CMS #5

Overall, what percent of casualties with stab wounds to the abdomen require surgical interventions? What present of casualties with gunshot wounds will need surgery for definitive management?

15% 85%

What is the difference between 1st, 2nd, and 3rd degree burns?

1st - superficial 2nd - partial-thickness 3rd - full-thickness

You are treating the 2 y/o daughter of an EPW. The vehicle her father was driving ignited when captured by US forces. She has extensive full and partial thickness burns. What fluids should she receive?

5% dextrose containing IV fluids at a standard maintenance rate in addition to burn resuscitation fluids

You are caring for a critically ill soldier at a theater hospital in Afghanistan. A CCATT team is en route to pick him up for transfer. Comment on CCATT components and capabilities.

CCATT equipment is self-contained and self-carried, the team is composed of an intensivist-trained physician + critical care nurse + respiratory therapist, the team augments a standard aeromedical evacuation (AE) team, they are capable of transporting unstable patients

Analgesic and sedative medications are sometimes used together with a synergistic effect for patients in severe pain. Benzodiazepines are an important class of anxiolytic medications. What are some benzodiazepines you could use?

Diazepam, Lorazepam, Alprazolam, Midazolam

T or F - dislocations should always be reduced before transport.

False

T or F - generally in aeromedical evacuation, a wounded soldier is considered a patient until he or she reaches the first point of definitive medical care. Once entered into the medical care system, the patient is then considered a casualty.

False

T or F - significant intra-abdominal bleeding will cause immediate peritoneal signs

False

T or F - the term CASEVAC refers only to rotary wing aircraft.

False

T or F - some pelvic ring fractures are associated with an increase in pelvic volume. Because the volume is increased, there is less tissue surrounding the pelvis to tamponade bleeding. Several companies manufacture "pelvic binders" which have been shown to decrease the need for blood transfusions and decrease overall mortality.

False - pelvic binders have not been shown to have any beneficial effect or improved outcome in the prehospital setting

T or F - superficial partial-thickness burns involving 5% BSA necessitate burn unit care.

False, some examples of burns that do necessitate burn unit care include full-thickness burns, burns to bilateral hands, and lightning burns

What medication is most likely to offer potent analgesia for severe pain without risk of histamine mediated hypotension?

Fentanyl

What are some analgesics (NOT anxiolytics) that you could use?

Morphine, Ketorolac, Fentanyl

You are a flight surgeon evaluating a patient for aeromedical evacuation. The treating physicians think the patient needs to arrive in Germany within the next 2-3 days. Which evacuation category should you indicate on his patient movement request (PMR)?

Priority

What is the injury most commonly associated with pelvic fracture?

TBI

What are the incidences of the following injuries associated with pelvic fractures? TBI long-bone fx thoracic injury urethral disruption in men splenic trauma liver trauma

TBI - 51% long bone fx - 48% thoracic injury - 20% urethral disruption - 15% splenic trauma - 10% liver trauma - 7%

T or F - covering a partial-thickness burn with a dressing will reduce a burn patient's pain?

True

T or F - if possible, medical procedures such as starting IV lines, applying splints or dressings, and airway procedures (e.g. endotracheal intubation) should be done before aeromedical evacuation flights. If a particular problem (e.g. unstable airway) is a concern, it is prudent to address this issue aggressively before transport, rather than midway through a flight at altitude and in the dark.

True

T or F - pediatric burns are frequently the result of child abuse.

True

T or F - the introduction of a helicopter evacuation system during the Korean War is usually credited as the most important component in the improved survival rate among combat casualties seen in that conflict. This system was further developed during the Vietnam War. The success of this evacuation system led to its widespread adaptation by civilian programs in the US.

True

T or F - you are a general surgeon caring for a patient with multiple traumatic injuries sustained in an IED blast. You have stabilized him and want to transfer him via aeromedical evacuation to Germany. You have thoroughly assessed the patient. At this point he needs to be cleared by a flight surgeon.

True

T or F - the abdominal exam is unreliable in a TBI victim

True - relies on patient feedback

T or F - a woman who is 36 weeks pregnant would be considered abnormal if she showed a decrease in cardiac output.

True, though it would be considered normal if she had supine hypotension lying flat on her back that is relieved by lying on the left side

A 90 kg man sustains 25% TBSA burn. According to the Parkland formula, what should the rate of fluid administration be for the first 8 hours?

V = 4*m*(A*100) first half w/i 8 hours, remaining over next 16 hours in this case give 563 ml/h

Define TACEVAC.

a new term introduced to encompass en route care from the point of wounding to the definitive care facility

A 31 y/o female who is 36 weeks pregnant presents to the ED after a MVC. She is complaining of severe abdominal pain and back pain. On her primary survey her airway and breathing are intact; her pulse is fast and regular. On secondary survey her abdomen is tense with diffuse tenderness on exam. What is your greatest concern for this patient?

abruptio placenta

Burns are extremely painful, debilitating injuries. What type of burns require no analgesia?

all burn patients will likely require pain control

What are pertinent historical questions for MVC's and penetrating injury?

amount of blood at the scene, type of weapon (handgun v. rifle, caliber, length of knife), number of times casualty was stabbed or shot, position of casualty in vehicle, extent of vehicle damage (compromise of passenger compartment, steering wheel deformity, requirement for prolonged extrication), use of safety devices (seat belt, airbag deployment, child safety seats), type of collision

You have just prepared a 9-line MEDEVAC request and have written down "B" for line 4. What does this mean?

an operational hoist needs to be sent with the aircraft

A soldier is brought into your aid station after a training accident during which he fell from a guard tower. He arrives with a bayonet impaled in his abdomen. After completing your primary survey you find he is stable with HR 102, RR 17, POx 98%, BP 127/68. What should you do next?

arrange for surgical care, no further abdominal examination is necessary (DON'T remove bayonet)

You are serving as a unit Flight Surgeon and are on the flight line preparing for your crew duties when a call comes in that there has been a fueling accident. On arrival to the ramp, you observe a flaming fuel truck and diffusely scattered debris. The first casualty you come across is having difficulty breathing and you discover a metal fragment impales in his right lateral chest wall in the 4th intercostal space; aside from this the rest of his exam does not show obvious signs of external trauma. What are some possible injuries?

both abdominal and chest injuries possible - liver laceration, tension pneumothorax, cardiac tamponade, hypovolemic shock

A patient has suffered a closed fracture of the ulna and radius, and a splint was applied. What is the next step?

check neurovascular status of limb

What clinical situation will most likely require an escharotomy?

circumferential thermal burn of lower extremity

You are treating one of your unit members on the drop zone at Ft. Bragg after a bad Parachute Landing Fall (PLF). On exam you find an open tibia fracture and absent pedal pulses. What is the most correct intervention you should make on the drop zone?

cover the bone ends with sterile dressing, attempt to restore normal anatomic position before splinting (extremity fx w/ absent distal pulses = orthopedic emergency)

A firefighter is rescued from a burning warehouse that manufactures plastics. He was not wearing a respirator. He is obtunded. The base-station physician is worried he may have a toxic inhalational injury. What is the most likely toxic gas and appropriate antidote?

cyanide -> hydroxycobalamin

You are preparing to transport a Marine with a blast lung injury. What are some altitude effects you should be concerned about?

decrease in partial pressure in O2 in the atmosphere (same overall percentage but decreased total pressure)

Assessing abdominal injuries can be difficult in trauma patients. What are some issues that increase your concern that a given patient has a serious internal abdominal injury?

degree of shock greater than can be explained by other injuries (e.g. fractures, external hemorrhage), presence of peritoneal signs, positive FAST exam, obvious signs of trauma (e.g. soft tissue injuries, GSWs), signs of hypovolemic shock without an obvious cause, concerning mechanism of injury (e.g. bent steering wheel)

What are some environmental stressors for casualties undergoing aeromedical evacuation?

dehydration, hypoxia, decreased atmospheric pressure, thermal stress, elevated ambient noise levels, vibration

During your secondary survey on a casualty with abdominal trauma, you auscultate and hear bowel sounds in the left lower lung fields. What does this most likely indicate?

diaphragmatic rupture

What anatomical structures are found in the retroperitoneal space?

duodenum, aorta, rectum, pancreas

What is Cullen's sign?

ecchymosis around the umbilicus

What is Grey-Turner's sign?

ecchymosis involving the flanks

Define MEDEVAC.

evacuation of a casualty from one point of care to another point of care within the tactical theater, this movement usually occurs with rotary-wing aircraft or tactical fixed-wing aircraft such as the C-130

What is the definitive treatment for compartment syndrome?

fasciotomy

An airman in your squadron is severely burned in a deployed setting. Once he reaches a level III facility for care, what is the most likely course of action?

he will be evacuated as expeditiously as possible to a CONUS facility for definitive treatment

You are the physician at a BAS when a soldier is carried in by medics with severe burns covering about 50% TBSA. Both arms and legs are burned as well as his chest, neck, and groin. The medics did not start an extremity IV because they were taught to never start an IV through burned skin. What should you tell them?

ideally IVs should not be placed through or adjacent to burned tissue; however placement through the burn is appropriate if no alternative sites are available

While on a field exercise, a young airman is involved in a role-over crash of his HMMWV and is pinned beneath the vehicle. After extrication, he complains of SOB, abdominal pain, and that he cannot move his feet. Vital signs are HR 144, BP 100/77, RR30, O2 sat 87%. He has loss of breath sounds on one side, bruising of his upper chest and neck, and a small piece of bowel and omentum protruding through his abdominal wall. What is the next best course of action?

immediate needle decompression of pneumothorax, cover intestine with clean moist dressing, place in c-collar and on rigid back board, begin IV while transporting to nearest trauma center

During your secondary survey in a casualty with abdominal trauma, you determine that he has peritonitis. What are some physical signs you may see?

involuntary guarding, significant abdominal ttp, rebound tenderness

You are transporting a trauma victim to the closest trauma center in rural Kansas; you expect to arrive within 25 minutes. He has a knife protruding from his abdomen in the left upper quadrant. He has become hypotensive (systolic blood pressure ~60) and tachycardic (HR 140s). How should you manage the patient en-route to the trauma center?

leave knife in place, administer IV fluids until SBP is about 80-90 mmHg

You have responded to a casualty who was involved in an aircraft mishap. On assessment he is stable after initial fluid resuscitation. His vital signs are HR 110, BP 110/75, RR 12-15. His GCS is 14. He has been splinted for upper and lower extremity fractures and several lacerations have been dressed. He has a significant abdominal wound with eviscerated bowel. What should you do next?

leave the bowel on the surface of the abdomen and protect with moist sterile dressings, provide pain medications and help him remain calm

What is the Seatbelt sign?

linear ecchymosis or abrasion across the abdomen

What of the following is NOT a contraindication to using a femur traction splint (e.g. HARE splint)? loss of pedal pulse on fractured leg amputation of foot suspected fx adjacent to knee suspected femoral neck fx suspected pelvic fx

loss of pedal pulse on fractured leg

Comment on suitable helicopter landing zones (HLZs)?

mark (or prepare to mark) the zone as per protocol (VS-17 panels, smoke, chem lights, strobe lights, vehicle lights), if possible have a wind indicator just outside the HLZ easily visible to the pilot, in a tactical situation keep the HLZ as inconspicuous as possible to prevent the enemy from zeroing in on it, the HLZ should be as flat as possible with even terrain and no surrounding large trees, wires, or tall structures

What is the primary concern when evaluating a casualty with abdominal trauma in the field?

massive blood loss in the abdomen as a result of blunt or penetrating trauma

Define the pelvic fracture - lateral compression fractures.

may occur when a pedestrian is struck by a car, account for the majority of pelvic ring fractures, decreases the volume of the pelvis

Define the pelvic fracture - anterior-posterior compression fractures.

may occur when a person is pinned between a vehicle and a wall, also known as "open book" pelvic fractures because usually the symphysis is separated and the volume of the pelvis is greatly increased, may have significant hemorrhage

Define the pelvic fracture - vertical shear fractures.

may occur with a fall from height landing on one leg first, account for the smallest proportion of pelvic ring fractures but tend to cause the highest mortality from severe hemorrhage

You are managing a patient with a severe pelvic fracture who has lost a significant amount of blood; he appears to have no other injury. GCS is 14, airway and breathing are intact, but the patient has diffuse abdominal pain. Current SBP is 85. How much crystalloid fluid should be administered in order to obtain an acceptable pressure in this hemorrhaging patient?

none, this is an acceptable pressure (permissive hypotension)

What complication of fracture is primarily associated with open fracture?

osteomyelitis

A 22 year old Marine is pulled by fellow Marines from a burning vehicle. He has diffuse full and partial thickness burns (35% TBSA). He has singed nasal hairs, and his eyebrows and mustache are burned off. He has strong radial pulses. What is most concerning regarding immediate life threat?

rapid airway compromise from inhalational injury secondary to being trapped in a super-heated vehicle

What are some appropriate steps in burn management?

remove all clothing and jewelry, use high-concentration antimicrobial dressings, start IV fluid therapy with lactated ringer's (do NOT terminate burning by irrigate with copious volumes of ice-water)

Crush syndrome carried a mortality of 90% in WWII, which was reduced to approximately 50% by the Vietnam era. What is an important complication of crush syndrome?

renal failure - myoglobin released from damaged muscle (rhabdomyolysis) causes acute renal injury

A 38 year old hiker was struck by lighting on a mountain ridge and sustains 5% TBSA burns. What complication is he at risk for?

renal failure due to myoglobinuria

While a rare complication, what is the greatest concern when using narcotics for control of acute pain?

respiratory depression

What is the approximate internal blood loss associated with the following fractures? rib radius or ulna humerus tibia or fibula femur pelvis

rib - 125 mL radius or ulna - 250-500 mL humerus - 500-750 mL tibia or fibula - 500-1000 mL femur - 1000-2000 mL pelvis - 1000-massive

What MSK injuries could be potentially life threatening?

rib fx, pelvic fx, femur fx

Define the pelvic fracture - Rami fractures.

seen in individuals who fall forcibly on their perineum ("straddle" injury)

You are examining a Marine who fell out of a helicopter during an assault. Your primary survey was unremarkable, as was your secondary survey, but his vital signs reveal a GCS of 14, HR 133, BP 60/30, RR 23, O2 sat 96%. What is the most likely reason for his being in shock?

spleen rupture (note - spinal cord injury or neurogenic shock classically presents with bradycardia, not tachycardia)

You have just prepared a 9-line MEDEVAC request for transmission and have written down "B" for line 7. What does this mean?

the evacuation site will be marked with pyrotechnics

You are evaluating a pregnant AD woman at 34 weeks estimated gestational age. Her husband struck her repeatedly in the abdomen with a baseball bat. She arrives in extremis. Comment on the fetus survival probability.

the fetus is unlikely to survive if the mother dies

Define the pelvic fracture - Acetabular fractures.

the head of the femur is driven into the acetabulum of the pelvis, may be associated with significant hemorrhage

A 22 y/o woman is brought into the ED via EMS after a MVC. Inspection reveals the following physical exam findings (see image, seatbelt sign). What can you conclude from the image, and what particular injuries are you concerned about?

the patient was likely wearing her seatbelt and has a significant risk of bowel or mesentery injury

Comment on CASEVAC by air.

the tactical situation may preclude evac by air, interventions such as intubation/electronic monitoring/fluid resuscitation may be impractical or impossible during CASEVAC operations, in some cases it is faster and safer to move casualties by ground, not all casualties require urgent evac, environmental conditions may preclude evac by air

You have just prepared a 9-line MEDEVAC request for transmission and have written down "E" for line 8. What does this indicate?

they will be picking up enemy casualties

You receive a 9-line MEDEVAC request. Line 3 is reported as "2 Alpha, 1 Bravo, 3 Charlie." What should you expect?

two urgent casualties, one urgent surgical casualty, and three priority casualties

What is an absolute contraindication to aeromedical evacuation (AE)?

untreated pneumothorax

What you should do when managing a casualty with an isolated fracture?

use pain medications liberally as needed to control pain (as tolerated by the patient)

What type of pelvic ring fracture has the highest associated mortality?

vertical shear fracture

What is the preferred method of decontaminating eyes after a chemical exposure?

copious irrigation via a Morgan lens

Define CASEVAC.

evacuation of a casualty from the forward line of conflict; may expose the crew and aircraft to hostile fire and involves aircraft that are designed for but not necessarily dedicated to casualty movement

Define aeromedical evacuation.

movement of a casualty from a point of care within the theater to a more rearward location such as a regional hospital or CONUS, traditionally this phase has employed fixed-wing aircraft such as the C-17 or C-130

What do you call a fracture associated with a break in the skin?

open fracture

What are the four acoustic windows that are imaged as part of the FAST exam?

perihepatic, perisplenic, pelvic, pericardial

Pediatric patients have unique anatomic and physiologic considerations compared to adult burn patients. Name some.

proportionally larger heads than adults, Lund-Browder chart takes into account the age-related changes in children and can be helpful in estimating pediatric TBSA

What are signs of compartment syndrome?

pulselessness, paralysis, paresthesias, pain out of proportion to injury, pallor, puffiness

A 24 y/o man falls playing football. He has a right shoulder dislocation. On neurovascular exam, he cannot move his right thumb normally. What nerve do you suspect is injured?

radial

Through what routes can Morphine be delivered for pain control?

SQ, IV, IM