TNCC Study Guide Quiz Questions and Correct Answers

TNCC Study Guide Quiz Questions and Correct Answers What roles are vital to a trauma team? - Ans: 1. Patient 2. Team leader 3. Core team 4. Contingency and support services What are the characteristics of an effective team? - Ans: 1. Clear roles and responsibilities 2. Shared mental model 3. Optimize resources 4. Strong team leadership 5. Engage in regular discipline of feedback 6. Strong sense of collective trust and confidence 7. Create mechanisms to cooperate and coordinate 8. Manage and optimize performance outcomes 9. Interdependent and adaptive What are the key foundations to successful teamwork in the care of the trauma patient? - Ans: 1. Communication 2. Cooperation 3. Coordination What tools can be used to promote communication within a team member? What are the benefits of each? - Ans: 1. *SBAR:* Situation, Background, Assessment, Recommendations-To provide a framework for communication among members of the healthcare team 2. *DESC:* Describe the specific situation or behavior, Express your concerns or how the situation makes you feel, Suggest alternatives and seek agreement, state Consequences in terms of impact on performance goals-Used in conflict management, paraphrasing the other person's comments is an important technique that should be done throughout the DESC support 3. *CUS:* I am Concerned, I am Uncomfortable, This is a Safety issue/I am Stressed-Used to "stop the line" if a team member senses or discovers an essential safety breach Kinematics - Ans: The study of energy transfer as it applies to identifying actual or potential injuries Biomechanics - Ans: The general study of forces and their effects Mechanism of Injury - Ans: How external energy forces in the environment are transferred to the body Newton's First Law of Motion - Ans: A body rest will remain at rest, and a body in motion will stay in motion Newton's Second Law of Motion - Ans: Force = mass x acceleration Newton's Third Law of Motion - Ans: For every action, there is an equal and opposite reaction Law of Conservation of Energy - Ans: Energy can neither be created nor destroyed, but can change form Describe how Newton's Laws of Motion and the Law of Conservation affect energy transfer in traumatic injury, and give an example - Ans: -1st: weight and speed are reasonable substitutions for mass and velocity, higher mass and/or higher speed delivers greater energy -2nd: an object's velocity changes when it is subjected to an external force; heavier objects require more force to accelerate (or decelerate) them -3rd: -Conservation: Ex: pot vs. child -1st: the force of gravity holds the pot on the flat stovetop until energy is transferred to the pot, such as by a toddler, grabbing the handle.Once the pot is in motion, it will sustain its motion until interrupted by another force. As the pot strikes the child in the head, the strength of bone imposes a force of resistance upon impact, thereby changing the directional path of the pot. The stationary head stays in a fixed position until a volume of energy adequate to move the head is transferred to it. This concept of movement-energy transfer-countermovement applies to all mechanical traumas -2nd: the pot continues to fall at a steady rate unless it is acted on by an outside force (a hand pushing it out of the way or catching it) -3rd: the transfer causes a redirection of the pot and movement of the head, as well as energy absorption causing anatomic changes to the tissue that received the energy transfer -Conservation: energy is not created, nor it is destroyed at the site where the pot impacts the head. Instead, energy is transferred from the kinetic (moving) object to the object being impacted What are the five forms in which energy exist? - Ans: 1. *Mechanical:* energy transfer form one object to another in the form of motion 2. *Thermal:* energy transfer of heat in the environment to the host 3. *Chemical:* heat energy transfer from active chemical substances, chlorine, drain cleaner, acids, or plants 4. *Electrical:* energy transfer from light socket, power lines, or lightning 5. *Radiant:* energy transfer from blast sound waves, radioactivity such as a nuclear facility, or rays of the sun Differentiate between internal and external forces of energy transfer in the context of trauma - Ans: *External forces:* -Can be exerted on the body by deceleration, acceleration, compression forces -Deceleration forces include those applied in falls and collisions where injuries are cause by a sudden stop in the body's motion -Acceleration forces are not as common as deceleration forces and result from a sudden and rapid onset of motion, like a parked car that is hit y vehicle traveling at the high rate of speed -Compression force is an external force applied at time of impact, like stationary objects-dashboards or steering wheels that collide with or push up into a person. Objects in motion-bullets, stabbing, bats, balls, fists and feet, or heavy falling objects -Blast forces *Internal forces:* -Stress describes the internal force that resists the applied external force -Stress is exerted on the body as tissues and organs change their dimensions -Body tissues respond differently to energy impact, and the capacity to withstand energy transfer is based on the characteristics, combined with biomechanics and MOIs -The strength of bone varies and can be augmented by adjacent muscle systems -Solid organs tolerated pressure-wave energy better than air-filled organs -Air-filled organs can often resist shear forces better than solid organs How do internal forces protect the body from injury? - Ans: -*Compression strength:* ability of tissue to resist crush injury or force -*Tensile strength:* ability to resist being pulled apart when stretched -*Shear strength:* ability to resist a force applied parallel to the tissue The various strengths of tissue, especially bone, can be augmented or diminished by the pre-event circumstances. The muscle density surrounding bone absorbs energy of compressing and shearing forces. Tensile strength is augmented by the strength of opposing muscles. The tissue most proximal to the point of impact is affected by the maximum amount of energy from the object striking the tissue, or maximal energy. As energy transverses tissue, it is absorbed by cells. As a result of this cellular energy absorption, the net energy available for transfer is attenuated over distance -If the flat bottom of the pot fell squarely on top of the toddler's head, the tissue would be strained primarily by the transfer of compressive energy-soft tissue flattens, and depending on the amount of energy transfer present, tissues may rupture, the microvasculature may rupture resulting in a hematoma, or skin may rupture resulting in laceration, or bone may be crushed resulting in fracture -If the pot struck the toddler on the side of the head in a glancing manner, the skin may experience tensile or stretching strain more than compression strain. Skin characteristically stretches; however, if the energy transfer is sufficient to exceed skin's tensile strength, a laceration is likely to result List the four main types of traumatic injury and give an example of each - Ans: 1. *Blunt trauma:* falls, MVA, vehicle vs. pedestrian collisions, assaults 2. *Penetrating trauma:* gunshots, cavitation 3. *Thermal trauma:* burns 4. *Blast trauma:* explosions Differentiate between deceleration and acceleration forces - Ans: *Deceleration forces:* occurs as energy that is dispersed from the moving object. For example, a body sliding across pavement transfers energy to the pavement through friction *Acceleration forces:* the sample principles used to describe deceleration forces apply to acceleration forces. For example, as energy is slowly transferred to the stationary pieces of gravel, the gravel accelerates while the body and internal organs continue to travel as a single entity What environmental and pathophysiologic factors are considered when the mechanism of injury is a fall? - Ans: Consider the old adult who becomes dizzy and falls from a standing position. The energy transfer begins as the patient begins to fall through the air. When the patient falls to the ground, the impact of the ground or floor causes energy to transfer and injuries related to the following: 1. The point of impact on the patient's body (head, hip, outstretched arm) determines the major point of energy transfer and underlying injuries or tissues impacted 2. The type of surface that is hit (tile floor, grassy yard, carpeted floor) and the extent that surface can absorb the energy affects injuries. Carpet and grass can help to absorb energy, but tile does not 3. The tissue's ability to resist also affects potential injuries, bone is less flexible than soft tissue. Air-filled organs may rupture; solid organs may fracture 4. If a person is pushed or accidentally knocked down, acceleration increases, causes additional transfer of energy, and results in a greater impact on deceleration Describe the three impacts in the motor vehicle impact sequence - Ans: 1. The first impact occurs when the vehicle hits another object such asa tree. The occupants experience a relative acceleration as the vehicle stops over the distance of the crushing metal, but they have not begun to absorb the energy if the abrupt vehicle stop 2. The second impact occurs when the vehicle occupant collides with the interior of the vehicle, yet the internal organs continue in motion. After the initial impact, the occupant continues to move in the original direction of travel until they collide with the interior of the vehicle or meet the resistance of a seatbelt or airbag 3. The third impact occurs when internal structures collide within the body cavity. The organs meet the resistance of the structures that encapsulate them and/or are town loose and continue in motion until they meet the resistance of another structure Define the five mechanisms of injury in blast trauma - Ans: 1. *Primary:* injuries are found in those closest to the detonation, with enclosed space detonation resulting in the most lethal impacts. Air-filled organs (tympanic membranes, lungs, stomach, and bowel) are most susceptible to rupture with primary blast injuries 2. *Secondary:* fragment injuries and generally cause the greatest volume of casualties. They can include injuries such as puncture wounds, lacerations, and impaled objects 3. *Tertiary:* include impacts with larger objects propelled by the bast wind resulting in blunt trauma. These cause high energy transfer and can result in pelvic or femur fractures or major thoracic injuries such as aortic and great vessel rupture 4. *Quaternary:* result of heat, flame, gas, and smoke. These injuries include external burns and internal burns from inhale hot gases 5. *Quinary:* those associated with exposure of hazardous materials from radioactive, biologic, or chemical components of a blast Describe the usefulness of the Haddon Matrix in prevention and reduction of injury - Ans: -Changing human behavior as a means of preventing injury, primarily in MVCs -Places emphasis of countermeasures, which are more effective on changing human behavior -Led to the introduction of passive restraints, airbags, vehicle design, and road blueprints as opposed to active restraints -Describes three phases of the injury event: pre-event, the event, and post-event -For each phase of the event, countermeasures for prevention can be applied -They include the host (human), the agent (motor vehicle), and the physical environment (socioeconomic environment) Example Pre-event: -Host: driver is studying for exams and did not get much sleep -Agent: motor vehicle is old, small and not well designed for crash protection -Physical environment: it is raining -Socioeconomic environment: driver was at. party and had 2-3 drinks Event: -Host: driver did not see the sign to slow down for a curve ahead -Agent: vehicle tires are worn -Physical environment: the exit ramp roadway slants outward and not inward (centrifugal force) -Socioeconomic environment: occupants are arguing and radio has loud music playing Post-event: -Host: driver has a history of diabetes -Agent: seats break apart and occupants trapped -Physical environment: temperature below 38 F -Socioeconomic environment: people drive by but delay in notifying 911 Fill in the blanks of the steps of initial assessment: Preparation and _____ Across-the-room observation to identify any uncontrolled ___________ and reprioritize to ___________________ - Ans: Preparation and triage Across-the-room observation to identify any uncontrolled hemorrhage and reprioritize to CABC Primary survery - Ans: A-Airway and Alertness with simultaneous cervical spine stabilization B-Breathing and ventilation C-Circulation and Control of hemorrhage D-Disability (neurologic status) E-Exposure and Environmental control Resuscitation Adjuncts - Ans: F-Full set of vital signs and Family presence G-Get resuscitation adjuncts: L-Laboratory studies: ABGs, blood type and screen M-Monitor for continuous cardiac rhythm and rate assessment N-Nasogastric or orogastric tube consideration O-Oxygenation and ventilation analysis: Pulse oximetry and end-total CO2 monitoring and capnography P-Pain assessment and management Reevaluation for signs of internal uncontrolled hemorrhage and ________ - Ans: Pneumothorax Secondary survey with reevaluation adjuncts - Ans: H-Head to toe assessment I-Inspect posterior suface Reevaluation and post resuscitation care Definitive care or transfer Why is there repeated emphasis on assessment for hemorrhage throughout the initial assessment? - Ans: Uncontrolled hemorrhage is the major cause of preventable death after injury Which tool can be used to rapidly assess the LOC during A-Airway and Alertness step? Why is it important to determine alertness along with airway? What are the components of this tool? - Ans: A - Alert V - Verbal stimuli; if verbal stimuli needed to respond, an airway adjunct may be needed to keep to keep tongue from obstructing airway P - Responds to pain; if pt responds only to pain, may need airway adjunct while determining need for intubation U - Unresponsive; announce loudly to team; get someone to check for pulse while you assess airway Uses LOC to determine need for airway Airway may be compromised with V,P, or U What method of opening airway is recommended for use in trauma? - Ans: Jaw thrust Describe the current guidelines for volume resuscitation in hemorrhagic shock - Ans: Component therapy is now suggested for fluid resuscitation to replace patient losses, including administer red blood cells, plasma, and platelets. This balanced approach to resuscitation includes massive transfusion so that oxygen delivery is optimized, acidosis is correct, coagulopathy is prevented, and damage control surgery is performed Exposure and environmental control is included in the Primary survey. Why is it such a high priority? - Ans: Hypothermia combined with hypotension and acidosis is a potentially lethal combination in the injured patient. This assessment parameter is intentionally placed in the primary survey in order to assure that aggressive measures are taken to prevent the loss of body heat G used to represent only Give comfort measure (pain). It has expanded now to Get resuscitation adjuncts and includes multiple adjuncts used during the resuscitation phase. List the components of Get resuscitation adjuncts - Ans: *L-Laboratory studies:* -ABGs or in some cases, venous blood gases, blood type and crossmatch -Lactic acid is an excellent reflection of tissue perfusion-high levels are associated with hypoperfusion and a lactic acid level greater than 2 to 4 mmol/L is associated with poor outcomes -ABGs provide values of oxygen, CO2, and base excess, which are reflective of endpoint measurements, ventilation, and the success of resuscitation-an abnormal base deficit may indicate poor perfusion and tissue hypoxia, which results in the generation of hydrogen ions and metabolic acidosis, a base deficit of less than -6 is associated with poor outcomes *M-Monitor cardiac rate and rhythm:* compare the patient's pulse to the monitor rhythm Dysrhythmias- such as PVCs, a-fib, or S-t segment changes may indicate blunt cardiac trauma.PEA may point to cardiac tamponade, tension pneumothorax, or profound hypovolemia *N-Naso- or orogastric tube consideration:* the insertion of a gastric tube provides for evacuation of stomach contents and the relief of gastric distention. May help optimize inflation of the lungs and prevent vomiting and/or aspiration. *If mid-face fractures or head injury are suspected, the oral route is preferred*. Maintain cervical spine immobilization and ensure that suction equipment is readily available *O-Oxygenation and ventilation assessment:* pulse oximetry detects changes in oxygenation that cannot be readily observed clinically, it is a non-invasive and measures the oxygen saturation (SpO2) of arterial blood or percentage of bound hemoglobin. A pulse oximetry reading of 95% or greater is viewed as convincing evidence that peripheral arterial oxygenation is adequate. Oximetry offers a measurement of oxygen saturation and not evidence of ventilation. ETCO2 monitoring (or capnography) provides instantaneous informatio Part of the history in the Secondary survey is a review of the prehospital report using the mnemonic MIST. What are the components of a MIST report? - Ans: M-MOI I-Injuries sustained S-Signs and symptoms (in the field) T-Treatment (in the field)--can be used as a guide Discuss why the insertion of a urinary catheter is no longer part of the primary survey? - Ans: Urinary tract infection in the healthcare setting are strongly associated with the presence of an indwelling catheter and alternate methods should be considered before placement Valid indications for the insertion of a urinary catheter include: urinary obstruction or retention, alternation in BP or volume status, the need to determine accurate input and output and the patient is unable to use a urinal or bedpan, emergency surgery or major trauma, urologic procedures or bladder irrigation, comfort care for the terminally ill Describe the endpoints of resuscitation and their normal values - Ans: Base deficit/excess: -2-+2, -6 associated with poor outcomes ABG: CO2 35-45, O2 62-84 Lactic acid: 2-4 Differentiate between: SaO2 SpO2 PaO2 FiO2 - Ans: SaO2: Percentage of hgb saturated with oxygen; determined by ABG SpO2: Pulse oximetry reading of arterial oxygen saturation (SaO2) PaO2: Partial pressure of oxygen dissolved in arterial blood; reflection of tissue oxygenation FiO2: Inspired concentration of oxygen measured in fraction; more commonly referred to as percentage *room air is approx. 0.21 or 21% FiO2* Ventilation - Ans: Movement of air in and out of lungs Diffusion - Ans: Passive movement of gases from area of high concentration to area of lower concentration Perfusion - Ans: Movement of blood to and from the lungs as a delivery medium of oxygen to the entire body What is the most common cause of airway obstruction in the patient with altered mental status? - Ans: The tongue can be a common cause of obstruction with patients who are not alert Identify contributing factors to ineffective ventilation - Ans: 1. Altered mental status from brain injury, prolonged LOC, increased intracranial pressure (ICP), hypoxia, or medication, substance, ETOH 2. Trauma in the high cervical spine with disruption of the sympathetic pathways 3. Spinal cord injury (SCI) with possible involvement of the phrenic nerve resulting in hypoventilation 4. Penetrating thoracic trauma resulting in a hemothorax or a pneumothorax 5. Pre-existing history of respiratory disease 6. Increased age with decreased pulmonary reserve 7. Tachypnea as compensation for diminished oxygenation and perfusion Identify the criteria for use and measurement of the airway adjuncts - Ans: 1. Nasopharyngeal airway: can be used in responsive or unresponsive patient but is contraindicated in patients with facial trauma or suspected basilar skull fracture -Use the largest diameter that can be easily inserted into the patients naris -Select the correct length by measuring from the tip of the nose to the tip of the earlobe -Apply a water-soluble lubricant before insertion -Insert into the right naris, bevel facing the nasal septum 2. Oropharyngeal airway: used in the unresponsive patient as a temporary measure to facilitate ventilation with a bag mask device or spontaneous ventilation until the patient can be intubated. It is important to measure for the correct fit *one that holds the tongue in the normal anatomic position and follows its natural curvature -Measure the correct size airway by placing the proximal end of the airway adjunct at the corner of the mouth, if the distal end reaches the tip of the earlobe, its a correct fit -Depress the tongue using a tongue blade and insert the airway board the back of the mouth, careful not to push the tongue backward, blocking the airway What are the three indicators for definitive airway placement? - Ans: -Apnea -GCS of 8 or less -Severe maxillofacial fractures -Evidence of inhalation injury (facial burns) -Laryngeal or tracheal injury or neck hematoma -High risk of aspiration inability to protect the airway -Compromised or ineffective ventilation -Anticipation of deterioration of neurologic status may result in an inability to maintain or protect the airway What are two types of rescue airways and what is their major risk when used? - Ans: 1. Supraglottic airway: does not provide protection against aspiration and is not recommended in patients who have recently eaten 2. Retroglottic airway List, in order, the seven steps to verifying ETT placement - Ans: 1. Attach a CO2 detection device or monitoring sensor and begin assisted ventilations 2. Watch for symmetric rise and fall of the chest and at the same time listen for the presence of gurgling over the epigastrium, which may indicate the tube is in the esophagus 3. Listen for the presence of bilateral breath sounds at the midaxillary and midclavicular lines -If breath sounds are head, after 5 to 6 breaths have been deliver, asses for positive indications of exhaled CO2 from the CO2 device or monitor -If breath sounds are absent, there is no rise and fall of the chest, gurgling is head at the epigastrium, and there is no evidence of exhaled CO2 remove the ETT and oxygenate the patient before another attempt -If the breath sounds are only heard on the right, the ETT is likely in the right mainstream bronchus and has been inserted too far, it needs to be pulled back until equal breath sounds are head bilaterally 4. Secure the ETT, note the number at the lip for positioning, and document 5. Prepare for mechanical ventilation 6. Note the patient's color for improvement, the patient's color is likely to improve once ventilations are assisted and the patient is oxygenated 7. Obtain a chest radiograph for verification of ETT depth after the secondary survey Identify and explain the circumstances in which the pulse oximetry reading may be unreliable and why - Ans: 1. Poor peripheral perfusion caused by vasoconstriction, hypotension, or hypothermia 2. A BP cuff inflated above the sensor 3. Carbon monoxide poisoning (carboxyhemoglobin) 4. Methemoglobinemia 5. Severe dehydration Differentiate between qualitative and quantitative end-total carbon dioxide - Ans: *Quanitative end-total carbon dioxide:* capnography monitors provide a numeric value, as well as continuous waveform, indicating real time measurement and trending over time. Capnometers provide a one time numeric value of the ETCO2, each breath without any waveform. They can be useful in obtaining a snapshot measurement for confirmation fo ETT placement or after movement or repositioning *Qualitative end-total carbon dioxide:* colorimetric CO2 detectors provideifnromation about the presence or absence of CO2. A chemically treated indicator strip changes color revealing the presence or absence of exhaled CO2. Deliver at least 6 breaths before taking the measurement since patients with gastric distention may produce higher levels of CO2 in the esophagus and contribute to an inaccurate reading Define hyperoxia and the pulse oximetry parameters used to monitor it - Ans: *Hyperoxia:* refers to an excess supply of oxygen in the tissues. Better outcomes depend on prompt titration of oxygen as indicated by maintaining SpO2 between 94-98% Discuss the steps of rapid sequence intubation - Ans: *1. Preparation:* -Gather and prepare supplies, medication, and equipment necessary for RSI procedure -Ensure potency of vascular access and attach monitors and verify proper working order of the equipment -In anticipation of a potentially failed intubation during this step, prepare and have available any additional equipment that me be needed *2. Preoxygenate:* -Provide high-flow oxygen at the highest concentration available to prepare the patient to tolerate the period of apnea without desaturation. Suggested strategies to precent oxygen desaturation during intubation include: -Place the patient in a heads up position -If the patient is on a spine board, the reverse Trendelenburg position can be used. This is also helpful for bariatric patients -Maintain airway patency with airway adjuncts -Use positive pressure ventilation for those patients unable to achieve SpO2 at or above 94% *3. Pretreatment:* -This is the phase during which medications can be administered to mitigate adverse effect associated with endotracheal intubation -The mnemonic *LOAD (lidocaine, opioids, atropine, and defasciculating dose of neuromuscular blocking agents)* has been used, but recent research has change the practice of routine use of atropine and defasciculation dosing. These practices may be evaluated for use in certain cases, but not recommended routinely -The goal during RSI is to produce deep sedation and muscular relaxation quickly, but administer sedative first to allow time for it to take effect. This will limit anxiety or panic that would result from paralysis if a neuromuscular blocking agent is given without sedation -Sedatives: *Etomidate, Ketamine, Midazolam, Propvol, short acting barbiturates (methohexital)* -*Neuromuscular blocking agents* used in RSI include: *1. Depolarizing agents-Succinycholine:* -Succinylcholine is Describe the etiology and pathophysiology of the four main classifications of shock - Ans: *1. Hypovolemic shock:* -Leading cause of preventable deaths in trauma patients -Caused by a decrease in the amount of circulating blood volume -Typically results from hemorrhage but could result from a precipitous loss of volume, such as vomiting or diarrhea -Burn trauma can result in hypovolemic shock from damage to the cell membranes, leading to plasma and protein leakage -Decreased circulating volume results in decreased preload -With less filling of the ventricles, heart muscle fibers stretch less at the end of the diastole -Starling's law states, that with less stretching there is less force of contraction, creating diminished CO and less oxygenated blood being transported to the tissues, resulting in hypoperfusion *2. Obstructive shock:* -Due to obstruction in either vasculature or heart; from tension pneumothorax and cardiac tamponade; results in obstruction to atrial filling *3. Cardiogenic shock:* -Due to pump failure in presence of adequate intravascular volume; from MI, dysrhythmias, or blunt cardiac trauma; results from loss of cardiac contractility and reduced CO *4. Distributive shock:* -Due to maldistribution of an adequate circulating blood volume with loss of vascular tone or increased permeability; from anaphylactic, septic, or neurogenic shock -Anaphylactic shock results from release of inflammatory mediators — contracts bronchial smooth muscle and increases vascular permeability and vasodilation -Septic shock results from systemic release of bacterial endotoxins — increased vascular permeability and vasodilation -Neurogenic shock that occurs with SCI results in the loss of SNS control of vascular tone; unopposed vagal activity may result in decreased CO through bradycardia Define the components of cardiac output - Ans: CO = SV x HR -Stroke volume is affected by preload (venous return) and afterload (peripheral vascular resistance) and contractility (strength of contraction) Differentiate the signs and symptoms of compensated, decompensated, and irreversible shock. List clinical manifestations of each phase of shock - Ans: *1. Compensated shock:* -Compensatory mechanisms are activated and the patient may begin to exhibit subtle changes in LOC and vital signs, including... -Anxiety, lethargy, confusion, and restlessness from oxygen being shunted to brainstem, maintaining survival function, and away from areas responsible for higher brain function -Systolic blood pressure, usually within normal range -A rising diastolic BP, results in a narrowed pulse pressure, which is a reflection of peripheral vasoconstriction -A bounding and/or slightly tachycardia pulse as a result of catecholamine release -Increased respiratory rate, which could also be a result of pain or anxiety -Decreased urinary output as the kidney works to retain fluid within the circulatory system *2. Decompensated shock:* occurs when compensatory mechanisms begin to fail and are unable to support or improve perfusion. Shock may still be reversible at this stage -LOC deteriorates and the patient becomes obtunded or unconscious as the cells switch to anaerobic metabolism with increasing levels of lactic and pyretic acids -Normal or slightly decreased systolic BP -Narrowing pulse pressure that continues until peripheral vascular vasoconstriction fails to provide cardiovascular support -Tachycardia greater than 100 bpm -Weak and thready pulses -Rapid and shallow respirations as the lungs try to correct acidosis -Cool, clammy, cyanotic skin as blood shunts to vital organs (may develop toward end of decompensated stage) -Base. excess not within normal range of -2 to +2 -Serum lactate levels greater than 2 to 4 *3. Irreversible shock:* will lead to death without rapid intervention, tissue and cells throughout the body become ischemic and necrotic, resulting in multiple organ dysfunction -Obtunded, stuporous, or comatose -Marked hypotension and heart failure -Bradycardia and possi List the three components of the trauma triad of death - Ans: 1. Coagulopathy 2. Metabolic acidosis 3. Hypothermia Describe the goals of damage control resuscitation - Ans: Early recognition of the patient at risk fr shock facilitates the use of goal-directed therapies: *1. Hypotensive resuscitation:* -Large volumes of crystalloid solution is associated with increased bleeding and decreased survival rates -This could be a result of hemodilution and decreased clotting factors -Delayed and restrictive administration of isotonic crystalloid solution in trauma patients (without head injury) may have better outcomes and lower mortality, by allowing the clotting cascade to work-which might limit the complications that lead to increased bleeding and re-bleeding, or "popping the clot". -Plasma and blood products are the primary fluids to correct blood loss and inadequate coagulation, the goal is not hypotension, but adequate resuscitation without producing hypertension *2. Hemostatic resuscitation:* -The key to early goal-directed therapy is to optimize oxygenation and perfusion by preventing further losses through hemodilational coagulopathy -When hemorrhage occurs, clotting factors and platelets are lost along with RBCs, excessive use of isotonic crystalloids alone or replacing whole blood loss with only PRBCs can produce a hemodilutional coagulopathy in which the effective concentrations of both platelets and clotting factors are significantly reduced -Hemorrhage control is optimized by giving component therapy, using both the transfusion of both PRBCs and FFP in a 1:1 ratio, platelets are added at a 1:1:1 ratio in the presence of actual or anticipated thrombocytopenia List the components of a massive transfusion protocol - Ans: -Provide balanced resuscitation with limited use of crystalloid solution -Dependent on early recognition and implementation -Using defined ratio of one part RBCs to one part thawed plasma to one part platelets Which lab value is unique to the administration of large amounts of banked blood and why? - Ans: *Calcium* -Hypocalcemia is a concern with massive transfusion because citrate is added as preservative to banked blood to prevent coagulation -Citrate binds with calcium, rendering it inactive -Hypocalcemia can worsen hypovolemic shock by permitting continued bleeding. *This is most likely seen if trauma pt requires more than 1 unit of blood every 5 minutes*-anticipate citrate toxicity and hypocalcemia and prepare to replace losses with calcium gluconate or calcium choride Define damage control surgery and its purpose - Ans: -A shift from rapid definitive surgery and complete repair to surgery tat is intended to stop the bleeding, restore normothermia, and treat coagulopathy and acidosis -In other words, resuscitation from the trauma triad -Damage control surgery is recommended to last no longer than 90 minutes -Definitive injury repair is accomplished later during planned or staged operations after the patient has been further resuscitated, stabilized, and warmed in the ICU What is considered adequate urinary output? - Ans: 0.5 mL/kg/hr Are vasoconstrictors and vasopressors indicated in hemorrhagic shock? - Ans: NO Describe the interventions, in order, for control of hemorrhage with extremity injuries - Ans: Oligoanalgesia - Ans: Concept of under treatment of pain Differentiate between acute and chronic pain - Ans: *Acute pain:* -An event -External agent or internal disease -Usually sudden -Transient (up to 6 mo) -Painful and non painful areas generally well identified -Typical response pattern with more visible signs -Informs person something is wrong Self-limiting or readily corrected -Suffering usually decreases over time -Leads to actions to relieve pain -Likelihood of complete relief *Chronic pain:* -A state of existence -Unknown or treatment unsuccessful -Sudden or develops insidiously -Prolonged (moths to years) -Painful and no painful areas less easily differentiated, change in sensation, becomes more difficult to evaluate -Response patterns vary with fewer overt signs (adaptation) -Person looks for significance -Continuous or intermittent, intensity may wary or remain constant -Leads to action to modify pain -Complete relief usually not possible Give examples of self-report and behavioral assessment tool for assessment of pain - Ans: *Self report:* -Acute pain assessment uses a scale, usually 0-10, to quantify the extent of the pain Ex: -*Numeric Rating Scale:* patient rates pain on a scale 0-10, zero represents no pain at all and 10 represents the worst possible pain -*The Visual Analog Scale:* colors and descriptors are plotted along a visual representation if the 0-10 scale -*The FACES scale:* simple drawings of faces represent varying degrees of expression of pain -*Nonverbal trauma:* patient who is alert, attempt alternate methods to elicit self report such as gestures, eye blinks, hand grasps, or nodding of the head *Behavior Assessment Tools:* -*The FLACC Scale*: developed for infants, validated for use in older children and adults who are nonverbal or have decreased LOC--assess: Facial expression, Leg position/movement, Activity, Crying, Consolability-each parameter scored from 0 to 2 fo a total of 0-10 points -*The Behavioral Pain Scale:* can be used for intubated patients and consist of 3 assessment components *1. Facial expression:* Relaxed 1 Partially tightened 2 Fully tightened 3 Grimacing 4 *2. Upper limb movement:* No movement 1 Partially bent 2 Fully bent with finger flexion 3 Permanently retracted 4 *3. Compliance with ventilation:* Tolerating movement 1 Coughing with movement 2 Fighting ventilator 3 Unable to control ventilation 4 -Each component scored from 1to 4 for a max of 12 *Critical-care Pain Observation Tool (CPOT):* -Intended for use in intubated or nonverbal patients unable to self report -Consist of 4 assessment parameters Facial expression 0-2 Body movements 0-2 Muscle tension 0-1 Compliance with ventilation 0-2 -Each parameter scored as above for total of 0 to 7 Describe physiologic effects of pain for each system - Ans: *1. Cardiovascular:* -Hypercoagulation -Increased cardiac workload -Increased oxygen demand *2. Respiratory:* -Splinting -Hypoventilation -Hypercarbia -Respiratory acidosis -Increased risk of atelectasis and pneumonia *3. MSK:* -Impaired muscle function -Immobility -Fatigue -Muscle spasm *4. GI:* -Decreased motility *5. Endocrine:* -Increased release of hormones and mediators *6. Metabolic:* -Glucogenesis -Hypergylcemia -Glucose intolerance -Insulin resistance -Muscle protein catabolism -Increased lipolysis *7. Immune:* -Decreased response Describe the optimum combination of pain management techniques - Ans: Optimum management involves the combined use of nonpharmacologic interventions, opioid, non-opioid, and adjuvant medications List nonpharmacologic pain management interventions - Ans: Physical: -Cold/heat therapy -Positioning -Massage -Immobilization -Elevation -Covering open wounds Cognitive/Behavioral: -Emotional support -Family presence -Imagery -Distraction -Music -Relaxation -Biofeedback -Breathing control -Play Describe the components of each of the three steps of the World Health Organization (WHO) pain ladder - Ans: *Step 1: non-opioids for mild pain rating (1-3)* -Acetaminophen -Ibuprofen -Ketorolac -Naproxen *Step 2: Weak opioids for mild to moderate pain rating (4-6)* -Codeine -Nalbuphine *Step 3: Strong opioids for moderate to severe pain rating (7-10)* -Morphine -Fentanyl -Hydromorphone Differentiate between the four levels of procedural sedation and anesthesia - Ans: *Minimal Sedation Anxiolysis:* Responsiveness: normal response to verbal stimulation Airway: unaffected Spontaneous ventilation: unaffected Cardiovascular function: unaffected *Moderate Sedation/Analgesia (Conscious sedation):* Responsiveness: purposeful response to verbal or tactile stimulation Airway: no intervention required Spontaneous ventilation: adequate Cardiovascular function: usually maintained *Deep sedation/Analgesia:* Responsiveness: purposeful response following repeated painful stimulation Airway: intervention may be required Spontaneous ventilation: may be inadequate Cardiovascular function: usually maintained *General anesthesia:* Responsiveness: unarousable even with painful stimulus Airway: intervention often required Spontaneous ventilation: Frequently inadequate Cardiovascular function: may be impaired Describe the responsibilities of the nurse during procedural sedation - Ans: Monitoring the patient's condition and level of sedation and is not involved in procedural tasks, such as immobilization or application or splitting material or dressing Define and list three types of primary brain injury - Ans: Primary injuries result from a direct transfer of energy -Skull and craniofacial fractures -Intracranial lesions (contusions or mild TBIs) -Lacerations, tearing, and shearing injuries and bleeding into the brain (epidural or subdural hematoma) Discuss the causes of secondary brain injury and give three examples - Ans: Secondary injuries result from complex pathophysiologic changes -Hypotension -Hypoxemia -Hypercarbia -Cerebral edema -Increased ICP -Decreased CPP -Cerebral ischemia Describe the effect of hypercarbia on cerebral blood flow. What are benefits and risks of hypercarbia in the context of intracranial pressure and cerebral blood flow? - Ans: -CO2 causes vasodilation, which can have a powerful, but reversible effect on cerebral blood flow -Hypercapnia causes significant dilation of cerebral arterial vasculature and increase blood flow; hypocapnia causes constriction and decreased blood flow -As ICP rises, cerebral perfusion pressure decreases, resulting in cerebral ischemia, hypoxemia, and lethal secondary insult -Small elevations in blood pressure and MPA are attempts by the body the protect against brain ischemia in a patient with elevated ICP -Intricate physiologic alteration result in a decrease PaO2 and increase PaCO2, both of which act to dilate cerebral blood vessels, increasing cerebral blood flow -Those combined with an expanding hematoma, inflammation, or edema of the brain parenchyma result in increases in ICP and herniation -ICP sustained at greater than 20mm Hg and unresponsive to treatment are associated with poor outcomes Define the components of and use for FOUR (Full Outline of UnResponsiveness) Score - Ans: -The FOUR score ranges from 0 to 16 and provides greater neurologic detail than the GCS score -The patient's total score suits from a summative score of 4 components of response that include: *Eye Response* *Motor Response* *Brainstem Reflexes* *Respiration* All components of the FOUR score can be rated in patients with or without an endotracheal tube Describe three tests for the presence of cerebral spinal fluid in otorrhea or rhinorrhea - Ans: Inspect the nose and ears for drainage -*Test otorrhea/rhinorrhea* for cerebral spinal fluid -B2-Transferrin is a test that requires fluid to be sent to the lab and is considered the gold standard for identifying CSF otorrhea or rhinorrhea -Two tests can be performed rapidly to give a general suspicion of CSF leak, but have high rate of false positive and are considered unreliable: 1. *Halo sign:* place fluid on clean gauze and a classic ring form if it is CSF. Tears, water and saline may also produce a halo if mixed with blood 2. *Glucose:* test for the presence of glucose, which is high in CSF, but also can be in nasal drainage 3. *Assess extra ocular eye movements (EOMs) to test the function on CN III, IV, VI:* the ability to perform EOMs indicates the brainstem is intact, in the presence of facial fractures, the inability to perform EOMs may indicate a trapped nerve -Observe for abnormal motor posturing (abnormal flexion, abnormal extension) or flaccidity Differentiate between epidural, acute subdural, and chronic subdural hemorrhage - Ans: *Epidural hematoma:* -Results from a collection blood that forms between the dura mater and the skull -The hematoma is frequently (90%) associated with fractures of the temporal or parietal skill that lacerate the middle meningeal artery -Since the source of bleeding is arterial, blood can accumulate rapidly, and the expanding hematoma may cause compression of underlying brain tissue, rapid rise in ICP, decrease CBF, and secondary brain injury -Required immediate surgical intervention -Common causes are MVCs and falls, or sports related injuries -Assessment findings: transient LOC followed by a lucid period lasting minutes to hours, HA, dizziness, N/V, Contralateral hemiparesis, hemiplegia, or abnormal motor posturing (flexion or extension--extension is associated with brainstem herniations and poor outcomes), Ipsilateral unilateral fixed and dilated pupils, rapid deterioration in neurologic status *Acute subdural hematoma:* -Generally manifest signs and symptoms within 72 hours of the injury event -The hematoma can cause reduction in CBF -This is commonly the type of bleed sustained by athletes who suffer a catastrophic head injury -Assessment findings: severe HA, changes in LOC, Ipsilateral dilated or nonreactive pupils, contralateral hemiparesis *Chronic subdural hematoma:* -Frequently associated with minor injury in the older adults, patients taking anticoagulation medications, and patients with chronic ETOH use -Increased incidence is due to brain atrophy, fragility of the bridging veins and coagulation alterations -The onset of signs and symptoms and effects neurologic function vary depending on the size and rapidity of the hematoma formation -Assessment findings develop overtime and may not be evident until up to 2 weeks after the injury event -Assessment findings: altered or steady decline in LOC, HA, loss o Differentiate between mild, moderate, and severe traumatic brain injury - Ans: *Mild TBI:* -GCS of 13 to 15 -Brief 30 min LOC -Post-traumatic amnesia of less than 24 hours -No change on neuroimaging studies *Moderate TBI:* -GCS score of 9 to 12 -Wide variety of symptoms, including alterations in consciousness, confusion, amnesia, and focal neurologic deficits -May deteriorate to severe head injury over time, so monitor patients closely *Severe TBI:* -GCS score of 8 or less -Significant alteration in consciousness -Abnormal pupillary response -Abnormal motor posturing Define second impact syndrome - Ans: -Refers to a condition that occurs when the patient suffers a second mild TBI before recovery from the first, it is rare but usually fatal, especially in pediatric patients -The second impact causes loss of auto regulation leading to cerebral edema Define and provide assessment findings for post concussive syndrome - Ans: -Manifests several days or months after the head trauma -Signs and symptoms usually resolve but may persist for long periods of time -Nausea -Dizziness and persistent HA -Memory and judgment impairment, as well as attention deficits -Insomnia and sleep disturbance -Loss of libido -Anxiety, irritability, depression, and emotional lability -Noise and light oversensitivity -Attention or concentration problems List signs and symptoms of LeFort I, II, and III, and mandibular fractures - Ans: *LeFort I:* -Independent movement of the maxilla from the rest of the face -Slight swelling of the maxillary area -Lip laceration or fractured teeth -Malocclusion *LeFort II:* -Massive facial edema -Nasal swelling with obvious fracture of the nasal bone -Malocclusion -CSF rhinorrhea *LeFort III:* -Massive facial edema -Mobility and depression of zygomatic bones -Ecchymoses -Diplopia -Open bite or malocclusion List the indications and contraindications of mannitol for brain injury - Ans: -Rule out other injuries before administering -Administration via bolus may be more effective than continuous infusion -*Indications:* acute neurologic deterioration such as dilated pupils, loss of consciousness, or hemiparesis while the patient is being monitored, weigh the risks -*Contraindications:* active intracranial bleeding, it is not for use in hypotensive patients since it will not lower ICP in hypovolemia and is potent osmotic diuretic Define the two classifications of open globe eye injuries - Ans: -Open globe injuries are classified as either lacerations or ruptures -These injuries penetrate through the eye wall and are described as a through and through injury to the cornea, sclera, or both -Lacerations: can be further categorized as penetrating, intraocular foreign body, or perforating Define anisocoria - Ans: Unequal pupils (25% population); a benign physiologic condition Causes: trauma, uncle herniation, oculomotor nerve (CN III) palsy, medications, and some nebulizers (ipratropium) Differentiate cyclopegic medications from ophthalmic sympathomimetic medications - Ans: Describe assessment findings and treatment for corneal abrasions - Ans: Assessment findings: -Photophobia and tearing -Pain -Injected conjunctiva or redness of the eye -Lid swelling -Complaint of a foreign body sensation in the eye Treatment: -Topical ophthalmic antibiotics (if caused by contact lenses, treat for pseudomonas) -Cycloplegic opthalmic lent to decrease spasms and pain -Topical ophthalmic NSAIDs, such as ketorolac or diclofenac, to reduce swelling -Oral analgesics -No patching; evidence shows abrasions heal faster if unpatched -Follow up with an ophthalmologist in 24 hrs List interventions for an intraocular foreign body - Ans: -Elevating the HOB -Obtaining an ophthalmologic consult -Immobilizing the foreign body if it is large with potential to become unstable -Limit concomitant eye movement by patching the unaffected eye -Performing globe closure ASAP -Administering systemic and topical ophthalmic antibiotics -Administering systemic analgesics List which ocular injuries are treated with antibiotic therapy - Ans: -Corneal abrasion -Corneal lac -Corneal foreign bodies -Intraocular foreign body -Orbital fracture -Ocular burns -Ultraviolet keratitis Differentiate the grades of traumatic hyphema - Ans: *Grade 1:* blood occupying less than 1/3 of the anterior chamber *Grade 2:* blood occupying 1/3 to 1/2 of the anterior chamber *Grade 3:* blood occupying 1/2 but less than total filling of the anterior chamber *Grade 4 :* blood occupying the entire anterior chamber Describe the treatment goal of treatment for chemical ocular burns - Ans: -Irrigating the area until pH returns to normal range (7-7.3) -Determine the baseline pH -Administering topic ophthalmic antibiotics and cycloplegics -Administering tetracaine drops for pain -Visual acuity reassessment Describe the characteristics of flail chest, including the clinical assessment findings - Ans: Characteristics: -2 or more fractures of 3 or more adjacent ribs an/or sternal fractures, creating a free-floating fractured segment -Pain that causes the patient to splint, with rapid, shallow breathing -Inefficiency of the muscles of respiration as the flail segment pulls in the opposite direction, decreasing tidal volume and secretion removal -Associated injury from jagged rib fragments including parenchymal laceration, pulmonary contusion, pneumothorax, or hemothorax Assessment findings: -Dyspnea -Chest wall pain -Chest wall contusions -Paradoxical movement of the chest: if the patient is splinting as a response to pain, this may be difficult to visualize, once the patient has received pain medication, it may be more visible Interventions: -Prepare for intubation and ventilator support Differentiate simple pneumothorax, open pneumothorax, tension pneumothorax, and hemothorax - Ans: *Simple pneumothorax:* caused by blunt trauma, air escapes from the injured lung into the pleural space, and negative intrapleural pressure is lost, resulting in a partial or complete collapse of the lung--decreased/absent breath sounds on the injured side *Open pneumothorax:* can be the result of a penetrating wound through the chest wall causing air to be trapped in the intrapleural space, during inspiration air enters the pleural space through the would, as well as the trachea--subcutaneous emphysema, chest would that creates a sucking sound on inspiration *Tension pneumothorax:* occurs when air enters the intrapleura space but cannot escape on expiration, the increasing intrathoracic pressure causes the lung on the injured side to collapse. If the pressure is not relieved, the mediastinum can shift toward the uninjured side, compressing the heart, great vessels, and ultimately the opposite lung--anxiety, hypotension, distended neck/head/upper veins, tracheal deviation *Hemothorax:* cause by blood accumulating in the intrapleural space. Results from injury to multiple structures including the lung, costal blood vessels, great vessels and other structures, may also result from a lac to liver or spleen combined with injury to the diaphragm. A massive hemothorax = rapid accumulation of more than 1,500 mL--anxiety, chest pain, signs of shock, decreased breath sounds on injured side List interventions for a pulmonary contusion - Ans: -Maintain SpO2 between 94% and 98% for adequate oxygenation and to avoid hyperoxia -Minimize or use intravenous fluids (IC) judiciously -Prepare for possible intubation and ventilation support List the components of the Beck triad as they relate to cardiac tamponade - Ans: -Hypotension -Distended neck veins -Muffled heart sounds-may be difficult to assess and may be absent Describe the insertion sites used for needle thoracentesis and chest tubes and explain why they are different - Ans: *Needle thoracentesis:* a 14 G needle is inserted into the second intercostal space in the midclavicular line on affect side over the top of the rib to avoid the neurovascular bundle that runs under the rib *Chest tubes:* at the fifth intercostal space at the anterior or midaxillary line, after inserted, it is connected to a chest drainage system Describe the injury patterns for blunt abdominal trauma - Ans: *1. Lacerations to the solid organs:* -Encapsulated organs--such as livers, spleen, and kidneys--are more likely to lacerate due to their semi-elastic capsule -The pancreas is prone to lacerations in blunt trauma from a compression injury due to the location in the body *2. Rupture of air-filled hollow organs:* -Such as the stomach, small bowel, large bowels, uterus, and bladder--can be the result of a sudden increase in intra-abdominal pressure *3. Tearing or shearing:* -Sudden deceleration or acceleration force causing extreme stress on fixed sites in the abdomen can result in injury -Organs most susceptible to this type of injury include small bowel, large bowel, ureters, urethra, and esophagus -Examples include lacerations of the liver and spleen where the supporting ligaments are fixed to they abdominal structures *4. Fractures of the pelvis occur as a result of a fall or MVC:* -Closed lateral compression forces resulting from a MVC can cause internal rotation of the pelvis -Open book fracture occurs as a result of anterior posterior compression forces resulting from a direct crush, vehicle vs pedestrian collision, or fall from height of more than 12 ft in adults-this type of fracture can cause opening of the pelvic ring, tearing of the vascular venous complex or the internal iliac artery, and uncontrolled hemorrhage Differentiate Cullen sign, Grey Turner sign, and Kehr sign - Ans: *Cullen sign:* periumbilical ecchymosis (late sign of retroperitoneal bleeding) *Grey Turner sign:* flank ecchymosis (late sign of retroperitoneal bleeding) *Kehr sign:* occurrence of acute pain in the tip of the shoulder due to the presence of blood or other irritants in the peritoneal cavity when a person is lying down and the legs are elevated. Kehr's sign in the left shoulder is considered a classic symptom of a ruptured spleen Describe the process for assessing pelvic stability - Ans: Apply gentle posterior or downward pressure with the palms of your hands to the iliac crests of the patient's pelvis. Finally, apply gentle downward pressure on the pubis to check for pelvic ring stability Define an unstable pelvis fracture and list the presenting clinical findings - Ans: -Unstable pelvic fractures are two or more fractures of the pelvic ring that have outward rotational displacement -Shortening on the leg -Blood at the urinary meatus or hematuria -Pelvic instability and/or pain -Unexplained hypotension or evidence of hypovolemic shock What is the greatest threat in an unstable pelvic fracture? Describe how to apply a sheet as a pelvic binder - Ans: Bleeding from iliolumbar vein may be significant enough to cause hypovolemic shock, and the patient may require a massive blood transfusion Which mechanisms of injury are associated with renal injury? - Ans: Blunt traumas to the flank, deceleration force, and fall from heights Describe the different mechanisms of injury to the vertebral column - Ans: *1. Hyperextension:* -Etiology of injury: backward thrust of the head beyond the anatomic capacity of the cervical vertebral column -Result of injury: damage to anterior ligaments ranging from stretching to ligament tears, bony dislocations -Ex: rear-end MVC resulting in whiplash -Common location: cervical spine *2. Hyerflexion:* -Etiology of injury: forceful forward flexion of the cervical spine with the head striking an immovable object -Result of injury: wedge fractures, facet dislocations, subluxation (due to ligament rupture), teardrop, odontoid, or transverse process fractures -Ex: head-on MVC with head striking windshield, creating a starburst effect -Common location: cervical spine *3. Rotational:* -Etiology of injury: a combination of forceful forward flexion with lateral displacement of the cervical spine -Result of injury: rupture of the posterior ligament anterior fracture, dislocation of the vertebral body -Ex: MVC to front of rear lateral area of the vehicle resulting in conversion of forward motion to a spinning type motion -Common location: cervical spine *4. Axial loading:* -Etiology of injury: direct force transmitted along the length of the vertebral column -Result of injury: deformity of the vertebral column, secondary edema of the spinal cord, resulting in neurologic deficit -Ex: diver striking head on bottom on pool -Common location: T12-L2 Differentiate primary and secondary spinal cord injury - Ans: *Primary:* -Typically refers to the initial mechanical damage to the spinal cord *Secondary:* -The progressive cell damage that results from biochemical and cellular reactions due to inflammatory response, hemorrhage, hypoperfusion, and hypoxemia Differentiate spinal shock from neurogenic shock - Ans: *Spinal shock:* -Precipitating injury: spinal cord injury at T6 or above -Pathophysiology: temporary loss of vasomotor tone and sympathetic innervation -Duration: temporary, often 72 hrs -S&S: hypotension, bradycardia, loss of ability to sweat below level of injury *Neurogenic shock:* -Precipitating injury: spinal cord injury at any level -Pathophysiology: transient loss of reflex (facility) below the level of injury -Duration: variable -S&S: flaccidity, loss of reflexes, bowel and bladder dysfunction Describe how the respiratory system is affected by the level of spinal cord injury - Ans: -Injury to the cord at *C3 to C5* can cause loss of phrenic nerve function, resulting in a paralyzed diaphragm and inability to breathe -*Hypoventilation:* injury to the spinal cord between *T1 and T11* may result in the loss of intercostal muscles and decrease respiratory effort -Loss of innervation from *T7 to T12* may result in loss of the use of abdominal muscles for support of breathing Differentiate between complete and incomplete spinal cord injury and how sacral sparing is related - Ans: *Complete spinal cord injury:* -Patients will lose all motor and sensory function at and below level of the lesion *Incomplete spinal cord injury:* -Comparison of motor and sensory function of bilateral upper and lower extremities is important to discern the exact cord syndrome -*Central cord syndrome:* loss of motor function in the upper extremities that is greater than that of the lower extremities. There is often sacral sparing. Bladder function may be affected -*Anterior cord syndrome:* loss of pain and temperature sensation with weakness, paresthesia, and urinary retention -*Brown-Sequard syndrome:* contralateral loss of pain and temperature sensation ipsilateral paralysis with reduced touch sensation (occurrence is rare) *Sacral sparing* represents some structural integrity of the lowest sacral segments of the spinal cord at S4 and S5 Sacral sparing is identified by: -Intact perianal sensation -Voluntary anal sphincter tone -Voluntary great toe flexor function What assessment findings differentiate neurogenic shock from hypovolemic shock - Ans: *Neurogenic shock:* Precipitating injury: spinal cord injury at T6 or above Pathophysiology: temporary loss of vasomotor tone and sympathetic innervation Duration: temporary, often 72 hrs S&S: hypotension, bradycardia, loss of ability to sweat below level of injury *Spinal shock:* Precipitating injury: spinal cord injury at any level Pathophysiology: transient loss of reflex (flaccidity) below the level of injury Duration: variable S&S: flaccidity, loss of reflexes, bowel and bladder dysfunction Describe the four types of thoracic vertebral fractures - Ans: *1. Anterior compression (Wedge):* MOI: axial loading, flexion Description: anterior portion rarely 25% shorter than the posterior body, most are stable *2. Burst (Comminuted):* MOI: vertical axial compression Description: comminuted fracture of vertebral body, may result in spinal cord injury, unstable *3. Chance fracture (seatbelt fracture):* MOI: hyper flexion Description: horizontal fracture lines with injury to bone and ligaments, suspect injuries to organs in the peritoneal cavity, certain types are unstable *4. Fracture-dislocation:* MOI: extreme flexion Description: disruption of the pedicles, facets, and lamina of the thoracic or lumbar vertebrae, subluxation can result in complete neurologic deficit, unstable, relatively uncommon What criteria allow the trauma patient cervical spinal clearance using NEXUS? - Ans: In patients who are awake, alert, not user the influence, and have no neurologic abnormalities: -If there is no presence of neck pain, midline tenderness, or distracting injury, an acute cervical spine fracture or instability is unlikely -After removing the collar and performing a manual palpation of the neck, if there is no pain, and the patient is able to move their neck without pain, imaging is not necessary -If neck pain and midline tenderness are present, imaging is necessary Define the ten types of fractures - Ans: *1. Open* fracture site is accompanied by compromised skin integrity near or over the fracture *2. Closed* skin is intact over or near fracture site *3. Complete* bony cortex is completely interrupted *4. Incomplete* bony cortex is not completely interrupted *5. Comminuted* bone is splintered into fragments *6. Greenstick* bone bends or is buckled *7. Impacted* bone is wedged into distal and proximal fracture sites *8. Displaced* bone fracture sites are not aligned List the assessment findings, most common sites, and treatment for compartment syndrome. Which symptoms are considered early signs? Which is considered the hallmark sign? Which electrolyte is most important? - Ans: Assessment findings: -"Tightness" feeling -Pain when the muscle is stretched -Rigidity on palpation 1. Pain: a hallmark sign of compartment syndrome is pain out of proportion to the extent of the injury. Pain on passive range of motion of the affected compartment can indicate development of or existing compartment syndrome 2. Pressure: the compartment or limb will feel tight or tense upon palpation. The skin may appear taut and shiny as the skin stretches 3. Pallor: poor skin color and cool temperature indicates poor perfusion. Delayed capillary refill may also indicate decreased perfusion 4. Pulses: pulses can remain normal in the presence of compartment syndrome. Weak or absent pulses are late signs 5. Paresthesia: numbness, tingling, or loss of sensation may occur as nerves and blood vessels are compressed. With loss of sensation, there may be a relief of pain, this is indicative of a worsening perfusion, not an improvement 6. Paralysis: motor dysfunction signifies injury to the nervous system Early signs: pain and pressure Electrolyte: K+ What mechanism of injury is commonly associated with rhabdomyolysis? What organ is often affected? - Ans: MOI: crush injury, significant muscle damage and cellular destruction Organ: kidneys List the six assessment P's of musculoskeletal trauma - Ans: 1. Pain 2. Pallor 3. Pressure 4. Pulses 5. Paresthesia 6. Paralysis Define residual limb - Ans: Part of the body that remains after an amputation--for instance, the part of the thigh that remains following an above-the-knee amputation is the residual limb Describe the care of an amputated part - Ans: -Keep the amputated part cool by wrapping it in slightly saline-moistened sterile gauze, and then place it in a sealed plastic bag -The bag containing the amputated part is then placed in a second bag containing ice water -Do not allow the amputated part to freeze or be submerged in liquid -Label the bag with appropriate patient identifiers -Administer antibiotics as ordered -Administer tetanus prophylaxis according to current CDC guidelines Abrasion - Ans: -A partial or full thickness wound that denudes the skin -Commonly occurring with falls and bicycle or motorcycle collisions -Can be mild to severe -Road burn or abrasions, resulting in a low side crash or laying down a motorcycle--large surface area Avulsion - Ans: -Full thickness wounds caused by a tearing or ripping of skin and soft t