Trauma Management: Principles and Practices, Exams of Nursing

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Assessed first in trauma patient - ✔✔Airway (*)Degree of burn that is characterized by bone involvement - ✔✔Fourth Complications of head trauma - ✔✔Intracerebral hematoma Extradural hematoma Brain abscess Most common cause of laryngotracheal stenosis - ✔✔Trauma Intervention that can help prevent development of acute renal failure - ✔✔Infusion of normal saline A 26-year-old male is resuscitated with blood transfusion after a motor vehicle collision that was complicated by a fractured pelvis. A few hours later, the patient becomes febrile, hypotensive with a normal CVP, and oliguric. Upon examination, the patient is found to be bleeding from the NG tube and IV sites. Which of the following is the most likely diagnosis? A. Hemorrhagic shock B. Acute adrenal insufficiency C. Fat embolism syndrome D. Transfusion reaction - ✔✔D. Transfusion reaction

Skin antiseptic - ✔✔-Ethanol 70% is an effective skin antiseptic

• Acetic acid can be used to treat Gram- skin infections
• Salicylic acid is used to treat certain skin yeast infections Class IV hemorrhage indicates what % blood loss - ✔✔55% How does shivering affect body temperature - ✔✔Increases body temperature Class III hemorrhage indicates what % of blood loss - ✔✔35% Management of a stable patient with kidney contusion - ✔✔Observation Associated with hypovolemic shock - ✔✔-Inadequate tissue perfusion with resultant tissue hypoxia
• Blood shunting to vital organs
• Decreased circulating blood volume and decreased venous return
• Low cardiac output
• Loss of less than 20% of the blood volume is usually without symptom except for mild tachycardia
• Patients become orthostatic with losses between 20 and 40%
• Shock is evidenced by tachycardia, hypotension, oliguria, flat neck veins The most effective method of monitoring the success of resuscitation during CPR? - ✔✔Reactivity of pupils to light

Used to ensure correct placement of endotracheal tube - ✔✔-Ultrasound

• Bilateral breath sounds
• Sustained end-tidal CO Total body surface area involved in a burn in an adult to the anterior chest and abdomen - ✔✔18% What is often caused by carotid massage? - ✔✔Bradycardia Step in a patient diagnosed with tension pneumothorax - ✔✔1. Needle decompression/ thoracotomy

2. Chest tube True statements regarding diaphragmatic injuries - ✔✔-Blunt diaphragmatic injuries are usually associated with skeletal trauma

• Penetrating diaphragmatic injuries may be missed
• Repair of traumatic diaphragmatic injuries usually does not require prosthetic material First priority in the treatment of an unconscious patient - ✔✔Checking the pulse A patient involved in a road accident is brought to the emergency department in an unconscious state. On arrival, her vitals show a temperature of 96.4 degrees Fahrenheit, a respiration rate of 24 breaths per minute, a heart rate of 140 beats per minute, and a blood pressure of 80/40 mm Hg. She is cold, shivering, and perspiring profusely. She has bilateral reactive pupils but she does not respond to pain. On physical examination, she has no obvious sign of external bleeding. Which of the following cannot be the cause of hypotension in this patient?

A. Pelvic fracture B. Fracture of femur C. Intracranial hemorrhage D. Hemothorax - ✔✔C. Intracranial hemorrhage A patient suffered a slash to his right neck. The wound is over the mid-portion of the sternocleidomastoid. There is a large hematoma and brisk bleeding when uncovered. He is stable. What is the next step in management? A. Get an angiogram B. Close the wound in the ER C. Take him to the operating room D. CT scan to evaluate neck structure - ✔✔C. Take him to the OR After abdominal injury, which of the following urinalysis findings would be an indication for further testing? A. 0-5 casts/HPF B. 5-10 WBC/HPF C. 10-20 RBC/HPF D. Gross hematuria - ✔✔D. Gross hematuria A laceration of the neck superficial to the deep cervical fascia along the sternocleidomastoid muscle at its midpoint would cause bleeding from which structure? - ✔✔External jugular vein Clinical features associated with tension pneumothorax - ✔✔Unilateral decrease in breath sounds

Hyperresonance Respiratory distress Tachycardia Tracheal shift Desatruation Decreased breath sounds Decreased compliance Asymmetric chest movement NOT hypertension, audible bronchial sounds Not recommended as a mode of ventilation for a patient with a diaphragmatic hernia A. Bag and mask B. LMA C. Endotracheal intubation D. Jet ventilation - ✔✔A. Bag and mask What is the next step in the assessment of a traumatic patient after airway is established? - ✔✔Breathing Blood group that is considered a universal donor - ✔✔O

A provider is examining a patient who sustained a severe traumatic head injury. He documents no Doll's eyes. What does this signify? - ✔✔Brainstem injury Which of the following is the least preferred method of administering IV fluids? A. Cubital veins B. Cephalic veins C. Subclavian veins D. Saphenous vein - ✔✔Subclavian veins Dermatome level for nipple sensation Dermatome level for umbilicus - ✔✔T T At which temperature would a hypothermic patient stop shivering? - ✔✔88 degrees F What is the energy recommendation for the first defibrillation in an adult (*) - ✔✔300 J Pharmacologic effects of Morphine - ✔✔Behavioral changes Analgesia Respiratory depression

NOT diarrhea A patient with which condition should be triaged to receive medical attention first? A. Choking B. Dizziness C. Leg cramp D. Vomiting - ✔✔A. Choking For pediatric patients, what volume of fluid resuscitation should be given initially in the setting of shock? A. 750 mL of saline uniformly B. 1 liter of saline C. 20 mL/kg of 0.45% NaCl with 5% glucose D. 10 to 20 mL/kg of Ringers lactate - ✔✔D. 10 to 20 mL/kg of Ringers lactate A patient is found unconscious after a fire in his bedroom. He is found to have severe burns around his face. What is the first aspect of treatment? A. Tetanus toxoid B. Cover the wound C. Airway D. Obtain blood work - ✔✔C. Airway Basilar skull fracture - ✔✔PE: raccoon eyes, battle sign, CSF ottorrhea (rhinorrhea), loculated pneumoencephalocele

Bone MC involved = Temporal A patient with von Willebrand disease is bleeding after sustaining a knife wound. Which of the following is most appropriate for the treatment of this patient? A. Vitamin K B. Cryoprecipitate C. Protamine D. DDAVP - ✔✔D. DDAVP What is the total body surface area involved in a burn to both lower extremities? - ✔✔36% Which injury is most common in rear end motor vehicle accidents? A. Cervical fractures B. Hypextension-hyperflexion neck injuries C. Forearm fractures D. Rotational neck injuries - ✔✔B. Hypextension-hyperflexion neck injuries What is true about an unrestrained pregnant driver? A. She is at increased risk of placenta previa B. She is at increased risk of placental abruption C. At 33 weeks, her fetus is well protected by an amniotic fluid cushion and thus the pregnancy is not at risk

D. If the mother's vital signs are stable, complications are unlikely - ✔✔B. She is at increased risk of placental abruption In adults, an aspirated foreign body is most likely to get stuck in the: A. Left main bronchus B. Carina C. Right main bronchus D. Esophagus - ✔✔C. Right main bronchus Skin finding characteristic of second-degree burns - ✔✔Blisters Which is true regarding cervical spine fractures? A. Seen most commonly in elderly females B. Athletic activities are the most common cause C. Falls are the most common cause D. Methylprednisolone should not be used in associated spinal cord injury in the first 48 hours - ✔✔D. Methylprednisolone should not be used in associated spinal cord injury in the first 48 hours In which patients can an oropharyngeal airway be used? - ✔✔Non-gag reflex If a trauma patient has clear fluid draining from the nose the provider should do which of the following? A. Tilt the head back B. Apply pressure

C. Collect the fluid D. Insert nasal tampons - ✔✔C. Collect the fluid What is the estimated time a person's brain can be anoxic from cardiopulmonary failure and not develop permanent brain damage? A. 10 minutes B. 5 minutes C. 2 minutes D. 20 minutes - ✔✔B. 5 minutes The laryngeal mask airway is contraindicated in patients with what condition? A. Spine injury B. Head trauma C. Giving birth D. Propensity to aspirate - ✔✔D. Propensity to aspirate A patient sustains blunt trauma to the back and left leg. Vital signs in the emergency department show temperature 36 degrees C, BP 120/80 mm Hg, heart rate 92, respirations 19, GCS 15. There is bilateral lower extremity paraplegia, T12 sensory level, and decreased rectal tone. Hemoglobin is 14.2 and the same in one hour. Which of the following tests is best for diagnosing an intraperitoneal bleed? A. Abdominal ultrasound B. Laparotomy C. KUB D. Diagnostic peritoneal lavage - ✔✔A. Abdominal ultrasound

Why is tracheostomy generally not performed at the first cartilage ring A. The trachea is too narrow B. A high chance of subglottic stenosis C. A high chance of tracheo-innominate artery fistula D. Inability to access the area - ✔✔B. A high chance of subglottic stenosis What does a carotid pulse indicate? A. A functioning pump for blood flow B. The circulating blood volume is reaching end organs C. Diastolic blood pressure D. None of the above - ✔✔B. The circulating blood volume is reaching end organs Which of the following generally causes hemorrhage associated with pelvic fractures? A. Obturator artery injury B. Superior gluteal artery C. Lateral sacral artery injury D. Venous bleeding - ✔✔D. Venous bleeding Hemothorax facts - ✔✔-Must have at least 500 cc of blood to make a diagnosis on chest x-rayin an adult

• Incomplete evacuation of hemothorax can lead to empyema
• Initial treatment of hemothorax is always a chest tube

In a 66 year old intubated, comatose patient, what is one of the most important information that one needs to obtain? A. Organ donation status B. Power of attorney C. Lawyer D. Driver's license - ✔✔B. Power of attorney A patient is hit by a car and has severe injuries to his extremities. He is immediately brought to the emergency room by EMS. Evaluation reveals that he has multiple organ injuries. He has an open, gaping wound which measures 2 x 2 centimeters, just below the right knee. The leg appears dislocated and ecchymotic. However, pulses are present in the distal extremity. He does not complain of any paresthesias. X-ray reveals that there is a fracture of the tibia. The trauma team is called. As their arrival is awaited, which of the following should NOT be done to help manage this patient? A. Obtain culture and close wound using a sterile technique B. Don't reduce the dislocation C. Give tetanus toxoid/booster shot D. Give antibiotics - ✔✔A. Obtain culture and close wound using a sterile technique During resuscitation, your intubated patient's intravenous fluid infiltrates. You know that you may deliver the following drugs via the endotracheal tube: - ✔✔Lidocaine Atropine Naloxone Epinephrine Prior to tracheobronchial suctioning, the patient should receive:

A. 5cc normal saline lavage B. Be placed on NPO status C. 100% oxygen prior to suctioning D. Versed 1 mg/mL - ✔✔C. 100% oxygen prior to suctioning In a patient with a pneumothorax following a stab wound, the chest tube is best inserted at which level?

• ✔✔Between the 4th and 5th intercostal spaces, just anterior to the mid axillary line Indications for a CT scan of the head in trauma patients - ✔✔-Glasgow coma scale score of less than 14
• Evidence of basilar skull fracture
• Amnesia lasting more than 30 minutes Most common Emergency Medical Services pediatric calls - ✔✔-Seizures
• Respiratory problems
• Trauma Treatments utilized in a patient with head trauma and raised intracranial pressure - ✔✔-Elevation of the head
• Sedation
• Use of diuretics NOT fluid restriction

How deep should the provider depress the patient's sternum during CPR in adults? - ✔✔2 to 3 inches First parameter to change in patient's with hypovolemic shock? A. Systolic blood pressure B. Pulse rate C. Respiratory rate D. Skin vasoconstriction - ✔✔B. Pulse rate A 34-year-old with severe head trauma and elevated intracranial pressures is intubated. Which of the following should be the target for mechanical ventilation? - ✔✔Set PaCO2 between 30- 35 A young motorcycle driver is thrown against a concrete bridge and sustains severe trauma about the face, with marked deformity and bleeding. Which of the following statements regarding this scenario is TRUE? A. Cervical spine evaluation takes precedence over facial injuries B. LeFort fractures rarely cause severe hemorrhage C. Nasotracheal intubation must be done urgently to prevent airway obstruction D. Plain radiographs are preferred to CT in emergencies - ✔✔A. Cervical spine evaluation takes precedence over facial injuries Which US industry has the highest accidental death rate? A. Construction B. Agriculture C. Manufacturing

D. Transportation - ✔✔B. Agriculture Subdural hematoma facts - ✔✔Etiology: tearing of bridging veins

• Most common in elderly individuals who fall
• Hematoma should be evacuated surgically
• Prognosis is much better for chronic subdurals than acute cases
• More common than epidural hematomas NOT often associated with skull fractures An 8-year old child is brought to the ER after being struck by a car while crossing the street. He is not alert and required immediate intubation at the scene by EMS. His GCS is 8 T. He appears to have a significant laceration of his scalp on the left side but there are no skeletal fractures. The initial chest x- ray revealed a right sided pneumothorax and a chest tube was inserted. His hematocrit is 23.5 and hemoglobin is 7.6. The next thing you would do is: A. CT head B. CT abdomen C. Repeat blood work D. Observe patient - ✔✔B. CT abdomen Class I hemorrhage indicates what percentage of blood loss? - ✔✔10% Which is not a clinical component of the Glasgow Coma Score?

A. Eye movement B. Sensation C. Verbal response D. Extremity movement - ✔✔B. Sensation How should epinephrine should be injected for treatment of anaphylaxis? - ✔✔Intramuscularly (IM) into vastus lateralis How would a patient with a change in mental status would be triaged using the simple triage and rapid treatment (START)? A. Delayed B. Immediate C. Minor D. Critical - ✔✔B. Immediate Appropriate site for insertion of a subclavian line - ✔✔-One centimeter inferior to the junctions of the middle and medial third of the clavicle

• One fingerbreadth lateral to the angle of the clavicle
• Inferior to the clavicle @ deltopectoral groove, lateral to the midclavicular line In head trauma, the majority of patients with post-traumatic CSF otorrhea: A. Need surgery B. Should be started on antibiotics C. Heal spontaneously

D. Develop meningitis - ✔✔C. Heal spontaneously Uncal herniation - ✔✔PE: Biot breathing, dilated and fixed pupil (out and down) Nerves affected: 3rd, 4th, parasympathetic input Laryngeal mask is usually seated over the which structure? A. Tonsils B. Esophagus C. Vallecula D. Pyriform fossa - ✔✔D. Pyriform fossa Patterns of injury seen in spinal cord trauma - ✔✔-Central cord syndrome

• Anterior cord syndrome
• Brown-Sequard syndrome Should be avoided in patient with suspected nasal fracture - ✔✔Nasal intubation What is the best way to evaluate a cardiac contusion? A. CT scan of the chest B. Echocardiogram C. ECG monitoring x 24 hours D. Cardiac enzymes - ✔✔C. ECG monitoring x 24 hours

Cerebral contusions - ✔✔May happen opposite to the point of impact An 18-year-old is thrown off his motorbike on a slippery road. At the scene, what is the first priority in the management of this patient? A. Assess vital signs B. Stabilize cervical spine C. Assess airway D. Start IV fluids - ✔✔C. Assess airway Normal adult respiratory rate - ✔✔ 12 - 20 breaths per minute Scapular fracture - ✔✔-Usually requires a tremendous force to fracture

• May be uneasily visible on plain xray
• Treatment requires prolonged immobilization
• Usually associated with other chest injuries A patient suffers a stab wound to the chest. In the emergency room, he is found to have an 80 percent pneumothorax with a midline shift of the trachea to the contralateral chest. There is evidence of circulatory and respiratory dysfunction. What is the next step in the management of this patient? A. Endotracheal tube B. Fluid bolus C. Epinephrine D. 20 gauge needle - ✔✔D. 20 gauge needle

Flail chest - ✔✔Mediastinum is pulled toward affected side during expiration Epidural hematoma - ✔✔MC due to injury of Middle meningeal artery Temporoparietal = area that has most epidural hematomas from trauma

• Can be intracranial or intraspinal (may follow LP)
• Often associated with skull fractures 7 - year-old girl is found at the bottom of a swimming pool. Initially she was in full arrest but after 5 minutes she showed sinus tachycardia but no respiratory effort. Intubation was done in the field and cervical collar placed. After transport to the emergency department she was unresponsive with a blood pressure of 100/60 mmHg, pulse 105, temperature 34.3C, and oxygen saturation 100%. The pupils were 3 mm and sluggishly responsive to light. There is no response to pain. The lungs show wheezing on the left and coarse breath sounds bilaterally. The monitor shows sinus tachycardia. There is no rectal tone. Which of the following should be the next step in management? A. Cervical spine films and CT of the head B. Portable chest radiograph C. Arterial blood gas D. Right and left decubitus chest radiographs - ✔✔A. Cervical spine films and CT of the head Position patient should be transported in when patient complains of neck pain and is 32 weeks pregnant
• ✔✔Supine on a backboard with her right hip elevated Air embolism - ✔✔PE: murmur, petechiae, desaturation

Tx: turn patient on left side in Trendelenburg position Fat embolism - ✔✔MCC = bone fx Clinical presentation

• Fever
• Petechial hemorrhage
• Desaturation
• Hypotension
• Altered mental status Cauda equina syndrome - ✔✔-Bilateral sciatica
• Bowel dysfunction
• Saddle sensory changes At what point should hyper oxygenation be administered when performing tracheal suctioning on a mechanically ventilated patient? A. Before the procedure B. After the procedure C. Before and after the procedure D. During the procedure - ✔✔C. Before and after the procedure

Nerve to muscle relationship - ✔✔C5 - Deltoid C6 - Wrist extension C7 - Elbow extension Most common cause of kidney injuries - ✔✔Motor vehicle accidents Crystalloid solutions - ✔✔Ringer's lactate Dextrose 5% D5W plus 1/2 NS NOT albumin Indication for emergency thoracotomy A. Pulmonary contusion B. Flail chest C. Hemothorax with initial blood loss of 700 cc D. Lung collapse with an air leak - ✔✔D. Lung collapse with an air leak Studies used for a patient with widened mediastinum after injury - ✔✔CT scan Upper endoscopy Transesophageal ultrasound Pericardial tamponade - ✔✔Muffled heart sounds

JVD

Equalization of cardiac chamber pressure NOT hypertension Blood groups facts - ✔✔-ABO compatibility is a must for renal transplant

• Febrile reactions may be due to bacterial contamination
• Citrate toxicity can cause hypocalcemia Which statement is most accurate regarding a chest tube connected to a water seal drainage system? A. Bubbles in the water indicate that the chest tube is no longer needed B. The water level should fall slightly with each spontaneous inspiration C. The drainage system should be kept below the level of chest tube insertion D. The chest tube should be clamped at all times when the patient is ambulatory - ✔✔C. The drainage system should be kept below the level of chest tube insertion Confirmatory test that is a reliable indicator of brain death A. Apnea test with a pCO2 less than 40 B. Electromyography C. 4-vessel cerebral angiography D. CT scan of the brain - ✔✔C. 4-vessel cerebral angiography MC spine problem seen in patient's with Down syndrome - ✔✔Atlanto-axial instability

As a result of burn trauma, fluid shifts can cause hematocrit levels to A. Rise B. Fall C. Remain unchanged while hemoglobin levels drop D. Rise initially then fall dramatically - ✔✔A. Rise A 17-year-old male is hit on the head with a baseball bat. He withdraws and opens his eyes in response to deep painful stimuli. He also mumbles incomprehensibly. What is his Glasgow coma scale score? - ✔✔ 8 Hypoxia - ✔✔PE: cyanosis Can be rapidly measured with pulse ox After placement of a chest tube for a traumatic pneumothorax, subcutaneous emphysema is observed. After checking the drainage and chest tube site, what else should be done? - ✔✔-Increase level of suction

• Insert second chest tube
• Adjust chest tube Do NOT flush tube with saline Which of the following injuries is most critical? A. Fractured femur

B. Fractured pelvis C. Fractured humerus D. Fractured fibula - ✔✔B. Fractured pelvis A patient on a mechanical ventilator is fighting the machine, and has elevated peak airway pressures. What medication should be used? A. Benzodiazepines B. Vecuronium C. Barbiturates D. Baclofen - ✔✔B. Vecuronium What is the primary goal in the initial resuscitation of a cardiac arrest? A. Renal perfusion B. Limb perfusion C. Myocardial perfusion D. Brain perfusion - ✔✔D. Brain perfusion During an MVA, what is most likely injury to occur after knees strike the dashboard A. Fractured femur B. Fractured humerus C. Lacerated spleen D. None of the above - ✔✔A. Fractured femur

Reason epinephrine is added to local anesthetics - ✔✔Prolongs its action Used to treat high ICP - ✔✔Control BG Hyperventilation (pCO2 30-35) Elevate head of bed Mannitol (osmotic diuretic) Furosemide (loop diur.) Earliest symptom of local anesthetic toxicity - ✔✔Tongue and circumoral numbness A 18-year-old male sustains a right femur fracture and a cerebral concussion in a motor vehicle accident. His initial blood pressure is 75/50 mmHg with a pulse of 90 beats per minute. After giving him 2 liters of Ringer lactate he stabilizes, but the blood pressure falls when he is seen in the ER. Which of the following would be the cause of suspected hypotension in this patient? A. Subdural hematoma B. Undiagnosed facial fracture C. Ruptured spleen D. 10% pneumothorax - ✔✔C. Ruptured spleen An unrestrained driver involved in a high speed MVA is transported by paramedics with c-spine precautions. GCS score is 7, but there is no obvious trauma. Respirations are shallow, and BVM is not providing adequate ventilation. Extremities are cool, and the pulses are thready. Prior to rapid sequence intubation, what should be done? A. Brief neurologic examination