Trauma Management: Principles and Practices, Exams of Medicine

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ATLS - Study Guide

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/ 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: - ANS 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: - ANS complete spine x-ray series What is true regarding the initial resuscitation of a trauma patient? - ANS 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: - ANS 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? - ANS 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: - ANS increasing the volume of blood loss to produce maternal hypotension. The best assessment of fluid resuscitation of the adult burn patient is: - ANS urinary output of 0. mL/kg/hr The diagnosis of shock must include: - ANS 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: - ANS direct pressure on the wound For the patient with severe traumatic brain injury, profound hypocarbia should be avoided to prevent: - ANS 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: - ANS perform an exploratory laparotomy What statements regarding abdominal trauma in the pregnant patient is TRUE? - ANS Leakage of amniotic fluid is an indication for hospital admission. The first maneuver to improve oxygenation after chest injury is: - ANS 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: - ANS 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: - ANS 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? - ANS respiratory rate of 40 breaths per minute

The most important, immediate step in the management of an open pneumothorax is: - ANS placement of an occlusive dressing over the wound The following are contraindications for tetanus toxoid administration: - ANS 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? - ANS breath sounds Bronchial intubation of the right or left mainstem bronchus can easily occur during infant endotracheal intubation because: - ANS 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/ 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: - ANS 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: - ANS 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? - ANS Flaccidity of the lower extremities and loss of deep tendon reflexes are expected.

What is the most effective method for initially treating frostbite? - ANS 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? - ANS 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: - ANS 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: - ANS 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: - ANS call the receiving hospital and speak to the surgeon on call Hemorrhage of 20% of the patient's blood volume is associated usually with - ANS tachycardia

What statement concerning intraosseous infusion is TRUE? - ANS 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 - ANS 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: - ANS 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)? - ANS 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? - ANS 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: - ANS restrict cervical motion and establish a definitive airway When applying the Rule of Nines to infants - ANS 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: - ANS placement of a pelvic binder What situations requires Rh immunoglobulin administration to an injured woman? - ANS 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: - ANS 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? - ANS A pulmonary contusion may be present in the absence of rib fractures. Adjuncts used during the primary survey - ANS ECG Pulse ox CO2 monitoringV Ventilatory rate ABGs Foleys (UOP) Gastric catheter FAST or eFAST DPL Urinary output is sensitive for - ANS Patient's volume status and renal perfusion

"Golden hour" - ANS 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 - ANS MVCs Trimodal death distribution - ANS 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? - ANS 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 - ANS Allergies Medications currently used Past illnesses/Pregnancy Last meal Events/Environment related to the injury Blunt trauma MOI - ANS Seatbelt use

Steering wheel deofrmation Presence/activation of airbags Direction of impact Damage to vehicle Patient position Ejection from vehicle? Penetrating trauma MOI - ANS Body region Velocity of weapon Caliber Heat loss can occur at moderated temperatures - ANS 59 to 68 F (15-20 C) Prehospital phase should include what interventions and considerations? - ANS Airway maintenance Breathing support Control of bleeding and shock Immobilization Immediate transport to closest appropriate facility Hospital preparation for trauma - ANS Resuscitation area Airway équipement Warmed IV crystalloid solution Monitoring devices Protocol for requesting additional assistance Transfer agreements

Primary survey - ANS 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 - ANS A cervical pine injury and cervical spine motion must be restricted PITFALL: equipment failure - ANS Test regularly Ensure spare equipment and batteries are readily available PITFALL: unsuccessful intubation - ANS 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 - ANS 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? - ANS Tension pneumothorax Hemorrhage

What is the best way to manage rapid external blood loss? - ANS Direct manual pressure on the wound What are the major areas of internal hemorrhage? - ANS Chest Abdomen Retroperitoneum Pelvis Long bones How should fluids be administered in trauma patients with shock? - ANS Warm IVFs If unresponsive to initial IVF, give blood transfusion immediately What are the uses for ETCO2? - ANS 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? - ANS Retrograde urethrogram DDX for blood in gastric aspirate in a trauma patient - ANS Swallowed blood Traumatic gastric tube placement UGI injury What's a C/I to NGT insertion? - ANS Fracture of the cribriform/midface fracture (insert OG instead) What injuries are at high risk of compartment syndrome in trauma patients? - ANS Long bones Crush injuries

Circumferential thermal burns Prolonged ischemia to the limb What's normal UOP? - ANS Adult: 0.5 ml/kg/hr Child: 1-2 ml/kg/hr MIST for obtaining info from EMS - ANS Mechanism and time of injury Injuries found and suspected Symptoms and signs Treatment initiated Retroperitoneal organs - ANS 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? - ANS 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? - ANS 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? - ANS Oxygen saturation by relative absorption of light by oxyhemoglobin and deoxyhemoglobin Gastric catheter placement can induce vomiting - ANS Be prepared to logroll Ensure suction is immediately available Special populations that may have physiological responses that do not follow expected patterns - ANS Children Pregnant females Elderly Obese individuals Athletes Why is info about mechanism of injury so important? - ANS 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 - ANS X-rays of spine and extremities CT scans of head, chest, abdomen, spine Contrast urography and angiography TEE Bronchoscopy Esophagoscopy

Frontal impact MVC - ANS 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 - ANS 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 - ANS Cervical spine injury Head injury Soft tissue injury to neck MVC vs pedestrian - ANS Head injury

Traumatic aortic disruption Abdominal visceral injuries Fractured lower extremities/ pelvis Fall from heigh - ANS Head injury Axial spine injury Abdominal visceral injuries Fractured pelvis or acetabulum Bilateral LE fractures Anterior stab wound - ANS Cardiac tamponade Hemothorax Pneumothorax Hemopneumothorax Left stab wound - ANS Left diaphragm injury Spleen injury Hemopneumothoax Abdomen stab wound - ANS Visceral injury Extremity GSW - ANS Neurovascular injury Fractures Compartment syndrome

Thermal burns - ANS Eschar on extremities or chest Electrical burns - ANS Cardiac arrhythmias Myonecrosis Compartment syndrome Inhalation burns - ANS CO poisoning Upper airway swelling Pulmonary edema What is your first step when a patient condition changes? - ANS ABCDEs What's the importance of meticulous record keeping? - ANS 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? - ANS 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? - ANS Events associated with injury What patient sign can be quickly observed to assess a patient's hemodynamic status? - ANS Skin perfusion

Definitive airway - ANS 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? - ANS Maintaining oxygenation and printing hypercarbia Triad of largyneal fracture - ANS Hoarseness Subcutaneous emphysema Palpable fracture In a conscious trauma patient, airway adequacy can quickly be assessed by - ANS 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? - ANS CT scan For a patient who is gurgling, initial assessment for ventilation should include - ANS 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? - ANS Pneumothorax, hemothoax, contusion, or flail chest Adjuncts of ventilation problems - ANS Pulse ox to measure oxygen saturation and gauge peripheral perfusion Capnography to assess adequacy fo ventilation What are the symptoms of inadequate ventilation? - ANS Difficulty breathing SOB

Request to sit up to breath LEMON assessment of difficult intubation - ANS Look externally Evaluate the 3-3-2 rule Mallampati Obstruction Neck mobility Types of definitive airways - ANS Orotracheal tube Nasotracheal tube Surgical airways (cricothyroidotomy and tracheostomy) Laryngeal manipulation for visualization - ANS Backward, upward, and rightward pressure on thyroid cartilage can aid in visualizing vocal cords Which surgical airway is recommended in children under 12? - ANS Needle cricothyroidotomy What're adjuncts that might be used during intubation? - ANS Suction Manual laryngealmanipulation (BURP) Elastic bougie Anesthetics, analgesics, and neuromuscular blocking agents Why is continual pulse ox monitoring necessary in critically injured patients? - ANS Because changes in oxygenation occur rapidly and are impossible to detect clinically What indicates that the endotracheal tube is in the proper position? - ANS Equal breath sounds bilaterally

Carbon dioxide monitor (capnograph or colorimetric CO2 device) Confirmed with CXR What suggests sufficient ventilation? - ANS 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 - ANS Obstructed airway In an agitated trauma patient who refuses to lay down - ANS Assessment of airway adequacy may include suctioning What's an indication for rapid sequence intubation? - ANS 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 - ANS 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? - ANS Hemorrhage Brain injury Stroke Intoxication What's the most common cause of shock after an injury? - ANS Hemorrhage What're the early clinical manifestations of shock? - ANS Tachycardia and cutaneous vasoconstriction

What's the preferred method of vascular access for a patient involved in a MVC? - ANS 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? - ANS 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 goodCO2 return on capnography. The most likely cause of his low oxygen saturation is - ANS Tracheobronchial tree injury Most injuries to the tracheobronchial tree occur where? - ANS Within 2.5 cm from the carina Do the vast majority of thoracic injuries (blunt and penetrating) require operative intervention? - ANS No, most are treated with technical procedures Airway thoracic injuries - ANS Airway obstruction (laryngeal injury, posterior dislocation of clavicular head, or penetrating trauma) Tracheobronchial tree injury Breathing thoracic injuries - ANS Tension pneumothorax Open pneumothorax Massive hemothorax Circulation thoracic injuries - ANS Massive hemothorax Cardiac tamponade Traumatic circulatory arrest

What's the most common cause of a tension pneumothorax? - ANS Mechanical positive-pressure ventilation in patients with a visceral pleural inury Where is the ideal location for needle decompression of a tension pneumothorax? - ANS 5th intercostal space, slightly anterior to midaxillary line What do you need to remember when treating an open pneumothorax? - ANS Place a dressing on the site and only secure is on 3 sides so air can escape, then place a chest tube Massive hemothorax - ANS Accumulation of >1500 ml of blood in one side of chest Causes of PEA? - ANS Hypovolemia Hypoxia Hydrogen acidosis Hypo/hyperkalemia Hypoglycemia Hypothermia Toxins Tamponade Tension pneumo Thrombosis Indications of a thoracotomy - ANS 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. - ANS Open pneumothorax A 46-year-old male sustained a gunshot wound to the chest - ANS 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 - ANS Cardiac tamponade Eight life-threatening injuries during the secondary survey? - ANS 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 - ANS 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 - ANS 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? - ANS 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. - ANS 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. - ANS Flail chest due to costochondral disruption What would confirm a diaphragmatic injury in a patient? - ANS Presence of NGT What is a common finding associated with traumatic asphyxia? - ANS 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? - ANS The incidence of PNA and mortality is doubled in older patients Pulmonary contusion/flail chest is best treated by? - ANS Supplemental oxygen, pain control, and recognition if the patient is unable to ventilate properly The cause of hypoxia associated with flail chest is - ANS 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 - ANS 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? - ANS 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 - ANS Abdominal contents that have become displaced into the chest cavity Stab wounds most commonly injury? - ANS Liver (40%) Small bowel (30%) Diaphragm (20%) Colon (15%) Gunshot wounds most commonly injury? - ANS Small bowel (50%) Colon (40%) Liver (30%) Abd vascular structures (25%) When is a retrograde urethrogram mandatory? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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 = - ANS 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? - ANS 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? - ANS 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 - ANS 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? - ANS 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? - ANS 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 - ANS Activation of massive transfusion protocol, application of pelvic binder, and CXR