Critical Care - Chapter 20: Trauma and Surgical Management

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.

7. 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.

13. During the treatment and management of the trauma patient, maintaining tissue perfusion, oxygenation, and nutritional support are strategies to prevent what potential complication? 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).

2. When providing information on trauma prevention, it is important to realize that individuals age 25 to 44 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 25 to 44 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.

14. Range-of-motion exercises, early ambulation, and adequate hydration are interventions to prevent this common complication observed in trauma patients? 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.

17. Which statement 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.

11. Which patient has 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.

8. In the trauma patient, what is the most common cause of symptoms of decreased cardiac output? 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 statement 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, 22 years old and smelling of alcohol, begins to vomit. Which intervention 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. What should the primary survey of this patient upon arrival to the ED include? a. A cervical spine x-ray study to determine the presence of a fracture. b. Turning the patient from side to side to get a look at his back. c. Getting a baseline assessment and establish priorities. d. 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.

16. Treatment and/or prevention of rhabdomyolysis in at-risk patients include aggressive fluid resuscitation to achieve how much urine output? 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.

12. 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.

9. 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).

15. Which intervention 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.

10. The nurse is caring for a patient who sustained rib fractures after hitting the steering wheel of a 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 what prescribed intervention? 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.