ATLS TEST REVIEW ALL QUESTIONS AND ANSWERS

1. A 22-year-old man is hypotensive and tachycardic after a shotgun wound to the left shoulder. His blood pressure is initially 80/40 mm Hg. After initial fluid resuscitation his blood pressure increases to 122/84mm Hg. His heart rate is now 100 beats per minute and his respiratory rate is 28 breaths per minute. A tube thoracostomy is performed for decreased left chest breath sounds with the return of a small amount of blood and no air leak. After chest tube insertion, the most appropriate next step is: re-examine the chest 2. A construction worker falls two stories from a build- ing and sustains bilateral calcaneal fractures. In the emergency department, he is alert, vital signs are normal, and he is complaining of severe pain in both heels and his lower back. Lower extremity pulses are strong and there is no other deformity. The suspected diagnosis is most likely to be confirmed by: complete spine X-ray series 3. What is true regarding the initial resuscitation of a Evidence of im- trauma patient? proved perfusion after fluid re- suscitation could include improve- ment in Glasgow Coma Scale score on reevaluation 4. In managing a patient with a severe traumatic brain injury, the most important initial step is to: 5. A previously healthy, 70-kg (154-pound) man suffers an estimated acute blood loss of 2 liters. What applies to this patient? 6. secure the airway An ABG would demonstrate a base deficit be-tween -6 and -10 mEq/L. increasing the vol-ume of blood los The physiological hypervolemia of pregnancy has to produce mater- clinical significance in the management of the severe- nal hypotension. ly injured, gravid woman by: 7. The best assessment of fluid resuscitation of the urinary output of adult burn patient is: 0.5 mL/kg/hr 8. The diagnosis of shock must include: evidence of inade- quate organ perfu- sion 9. A 7-year-old boy is brought to the emergency de- direct pressure on partment by his parents several minutes after he fell the wound through a window. He is bleeding profusely from a 6-cm wound of his medial right thigh. Immediate man- agement of the wound should consist of: 10. For the patient with severe traumatic brain injury, cerebral vasocon- profound hypocarbia should be avoided to prevent: striction with di- minished perfu- sion 11. After being involved in a motor vehicle crash, a 25-year-old man is brought to a hospital that has surgery capabilities available.. Computed tomogra-phy of the chest and abdomen shows an aortic injury and splenic laceration with free abdominal fluid. His blood pressure falls to 70 mm Hg after CT. The next step is: 12. What statements regarding abdominal trauma in the pregnant patient is TRUE? perform an ex-ploratory laparoto-my Leakage of amni-otic fluid is an indi-cation for hospital admission. 13. The first maneuver to improve oxygenation after administer supple- chest injury is: mental oxygen 14. A 25-year-old man, injured in a motor vehicular crash, 9 is admitted to the emergency department. His pupils 2/67 react sluggishly and his eyes open to pressure. He does not follow commands, but he does moan pe-riodically. His right arm is deformed and does not respond to pressure; however, his left hand reaches purposefully toward the stimulus. Both legs are stiffly extended. His GCS score is: 15. A 20-year-old woman who is at 32 weeks gestation, is stabbed in the upper right chest. In the emergency department, her blood pressure is 80/60 mm Hg. She is gasping for breath, extremely anxious, and yelling for help. Breath sounds are diminished in the right chest. The most appropriate first step is to: 16. What findings in an adult is most likely to require immediate management during the primary survey? 17. The most important, immediate step in the manage-ment of an open pneumothorax is: 18. The following are contraindications for tetanus toxoid administration: 19. A 56-year-old man is thrown violently against the steering wheel of his truck during a motor vehicle crash. On arrival in the emergency department he is diaphoretic and complaining of chest pain. His blood pressure is 60/40 mm Hg and his respiratory rate is 40 breaths per minute. What best differentiates cardiac tamponade from tension pneumothorax as the cause of his hypotension? 20. Bronchial intubation of the right or left mainstem bronchus can easily occur during infant endotracheal intubation because: perform needle or finger decompres-sion of the right chest respiratory rate of 40 breaths per minute placement of an occlusive dressing over the wound history of neuro-logical reaction or severe hypersen-sitivity to the prod-uct breath sounds The trachea is rel-atively short. 3/67 21. A 23-year-old man sustains 4 stab wounds to the upper right chest during an altercation and is brought by ambulance to a hospital that has full surgical ca- urgently transfer the patient to the operating room pabilities. His wounds are all above the nipple. He is endotracheally intubated, closed tube thoracostomy is performed, fluid resuscitation is initiated through 2 large-caliber IVs. FAST exam does not reveal intraab-dominal injuries. His blood pressure now is 60/0 mm Hg, heart rate is 160 beats per minute, and respiratory rate is 14 breaths per minute (ventilated with 100% O2). 1500 mL of blood has drained from the right chest. The most appropriate next step in managing this patient is to: 22. A 39-year-old man is admitted to the emergency de- partment after an automobile collision. He is cyanotic, has insufficient respiratory effort, and has a GCS score of 6. His full beard makes it difficult to fit the oxygen facemask to his face. The most appropriate next step is to: restrict cervical motion and attempt orotracheal intubation using 2 people 23. A patient is brought to the emergency department af- Flaccidity of the ter a motor vehicle crash. He is conscious and there is lower extremities no obvious external trauma. He arrives at the hospital and loss of deep completely immobilized on a long spine board. His tendon reflexes blood pressure is 60/40 mm Hg and his heart rate is are expected. 70 beats per minute. His skin is warm. What do you expect to see with the patient? 24. What is the most effective method for initially treating frostbite? Moist heat 25. A 32-year-old man's right leg is trapped beneath his overturned car for nearly 2 hours before he is extricated. On arrival in the emergency department, his right lower extremity is cool, mottled, insensate, and motionless. Despite normal vital signs, pulses cannot be palpated below the right femoral artery and the muscles of the lower extremity are firm and hard. 4/67 During the management of this patient, what is most likely to improve the chances for limb salvage? surgical consultation for right lower extremity fasciotomy 26. A patient arrives in the emergency department after being beaten about the head and face with a wooden club. He is comatose and has a palpable depressed skull fracture. His face is swollen and ecchymotic. He has gurgling respirations and vomitus on his face and clothing. The most appropriate step after provid-ing supplemental oxygen and elevating his jaw is to: 27. A 22-year-old man sustains a gunshot wound to the left chest and is transported to a small community hospital no surgical capabilities are available. In the emergency department, a chest tube is inserted and 700 mL of blood is evacuated. The trauma center ac-cepts the patient in transfer. Just before the patient is placed in the ambulance for transfer, his blood pressure decreases to 80/68 mm Hg and his heart rate increases to 136 beats per minute. The next step should be to: suction the oropharynx repeat the prima-ry survey and pro-ceed with transfer 28. A 64-year-old man involved in a high-speed car crash, is resuscitated initially in a small hospital without surgical capabilities. He has a closed head injury with -a GCS score of 13. He has a widened mediastinum on chest x-ray with fractures of left ribs 2 through 4, but no pneumothorax. After initiating fluid resuscitation, his blood pressure is 110/74 mm Hg, heart rate is 100 beats per minute, and respiratory rate is 18 breaths per minute. He has gross hematuria and a pelvic fracture. You decide to transfer this patient to a facility capable of providing a higher level of care. The facility is 128 km (80 miles) away. Before transfer, you should first: call the receiving hospital and speak to the surgeon on call 29. Hemorrhage of 20% of the patient's blood volume is tachycardia associated usually with 30. 5/67 What statement concerning intraosseous infusion is TRUE? 31. A young woman sustains a severe head injury as the result of a motor vehicle crash. In the emergency de-partment, her GCS is 6. Her blood pressure is 140/90 mm Hg and her heart rate is 80 beats per minute. She is intubated and mechanically ventilated. Her pupils are 3 mm in size and equally reactive to light. There is no other apparent injury. The most important prin-ciple to follow in the early management of her head injury is to 32. A 33-year-old woman is involved in a head-on motor vehicle crash. It took 30 minutes to extricate her from the car. Upon arrival in the emergency department, her heart rate is 120 beats per minute, BP is 90/70 mm Hg, respiratory rate is 16 breaths per minute, and her GCS score is 15. Examination reveals bilaterally equal breath sounds, anterior chest wall ecchymosis, and distended neck veins. Her abdomen is flat, soft, and not tender. Her pelvis is stable. Palpable distal pulses are found in all 4 extremities. Of the following, the most likely diagnosis is: 33. A hemodynamically normal 10-year-old girl is hospi-talized for observation after a Grade III (moderately severe) splenic injury has been confirmed by com-puted tomography (CT). What mandates prompt ce-liotomy (laparotomy)? 34. A 40-year-old woman who was a restrained driver in a motor vehicle crash is evaluated in the emergency de-partment. She is hemodynamically normal and found to be paraplegic at the level of T10. What precaution should be taken during evaluation and management? Aspiration of bone marrow confirms appropriate posi-tioning of the nee-dle. avoid hypotension cardiac tampon-ade development of peritonitis on physical exam Log rolling using 4 people is a safe approach to re-strict spinal mo-tion when moving her. 6/67 35. A trauma patient presents to your emergency depart- ment with inspiratory stridor and a suspected c-spine injury. Oxygen saturation is 88% on high-flow oxygen via a nonrebreathing mask. The most appropriate next step is to: restrict cervical motion and establish a definitive air-way 36. When applying the Rule of Nines to infants The head is pro- portionally larger in infants than in adults 37. A healthy young male is brought to the emergency department following a motor vehicle crash. His vital signs are a blood pressure of 84/60, pulse 123, GCS 10. The patient moans when his pelvis is palpated. After initiating fluid resuscitation, the next step in management is: 38. What situations requires Rh immunoglobulin admin-istration to an injured woman? 39. A 22-year-old female athlete is stabbed in her left chest at the third interspace in the anterior axillary line. On admission to the emergency department and 15 minutes after the incident, she is awake and alert. Her heart rate is 100 beats per minute, blood pressure 80/60 mm Hg, and respiratory rate 20 breaths per minute. A chest x-ray reveals a large left hemothorax. A left chest tube is placed with an immediate return of 1600 mL of blood. The next management step for this patient is: placement of a pelvic binder positive pregnan-cy test, Rh nega-tive, and has torso trauma prepare for an ex-ploratory thoraco-tomy 40. A 6-year-old boy walking across the street is struck by the front bumper of a sports utility vehicle traveling at 32 kph (20 mph). What's true about this patient? A pulmonary con tusion may be present in the absence of rib fractures. 7/67 41. Adjuncts used during the primary survey ECG Pulse ox CO2 monitoringV Ventilatory rate ABGs Foleys (UOP) Gastric catheter FAST or eFAST DPL 42. Urinary output is sensitive for Patient's volume status and renal perfusion 43. "Golden hour" The time from in- jury to definitive care, during which treatment of shock and traumatic in- juries should oc- cur because sur- vival potential is best; also called the Golden Peri- od. 44. Leading cause of trauma deaths worldwide MVCs 45. Trimodal death distribution 1st: seconds to minutes of injury (apnea) 2nd: minutes to several hours (EDH, SDH, liv- er lac, pelvic frac- tures, spleen rup- tures) 3rd: several days to weeks after in- 8/67 jury (sepsis and multi-organ fail- ure) 46. An 18-year-old male was the unrestrained driver in Airway equipment a MVC involving contact with a tree, He is being for possible intu- transported to the ED by ambulance after a prolonged bation extrication process. He is receive oxygen by mask IV equipment to and IVF via one large-bore IV, and he is immobilized place a second on a long spine board. How would you prepare for IV and get blood arrival of this patient? work Lab/Xray available Monitor equip- ment ready Notify blood bank and have transfu- sion protocol avail- able Consider appro- priate transfer 47. AMPLE hx Allergies Medications cur- rently used Past illness- es/Pregnancy Last meal Events/Environ- ment related to the injury 48. Blunt trauma MOI Seatbelt use Steering wheel deofrmation Presence/activa- tion of airbags Direction of impact Damage to vehicle Patient position 9/67 Ejection from vehi- cle? 49. Penetrating trauma MOI Body region Velocity of weapon Caliber 50. Heat loss can occur at moderated temperatures 59 to 68 F (15-20 C) 51. Prehospital phase should include what interventions Airway mainte- and considerations? nance Breathing support Control of bleed- ing and shock Immobilization Immediate trans- port to closest ap- propriate facility 52. Hospital preparation for trauma Resuscitation area Airway équipement Warmed IV crys- talloid solution Monitoring de- vices Protocol for re- questing addition- al assistance Transfer agree- ments 53. Primary survey Airway mainte- nance with restric- tion of cervical spine motion Breathing 10/67 Circulation Disability Exposure/Environ- mental control 54. Patients with maxillofacial or head trauma should be A cervical pine in- presumed to have jury and cervical spine motion must be restricted 55. PITFALL: equipment failure Test regularly Ensure spare equipment and batteries are read- ily available 56. PITFALL: unsuccessful intubation Identify patients with difficult anato- my Identify the most experi- enced/skilled air- way manager on team Ensure appropri- ate equipment is available Be prepared to prefer a surgical airway 57. PITFALL: progressive airway loss Recognize the dy- namic status of the airway Recognize the in- juries that can re- sult in progressive airway loss Frequently re- assess the patient 11/67 for signs of deteri- oration of the air- way 58. In a trauma patient with hypotension, what are the two most important causes to consider in order of importance? Tension pneu-mothorax Hemorrhage 59. What is the best way to manage rapid external blood Direct manual loss? pressure on the wound 60. What are the major areas of internal hemorrhage?Chest Abdomen Retroperitoneum Pelvis Long bones 61. How should fluids be administered in trauma patients Warm IVFs with shock? If unresponsive to initial IVF, give blood transfusion immediately 62. What are the uses for ETCO2? Detect ROSC Confirm ET intu- bation Help avoid hy- poventilation and hyperventilation 63. You'd like to insert a foley catheter for a trauma pa- Retrograde ure-tient but you notice urethras injury. What test should throgram be performed prior to the insertion of a urinary catheter? 64. DDX for blood in gastric aspirate in a trauma patient Swallowed blood Traumatic gastric tube placement UGI injury 12/67 65. What's a C/I to NGT insertion? Fracture of the cribriform/mid- face fracture (in- sert OG instead) 66. What injuries are at high risk of compartment syn- Long bones drome in trauma patients? Crush injuries Circumferential thermal burns Prolonged is- chemia to the limb 67. What's normal UOP? Adult: 0.5 ml/kg/hr Child: 1-2 ml/kg/hr 68. MIST for obtaining info from EMS Mechanism and time of injury Injuries found and suspected Symptoms and signs Treatment initiated 69. Retroperitoneal organs Abdominal aorta IVC Duodeum Pancreas Kidneys Ureters Posterior aspects of ascending/de- scending colon Bladder Rectum Reproductive or- gans 70. What's the most frequently injured abdominal organ Spleen (40-55%) in blunt trauma? Followed by? Liver (35-45%) 13/67 Small bowel (5-10%) 71. Which patients should you consider transferring, and The patients what tests should be performed prior to transfer? whose injuries ex- ceed your ability to care for them, ei- ther sue to spe- cialize needs, or resource availably. Only perform test- ing that enables the referring physi- cian to resusci- tate, stabilize, and ensure the safer transfer of the pa- tient 72. What's a pulse oximetry measure? Oxygen saturation by relative ab- sorption of light by oxyhemoglobin and deoxyhemo- globin 73. Gastric catheter placement can induce vomiting Be prepared to logroll Ensure suction is immediately avail- able 74. Special populations that may have physiological re- Children sponses that do not follow expected patterns Pregnant females Elderly Obese individuals Athletes 75. Why is info about mechanism of injury so important? The patient's con-dition is greatly in- 14/67 fluenced by MOI. It can enhance the understanding of the patient's con- dition and antici- pated injuries 76. Possible adjuncts to secondary survey X-rays of spine and extremities CT scans of head, chest, abdomen, spine Contrast urogra- phy and angiogra- phy TEE Bronchoscopy Esophagoscopy 77. Frontal impact MVC Cervical spine fracture Flail chest Myocardial contu- sion Pneumothroax Traumatic aortic disruption Fractured spleen or liver Posterior fracture/disloca- tion hip/knee Head injury Facial fractures 78. Side impact MVC Contralateral neck sprain Head injury Cervi- cal spine fracture 15/67 Flail chest Pneumothorax Traumatic aortic disrution Diaphragmatic rupture Fractured spleen/liver/kid- ney Fractured pelvis or acetabulum 79. Rear impact MVC Cervical spine in- jury Head injury Soft tissue injury to neck 80. MVC vs pedestrian Head injury Traumatic aortic disruption Abdominal viscer- al injuries Fractured lower extremities/ pelvis 81. Fall from heigh Head injury Axial spine injury Abdominal viscer- al injuries Fractured pelvis or acetabulum Bilateral LE frac- tures 82. Anterior stab wound Cardiac tampon- ade Hemothorax Pneumothorax 16/67 Hemopneumotho- rax 83. Left stab wound Left diaphragm in- jury Spleen injury Hemopneu- mothoax 84. Abdomen stab wound Visceral injury 85. Extremity GSW Neurovascular in- jury Fractures Compartment syndrome 86. Thermal burns Eschar on extrem- ities or chest 87. Electrical burns Cardiac arrhyth- mias Myonecrosis Compartment syndrome 88. Inhalation burns CO poisoning Upper airway swelling Pulmonary edema 89. What is your first step when a patient condition ABCDEs changes? 90. What's the importance of meticulous record keep- Crucial during pa- ing? tient assessment and management because often more than one clinician cares for 17/67 an individual pa- tient and allows those to evalu- ate the patient's needs and clinical status 91. What info should be provided to the receiving facility As much info as for a transferring patient? possible! Event of injury, pa- tient exam, treat- ments done, re- sponses of treat- ments, tests and results, and possi- ble injuries 92. What key information should prehospital providers obtain and report to the receiving hospital? Events associated with injury 93. What patient sign can be quickly observed to assess Skin perfusion a patient's hemodynamic status? 94. Definitive airway A tube placed in the trachea with the cuff in- flated below the vocal cords, the tube connected to a form of oxy- gen-enriched as- sisted ventilation and the airway secured in place with an appro- priate stabilizing method 95. What's critical management for trauma patients, es- Maintaining oxy- pecially those with sustained head injuries? genation and 18/67 printing hypercar- bia 96. Triad of largyneal fracture Hoarseness Subcutaneous emphysema Palpable fracture 97. In a conscious trauma patient, airway adequacy can quickly be assessed by Talking to the pa-tient-- A positive verbal response with clear voice in-dicated patent air-ways, ventilation, and brain perfu-sion 98. What can conform a suspected laryngeal fracture? 99. For a patient who is gurgling, initial assessment for ventilation should include CT scan Looking for sym-metrical chest rise and listening for breath sounds 100. Decreased or absent breath sounds over one or both Pneumothorax, hemithoraxes should alert the examiner to the pres- hemothoax, ence of? contusion, or flail chest 101. Adjuncts of ventilation problems Pulse ox to mea- sure oxygen satu- ration and gauge peripheral perfu- sion Capnography to assess adequacy fo ventilation 102. What are the symptoms of inadequate ventilation? Difficulty breath-ing 19/67 SOB Request to sit up to breath 103. LEMON assessment of difficult intubation Look externally Evaluate the 3-3-2 rule Mallampati Obstruction Neck mobility 104. Types of definitive airways Orotracheal tube Nasotracheal tube Surgical air- ways (cricothy- roidotomy and tra- cheostomy) 105. Laryngeal manipulation for visualization Backward, up-ward, and right-ward pressure on thyroid cartilage can aid in visualiz-ing vocal cords 106. Which surgical airway is recommended in children under 12? Needle cricothy-roidotomy 107. What're adjuncts that might be used during intuba- tion? Suction Manual laryngealmanipu- lation (BURP) Elastic bougie Anesthetics, anal- gesics, and neuro- muscular blocking agents 108. Why is continual pulse ox monitoring necessary in critically injured patients? Because changes in oxygenation oc- 20/67 cur rapidly and are impossible to de- tect clinically 109. What indicates that the endotracheal tube is in the Equal breath proper position? sounds bilaterally Carbon dioxide monitor (capno- graph or colori- metric CO2 de- vice) Confirmed with CXR 110. What suggests sufficient ventilation? ABG or continu-al end-tidal carbon dioxide analysis 111. On exam, an unrestrained driver is hoards and has Obstructed airway minimal subcutaneous neck emphysema. This pa- tient likely has a/an 112. In an agitated trauma patient who refuses to lay down Assessment of airway adequacy may include suc-tioning 113. What's an indication for rapid sequence intubation? Patients who need airway control, have intact gag reflex, especially those who have sustained head in-jury 114. A surgical airway is indicated in the presence of Edema of the glot- tis Fracture of larynx Severe oropha- ryngeal hemor- 21/67 rhage that ob- structs airway Inability to place an endotracheal tube 115. Possible causes of confusion after traumatic event? Hemorrhage Brain injury Stroke Intoxication 116. What's the most common cause of shock after an Hemorrhage injury? 117. What're the early clinical manifestations of shock? Tachycardia and cutaneous vaso-constriction. 118. What's the preferred method of vascular access for a2 large bore PIVs patient involved in a MVC? in the antecubital veins 119. What's the most appropriate means to restore car-diac output and end organ perfusion in hemorrhagic shock? Stopping the source of bleeding and ensuring ap-propriate volume repletion 120. A 24-year-old male arrives in ED already intubated. Tracheobronchial He has significant crepitus of the right chest wall and tree injury diminished breath sounds. You place a chest tube and note a large amount of bubbling in the water seal chamber. His O2 saturation remains at 85% and he has goodCO2 return on capnography. The most likely cause of his low oxygen saturation is 121. Most injuries to the tracheobronchial tree occur Within 2.5 cm from where? the carina 122. 22/67 Do the vast majority of thoracic injuries (blunt and penetrating) require operative intervention? No, most are treat-ed with technical procedures 123. Airway thoracic injuries Airway obstruction (laryngeal injury, posterior disloca- tion of clavicular head, or penetrat- ing trauma) Tracheobronchial tree injury 124. Breathing thoracic injuries Tension pneu- mothorax Open pneumotho- rax Massive hemotho- rax 125. Circulation thoracic injuries Massive hemotho- rax Cardiac tampon- ade Traumatic circula- tory arrest 126. What's the most common cause of a tension pneu-mothorax? Mechanical posi-tive-pressure ven-tilation in patients with a visceral pleural inury 127. Where is the ideal location for needle decompression 5th intercostal of a tension pneumothorax? space, slightly an- terior to midaxil- lary line 128. What do you need to remember when treating an Place a dressing open pneumothorax? on the site and 23/67 only secure is on 3 sides so air can escape, then place a chest tube 129. Massive hemothorax Accumulation of >1500 ml of blood in one side of chest 130. Causes of PEA? Hypovolemia Hypoxia Hydrogen acido- sis Hypo/hyper- kalemia Hypoglycemia Hypothermia Toxins Tamponade Tension pneumo Thrombosis 131. Indications of a thoracotomy Immediate return of > 1500 ml of blood or signifi- cant bleeding Persistent blood transfusions Penetrating anteri- or chest wounds medial to the nip- ple line Posterior wounds medial to the scapula 132. A 26-year-old male sustained a posterior stab wound. Open pneumotho- Blood and bubbling are coming from the wound. rax 24/67 133. A 46-year-old male sustained a gunshot wound to the Massive hemotho- chest rax 134. A 65-year-old female who takes warfarin was involved Cardiac tamponade-in a MVC. She initially presented complaining of ster- nal pain. BP deteriorated to 90/60 after arriving to the ED 135. Eight life-threatening injuries during the secondary survey? Simple pneumoth- orax Hemothorax Flail chest Pulmonary contu- sion Blunt cardiac in- jury Traumatic aortic disruption Traumatic di- aphragmatic injury Blunt esophageal rupture 136. A patient with a simple pneumothorax May be watched for progression if pneumothorax is small (<15%) and patient is stable and does not re- quire transfer 137. A 38-year-old male presents to the ED after a head-on, Administer agents high-speed collision. His vitals are HR 130, BP 156/90, to manage his RR 20, and O2 sat 92% on 15L of O2. His voice is pain and lower his raspy and he complains of chest pain that radiates HR and BP (aortic to his back. A CXR shows a widened mediastinum, disruption) obliteration of the aortic notch, and depression of the left mainstream bronchus. You should 138. What's a characteristic that is shared by all traumaticContained aortic disruption survivors? hematoma 139. A 36-year-old female was involved in an altercation, sustaining a knife wound to the chest, below the left nipple. She is mildly short of breath with an oxygen sat of 92%. BP is 115/80. 140. A 56-year-old male archer was riding a horse when it bucked and the saddle struck him in the chest wall. You note paradoxical chest wall movement on the left anterior chest. CXR is negative. 141. What would confirm a diaphragmatic injury in a pa-tient? 142. What is a common finding associated with traumatic asphyxia? Simple pneumoth-orax Flail chest due to costochondral dis-ruption Presence of NGT Upper torso, fa-cial, and arm plethora with pe-techiae secondary to acute tempo- 26/67 rary compression of SVC. Massive swelling and cere- bral edema may be present. 143. Why are rib fractures in older adults a more signifi-cant concern than in young patients? The incidence of PNA and mortality is doubled in older patients 144. Pulmonary contusion/flail chest is best treated by? Supplemental oxygen, pain control, and recognition if the patient is unable to ventilate properly 145. The cause of hypoxia associated with flail chest is Pulmonary contu-sion 146. A patient arrives in your hospital after a fall from 20 ft landing on his right side. He has been intubated and two large-bore IVs have been started. His o2 sat is 82%, he has a good capnography waveform, and significant deformity to right chest wall. He has no breath sounds on the right. His BP is 75/30. Your next step should be to Perform a needle decompression or finger throacosto-my on the right side 147. You have completed a secondary survey on a patient who feel from a standing height. You note exquisite tenderness posterolaterally on the left chest wall at 9-11 ribs. This should raise suspicion for what other injury? Splenic injury 148. A patient's CXR reveals left pneumothorax. Additionally, the left diaphragm is obscured and there is an air fluid level in the left hemithorax. You decide to place a Abdominal contents that have become displaced 27/67 chest tube. The patient is at increased risk for damage into the chest cav- to ity 149. Stab wounds most commonly injury? Liver (40%) Small bowel (30%) Diaphragm (20%) Colon (15%) 150. Gunshot wounds most commonly injury? Small bowel (50%) Colon (40%) Liver (30%) Abd vascular structures (25%) 151. When is a retrograde urethrogram mandatory? Patient is unable to void, requires pelvic binder, or has blood at the meatus, scro- tal hematoma, or perineal ecchymo- sis 152. A 28-year-old male, helmeted motorcyclist was in a high speed MVC, striking head-on into the side of a vehicle. He arrives on a backboard and with a cervical collar in place via pre-hospital BLS transport. Vitals are: BP 100/75, HR 115, RR 20, GCS 15. The patient reports a brief loss of consciousness and is com-plaining of pain in the chest, abdomen, and pelvis. What're the priorities for management? 153. A 28-year-old male, helmeted motorcyclist was in a high speed MVC, striking head-on into the side of a vehicle. He arrives on a backboard and with a cervical collar in place via pre-hospital BLS transport. Vitals are: BP 100/75, HR 115, RR 20, GCS 15. The patient re-ports a brief loss of consciousness and is complain- Rapidly assess ABCs Auscultate the lungs, provide supplemental oxy- gen, and apply pulse ox VS are consis-tent with hemor-rhagic shock from intraabdominal or pelvic sound Maintain IV/IO ac- 28/67 ing of pain in the chest, abdomen, and pelvis. What'scess and initi- the interpretation of the VS and the initial therapy? ate volume resus- citation, including blood transfusion if indicated Pelvic binder ap- plication may be appropriate 154. Will retroperitoneal injuries prevent with obvious No, retroperi- signs of peritoneal irritation? toneal structures are separated from anterior peri- toneum by the in- traperitoneal vis- cera, therefore no peritonitis may be present 155. A patient was found 10' from his motorcycle, laying on his right side. He was wearing a helmet. He was going ~45 mph. He had brief LOC. He states he has no allergies, medications that he takes, no current illness. Last meal was 6 hours ago. Based on mech-anism, what intra-abdominal and/or pelvic injuries is he likely to have sustained? 156. A patient was found 10' from his motorcycle, laying on his right side. He was wearing a helmet. He was going ~45 mph. He had brief LOC. He states he has no allergies, medications that he takes, no current illness. Last meal was 6 hours ago. How would the risk of intra-abdominal injury change if the patient de-scribed stroking the handlebar into the epigastrium? 157. A 30-year-old male presents with a 2 cm stab wound to the mid-abdomen, 3 cm to the right of the umbili- Visceral lacera- tions (liver/spleen) Bowel viscer- al/vascular in- juries Retroperitoneal visceral/vascular injuries (kidneys/adrenal) Pelvic fractures A direct blow to the epigastrium would raise the risk of a pancreas, duode-nal, or small bowel injury Airway appears intact. Breathing 29/67 cus. VS are BP 85/60, HR 130, RR 25, GCS 14. Neck has increased veins are flat. Chest exam is CTAB. The abdomen is rate. Circulation tender. What's the ONE BEST therapy to treat this demonstrated he- patient's injury? morrhagic shock. Penetrating ab- dominal injury with shock is one of the indications for emergent laparo- tomy. 158. In a patient with a possible pelvic fracture, how fre-quently should the pelvis be tested for mechanical stability? The pelvis should not be tested in a hemodynacilly un-stable patient. Me-chanical instabili-ty of he pelvic ring should be as-sumed in patients who have sus-pected pelvic frac-tures. Avoid man-ually manipulating the pelvis (dis-lodge an existing clot) 159. Hypotension + pelvic fracture = High mortality 160. A 12-year-old male complains of LUQ tenderness and Observation L shoulder pain 8 hours after playing rugby. ABCDE are normal. Circulatory assessment remains normal. Abdominal exam reveals mild LUQ TTP without peri-toneal signs. FAST demonstrated fluid in the hepa-torenal space and the plenorenal recess. What's the appropriate next step? 161. A 29-year-old woman is the restrained driver in a head-on collision. Airbags deployed. ABCDE are normal. The patient complains of lower abd and back 30/67 pain. A lower abd contusion is present and associated with tenderness. There is no evidence of diffuse peritonitis. Your institution has NOT surgical capabil-ities. What's the most appropriate treatment plan? The patient should be urgently trans ferred for surgical intervention 162. A 50-year-old male arrives to the ED following fall of 163. 26'. He hs gurgling respirations and is not responsive to voice. VS are BP 80/5-, RR 30, HR 138, O2 sat is undetectable. Your hospital does not have surgical capabilities. The first step in management is Application of oxygen and securing an airway 163. A 25-year-old ale arrives at the ED following a motor- Application of a cycle crash. BP is 80/60, HR 140. Airway and breath- pelvic binder ing are controlled. There are no open wounds. The abd is not distended. Both legs are externally rotated but soft. The pelvis is tender. The scrotum is swollen and ecchymotic. While vascular access is obtained, what the next most appropriate step? 164. A 45-year-old male with a BMI of 48 was working in an industrial plant when 2 pieces of wood flew off a sa and struck him in the abdomen and right chest. CXR demonstrates rib fractures. What's true about this scenario? Despite multi-ple imaging stud-ies, detection of intestinal and retroperitoneal in-juries may be diffi-cult 165. Your institution does not have surgical capabilities. Activation of mas- You have intubated a 25-year-old man who was in sive transfusion a rollover MVC. You have also placed bilateral chest protocol, applica-tubes for pneumothoraxes. The patient's SBP is con-tion of pelvic tinually < 90 and HR > 140. Potential therapy and binder, and CXR evaluation includes 166. What's the primary goal of treatment for patient's withTo prevent sec- suspected TBIs? ondary brain injury by ensuring ade- quate oxygenation and maintain BP 31/67 that's sufficient to perfuse the brain 167. Cerebral perfusion pressure (CPP) MAP - ICP 168. A 23-year-old male fell from a bike, striking his head Airway protection on the curb. He was not wearing a helmet. The patient with a subglottic has a 10 cm laceration to the temporal-parietal region device of the left scalp. He is initially able to say hi name. VS Oxygenation to are HR 115, BP 100/60, oxygen sat 88%, GCS initially prevent hypoxia 12. 2 hours after transfer to a local hospital, he has Maintain SBP > sonorous respirations, a HR of 120, BP 100/70, and 100 mmHg GCS of 6. What the initial priorities in the management of this patient? 169. A 23-year-old male fell from a bike, striking his head Decreased GCS on the curb. He was not wearing a helmet. The patient indicates wors-has a 10 cm laceration to the temporal-parietal region ening intracranial of the left scalp. He is initially able to say hi name. VS pathology with are HR 115, BP 100/60, oxygen sat 88%, GCS initially possible intracra- 12. 2 hours after transfer to a local hospital, he has nial HTN and sonorous respirations, a HR of 120, BP 100/70, and impending hernia- GCS of 6. What are the signs that the patient's injurytion is progressing? 170. A 78-year-old ale is found down in the bathroom with a large left scalp laceration from striking the corner of the sink. He arrives in the ED with a BP 180/90, HR 60, dilated, non-responsive right pupil. The most likely finding on the patient's CT scan will be 171. Intracranial mass effect is defined by the 172. Illustrtive of im-pending uncle her-nia associated with Cushing re-sponse (high BP + bradycardia)-- associated with a large subdur-al hematoma with midline shift Monro-Kellie Doc-trine 32/67 A trauma patient opens her eyes, moans, and with-draws from pain. What is her GCS score? Eye opening: 2 Verbal response: 2 Best motor re-sponse: 4 Total = 8 173. A 48-year-old female falls from a balcony. She was witnessed striking her head on the steps after an ~8' fall. The patient briefly lost consciousness and is found confused, lying at the bottom of the steps. Her eyes are open, and she is rubbing her forehead. The most important finding related to this patient's long-term outcome is GCS score 174. A 56-year-old male repeats questions, his eyes are open, and he moves to command GCS 14 175. A 17-year-old female was struck by a vehicle while crossing the road. Upon arrival she is moaning, her eyes open, and she withdraws to painful stimuli GCS 8 176. A 82-year-old female was found home by family. Her GCS 4 eyes are closed, she extends to pain, and is not speaking 177. A 63-year-old male fell off a ladder. Witnesses report GCS 11 loss of consciousness. His eyes open to voice, he localizes to pain, and has garbled speech 178. What types of intracranial hemorrhage can be identi- Epidural fied on CT scan? Sudural Intra-ventricular Subarachnoid Intra-parenchymal 179. What CT scan findings are indicative of severe head Midline shift (> injury that may require intervention? 5mm), loss of def-inition of the basil cisterns, and se-vere skull frac- tures with intru- sion into the brain matter 180. A 70-year-old female falls at home and strikes her head on the bathtub. She is found down by her grand-daughter ~6 hours later. GCS is 8: eye opening 2, Current anti platelet therapy, beta blockade, verbal 2, motor 4. She is intubated for airway protec- and anticoagula-tion upon arrival in the trauma bay. What preexisting tion patient characteristics should you consider that may affect this patient's outcome? 181. What is the purpose of intubation in a comatose pa- Prevent hypox- tient? ia and secondary brain injury occurs with a protection of the airway 182. Ancillary studies to confirm brain death? EEG: no activity at high gain CBF studies Cerebral angiog-raphy 183. Diagnosing brain death GCS=3 Nonreactive pupils Absent brainstem reflexes (oculo- cephalic corneal, doll's eyes, and no gag reflex) No spontaneous ventilatory effect on formal apnea testing Absence of con- founding factors such as alcohol or drug intoxica- 34/67 tion or hypother- mia 184. What are the initial management options for mild brain injury? Monitoring isnt' re-quired but know long-term effects can manifest over time 185. What are the initial management options for moder- Monitoring for de- ate brain injury? compensation is important and re- quires hospital ad- mission, ongoing neurologic exam, possible further CT imaging 186. What are the initial management options for severe Requires a center brain injury? with neurosurgical support and asso- ciated aggressive- ly treat intracranial swelling, osmotic intravascular fluid management, and rapid surgical in- tervention 187. A CT scan reveals intracranial hemorrhage and Mannitol, hyper- swelling with collapse of the 3rd and 4th cventricles tonic saline, and and impending uncle herniation. What treatment mea- phenytoin are ini- sures are appropriate? tial management of intracranial HTN 188. An 81-year-old female arrives in the ED after a fall Repair the scalp from standing. The only visible sign of injury is a laceration large scalp laceration. Paramedics report that she has been getting progressively hypotensive over the 35/67 past 20 minutes. They infused 2 L NS IVF, after which BP is 135/70. She is somnolent, but arousable. There is some hemorrhage from a large 20 cm scalp lac-eration. What's the best next step in managing this patient? 189. What are the initial treatment options that may protect the brain from ongoing swelling? 190. A 22-year-old male is hit by a car while traveling downhill on a skateboard. He was found unconscious at the scene and arrives with bag-mask ventilation by the EMS crew. He only mumble incoherently, does not open his eyes, and only flexes to pain. Upon arrival in the ED, the primary goal is 191. What treatment measures is essential in maintaining cerebral perfusion pressure? 192. A 45-year-old female is involved in a MVC and brought to a local ED with limited capabilities. She does not remember the event and has repetitive questioning. You would like to get a CT scan of the head, but the technician must be called in from home, which will take at least 30 minutes. You should 193. A patient arrives after a blow to the right temporal region secondary to a tree limb striking him while chopping down a tree. He was intubated in the field for a declining mental status. His PE reveals 6 mm and non-reactive right pupil and a 4 mm L pupil with brisk reaction to 2 mm. His GCS reveals extensor Decreasing agita-tion with sedation, reducing cerebral swelling with man-nitol, or hyperton-ic saline. A neuro-surgeon can drain CSF. Intubate the pa-tient Sedation, manni-tol, and IVF will help decrease ICP or increase MAP Transfer the pa-tient to a higher level of care Epidural hematoma causes same side pupil dilation and opposite side weakness 36/67 posturing with no eye opening, and he is intubated. The presumed extent of his intracranial injury is most likely? 194. Many patients with c-spine fractures have a second, noncon- tiguous vertebral column fracture 195. A helmeted 28-year-old male fell from scaffolding. A bystander witnessed the fall and reports that the patient landed head first, causing his neck to hy-perextend. His VS are BP 90/62, HR 58, RR 28, GCS 15. The patient is alert and following commands. His breathing is shallow and he is not moving his arms or legs. What injuries has this patient likely incurred? 196. A helmeted 28-year-old male fell from scaffolding. A bystander witnessed the fall and reports that the patient landed head first, causing his neck to hy-perextend. His VS are BP 90/62, HR 58, RR 28, GCS 15. The patient is alert and following commands. His breathing is shallow and he is not moving his arms or legs. What type of shock does this patient exhibit? 197. Cervical spine injuries represent more than 1/2 of all spinal column injuries. What additional injuries are commonly associated with cervical fractures? 198. Neurogenic shock is associated with what level of spinal cord injury and causes systemic hypotension via what mechanism? The initial assess-ment raises con-cerns for a spinal cord injury. How-ever, complete a primary and sec-ondary survey to rule out additional life-threatening in-jures. Neurogenic 25% of all spine in-juries have at least a mild brain in-jury and 10% with a cervical fracture have another non-contiguous spine fracture T6 and higher, distributive shock from lack of vaso-motor tone 37/67 199. The patient is unable to move his legs. He can move his fingers and wrists bilaterally. He has weal triceps extension on the left. He is unable to move right elbow. He is able to feel his fingers and thumbs bilat-erally, but not feel anything above his elbow. Where is the suspected spine lesion? 200. The patient is unable to move his legs. He can move his fingers and wrists bilaterally. He has weal triceps extension on the left. He is unable to move right elbow. He is able to feel his fingers and thumbs bi-laterally, but not feel anything above his elbow. Why is there a difference b/t the PW findings for the UE on PE? 201. Spinal cord injuries can be defined by neurologic lev-el and severity in addition to associated syndromes and morphology. Describe Brown-Sequard syndrome lesion at T5. 202. Which type of thoracic spinal fracture is associated with MVC with restrained passengers using lap belt, a forward flexion mechanism, likely visceral organ injury, and frequent need for internal fixation? C6 or C7 The difference be-tween the PE find-ings for the UE is likely due to ini-tial inflammatory response, edema, and/or the pres-ence of an incom-plete spinal cord injury. T5, penetrating in-jury to one side (partial) Chance fracture 203. What's the appropriate treatment for a C6 vertebral body fracture Spinal immobiliza-tion and IVFs, fol-lowed by vaso-pressors if patient remains brady-cardic after fluids 204. A patient with a known cervical spine fracture who Semi-regid collar is being transferred from a rural hospital to definitive and head restraint care should be transported in which way? 38/67 205. Patients with cerviacl fractures above C6 require spe- Potential progres- cial consideration prior to transportation due to? sion to respiratory failure 206. A 35-year-oldman was ejected from a MV. On arrival, Although this pa- his VS are BP 80/40, HR 110,RR 24, GCS 15. Airway tient likely has a and breathing are intact. He complains of severe back spinal cord injury, pain, has no sensation below umbilicus, has lower perform a FAST thoracic tenderness, and is unable to move LE. Chest exam or DPL to r/o and pelvic X-rays are normal. Along with IVFs, what is other etiology. most appropriate treatment for this patient's hypoten-sion? 207. An elderly female falls and sustains a hyperextension Central cord syn-injury to her neck. Her exam demonstrated decreased drome strength in UE compared to LE. What is the cause of her unusual neurologic findings? 208. What's the most common location of all spinal in-juries? C5 209. A 40-year-old M involved in a MVC is evaluated in Crystalloid bolus, a rural hospital without spine surgical capacity. The initiate pressers, patient has a clear C-spine fracture at C4 on plain film intubate, and then and the inability to move any extremities and sensa- transfer patient tion limited to supraclavicular region. He is having once he is hemo-difficulty breathing with a RR 30. BP 80/40 and HR 50. dynamically stable What should be performed prior to transfer? 210. Potentially life threatening extremity injuries Marjor arterial he- morrhage Bilateral femoral fractures Crush syndrome 211. Rhabdomyolysis can lead to Metabolic acidosis Hyperkalemia Hypocalcemia Disseminated in- 39/67 travascular coagu- lation (DIC) 212. A 38-year-old female restrained driver is involved in a A femur fracture high-speed, head-on collision with a truck. Following can result in blood a prolonged extrication, she noted to have deformity loss up to 2 L and of her right thigh. On arrival, her VS are HR 120, BP each tibial fracture 90/50, RR 22, GC 15. 2 large bore IVs are inserted in can cause up to UE. VS are now HR 13- BP 80/40, RR 24, GCS 14. CXR, 1.5 L of blood loss. pelvis X-ray, and FAST are negative. You suspect the Fracture immobi-source of hypotension is a femur fracture and bilater- lization is the best al tibial shaft fractures. How much blood loss would control. you expect from this patient's extremity injuries and what's the best way to control it? 213. How should femur and tibial shaft fractures be stabi- A traction splint lized? should NOT be used. Tibial frac-ture should be placed in a long leg splint. A femur and tibial fracture should be placed in a long leg pos-terior splint. Open fractures should be covered with moist saline gauze before placed in splint. Neu-rovascular exams should be per-formed before and after splint place-ment 214. Extremity bleeding control order 1) Manual pres- sure to the wound 2) Pressure dress- ing 3) Compression of the artery proxi- mal to the injury 4) Tourniquet ap- plication 215. Cold, pale, pulseless extremity Interrupted arteri- al blood supply 216. Rapidly expanding hematoma Significant vascu- lar injury 217. Tourniquet use 1) Tightening tourniquet until bleeding stops 2) Ensure arterial inflow is occluded 3) Document time of application 4_ Obtain imme- diate surgical con- sult and transfer patient, if neces- sary 5) If time to surgery is pro- longed in stable patient, consider one attempt to de- flate tourniquet 6) If tourniquet use if prolonged, con- sider chose of life over limb 218. An ABI < ___ indicates abnormal arterial flow sec-ondary to injury or PVD. < 0.9 219. All open fractures and open joint injuries require 41/67 Up to date tetanus vaccine IV antibiotics (1st generation cephalosporin) 220. Abnormal motion through a joint segment Tendon or liga- ment rupture 221. Absent spontaneous extremity movement in uncon- Neurologic and/or scious patient muscular impair-ment 222. Swollen extremity in region of major muscle group Crush injury with impending com-partment syn-drome 223. Pale or white distal extremity Lack of arterial blood flow 224. Diagnosis of an open fracture is made based on? Physical exam and x-ray 225. What's high risk for compartment syndrome? Ischemia reper-cussion injury to enclosed muscle Crush injury Tight dressing or cast 226. How is an open joint injury confirmed? CT or saline/dye injection 227. When does muscle necrosis begin? When there is a lack of arteri- al blood flow for more than 6 hours 228. 42/67 A 38-year-old female restrained driver is involved in a high-speed, head-on collision with a truck. Following a prolonged extrication, she noted to have deformity of her right thigh. On arrival, her VS are HR 120, BP 90/50, RR 22, GC 15. 2 large bore IVs are inserted in UE. VS are now HR 13- BP 80/40, RR 24, GCS 14. CXR, pelvis X-ray, and FAST are negative. You suspect the source of hypotension is a femur fracture and bilat-eral tibial shaft fractures. Transfer is initiated. What antibiotics and at what dose should be given tot he patient? 229. What does splinting accomplish in patients with mus-culoskeletal trauma? Cefazolin 3g + ciprofloxacin or gentamicin Control blood loss, prevent fur-ther neuromuscu-lar compromise and soft tissue in-jury, and reduce the patient's pain 230. A 25-year-old male presents after a motorcycle crash. Splint the extrem-VS are BP 128/70, HR 124, GCS 15. He complains of R ity and administer leg pain. On exam, the patient is found to have proxi- a small dose of mal right thigh deformity. Distal pulses intact. What'san IV narcotic, like the best initial magement of this patient's symptoms?fentanyl 231. When should IV antibiotics be given to patients with All patients with open fractures? an open fracture should receive IV antibiotics 232. A 22-year-old female presents after jumping from the Radiographic 3rd story of a building in a suicide attempt. She's work-up of the stable, but GCS is 13. Both ankles are swollen. Her spine to rule out pulses intact. Initial chest and pelvis films are normal. occult injury Ankle films reveal bilateral calcanea fracture. What additional work-ip is important to undertake in this patient? 233. What's true about tourniquets? 43/67 It must occlude ar- terial inflow 234. Musculoskeletal adjuncts to the primary survey may Proper application include? of a splint can help control blood loss, reduce pain, and prevent fur-ther neurovasculr compromise 235. ABLS indications for early intubation Signs of airway obstruction TBSA > 40-50% Extensive and deep facial burns Burns inside the mouth Significant edema or risk for edema Difficulty swallow- ing Signs of respirato- ry compromise Decreased LOC Anticipated pa- tient transfer of large burn with air- way issue with- out qualified per- sonnel to intake en route 236. Parkland formula 2-4 ml of LR x pa- tient's weight (kg) x % TBSA for 2nd and 3rd degree burns with 1/2 ad- ministered in the 1st 8h and the 2nd 1/2 adminis- tered during the subsequent 16h 237. Simplest way to remove tar from trauma patient? Mineral oil 238. Reperfusion syndrome Indicated by aci- dosis, hyper- kalemia, and local swelling; therefore monitor the pa- tient's cardiac sta- tus and peripher- al perfusion during rewarming 239. Immediate lifesaving measures for patients with burn Stopping the burn injuries process Recognize inhala- tion injury Assuring an ade- quate airway Oxygenation and ventilation Rapidly initiating IVF 240. What's the most significant difference between burnsThe consequence and other injuries? of a burn injury are directly linked to the extent of the inflammatory response to the in- jury 241. A 29-year-old M jumps from the 1st story of a burn-ing house. His clothes are on fire. Bystanders ex-tinguished the flames. He is conscious, agitated, and complaining of abdominal and leg pain. The pa- Some interven-tions to be consid-ered are early in-tubation and initia- 45/67 tient's head and upper body appear to be extensivelytion of burn resus-burned. What are the unique considerations that a citation. burn injury adds to the initial management of this patient? 242. What is the primary difference b/t the presentation of airway injury in patients with burns compared to other forms of trauma? 243. How does hypovolemia from burn injury differ from hypovolemia from other forms of trauma? Airway injury can develop over time due to edema from burn injury Other trauma usu-ally result in hemorrhagic vol-ume loss, however burn hypovolemia is due to inflam-matory changes and capillary leak 244. When do you provide burn resuscitation? Deep partial and full thickness burns larger than 20% TBSA 245. A 29-year-old M jumps from the 1st story of a burn- ABC management ing house. His clothes are on fire. Bystanders ex- in addition to stop- tinguished the flames. He is conscious, agitated, ping the burning and complaining of abdominal and leg pain. The pa- process, cleans-tient's head and upper body appear to be extensivelying the wound, burned. The patient is now intubated with IV access. protecting it from A foley is placed with minimal dark urine output. infection, and pre- The estimate of burn size is 45% TBSA. How should venting hypother-the patient's burn wound be managed in the initial mia stages? 246. What is the goal of burn resuscitation? To maintain end-organ perfu-sion in the con-text of ongoing 46/67 intravascular fluid loss 247. What info should be recorded on the trauma flow sheet? Depth and extent of burn Fluids given UOP Any significant in- terventions, in- cluding escharo- tomies 248. What are the factors that contribute to the need for an Edema from the escharotomy? inflammatory re-sponse to the burn and re-duced elasticity of burned skin (in-creased pressure in the underlying soft tissue) 249. How cana circumferential burn injury affect muscle tissue? Can cause the pressure from burn edema to build to the point that it compro-mises tissue per-fusion, similar to compartment syn-drome 250. How is burn resuscitation affected when the patient Control bleeding also has an injury causing hemorrhage? and resuscitate the patient per standard ATLS protocol for hem-orrhagic shock be-fore starting burn resuscitation 47/67 251. In what situation is it not advisable to immediately wash off chemicals with irrigation? Not until airway has been as-sessed and se-cured and when the chemical is a powder (brush off before irrigation) 252. What are two interventions for treating rhabdomyoly-sis? 253. A 20-year-old is brought to ED after his shovel hits a 14,000 volt underground wire and he suffers an electrical contact injury to his arms. He is covered in powdered cement from the work site. How should be be initially treated? Increase IVF to target UOP of 100 ml/hr which wash-es out the myoglo-bin before it settles Administer manni-tol which acts as a free radical scav-enger and osmotic diuretic therefore increasing UOP and washing out myoglobin Establish ABCs Brush powder off before irrigating Monitor due to electrical injuries later manifesting 254. If a burn patient's urine were reddish-brown in color,Signifying myoglo- what would change in your burn resuscitation? binuria secondary to rhabdomyolysis should be treat- ed with aggressive IVF and possible mannitol 255. What's the difference between active and passive Passive involves rewarming? placing the patient 48/67 in an environment that reduces heat loss and relies on patient's intrin- sic thermoregular- tory mechanisms Active involves supplying a heat source (warm IVFs, warmed packs of high vas- cular flow and ini- tiating circulatory bypass) 256. Why is the issue of iatrogenic hypothermia impor- Shown to increase tant? trauma related mortality, which is preventable 257. A 35-year-old female is brought into the hospital after being lost for two days while snowmobiling in -30 C weather. She has a core body temperature of 30 C and her toes are frozen. How and when should rewarming start 258. A 35-year-old female is brought into the hospital after being lost for two days while snowmobiling in -30 C weather. She has a core body temperature of 30 C and her toes are frozen. How should the toes be thawed? 259. The most significant difference between burn and other traumatic injuries is? Immediate active rewarming Moist rewarming In a burn injury, the full extent of the injury may not be evidence im-mediately 260. In an adult patient with suspected inhalation injury, it Use an ETT larg- is important to? er than 7.5 in an adult to enable 49/67 clearance of se- cretions 261. Burn shock is a result of? Interstitial loss due to inflammation 262. The immediate treatment of electrical injury consists Maintaining UOP of? of 100 ml/hr 263. What're the leading causes of unsuccessful resusci-Failure to secure a tation in pediatric patients with severe trauma? compromised air- way Failure to support breathing Failure to rec- ognize and re- spond to intra-ab- dominal and in- tracranial hemor- rhage 264. A 3-year-old falls 10 meters out of an apartment window onto pavement. He does not open his eyes, moans incomprehensibly, and extending abnormally when stimulated. The patient is unresponsive on ar-rival to the ED, and pupils are unequal. He has blood coming from his right ear, is breathing rapidly, and is pale, with mottled extremities. VS are BP 74/57,HR 156, RR 49. What steps and maneuvers would you use to manage this patient's airway? 265. A 3-year-old falls 10 meters out of an apartment window onto pavement. He does not open his eyes, moans incomprehensibly, and extending abnormally when stimulated. The patient is unresponsive on ar-rival to the ED, and pupils are unequal. He has blood coming from his right ear, is breathing rapidly, and is pale, with mottled extremities. VS are BP 74/57,HR 156, RR 49. Is this child in shock? Maintain airway with chin-lift and jaw-thrust with as-sisted ventilation using bag mask with placement of laryngeal mask or ETT Yes (tachycardia, mottled extremi-ties, and hypoten-sion) indicates sig-nificant compro-mise, likely due to bleeding but other etiology must be ruled out. 266. Trauma triad of death Hypothermia Acidosis Coagulopathies 267. A 5-year-old boy is struck by a car and brought to the Placement of in-ED. He is lethargic but withdraws from painful stimuli. traosseous device VS are BP 90, HR 160, RR 40, and oxygen sat 85%. into proximal tibia The best option for establishing vascular access after experienced nurses have failed to obtain PIV on two attempts is? 268. When treating a severely injured child, it is very im- Asking parent or portant to rapidly establish the patient's weight in or-caregiver der to determine equipment size, drug doses, and re- Using a suscitation volumes. What are options for estimating length-based pe-weight quickly or determining appropriate equipment diatric resuscita- size? tion tape Using the formula (2 x age in years + 10) 269. Common causes of deterioration in intubated pa- Dislodgement tients Obstruction Pneumothorax Equipm