Module 10 - Multiple Trauma Chest/Abdomen

The NP is assessing a trauma patient's readiness for discharge by determining the level of comfort the patient prefers. The NP completes this portion of the pain assessment by asking about the patient's: a. Aggravating and alleviating factors b. Functional pain goal c. Intensity of pain d. Onset of pain

b. Functional pain goal

The single agent antibiotic regimen for a trauma patient with a lacerated liver includes: a. Cefepime b. Imipenem-cilastatin c. Metronidazole d. Penicillin

b. Imipenem-cilastatin • Antibiotics for liver lacerations (per PPT) • Single agent regimen: • Imipenem-cilastatin 500mg IV q 6 hours • Meropenem 1 gm IV q 8 hours • Piperacillin-tazobactam 3.375 gms IV q 6 hours • Combination regimen • Cefepime 2 gms IV q 12 hours or ceftazidime 2 gms IV q 8 hours + • Metronidazole 500mg IV q 8 hours Impipenem-cilastin is a wide spectrum of antibacterial activity against gram-negative and gram-positive aerobic and anaerobic bacteria, including many multiresistant strains. It is stable to many beta-lactamases (class: carbapenem)

Your multiple trauma patient incurred multiple rib fractures. The initial recommended medication for sedation and pain relief is : a. Dilaudid b. Ketorolac (Toradol) c. Lidocaine 1% nerve block d. Morphine Sulfate

b. Ketorolac (Toradol) Pain management strategies to treat multiple rib fractures includes: · Toradol 30mg IV q6h prn with Morphine 2mg IV & titrated · Dilaudid 0.2mg IV q15 mins x3 then 0.5mg IM/SQ q4h · Lidocaine 1% in the form of a block, ice over site · Oxygen · Pain is relieved in 5-7 days Morphine is the medication of choice for pain treatment with flail chest; Morphine is used WITH toradol

In which situation is a person most likely to experience a blunt cardiac injury? a. After getting hit in the chest with a baseball b. After falling off their bicycle onto cement c. After going skydiving d. After having coronary bypass surgery

a. After getting hit in the chest with a baseball Question 4 In which situation is a person most likely to experience a blunt cardiac injury? After getting hit in the chest with a baseball After falling off their bicycle onto cement After going skydiving After having coronary bypass surgery Blunt cardiac injuries: 90% are lethal within minutes & direct impact or pressure transmitted fixed and mobile parts (atriocaval disruptions) Examples of blunt trauma: BCI occurs most often from motor vehicle collisions (MVCs). Falls and crush injuries cause a smaller number. Commotio cordis, a rare type of BCI in which low impact chest trauma causes sudden cardiac arrest, usually occurs from being struck by a projectile during sports. Arrest appears to stem from the timing of the blow during a period of electrical susceptibility.

Which of the following is NOT a common diagnostic procedure that is used to diagnose injuries associated with acute abdominal trauma? a. Biopsy b. CT scan c. Exploratory laparotomy d. Ultrasound

a. Biopsy Diagnostics for acute abdominal trauma: Fast exam, DPL, Exploratory Lap is done with significant penetrating injuries to abdomen, CT of the abdomen/pelvis, CXR, and Ultrasound

What is the most common medical intervention required for patients with thoracic trauma? a. Chest tube insertion b. Pericardiocentesis c. Thoracotomy d. VATS (video-assisted thoracoscopic surgery)

a. Chest tube insertion chest tube insertion is utilized with pneumothorax is relevant or patient is MV. · VATS is indicated with penetrating injury with little blood loss in a stable patient, persist3ent hemothorax, empyema, persistent air leakage, suspicion of diaphragm rupture · Pericardiocentesis: emergency treatment with cardiac tamponade · Thoracotomy: indicated after Chest Tube if the output is >1.5L in 1 hour and >200cc/hr over next 2-4 hours (ATLS ppt) . Fluid resuscitates prior to attempting in the case of pneumo

Generalized abdominal pain following rupture of a hollow organ is MOST suggestive of: a. Diffuse peritoneal contamination b. Gas accumulation in the peritoneum c. Inflammation of deep nerve endings d. Severe internal bleeding

a. Diffuse peritoneal contamination

When should antibiotics be initiated in a patient with abdominal trauma? a. Emergency Department b. Intensive Care Unit c. Surgery d. None of the above

a. Emergency Department Per powerpoint, ED is responsible for starting the antibiotic therapy.

There are a number of options for resuscitative fluids. Which of the following statement(s) is/are true concerning fluids used for resuscitation of shock? a. Hypertonic saline solution results in volume expansion, an increase in left ventricular performance, decreased peripheral resistance, and redistribution of cardiac output to kidneys and viscera b. Resuscitation with crystalloid requires volume replacement in a ration of 1:1 volume lost c. The literature strongly supports the use of colloid as being superior to crystalloid in the resuscitation of shock d. The use of perfluorocarbons as an experimental resuscitative fluid has been demonstrated to stimulate the immune system

a. Hypertonic saline solution results in volume expansion, an increase in left ventricular performance, decreased peripheral resistance, and redistribution of cardiac output to kidneys and viscera Hypertonic fluids have a higher osmolarity than serum. Pulls fluid and electrolytes from the intracellular and interstitial compartments into the intravascular compartment. Can help stabilize blood pressure, increase urine output, and reduce edema. Rarely used in the prehospital setting. Care must be taken with their use. Dangerous in the setting of cell dehydration.

Your patient developed respiratory depression after her first dose of intravenous (IV) morphine. After ordering 0.2mg of nalozone (Narcan) IVP, the patient's respiratory rate and depth are within normal limits. Which action do you order next? a. Administer another dose of naloxone in 1 hour b. Assess the patient's vital signs q15 minutes for 2 hours c. Discontinue all pain medications ordered d. Allow the patient to sleep

b. Assess the patient's vital signs q15 minutes for 2 hours

When assessing a multisystems trauma patient, it is MOST important to: a. Administer an analgesic promptly to minimize pain b. Avoid being distracted by visually impressive injuries c. Only splint fractures involving long bones at the scene d. Splint swollen, painful extremities as soon as possible

b. Avoid being distracted by visually impressive injuries (PPT) The appearance of an external wound may be deceptive because pneumothorax, hemothorax, lung contusion, cardiac tamponade, along with severe and continue hemorrhage can occur from any small wound

Because of its anatomic position in the retroperitoneum, it typically takes high-energy force to damage the: a. Liver b. Pancreas c. Spleen d. Stomach

b. Pancreas Blunt abdominal injuries most commonly affect spleen > liver > small & large intestines

Blunt force trauma to the abdomen can lead to an internal injury that involves blood accumulating around injured tissue, such as the liver or spleen. What is this type of injury called? a. Edema b. Hematoma c. Laceration d. Rupture

c. Laceration · Edema is when area is filled with fluid · laceration is a cut with a knife or other surface that would make a cut in the spleen. · Rupture implies blunt force was applied and nothing external penetrated the organ.

Your patient's x-ray reveals a flail chest. Which of the following is the preferred medication for initial pain management? a. Dilaudid b. Ketorolac (Toradol) c. Morphine Sulfate d. None of the above

c. Morphine Sulfate Morphine is the medication of choice for pain treatment with flail chest · Morphine 2mg IV then titrate for pain & monitor for resp depression · Dilaudid 0.2mg IV q15mins x 3 then 0.5mg IM/SQ q4h prn Pain management strategies to treat multiple rib fractures includes: · Toradol 30mg IV q6h prn with Morphine 2mg IV & titrated · Dilaudid 0.2mg IV q15 mins x3 then 0.5mg IM/SQ q4h · Lidocaine 1% in the form of a block, ice over site · Oxygen

Your patient in the ED has presented with cardiac tamponade. Which of the following medications is recommended to maintaining a systolic BP <100-110mmHG for aortic rupture? a. Dobutamine b. Dopamine c. Nipride d. Nitroglycerine

c. Nipride Management of Cardiac Tamponade vis medication is: · Nitroprusside (Nipride) 0.2-8mcg/kg/min and increase q10 minutes to maintain SBP <100-110mmHG for aortic rupture until taken to surgery · Esmolol 50-300mcg/kg/min may also be sued (rember this is ultra short acting) · Dopamine will raise the blood pressure; · Dobutamine: Stimulates B1 receptors & Stimulates B2 and alpha to lesser extent. ADE: ↑ contractility, HR vasodilatation at higher doses Nitroglycerine: Venous vasodilator (preload only until high doses). Dose with CHF exacerbation 10-200 mcg/min

When blood is released into the peritoneal cavity: a. Blood pressure falls with as little as 500 ml of internal blood loss b. It is most often the result of blunt force trauma to the pancreas c. Nonspecific signs such as tachycardia and hypotension may occur d. The abdomen almost immediately becomes grossly distended

c. Nonspecific signs such as tachycardia and hypotension may occur -In the event of acute hemorrhaging (internal bleeding), the venous blood, the blood volume and consequently cardiac output are reduced, and progresses inevitably to inadequate tissue perfusion and cardio-circulatory arrest and death. -Hypovolemic shock is a severe and acute metabolic disturbance caused by a reduction in volume of blood, as from hemorrhage or dehydration. -Blood loss from the vascular system reduces the volume of venous blood returning to the heart

Which of the following is NOT a sign/symptom of a chest injury? a. Dyspnea b. Hemoptysis c. Normal chest expansion d. Rapid, weak pulse and low blood pressure

c. Normal chest expansion signs of a chest injury include: any form of physical injury to the chest including the ribs, heart, and lungs. Normal chest expansion is a NORMAL finding

Which of the following conditions could result in flail chest from a lot less force than in a healthy person? a. Atopic dermatitis b. Meningitis c. Osteoporosis d. Urinary tract infection

c. Osteoporosis Osteoporosis increases susceptibility to fractures

You should expect a ruptured kidney if a patient presents with flank pain, gross hematuria and: a. Left shoulder pain b. Pain with exhalation c. Pain with inhalation d. Right shoulder pain

c. Pain with inhalation s/s of Kidney rupture include pain in the abdomen or flank: flank bruising (aka Grey Turner's sign), Hematuria, palpable mass in flank area, possible hemodynamic instability. --> Lower back pain is a common complaint in kidney rupture cases. The kidneys are present around the lower back of your body, so when they rupture, a patient experiences lower back pain.

Which of the following is NOT a function of the pancreas? a. Enzyme secretion b. Glucagon secretion c. Reservoir for bile d. Secretion of insulin

c. Reservoir for bile The pancreas makes pancreatic juices, which contain enzymes that aid in digestion, and it produces several hormones, including insulin. The pancreas is surrounded by the stomach, intestines, and other organs--> injury to pancreas is due to direct blow with abdominal pain and +/- vomiting. The reservoir for bile is the liver

The radiographic findings indicating a torn thoracic aorta include: a. First rib fractures b. Left hemothorax c. Widened mediastinum d. All of the above

d. All of the above · A supine chest radiograph is the initial screening investigation in the trauma patient. The mediastinum on a portable supine film can be difficult to assess, especially if taken in expiration or if the patient is rotated. Direct signs of aortic injury are not visible on chest radiographs but indirect signs may be detected: either a mediastinal hematoma or signs of concomitant chest injuries. · Signs of mediastinal hematoma: · widened mediastinum (more than 8 cm when supine, or more than 6 cm when upright), indistinct or abnormal aortic contour, deviation of trachea, ETT or NGT to the right, depression of left main bronchus, loss of the aortopulmonary window, widened paraspinal stripe, widened paratracheal stripe, left apical pleural cap, large left hemothorax

Blunt force trauma is a specific type of acute abdominal trauma that can result in various abdominal injuries. Which of the following would NOT be considered blunt force trauma? a. Falling off a roof and landing on the stomach b. Getting hit in the stomach by a steering wheel during a car accident c. Getting kicked in the stomach d. Getting stabbed in the stomach

d. Getting stabbed in the stomach o penetrating trauma--> Getting stabbed in the stomach, gunshot o Blunt trauma--> due to force, does not penetrate, crush injury--> due to motion. o Acceleration-Deceleration--> Going in one direction and abruptly stopping

Which of the following pain medications is considered the 'gold standard' for pain relief in trauma? a. Acetaminophen b. Codeine c. Ketamine d. Morphine

d. Morphine Morphine is the medication of choice for pain treatment with flail chest; Morphine is used WITH toradol

Which injuries are considered life-threatening requiring immediate intervention? a. Cardiac contusion and rib fractures b. Clavicle fracture and pulmonary contusion c. Pneumomediastinum and subcutaneous emphysema d. Tension pneumothorax and pericardial tamponade

d. Tension pneumothorax and pericardial tamponade Tension pneumo and pericardial tamponade can lead to death quickly. Trauma to the chest can be life threatening because the heart, lungs, and great vessels are housed; when injuries to the chest cage occur, it restricts the heart's ability to pump blood or lungs ability to exchange air and oxygenated blood. All others are serious but not as serious as D

Intraabdominal bleeding may produce few signs and symptoms of trauma because: a. Blood in the peritoneum can compress the aorta and maintain perfusion b. It takes approximately 4 L of blood loss before signs of shock manifest c. The abdominal musculature can sustain massive blunt force without bruising d. The intraabdominal cavity can accommodate large amounts of blood

d. The intraabdominal cavity can accommodate large amounts of blood

An NP working in the ED evaluating a patient following an acute chest trauma. Which of the following findings indicates the client is possibly experiencing a tension pneumothorax? a. Collapsed neck veins on the affected side b. Collapsed neck veins on the unaffected side c. Tracheal deviation to the affected side d. Tracheal deviation to the unaffected side

d. Tracheal deviation to the unaffected side

Flail chest is defined as : a. Chyle in the pleural space b. Excess fluid in the pericardium c. Multiple rib fractures with subsequent subcutaneous emphysema d. Two or more ribs fractured at two points

d. Two or more ribs fractured at two points Flail chest is the fracture of 2 or more ribs in 2+ locations; most serious chest WALL injury due to ability to cause contusion and respiratory distress. Management: High flow oxygen to maintain SpO2 target (e.g. 15L/min via non-rebreather mask); Analgesia: Morphine 2mg IV then titrate PRN while monitoring for respiratory depression. OR Dilaudid 0.2mg IV q15 x 3 doses then 0.5mg IV SQ q4h prn. Respiratory monitoring and support: close monitoring of SaO2, respiratory effort, and ABGs is important as patients tend to gradually deteriorate and may require intubation and mechanical ventilation. May benefit from non-invasive ventilation. · Chyle in pleural space = chylothorax-- lymph fluid in pleural space due to thoracic duct leak. · Excess fluid in the pericardium = is cardiac tamponade when it causes compression to the heart. · Multiple rib fractures with subQ emphysema = sternal fx?? crepitus = subQ emph.

The patient is admitted to the ED with chest trauma. When assessing the patient, which signs/symptoms would the NP expect to find that support the diagnosis of pneumothorax? a. Barrel chest and polycythemia b. Bronchovesicular lung sounds and bradypnea c. Frothy blood sputum and consolidation d. Unequal lung expansion and dyspnea

d. Unequal lung expansion and dyspnea

The NP follows the recommended protocol for preventing constipation when starting a patient on opioids by: a. Adding bulk to the diet b. Giving the patient enemas as needed c. Increasing fluids and exercise d. Using bowel stimulant and stool softener

d. Using bowel stimulant and stool softener opioids = constipation; add stool softeners and stimulants

Which of the following is NOT an indicator of cardiac tamponade? a. Dyspnea with equal breath sounds b. Jugular venous distension c. Muffled heart tones d. Widening pulse pressure

d. Widening pulse pressure PPT: Signs of cardiac tamponade: BECKS TRIAD: dyspnea, weakness, BP & Pulse pressure are greater than the extremities (pulsus paradoxus), chest/back pain, circulatory collapse, narrow pulse pressure, prominent neck veins, anxiety