a big difference in a physical finding between hypovolemic and neurogenic shock? - answerHypovolemic = usually TACHY, Neurogenic = usually BRADY Partial or total loss of respiratory function may be seen in a patient with a cervical spine injury above . - answerC6 Why might someone not be able to breathe if they have a long bone fracture? - answerFat embolism - uncommon though Abnormal arterial blood flow is indicated by an ABI of . - answer<0.9 By LOOKING at the patient, what findings might suggest pelvic injury? - answerLeg-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? - answerVolume expansion, and alkalization of urine with bicarb will reduce intratubular precipitation of myoglobin. UOP should be 100 mL/hr until myoglobinuria is cleared. What percent partial/full thickness burns would qualify a 25 year old for a burn center transfer? - answer20% What anatomical positions with partial/full thickness burns warrant burn center transfer? - answerFace, eyes, ears, hands, genitalia, perineum, feet, skin overlying joints. Does an inhalation injury warrant transfer to a burn center? - answerYES!!!!! Should you treat frostbite by soaking body part in water or not? - answerYES, 40 degree (104F) for 20-30 min should suffice. Don't warm if there is risk of REFREEZING. Insofar as hypothermia is concerned, patients are not pronounced dead until they are and dead. - answerwarm What are you thinking if a child has broken ribs? - answerMASSIVE force and highly likely organ damage (since their ribs are very pliable, a huge amount of force is required to break them, there is often underlying organ damage WITHOUT broken ribs). How should you insert a Guedel in a kid? - answerUse tongue blade depressor and insert gently without turning - otherwise there is great risk for trauma and resultant hemorrhage. NOT the 180 degree spin trick. The normal systolic BP in kids can be estimated by what? - answer90 mm Hg + (age x 2) How do you estimate a child's total circulating volume? - answer80 mL/kg When shock in a child is suspected, how much fluid do you give them? - answer20 mL/kg warm crystalloid May need to repeat up to 3 times (60 mL/kg) then consider blood products. Optimal UOP for infants is mL/kg/hr. - answer2 (1.5 for younger kids, and 1.0 for older kids). How much warmed crystalloid should be used for a DPL in kids? - answer10 mL/kg (up to 1000 mL) What would you see in an infant that would make you suspect very severe brain injury despite normal LOC? - answerBulging fontanelles - these allow tolerance for expanding masses/swelling... What is a possible mistake about a blood pressure of 120/80 in a 87 year old man? - answerAssuming that normal blood pressure = normovolemia. Many geriatric patients have uncontrolled hypertension, and if their normal systolic is 180, then 120/80 is relative HYPOtension for them. How well do geriatric patients do with non-operative management of abdominal injuries compared to younger people? - answerNot as well - the risks of non-operative management are often worse than the risks of surgery. Why would geriatric patients be MORE susceptible to head bleeds when there is increased space around a shrinking brain to protect them from contusion? - answerAtrophic brains = stretching of the parasagittal bridging veins, making them more prone to rupture upon impact. Plasma volume increases during pregnancy, what happens to hematocrit? - answerDecreases - dilution by plasma (31-35% is normal in pregnancy) What would you think of a WBC of 15,000 in a pregnant woman? - answerNormal, it can go up to 25,000 during labor! What should you always assume about a pregnant patient's stomach? - answerThat it is always full. (Gastric emptying time increases during pregnancy). Early NG tube placement recommended. A PaCO2 of 35 to 40 in a pregnant patient may indicate what? - answerImpending respiratory failure. It is usually around 30 due to hyperventilation due to increased levels of progesterone. True or False: All Rh negative pregnant trauma patients should get Rhogam? - answerTrue, unless the injury is remote from the uterus (distal extremity injury only). This therapy should be initiated within 72 hours of injury. When worn correctly, seatbelts reduce fatalities by %. - answer65-70%, with a 10-fold reduction in serious injury.