TCAR pratice exam

Intra-abdominal organs experience perfusion compromise when bladder pressure exceeds 5-7 mm Hg. 0-5 mm Hg. 16-20 mm Hg. 10-12 mm Hg.

16-20 mm Hg. Because the belly is a closed air and fluid-filled container, pressure equalizes throughout the abdomen. Therefore, in most circumstances, bladder pressure equals intra-abdominal pressure (IAP). Preperitoneal packing (in the pelvic trauma patient) is one circumstance where bladder pressure does not accurately reflect IAP. Intra-abdominal organs begin to experience perfusion compromise when bladder pressure exceeds 16-20 mm Hg. Normal IAP is LOW: 0-5 mm Hg. Physiological compromise starts at 10-15 mm Hg, and irreversible tissue injury occurs around 20-30 mm Hg. Why? **Approximately 20 mm Hg is the pressure required to squeeze a capillary closed, ANY capillary. Whenever capillary blood flow is compromised, tissue damage occurs, regardless of where the vessel is in the body.**

A patient struck by a bus has an unstable pelvic injury and bilateral femur fractures. 1 liter of 0.9% saline was infused prior to arriving at a major trauma center. In the ED, vital signs are: BP 80/62 mm Hg; HR 130/min; respirations 28/min. Which fluid and orthopedic interventions are indicated next? 2 units of red cells; bilateral femoral traction splint placement 2 more liters of 0.9% saline; bilateral tibial traction pin insertion 2 liters of PlasmaLyte-A; pelvic external fixator application 2 units of red cells and 2 units of plasma; pelvic binder application

2 units of red cells and 2 units of plasma; pelvic binder application Hemorrhage is the most life-threatening consequence of pelvic fractures. Potential blood loss ranges from 750 to 5000 mL, which is 15% to 100% of circulating volume. This patient is demonstrating signs of uncompensated hemorrhagic shock: hypotension, tachycardia, narrowed pulse pressure (SBP minus DBP), and increased shock index (HR ÷ SBP). The priority of care in any hemorrhaging patient is to STOP THE BLEEDING. A pelvic binder (either a commercial device or a do-it-yourself version) stabilizes the fractures and minimizes hemorrhage potential. This patient requires massive transfusion, not crystalloid administration. Start immediately infusing both RBCs and plasma. Femoral traction splints are contraindicated in patients who have unstable pelvic fractures because the devices work by pushing on the pelvis and pulling on the ankle. Pushing on an unstable pelvis is painful and ineffectiv

Which of the following IV solutions is NOT (more or less) isotonic in the body? Normal saline Plasma-Lyte A Lactated Ringer's solution 5% Dextrose/.45 saline

5% Dextrose/.45 saline Intravenous crystalloid solutions are categorized as hypotonic, isotonic, or hypertonic based on their solute concentration compared to their concentration in human cells and blood. ISOtonic intravenous crystalloid solutions have the same concentration of solutes (e.g., electrolytes, glucose) as found in the serum. In contrast, HYPOtonic solutions are less concentrated. HYPERtonic solutions have a greater solute concentration than the cells and blood. Plasma-Lyte A, lactated Ringer's solution, and normal saline are more-or-less isotonic. Although 5% Dextrose/.45 saline is HYPERtonic in the bag (406 mmol/L), once infused, dextrose rapidly moves into the cells leaving only water (a hypotonic solution) behind in the circulation

Which patient is at the highest risk for a severe deceleration injury? A 4-year-old who fell from an upper bunk bed to a hard floor A 23-year-old who was fully ejected from moving vehicle 40-year-old lap-belted driver who collided with a steering wheel An 83-year-old who fell from standing to a carpeted floor

A 23-year-old who was fully ejected from moving vehicle Of these individuals, the 23-year-old ejected from a moving vehicle is at the highest risk for a serious deceleration injury. Deceleration injuries occur when the body comes to an abrupt stop. This is the opposite of an acceleration injury, where the body is thrown into motion. Deceleration injuries are more common. Coming to a sudden stop can apply tremendous force to the body surface (collision #2) and to internal body structures (collision #3). Both a patient's SPEED and DECELERATION DISTANCE predict injury probability. Therefore, significant deceleration injury often occurs in situations involving high speeds and an abrupt slowdown, as in the case of ejection from a moving vehicle. Such events are associated with significant morbidity and mortality

Four patients involved in a motor vehicle collision are initially transported to a Level III trauma center. Three require transfer to a higher level of care. Which one can safely remain at the original hospital? A 9-year-old with abdominal distention; HR is 112/min An 82-year-old with second degree facial burns A 43-year-old with an incomplete aortic disruption A 23-year-old with mild traumatic brain injury; GCS is 14

A 23-year-old with mild traumatic brain injury; GCS is 14 The Centers for Disease Control and Prevention's (CDC) trauma triage tool provides guidelines regarding the appropriate level of care for injured patients. Those with obvious or potentially severe injuries, significant comorbidities, and complex special considerations should be managed at a designated Level I or Level II trauma center. In this motor vehicle collision scenario, the patient with an aortic injury will require specialized vascular services found only at a major (Level I or II) trauma center. The 9-year-old child showing signs of bleeding (abdominal distension, tachycardia) needs admission to a pediatric trauma center (all of which are Level I or Level II). And the burned older adult requires referral to a burn unit. However, the Level III trauma center where the patients were initially treated is well equipped to care for the mild traumatic brain injury patient (GCS score = 14) and to stabilize the others for transfer.

A construction worker fell 10 feet from scaffolding, striking his chest wall. Which assessment finding indicates the patient has a flail chest? A bubbling wound located on the upper thorax Paradoxical movement of the left chest wall Crackles auscultated with deep inspirationn Chest dissymmetry with unilateral hyperexpansion

A bubbling wound located on the upper thorax Paradoxical movement of the left chest wall A flail chest (a.k.a. unstable chest wall) involves two or more contiguous ribs fractured in two or more places or a detached ("free-floating") sternum. If not for the skin, muscles, and other soft tissue, the bony segment would fall out. A flail chest is a severe injury because ventilation ("air goes in, air goes out") is such a mechanical process. In a flail chest patient, the unattached chest wall segment is sucked INWARD during INHALATION due to negative pressure ventilation. It puffs OUTWARD on EXHALATION, an assessment finding called "paradoxical respiration." This abnormality makes basic chest wall mechanics very ineffective. Large areas of chest wall instability are readily detected in the resuscitation phase of care. However, small flail segment detection may be delayed because muscle spasms can initially splint the affected area. The defect only becomes apparent when muscle spasm subsides. A bubbling chest wound indicates an open pneumothorax and rales on auscultation is a finding associated with fluid overload. Chest dissymmetry, with marked hyper-expansion on one side, occurs in the tension pneumothorax patient.

In a patient with blunt abdominal trauma, which diagnostic study best identifies the extent of solid organ injury? A kidneys-ureters-bladder radiograph An MR angiogram An abdominal ultrasound. A computed tomography scan

A computed tomography scan

A patient who sustained a lower leg crush wound complains of severe pain. Muscle tenseness, pallor, and paresthesia are noted on exam. What bedside screening test can be quickly performed to evaluate this man's injury objectively? Ankle-brachial index Ultrasound of the extremity Allen's test Tonometry test

Ankle-brachial index The ankle-brachial index (ABI) is a simple, bedside assessment technique based on the concept that (when supine) systolic pressure in the upper arm and systolic pressure in the lower leg should be about the same. An ankle systolic pressure more than 10% lower than the brachial pressure indicates perfusion compromise, acute or chronic. [ABI = Ankle SBP/Arm SBP. Normal = >0.9] Relaying this data and your suspicions to the medical team will objectively convey your concerns regarding muscle compartment syndrome. Ultrasonography alone is not helpful for compartment syndrome diagnosis, but it may exclude venous thromboembolism. Allen's test is used to assess collateral blood flow to hands before a procedure that could potentially disrupt arterial blood flow to the area. Tonometry is a diagnostic test that measures intraocular pressure

Paramedics are transporting a patient with a large, left thigh stab wound to a trauma center. The patient is alert and is talking. Vital signs are: BP 95/72 mm Hg; HR 117/min. Which of the following interventions is most likely to improve patient outcome? Keep systolic blood pressure >100 mm Hg. Perform rapid sequence induction intubation. Bolus the patient with 2 liters intravenous 0.9% saline. Apply direct pressure to actively bleeding wound sites

Apply direct pressure to actively bleeding wound sites The priority intervention for any actively hemorrhaging patient is to STOP THE BLEEDING. In this case, applying direct pressure to the wound is the initial approach to hemostasis. Tourniquet application is indicated if bleeding cannot be controlled. Other vital interventions for hemorrhage management include keeping the patient warm and facilitating rapid access to a surgical team. Preserving body temperature can be problematic in the transport environment. Interventions include limiting skin exposure and increasing the transport vehicle's internal temperature. In hypotensive trauma patients without brain or spinal cord injuries, keep systolic pressure at or slightly above 90 mm Hg. Aggressive crystalloid resuscitation in this patient will only pop the newly forming clots, dilute existing clotting factors, and contribute to endothelial damage

A patient was admitted to the ICU following a damage control laparotomy. He received 6 L of lactated Ringer's solution, 4 units of red cells, and 4 units of plasma. Currently, vital signs are acceptable, but his urine output is down, and the ventilator high-pressure alert is sounding. Measuring which parameter is most likely to explain this patient's condition? Peak end expiratory pressure Central venous pressure Bladder pressure Intracranial pressure

Bladder pressure This patient's abdominal injury, surgical bowel manipulation, and large crystalloid intake all contribute to abdominal compartment syndrome (ACS) development. ACS is a clinical spectrum of elevated intra-abdominal pressure caused by tissue edema, free fluid in the abdominal cavity, or (occasionally) by external compression such as burn eschar. Dropping urine output in the abdominal trauma patient WHO HAS BEEN ADEQUATELY FLUID RESUSCITATED (i.e., there is nothing to indicate the patient is dry) STRONGLY suggests ACS due to renal vascular compression. Another red flag is the ventilator high-pressure alarm. In the absence of patient-ventilator dyssynchrony or tubing obstruction, consider limited diaphragm excursion (due to ACS) as an etiology for increased intrathoracic pressure. Other signs of ACS include jugular vein distension, peripheral blood pooling, and low cardiac output. However, elevated bladder pressure confirms the diagnosis.

A TBI patient's left pupil is sluggishly reactive to light and appears larger than the right pupil. This finding suggests compression of which cranial nerve? CN XII CN VIII CN IV CN III

CN III Cranial nerve III, the oculomotor nerve, has three motor functions: 1) pupillary constriction to light, 2) eyelid elevation, and 3) most extraocular movements. Cranial nerves don't cross. Therefore, a dilated left pupil that reacts sluggishly to light suggests compression of the LEFT CN III. CN IV, the trochlear nerve, controls the inward and down gaze directions. CN VIII, the acoustic (a.k.a. vestibulocochlear) nerve, has both auditory and balance functions. CN XII, the hypoglossal nerve, controls tongue movement and keeps the tongue midline. Assessing CN function is an integral part of caring for a traumatic brain injury patient. Bedside care providers must be able to detect changes in a patient's clinical condition quickly, understand their causes, and intervene to prevent further deterioration.

Two hours after critical care unit admission, a patient who sustained a severe head injury quickly develops dilated pupils that do not respond to light. Which is the most likely explanation? Downward brain herniation Severe meningeal irritation Cerebral contusion blossoming Spontaneous subarachnoid bleeding

Downward brain herniation When the brain squeezes through the foramen magnum, herniation is the result. As the brain under pressure moves downward, it compresses the cranial nerves against the base of the skull. Compression of the oculomotor nerve (CN III) against the tentorium causes pupils to dilate unilaterally or on both sides. Significant pupil abnormalities, bradycardia, and a widened pulse pressure are all LATE signs of neurological deterioration. Symptoms of meningeal irritation include headache, photophobia, neck stiffness, and seizures. Most major subarachnoid hemorrhages are caused by spontaneous rupture of an aneurysm or AVM. A cerebral contusion will "blossom" in the post-resuscitation period, evidenced by slow, progressive neurological deterioration as the contusion evolves

A patient's injury severity is quantified according to the Organ Injury Scaling system. Which statement best describes this scoring tool? Grades I through V or VI for each listed organ; I least severe, VI not survivable Grades I through × for each organ; the higher the score, the more severe the injury Grades I-VI for liver, spleen, and kidneys only; I is minor, V is major, VI describes injuries only discovered on autopsy Grades I through IV for heart, liver, spleen, and kidney; I is minor injury, IV is major injury

Grades I through V or VI for each listed organ; I least severe, VI not survivable The Organ Injury Scaling system was developed by a subcommittee of the American Association for the Surgery of Trauma. The scale can be used for thoracic vascular, lung, heart, chest wall, diaphragm, spleen, liver, abdominal vascular, kidney, ureter, bladder, and urethral injuries. A grade I injury is the least severe. A grade V injury is the most severe that can be survived. Grade VI injuries are non-survivable. Because patients can live without certain structures (e.g., a spleen, kidney, ureter) there is no grade VI for these organs. Bedside care providers don't score a patient's organ injuries, but it is important to understand the Organ Injury Scaling system and its implications for patient care and outcomes. Solid organ injuries are commonly scored based on radiology reports. Other injuries are graded upon visual inspection during surgery or in an autopsy report.

Of the following energy types, which one is most commonly involved in traumatic injury? Radiant Gravitational Thermal Electrical

Gravitational There are six types of energy involved in traumatic injury: mechanical, gravitational, thermal, chemical, electrical, and radiant energy. Gravitational and mechanical energy are by far the most common energy types involved in injuries. Mechanical energy mechanisms included being struck by a moving vehicle or being hit by a baseball bat. Gravitational energy involves patient falls and falling objects of all types. The remaining four energy types—thermal, chemical, electrical, and radiant—cause burn trauma. Because energy is usually applied to the tissues in characteristic patterns, knowing the kind of energy involved facilitates appropriate care

A 75-year-old patient who takes daily warfarin for chronic atrial fibrillation experienced a same-level fall three weeks ago. The patient was admitted today for new-onset confusion. Which of the following diagnostic tests would most likely identify the cause of the patient's altered mental status? Brain magnetic resonance imaging Cerebral digital subtraction angiography Head computed tomography scan Prothrombin time, international normalized ratio

Head computed tomography scan This patient's history and clinical findings suggest a subacute subdural hematoma (SDH). SDHs form when blood accumulates in the subdural space, causing mechanical pressure and chemical damage (from blood degradation) to the brain. Older adults and alcoholics are at high risk for SDHs. Both groups may be anticoagulated (due to medications or liver disease), routinely experience minor head injury, and have cerebral atrophy. Brain atrophy is a normal part of aging, but tissue loss is greatly accelerated by alcohol abuse and dementia. Atrophy leaves excessive room to stretch out the tiny bridging veins and for blood to accumulate between the brain and the dura. SDHs can occur acutely; patients are symptomatic within minutes or hours of injury. However, subacute accumulation will delay symptom onset for days or weeks in the anticoagulated patient with brain atrophy. Chronic SDHs usually occur in people with severe brain atrophy. Computed tomography is the diagnostic study that best identifies intracranial bleeding

Which of the following procedures will best preserve evidence for use in forensic cases? In addition to written documentation, photograph wounds and injuries. Cut clothing to remove bullet and stab marks, leaving a 2-inch margin around the hole. Store removed foreign objects in a location out of visitors' line of sight. Put all wet or bloody clothing in a plastic bag to prevent leakage

In addition to written documentation, photograph wounds and injuries. To preserve evidence for legal and forensic review and potential prosecution, "chain of custody" must be ensured. When cutting a patient's clothing off, AVOID cutting through suspected knife or bullet holes and leave clothing as intact as possible. Air dry wet or bloody garments before placing them in a PAPER bag. If the patient may have fired a weapon, put each hand in a paper bag and seal it around the wrist. Document the patient's recall of events. Precisely describe wounds and take photographs as necessary. Unless immediate intervention is essential, avoid cleaning minor wounds prior to police examination or documentation. Place any removed foreign bodies (e.g., bullets, blades) in a sealed and labeled container and keep the containers secure until handed over to law enforcement officials. If possible, get a forensic specialist involved

Two days after hospital admission, a 25-year-old polytrauma patient is febrile. His hemoglobin level is stable, yet his urine output is down, and he's mildly tachycardic and hypotensive. Which of the following is the most likely cause of this patient's hypovolemia? Plasma infusion during resuscitation Increased metabolic demands Evolving cerebral edema New onset hyperchloremic acidosis

Increased metabolic demands When a trauma patient is hypovolemic, first and always look for bleeding. Patients occasionally experience significant hemorrhage from delayed-onset organ or vessel rupture. Many injured patients will continue to experience blood loss from chest tubes, surgical drains, onto dressings, into body cavities, and around wounds. Cumulative losses from these sources can add up. However, 99% of hemorrhagic trauma deaths occur in the first 24 hours post-injury, and most happen within the first 3 hours. Therefore, the further out a patient is from the time of injury, the LESS likely it is that bleeding is the primary volume problem. There are many additional routes to hypovolemia, including diuresis from excessive urine production, such as diabetes insipidus in TBI patients. Other causes of hypovolemia in the post-resuscitation phase include insensible water loss (due to high metabolic demands), sweating (from fever or sympathetic storming), and plasma ooze (from open wounds). Fluid redistribution can also occur into the cells and interstitium ("3rd spacing"). The fluid is in the body but not in the intravascular compartment, thus not participating in circulation. Additional routes to hypovolemia include GI losses from diarrhea and vomiting.

During a karate match, a patient received a forceful kick to the epigastrium. 14 hours after hospital admission, which of the following findings suggests pancreatic injury? Right lower quadrant pain Lipase and amylase level elevation Low hemoglobin and hematocrit levels Right flank contusion

Lipase and amylase level elevation Most pancreatic injuries result from a direct epigastric blow that compresses the organ between a rigid object (foot, fist, steering wheel, handlebars, etc.) and the rigid spine. The pancreas is a semi-solid and mostly retroperitoneal structure that leaks tiny amounts of digestive enzymes when injured. These characteristics make pancreatic injuries more difficult to evaluate than solid organ trauma. Extensive pancreatic injuries are readily visualized on computed tomography scans, but small cracks and tears (and their digestive enzyme leaks) are not. FAST studies are inadequate for identifying pancreatic trauma because no significant quantity of free fluid is involved. Serial serum amylase or lipase studies are used to identify pancreatic injuries but are not highly sensitive or specific. Sometimes, levels are never elevated, even in patients with significant pancreatic damage. Pancreatic pain is typically burning in nature and located in the epigastric region. Significant blood loss from these injuries is uncommon.

A construction worker fell 20 feet from scaffolding, landing feet-first on a concrete surface. He subsequently pitched forward onto outstretched arms. Which orthopedic injuries can be anticipated with this injury mechanism? Lower rib fractures, femur fractures, and shoulder dislocation Lumbar spine, bilateral calcaneal, and wrist fractures Thoracic spinous process fractures and patellar fractures An open humeral fracture and a pelvic vertical shear injury

Lumbar spine, bilateral calcaneal, and wrist fractures This classic pattern of injuries occurs when a patient falls from a significant height and lands on the feet, especially when landing on an unforgiving surface such as concrete because there is no deceleration distance to dissipate energy. The feet strike first, and the calcaneal (heel) bones frequently fracture. As always, "the force went somewhere," so energy is transmitted upward, along the body's long axis, producing compression fractures of the lower lumbar spine. After hitting the ground, patients are commonly propelled forward. Outstretched arms catch the falling individual, thus protecting the head and torso but subjecting patients to bilateral wrist or forearm injuries.

Which of the following strategies is most likely to decrease intracranial pressure in agitated, brain-injured patients? Positioning patients with knees and hips flexed Elevating the head of the bed 20 degrees Suctioning endotracheal tube secretions Minimizing environmental stimulation

Minimizing environmental stimulation Minimizing environmental stimulation has a positive effect on (it lowers) intracranial pressure (ICP), which facilitates brain healing. Reduce lights, noise, and any painful interactions such as suctioning. Family members may have a very calming effect and can thus contribute to a patient's care. However, family members frequently require instruction regarding how best to be present with a brain-injured patient. Teach them to use quiet, gentle touches, one person at a time, to limit overstimulation. Flexion of the hips and knees at or beyond 90° increases ICP. To maximize cerebral perfusion and reduce ICP, optimal head positioning for most TBI patients is a 30-45° elevation.

An unrestrained driver involved in a collision has mid-face fractures. Which of the following interventions is CONTRAINDICATED? Nasal packing by a maxillofacial surgeon for hemorrhage control Orotracheal intubation by an anesthesiologist for mechanical ventilation Oropharyngeal airway insertion by a paramedic for airway management Nasogastric feeding tube placement by a nurse for early enteral nutrition

Nasogastric feeding tube placement by a nurse for early enteral nutrition Mid-face fractures are known as LeFort II fractures. Fractures in this region are associated with a break in the ethmoid bone, just behind the nose. The ethmoid bone forms part of the skull base. When they are large, cracks in this area make it possible for foreign bodies to enter the brain. Thus, in the patient with mid-face trauma, NOTHING should be inserted in the nose (NG, nasopharyngeal, feeding, or suction tubes) unless it is placed there by a specialist (e.g., nasal packing), or until the nose has been declared safe by a qualified provider.

A blunt thoracic trauma patient was diagnosed with pulmonary contusions. Ten hours after admission, which of the following findings is the best indicator of deterioration? Negative inspiratory force is 38 cm H2O PaCO2 is 48 mm Hg SpO2 is 97% on 3L O2 via nasal cannula PaO2:FiO2 ratio is 250

PaO2:FiO2 ratio is 250 Pulmonary contusion is a nonspecific term for a bruised lung. Like any bruise, pulmonary contusions can be large or small, but all bruises evolve over time. It is this insidious onset that requires close monitoring. Patients who initially present with adequate respiratory function may deteriorate, just as care providers become complacent about their status. When lung tissue is contused, capillaries are damaged, and alveoli become edematous. Refractory hypoxemia develops. Observe pulmonary contusion patients closely for signs of PROGRESSIVE deterioration in the hours and days following injury. Because pulmonary contusions affect DIFFUSION rather than ventilation (PaCO2), the P:F ratio (PaO2:FiO2) is the appropriate monitoring parameter. When PaO2 is measured in mm Hg, a P:F ratio ?450 = normal; 300-200 = mild ARDS; 200-100 = moderate ARDS; <100 = severe ARDS.

A hemorrhaging patient is admitted to the hospital following injuries sustained in an auto-pedestrian incident. In the first 12 hours after admission, the patient is at greatest risk for which type of acute kidney injury? Pre-renal Post-renal Intra-renal Infra-renal

Pre-renal Pre-renal failure results from "nothing in, nothing out" to the kidneys. In the initial phase of trauma care, volume loss (low preload) is the most common etiology of pre-renal failure (pre = before). However, generalized hypoperfusion will also result in pre-renal failure, as is seen in septic patients and those with poor heart function. In the hours immediately following traumatic injury, hemorrhage is a frequent complication. Intra-renal failure happens when the kidney is not functioning correctly (due to acute or chronic nephron damage), and it typically takes many hours or days to develop. Post-renal failure is a less-common "plumbing problem" that occurs beyond the kidney (post = after) due to traumatic obstruction or disruption of the ureters, bladder, or urethra. Infra-renal failure is not a recognized medical term

A healthy skier sustained an isolated femur fracture. An intramedullary rod was inserted the same day. By hospital Day 3, the patient is hemodynamically normal and is ambulating independently with crutches several times per shift. Today's hemoglobin level is 7.5 g/dL. Which of the following is the most likely intervention? Transfuse 2 units of red blood cells. Administer 1 unit of RBCs and 1 unit of plasma. Reevaluate the patient's hemoglobin level in the morning. Infuse 2 units of plasma and 1 liter of 0.9% saline.

Reevaluate the patient's hemoglobin level in the morning This woman experienced substantial red cell loss (a low hemoglobin level). However, she shows no signs of hypovolemia or hypoxic stress. At this time, the patient is hemodynamically normal, stands without postural hypotension, and is ambulating independently with no shortness of breath or fatigue. No clinical findings suggest this woman needs red cell replacement. Current trauma guidelines for red cell transfusion are: hemoglobin > 9 g/dL, do not transfuse; hemoglobin < 7 g/dL, transfuse. Importantly, the big picture must be considered in each individual's case. Is the patient still losing substantial amounts of blood (e.g., the newly injured patient)? Is she likely to lose blood (e.g., scheduled for major surgery)? Is the woman generally healthy or does she have a significant medical condition (e.g., cardiac or pulmonary disease)? Physicians consider each of these patient-specific characteristics before making a transfusion decision

A hemodynamically unstable, polytrauma patient requires transfer from a Level III to a Level I trauma center. Prior to transport, appropriate imaging studies include spinal magnetic resonance imaging if paralysis is present. a chest radiograph if the patient was endotracheally intubated. 2-view radiographs if there are any obvious extremity fractures. computed tomography with contrast if the abdomen is distended

a chest radiograph if the patient was endotracheally intubated. Imaging studies should never delay the transfer of an injured patient to a trauma center capable of providing definitive care. Only studies necessary to stabilize the patient, and those crucial to decision-making, are indicated prior to transport. Examples include images required to confirm airway placement (is the ET tube in the right place?), secure functional ventilation (is the chest tube in the pleural cavity?), and reduce hemorrhage (is the pelvis unstable and in need of a binder?). Although a polytrauma patient may need a brain CT, a contrast-enhanced abdominal scan, radiographic evaluation of fractures, angiography, or emergent MRI for paralysis evaluation, these imaging studies can be performed at the receiving institution. Early patient transfer is associated with reduced morbidity and mortality.

A patient who was hit with a baseball bat was admitted to the hospital with multiple facial fractures. There is clear fluid draining from her nose. This finding suggests that the patient has an ethmoid bone fracture. a LeFort I fracture. a zygomatic fracture. an orbital blowout fracture

an ethmoid bone fracture Clear or blood-tinged fluid draining from the nose of a trauma patient suggests an ethmoid fracture. The cribriform plate of the ethmoid bone (just behind the nose) is the thinnest point in the entire skull. When fractured, the dura mater is torn, allowing CSF to leak out of the nose through the break (CSF rhinorrhea). Maxillary fractures are common in patients sustaining mid-face trauma. A Le Fort I fracture is a horizontal fracture through the body of the maxilla just below the nose. In the Le Fort I fracture patient, speech is difficult, and pulling on the upper teeth causes the teeth and hard palate to wiggle. The patient with an orbital blowout fracture has visual impairment, periorbital ecchymosis, facial numbness ipsilateral to the injury, and direction of gaze limitations

Which of the following vascular structures is most commonly injured in the patient with blunt thoracic trauma? Mammary artery Jugular vein Subclavian artery Aortic isthmus

aortic isthmus The aortic isthmus is the proximal portion of the descending aorta, the largest vessel in the body. The ligamentum arteriosum (a remanent of fetal circulation) is a fixed point that attaches the heart to the aorta at the isthmus. Prenatally, this structure was the ductus arteriosus, which shunted blood from the right heart to the left, bypassing the unused fetal lungs. This fixed point is susceptible to shearing because it tethers the heart to the aorta. In a rapid deceleration event—such as a high-speed motor vehicle collision or a fall from a significant height—the heart can swing violently forward (in collision #3), ripping the ligament from its attachment point. Massive intrathoracic blood loss occurs if the aorta tears through all three layers. Blunt traumatic aortic injury (BTAI) results in immediate death in 80% of patients and is one of the leading causes of death at the injury scene. The younger the patient, the LOWER the incidence of great vessel injury because mediastinal structures are more elastic and mobile and are thus less likely to tear with deceleration. Patients with BTAI who survive long enough to reach surgical care do so because they have a minor or incomplete disruption. Although any vessel can tear, the subclavian arteries, mammary arteries, and jugular veins are anatomically more mobile than the aorta and are less prone to shearing

The chief goal of providing trickle (a.k.a. trophic) enteral feedings in the early days after trauma is to support the intestinal mucosa and reduce bacterial and toxin translocation. gastrointestinal bleeding. the incidence of C. difficile infection. peptic ulcer formation

bacterial and toxin translocation. Trauma patients will not heal without adequate nutritional support. However, feeding is usually withheld until patients are hemodynamically stable, which should be no more than 48 hours from the time of injury. Most trauma patients will tolerate oral nutrition, but a modified (e.g., soft, clear liquid) diet may be necessary. Even the majority of patients who are endotracheally intubated, unconscious, or bowel-injured will tolerate some form of enteral (oral, gastric, duodenal, or jejunal) tube feeding. Occasionally, total parenteral nutrition is necessary. However, the intestinal villi require ongoing nutrition to maintain a healthy mucosa, and most of their nourishment is derived directly from the gut. Without this nourishment (even small amounts), the villi atrophy, promoting bacterial translocation from the gut into the peritoneal cavity, the blood, and the lymph system. Maintaining a healthy intestinal mucosa is crucial to overall patient well-being and sepsis prevention, which is why the bowel is now recognized as a vital IMMUNE system organ

A race car driver involved in a high-speed collision sustained multiple injuries. In surgery, his heart rate is 134/min, and his BP is 76/60 mm Hg. The most appropriate intervention is to administer an inotropic agent. crystalloid solutions. a vasopressor drug. blood products.

blood products. As initial interventions, hemorrhage control and close ratio blood product replacement (or whole blood) are indicated. Cardiac output (CO) must be adequate to meet tissue perfusion needs. In the early phase of trauma care, hemorrhagic hypovolemia is the most common reason for low cardiac output. A patient's cardiac output is determined by heart rate and stroke volume. Stroke volume is the amount of blood (in milliliters) ejected from the heart with each contraction. Stroke volume is a function of 3 factors: preload, contractility, and afterload. Preload refers to the volume of blood that goes into the heart. Increasing a patient's preload—by infusing blood products, crystalloids, or colloids—is one way to increase cardiac output, but only blood improves oxygen-carrying capacity and enhances clotting. Contractility is improved by relieving mechanical obstructions (e.g., tension pneumothorax, pericardial tamponade) or administering an inotropic drug such as dobutamine or milrinone. Afterload (the resistance the heart pumps against to empty) can be manipulated with vasoconstrictors (to increase CO) and vasodilators (to decrease CO), but only AFTER normovolemia has been restored

Six hours after being hit in the chest by a baseball bat, a patient becomes hypotensive, tachycardic, and has occasional premature ventricular complexes. She denies new or increased chest pain and has no overt signs of bleeding. Her hemoglobin level hasn't changed. This patient's unexplained hypotension is most likely due to a blunt cardiac injury. tension pneumothorax. partial aortic tear. sternal fracture

blunt cardiac injury. These findings are consistent with blunt cardiac injury. This patient sustained a significant blow to the chest, which contused the heart, and all bruises blossom over time. Myocardial contusions cause cardiac irritability (dysrhythmias) and decreased contractility, which can lead to hypotension and compensatory tachycardia. A traumatic aortic tear is associated with intense pain (typically between the shoulder blades) and often profound hypotension as the patient bleeds into the chest or abdominal cavity. A sternal fracture is not unusual in a patient who sustained a severe, blunt cardiac injury but would not be a direct cause of hypotension. Hypotension is a late finding in patients with tension pneumothorax, which first manifests as severe respiratory symptoms (tachypnea and dyspnea

A woman who was kicked by a horse has a large abdominal bruise. No specific organ injuries were identified but she was admitted for observation. Recent blood test results have all been normal. The patient has been eating, ambulating, and anticipating discharge. On the morning of hospital Day 3, she is experiencing nausea, anorexia, and mild, diffuse abdominal pain. Bowel sounds are hypoactive. These findings suggest bowel contusion. delayed splenic bleeding. acute bowel rupture. pancreatic laceration.

bowel contusion Bowel contusions are the mildest form of blunt intestinal trauma. As with any area of bruising, contused bowel progressively worsens after injury before slow resolution begins. Nausea and vomiting can evolve in the post-resuscitation phase of care as bowel contusions blossom, edema forms, and ileus develops. The patient with an acute bowel rupture would be symptomatic well before the 3-day mark. Patients with delayed splenic bleeding present with signs of hemorrhagic loss. A pancreatic trauma patient may experience nausea and vomiting, but epigastric pain is a prominent finding. One other differential to consider in this scenario is narcotic-induced constipation. Examine the patient's recent bowel movement history before excluding this possibility. The combination of narcotics, reduced activity, and feeding patients make constipation a very plausible alternative explanation.

An 81-year-old woman slipped and fell, striking her chin on a coffee table. Several hours after surgical ward admission she complains of burning and weakness in the upper extremities but has no lower extremity deficits. These findings are consistent with central cord syndrome. Brown-Séquard syndrome. anterior cord syndrome. posterior cord syndrome.

central cord syndrome. Spinal cord injuries are categorized as complete (no sensation or function beyond the lesion) or incomplete (some sensation or function is maintained below the lesion). Incomplete injuries are more common, especially in the cervical region. There are 4 incomplete cord syndromes: central cord, anterior cord, Brown-Séquard, and posterior cord. The tracts of the spinal cord are neural fibers grouped like bundles of cable wires. The bundles of fibers that control the UPPER extremities and torso are in the CENTER of the cord, and those that control the LOWER extremities run along the cord's OUTER edge. Damage to the cord's center produces a strange form of paraplegia, in which leg function exceeds that of the arms. Central cord syndrome is the most frequent type of cord injury in older adults, due largely to preexisting conditions such as spinal stenosis

Hemoglobin levels drop in the hemorrhagic shock patient due to compensatory hemodilution. inhibition of antidiuretic hormone release. decreased RBC production in the bone marrow. generalized hemoconcentration.

compensatory hemodilution. Compensatory hemodilution explains dropping hemoglobin levels in patients experiencing hemorrhagic shock. As blood volume decreases due to acute bleeding, several mechanisms are activated to maintain cardiac output. One of the body's vital compensatory responses is shifting fluid from the intracellular and interstitial spaces into the intravascular space to replace lost circulating volume. This hemodilution process occurs over several hours. Therefore, it is possible for trauma patients with uncontrolled bleeding to exsanguinate (bleed to death!) and still have a normal hemoglobin level if they bleed rapidly. SERIAL hemoglobin levels are measured in trauma patients to identify hemodilution that suggests ongoing hemorrhage. Overzealous crystalloid infusion will also dilute the blood, reducing (watering down) the hemoglobin. Generalized hemoconcentration does not occur in hemorrhagic shock. A patient with normal bone marrow function will INCREASE red cell production when anemic. Antidiuretic hormone release increases in shock states, thus enhancing renal water reabsorption, which boosts circulating blood volume

12 hours after falling from a bicycle, a patient complains of headache, nausea, and dizziness when standing and he doesn't remember the fall. His brain computed tomography scan is normal. Which brain injury do these findings suggest? Diffuse axonal injury Traumatic stroke Concussion Subdural hematoma

concussion Traumatic brain injuries (TBIs) can be classified by severity, according to Glasgow Coma Scale scores: GCS > 13 = mild, 9-12 = moderate, < 8 = severe. TBIs are also classified by their general type: DIFFUSE (a.k.a. global or generalized) or FOCAL (a.k.a. local). Diffuse injuries DIRECTLY affect consciousness; local injuries INDIRECTLY affect consciousness. Focal injuries (fractures and bleeds) are readily apparent on CT shortly after injury; diffuse injuries (concussion and diffuse axonal injuries) are not. Mild TBI is also referred to as mTBI, concussion, mild brain injury, and minor head trauma. Mild TBI findings fall into three categories: 1) Somatic symptoms (headache, nausea, vomiting, blurred vision, and fatigue), 2) Cognitive symptoms (confusion, impaired judgment, and poor problem-solving), and 3) Emotional symptoms (depression, irritability, sleep disturbances, anxiety). Emotional symptoms may not be apparent for days or weeks after injury.

A woman pinned between two car bumpers has compartment syndrome in both lower legs. This patient requires close monitoring for signs of rhabdomyolysis, including diminished urine output and hypokalemia. dilute urine and an elevated creatine kinase level. increasing urine output and myoglobinemia. dark-colored urine and dropping urine output

dark-colored urine and dropping urine output When skeletal muscle is destroyed, cellular contents leak into the serum. This syndrome is known as rhabdomyolysis. Muscle cells can be directly destroyed by trauma (crushing, tearing, burning, freezing, pounding, or dissolving) or indirectly injured as a result of tissue ischemia (of any etiology), as occurs in patients with compartment syndrome. Important substances released into the serum from damaged muscle cells include potassium, creatine kinase (CK), and myoglobin. CK has no harmful effects but is the best clinical marker of the extent of tissue destruction. Myoglobin is nephrotoxic, particularly in a patient who is acidotic and oliguric. Bedside care providers can detect rhabdomyolysis—and minimize kidney injury—in patients with a high-risk history by closely monitoring for dark-colored urine, dropping output, hyperkalemia, and elevated serum CK levels

A patient with multiple bilateral rib fractures and a pulmonary contusion is wearing a 40% FiO2 mask and has a PaO2 of 146 mm Hg. This finding indicates a problem at what point on the tissue oxygenation cascade? Cardiac ouput Ventilation Diffusion Hemoglobin availability

diffusion FiO2 × 5 = expected PaO2 (in mm Hg) at sea level in a healthy young adult. For example, if a patient is breathing room air (21% oxygen), then 21 × 5 = 105 mm Hg. Expected PaO2 would be somewhere around this number, although PaO2 decreases in old age and at altitude. Thus, if a chest trauma patient is on 40% oxygen, the expected PaO2 would be about 200 mm Hg (40 × 5 = 200). However, in this example, the patient's PaO2 is only 146 mm Hg. This number is more than adequate—you don't NEED a higher PaO2—but it SHOULD BE 200 mm Hg. This information tells us that a substantial amount of oxygen is getting into the lungs (40%) but not reaching the blood. Therefore, the patient has a DIFFUSION problem rather than a ventilation issue. We need to identify the underlying etiology and appropriately address the problem

Four days after admission, a multiply-injured patient's condition deteriorates. His vital signs are: BP 91/46; HR 139/min; RR 24/min. Urine output is 15 mL/hr, and he's cool and mottled. The pulse oximeter is only sensing intermittently. These findings are consistent with an anaphylactic reaction. neurogenic shock. hemorrhagic hypovolemia. early sepsis

early sepsis Although trauma patients can develop sepsis at any time during their hospital stay, symptom onset is unusual in the first couple of days. Patients begin to exhibit sepsis findings as infection and inflammation progress, usually not before hospital Day 3-4. This patient has a low mean pressure (MAP = SBP + DBP + DBP/3 = 61 mm Hg), a shock index of 1.52 (HR/SBP), which is well above the adult norm of 0.5-0.7, a wide pulse pressure (91 - 46 = 45 mm Hg), and an elevated respiratory rate (24/min). These vital sign findings are all consistent with septic shock, as are low urine output and poor distal perfusion (cool mottled skin and poor pulse oximeter sensing). The patient with hemorrhagic hypovolemic shock would have the same findings EXCEPT pulse pressure is narrow. The patient in neurogenic shock loses sympathetic stimulation below the level of injury. Therefore, neurogenic shock patients are not tachycardic, their pulse pressure is wide, urine production is adequate, and their skin is warm and dry. The anaphylactic patient is tachycardic, hypotensive, and has a wide pulse pressure, but also has signs of an allergic reaction, such as hives, edema, and airway compromise

In the trauma patient population, the most frequent injury mechanism for all age groups is auto-pedestrian incidents. fire and burn injuries. falls. motor vehicle crashes

falls. Falls are by far the most frequent mechanism of injury that leads to injury. In the US alone, there are 43,000 fatal falls each year, 85% of these occuring in patients over the age of 65

Oxygen content (CaO2) = SpO2 × Hgb × 1.36. Of the three numbers in this formula, which one has the greatest influence on the amount of oxygen in a patient's blood? hemoglobin level 1.36 (a mathematical constant) PaO2 measurement oxygen saturation

hemoglobin level

In adults, the body's responses to shock include vasoconstriction, histamine release, and bradycardia. fluid shifts, hypotension, and decreased antidiuretic hormone. hypotension, hypoglycemia, and diuresis. hyperglycemia, vasoconstriction, and tachycardia

hyperglycemia, vasoconstriction, and tachycardia The liver stores glucose as glycogen. In times of physiological stress and anaerobic metabolism, the body burns through glucose at a much higher than normal rate. Adults initially become HYPERglycemic as the liver responds to the increased glucose demand. However, because infants and toddlers have limited glycogen stores, small children can quickly deplete their supply and become HYPOglycemic. Vasoconstriction and tachycardia are signs of sympathetic nervous system compensation, that "fight or flight" response that kicks in rapidly in times of fear or physiological compromise. Massive histamine release is characteristic of anaphylaxis, bradycardia is a component of neurogenic shock, and significant interstitial fluid shifts occur in septic and anaphylactic patients

A penetrating trauma patient is admitted to the critical care unit immediately following damage control surgery. She has received 8 units of red blood cells and 6 units of FFP. A priority nursing intervention is to prevent hypercalcemia. alkalosis. hemodilution. hypothermia

hypothermia Massive transfusion involves the rapid infusion of blood components. Except in rare cases of warm, fresh, whole blood use (e.g., in special military circumstances), whole blood, red blood cells, and plasma must be refrigerated at just 2-6 degrees (Celsius) above freezing. The extreme temperature difference between banked blood and blood in the body can quickly drop body temperature. Hypothermia is especially a problem in severely injured patients in whom the "trauma triad of death"—acidosis, hypothermia, and coagulopathy—is already an issue. Bedside care providers must aggressively prevent or reverse hypothermia by warming blood products before infusion and employing other patient warming strategies. Hemodilution is a problem in patients who have received large volumes of intravenous crystalloid solutions. Acidosis rather than alkalosis is a common problem in those requiring massive transfusion. And HYPOcalcemia, not hypercalcemia, can result from the citrate anticoagulant necessary for red cell storage

Four hours after emergent surgery for traumatic bowel perforation, a patient is alert and oriented, skin is warm and dry, and urinary output is 100 mL of concentrated urine. Vital signs are: BP 100/78 mm Hg; HR 102/min; RR 20/min; T 37.4° C (99.3° F). The patient is most likely in septic shock; notify the medical team for antibiotics. stable; continue monitoring vital signs. hypovolemic; contact the patient's medical team. experiencing pain; consider increasing analgesic dosing.

hypovolemic; contact the patient's medical team. Although each of these clinical findings falls short of the definition of shock, they are all a little concerning. The patient is making urine, but it is concentrated, and the output volume is low. Pulse pressure (SBP - DBP) is narrow (only 22 mm Hg, normal 30-40), indicating vasoconstrictive compensation for low cardiac output. Though not by much, this patient's heart rate exceeds his systolic pressure (therefore, shock index is > 1), which is backward! And both temperature and respiratory rate are on the high side of normal. Individually, these findings might not be alarming. But when viewed collectively, they suggest hypovolemia and are red flags indicating the patient is on the verge of decompensation. Importantly, examine the TRENDS over time. If the trends are in a negative direction, we need to respond NOW to prevent further decline

A patient is admitted for multiple rib fractures related to a fall. Three days after hospital admission, the patient is pulling low volumes on his incentive spirometer. The optimal course of action is to continue with the current plan of care. increase progressive mobilization. reduce spirometer use to every 4 hr. discontinue analgesic agents.

increase progressive mobilization. Mobility is a crucial aspect of all trauma patient's recovery. Anything that the trauma nurse can do to facilitate progressively increased mobility is important. Early ambulation can reduce hospital-acquired infections like pneumonia and reduces ventilator days, VTE, and length of stay

A patient fell and was impaled by a pitchfork. Three days after admission, he is at greatest risk for which common complication? Paresthesia Paralysis Infection Hemorrhage

infection Because they are usually caused by dirty objects such as nails, tree branches, fence posts, metal reinforcing bars, fish hooks, etc., impalement injuries are often grossly contaminated. These wounds are highly susceptible to infection from introduced microorganisms and retained foreign bodies, which may have been deeply embedded in the tissues. Paresthesia and paralysis can be the result of nerve damage caused by impalement, but these findings would not be delayed. Major hemorrhage is not typically associated with impalement injuries because their low velocity tends to push vessels and vital organs aside. Moreover, any significant bleeding would likely occur at the time of injury rather than days after admission

The goals of damage control surgery in the trauma patient include each of the following EXCEPT restoration of normal physiology. active hemorrhage control. early blood product transfusion. repair of all traumatic injuries

repair of all traumatic injuries Damage control surgery is indicated for patients with life- or limb-threatening thoracic, abdominal, pelvic, or orthopedic trauma. The primary goal is to restore normal physiology, NOT normal anatomy. Damage control surgery usually involves early blood product transfusion. Surgeons strive to get in, halt the hemorrhage, reperfused ischemic tissues, control any intestinal content leaks, and get out. Only lifesaving interventions should be performed on cold, acidotic, coagulopathic individuals. Once the patient is hemodynamically and metabolically stable, definitive surgical repairs of all appropriate injuries can be performed, often within less than 24 hours.

Yesterday, an 82-year-old woman fell, striking her chest on a chair. She was admitted to the hospital for monitoring. A chest radiograph shows no significant findings. Breathing is shallow and painful but unlabored. This patient has most likely sustained a sternal fracture. simple rib fracture. flail chest. simple pneumothorax

simple rib fracture. Simple rib fracture is a term used to refer to a cracked rib or non-displaced fracture. Because they are non-displaced, these injuries are difficult to visualize on routine chest radiographs when fresh, making them commonly missed injuries. Some studies suggest up to half of all rib fractures are not detected on standard chest radiographs at the time of admission. In addition to the thoracic bones, cartilage in the chest can be disrupted (separated from adjacent bone), resulting in injuries that are clinically very similar to, and just as significant as, some bony fractures. Unfortunately, cartilage injuries (e.g., costochondral separations) are frequently missed because they are not readily noted on radiographs. With healing, fractures become visible as bony scar tissue (known as a callus) is formed. The sternum is a strong bone that requires significant force to fracture. A simple pneumothorax would be identified on an upright chest X-ray. A flail chest (a.k.a. unstable chest wall) involves two or more adjacent ribs fractured in two or more places. A flail chest is readily imaged and produces significant respiratory distress

the following rhythm strip is noted on the monitor of a traumatically injured patient. which of the following injuries does the patient most likely have? sternal fracture diaphragmatic rupture pericardial tamponade cervical spinal injury

sternal fracture ST elevation! due to cardiac injury

A newly admitted patient was dragged by a horse. She has multiple abrasions and small areas of dermal avulsion. Which of these is the most appropriate wound-cleaning solution for this woman? povidone iodine. hydrogen peroxide. tap water. chlorhexidine.

tap water. Over the years, healthcare providers have used many substances to clean wounds. Most kill bacteria, but they're all harmful to the tissues. Toxic wound cleansers kill off or impede new cell growth, thus giving bacteria more to feed on. Today's general approach to wound care is: if you wouldn't put it in your eye (betadine, bleach, hydrogen peroxide, chlorhexidine, etc.), don't put it in a patient's wound. This leaves a relatively short list of options. Use a non-toxic, isotonic solution such as tap water, normal saline, or a commercial wound-cleaning product. But don't confuse wound cleansers with skin cleansers. They are two different things. Skin cleansers are designed for use solely on intact skin. However, a sutured, stapled, or glued wound is considered "intact" within 12-24 hours of closure

A trauma center's designation level indicates the clinical resources available to care for trauma patients. the staff members' commitment to the care of injured patients. compliance with Joint Commission standards. an organization's bed and operating room capacity.

the clinical resources available to care for trauma patients. A trauma center's designation level indicates the extent of clinical resources available to care for trauma patients; it is NOT a measure of competence or dedication to the care of injured patients. Each trauma center level plays a vital role in the chain of patient survival. The resources a trauma center must have to provide optimal care extend well beyond its facilities, such as bed count, CT scanners, and operating room capacity. Other vital resources include essential personnel, staffing levels, training, protocols, supplies, equipment, and a robust quality improvement process. In the United States, governmental agencies (states, regions, counties) and the American College of Surgeons (ACS) establish standards for trauma care independent of The Joint Commission.

effective ventilator management of a patient with ARDS involves lowering which of the following ventilator settings below normal? fio2 PEEP tidal volume respiratory rate

tidal volumes PEEP will be elevated at whatever the patient will tolerate, sometimes 15-20

why does proning benefit a patient with ARDS?

when youre laying on your back, your heart puts some pressure on your left lung, which can affect inflation also helps oxygenate areas of the lung that are not fibrotic