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

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TCRN REVIEW - TRUNK (THORACIC

TRAUMA, ABDOMINAL TRAUMA,

GENITOURINARY TRAUMA,

OBSTETRICAL TRAUMA) (

QUESTIONS ON EXAM) 2024

What is a collection of excess fluid between the visceral pericardium and the parietal pericardium? - correct answer✔✔ Pericardial Tamponade What are the classic signs and symptoms of a pericardial tamponade? - correct answer✔✔ Beck's Triad What are the 3 findings in Beck's Triad? - correct answer✔✔ Muffled heart tones Systemic Hypotension Distended Neck Veins (may not be present with hypovolemia) What are the cardiovascular effects of Pericardial Tamponade? - correct answer✔✔ Elevated CVP Narrowed Pulse Pressure Rapidly falling cardiac output Tachycardia Pulsus alternans Blunting of the QRS complex Pulseless Electrical Activity Pulsus paradoxus or paradoxical pulse What is Pulsus Alternans? - correct answer✔✔ Alternating morphology of the QRS complex

What is pulsus paradoxus or paradoxical pulse? - correct answer✔✔ A change of more than 10 mmHg in arterial pressure during inspiration How is pulsus paradoxus or paradoxical pulse found? - correct answer✔✔ Usually seen as a decreased amplitude on the arterial waveform, but may also be palpated as a reduction in the strength of the radial pulse during inspiration. What are the non-cardiac indications of a pericardial tamponade? - correct answer✔✔ Grey, death-like appearance Extreme anxiety Inability to lie supine Dyspnea Cyanosis How is pericardial tamponade diagnosed? - correct answer✔✔ Clinically or via FAST exam What is the treatment for pericardial tamponade? - correct answer✔✔ Pericardiocentesis Observe monitor for ventricular irritation during insertion How do you determine if blood aspirated from a pericardiocentesis is pericardial blood or ventricular blood? - correct answer✔✔ Pericardial blood WILL NOT clot Ventricular blood WILL clot In blunt cardiac injury, what part of the heart is most likely to be injured? - correct answer✔✔ Right ventricle (anterior chest) Blunt cardiac injury is frequently associated with _____ and _____. - correct answer✔✔ External chest wall trauma Fractures of the sternum or ribs overlying the heart What are the symptoms of blunt cardiac injury? - correct answer✔✔ Electrical disturbances

Chest Pain Heart Failure Describe electrical disturbances associated with blunt cardiac injury. - correct answer✔✔ PVC's A-Fib Atrioventricular blocks S-T segment changes What is the treatment for electrical disturbances associated with blunt cardiac injury? - correct answer✔✔ Continuous ECG monitoring Antiarrhythmics for clinically significant arrhythmias Describe chest pain associated with blunt cardiac injury and its treatment. - correct answer✔✔ Does not radiate or respond to standard treatment for chest pain. Treatments: analgesia and treat as per MI Describe heart failure associated with blunt cardiac injury. - correct answer✔✔ Right sided heart failure (JVD, Hypotension, Tachycardia) What is the treatment for heart failure associated with blunt cardiac injury? - correct answer✔✔ IV fluids per hemodynamic parameters Inotropic drugs List the Great Vessels - correct answer✔✔ Aorta 3 branches of the aorta: brachiocephalic, left common carotid, left subclavian Pulmonary artery and veins Superior Vena Cava What percentage of aortic injuries die on scene? - correct answer✔✔ 80%

Of the patients with aortic injuries that make it to the hospital, how many will die within 6 hours? - correct answer✔✔ 30% Of the patients with aortic injuries that make it to the hospital, how many will die with 24 hours? - correct answer✔✔ 40% What is the mortality rate in patients with pulmonary vascular trauma? - correct answer✔✔ 60% Of patients with great vessel injuries, what percentage are asymptomatic? - correct answer✔✔ 30-50% What are the subjective symptoms of great vessel injuries? - correct answer✔✔ Chest pain (ripping or tearing) Radiates through to the back Difficulty breathing Vagal complaints Dysphagia What are the objective symptoms of great vessel injuries? - correct answer✔✔ Signs of hemorrhagic shock Dyspnea Asymmetric pulse pressure (stronger upper extremity pulses as opposed to femoral pulses) Vascular bruits over precordium or intrascapular region Focal neurological findings Hoarseness What injury does asymmetric pulse pressure indicate? - correct answer✔✔ Vascular injury to the descending aorta What are the treatments for great vessel injuries? - correct answer✔✔ Keep the patient calm and quiet Type and cross 10 units of blood (assure blood is readily available)

Beta-blockade with a goal of: SBP: 80-100 and HR 60- Operative management Describe fractures of upper ribs (1st and 2nd). - correct answer✔✔ Protected by surrounding tissue and requires great force to fracture. Fractures of 1st and 2nd ribs are usually associated with what other injuries? - correct answer✔✔ Lungs, trachea, aortic arch, great vessels, vertebral column Describe fractures of ribs 3 through 9. - correct answer✔✔ Challenges include pain management, ineffective ventilation and secretion retention. What injures are frequently associated with fractures of ribs 3 through 9? - correct answer✔✔ Pulmonary contusions Pneumothorax What injuries are commonly associated with sternum fractures? - correct answer✔✔ Blunt cardiac injury and great vessel injury What injuries are commonly associated with left sided ribs 9-12 fractures? - correct answer✔✔ Pulmonary injury, splenic injury, left kidney injury What injuries are commonly associated with right sided ribs 9-12 fractures? - correct answer✔✔ Pulmonary injury, liver injury, right kidney injury Define a flail chest segment - correct answer✔✔ Three or more rib fractures in two or more locations causing a free floating segment of the rib cage Define paradoxical chest wall movement. - correct answer✔✔ Sinking of the flail segment during inspiration when the remainder of the chest bulges; bulging of the flail segment during exhalation when the remainder of the chest sinks.

List some common symptoms of flail chest. - correct answer✔✔ Paradoxical chest wall movement Decreased tidal volume Increased respiratory effort Verying degrees of hypoxia What types of pain management are used in flail chest? - correct answer✔✔ IV analgesia Epidural anesthesia (for 3 or more rib fractures) Intercostal nerve block Intrapleural anesthesia TENS List the treatments for flail chest. - correct answer✔✔ Pain management Judicious use of crystalloids (goal of euvolemia) Appropriate ventilator support (adjusted to insure normal blood gases, pulse ox and respiratory effort) Aggressive chest physiotherapy (postural drainage, percussion, vibration) Suctioning Early mobilization Position to insure optimal ventilation, oxygenation and chest wall stability What should be considered with rib fractures in children? - correct answer✔✔ Rib fractures in children are often associated with abuse What should be considered with rib fractures in the older population? - correct answer✔✔ Rib fractures occur frequently in the elderly and often lead to respiratory complications, therefore, admission with aggressive pain control may be necessary. After trauma, symptoms of pulmonary contusions evolve when? - correct answer✔✔ 6-48 hours after the trauma

List the symptoms of pulmonary contusions - correct answer✔✔ Reduction of PaO2 (below 60 mmHg on room air) Signs of respiratory distress (increased HR and RR) Pleuritic chest pain Crackles on auscultation Severe hypoxemia and respiratory acidosis Cough/inability to clear secretions Local areas of wheezing Increasing plateau pressures What are the treatment goals of pulmonary contusions? - correct answer✔✔ Pain relief Maintain euvolemia Adequate respiratory gas exchange (application of oxygen and non-invasive or invasive ventilation if needed) What are the long term treatments for pulmonary contusions? - correct answer✔✔ Mobilize and clear blood and secretions (chest physiotherapy, postural drainage, mobilization) What is the term for excess air in the pleural space? - correct answer✔✔ Pneumotherax What are the sources of pneumothorax and their frequency? - correct answer✔✔ Pulmonary laceration (71%) Tracheobronchial Injury (13%) Esophagus (7%) External wound or open pneumothorax (7%) What are the symptoms of an open pneumothorax? - correct answer✔✔ Sucking sound on inhalation Bubbling on exhalation May cause subcutaneous emphysema Emergent treatment is a three-sided occlusive dressing

What are the symptoms of a tension pneumothorax? - correct answer✔✔ Severe respiratory distress Significantly diminished or absent breath sounds on the affected side Signs of obstructive shock What are the signs of obstructive shock associated with a tension pneumothorax? - correct answer✔✔ anxiety or severe restlessness hypotension distended neck, head or upper extremity veins (absent if the patient has hypovolemia) tracheal deviation toward uninjured side cyanosis What is the treatment for tension pneumothorax? - correct answer✔✔ Needle decompression Describe the process of needle decompression. - correct answer✔✔ 2nd intercostal space at midclavicular line Use a large bore needle darted directly above the third rib on the opposite side of tracheal deviation What is the term for a collection of blood in the pleural space? - correct answer✔✔ Hemothorax What is the term for more than 1500 mL of blood, or more than 200 mL/hr of blood over 2-4 hours in the collection chamber? - correct answer✔✔ Massive Hemothorax What are some key considerations with a massive hemothorax? - correct answer✔✔ May cause hypovolemic and obstructive shock Consider autotransfusion List the advantages of autotransfusion. - correct answer✔✔ Immediately available No incompatibility concerns Elimination of complications related to storage (hyperkalemia, hypocalcemia, metabolic acidosis)

Blood is at body temperature May be more acceptable to patients with religious objections to blood transfusion List the disadvantages of autotransfusion. - correct answer✔✔ Limited to non-contaminated wounds Requires special equipment and some operator training Cannot be used with wounds <4-6 hours old What are the differences in pain between a pneumothorax and a hemothorax? - correct answer✔✔ Hemothorax - dull ache on side of fluid Pneumothorax - sharp pain which may radiate to the shoulder on the side of the pneumothorax Describe the differences in fremitus of a hemothorax and pneumothorax - correct answer✔✔ Hemothorax - fremitus is absent over fluid Pneumothorax - fremitus is decreased over air Describe the differences in breath sounds between a hemothorax and pneumothroax. - correct answer✔✔ Breath sounds are decreased over both. Describe the differences in percussion of a hemothorax and percussion of a pneumothorax. - correct answer✔✔ Hemothorax - hypo-resonance Pneumothorax - hyper-resonance How are treatments of hemothorax and pneumothroax determined? - correct answer✔✔ Based on size, symptoms and patient stability What is the treatment for an asymptomatic and stable pneumothorax? - correct answer✔✔ Supplemental oxygen (promotes reabsorption of pleural air) Observe for deterioration What is the treatment for an asymptomatic and stable hemothorax? - correct answer✔✔ IV Encourage deep breathing

Observe for deterioration What are the treatments for a patient with indications of instability in a pneumothorax? - correct answer✔✔ Support oxygenation / ventilation (oxygen administration) Chest Tube placement Consider Thoracotomy What are the treatments for a patient with indications of instability in a hemothorax? - correct answer✔✔ Support oxygenation/ventilation Chest Tube Placement Consider Thoracotomy Treat hypovolemic shock Blood loss replacement / autotransfusion List the factors of care for the chest drainage set. - correct answer✔✔ Maintain the drainage set below the level of the chest. Keep the unit upright Prevent dependent loops Describe bubbling in a patent system. - correct answer✔✔ Bubbling should be noted in the suction control chamber with intermittent bubbling in the water seal chamber. There should be no bubbling in the collection chamber. If the fluctuation or bubbling in the water seal chamber suddenly ceases, what are the likely causes? - correct answer✔✔ Tubing is kinked Obstruction (clot in the tubing) Pneumothorax has re-expanded What is the pneumonic FOCA and what is it used for? - correct answer✔✔ FOCA is used for problem solving for chest tubes. F - presnece of fluctuation

O - Output C - Color A - Presence of Air Leak Chest Tube drainage of more than 1000 mL initially or 200 mL/hour over 2-4 hours will likely need _____. - correct answer✔✔ Thoracotomy Sudden increase in bright red blood may indicate _____. - correct answer✔✔ New arterial bleeding Continuous bubbling noted in water seal chamber is indicative of _____. - correct answer✔✔ Presence of air leak What are the possible causes of a chest tube air leak? - correct answer✔✔ Expected in an unexpanded lung Check for air leak at insertion site Check for hole in tubing Change out the chest drainage set Consider large internal leak What is ARDS? - correct answer✔✔ Acute Respiratory Distress Syndrome: non-cardiogenic pulmonary edema What are the symptoms of ARDS? - correct answer✔✔ Hypoxemia Non-cardiogenic pulmonary edema Pulmonary hypertension Intrapulmonary shunting ARDS mneumonic symptoms: - correct answer✔✔ A - Acute in onset R - Ratio of PaO2 to FiO2 (P/F ratio) less than 20 regardless of PEEP D - Diffuse bilateral pulmonary infiltrates on CXR

S - Swan-Ganz pulmonary artery wedge pressure less than 18 mmHg or no clinical evidence of left atrial hypertension Describe ARDS related to the PF ratio. (PaO2 to FiO2). - correct answer✔✔ Healthy adult: > Mild ARDS: 200- Moderate ARDS: 100- Severe ARDS: < 100 List the risk factors for ARDS: - correct answer✔✔ Occurs more frequently in patients with any type of shock Multi-system trauma with extensive tissue destruction Pulmonary contusion Multiple orthopedic injuries (especially pelvic or long bone fractures) Massive transfusions Thoracic trauma Bacterial Pneumonia Sepsis Near-Drowning Gastric aspiration Major head injuries What are some physiological symptoms of impending insufficiency in ARDS? - correct answer✔✔ Physical assessment normal initially Dyspnea (although relatively normal PaO2) Decreased PaCO2 and respiratory alkalosis CXR may be normal In ARDS, impending insufficiency usually leads to clinical insufficiency which includes symptoms like_____. - correct answer✔✔ Usually starts within 24 hours Markedly decreased oxygenation

Significant dyspnea Hyperdynamic state with elevated Cl Patchy infiltrates on CXR Physiological deadspace increases High levels of PEEP required for oxygenation What are the late symptoms of ARDS? - correct answer✔✔ Frequently irreversible with fibrosis, atelectasis and recurrent pneumonia Hypoxemia is refractory to increased oxygenation Decreased lung compliance Patient often dies within two weeks with multi-organ dysfunction syndrome Many ARDS survivors have _____. - correct answer✔✔ Lasting lung damage In treatment of ARDS, vent settings: Tidal volume should be_____. - correct answer✔✔ 6-10 mL/kg Permissive hypercapnia PaCO2 65-85 tolerated unless there is increased ICP In treatment of ARDS, vent settings for end-expiratory plateau pressure should be _____. - correct answer✔✔ <30 cm H2O Barotrauma and air leaks above this limit In the treatment of ARDS, vent settings for PEEP (positive end-expiratory pressure) should be _____. - correct answer✔✔ 10-15 cm H2O Consider early prone positioning In treatment of ARDS, vent settings for RR should be _____. - correct answer✔✔ 18-24 breaths per minute Higher than normal limits, hypercapnia

In treatment of ARDS, vent settings inspiratory:expiratory ratio should be _____ - correct answer✔✔ 1: to 1: Check for inadvertent PEEP In treatment of ARDS, vent settings FiO2 should be _____. - correct answer✔✔ <60-80% Goal PaO2 40- Goal SpO2 85-95% Lowest possible to reduce O2 toxicity What are the vent settings on high frequency oscillatory ventilation in treatment of ARDS? - correct answer✔✔ Amplitude pressure (30-50 cmH2O) Mean airway pressure (15-30 cmH2O) Respiratory rate (3-10) FiO2 (<60-80%) What are the symptoms of a ruptured diaphragm? - correct answer✔✔ Heart sounds shifted to the right side of the chest Signs of obstructive shock Dysphagia Dyspnea Decreased breath sounds on the affected side Bowel sounds in the middle to lower chest Lower chest, abdominal or epigastric pain that radiates to left shoulder In 66% of abdominal trauma, the _____ is the only damaged intraperitoneal structure. - correct answer✔✔ Spleen Organs most likely affected in penetrating abdominal trauma are: - correct answer✔✔ 1. Small Intestine

2. Colon
3. Liver

Organs most likely affected in blunt abdominal trauma are: - correct answer✔✔ 1. Spleen

2. Liver
3. Small Bowel _____ are more likely but less lethal than gunshot wounds. - correct answer✔✔ Stab wounds Which abdominal quadrant is most likely to be affected in stab wounds? - correct answer✔✔ Left Upper Quadrant Only ____% of stab wounds penetrate the peritoneum. Of those, only _____ result in vascular or visceral injury. - correct answer✔✔ 66% 50-75% _____% of gunshot wounds penetrate the peritoneum. - correct answer✔✔ 85% _____% of gunshot wounds result in significant abdominal trauma. - correct answer✔✔ 68-94% Penetration below the nipple line may cause _____. - correct answer✔✔ Abdominal or chest trauma or both _____ carries a higher rate of infection than other penetrating trauma. - correct answer✔✔ Impalement Shoulder restraints cause _____ in the driver and _____ in the passenger. - correct answer✔✔ Right- sided rib fractures with underlying visceral trauma Left-sided rib fractures Underarm usage of shoulder restraints _____. - correct answer✔✔ Increases abdominal compressive forces, especially in front-end crashes.

What is the term for contusions or bruising along the lower abdomen from the lap belt? - correct answer✔✔ Seat-Belt Sign 33% of patients with seat-belt sign will have _____. - correct answer✔✔ Associated small bowel injury Mesenteric tears Fractures of the lumbar spine Accuracy of abdominal assessment may be diminished with: - correct answer✔✔ distracting injuries spinal cord injuries neuropathies from diabetes alcohol or drug use head injuries psychiatric problems In the exam of a patient with abdominal trauma, nausea and vomiting are suspect for what injuries? - correct answer✔✔ Peritoneal irritation, hypovolemia and obstructions In the exam of a patient with abdominal trauma, dyspnea is suspect for what injuries? - correct answer✔✔ Gastric distension, diaphragmatic irritation, or diaphragmatic tear with visceral herniation In the exam of a patient with abdominal trauma, a distended abdomen is suspect for what injuries? - correct answer✔✔ pneumoperitoneum, gastric dilation, ileus and hemoperitoneum In the exam of a patient with abdominal trauma, brusising in the flanks or around the umbilicus is suspect for what injuries? - correct answer✔✔ Retroperitoneal injuries (delayed by 12 hours or more) In the exam of a patient with abdominal trauma, decreased bowel sounds are suspect for what injuries?

• correct answer✔✔ Fluid or blood irritating the peritoneum, ileus from spinal cord injury, or peritonitis In the exam of a patient with abdominal trauma, RUQ tenderness is suspect for what injuries? - correct answer✔✔ Liver, gallbladder, duodenum injuries

In the exam of a patient with abdominal trauma, LUQ tenderness is suspect for what injuries? - correct answer✔✔ Spleen, Stomach or pancreatic trauma In the exam of a patient with abdominal trauma, lower abdominal tenderness is suspect for what injuries? - correct answer✔✔ Colonic, bladder or urethral injuries In the exam of a patient with abdominal trauma, rebound tenderness is suspect for what injuries? - correct answer✔✔ Blood in the peritoneum, chemical peritonitis (leakage of gastric contents) enzyme spillage (from pancreas) or bacterial contaminants from bowel contents In the exam of a patient with abdominal trauma, dullness over hollow organs is suspect for what injuries? - correct answer✔✔ Free fluid in the perineum, solid mass In the exam of a patient with abdominal trauma, hyper-resonance over solid organs is suspect for what injuries? - correct answer✔✔ Free air in the abdomen or rupture of a hollow organ In the exam of a patient with abdominal trauma, fixed areas of dullness is suspect for what injuries? - correct answer✔✔ Bleeding from a specific organ (dullness in the LUQ caused by splenic bleeding) In the exam of a patient with abdominal trauma, dullness that does not change position is suspect for what injuries? - correct answer✔✔ Retroperitoneal hematoma Focused Abdominal Sonography for Trauma is _____. - correct answer✔✔ a FAST exam Name 4 things a FAST exam can be used to detect. - correct answer✔✔ Hemoperitoneum (as little as 100 mL of blood) Pericardial Fluid Pneumothorax Hemothorax

List two drawbacks of the FAST exam. - correct answer✔✔ It does not identify or grade solid organ injury It has lower accuracy for retroperitoneal bleeding and for small bowel or diaphragm injuries _____ or _____ is rarely used today because of other diagnostic options, but remains 95% accurate for hemoperitoneum. - correct answer✔✔ Diagnostic Peritoneal Aspiration (DPA) or Diagnostic Peritoneal Lavage (DPL) What should be placed prior to performing a DPL? - correct answer✔✔ Catheter and Gastric Tubes Discuss the procedure of DPL. - correct answer✔✔ Aspiration of 10mL or more of blood, bile, food particles or GI contents is an indication for laparotomy. If DPL is negative, instill one liter of crystalloid into the abdomen and drain, send to lab for analysis. List the symptoms of abdominal trauma that are an indication for surgical intervention. (8) - correct answer✔✔ Signs of hypovolemia with persistent hypotension in a patient for whom there is no other reasonable explanation for blood loss, or intra-abdominal injury is strongly suspected. Ongoing hemodynamic instability More than 2 units of blood required to maintain hemodynamic stability Clear and persistent signs of peritoneal irritation Radiological evidence of pneumoperitoneum consistent with viscus rupture. Persistent, significant gastrointestinal bleeding seen in the gastric tube return, vomitus, or gross blood per rectum. Evisceration List some symptoms of abdominal trauma that are indications for non-operative management. - correct answer✔✔ Solid organ injuries are less likely to require surgical intervention when compared to hollow organ injuries. Hymodynamically stable Stable hemoglobin levels during the first 12-48 hours. Less than 2 units of PRBC's Less than 55 years old

Alert and able to interact during abdominal examination. List three important factors in post-operative abdominal surgical monitoring. - correct answer✔✔ Progressive anemia Hypotension / Tachycardia Failure to correct base defecit despite volume resuscitation. List the signs of abdominal compartment syndrome. - correct answer✔✔ Decreased urinary output Increased central venous pressures Increased pulmonary artery wedge pressures Increased systemic vascular resistance Decreased blood pressure Decreased tidal volume Respiratory Acidosis What is usually the initial indication of abdominal compartment syndrome? - correct answer✔✔ Decreased urinary output What are the effects of intra-abdominal pressure above 20 mmHg? - correct answer✔✔ Increased ICP Increased peak pressures on mechanical ventilator with difficult ventilation and oxygenation Increased gut ischemia Cardiovascular instability Venal caval flattening anuria/acute renal failure Acidosis Describe the procedure for measuring intra-abdominal pressure. - correct answer✔✔ Supine position End-expiration Transducer zeroed at mid-axillary line

Instill fluid Measure pressure 30-60 seconds after fluid instillation is the absence of active abdominal muscle contractions. How is abdominal compartment syndrome measured? - correct answer✔✔ Grades I - IV Describe the grades of abdominal compartment syndrome. - correct answer✔✔ Grade I - 12-15 mmHg - management is maintenance of euvolemia Grade II - 16-20 mmHg - management is volume administration Grade III - 21-25 mmHg - management is decompression Grade IV - >25 mmHg - management is re-exploration It may be more beneficial to measure _____ rather than intra-abdominal pressure (IAP) - correct answer✔✔ Abdominal perfusion pressure (APP) To measure APP: - correct answer✔✔ Subtract the patient's IAP (intra-abdominal pressure) from their MAP (mean arterial pressure) APP = MAP-IAP Ideally, APP should always be above _____. - correct answer✔✔ 50 mmHg What are the treatments for abdominal compartment syndrome? - correct answer✔✔ Avoid elevating HOB Maintain MAP but avoid over-resuscitation (especially with isotonic crystalloids) Consider diuresis Percutaneous catheter decompression for patients with intraperitoneal fluid, abscess or blood Bedside or operative decompression Describe the symptoms of pain in peritonitis. - correct answer✔✔ Diffuse, Guarding, Rebound Tenderness, Worse with movement or pain, Relieved by flexion of the knees, positive Markle test

Describe a Markle Test. - correct answer✔✔ Have a patient stand on their tiptoes and drop onto their heels. This will elicit abdominal pain in the patient with peritonitis. In the stretcher patient, strike the bottom of the heel with a fist. If this maneuver elicits abdominal pain, it is a possible indication of peritonitis. What are the symptoms of peritonitis? - correct answer✔✔ Pain Rigid washboard abdomen Fluid shifting with dehydration, electrolyte imbalances and respiratory difficulties What is the treatment for peritonitis? - correct answer✔✔ Aggressive fluid resuscitation Correction of electrolyte and coagulation imbalances Prompt initiation of systemic broad-spectrum antibiotics Adequate drainage of abscesses Describe pain in pancreatitis. - correct answer✔✔ Sudden onset LUQ or epigastric (radiates through the back) Pain decreased in the sitting or fetal position Describe the signs and symptoms of pancreatitis. - correct answer✔✔ Pain Abdominal tenderness and guarding Nausea, vomiting and anorexia Fever and tachycardia What is the term for bruising in the flanks? - correct answer✔✔ Gray-Turner Sign What is the term for bruising around the umbilicus? - correct answer✔✔ Cullen Sign List some characteristics of Pancreatitis: - correct answer✔✔ Bruising in the flank (Gray-Turner sign), bruising around the umbilicus (Cullen Sign), Hypocalcemia (may include signs such as tetany, prolonged QT interval, muscle cramping), pleural effusion, acute respiratory distress syndrome, sepsis

Describe the laboratory findings associated with pancreatitis. (5) - correct answer✔✔ Serum amylase rises quickly but returns to normal in 24-72 hours. Serum lipase rises slowly, but may remain elevated for up to 2 weeks. Hypocalcemia Decreased H/H Elevated serum glucose What is the treatment for pancreatitis? - correct answer✔✔ IV fluid resuscitation as needed Analgesia (morphine should be avoided) Antiemetics IV calcium PRN Antibiotics for abscess or sepsis What medication should be avoided in pancreatitis and why? - correct answer✔✔ Morphine. It can cause spasms of the sphincter of Oddi What should an ongoing monitoring of pancreatitis consist of? - correct answer✔✔ Monitor for worsening hemorrhage Monitor for respiratory failure Monitor for hyperglycemia Monitor for Hypocalcemia Monitor for signs of sepsis The _____ is rarely injured and is rarely a single system injury. - correct answer✔✔ Esophagus Where do most esophagus injuries occur? - correct answer✔✔ In the cervical region (the abdominal region is rarely injured)

Is esophageal trauma more common in blunt or penetrating trauma? - correct answer✔✔ More common in penetrating Esophageal trauma may result in _____ leading to respiratory distress. - correct answer✔✔ Significant fluid losses in the thorax and abdomen What are the symptoms of esophageal trauma? - correct answer✔✔ Pain in the neck, chest, shoulders and throughout the abdomen Dysphagia Fever (delayed finding) Signs of peritonitis Dyspnea and pleural pain What are the treatments for esophageal trauma? - correct answer✔✔ Gastric decompression Antibiotic therapy Operative intervention What are some common complications of esophageal trauma? - correct answer✔✔ Peritonitis Respiratory compromise Fistula formation Esophageal strictures A stomach injury is more common in _____ trauma (20%) versus _____ trauma (1%). - correct answer✔✔ penetrating blunt Stomach injury is _____ an isolated injury in blunt trauma. - correct answer✔✔ Rarely Due to _____, the stomach has low bacterial growth. - correct answer✔✔ Acidity

List the symptoms of a stomach injury. - correct answer✔✔ Bloody drainage from gastric tube Tenderness (primarily epigastric) Free air on the x-ray initial pain due to chemical irritation, later pain due to bacterial peritonitis What are some common complications of a stomach injury? - correct answer✔✔ Peritonitis Intra-abdominal abscess formation Gastric fistulas What is the encapsulated, dense organ with little elasticity and flexibility, making it the most frequently injured organ from blunt trauma? - correct answer✔✔ Spleen The spleen stores _____ of blood, which can be released in a significant injury, and another _____ of blood circulates through the spleen each minute. - correct answer✔✔ 200-300 mL 250 mL Subcapsular hematoma <10% and a capsular laceration <1 cm parenchymal depth describe what grade of splenic injury? - correct answer✔✔ Grade 1 Subcapsular hematoma 10%-50% surface area, intraparenchymal , <5cm in diameter describes what grade of splenic injury? - correct answer✔✔ Grade 2 Capsular tear, 1-3 cm parenchymal depth that does not involve a trabecular vessel describes what grade of splenic injury? - correct answer✔✔ Grade 2 Subcapsular hematoma >50% surface area or expanding/ ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma > 5cm or expanding, describe what grade of splenic injury? - correct answer✔✔ Grade 3 A laceration >3 cm parenchymal depth or involving trabecular vessels describes what grade of splenic injury? - correct answer✔✔ Grade 3

A spleen laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen) describes what grade of splenic injury? - correct answer✔✔ Grade 4 A completely shattered spleen or laceration to hilar vascular injury devascularizing the spleen describes what grade of splenic injury? - correct answer✔✔ Grade 5 In regard to spleen injuries, if splenic blood remains capsular it is known as a _____. - correct answer✔✔ Hematoma In regard to spleen injuries, if a capsule ruptures, it is known as a _____. - correct answer✔✔ Laceration Describe pain related to spleen injuries. - correct answer✔✔ Left shoulder pain exacerbated in the supine or Trendelenburg's position Left upper quadrant pain Rebound tenderness due to peritoneal irritation What are the symptoms of splenic injury? - correct answer✔✔ Surface trauma to the LUQ Indications of intraperitoneal bleeding (abdominal distension, asymmetry, abnormal contour, tight abdomen) Tenderness, guarding and rigidity in the LUQ Pain What are the indications for operative repair of the spleen? - correct answer✔✔ Surgical packing and repair Splenorrhaphy Splenectomy (reserved for unstable patients or patients with a grade IV or V injury). What are the common inpatient complications of spleen injuries? - correct answer✔✔ Gastric perforation Recurrent bleeding Acute gastric dilation