TCRN Review Extremity and Wound Trauma Musculoskeletal Trauma, Surface and Burn Trauma with 249 Questions with Answers

TCRN Review Extremity and Wound Trauma Musculoskeletal Trauma, Surface and Burn Trauma with 249 Questions with Answers List some special considerations for abrasions. - CORRECT ANSWER Pain control - full thickness abrasions may be associated with nerve damage and may have less pain Evaporative heat loss - consider warming measures Evaporative fluid loss - consider need for fluid replacement Scarring - anesthetize wound and aggressively remove debris Define contusion. - CORRECT ANSWER Rupture of subcutaneous blood vessels with extravasation of erythrocytes. Define hematoma. - CORRECT ANSWER Rupture of artery or vein that will continue to expand until the pressure in the tissue exceeds the pressure in the ruptured vessel. Contusions and hematomas have the potential for what significant complication? - CORRECT ANSWER Compartment Syndrome List 2 special considerations related to contusions / hematomas. - CORRECT ANSWER Potential for enough blood loss to cause hypovolemia, especially in areas of the body with greater dispensability (like the thigh). Blood is a medium for bacterial growth, therefore wounds with contusions and hematomas may have a greater risk for infection. What are the treatments for contusions / hematomas? - CORRECT ANSWER Elevation Application of Ice Packs Puncture wounds have a high rate of _____. - CORRECT ANSWER Infection What treatment should be done with puncture wounds? - CORRECT ANSWER Soaking At time of discharge, what teaching should be given to a patient who sustained a puncture wound? - CORRECT ANSWER Soak wound 2-3 times per day for 2-4 days What type of bites tend to be deep wounds involving crushing of the tissue or avulsion? - CORRECT ANSWER Dog Bites Are larger bites or smaller bites more susceptible to infection? - CORRECT ANSWER Smaller. The larger size of wounds allows bacteria to exit, decreasing the incidence of infection. How many hours after a cat bite does infection usually start? - CORRECT ANSWER 12 hours What complications are often associated with cat bites? - CORRECT ANSWER Abscess, Cellulitis, Osteomyelitis Smaller puncture wounds traps bacteria increasing rate of infectious complications. What type of bites have very high infection rates? - CORRECT ANSWER Human bites How many days after a human bite does infection usually start? - CORRECT ANSWER 1-2 days after bite What diseases can be associated by human bite? - CORRECT ANSWER Hepatitis B, Hepatitis C and potentially HIV Teeth marks over knuckles from "punching someone" are associated with _____. - CORRECT ANSWER Fractures of the third and fifth metacarpal, osteomyelitis and joint infection. Wounds caused by high pressure devices (paintball gun, grease gun) can cause _____. - CORRECT ANSWER Compartment Syndrome If a device triggers releasing foreign matter into the wound, it may travel deep into the tissue separating fascial planes and causing _____. - CORRECT ANSWER Compartment Syndrome _____ requires high triage prioritization and potential surgical intervention. - CORRECT ANSWER Compartment Syndrome List the 3 types of tissue damage that occur with gunshot wounds. - CORRECT ANSWER Permanent cavity Temporary cavity Pressure Wave What is the permanent cavity associated with a gunshot wound? - CORRECT ANSWER Penetrating trauma following the path of the projectile What is the temporary cavity associated with a gunshot wound? - CORRECT ANSWER Crush injuries around the permanent cavity caused by temporary displacement of tissue as the projectile moves through the tissue. What is the pressure wave associated with a gunshot wound? - CORRECT ANSWER Damage in areas adjacent to the permanent cavity as the projectile moves through the tissue (increased damage to hollow organs). In gunshot wounds, the faster the projectile is moving as it passes through the tissue, the _____. - CORRECT ANSWER Greater the size of the temporary cavity and pressure wave. The longer the barre of the firearm, the _____ the projectile will strike the patient. - CORRECT ANSWER Faster The farther the patient is from the firearm when it is fired, the _____ the projectile will be moving as it enters the body. - CORRECT ANSWER Slower _____ has more impact on wounding potential than the size of the projectile. - CORRECT ANSWER Speed When dealing with projectiles, it is important to remember that _____. - CORRECT ANSWER The path of the projectile is unpredictible. Especially if it hits bone. Does the site of projectile entry always predict the path within the body? - CORRECT ANSWER No. This is why you mark the entry site with a paperclip. What are the 2 types of bullets? - CORRECT ANSWER Full Metal Jacket Hollow-Point How do full metal jacket bullets usually injure tissue? - CORRECT ANSWER Tend to stay intact and pass cleanly through tissue How do hollow point bullets usually affect tissue? - CORRECT ANSWER Tend to deform increasing energy transfer to the tissue and increases tissue damage. It is less likely to exit the body. List some characteristics of high velocity projectiles. - CORRECT ANSWER They may splinter bone, rupture blood vessels, and break apart, causing injury to tissue far from the initial pathway. Describe what a close range shotgun wound (birdshot) does. - CORRECT ANSWER At close range, pellets act as one mass causing massive tissue destruction. Describe what a far range shotgun wound (birdshot) does. - CORRECT ANSWER At farther range, pellets scatter and tissue penetration is significantly reduced to superficial skin or deep fascia. What is the priority with an amputation? - CORRECT ANSWER Control hemorrhage What are 4 ways to control hemorrhage on an amputation? - CORRECT ANSWER Direct pressure over stump Compress artery above the site Elevate the extremity Apply tourniquets as needed Give 2 facts about tourniquet placement. - CORRECT ANSWER Place as close to the amputation as possible Release the tourniquet as soon as the hemorrhage is controlled Describe how to care for an amputated part. - CORRECT ANSWER Remove dirt and debris from exposed end Wrap in slightly saline-moistened sterile gauze Place in a sealed bag Place on ice Why do you not allow water onto an amputated limb? - CORRECT ANSWER Water is hypotonic and can cause tissue edema. Should you allow an amputated part to freeze? - CORRECT ANSWER No Define compartment syndrome - CORRECT ANSWER Increase in pressure inside a fascial compartment. What are the potential complications of a crush injury? - CORRECT ANSWER Compartment Syndrome Hyperkalemia Rhabdomyolysis Hypovolemia What are the 6 P's of Compartment Syndrome? - CORRECT ANSWER Pain Pressure Pallor Pulses Paresthesia Paralysis Which of the 6 P's of compartment syndrome are late signs? - CORRECT ANSWER Pallor, Pulses, Paresthesia, Paralysis Describe the pain associated with compartment syndrome - CORRECT ANSWER Pain out of proportion to injury (often described as tightness, burning or searing) Pain not relieved by narcotic medications Pain on passive motion (pain when the muscle is stretched) Describe the pressure associated with compartment syndrome - CORRECT ANSWER Limb feels tight or tense on palpation Skin may appear taut or shiny Describe the Pallor of compartment syndrome - CORRECT ANSWER Indication of poor perfusion (may include delayed capillary refill and cool temperature) Describe pulses in compartment syndrome - CORRECT ANSWER Weak or absent pulses are a poor indicator for positive outcomes Describe paresthesia in compartment syndrome. - CORRECT ANSWER Numbness, tingling, loss of sensation (may result in a loss of pain that may give a false sense of improvement) Describe paralysis in compartment syndrome. - CORRECT ANSWER Indicates injury to the nervous system. How is compartment syndrome diagnosed? - CORRECT ANSWER Measurement of intra-compartmental pressure using a manometer What is normal compartment pressure? - CORRECT ANSWER 0-10 mmHg What is considered elevated compartment syndrome? - CORRECT ANSWER >20 mmHg What compartment pressure causes ischemia to the muscles and nerves? - CORRECT ANSWER >30 mmHg What are the treatments for Compartment Syndrome? - CORRECT ANSWER Remove external pressure (casts, splints, dressings) Elevate limb TO (not above) level of the heart Anticipate fasciotomy, surgical debridement or amputation In compartment syndrome, hyperkalemia peaks _____ hours after the injury. - CORRECT ANSWER 12-36 hours after the injury then steadily decreases What is the treatment for hyperkalemia in compartment syndrome? - CORRECT ANSWER Cardio-Protection: calcium gluconate Temporary K reduction: insulin/glucose and /or nebulized beta-adrenergic agonists (like albuterol) Permanent K reduction: diuresis, intestinal potassium binders (kayexalate) or dialysis Define Rhabdomyolysis - CORRECT ANSWER Release of myoglobin from severe muscular or cellular destruction List 7 signs and symptoms of rhabdomyolysis. - CORRECT ANSWER Muscle Pain Numbness Changes in Sensation Weakness / Paralysis Dark red or brown urine Generalized weakness/malaise Elevated creatinine kinase levels (ck) What are the treatments and goals of rhabdomyolysis? - CORRECT ANSWER IV isotonic crystalloids (NS/LR) with a goal of UO 100 mL/hr Alkalinization of urine with sodium bicarbonate or osmotic diuretics with a goal of urine pH above 8.0 Hemodialysis, peritoneal dialysis, renal replacement therapy with a goal of preservation of the kidneys Why should imbedded objects be left in place? - CORRECT ANSWER They may be tamponading underlying bleeding. Is hair removal around wounds encouraged or discouraged? - CORRECT ANSWER Discouraged. If needed, use scissors or clippers, do not shave. What solution should be used to irrigate wounds? - CORRECT ANSWER Copious amounts of normal saline What type of irrigation works best to remove smaller contaminants and bacteria? - CORRECT ANSWER high-pressure irrigation What body parts should not receive lidocaine with epi? - CORRECT ANSWER Digits Penis Ears Tip of the Nose Avulsions Grossly contaminated wounds What types of foreign bodies are not seen on x-ray? - CORRECT ANSWER Vegetative matter such as splinters, thorns, cactus splines Plastic What diagnostics are used to find matter that does not show up on x-ray? - CORRECT ANSWER CT, Sono or MRI List and describe the 3 types of wound closure. - CORRECT ANSWER Primary - Immediate Wound Closure Secondary - Wounds are allowed to close on their own over time Tertiary - Wounds closure is delayed for a period of time What type of wound closure is used for wounds with significant bacterial contamination? - CORRECT ANSWER Tertiary What type of wound closure is used for wounds with significant tissue loss? - CORRECT ANSWER Secondary What type of wound closure is used for wounds with minimal tissue loss? - CORRECT ANSWER Primary How does clay (found near excavation sites) affect wounds? - CORRECT ANSWER Clay inhibits host defense system increasing the risk of infection. What type of injuries have highest risk for tetanus infection and why? - CORRECT ANSWER Tetanus is found in animal excreta, therefore farm injuries have a higher rate of tetanus infection. Organic fractions heavily concentrated in swamps, bogs and marshes are more likely to cause _____ - CORRECT ANSWER Wound contamination. In regard to wound healing, how long should inflammation (redness/swelling) be present? - CORRECT ANSWER Until the 3rd to 5th day. Lack of inflammation during this time is concerning; inflammation beyond this time is concerning. A palpable healing ridge should be noted by the _____ day. - CORRECT ANSWER 7th to 9th day. Lack of healing ridge may be concerning. Continued drainage from an incision after the 9th day may indicate _____. - CORRECT ANSWER Lack of epithelial seal List 6 factors that may delay wound healing. - CORRECT ANSWER Poor tissue perfusion poor nutrition compromised vascular supply medications that slow collagen formation poor vascular supply advanced patient age What are some ways to increase tissue perfusion for wound healing? - CORRECT ANSWER Ensure adequate fluid resuscitation Ensure adequate patient oxygenation Hypothermia Pressure (frequent repositioning and early ambulation) What medical problems cause compromised vascular supply in wound healing? - CORRECT ANSWER history of smoking, diabetes, severe atherosclerosis What medications slow collagen formation in wound healing? - CORRECT ANSWER corticosteroids, phenytoin What medical problems cause poor vascular supply in wound healing? - CORRECT ANSWER COPD, Anemia List three types of burns. - CORRECT ANSWER Thermal Electrical Chemical Describe airway burns. - CORRECT ANSWER Inhalation of heat can lead to edema in the upper airway with advancing airway obstruction. What are some symptoms of heat inhalation burns? - CORRECT ANSWER Hoarse voice Carbonaceous sputum Burns around mouth or nares Stridor What is the treatment for heat inhalation burns? - CORRECT ANSWER Prophylactic intubation Carbon monoxide, when inhaled, crosses the alveolar membrane and has a strong affinity to hemoglobin, known as _____. - CORRECT ANSWER Carboxyhemoglobin Symptoms of carbon monoxide poisoning are dependent upon _____. - CORRECT ANSWER The percentage of hemoglobin that has converted to carboxyhemoglobin (COHb). What are the symptoms of a 5-10% carboxyhemoglobin conversion? - CORRECT ANSWER Headache, Dizziness What are the symptoms of a 10-20% carboxyhemoglobin conversion? - CORRECT ANSWER Headache, Nausea and Vomiting, Loss of coordination, Dyspnea, Flushed skin What are the symptoms of a 20-40% carboxyhemoglobin conversion? - CORRECT ANSWER Confusion, Lethargy, Visual Disturbances, Angina What are the symptoms of a 40-60% carboxyhemoglobin conversion? - CORRECT ANSWER Dysrhythmias, Seizures, Coma What are the symptoms of >60% carboxyhemoglobin conversion? - CORRECT ANSWER Cherry-Red Skin, Death What is the oxygen saturation for a patient with carbon monoxide poisoning? - CORRECT ANSWER Normal O2 sat What is the treatment for carbon monoxide poisoning? - CORRECT ANSWER 100% oxygen (until asymptomatic or COHb is less than 10%) Monitor cardiac rhythm and COHb level Hyperbaric chamber may be required for carbon monoxide poisoning resistant to oxygen or for pregnant patients Describe inhalation pulmonary injury - CORRECT ANSWER Caused by inhalation of noxious substances such as carbon or noxious fumes. List characteristics of pulmonary injury. - CORRECT ANSWER Damages mucosal cells or bronchioles Increases pulmonary capillary permeability (ARDS) Sloughing of damaged cells causing obstructed airways Decreased production of surfactant causing atelectasis How long can symptoms of pulmonary injury be delayed? - CORRECT ANSWER Up to 24 hours after injury What is the treatment and goal of pulmonary injuries? - CORRECT ANSWER Deliver oxygen with a goal of an SpO2 between 94-98%. Burns covering more than _____ of the body surface area may cause systemic inflammatory response with systemic capillary leakage. - CORRECT ANSWER 20% What is the Modified Parkland Burn Formula for Adults? - CORRECT ANSWER TBSA x 2 mL x Body Weight in Kg What is the Modified Parkland Burn Formula for Peds? - CORRECT ANSWER TBSA x 3 mL x Body Weight in Kg Using the rule of 9's, what TBSA is the head? - CORRECT ANSWER 9% in adults and 18% in peds Using the rule of 9's, what TBSA is the abdomen? - CORRECT ANSWER 18% in both adults and peds Using the rule of 9's, what TBSA is the back? - CORRECT ANSWER 18% in both adults and peds Using the rule of 9's, what TBSA is the genitalia? - CORRECT ANSWER 1% in both adults and peds Using the rule of 9's, what TBSA are the legs? - CORRECT ANSWER 18% EACH in adults and 14% EACH in peds The palmar surface of teh hand is _____ TBSA in both adults and children. - CORRECT ANSWER 1% What type of burns are considered when determining TBSA for the modified Parkland Burn formula? - CORRECT ANSWER Only partial and full thickness burns The amount of fluid determined when using the Parkland Burn Formula is the estimated fluid a patient will need in the _____ after the burn. - CORRECT ANSWER 24 Hours Because the majority of fluid shifting occurs in the first few hours after the burn, half the calculated amount should be infused by the _____ hour after the burn. - CORRECT ANSWER Eighth The remaining half of fluid determined by the Parkland Burn Formula should be infused within the remaining _____ hours. - CORRECT ANSWER 16 For children under 40 kg, urinary output should be _____. - CORRECT ANSWER 1 mL/kg/hr After fluid resuscitation begins using the Modified Parkland Burn Formula, fluids should be adjusted to _____. - CORRECT ANSWER Urinary Output Ideally, urinary output will be _____. If urinary output falls below this threshold, increase fluids by _____. If urinary output is above this threshold, decrease fluids by _____. - CORRECT ANSWER 0.5 ml/kg/hr 33% 33% In burn fluid resuscitation, which is preferred: NS or LR? - CORRECT ANSWER LR - however, you should consider using dextrose containing solutions (especially in pediatric patients) _____ burns involve only the epidermis. - CORRECT ANSWER First Degree True or False: First degree burns do not blister. - CORRECT ANSWER True Describe the pain in first degree burns. - CORRECT ANSWER Mildly irritating to pruritic to exquisitely painful. Describe the healing process of first degree burns. - CORRECT ANSWER Painful for 2-3 days, begins to peel at day 4. More vulnerable to sunburn, windburn and skin irritation for months. There are 2 types of second degree burns. _____ & _____ - CORRECT ANSWER Superficial Partial Thickness; Deep Thickness What skin layers are involved with second degree superficial partial thickness burns? - CORRECT ANSWER Epidermis and Upper Layers of Dermis What layers of skin are involved with second degree deep thickness burns? - CORRECT ANSWER Epidermis and deep dermis Describe the appearance of second degree superficial partial thickness burns. - CORRECT ANSWER Blisters (may be delayed by several hours) with pink, wet skin beneath. Blanches with pressure. Describe the appearance of second degree deep thickness burns. - CORRECT ANSWER Appears mottled white or white immediately after injury. Will either blister or appear dry with cherry red color but does not blanch. Appears white and dry by day 2. Discuss the pain associated with second degree superficial partial thickness burns. - CORRECT ANSWER Extremely painful (especially to air currents) Discuss the pain associated with second degree deep thickness burns. - CORRECT ANSWER Causes discomfort rather than pain, and area is less sensitive to touch than surrounding skin. Describe the healing process of second degree superficial partial thickness burns. - CORRECT ANSWER Heals within 3 weeks without functional impairment and rarely causes scarring. Describe the healing process of second degree deep thickness burns. - CORRECT ANSWER Takes greater than 3 weeks to heal and may require grafting. What layers of skin are involved with third degree (full thickness) burns? - CORRECT ANSWER All layers of the skin and subcutaneous fat. Describe the appearance of third degree burns. - CORRECT ANSWER May be "leathery" "firm" "depressed compared to adjoining unaffected sking" Describe the pain associated with third degree burns. - CORRECT ANSWER Insensitive to light touch or pin prick (perceptive to pressure only) Describe the healing process for third degree burns. - CORRECT ANSWER Requires surgical grafting What layers of skin are involved with 4th degree burns? - CORRECT ANSWER Extends into underlying fat, tissue, muscle and bone Describe the appearance of 4th degree burns - CORRECT ANSWER May appear similar to full thickness burn (3rd degree) obvious tissue loss often noted. Describe the pain associated with 4th degree burns. - CORRECT ANSWER Perceptive of deep pressure only. Describe the healing process of 4th degree burns. - CORRECT ANSWER Will require surgical grafting. Circumferential burns put pressure on underlying structures potentially causing _____ and may require _____. - CORRECT ANSWER Compartment Syndrome Escharotomies ____ and _____ burns have a high risk for post-burn stricture and necessitate burn center care along with intense rehabilitation. - CORRECT ANSWER Hand and Foot Perineal burns have a high risk for _____. - CORRECT ANSWER Contamination and Infection _____ is the assumption of room temperature. - CORRECT ANSWER Poikelothermy Describe burn wound care - CORRECT ANSWER Cover with clean dry dressing or sheets to reduce air currents do NOT apply ice Insert gastric tube for burns greater than 20% TBSA Maintain body temperature at normal Patient with TBSA > _____ require a gastric tube. - CORRECT ANSWER 20% Why is it important to know that electricity seeks the path of least resistance? - CORRECT ANSWER Skin and bone resist electricity; muscle, blood and nerve do not Electric burns are typically seen at the point of _____ creating surface burns. - CORRECT ANSWER Entry and Exit Electricity will seek _____. - CORRECT ANSWER The Ground Alternating Current (AC) causes _____ - CORRECT ANSWER Muscle tetany and may produce more severe burns. Which type of current may change directions? - CORRECT ANSWER AC Alternating Current Direct Current (DC) decreases contact with the electrical source and _____. - CORRECT ANSWER May cause less severe burns. Which type of current goes in one direction? - CORRECT ANSWER DC Direct Current After an electrical burn, what should be monitored? - CORRECT ANSWER Monitor for Compartment Syndrome Monitor for fractures and cervical spine injuries due to violent muscular contractions during electrocution Damaged muscles may cause _____. (3) - CORRECT ANSWER Hyperkalemia Rhabdomyolysis Elevated CK levels _____ of patients have arrhythmias after electrical burns. - CORRECT ANSWER 25% When do cardiac arrhythmias occur in association with electrical burns? - CORRECT ANSWER Most occur right after the shock, but may occur up to 12 hours later. What type of cardiac abnormalities may occur and resolve spontaneously after electrical shock? - CORRECT ANSWER T wave and ST abnormalities Fatal arrhythmias are more common in _____. - CORRECT ANSWER Horizontal injuries (arm to arm) Do electrical burns require fluid replacement? - CORRECT ANSWER Yes. But fluids are difficult to determine because the TBSA is not known. How much fluids are given to patients who experience electrical burns? - CORRECT ANSWER Start with 20 ml/kg bolus and adjust as needed to maintain a urinary output of 1 mL/kg/hr What other treatments are necessary for patients who experience electrical burns? - CORRECT ANSWER Continuous cardiac monitoring Osmotic diuretics (enhance urinary output) Sodium bicarbonate to alkalinize urine Monitor for Compartment Syndrome All patients potentially exposed to a chemical should be _____. - CORRECT ANSWER Redirected from the hospital to separate area to minimize contamination of other individuals. What activity occurs in a HOT zone? - CORRECT ANSWER Undressing (removes 75-90% of the chemical) and life-saving medical care. Which individuals are placed in a HOT or a WARM zone? - CORRECT ANSWER Reserved for contaminated individuals and rescuers wearing appropriate protective equipment What activity occurs in a WARM zone? - CORRECT ANSWER Rinse with warm water (soap and shampoo as available) for 5 minutes until the patient states the burning sensation has stopped. The patient should stand with arms and legs spread apart, cleansing from back to front, head to toe. Which individuals are placed in a COLD zone? - CORRECT ANSWER Reserved for decontaminated individuals. Rescuers do not have to wear protective equipment. What activity occurs in a COLD zone? - CORRECT ANSWER Provide all appropriate medical care (use local burn center and/or poison control as resource). How are dry chemicals contained? - CORRECT ANSWER Remove clothing first using caution not to scatter any of the agent. Brush remaining chemical off the skin before cleansing with water. How do you treat a Hydrofluoric Acid burn? (industrial purposes) - CORRECT ANSWER Irrigate with water for 30 minutes. Apply calcium chloride gel to exposed area, changing gel every 15 minutes until the burning stops. Monitor for hypocalcemia (including prolonged QT interval) and administer IV calcium as needed. How do you treat a tar or asphalt burn? - CORRECT ANSWER Immediately cool the tar and asphalt with cool compresses or cool water. Remove the cooled tar or asphalt with fat emollient (mayonnaise, cooking oil, bacitracin ointment, mineral oil, petrolatum, medisol or shur-clens). What are some examples of phenols? - CORRECT ANSWER Disinfectant / Carbolic Acid How do you treat phenol burns? - CORRECT ANSWER Irrigate copiously with water followed by application of 50% polyethylene glycol (PEG). Phenol burns cause a thick eschar to the affected area if not removed quickly. What are some examples of hydrocarbons? - CORRECT ANSWER Natural gases / Fuels How do hydrocarbons cause burns? - CORRECT ANSWER Hydrocarbons cause cell membrane dissolution and skin necrosis, leaving burns that are typically superficial and heal spontaneously. Skin will appear reddened and blistered. What are complications of hydrocarbon burns? - CORRECT ANSWER Respiratory failure and hepatic injury (delayed) All patients potentially exposed to _____ should be redirected from the hospital to a separate area to minimize contamination of other individuals. - CORRECT ANSWER Radiation It is important to remember that radiation can cause external contamination (skin and clothes) as well as _____. - CORRECT ANSWER Penetrate tissue to cause internal contamination. Which individuals go in a Radiation HOT or Radiation WARM zone? - CORRECT ANSWER Reserved for contaminated individuals and rescuers wearing appropriate protective equipment. Which individuals go in a Radiation COLD zone? - CORRECT ANSWER Reserved for decontaminated individuals. What activities occur in a Radiation HOT zone? - CORRECT ANSWER The patient should be undressed as radiation on the clothing can be aerosolized putting others at risk of contamination. What activities occur in a Radiation WARM zone? - CORRECT ANSWER Rinse with warm water (soap and shampoo as available). The clothing can be removed once it is soaking wet. What activities occur in a Radiation COLD zone? - CORRECT ANSWER Provide all appropriate medical care. Precautions must be taken for any fluids emanating from the patient (urine, blood, feces, etc.) which can be contaminated. What are the indications of radiation sickness? - CORRECT ANSWER Nausea, vomiting, diarrhea, malaise, anorexia, GI bleeding Surface burns (skin will be red and moist like a partial thickness burn, but without blistering). How do you test the radial nerve? - CORRECT ANSWER Loss of sensation to web space between thumb and first finger and base of thumb Test for ability to move thumb ("hitchhiker sign") What injuries are associated with the radial nerve? - CORRECT ANSWER Humerus fractures, elbow injuries How do you test the Median Nerve? - CORRECT ANSWER Loss of sensation to the palm of the hand as well as the second and third finger Test the ability to make a fist or bring the thumb across the palm to the fifth finger. What injuries are associated with the Median Nerve? - CORRECT ANSWER Elbow and wrist injuries How do you test the Ulnar Nerve? - CORRECT ANSWER Loss of sensation to the Forth and Fifth fingers and the area of the hand below these fingers. Test the ability to fan the fingers. What injuries are associated with the ulnar nerve? - CORRECT ANSWER elbow, forearm and wrist injuries How do you test the Femoral Nerve? - CORRECT ANSWER Loss of sensation to anterior surface of the thigh and medial lower leg from the knee to the ankle. Test the ability to extend the knee against resistance or flex the hip against resistance What injuries are associated with the Femoral Nerve? - CORRECT ANSWER Pelvic, hip and femur injuries How do you test the Tibial Nerve? - CORRECT ANSWER Loss of sensation to the plantar aspect of the foot. Test the ability to plantar flex the ankle and toes. What injuries are associated with the Tibial Nerve? - CORRECT ANSWER Knee and ankle injuries How do you test the Peroneal Nerve? - CORRECT ANSWER Loss of sensation to the dorsal aspect of the foot. Test the ability to dorsiflex the ankle and toes. What injuries are associated with the Peroneal Nerve? - CORRECT ANSWER Knee and ankle injuries What is Volkmann's Contracture? - CORRECT ANSWER Contracture of the muscles distal to a nerve impingement or injury. Prevention of Volkmann's Contracture includes: - CORRECT ANSWER Expedient recognition of nerve injuries/compression as well as appropriate reduction of fractures/dislocations to reduce the incidence and severity of the contracture. What is the treatment for open fractures? - CORRECT ANSWER Cover wounds with saline soaked gauze and anticipate antibiotics and surgical repair. When can a fat emboli occur? - CORRECT ANSWER May occur after 12 hours and up to two weeks after a long bone fracture. When are fat emboli most common? - CORRECT ANSWER 24-72 hours after the fracture. List the symptoms of fat emboli. - CORRECT ANSWER Altered mentation (decreased LOC, restless, agitated) Respiratory distress Tachycardia and Hypotension Petechial rash on head, neck, anterior thorax, conjunctivae buccal mucos membranes and axillae How are Fat Emboli diagnosed? - CORRECT ANSWER CT CXR will show patchy infiltrates ABG What is the treatment for fat emboli? - CORRECT ANSWER Oxygenation and Ventilation Correction of Hemodynamic Instability What is the treatment for clavicular and scapular fractures? - CORRECT ANSWER Sling and Rest What are some complications of clavicular and scapular fractures? - CORRECT ANSWER Complications include large vessel injury, rib fractures and cervical spinal fractures. Scapular fractures are rare and associated with great force, may also cause brachial plexus injuries, splenic injuries, and humerus fractures. What is the brachial plexus? - CORRECT ANSWER A network of nerves from the spine to the arm to the hand. What are the symptoms of an anterior shoulder dislocation? - CORRECT ANSWER Visible deformity with abduction and external rotation of the arm. Will be unable to bring the affected arm high enough to touch the ear on the opposite side of the dislocation. What are the symptoms of a posterior shoulder dislocation? - CORRECT ANSWER Arm held in adduction with internal rotation and visible deformity. What are the treatments for shoulder dislocation - CORRECT ANSWER Shoulder immobilizer Sling and swathe to the body How many shoulder fractures require surgical intervention? - CORRECT ANSWER 20% Describe older vs. younger patients and shoulder injuries. - CORRECT ANSWER Older people fracture their shoulder and younger people tend to dislocate their shoulder. How are anterior shoulder dislocations typically caused? - CORRECT ANSWER Falling on an outstretched arm. How are posterior shoulder dislocations typically caused? - CORRECT ANSWER Rare injury caused by arm being forced while extended ( may be seen after seizure ) What is the treatment for a mid-shaft humerus fracture? - CORRECT ANSWER Allow arm to hang so the weight of the elbow helps reduce the fracture. May require casts and slings or surgery, depending on the severity and nerve involvement. What are common complications of a mid-shaft humerus fracture? - CORRECT ANSWER Brachial artery injury (may lose up to 750 mL of blood) Radial nerve damage Fat Emboli What are symptoms of nurse maid's elbow (dislocation of the radial head)? - CORRECT ANSWER Refusal to use the arm with limited supination (can flex and extend the elbow) What is the treatment for nurse maid's elbow? - CORRECT ANSWER Easily reduced with manipulation Nurse maid's elbow dislocations tend to recur until age _____. - CORRECT ANSWER 5 What are the symptoms of a complete elbow dislocation? - CORRECT ANSWER Obvious loss of arm length and rapid swelling What is the common mechanism of a complete elbow dislocation? - CORRECT ANSWER FOOSH Fall on outstretched hand. What are some complications of a complete elbow dislocation? - CORRECT ANSWER Frequently has neurovascular involvement (Brachial artery laceration, median nerve impingement or damage) What is the treatment for a displaced elbow fracture with nerve involvement? - CORRECT ANSWER Surgical intervention What is important when assessing an elbow injury? - CORRECT ANSWER Assess for brachial artery involvement Assess for nerve involvement (median nerve is most vulnerable) What is a Monteggia's Fracture? - CORRECT ANSWER Fracture of the proximal 1/3 of the ulna with radial head dislocation What is a Nightshift Fracture? - CORRECT ANSWER Fracture of the mid-shaft of the ulna from a direct blow. What is the treatment for a forearm fracture? - CORRECT ANSWER Closed reduction with cast application (cast applied with elbow flexed at 90 degrees) What important parent teaching should occur with children with forearm fractures? - CORRECT ANSWER Prevent dependency of arm or drooping of wrist inside sling after cast application What is a Smith's Fracture? - CORRECT ANSWER Wrist fracture that takes on the appearance of a hoe when visualized laterally What is a Colle's Fracture? - CORRECT ANSWER Wrist fracture that takeson the appearance of a fork when visualized laterally Falling on the back of the hand causes upward displacement of the distal radius and ulna called a _____. - CORRECT ANSWER Smith's Fracture Falling on the front of the hand causes downward displacement of the distal radius and ulna called a _____. - CORRECT ANSWER Colle's Fracture What are the symptoms of a scaphoid fracture? - CORRECT ANSWER Wrist pain / pain with pressure on the snuff box area of the hand. What is the treatment for a scaphoid fracture? - CORRECT ANSWER Cast with the thumb in opposition What are the symptoms of an anterior hip dislocation? - CORRECT ANSWER Extreme external rotation, less pronounced abduction and flexion What are the symptoms of a posterior hip dislocation? - CORRECT ANSWER Hip flexed, internally rotated and adducted A hip dislocation must be reduced within _____ hours to prevent _____. - CORRECT ANSWER 6 Femoral head necrosis What is the treatment for a femur fracture? - CORRECT ANSWER Apply a traction splint: utilized for mid-shaft femur fractures and fractures of the upper 1/3 of the tibia. What types of leg fractures DO NOT get traction splints placed? - CORRECT ANSWER Injuries involving the hip, lower tibia/fibula or ankle What are the complications of a femur fracture? - CORRECT ANSWER Hypovolemia (average blood loss = 1000 ml but can exceed 3000 ml. Damage to the peroneal nerve, sciatic nerve and popliteal artery What are common complications of a knee fracture or dislocation? - CORRECT ANSWER Damage to the peroneal/tibial nerve and popliteal artery involvement What is the treatment for a patellar fracture? - CORRECT ANSWER Application of knee immobilizer or surgical intervention Of the lower leg, which type of fracture may be able to bear weight with pain? - CORRECT ANSWER An isolated fibula fracture What are the common complications of a tib/fib fracture? - CORRECT ANSWER Blood loss (up to 2L) infection with open fractures soft tissue damage neurovascular compromise What are the complications of ankle dislocations/fractures? - CORRECT ANSWER Neurovascular compromise Peroneal nerve is more commonly affected Describe the symptoms of an achilles tendon rupture. - CORRECT ANSWER Sudden sharp pain or "pop" in the heel, flat foot, unable to stand on the ball of the foot, or plantar flex the foot. What is the treatment for an achilles tendon rupture? - CORRECT ANSWER Splint the foot in plantar flexion, crutches for ambulation, surgical repair What is a common mechanism for an achilles tendon rupture? - CORRECT ANSWER Sudden forced plantar flexion, or unexpected dorsiflexion, especially if associated with use of fluoroquinolone medications or direct steroid injections into the tendon What are the symptoms of a calcaneous fracture? - CORRECT ANSWER Pain with hyperfelxion of the foot Describe the common mechanisms for calcaneous fractures. - CORRECT ANSWER Associated with falls resulting in feet-first landing, causing axial loading with potential vertebral fractures and tibial plateau fractures.