Critical Care: Chapter 20: Trauma

3. An 18-year-old unrestrained passenger who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. This patient should be treated at which level trauma center? a. Level I b. Level II c. Level III d. Level IV

ANS: A Because the patient is hypotensive and was unrestrained, the patient is at higher risk for more severe injuries related to the mechanism of injury; thus, treatment should occur at a level I trauma center. Patients with less severe injuries can be treated at lower level trauma centers.

2. When providing information on trauma prevention, it is important to realize that individuals age 35 to 54 years are most likely to experience which type of trauma incident? a. High-speed motor vehicle crashes b. Poisonings from prescription or illegal drugs c. Violent or domestic traumatic altercations d. Work-related falls

ANS: B People age 35 to 54 years are at greater risk of experiencing poisonings from prescription and/or illegal drugs resulting in unintentional injury, followed by motor vehicle crashes (MVCs). MVCs and homicide are the leading causes of death for individuals age 16 to 24 years, and falls are responsible for traumatic injuries in the 65 years and older population. Domestic violence is not well defined as an age-related trauma incident.

10. A community-based external disaster is initiated after a tornado moved through the city. A nurse from the medical records review department arrives at the emergency department asking how she can assist. The best response by a nurse working for the trauma center would be to: a. assign the nurse administrative duties, such as obtaining patient demographic information. b. assign the nurse to a triage room with another nurse from the emergency department. c. thank the nurse but inform her to return to her department as her skill set is not a good match for patients' needs. d. have the nurse assist with transport of patients to procedural areas.

ANS: A A nurse in the medical records department is most likely familiar with the disaster plan and although she doesn't currently provide direct care to patients, she is a knowledgeable healthcare provider who can help in a disaster by obtaining essential patient information. Assigning the nurse to provide direct care to patients, such as assisting in the triage room or transporting patients, may not be appropriate, as the direct care skills are not known. Asking the nurse to return to her department also may not be appropriate because the nurse offers a skill set that can be used during the disaster.

8. The nurse is having difficulty inserting a large caliber intravenous catheter to facilitate fluid resuscitation to a hypotensive trauma patient. The nurse recommends which of the following emergency procedures to facilitate rapid fluid administration? a. Placement of an intraosseous catheter b. Placement of a central line placement c. Insertion of a femoral catheter by a trauma surgeon d. Rapid transfer to the operating room

ANS: A Infusion of volume is required for optimal fluid resuscitation and may be achieved through large caliber venous cannulation or intraosseous access. A central line or femoral vein access may be obtained by the physician, but the procedure requires time. Transport to the operating room is not a priority in the goal to obtain intravenous access for fluid resuscitation.

7. Which of the following interventions would not be appropriate for a patient who is admitted with a suspected basilar skull fracture? a. Insertion of a nasogastric tube b. Insertion of an indwelling urinary catheter c. Endotracheal intubation d. Placement of an oral airway

ANS: A Nasogastric tubes are contraindicated in basilar skull fractures because insertion may result in penetration of the meninges. An indwelling urinary catheter may be necessary to monitor fluid balance. Protection of the airway to include placement of an oral airway or endotracheal tube may be indicated.

2. Trauma patients are at high risk for multiple complications not only due to the mechanism of injury but also due to the patients' long-term management. Which of the following statements apply to trauma patients? (Select all that apply.) a. Indwelling urinary catheters are a source of infection. b. Patients often develop infection and sepsis secondary to central line catheters. c. Pneumonia is often an adverse outcome of mechanical ventilation. d. Wounds require sterile dressings to prevent infection.

ANS: A, B, C Prevention of infection is essential in the care of trauma and postsurgical patients. Removing invasive devices when they are no longer needed for monitoring and ensuring aseptic care of devices are important nursing care considerations for management of indwelling urinary catheters, central lines, and airway adjuncts. Wounds, other than the immediate postoperative dressing, are not required to be sterile. Aseptic technique is used for wound care.

7. Nursing priorities to prevent ineffective coagulation include which of the following? (Select all that apply.) a. Prevention of hypothermia b. Administration of fresh frozen plasma as ordered c. Administration of potassium as ordered d. Administration of calcium as ordered

ANS: A, B, D Ineffective coagulation is a serious complication for a trauma patient that can be prevented by maintaining normothermia, evaluating and treating for hypocalcemia, administering clotting factors found in fresh frozen plasma or platelets, and evaluating and treating metabolic acidosis. Evaluating and treating serum potassium levels is important for effective cardiac muscle function, not coagulation.

6. Which interventions can the nurse implement to assist the patient's family in coping with the traumatic event? (Select all that apply.) a. Establish a family spokesperson and communication system. b. Ask the family about their normal coping mechanisms. c. Limit visitation to set times throughout the day. d. Coordinate a family conference.

ANS: A, B, D The trauma team can assist the patient and family in crisis by helping them establish a consistent communication process between the healthcare team and family. Other interventions include exploring the family's perceptions of the event, support systems, and coping mechanisms. Family conferences early in the emergent phase and frequently during the critical care phase assist with communication and with understanding the patient's and family's expectations for care. Limiting visitation will not assist the patient or the family's ability to cope with the traumatic event.

5. Which of the following patients would require greater amounts of fluid resuscitation to prevent acute kidney injury associated with rhabdomyolysis? (Select all that apply.) a. Crush injury to right arm b. Gunshot wound to the abdomen c. Lightning strike of the left arm and chest d. Pulmonary contusion and rib fracture

ANS: A, C Causes of rhabdomyolysis include crush injuries, compartment syndrome, burns, and injuries from being struck by lightning. Acute kidney injury may result from a gunshot wound related to prolonged hypotension. Acute kidney injury would not have a direct cause associated with a pulmonary contusion.

3. During the assessment of a patient after a high-speed motor vehicle crash, which of the following findings would increase the nurse's suspicion of a pulmonary contusion? (Select all that apply.) a. Chest wall ecchymosis b. Diminished or absent breath sounds c. Pink-tinged or blood secretions d. Signs of hypoxia on room air

ANS: A, C, D Pulmonary contusion is a serious injury associated with deceleration or blast forces and is a common cause of death after chest trauma. The clinical presentation includes chest wall abrasions, ecchymosis, bloody secretions, and a partial pressure of arterial oxygen (PaO2) of less than 60 mm Hg while breathing room air. The bruised lung tissue becomes edematous, resulting in hypoxia and respiratory distress. Absence of breath sounds is more suggestive of atelectasis or a collapsed lung.

8. Which of the following findings require immediate nursing interventions related to the assessment of a patient with a traumatic brain injury? (Select all that apply.) a. Mean arterial pressure 48 mm Hg b. Elevated serum blood alcohol level c. Non-reactive pupils d. Respiratory rate of 10 breaths per minute

ANS: A, C, D Rapid assessment of patients with neurological injury is vital to the treatment of patients with traumatic brain injury. Preventing hypotension (mean arterial pressure less than 50 mm Hg) is essential to maintain cerebral perfusion; non-reactive pupils are an abnormal finding and require immediate attention to evaluate the cause. Adequate oxygenation and ventilation are necessary to deliver oxygen to the brain; thus, a respiratory rate of 10 requires further evaluation. An elevated blood alcohol level interferes with the ability to conduct a neurological examination but does not require immediate intervention.

21. A 36-year-old driver was pulled from a car after it collided with a tree and the gas tank exploded. What assessment data suggest the patient suffered tissue damage consistent with a blast injury? a. Blood pressure 82/60, heart rate 122, respiratory rate 28. b. Crackles (rales) on auscultation of bilateral lung fields. c. Responsive only to painful stimuli. d. Irregular heart rate and rhythm.

ANS: B Explosive blast energy generates shock waves that create changes in air pressure, causing tissue damage. Initially after an explosion, there is a rapid increase in positive pressure for a short period, followed by a longer period of negative pressure. The increase in positive pressure injures gas-containing organs. The tympanic membrane ruptures, and the lungs may show evidence of contusion, acute edema, or rupture. A low blood pressure and corresponding tachycardia is more suggestive of hypovolemia. Lack of response to stimuli suggests a neurological injury. An irregular heart rate and rhythm may be associated with blunt trauma to the heart (e.g. cardiac contusion).

16. During the treatment and management of the trauma patient, maintaining tissue perfusion, oxygenation, and nutritional support are strategies to prevent: a. disseminated intravascular coagulation. b. multisystem organ dysfunction. c. septic shock. d. wound infection.

ANS: B Patients with multisystem injuries are at high risk of developing myriad complications associated with the overwhelming stressors of the injury, prolonged immobility, and consequences of inadequate tissue perfusion and oxygenation. Maintaining effective tissue perfusion, oxygenation, and nutritional support are all vital to prevent progression into multiple organ dysfunction syndrome. Disseminated intravascular coagulation, septic shock, and wound infections are best prevented by addressing infection early and aggressively with appropriate antibiotics and nursing interventions to reduce infection (e.g. hand hygiene).

17. Range-of-motion exercises, early ambulation, and adequate hydration are interventions to prevent: a. catheter-associated infection. b. venous thromboembolism. c. fat embolism. d. nosocomial pneumonia.

ANS: B Prevention of venous thromboembolism is essential in the management of trauma patients. If not medically contraindicated, patients should receive pharmacological prophylaxis (e.g. heparin or heparin derivatives). Nurses should encourage ambulation, evaluate the patient's overall hydration, and ensure sequential compression devices are used properly. Prevention of catheter-associated infections is also important through interventions that maintain the integrity of the catheter site and injection ports. Hydration and ambulation, along with pulmonary exercises, help prevent pneumonia. Fat embolism is associated with long bone fractures and early recognition of this complication is essential to treatment.

4. Which of the following injuries would result in a greater likelihood of internal organ damage and risk for infection? a. A fall from a 6-foot ladder onto the grass b. A shotgun wound to the abdomen c. A knife wound to the right chest d. A motor vehicle crash in which the driver hits the steering wheel

ANS: B The penetrating injury of the gunshot wound would cause the greatest amount of injury because of the kinetic energy and dispersion pattern of the shotgun ammunition once it penetrated the body. A fall would cause a compression injury from the blunt force of the fall. The knife wound would cause a penetrating injury in which the magnitude of the injury would depend on damage to the vessels and lung. Blunt chest trauma that may include a cardiac contusion is possible following an injury in which the patient hits the steering column.

1. Fluid resuscitation is an important component of managing the trauma patient. Which of the following statements are true regarding the care of a trauma patient? (Select all that apply.) a. 5% Dextrose is recommended for rapid crystalloid infusion. b. IV fluids may need to be warmed to prevent hypothermia. c. Massive transfusions should be avoided to improve patient outcomes. d. Only fully cross-matched blood products are administered.

ANS: B, C Lactated Ringer's and normal saline are the crystalloids of choice in trauma resuscitation. Because hypothermia is a concern, fluids should be warmed. Massive blood transfusions are associated with poor outcomes. Cross-matched blood is preferred, but blood type O, universal donor blood, can be administered in an emergency.

20. Which of the following statements about mass casualty triage during a disaster is true? a. Priority treatments and interventions focus primarily on young victims. b. Disaster victims with the greatest chances for survival receive priority for treatment. c. Once interventions have been initiated, healthcare providers cannot stop the treatment of disaster victims. d. Color-coded systems in which green indicates the patient of greatest need are used during disasters.

ANS: B Victims are triaged based on the severity of injury. Patients receive treatment based on the assessment of greatest chances for survival matched to resources available for medical intervention. Age is not a determination in rendering interventions. Patient survival and severity of injury are the priority assessment for triage. If interventions are initiated and found to be ineffective, treatment can be stopped according to principles of ethical care. Color-coded systems are frequently used during disasters to signify patients in greatest need of assistance, with red indicating worse severity of injury and green being most stable.

4. It is important to prevent hypothermia in the trauma patient because hypothermia is associated with which of the following? (Select all that apply.) a. ARDS b. Coagulopathies c. Dysrhythmias d. Myocardial dysfunction

ANS: B, C, D Prolonged hypothermia is associated with the development of myocardial dysfunction, coagulopathies, reduced perfusion, and dysrhythmias (bradycardia and atrial or ventricular fibrillation). ARDS is a complication associated with excessive inflammation and over-resuscitation.

11. A near-infrared spectroscopy (NIRS) probe is placed in a trauma patient during the resuscitation phase to: a. assess severity of metabolic acidosis. b. determine intraperitoneal bleeding. c. determine tissue oxygenation. d. prevent complications of over-resuscitation.

ANS: C NIRS is a continuous noninvasive technology that uses principles of light transmission to measure skeletal muscle oxygenation as an indicator of shock. Low oxygenation levels detected by NIRS may suggest metabolic acidosis but requires laboratory analysis. Poor tissue perfusion determined through NIRS requires further evaluation of causes of shock, including intraperitoneal bleeding. NIRS would not be helpful in determining complications associated with over-resuscitation.

14. Which of the following patients have the greatest risk of developing acute respiratory distress syndrome (ARDS) after traumatic injury? a. A patient who has a closed head injury with a decreased level of consciousness b. A patient who has a fractured femur and is currently in traction c. A patient who has received large volumes of fluid and/or blood replacement d. A patient who has underlying chronic obstructive pulmonary disease

ANS: C During states of hypoperfusion and acidosis, inflammation occurs and vessels become more permeable to fluid and molecules. With aggressive fluid resuscitation, this change in permeability allows the movement of fluid from the intravascular space into the interstitial spaces (third spacing). As more IV fluids are given to support systemic circulation, fluids continue to migrate into the interstitial space, causing excessive edema and predisposing the patient to additional complications such as abdominal compartment syndrome, ARDS, acute kidney injury, and MODS. A patient with a closed head injury, a patient with a fractured femur stabilized by traction, and a patient with chronic obstructive pulmonary disease may develop ARDS, but it would be related to fluid resuscitation and excessive inflammation associated with traumatic injury.

9. In the trauma patient, symptoms of decreased cardiac output are most commonly caused by: a. cardiac contusion. b. cardiogenic shock. c. hypovolemia. d. pericardial tamponade.

ANS: C Hypovolemia is commonly associated with traumatic injury resulting from acute blood loss. Cardiac contusion may decrease cardiac output, but hypovolemia occurs more often. Cardiogenic shock is not typically associated with trauma. Pericardial tamponade would decrease cardiac output but is not as common as hypovolemia.

1. Which of the following best defines the term traumatic injury? a. All trauma patients can be successfully rehabilitated. b. Traumatic injuries cause more deaths than heart disease and cancer. c. Alcohol consumption, drug abuse, or other substance abuse contribute to traumatic events. d. Trauma mainly affects the older adult population.

ANS: C Many patients who sustain traumatic injury are under the influence of alcohol, drugs, or other substances. Rehabilitation potential depends on multiple factors including severity of injury, patient age, and comorbidities. Heart disease and cancer claim more lives than trauma, but trauma claims lives of predominantly young individuals.

6. The nurse has admitted a patient to the ED following a fall from a first-floor hotel balcony. The patient is 22 years old and smells of alcohol. The patient begins to vomit in the ED. Which of the following interventions is most appropriate? a. Insert an oral airway to prevent aspiration and to protect the airway. b. Offer the patient an emesis basin so that you can measure the amount of emesis. c. Prepare to suction the oropharynx while maintaining cervical spine immobilization. d. Send a specimen of the emesis to the laboratory for analysis of blood alcohol content.

ANS: C Stabilization of the cervical spine, preventing aspiration, and maintaining a patent airway are essential elements of trauma management. An oral airway may increase the risk of aspiration related to the emesis and offering an emesis basin would contradict spine precautions. Alcohol level is best determined by serum analysis.

5. A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. The primary survey of this patient upon arrival to the ED: a. includes a cervical spine x-ray study to determine the presence of a fracture. b. involves turning the patient from side to side to get a look at his back. c. is done quickly in the first few minutes to get a baseline assessment and establish priorities. d. is a methodical head-to-toe assessment identifying injuries and treatment priorities.

ANS: C The primary survey is a systematic rapid assessment of the patient's airway with cervical spine immobilization, breathing and ventilation, circulation with hemorrhage control, disability or neurological status, and exposure/environmental considerations. The secondary survey is more methodical and involves identifying injuries and specific treatment priorities.

19. Treatment and/or prevention of rhabdomyolysis in at-risk patients includes aggressive fluid resuscitation to achieve urine output of: a. 30 mL/hr. b. 50 mL/hr. c. 100 mL/hr. d. 300 mL/hr.

ANS: C Treatment of rhabdomyolysis consists of aggressive fluid resuscitation to flush the myoglobin from the renal tubules. A common protocol includes the titration of IV fluids to achieve a urine output of 100 to 200 mL/hr. Urine volumes less than 100 mL/hr are insufficient and a urine volume greater than 200mL/hr will not harm the patient but may create too aggressive a diuresis.

15. Patients with musculoskeletal injury are at increased risk for compartment syndrome. What is an initial symptom of a suspected compartment syndrome? a. Absence of pulse in affected extremity b. Pallor in the affected area c. Paresthesia in the affected area d. Severe, throbbing pain in the affected area

ANS: D Patients with compartment syndrome complain of increasing throbbing pain disproportionate to the injury. Narcotic administration does not relieve the pain. The pain is localized to the involved compartment and increases with passive muscle stretching. The area affected is firm. Paresthesia distal to the compartment, pulselessness, pallor, and paralysis are late signs and must be reported immediately to prevent loss of the extremity.

12. The need for fluid resuscitation can be assessed best in the trauma patient by monitoring and trending which of the following tests? a. Arterial oxygen saturation b. Hourly urine output c. Mean arterial pressure d. Serum lactate levels

ANS: D Serum lactate levels are useful in assessing acidosis and the need for aggressive fluid resuscitation. Arterial oxygen saturation provides clinical information on oxygen delivery to cells. Hourly urine output and mean arterial pressure provide information on systemic perfusion and are monitored in the assessment of effective resuscitation; however, serum lactate is a better indicator of metabolic acidosis caused by under-perfusion (under-resuscitation).

18. Which of the following interventions is a strategy to prevent fat embolism syndrome? a. Administer lipid-lowering statin medications. b. Intubate the patient early after the injury to provide mechanical ventilation. c. Provide prophylaxis with low-molecular weight heparin. d. Stabilize extremity fractures early.

ANS: D Stabilization of extremity fractures to minimize both bone movement and the release of fatty products from the bone marrow must be accomplished as early as possible. Administration of statin medications has no effect on prevention of fat embolism. Intubation and mechanical ventilation may be necessary to support the pulmonary system in the event the patient has a fat embolism, but it will not prevent this complication. Heparin will not prevent fat embolism; it is for venous thromboembolism prophylaxis.

13. The nurse is caring for a patient who sustained rib fractures after hitting the steering wheel of his car. The patient is spontaneously breathing and receiving oxygen via a face mask; the oxygen saturation is 95%. During the nurse's assessment, the oxygen saturation drops to 80%. The patient's blood pressure has dropped from 128/76 mm Hg to 84/60 mm Hg. The nurse assesses that breath sounds are absent throughout the left lung fields. The nurse notifies the physician and anticipates: a. administration of lactated Ringer's solution (1 L) wide open. b. chest x-ray study to determine the etiology of the symptoms. c. endotracheal intubation and mechanical ventilation. d. needle thoracostomy and chest tube insertion.

ANS: D These are classic symptoms of a tension pneumothorax in a patient at high risk related to mechanism of injury. Emergent decompression by a needle thoracostomy followed by a chest tube insertion is needed. A chest x-ray would delay treatment and is not needed prior to emergent intervention. Administration of IV fluids would not assist with blood pressure, as increased thoracic pressure from the tension pneumothorax needs to be relieved to restore cardiac output (and blood pressure). Endotracheal intubation and mechanical ventilation may be necessary after the tension pneumothorax is relieved to assist with the patient's ventilation.

1. The correct order of actions in the management of the postoperative surgical trauma patient who has been admitted to the critical care unit after surgery is: _______________, _______________, _______________,_______________. (Put a comma and space between each answer choice.) a. Connect the patient to bedside monitor and mechanical ventilator. b. Obtain vital signs, rhythm, oxygen saturation, and neurological status. c. Assess airway, breathing, and circulation. d. Reassess and evaluate patency of IV lines, and adjust rate of fluid administration as ordered.

C, A, B, D The initial intervention upon admission to the critical care unit is a rapid assessment of airway, breathing, and circulation. The nurse quickly connects the patient to the bedside monitor and ventilator, and completes an assessment of vital signs, cardiac rhythm, pulse oximetry reading, level of consciousness, and pupil reactivity. The nurse reassesses IV access and evaluates the patency of IV catheters, because they may have become dislodged during transport. Calculation of medication dosages and rates is completed as part of the initial assessment. Once the assessment and initial interventions have been completed, the family is contacted to see the patient.

2. Prevention of hypothermia is crucial in caring for trauma patients. The correct order of actions for the preparation for the trauma patient is: _______________, _______________, _______________, _______________. (Put a comma and space between each answer choice.) a. Remove wet clothing. b. Warm fluids and blood products before administration. c. Cover the patient with an external warming device. d. Warm the ED or intensive care unit (ICU) room before the patient's arrival.

D, A, C, B Before arrival to the ED or ICU, the receiving room needs to be warmed. The patient's clothing is removed, and he or she should be covered to prevent external loss of heat. An external warming device needs to be immediately available for warming the patient after arrival. Fluids that are administered should be warmed via active internal devices.