AEMT Chapter 39
You are caring for a patient who you suspect has severe peritonitis. If this field impression is correct, what type of organ has likely perforated, causing the problem? A. vascular B. hollow C. solid D. retroperitoneal
B. hollow Hollow organs are not as vascular as solid organs. Therefore, they do not produce as much risk of internal bleeding when injured. However, they do contain digestive enzymes and waste that can cause inflammation and infection of the peritoneum called peritonitis. When acidic digestive enzymes are released into the peritoneal cavity, it typically results in immediate pain.
What is the large solid organ located primarily in the upper right quadrant of the abdominal cavity? A. spleen B. liver C. ascending colon D. right kidney
B. liver The liver is the solid organ that is located primarily in the upper right quadrant of the abdomen. The spleen is in the upper left quadrant, and the right kidney is a lower situated, retroperitoneal structure. The ascending colon is partly in the upper right quadrant, but it is a hollow organ.
Which of the following injuries that occurs to the abdomen would most likely create a life-threatening intra-abdominal bleed? A. stomach laceration B. liver fracture C. tear to the jejunum D. rupture of the urinary bladder
B. liver fracture The liver is a solid organ that receives a large amount of cardiac output, owing to its vascularity. When it is injured (the term used for a damaged liver is "fractured"), it can bleed profusely into the fascia capsule that encases it. If that capsule ruptures, the bleeding can occur freely into the abdominal cavity. Hollow organs however, do not bleed to the same extent as solid organs do; therefore, injuries to hollow organs are not as life threatening.
The patient you are caring for is complaining of intense abdominal pain. During your physical assessment, you start to palpate the abdomen but notice that every time you do so, the patient tenses up his abdominal muscles. This is known as: A. active abdominal spasms. B. voluntary guarding. C. autonomic muscle guarding. D. purposeful contraction.
B. voluntary guarding. When a tender area of the abdomen is being palpated, the abdomen may tense up in anticipation of palpation. This is called voluntary guarding and is a natural response to reduce pain associated with palpation.
Why would a patient with significant intra-abdominal injury and a suspected intra-abdominal bleed, who is found unresponsive and hypotensive, most likely have an airway occlusion? A. The hypoperfusion from the blood loss can cause brainstem failure, causing the patient to be unable to manage her own airway B. As the patient becomes unresponsive, the weight of the abdominal cavity pushes up on the diaphragm and causes the airway to close off. C. Many times, abdominal trauma co-occurs with neck trauma that can occlude the airway. D. Because the patient is supine and probably on a backboard, the neck muscles relax and occlude the airway.
A. The hypoperfusion from the blood loss can cause brainstem failure, causing the patient to be unable to manage her own airway During a hypoperfusive state, the brainstem does not receive adequate blood flow and, as a result, is unable to provide appropriate neural stimulation to the muscles of the airway to keep it patent.
An injury to the abdomen that results in an overlying contusion, abdominal pain, and guarding but no open soft-tissue trauma would most likely be from what mechanism? A. getting hit in the abdomen by a baseball bat B. puncture wound from a knife C. injury with external bleeding from an explosion D. primary blast injury
A. getting hit in the abdomen by a baseball bat Blunt trauma is the type of mechanism by which energy is transmitted to the abdomen by an object that strikes the abdomen (in this instance, the bat). The internal structures of the body can become damaged, resulting in pain and guarding. However, there is no open soft-tissue injury from blunt trauma mechanisms.
A patient with Kehr's sign would display what finding? A. pain in the left shoulder B. premature contraction of the ventricles C. difficulty in swallowing D. RLQ pain on palpation
A. pain in the left shoulder Kehr's sign is referred pain to the left shoulder caused by diaphragmatic irritation, which is caused by the presence of blood and may indicate splenic injury.
What is the superior border of the abdominal cavity? A. inferior mesenteric fold B. diaphragm C. rectus abdominus muscle D. parietal peritoneum
B. diaphragm The upper border of the abdominal cavity is the diaphragm. The anterior and lateral borders are the abdominal musculature, and the inferior border is the pelvis.
During your reassessment of the patient with abdominal trauma, you note that the patient's pulse pressure is continuing to narrow, even though his systolic pressure is still >90 mmHg. The heart rate has gone from 112/min initially to 124/min currently. What does this reassessment information tell you? A. The patient should have been flown from the scene by an aeromedical service. B. The patient is remaining clinically stable. C. The patient is continuing to deteriorate. D. The patient is improving with treatment.
C. The patient is continuing to deteriorate The narrowing of the pulse pressure and the elevating heart rate are both indicative of ongoing shock syndrome. The patient should receive ongoing management for the injuries and expedient transport to the hospital. If the patient was previously categorized as stable, this new information should be considered as demonstrating instability.
What should you suspect if a patient is complaining of pain to the left shoulder even though is traumatic injury occurred to the anterior abdominal wall? A. A fractured scapula is also likely present. B. It results from referred pain due to liver injury. C. The patient may have a splenic injury. D. It is referred pain from an anterior clavicular injury.
C. The patient may have a splenic injury. Kehr's sign is referred pain to the left shoulder caused by diaphragmatic irritation, which is caused by the presence of blood and may indicate splenic injury. You need to maintain a high index of suspicion for abdominal injuries whenever there is atypical presentation.
A patient is found unresponsive in an alley and is suspected to be the victim of a robbery. The patient is found unresponsive and hypotensive. The only outward sign of injury is a puncture to the abdomen near the umbilicus, and the abdomen is markedly distended. Given this information, what would be the most likely mechanism of injury? A. disruption of the spinal cord from a traumatic fall B. blunt trauma to the abdomen from getting punched C. penetration from a knife wound D. brain injury from a skull fracture
C. penetration from a knife wound Penetration injuries to the abdomen are a common mechanism that results in vascular structure damage. This would result in an obvious soft-tissue injury on the abdominal wall (the knife wound), and with the heavy bleeding that would accompany the injured vascular structure, the abdomen would become distended.
You arrive on scene to a female patient who is in cardiac arrest secondary to a MVC. The patient is seemingly uninjured except for a large abdominal contusion and significant abdominal distention. If the patient went into arrest due to an intra-abdominal bleed and severe hemorrhage, what organ was most likely damaged? A. duodenum B. transverse colon C. spleen D. uterus
C. spleen The spleen is a solid organ that is highly vascular and, if damaged due to trauma, can bleed significantly into the abdominal cavity, causing abdominal distention. The blood loss can be severe enough to cause the patient to go into cardiac arrest. The other organs listed are hollow and do not characteristically bleed significantly with damage.
You are managing a patient with a suspected abdominal injury. The patient is found unresponsive with rapid breathing, tachycardia, and hypotension. Capillary refill is delayed, the pulse ox is diminishing, and you see a large contusion to the upper and lower left quadrants of the abdomen. What type of injury has most likely occurred? A. solid organ damage B. hollow organ damage C. vascular organ damage D. skeletal structure damage
C. vascular organ damage There are essentially three types of abdominal organs: solid organs such as the liver, spleen, pancreas, and kidneys; hollow organs such as the GI structures; and vascular organs such as the descending aorta and inferior vena cava. Of these, injury to the vascular organs would result in the most severe hemorrhage.
You are managing a patient who has a grossly distended abdomen following a MVC in which he was ejected from a car. Given the mechanism of injury and the concurrent findings, you believe that the patient is suffering from a significant intra-abdominal bleed. During your management, you are attempting to ventilate the patient with a BVM, but you notice that there is poor lung compliance with each delivered breath. Why would a large bleed into the abdomen make it more difficult to ventilate the patient? A. The blood that you think is going into the abdominal compartment is actually going into the thoracic compartment. B. Bleeding in the abdomen causes hypotension, which causes the brainstem to fail, resulting in poor lung compliance. C. It is normal for a hemorrhage into the abdomen to leak into the thoracic cavity, causing a hemothorax. D. A large amount of blood in the free abdomen makes it harder for the diaphragm to drop lower during ventilations.
D. A large amount of blood in the free abdomen makes it harder for the diaphragm to drop lower during ventilations. During breathing, the diaphragm has to descend lower into the abdominal cavity to allow space for lung inflation. However, if the abdominal cavity is distended with blood, it will be harder for the diaphragm to displace itself into the abdominal cavity, thereby making it harder to ventilate the lungs.
A patient with blunt abdominal trauma presents as hypotensive and tachycardic and responds only to pain. You notice that the patient has an extremely distended abdomen that is firm to palpation. Given these findings, which of the following is most correct? A. The patient has early indications of abdominal trauma. B. The patient will also display Kehr's sign from the abdominal trauma. C. The hypotension and tachycardia are not related to the distended abdomen. D. He has likely lost more than 1.5 liters of blood in the abdomen.
D. He has likely lost more than 1.5 liters of blood in the abdomen. The abdominal cavity can hold 1.5 or more liters of blood before distention occurs. Therefore, distention is a late sign of hemorrhagic abdominal injury. Loss of this much blood can easily cause the patient's orientation to diminish, blood pressure to drop, and heart rate to increase. However, patients can also have very significant intra-abdominal injury without the presence of distention.
A 17-year-old boy was stabbed once in the abdomen in an altercation. He presents with several loops of bowel protruding from a 4-inch laceration of the abdomen, just below the umbilicus. Bleeding is minimal, but the patient is very distraught. He is alert and oriented, but gaining cooperation is difficult because of his emotional state. His skin is warm and moist. Vital signs: HR 92, BP 118/84, RR 20, SpO2 100% on room air. What treatment plan is best for this patient? A. complete a rapid trauma exam, cover the eviscerated organs with a sterile dressing wetted with normal saline, cover the wet dressing with an occlusive dressing, position the patient in a position of comfort, transport, start two large-bore IVs and rapidly infuse isotonic crystalloids B. complete a rapid trauma exam and a detailed head-to-toe exam, cover the eviscerated organs with an occlusive dressing that is sealed on three sides, position the patient in a position of comfort, start two large-bore IVs at a keep-open rate, transport C. immediately cover the open wound with an occlusive dressing, perform a detailed head-to-toe examination, immobilize the patient to a long-backboard, transport D. complete a rapid trauma exam, cover the eviscerated organs with a sterile dressing wetted with normal saline, cover the wet dressing with an occlusive dressing, position the patient in a position of comfort, transport, start two large-bore IVs at a keep-open rate
D. complete a rapid trauma exam, cover the eviscerated organs with a sterile dressing wetted with normal saline, cover the wet dressing with an occlusive dressing, position the patient in a position of comfort, transport, start two large-bore IVs at a keep-open rate Even though the patient's vital signs are normal, he has a significant mechanism of injury (penetrating trauma to the torso). He requires a rapid trauma assessment and basic stabilization on the scene, transport without undue delay, and further assessment and management en route to the emergency department. Penetrating injury to the torso carries a high risk of hemorrhage, so the patient should have two IVs in place, although fluid infusion is not warranted at this point. The mechanism of injury is not consistent with the potential for spinal cord injury, and spinal immobilization is not necessary. Therefore, the patient should be transported in a position of comfort, which is most likely to be supine with the hips and knees flexed. The specific management of evisceration is to use a wet, sterile dressing to prevent the exposed organs from drying out and protect them from contamination; and to cover the wet dressing with an occlusive dressing to prevent the wet dressing from drying out, prevent contamination of the wet dressing, and to help maintain the temperature of the exposed organs.
A 52-year-old man was the restrained driver of a midsized sedan that struck a bridge abutment at about 55 miles per hour. He is alert and anxious, with cool, dry, slightly pale skin. His chief complaints are pain across his sternum and abdominal pain. Your examination reveals minor abrasions to the face that are consistent with front airbag deployment, a developing contusion from the left shoulder to the right upper abdomen, consistent with his shoulder harness, and a developing contusion across the abdomen, just below the umbilicus, consistent with wearing the lap belt incorrectly. The patient states that he has pain with inspiration. You find no deformity or instability of the chest wall or sternum, and breath sounds are clear. The abdomen is diffusely tender to palpation with voluntary guarding. Vital signs: HR 92, BP 132/90, RR 24, SpO2 93% on room air. The best way to prioritize management of this patient is: A. oxygen by nasal cannula, spinal immobilization, transport, two large-bore IVs at a keep open rate, nitrous oxide by self-administration B. oxygen by nonrebreather mask, transport the patient in a position of comfort, start two large-bore IVs and rapidly infuse isotonic crystalloid fluids C. transport in a position of comfort, start an IV en route as a precautionary measure D. oxygen by nasal cannula, spinal immobilization, transport, two large-bore IVs at a keep-open rate
D. oxygen by nasal cannula, spinal immobilization, transport, two large-bore IVs at a keep-open rate The patient has a critical mechanism of injury (impact at 55 mph) with evidence of chest and abdominal injury. The mechanism is significant for not only cervical spine injury, but lumbar spine injury as well (the misplaced lap belt can result in forcing the lumbar spine beyond its range of motion). Spinal immobilization is necessary. The vital signs are currently normal, except for a slightly low SpO2 of 93%, but the potential for deterioration must be taken seriously, given the mechanism of injury and evidence of chest and abdominal injury. You should treat the mild hypoxia with oxygen by NRB mask, immobilize, and begin transport to minimize scene time. Start two large-bore IVs en route to the emergency department, but the patient's perfusion status does not currently call for aggressive fluid resuscitation. Nitrous oxide is contraindicated in patients who may have injuries to the bowel or potential for pneumothorax.
On which patient should the Advanced EMT plan to complete a reassessment every 5 minutes during transport to the hospital? A. responsive male with an open fracture to his left forearm B. responsive female with tachycardia, normotension, and adequate respirations C. unresponsive male found pinned beneath a car, with an open skull fracture with brain matter showing, a distended abdomen, and currently no pulse or breathing. D. unresponsive female with a distended abdomen after a MVC
D. unresponsive female with a distended abdomen after a MVC An unresponsive patient with a distended abdomen has likely been bleeding into the abdominal cavity, which results in distention. Also, the drop in blood pressure will cause a diminishment in the cerebral perfusion pressure, contributing to the disorientation or unresponsiveness.
