Trauma Management: Principles and Practices, Exams of Nursing

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A 22-year-old man is hypotensive and tachycardic after a shotgun wound to the left shoulder. His blood pressure is initially 80/40 mm Hg. After initial fluid resuscitation his blood pressure increases to 122/84 mm Hg. His heart rate is now 100 beats per minute and his respiratory rate is 28 breaths per minute. A tube thoracostomy is performed for decreased left chest breath sounds with the return of a small amount of blood and no air leak. After chest tube insertion, the most appropriate next step is:

--- re-examine the chest

A construction worker falls two stories from a building and sustains bilateral calcaneal fractures. In the emergency department, he is alert, vital signs are normal, and he is complaining of severe pain in both heels and his lower back. Lower extremity pulses are strong and there is no other deformity. The suspected diagnosis is most likely to be confirmed by:

--- complete spine x-ray series

What is true regarding the initial resuscitation of a trauma patient? --- Evidence of improved perfusion after fluid resuscitation could include improvement in Glasgow Coma Scale score on reevaluation

In managing a patient with a severe traumatic brain injury, the most important initial step is to: --- secure the airway

A previously healthy, 70-kg (154-pound) man suffers an estimated acute blood loss of 2 liters. What applies to this patient?

--- An ABG would demonstrate a base deficit between -6 and -10 mEq/L.

The physiological hypervolemia of pregnancy has clinical significance in the management of the severely injured, gravid woman by: --- increasing the volume of blood loss to produce maternal hypotension.

The best assessment of fluid resuscitation of the adult burn patient is:

--- urinary output of 0.5 mL/kg/hr

The diagnosis of shock must include:

--- evidence of inadequate organ perfusion

A 7-year-old boy is brought to the emergency department by his parents several minutes after he fell through a window. He is bleeding profusely from a 6-cm wound of his medial right thigh. Immediate management of the wound should consist of:

--- direct pressure on the wound

For the patient with severe traumatic brain injury, profound hypocarbia should be to prevent:

--- cerebral vasoconstriction with diminished perfusion

After being involved in a motor vehicle crash, a 25-year-old man is brought to a hospital that has surgery capabilities available.. Computed tomography of the chest and abdomen shows an aortic injury and splenic laceration with free abdominal fluid. His blood pressure falls to 70 mm Hg after CT. The next step is:

--- perform an exploratory laparotomy

What statements regarding abdominal trauma in the pregnant patient is TRUE?

--- Leakage of amniotic fluid is an indication for hospital admission.

The first maneuver to improve oxygenation after chest injury is:

--- administer supplemental oxygen

A 25-year-old man, injured in a motor vehicular crash, is admitted to the emergency department. His pupils react sluggishly and his eyes open to pressure. He does not follow commands, but he does moan periodically. His right arm is deformed and does not respond to pressure; however, his left hand reaches purposefully toward the stimulus. Both legs are stiffly extended. His GCS score is:

--- 9

A 20-year-old woman who is at 32 weeks gestation, is stabbed in the upper right chest. In the emergency department, her blood pressure is 80/60 mm Hg. She is gasping for breath, extremely anxious, and yelling for help. Breath sounds are diminished in the right chest. The most appropriate first step is to:

--- perform needle or finger decompression of the right chest

What findings in an adult is most likely to require immediate management during the primary survey?

--- respiratory rate of 40 breaths per minute

The most important, immediate step in the management of an open pneumothorax is:

--- placement of an occlusive dressing over the wound

avoided

The following are contraindications for tetanus toxoid administration:

--- history of neurological reaction or severe hypersensitivity to the product

A 56-year-old man is thrown violently against the steering wheel of his truck during a motor vehicle crash. On arrival in the emergency department he is diaphoretic and complaining of chest pain. His blood pressure is 60/40 mm Hg and his respiratory rate is 40 breaths per minute. What best differentiates cardiac tamponade from tension pneumothorax as the cause of his hypotension?

--- breath sounds

Bronchial intubation of the right or left mainstem bronchus can easily occur during infant endotracheal intubation because:

--- The trachea is relatively short.

A 23-year-old man sustains 4 stab wounds to the upper right chest during an altercation and is brought by ambulance to a hospital that has full surgical capabilities. His wounds are all above the nipple. He is endotracheally intubated, closed tube thoracostomy is performed, fluid resuscitation is initiated through 2 large-caliber IVs. FAST exam does not reveal intraabdominal injuries. His blood pressure now is 60/0 mm Hg, heart rate is 160 beats per minute, and respiratory rate is 14 breaths per minute (ventilated with 100% O2). 1500 mL of blood has drained from the right chest. The most appropriate next step in managing this patient is to:

--- urgently transfer the patient to the operating room

A 39-year-old man is admitted to the emergency department after an automobile collision. He is cyanotic, has insufficient respiratory effort, and has a GCS score of 6. His full beard makes it difficult to fit the oxygen facemask to his face. The most appropriate next step is to:

--- restrict cervical motion and attempt orotracheal intubation using 2 people

A patient is brought to the emergency department after a motor vehicle crash. He is conscious and there is no obvious external trauma. He arrives at the hospital completely immobilized on a long spine board. His blood pressure is 60/40 mm Hg and his heart rate is 70 beats per minute. His skin is warm. What do you expect to see with the patient?

--- Flaccidity of the lower extremities and loss of deep tendon reflexes are expected.

What is the most effective method for initially treating frostbite?

--- Moist heat

A 32-year-old man's right leg is trapped beneath his overturned car for nearly 2 hours before he is extricated. On arrival in the emergency department, his right lower extremity is cool, mottled, insensate, and motionless. Despite normal vital signs, pulses cannot be palpated below the right femoral artery and the muscles of the lower extremity are firm and hard. During the management of this patient, what is most likely to improve the chances for limb salvage?

--- surgical consultation for right lower extremity fasciotomy

A patient arrives in the emergency department after being beaten about the head and face with a wooden club. He is comatose and has a palpable depressed skull fracture. His face is swollen and ecchymotic. He has gurgling respirations and vomitus on his face and clothing. The most appropriate step after providing supplemental oxygen and elevating his jaw is to:

--- suction the oropharynx

A 22-year-old man sustains a gunshot wound to the left chest and is transported to a small community hospital no surgical capabilities are available. In the emergency department, a chest tube is inserted and 700 mL of blood is evacuated. The trauma center accepts the patient in transfer. Just before the patient is placed in the ambulance for transfer, his blood pressure decreases to 80/68 mm Hg and his heart rate increases to 136 beats per minute. The next step should be to:

--- repeat the primary survey and proceed with transfer

A 64-year-old man involved in a high-speed car crash, is resuscitated initially in a small hospital without surgical capabilities. He has a closed head injury with a GCS score of 13. He has a widened mediastinum on chest x-ray with fractures of left ribs 2 through 4, but no pneumothorax. After initiating fluid resuscitation, his blood pressure is 110/74 mm Hg, heart rate is 100 beats per minute, and respiratory rate is 18 breaths per minute. He has gross hematuria and a pelvic fracture. You decide to transfer this patient to a facility capable of providing a higher level of care. The facility is 128 km (80 miles) away. Before transfer, you should first:

--- call the receiving hospital and speak to the surgeon on call

Hemorrhage of 20% of the patient's blood volume is associated usually with

--- tachycardia

What statement concerning intraosseous infusion is TRUE?

--- Aspiration of bone marrow confirms appropriate positioning of the needle.

A young woman sustains a severe head injury as the result of a motor vehicle crash. In the emergency department, her GCS is 6. Her blood pressure is 140/90 mm Hg and her heart rate is 80 beats per minute. She is intubated and mechanically ventilated. Her pupils are 3 mm in size and equally reactive to light. There is no other apparent injury. The most important principle to follow in the early management of her head injury is to

--- avoid hypotension

A 33-year-old woman is involved in a head-on motor vehicle crash. It took 30 minutes to extricate her from the car. Upon arrival in the emergency department, her heart rate is 120 beats per minute, BP is 90/70 mm Hg, respiratory rate is 16 breaths per minute, and her GCS score is 15. Examination reveals bilaterally equal breath sounds, anterior chest wall ecchymosis, and distended neck veins. Her abdomen is flat, soft, and not tender. Her pelvis is stable. Palpable distal pulses are found in all 4 extremities. Of the following, the most likely diagnosis is:

--- cardiac tamponade

A hemodynamically normal 10-year-old girl is hospitalized for observation after a Grade III (moderately severe) splenic injury has been confirmed by computed tomography (CT). What mandates prompt celiotomy (laparotomy)?

--- development of peritonitis on physical exam

A 40-year-old woman who was a restrained driver in a motor vehicle crash is evaluated in the emergency department. She is hemodynamically normal and found to be paraplegic at the level of T10. What precaution should be taken during evaluation and management?

--- Log rolling using 4 people is a safe approach to restrict spinal motion when moving her.

A trauma patient presents to your emergency department with inspiratory stridor and a suspected c-spine injury. Oxygen saturation is 88% on high-flow oxygen via a nonrebreathing mask. The most appropriate next step is to:

--- restrict cervical motion and establish a definitive airway

When applying the Rule of Nines to infants

--- The head is proportionally larger in infants than in adults

A healthy young male is brought to the emergency department following a motor vehicle crash. His vital signs are a blood pressure of 84/60, pulse 123, GCS 10. The patient moans when his pelvis is palpated. After initiating fluid resuscitation, the next step in management is:

--- placement of a pelvic binder

What situations requires Rh immunoglobulin administration to an injured woman?

--- positive pregnancy test, Rh negative, and has torso trauma

A 22-year-old female athlete is stabbed in her left chest at the third interspace in the anterior axillary line. On admission to the emergency department and 15 minutes after the incident, she is awake and alert. Her heart rate is 100 beats per minute, blood pressure 80/60 mm Hg, and respiratory rate 20 breaths per minute. A chest x-ray reveals a large left hemothorax. A left chest tube is placed with an immediate return of 1600 mL of blood. The next management step for this patient is:

--- prepare for an exploratory thoracotomy

A 6-year-old boy walking across the street is struck by the front bumper of a sports utility vehicle traveling at 32 kph (20 mph). What's true about this patient?

--- A pulmonary contusion may be present in the absence of rib fractures.

Adjuncts used during the primary survey

--- ECG Pulse ox CO2 monitoringV Ventilatory rate ABGs Foleys (UOP) Gastric catheter FAST or eFAST DPL

Urinary output is sensitive for

--- Patient's volume status and renal perfusion

"Golden hour"

--- The time from injury to definitive care, during which treatment of shock and traumatic injuries should occur because survival potential is best; also called the Golden Period.

Leading cause of trauma deaths worldwide --- MVCs

Trimodal death distribution

--- 1st: seconds to minutes of injury (apnea) 2nd: minutes to several hours (EDH, SDH, liver lac, pelvic fractures, spleen ruptures) 3rd: several days to weeks after injury (sepsis and multi-organ failure)

An 18-year-old male was the unrestrained driver in a MVC involving contact with a tree, He is being transported to the ED by ambulance after a prolonged extrication process. He is receive oxygen by mask and IVF via one large-bore IV, and he is immobilized on a long spine board. How would you prepare for arrival of this patient?

--- Airway equipment for possible intubation IV equipment to place a second IV and get blood work Lab/Xray available Monitor equipment ready Notify blood bank and have transfusion protocol available Consider appropriate transfer

AMPLE hx

--- Allergies Medications currently used Past illnesses/Pregnancy Last meal Events/Environment related to the injury

Blunt trauma MOI

--- Seatbelt use Steering wheel deofrmation Presence/activation of airbags Direction of impact Damage to vehicle Patient position Ejection from vehicle?

Penetrating trauma MOI

--- Body region Velocity of weapon Caliber

Heat loss can occur at moderated temperatures --- 59 to 68 F (15-20 C)

Prehospital phase should include what interventions and considerations? --- Airway maintenance Breathing support Control of bleeding and shock Immobilization Immediate transport to closest appropriate facility

Hospital preparation for trauma

--- Resuscitation area Airway équipement Warmed IV crystalloid solution Monitoring devices Protocol for requesting additional assistance Transfer agreements

Primary survey

--- Airway maintenance with restriction of cervical spine motion Breathing Circulation Disability Exposure/Environmental control

Patients with maxillofacial or head trauma should be presumed to have

--- A cervical pine injury and cervical spine motion must be restricted

PITFALL: equipment failure

--- Test regularly Ensure spare equipment and batteries are readily available

PITFALL: unsuccessful intubation

--- Identify patients with difficult anatomy Identify the most experienced/skilled airway manager on team Ensure appropriate equipment is available Be prepared to prefer a surgical airway

PITFALL: progressive airway loss

--- Recognize the dynamic status of the airway Recognize the injuries that can result in progressive airway loss Frequently reassess the patient for signs of deterioration of the airway

In a trauma patient with hypotension, what are the two most important causes to consider in order of importance? --- Tension pneumothorax Hemorrhage

What is the best way to manage rapid external blood loss? --- Direct manual pressure on the wound

What are the major areas of internal hemorrhage? --- Chest Abdomen Retroperitoneum Pelvis Long bones

How should fluids be administered in trauma patients with shock? --- Warm IVFs If unresponsive to initial IVF, give blood transfusion immediately

What are the uses for ETCO2? --- Detect ROSC Confirm ET intubation Help avoid hypoventilation and hyperventilation

You'd like to insert a foley catheter for a trauma patient but you notice urethras injury. What test should be performed prior to the insertion of a urinary catheter? --- Retrograde urethrogram

DDX for blood in gastric aspirate in a trauma patient --- Swallowed blood Traumatic gastric tube placement UGI injury

What's a C/I to NGT insertion? --- Fracture of the cribriform/midface fracture (insert OG instead)

What injuries are at high risk of compartment syndrome in trauma patients? --- Long bones Crush injuries Circumferential thermal burns Prolonged ischemia to the limb

What's normal UOP? --- Adult: 0.5 ml/kg/hr Child: 1-2 ml/kg/hr

MIST for obtaining info from EMS --- Mechanism and time of injury Injuries found and suspected Symptoms and signs Treatment initiated

Retroperitoneal organs --- Abdominal aorta IVC Duodeum Pancreas Kidneys Ureters Posterior aspects of ascending/descending colon Bladder Rectum Reproductive organs

What's the most frequently injured abdominal organ in blunt trauma? Followed by? --- Spleen (40-55%) Liver (35-45%) Small bowel (5-10%)

Which patients should you consider transferring, and what tests should be performed prior to transfer? --- The patients whose injuries exceed your ability to care for them, either sue to specialize needs, or resource availably. Only perform testing that enables the referring physician to resuscitate, stabilize, and ensure the safer transfer of the patient

What's a pulse oximetry measure? --- Oxygen saturation by relative absorption of light by oxyhemoglobin and deoxyhemoglobin

Gastric catheter placement can induce vomiting --- Be prepared to logroll Ensure suction is immediately available

Special populations that may have physiological responses that do not follow expected patterns --- Children Pregnant females Elderly Obese individuals Athletes

Why is info about mechanism of injury so important? --- The patient's condition is greatly influenced by MOI. It can enhance the understanding of the patient's condition and anticipated injuries

Possible adjuncts to secondary survey --- X-rays of spine and extremities CT scans of head, chest, abdomen, spine Contrast urography and angiography TEE Bronchoscopy Esophagoscopy

Frontal impact MVC --- Cervical spine fracture Flail chest Myocardial contusion Pneumothroax Traumatic aortic disruption Fractured spleen or liver Posterior fracture/dislocation hip/knee Head injury Facial fractures

Side impact MVC --- Contralateral neck sprain Head injury Cervical spine fracture

Flail chest Pneumothorax Traumatic aortic disrution Diaphragmatic rupture Fractured spleen/liver/kidney Fractured pelvis or acetabulum

Rear impact MVC --- Cervical spine injury Head injury Soft tissue injury to neck

MVC vs pedestrian --- Head injury Traumatic aortic disruption Abdominal visceral injuries Fractured lower extremities/ pelvis

Fall from heigh --- Head injury Axial spine injury Abdominal visceral injuries Fractured pelvis or acetabulum Bilateral LE fractures

Anterior stab wound --- Cardiac tamponade Hemothorax Pneumothorax Hemopneumothorax

Left stab wound --- Left diaphragm injury Spleen injury Hemopneumothoax

Abdomen stab wound --- Visceral injury

Extremity GSW --- Neurovascular injury Fractures Compartment syndrome

Thermal burns --- Eschar on extremities or chest

Electrical burns --- Cardiac arrhythmias Myonecrosis Compartment syndrome

Inhalation burns --- CO poisoning Upper airway swelling Pulmonary edema

What is your first step when a patient condition changes? --- ABCDEs

What's the importance of meticulous record keeping? --- Crucial during patient assessment and management because often more than one clinician cares for an individual patient and allows those to evaluate the patient's needs and clinical status

What info should be provided to the receiving facility for a transferring patient? --- As much info as possible! Event of injury, patient exam, treatments done, responses of treatments, tests and results, and possible injuries

What key information should prehospital providers obtain and report to the receiving hospital? --- Events associated with injury

What patient sign can be quickly observed to assess a patient's hemodynamic status? --- Skin perfusion

Definitive airway --- A tube placed in the trachea with the cuff inflated below the vocal cords, the tube connected to a form of oxygen-enriched assisted ventilation and the airway secured in place with an appropriate stabilizing method

What's critical management for trauma patients, especially those with sustained head injuries? --- Maintaining oxygenation and printing hypercarbia

Triad of largyneal fracture --- Hoarseness Subcutaneous emphysema Palpable fracture

In a conscious trauma patient, airway adequacy can quickly be assessed by --- Talking to the patient-- A positive verbal response with clear voice indicated patent airways, ventilation, and brain perfusion

What can conform a suspected laryngeal fracture? --- CT scan

For a patient who is gurgling, initial assessment for ventilation should include --- Looking for symmetrical chest rise and listening for breath sounds

Decreased or absent breath sounds over one or both hemithoraxes should alert the examiner to the presence of? --- Pneumothorax, hemothoax, contusion, or flail chest

Adjuncts of ventilation problems --- Pulse ox to measure oxygen saturation and gauge peripheral perfusion Capnography to assess adequacy fo ventilation

What are the symptoms of inadequate ventilation? --- Difficulty breathing SOB Request to sit up to breath

LEMON assessment of difficult intubation --- Look externally

Evaluate the 3-3-2 rule Mallampati Obstruction Neck mobility

Types of definitive airways --- Orotracheal tube Nasotracheal tube Surgical airways (cricothyroidotomy and tracheostomy)

Laryngeal manipulation for visualization --- Backward, upward, and rightward pressure on thyroid cartilage can aid in visualizing vocal cords

Which surgical airway is recommended in children under 12? --- Needle cricothyroidotomy

What're adjuncts that might be used during intubation? --- Suction Manual laryngealmanipulation (BURP) Elastic bougie Anesthetics, analgesics, and neuromuscular blocking agents

Why is continual pulse ox monitoring necessary in critically injured patients? --- Because changes in oxygenation occur rapidly and are impossible to detect clinically

What indicates that the endotracheal tube is in the proper position? --- Equal breath sounds bilaterally Carbon dioxide monitor (capnograph or colorimetric CO2 device) Confirmed with CXR

What suggests sufficient ventilation? --- ABG or continual end-tidal carbon dioxide analysis

On exam, an unrestrained driver is hoards and has minimal subcutaneous neck emphysema. This patient likely has a/an --- Obstructed airway

In an agitated trauma patient who refuses to lay down --- Assessment of airway adequacy may include suctioning

What's an indication for rapid sequence intubation? --- Patients who need airway control, have intact gag reflex, especially those who have sustained head injury

A surgical airway is indicated in the presence of --- Edema of the glottis Fracture of larynx Severe oropharyngeal hemorrhage that obstructs airway Inability to place an endotracheal tube

Possible causes of confusion after traumatic event? --- Hemorrhage Brain injury Stroke Intoxication

What's the most common cause of shock after an injury? --- Hemorrhage

What're the early clinical manifestations of shock? --- Tachycardia and cutaneous vasoconstriction

What's the preferred method of vascular access for a patient involved in a MVC? --- 2 large bore PIVs in the antecubital veins

What's the most appropriate means to restore cardiac output and end organ perfusion in hemorrhagic shock? --- Stopping the source of bleeding and ensuring appropriate volume repletion

A 24-year-old male arrives in ED already intubated. He has significant crepitus of the right chest wall and diminished breath sounds. You place a chest tube and note a large amount of bubbling in the water seal chamber. His O2 saturation remains at 85% and he has goodCO return on capnography. The most likely cause of his low oxygen saturation is --- Tracheobronchial tree injury

Most injuries to the tracheobronchial tree occur where? --- Within 2.5 cm from the carina

Do the vast majority of thoracic injuries (blunt and penetrating) require operative intervention? --- No, most are treated with technical procedures

Airway thoracic injuries --- Airway obstruction (laryngeal injury, posterior dislocation of clavicular head, or penetrating trauma) Tracheobronchial tree injury

Breathing thoracic injuries --- Tension pneumothorax Open pneumothorax Massive hemothorax

Circulation thoracic injuries --- Massive hemothorax Cardiac tamponade Traumatic circulatory arrest

What's the most common cause of a tension pneumothorax? --- Mechanical positive- pressure ventilation in patients with a visceral pleural inury

Where is the ideal location for needle decompression of a tension pneumothorax? --- 5th intercostal space, slightly anterior to midaxillary line

What do you need to remember when treating an open pneumothorax? --- Place a dressing on the site and only secure is on 3 sides so air can escape, then place a chest tube

Massive hemothorax --- Accumulation of >1500 ml of blood in one side of chest

Causes of PEA? --- Hypovolemia

Hypoxia Hydrogen acidosis Hypo/hyperkalemia Hypoglycemia Hypothermia Toxins Tamponade Tension pneumo Thrombosis

Indications of a thoracotomy --- Immediate return of > 1500 ml of blood or significant bleeding Persistent blood transfusions Penetrating anterior chest wounds medial to the nipple line Posterior wounds medial to the scapula

A 26-year-old male sustained a posterior stab wound. Blood and bubbling are coming from the wound. --- Open pneumothorax

A 46-year-old male sustained a gunshot wound to the chest --- Massive hemothorax

A 65-year-old female who takes warfarin was involved in a MVC. She initially presented complaining of sternal pain. BP deteriorated to 90/60 after arriving to the ED --- Cardiac tamponade

Eight life-threatening injuries during the secondary survey? --- Simple pneumothorax Hemothorax Flail chest Pulmonary contusion Blunt cardiac injury Traumatic aortic disruption Traumatic diaphragmatic injury Blunt esophageal rupture

A patient with a simple pneumothorax --- May be watched for progression if pneumothorax is small (<15%) and patient is stable and does not require transfer

A 38-year-old male presents to the ED after a head-on, high-speed collision. His vitals are HR 130, BP 156/90, RR 20, and O2 sat 92% on 15L of O2. His voice is raspy and he complains of chest pain that radiates to his back. A CXR shows a widened mediastinum, obliteration of the aortic notch, and depression of the left mainstream bronchus. You should --- Administer agents to manage his pain and lower his HR and BP (aortic disruption)

What's a characteristic that is shared by all traumatic aortic disruption survivors? --- Contained hematoma

A 36-year-old female was involved in an altercation, sustaining a knife wound to the chest, below the left nipple. She is mildly short of breath with an oxygen sat of 92%. BP is 115/80. --- Simple pneumothorax

A 56-year-old male archer was riding a horse when it bucked and the saddle struck him in the chest wall. You note paradoxical chest wall movement on the left anterior chest. CXR is negative. --- Flail chest due to costochondral disruption

What would confirm a diaphragmatic injury in a patient? --- Presence of NGT

What is a common finding associated with traumatic asphyxia? --- Upper torso, facial, and arm plethora with petechiae secondary to acute temporary compression of SVC. Massive swelling and cerebral edema may be present.

Why are rib fractures in older adults a more significant concern than in young patients? --- The incidence of PNA and mortality is doubled in older patients

Pulmonary contusion/flail chest is best treated by? --- Supplemental oxygen, pain control, and recognition if the patient is unable to ventilate properly

The cause of hypoxia associated with flail chest is --- Pulmonary contusion

A patient arrives in your hospital after a fall from 20 ft landing on his right side. He has been intubated and two large-bore IVs have been started. His o2 sat is 82%, he has a good capnography waveform, and significant deformity to right chest wall. He has no breath sounds on the right. His BP is 75/30. Your next step should be to --- Perform a needle decompression or finger throacostomy on the right side

You have completed a secondary survey on a patient who feel from a standing height. You note exquisite tenderness posterolaterally on the left chest wall at 9-11 ribs. This should raise suspicion for what other injury? --- Splenic injury

A patient's CXR reveals left pneumothorax. Additionally, the left diaphragm is obscured and there is an air fluid level in the left hemithorax. You decide to place a chest tube. The patient is at increased risk for damage to --- Abdominal contents that have become displaced into the chest cavity

Stab wounds most commonly injury? --- Liver (40%) Small bowel (30%) Diaphragm (20%) Colon (15%)

Gunshot wounds most commonly injury? --- Small bowel (50%) Colon (40%) Liver (30%) Abd vascular structures (25%)

When is a retrograde urethrogram mandatory? --- Patient is unable to void, requires pelvic binder, or has blood at the meatus, scrotal hematoma, or perineal ecchymosis

A 28-year-old male, helmeted motorcyclist was in a high speed MVC, striking head-on into the side of a vehicle. He arrives on a backboard and with a cervical collar in place via pre- hospital BLS transport. Vitals are: BP 100/75, HR 115, RR 20, GCS 15. The patient reports a brief loss of consciousness and is complaining of pain in the chest, abdomen, and pelvis. What're the priorities for management? --- Rapidly assess ABCs Auscultate the lungs, provide supplemental oxygen, and apply pulse ox

A 28-year-old male, helmeted motorcyclist was in a high speed MVC, striking head-on into the side of a vehicle. He arrives on a backboard and with a cervical collar in place via pre- hospital BLS transport. Vitals are: BP 100/75, HR 115, RR 20, GCS 15. The patient reports a brief loss of consciousness and is complaining of pain in the chest, abdomen, and pelvis. What's the interpretation of the VS and the initial therapy? --- VS are consistent with hemorrhagic shock from intraabdominal or pelvic sound Maintain IV/IO access and initiate volume resuscitation, including blood transfusion if indicated Pelvic binder application may be appropriate

Will retroperitoneal injuries prevent with obvious signs of peritoneal irritation? --- No, retroperitoneal structures are separated from anterior peritoneum by the intraperitoneal viscera, therefore no peritonitis may be present

A patient was found 10' from his motorcycle, laying on his right side. He was wearing a helmet. He was going ~45 mph. He had brief LOC. He states he has no allergies, medications that he takes, no current illness. Last meal was 6 hours ago. Based on mechanism, what intra-abdominal and/or pelvic injuries is he likely to have sustained? --- Visceral lacerations (liver/spleen) Bowel visceral/vascular injuries Retroperitoneal visceral/vascular injuries (kidneys/adrenal) Pelvic fractures

A patient was found 10' from his motorcycle, laying on his right side. He was wearing a helmet. He was going ~45 mph. He had brief LOC. He states he has no allergies, medications that he takes, no current illness. Last meal was 6 hours ago. How would the risk of intra-abdominal injury change if the patient described stroking the handlebar into the epigastrium? --- A direct blow to the epigastrium would raise the risk of a pancreas, duodenal, or small bowel injury

A 30-year-old male presents with a 2 cm stab wound to the mid-abdomen, 3 cm to the right of the umbilicus. VS are BP 85/60, HR 130, RR 25, GCS 14. Neck veins are flat. Chest exam is CTAB. The abdomen is tender. What's the ONE BEST therapy to treat this patient's injury? --- Airway appears intact. Breathing has increased rate. Circulation demonstrated hemorrhagic shock. Penetrating abdominal injury with shock is one of the indications for emergent laparotomy.

In a patient with a possible pelvic fracture, how frequently should the pelvis be tested for mechanical stability? --- The pelvis should not be tested in a hemodynacilly unstable patient. Mechanical instability of he pelvic ring should be assumed in patients who have suspected pelvic fractures. Avoid manually manipulating the pelvis (dislodge an existing clot)

Hypotension + pelvic fracture = --- High mortality

A 12-year-old male complains of LUQ tenderness and L shoulder pain 8 hours after playing rugby. ABCDE are normal. Circulatory assessment remains normal. Abdominal exam reveals mild LUQ TTP without peritoneal signs. FAST demonstrated fluid in the hepatorenal space and the plenorenal recess. What's the appropriate next step? --- Observation

A 29-year-old woman is the restrained driver in a head-on collision. Airbags deployed. ABCDE are normal. The patient complains of lower abd and back pain. A lower abd contusion is present and associated with tenderness. There is no evidence of diffuse peritonitis. Your institution has NOT surgical capabilities. What's the most appropriate treatment plan? --- The patient should be urgently transferred for surgical intervention

A 50-year-old male arrives to the ED following fall of 26'. He hs gurgling respirations and is not responsive to voice. VS are BP 80/5-, RR 30, HR 138, O2 sat is undetectable. Your hospital does not have surgical capabilities. The first step in management is --- Application of oxygen and securing an airway

A 25-year-old ale arrives at the ED following a motorcycle crash. BP is 80/60, HR 140. Airway and breathing are controlled. There are no open wounds. The abd is not distended. Both legs are externally rotated but soft. The pelvis is tender. The scrotum is swollen and ecchymotic. While vascular access is obtained, what the next most appropriate step? --- Application of a pelvic binder

A 45-year-old male with a BMI of 48 was working in an industrial plant when 2 pieces of wood flew off a sa and struck him in the abdomen and right chest. CXR demonstrates rib fractures. What's true about this scenario? --- Despite multiple imaging studies, detection of intestinal and retroperitoneal injuries may be difficult

Your institution does not have surgical capabilities. You have intubated a 25-year-old man who was in a rollover MVC. You have also placed bilateral chest tubes for pneumothoraxes. The patient's SBP is continually < 90 and HR > 140. Potential therapy and evaluation includes --- Activation of massive transfusion protocol, application of pelvic binder, and CXR

What's the primary goal of treatment for patient's with suspected TBIs? --- To prevent secondary brain injury by ensuring adequate oxygenation and maintain BP that's sufficient to perfuse the brain

Cerebral perfusion pressure (CPP) --- MAP - ICP

A 23-year-old male fell from a bike, striking his head on the curb. He was not wearing a helmet. The patient has a 10 cm laceration to the temporal-parietal region of the left scalp. He is initially able to say hi name. VS are HR 115, BP 100/60, oxygen sat 88%, GCS initially 12. 2 hours after transfer to a local hospital, he has sonorous respirations, a HR of 120, BP 100/70, and GCS of 6. What the initial priorities in the management of this patient? --- Airway protection with a subglottic device Oxygenation to prevent hypoxia Maintain SBP > 100 mmHg

A 23-year-old male fell from a bike, striking his head on the curb. He was not wearing a helmet. The patient has a 10 cm laceration to the temporal-parietal region of the left scalp. He is initially able to say hi name. VS are HR 115, BP 100/60, oxygen sat 88%, GCS initially 12. 2 hours after transfer to a local hospital, he has sonorous respirations, a HR of 120, BP 100/70, and GCS of 6. What are the signs that the patient's injury is progressing? --- Decreased GCS indicates worsening intracranial pathology with possible intracranial HTN and impending herniation

A 78-year-old ale is found down in the bathroom with a large left scalp laceration from striking the corner of the sink. He arrives in the ED with a BP 180/90, HR 60, dilated, non- responsive right pupil. The most likely finding on the patient's CT scan will be --- Illustrtive of impending uncle hernia associated with Cushing response (high BP + bradycardia)-- associated with a large subdural hematoma with midline shift

Intracranial mass effect is defined by the --- Monro-Kellie Doctrine

A trauma patient opens her eyes, moans, and withdraws from pain. What is her GCS score? --- Eye opening: 2 Verbal response: 2 Best motor response: 4 Total = 8

A 48-year-old female falls from a balcony. She was witnessed striking her head on the steps after an ~8' fall. The patient briefly lost consciousness and is found confused, lying at the bottom of the steps. Her eyes are open, and she is rubbing her forehead. The most important finding related to this patient's long-term outcome is --- GCS score

A 56-year-old male repeats questions, his eyes are open, and he moves to command --- GCS 14

A 17-year-old female was struck by a vehicle while crossing the road. Upon arrival she is moaning, her eyes open, and she withdraws to painful stimuli --- GCS 8

A 82-year-old female was found home by family. Her eyes are closed, she extends to pain, and is not speaking --- GCS 4

A 63-year-old male fell off a ladder. Witnesses report loss of consciousness. His eyes open to voice, he localizes to pain, and has garbled speech --- GCS 11

What types of intracranial hemorrhage can be identified on CT scan? --- Epidural Sudural Intra-ventricular Subarachnoid Intra-parenchymal

What CT scan findings are indicative of severe head injury that may require intervention? --- Midline shift (> 5mm), loss of definition of the basil cisterns, and severe skull fractures with intrusion into the brain matter

A 70-year-old female falls at home and strikes her head on the bathtub. She is found down by her granddaughter ~6 hours later. GCS is 8: eye opening 2, verbal 2, motor 4. She is intubated for airway protection upon arrival in the trauma bay. What preexisting patient characteristics should you consider that may affect this patient's outcome? --- Current anti platelet therapy, beta blockade, and anticoagulation

What is the purpose of intubation in a comatose patient? --- Prevent hypoxia and secondary brain injury occurs with a protection of the airway

Ancillary studies to confirm brain death? --- EEG: no activity at high gain CBF studies Cerebral angiography

Diagnosing brain death --- GCS = 3 Nonreactive pupils Absent brainstem reflexes (oculocephalic corneal, doll's eyes, and no gag reflex) No spontaneous ventilatory effect on formal apnea testing Absence of confounding factors such as alcohol or drug intoxication or hypothermia

What are the initial management options for mild brain injury? --- Monitoring isnt' required but know long-term effects can manifest over time

What are the initial management options for moderate brain injury? --- Monitoring for decompensation is important and requires hospital admission, ongoing neurologic exam, possible further CT imaging

What are the initial management options for severe brain injury? --- Requires a center with neurosurgical support and associated aggressively treat intracranial swelling, osmotic intravascular fluid management, and rapid surgical intervention

A CT scan reveals intracranial hemorrhage and swelling with collapse of the 3rd and 4th cventricles and impending uncle herniation. What treatment measures are appropriate? --- Mannitol, hypertonic saline, and phenytoin are initial management of intracranial HTN

An 81-year-old female arrives in the ED after a fall from standing. The only visible sign of injury is a large scalp laceration. Paramedics report that she has been getting progressively hypotensive over the past 20 minutes. They infused 2 L NS IVF, after which BP is 135/70. She is somnolent, but arousable. There is some hemorrhage from a large 20 cm scalp laceration. What's the best next step in managing this patient? --- Repair the scalp laceration

What are the initial treatment options that may protect the brain from ongoing swelling? --- Decreasing agitation with sedation, reducing cerebral swelling with mannitol, or hypertonic saline. A neurosurgeon can drain CSF.

A 22-year-old male is hit by a car while traveling downhill on a skateboard. He was found unconscious at the scene and arrives with bag-mask ventilation by the EMS crew. He only mumble incoherently, does not open his eyes, and only flexes to pain. Upon arrival in the ED, the primary goal is --- Intubate the patient

What treatment measures is essential in maintaining cerebral perfusion pressure? --- Sedation, mannitol, and IVF will help decrease ICP or increase MAP

A 45-year-old female is involved in a MVC and brought to a local ED with limited capabilities. She does not remember the event and has repetitive questioning. You would like to get a CT scan of the head, but the technician must be called in from home, which will take at least 30 minutes. You should --- Transfer the patient to a higher level of care

A patient arrives after a blow to the right temporal region secondary to a tree limb striking him while chopping down a tree. He was intubated in the field for a declining mental status. His PE reveals 6 mm and non-reactive right pupil and a 4 mm L pupil with brisk reaction to 2 mm. His GCS reveals extensor posturing with no eye opening, and he is intubated. The presumed extent of his intracranial injury is most likely? --- Epidural hematoma causes same side pupil dilation and opposite side weakness

Many patients with c-spine fractures have --- a second, noncontiguous vertebral column fracture

A helmeted 28-year-old male fell from scaffolding. A bystander witnessed the fall and reports that the patient landed head first, causing his neck to hyperextend. His VS are BP 90/62, HR 58, RR 28, GCS 15. The patient is alert and following commands. His breathing is shallow and he is not moving his arms or legs. What injuries has this patient likely incurred? --- The initial assessment raises concerns for a spinal cord injury. However, complete a primary and secondary survey to rule out additional life-threatening injures.

A helmeted 28-year-old male fell from scaffolding. A bystander witnessed the fall and reports that the patient landed head first, causing his neck to hyperextend. His VS are BP 90/62, HR 58, RR 28, GCS 15. The patient is alert and following commands. His breathing is shallow and he is not moving his arms or legs. What type of shock does this patient exhibit? --- Neurogenic

Cervical spine injuries represent more than 1/2 of all spinal column injuries. What additional injuries are commonly associated with cervical fractures? --- 25% of all spine injuries have at least a mild brain injury and 10% with a cervical fracture have another noncontiguous spine fracture

Neurogenic shock is associated with what level of spinal cord injury and causes systemic hypotension via what mechanism? --- T6 and higher, distributive shock from lack of vasomotor tone

The patient is unable to move his legs. He can move his fingers and wrists bilaterally. He has weal triceps extension on the left. He is unable to move right elbow. He is able to feel his fingers and thumbs bilaterally, but not feel anything above his elbow. Where is the suspected spine lesion? --- C6 or C7

The patient is unable to move his legs. He can move his fingers and wrists bilaterally. He has weal triceps extension on the left. He is unable to move right elbow. He is able to feel his fingers and thumbs bilaterally, but not feel anything above his elbow. Why is there a difference b/t the PW findings for the UE on PE? --- The difference between the PE findings for the UE is likely due to initial inflammatory response, edema, and/or the presence of an incomplete spinal cord injury.

Spinal cord injuries can be defined by neurologic level and severity in addition to associated syndromes and morphology. Describe Brown-Sequard syndrome lesion at T5. --- T5, penetrating injury to one side (partial)

Which type of thoracic spinal fracture is associated with MVC with restrained passengers using lap belt, a forward flexion mechanism, likely visceral organ injury, and frequent need for internal fixation? --- Chance fracture

What's the appropriate treatment for a C6 vertebral body fracture --- Spinal immobilization and IVFs, followed by vasopressors if patient remains bradycardic after fluids

A patient with a known cervical spine fracture who is being transferred from a rural hospital to definitive care should be transported in which way? --- Semi-regid collar and head restraint

Patients with cerviacl fractures above C6 require special consideration prior to transportation due to? --- Potential progression to respiratory failure

A 35-year-oldman was ejected from a MV. On arrival, his VS are BP 80/40, HR 110,RR 24, GCS 15. Airway and breathing are intact. He complains of severe back pain, has no sensation below umbilicus, has lower thoracic tenderness, and is unable to move LE. Chest and pelvic X-rays are normal. Along with IVFs, what is most appropriate treatment for this patient's hypotension? --- Although this patient likely has a spinal cord injury, perform a FAST exam or DPL to r/o other etiology.

An elderly female falls and sustains a hyperextension injury to her neck. Her exam demonstrated decreased strength in UE compared to LE. What is the cause of her unusual neurologic findings? --- Central cord syndrome

What's the most common location of all spinal injuries? --- C5

A 40-year-old M involved in a MVC is evaluated in a rural hospital without spine surgical capacity. The patient has a clear C-spine fracture at C4 on plain film and the inability to move any extremities and sensation limited to supraclavicular region. He is having difficulty breathing with a RR 30. BP 80/40 and HR 50. What should be performed prior to transfer? --- Crystalloid bolus, initiate pressers, intubate, and then transfer patient once he is hemodynamically stable

Potentially life threatening extremity injuries --- Marjor arterial hemorrhage Bilateral femoral fractures Crush syndrome

Rhabdomyolysis can lead to --- Metabolic acidosis Hyperkalemia Hypocalcemia Disseminated intravascular coagulation (DIC)

A 38-year-old female restrained driver is involved in a high-speed, head-on collision with a truck. Following a prolonged extrication, she noted to have deformity of her right thigh. On arrival, her VS are HR 120, BP 90/50, RR 22, GC 15. 2 large bore IVs are inserted in UE. VS are now HR 13- BP 80/40, RR 24, GCS 14. CXR, pelvis X-ray, and FAST are negative. You suspect the source of hypotension is a femur fracture and bilateral tibial shaft fractures. How much blood loss would you expect from this patient's extremity injuries and what's the best way to control it? --- A femur fracture can result in blood loss up to 2 L and each tibial fracture can cause up to 1.5 L of blood loss. Fracture immobilization is the best control.

How should femur and tibial shaft fractures be stabilized? --- A traction splint should NOT be used. Tibial fracture should be placed in a long leg splint. A femur and tibial fracture should be placed in a long leg posterior splint. Open fractures should be covered with moist saline gauze before placed in splint. Neurovascular exams should be performed before and after splint placement

Extremity bleeding control order --- 1) Manual pressure to the wound

2. Pressure dressing
3. Compression of the artery proximal to the injury
4. Tourniquet application

Cold, pale, pulseless extremity --- Interrupted arterial blood supply

Rapidly expanding hematoma --- Significant vascular injury

Tourniquet use --- 1) Tightening tourniquet until bleeding stops

2. Ensure arterial inflow is occluded
3. Document time of application 4_ Obtain immediate surgical consult and transfer patient, if necessary
4. If time to surgery is prolonged in stable patient, consider one attempt to deflatetourniquet
5. If tourniquet use if prolonged, consider chose of life over limb

An ABI < indicates abnormal arterial flow secondary to injury or PVD. --- < 0.9

All open fractures and open joint injuries require --- Up to date tetanus vaccine IV antibiotics (1st generation cephalosporin)

Abnormal motion through a joint segment --- Tendon or ligament rupture

Absent spontaneous extremity movement in unconscious patient --- Neurologic and/or muscular impairment

Swollen extremity in region of major muscle group --- Crush injury with impending compartment syndrome

Pale or white distal extremity --- Lack of arterial blood flow

Diagnosis of an open fracture is made based on? --- Physical exam and x-ray

What's high risk for compartment syndrome? --- Ischemia repercussion injury to enclosed muscle Crush injury Tight dressing or cast

How is an open joint injury confirmed? --- CT or saline/dye injection

When does muscle necrosis begin? --- When there is a lack of arterial blood flow for more than 6 hours

A 38-year-old female restrained driver is involved in a high-speed, head-on collision with a truck. Following a prolonged extrication, she noted to have deformity of her right thigh. On arrival, her VS are HR 120, BP 90/50, RR 22, GC 15. 2 large bore IVs are inserted in UE. VS are now HR 13- BP 80/40, RR 24, GCS 14. CXR, pelvis X-ray, and FAST are negative. You suspect the source of hypotension is a femur fracture and bilateral tibial shaft fractures. Transfer is initiated. What antibiotics and at what dose should be given tot he patient? --- Cefazolin 3g + ciprofloxacin or gentamicin

What does splinting accomplish in patients with musculoskeletal trauma? --- Control blood loss, prevent further neuromuscular compromise and soft tissue injury, and reduce the patient's pain

A 25-year-old male presents after a motorcycle crash. VS are BP 128/70, HR 124, GCS 15. He complains of R leg pain. On exam, the patient is found to have proximal right thigh

deformity. Distal pulses intact. What's the best initial magement of this patient's symptoms? --- Splint the extremity and administer a small dose of an IV narcotic, like fentanyl

When should IV antibiotics be given to patients with open fractures? --- All patients with an open fracture should receive IV antibiotics

A 22-year-old female presents after jumping from the 3rd story of a building in a suicide attempt. She's stable, but GCS is 13. Both ankles are swollen. Her pulses intact. Initial chest and pelvis films are normal. Ankle films reveal bilateral calcanea fracture. What additional work-ip is important to undertake in this patient? --- Radiographic work-up of the spine to rule out occult injury

What's true about tourniquets? --- It must occlude arterial inflow

Musculoskeletal adjuncts to the primary survey may include? --- Proper application of a splint can help control blood loss, reduce pain, and prevent further neurovasculr compromise

ABLS indications for early intubation --- Signs of airway obstruction TBSA > 40-50% Extensive and deep facial burns Burns inside the mouth Significant edema or risk for edema Difficulty swallowing Signs of respiratory compromise Decreased LOC Anticipated patient transfer of large burn with airway issue without qualified personnel to intake en route

Parkland formula ---- 2-4 ml of LR x patient's weight (kg) x % TBSA for 2nd and 3rd degree burns with 1/2 administered in the 1st 8h and the 2nd 1/2 administered during the subsequent 16h

Simplest way to remove tar from trauma patient? ---- Mineral oil

Reperfusion syndrome ---- Indicated by acidosis, hyperkalemia, and local swelling; therefore monitor the patient's cardiac status and peripheral perfusion during rewarming

Immediate lifesaving measures for patients with burn injuries ---- Stopping the burn process Recognize inhalation injury Assuring an adequate airway Oxygenation and ventilation Rapidly initiating IVF

What's the most significant difference between burns and other injuries? ---- The consequence of a burn injury are directly linked to the extent of the inflammatory response to the injury