TCAR QUESTIONS AND ANSWERS LATEST UPDATE

TCAR QUESTIONS AND ANSWERS
LATEST UPDATE
3AquestionsAtoAaskAinAtraumaA-ACORRECTAANSWERSA--whatAwasAtheAdoseAofAenergy?
-whereAdidAitAgo?
-whatAinjuriesAareAlikely?
2Aq'sAtoAaskAinAGSW A-ACORRECTAANSWERSA-caliber
typeAofAgun
#AofAentrance/exitAwounds
high/lowAvelocity
1stAquestionAtoAaskAinAanyAtraumaticAinjury?A-ACORRECTAANSWERSA-
whatAwasAtheAdoseAofAenergyAinvolved?
(wasAitAhighAorAlow?)
whatAisAtheAcaliberAofAaAbullet?A-ACORRECTAANSWERSA-diameter
akaAdiameterAofAaAbulletA-ACORRECTAANSWERSA-caliber
whatAhappensAtoAprojectilesAwhenAtheyAenterAtheAbodyA-ACORRECTAANSWERSA-
projectilesAdon'tAtravelAinAaAstraightAline
considerAtemporaryAcavityAwound
whatAshouldAyouAconsiderAaboutAtissueAaAprojectileAenountersA-ACORRECTAANSWERSA-
temporaryAcavitation
primaryAgoalAofAGSW AsurgeryA-ACORRECTAANSWERSA-
usuallyAdamageArepairA&AnotAbulletAremoval
-ifAsuperficial,AitAmayAmigrateAtheAsurfaceAwithAtime
importantAthingAtoArememberAaboutAretainedAprojectilesA-ACORRECTAANSWERSA-
theyAmayAmigrateAoverAtime.AbullettAmigrationAmightAexplainAunexplainedAclinicalAfindingsA
(VPACheneyAaccidentallyAshotAhisAfriendAwhileAhuntingAinA2006.AICUAandAdidAgreat.Amove
dAtoAanAinpatientAunit.AhadAaAsilentAMIAbcAaAshotAgunApelletsAmigratedAintoAaAcanaryAarteryA
causingAanAinfract.AsoAhadAaAMIAbutAfibrinolyticAnotAtheAanswerAinAthisAcaseAb/cAitAwasAaA"pr
ojectileAembolus"
akaAbrestboneA-ACORRECTAANSWERSA-sternum
whatAattachesAtheAribsAtoAtheAsternumA-ACORRECTAANSWERSA-cartliage
whatAbreaksAthoracicAbonesA-ACORRECTAANSWERSA-significantAforce
-1-2ndAribs,AposteriorAribs,Asternum,Ascapulae,AT2-10
givesAusAinfoAaboutAtheAforceAakaA"dose"AofAenergyAreceived
considerAinjuryAtoAinternalAstructuresAb/cAforce
ribsAthatAareAtheAmostAfrequentlyAbrokenA-ACORRECTAANSWERSA-ribsA4-
9Ab/cAlong,Athin,AandApoorlyAprotecte
itAisAharderAtoAbreakAaAshortApencilA(T1-2)AandAeasierAtoAbreakAaAlongerAone
*askAhowAmanyAandAwhereAtoAunderstandAtheAforceAinvolved
whatAisAtheAsignificanceAofAposteriorAribAfracturesA-ACORRECTAANSWERSA-
unusualAdirectionAofAinjury
shorterAstubbyAribs
goodAmuscleAprofection

,**posteriorAribAfracturesAhaveAaAlotAofAforceAsoAneedAaAhighAdose.
***PRFAneedAaAlotAofAforceAsoAhighAdoseAofAenergy.AbigAredAflagAforAt-spineAinjury
indicationAofAc-spineAinjuryA-ACORRECTAANSWERSA-toAinjureAc-
spine,AyouAdon'tAneedAaAbigAenergyAblow.AallAitAtakesAisAshakingAaround.
cAspineAversusAtAspineAfracturesA-ACORRECTAANSWERSA-c-
spineAdoesn'tAneedAaAbigAenergyAblow.AjustAsomeAshakingAaroundA

t-spineAneedsAaAgreatAstrongAdirectAblowA(notAjustAaAshock_
treatmentAforAribAfracturesA-ACORRECTAANSWERSA-
largelyAsupportiveAnursingAcareAlikeApulmonaryAtoilet
CXRAandAribAfracturesA-ACORRECTAANSWERSA-
simpleAribAfracturesAareAdifficultAtoAseeAonACXRAandAcanAbeAcommonlyAmissed
(1/2AofAallAribAfracturesAaren'tAidentifiedAatAtheAPOIACXR)
identifyAaApreviousAribAfractureAonACXRA-ACORRECTAANSWERSA-
onceAhealed,AribAfracturesAformAbonyAcallousesAandAbecomeAmoreAvisibleAonACXR
howAtoAtellAaAptAhasAaApneumoniaAfromAaACXRA-ACORRECTAANSWERSA-
darkAspotAthatAisAnotAequalAtoAtheAoppositeAside
considerAifAaAptAhasAaAlowerAribAfractureA-ACORRECTAANSWERSA-liverA&AspleenAinjury
actsAlikeABBQ/marshmellowAskewers
howAhighAdoesAtheAdiaphragmAriseAonAinspirationA-ACORRECTAANSWERSA-
levelAofA4thAICS
riskAofAribAfracturesA-ACORRECTAANSWERSA-canApunctureAliver,Aspleen,,Adiaphragm
popAlungs
+2AadjacentAribAfracturesA-ACORRECTAANSWERSA-flailAchest
freeAfloatingAsternumA-ACORRECTAANSWERSA-flailAchest
definitionAofAflailAchestA-ACORRECTAANSWERSA-+2AadjacentAribAfracture
freeAfloatingAsternum
whyAisAflailAchestAaAproblemA-ACORRECTAANSWERSA-
b/cAbreathingAisAaAmechanicalAprocess
paradoxicalAchestAmovementsA-ACORRECTAANSWERSA-inAflailAchest
s/sAofAflailAchestA-ACORRECTAANSWERSA-paradoxicalAchestAwallAmovement
whereAonAtheAtissueAoxygenationAcascadeAisAthoracicAcageAfracturesAaAproblemA-
ACORRECTAANSWERSA-ventilation

parametersAtoAassessAventilationA-ACORRECTAANSWERSA-
ETCO2,APaCO2,AclinicalAassessment
whatAareAconsideredA"greatAvessels"A-ACORRECTAANSWERSA-
thoraxA-ACORRECTAANSWERSA-
whatAtypeAofAinjuriesAoccurAwhenAtheAlungsAareAsubjectedAtoAforce?A-
ACORRECTAANSWERSA-bruiseA=Acontusion

tearA=Alacerations
popA=Apunctures
inhalationAinjury
bruiseAonAtheAlungsA-ACORRECTAANSWERSA-pulmonaryAcontusion
causesAofApulmonaryAcontusionsA-ACORRECTAANSWERSA-
highAspeedAbluntAorApenetratingAinjury

,whatAhappensAtoAtheAlungsAinApulmonaryAcontusionsA-ACORRECTAANSWERSA-
bigAboggyAbruiseAonAtheAlungs
diffusionAproblems
whenAitAbecomesAcontusedA&Aedematous,AitAbecomesAdifficultAforAoxygenAtoAmoveAfromAth
eAalveoliAintoAtheAcapillaries
whereAonAtheAtissueAoxygenationAcascadeAdoApulmonaryAcontusionsAcauseAtheirAproblem
sA-ACORRECTAANSWERSA-diffusion
allAcontusionsAoverAtimeA-ACORRECTAANSWERSA-
allAcontusionsA"blossom"AoverAtime.AtheAfullAextentAofAtheAinjuryAisAnotAinitiallyAapparent
importantAthingAtoArememberAwhenAyouAareAevaluatingAaApatientAforApulmonaryAcontusion
sA-ACORRECTAANSWERSA-70%AofApulmonaryAcontusionsAaren'tAinitialAonAtheAinitialACXR
whatAshouldAyouAmonitorAwhenAaAptAhasAtraumaAtoAtheAthroaxA-ACORRECTAANSWERSA-
closelyAmonitorAforApulmonaryAcontustiobsA=A70%AnotApresentAonAtheAinitialACXRAandA"blo
ssom"AoverAtime
-monitorAforAprogressAeAdeteriorationAinAhours/daysApostAinjury
*mightAlookAokAinAER
bestAparameterAofAserialAmonitoringAforApt'sAwhoAhaveAriskAfactorsAforApulmonaryAcontusio
nsA-ACORRECTAANSWERSA-
anticipateA"blossoming"AoverAtimeAb/cA70%AofApulmonaryAcontusionsAaren'tApresentAonAth
eAinitialACXR
P:FAratio
problemAofAusingACXRAasAaAdefinitiveAclinicalAdxAtoolA-ACORRECTAANSWERSA-
CXRAmayAlagAbehindAclinicalAstatus
*b/cA70%AofApulmonaryAcontusionsAaren'tApresentAonAinitialACXR.AtheyA"blossom"AoverAtim
e
tearAinAlungAtissueA-ACORRECTAANSWERSA-pulmonaryAlaceration
problemAofApulmonaryAlacerationsA-ACORRECTAANSWERSA-
riskAofAmassiveAhemothoaxAb/cAthoseAvesselsAareAveryAvascular
simpleAv.AtensionAv.AopenAv.Aclosed.Av.AhemothoraxAv.AhemopneumothoraxA-
ACORRECTAANSWERSA-

whatAisAaAsimpleApneumothoraxA-ACORRECTAANSWERSA-
anyAairAthatAentersAtheApleuralAcavityAcanAalsoAleaveAatAtheAsameArate.AlungsAdeflatedAbutA
noAincreaseAinAintrathroacicApressure.AairAin/outAexitsAatAtheAsameArate.AptAmightAbeAableAt
oAtolerateAaAsimpleApneumothraox
causesAaAproblemAatAtheAventilationApointAatAtheAtissueAoxygenAcascade
intrathroacicApressureAinAsimpleApneumothoraxA-ACORRECTAANSWERSA-
airAthatAentersAtheApleuralAcavityAleavesAatAtheAsameArate
lungsAareAdeflatedAbutAnoAincreaseAinApressure
airAin/outAatAtheAsameArate
whereAisAtheAproblemAinAtheAtissueAoxygenationAcascadeAinAsimpleApneumothroaxA-
ACORRECTAANSWERSA-ventilation

whatAhappensAinApenumothoraxA-ACORRECTAANSWERSA-lungsAareAcollapsed/deflated
aireAentersAspaceAbetweenAtheAvisceralA&Aparietal
twoAlayersAofAtheAlungsA-ACORRECTAANSWERSA-visceralA&Aparietal
QA-AinAaApneumothorax,AnoAligamentsAattachAtheAlungAtoAtheAwall.AsoAwhatAholdsAitAup?A-
ACORRECTAANSWERSA-AA-

, AaAthinAlayerAofApleuralAfluidA&AnegativeApressure.AtheAliquidAhelpsAitAstickAlikeAhowAaAspilled
AliquidAformsAaAsealAbetweenAaAglassAandAaAsmoothAtableAtop

differenceAbetweenAaAsimpleAandAtensionApneumoA-ACORRECTAANSWERSA-
akaAchestAtubeA-ACORRECTAANSWERSA-chestAthoacotomy
purposeAofAusingAaAchestAtubeAinAsimpleApneumothoraxA-ACORRECTAANSWERSA-
toAallowAforAnegativeApressureAtoAreestablishA.
tensionApnumothoraxA-ACORRECTAANSWERSA-
airAentersAunderApressureAbutAdoesn'tAexitAatAtheAsameArate.A=AaccumulationAofAairAunderA
pressure
exampleAofAtensionApneumothoraxA-ACORRECTAANSWERSA-
likeAusingAaAbicycleApumpAtoAputAmoreAandAmoreAairAintoAtheAlungsAoverAtime.AnoAescape
*pressureAmeansAnoAlungAfunctionAonAtheAsideAofAtheAinjuryAandAcompromisesAfunctionAon
AtheAunAinjuredAheartAandAgreatAvesselAcompressionA

(decreasesApreload/CO
increasesAafterload
effectAofAtensionApneumothoraxAonAheartAfunctionA-ACORRECTAANSWERSA-
increasesAintrathoracicApressure
decreasesApreload/CO
increasesAafterload
normalApressureAinAtheAvenaAcavasA-ACORRECTAANSWERSA-normallyAisAlow
similarAtoAtheAcentralAvenousApressureAwhichAisAsimilarAtoArightAatrialApressureA(2-
8mmAhg)AsoAveryAlittleAincreaseAinApressureAtoAimpedeAvenousAreturnAtoAtheAheart
whatApartAonAtheAtissueAoxygenationAcascadeAisAaffectedAbyAtensionApneumothoraxA-
ACORRECTAANSWERSA-ventilationAr/tAcollapsedAlung

COAb/cApressure
whyAisAtensionApneumothoraxAmoreAlifeAthreateningAthanAsimpleApneumothoraxA-
ACORRECTAANSWERSA-

tensionApneumaAisAmoreAlifeAthreateningAthanAsimpleAb/cAofAtheApressureAitAputsAonAtheAgr
eatAvesselsAsoAdecreasedACO
considerationsAofAchestAtraumaA-ACORRECTAANSWERSA-
pneumonia,AgreatAvesselAtrauma,ApressureAsoAlowACO
whenAisAaAhospitalizedAchestApatientAtheAmostAlikelyAtoAdevelopAtensionApneumothraxA-
ACORRECTAANSWERSA-whenAweAinitiateApositiveApressureAventilation

whatAcanArapidlyAconvertAaAsimpleApneumothoraxAtoAaAtensionApneumothraoxA-
ACORRECTAANSWERSA-

positiveApressureAcanArapidlyAconvertAaAsimpleApneumothoraxAtoAaAtensionApneumothora
xA(BVMAorAm.Aventilation)AorAifAaAchestAtubeAisAkinked/clamped/occluded
chestApainAw/breathignA-ACORRECTAANSWERSA-pleuritic
pleuriticAchestApainA-ACORRECTAANSWERSA-painAwithAbreathing
assessmentAofAt.ApneumothraoxA-ACORRECTAANSWERSA-
pleuriticAchestApainA(hurtsAtoAbreathe)
respiratoryAdistress
increasedAHR
hyppoxemia
agitation
decreasedALS