TNCC pp5 Final Exam Questions and Answers,100% CORRECT

TNCC pp5 Final Exam Questions and Answers What roles are vital to a trauma team? -The patient -The team leader -Core team -Contigency and support services What are the characteristics of an effective team? - Clear roles and responsibilities - Shared mental model - Optimize resources - Strong team leadership - Engage in regular discipline of feedback - Strong sense of collective trust and confidence - Create mechanisms to cooperate and coordinate - Manage and optimize performance outcomes -Interdependent and adaptive What are key foundations to successful teamwork in the care of the trauma patient? ... What tools can be used to promote communication within a team structure? What are the benefits of each? - Brief: designed to form the team, designate team roles and responsibilities, establish climate and goals, and engage the team in short and long-term planning - Huddle: ideally convened prior to trauma patient's arrival; communicate critical issues and emerging events, anticipate outcomes and likely contingencies, assign resources, express concerns - Debrief: process improvement Define trauma Injury to living tissue caused by an extrinsic agent; creates stressors that exceed tissue or organ's ability to compensate Define epidemiology Study of factors that determine and influence the frequency and distribution of injury, disease, and other health-related events and their causes in a defined human population When is the potential for traumatic injury present? Whenever energy comes in contact with the human body Define kinematics The study of energy transfer as it applies to identifying actual or intentional injuries Define biomechanics The general study of forces and their effects Define mechanism of injury How external forces are transferred to the body, resulting in injury Define potential energy Stored energy; "at rest" Define kinetic energy Energy in motion Describe Newton's First Law of Motion A body at rest will remain at rest, and a body in motion will stay in motion unless acted upon by an outside force (energy) Describe Newton's Second Law of Motion (F)orce = (m)ass x (a)cceleration; It takes more force to move a heavy object Describe Newton's Third Law of Motion For every action, there is an equal and opposite reaction resulting from the transfer of energy Describe the Law of Conservation of Energy Energy can neither be created nor destroyed, but it can change form What are the five forms in which energy exist? - Mechanical: direct impact of an object - Thermal - Chemical - Electrical - Radiant The consequences of mechanical energy are directly related to energy Kinetic Kinetic Energy (KE) is equal to 1/2 the mass multiplied by the velocity squared In other words: when mass is doubled, energy is doubled; when velocity is doubled, energy is quadrupled Kinetic Energy formula KE=1/2mv^2 Differentiate between internal and external forces of energy transfer in the context or trauma. External forces are how energy can impact the body (e.g., deceleration, acceleration, compression). Internal forces represent the ability of the body to withstand external forces. How do internal forces protect the body from injury? - 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 List four main types of traumatic injury - Blunt trauma - Penetrating trauma - Thermal trauma - Blast trauma Examples of blunt trauma Falls MVA Vehicle vs. pedestrian collisions Assaults *Can result from broad energy impacts across large surface areas and involve energy transfer causing deceleration or acceleration *Greater distance of transfer diminishes deleterious impacts, and the more focused the impact, the greater the damage Deceleration injuries Occurs as energy is dispersed from the moving object * The speed of an impact is often less significant than the distance over which the energy is transferred Differentiate between deceleration and acceleration forces. pg. 28 What environmental and pathophysiologic factors are considered when the mechanism of injury is a fall? - Point of impact - Type of surface that is hit - Tissue's ability to resist - Acceleration When is a fall considered significant in the pediatric patient? If the fall is from three times his or her height Describe the three impacts in the motor vehicle impact sequence. 1. Vehicle hits another object 2. Occupant hits interior of vehicle (energy of impacts limited by seatbelt and airbag) 3. Organs hit other internal structures *Organs continue in motion and can be torn away from their attachments Examples of penetrating trauma - Gunshot - Stab wounds - Impalement - Cavitation Define Cavitation Separation of tissue resulting from a sound and/or hydraulic wave force *the leading side of the projectile pushes a wave of high pressure, the trailing edge draws a vacuum Examples of thermal trauma ... Examples of blast trauma - Overpressure - Dynamic pressure What is overpressure? Sudden change in atmospheric pressure caused by blast; can cause crushing forces What is dynamic pressure? Directional, similar to a gust of wind. Can carry with it fragments and debris that are displaced by explosion. *Can carry fragment and debris at velocities exceeding those in high-velocity firearms Primary MOI in blast trauma Found in those closest to detonation; air filled organs most susceptible to rupture Secondary MOI in blast trauma Results from flying debris and bomb fragments; causes most casualties Tertiary MOI in blast trauma Results from individuals being thrown by the blast wind; high-energy transfer can result in major thoracic injuries or pelvic/femur fractures Quaternary MOI in blast trauma Result from heat, flame, gas, and smoke Quinary MOI in blast trauma Result from radioactive, biological, or chemical elements present in explosion Describe the usefulness of the Haddon Matrix in prevention and reduction of injury. Places emphasis on countermeasures instead of changing human behaviors Initial Assessment - Preparation and triage - Across the room observation to identify any uncontrolled external hemorrhage - Primary survey ~ A: Airway and Alertness with simultaneous cervical spinal stabilization ~ B: Breathing and Ventilation ~ C: Circulation and Control of hemorrhage ~ D: Disability (neurological status) ~ E: Exposure and Environmental control - Resuscitation adjuncts ~ F: Full set of vitals and Family presence ~ G: Get resuscitation adjuncts - L: Labs and obtain blood for type & xmatch - M: Monitor for continuous cardiac rhythm and rate assessment - N: Naso- or orogastric tube consideration - O: Oxygenation and ventilation analysis: pulse oximetry and end-tidal CO2 monitoring or capnography - P: Pain assessment and management - Re-evaluation (consideration of transfer) - Secondary survey with re-evaluation adjuncts ~ H: History and Head-to-toe assessment ~ I: Inspect posterior surfaces - Re-evaluation and post resuscitation care - Definitive care or transfer to an appropriate trauma center Why is there repeated emphasis on assessment for hemorrhage throughout the initial assessment? Uncontrolled hemorrhage is the major cause of preventable death after injury When is cervical spinal injury (CSI) suspected? In any patient with multi system trauma, until pt has GCS of 15 and has CSI has been ruled out by physician or radiography *Can be stabilized manually or with semi-rigid cervical collar Which tool can be used to rapidly assess the LOC during the A - Airway and Alertness step? Why is it important to determine alertness along with airway? What are the components of this tool? 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 to inspect for when checking airway: - Tongue obstructing airway - Loose or missing teeth - Foreign objects - Blood, vomitus, or secretions - Edema - Burns or evidence of inhalation injury What to auscultate for when assessing airway: Obstructive airway sounds (snoring, gurgling, stridor) What to palpate for when assessing airway: - Possible occlusive maxillofacial body deformity - SQ emphysema How do you check for proper placement of definitive airway (endotracheal intubation)? - Adequate rise and fall of chest - Absence of gurgling on auscultation over epigastrium - BBS present - Presence of CO2 verified by CO2 detector device or monitor Which method of opening airway is recommended for use in trauma? Jaw-thrust maneuver *Performed by two people when needing to stabilize cervical spine What conditions or situations require definitely secure airway? - Apnea - GCS score of 8 or less - Severe maxillofacial fractures - Evidence of inhalation injury (facial burns) - Laryngeal or tracheal injury or neck hematoma - High risk of aspiration and patients inability to protect airway - Compromised or ineffective ventilation - Anticipation of deterioration of neuro status that may result in inability to maintain or protect airway *Ventilate with bag-mask at 15 L until airway can be established Breathing and Ventilation: Assessment Inspect for: - Spontaneous breathing - Symmetrical rise and fall of chest - Depth, pattern, and rate - Signs of respiratory difficulty (use of accessory muscles or diaphragmatic breathing) - Skin color - Contusion, abrasions, deformities hat suggest underlying injury - Open pneumothorax (open chest wound) - JVD and position of trachea - Signs of inhalation injury Auscultation for: - Presence, quality, and equality if breath sounds bilaterally at second intercostal space, midclavicular line and bases at fifth intercostal space at anterior axillary line Palpate for: - Bony structures and possible rib fractures - SQ edema - Soft tissue injury - Jugular venous pulsations at the suprasternal notch or in supraclavicular area How to determine if ventilation is effective? - SpO2 of 94% of greater - End tidal CO2 (ETCO2) between 35 and 45 *If ventilation ineffective, assist with bag-mask device at 15 L and administer 10-12 breathes/min or 1 breathe q 5-6 seconds Circulation and Control of Hemorrhage: Assessment Inspect for: - Uncontrolled external hemorrhage - Skin color Auscultation for: - Muffled heart sounds Palpate for: - Presence of carotid or femoral pulses and rate, rhythm, and strength - Skin temperature and moisture Describe the current guidelines for volume resuscitation in hemorrhagic shock? Component therapy to replace losses, including administering RBCs, plasma, and platelets *Use to infuse large volumes of IV fluids; Leads to dilutional coagulopathy and worsening of metabolic acidosis; Increased BP may dislodge clots and promote further bleeding Disability (Neurologic Status): Assessment - GCS; Assesses eye opening, verbal and motor response 15 = best response 8 or less = comatose 3 = totally unresponsive - PERRL *Decreased LOC may be r/t CNS injury (consider CT), decrease cerebral perfusion, hypoventilation, acid-base imbalance (consider ABG), hypoglycemia, drugs or alcohol Exposure and environmental control is included in the Primary Survey. Why is it such a high priority? To ensure aggressive measures are taken to prevent loss of body heat. Hypothermia combined with hypotension and acidosis is a potentially lethal combo. G used to represent only Give Comfort Measures (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. - L: Lab studies ~ ABGs - Abnormal base deficit may indicate poor perfusion and tissue hypoxia, which results in the generation of hydrogen ions and metabolic acidosis - Base deficit less than -6 associated with poor outcomes ~ Type and cross match ~ Lactic acid - Reflects tissue perfusion - High levels associated with hypo-perfusion - Levels greater than 2-4 associated with poor outcomes - M: Monitor cardiac rate and rhythm ~ PVCs, a-fib, or ST segment changes may indicate blunt cardiac trauma ~ PEA may indicate cardiac tamponade, tension pneumothorax, or profound hypovolemia - N: Naso- or orogastric tube consideration ~ For evacuation of stomach contents to optimize lung inflation, prevent vomiting and/or aspiration ~ Oral route preferred with mid-face fx or head injury - O: Oxygenation and ventilation assessment ~ Pulse ox measures oxygen saturation of arterial blood or % of bound hgb - Pulse ox relies on adequate peripheral perfusion for accuracy - Not evidence of ventilation - Normal: >94% ~ ETCO2 monitoring (capnography) - Provides info on ventilation, perfusion, and metabolism of CO2 - Normal: 35-45 mmHg - P: Pain assessment and management ~ Provide comfort for pt ~ Avoid respiratory depression 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? - M: MOI - I: Injuries sustained - S: SSx (in the field) - T: Treatment (in the field) Components of the SAMPLE pneumonic that highlights important aspects of patient history - S: Symptoms associated with the injury - A: Allergies and tetanus status - M: Meds currently used - P: Past medical hx (include hospitalizations and surgeries) - L: Last oral intake - E: Events and Environmental factors related to injury Head-to-toe Assessment: General Appearance - Position and posture - Guarding - Stiffness, rigidity, and flaccidity of extremities - Odors Head-to-toe Assessment: Head and Face - Soft tissue injuries - Lacerations, puncture wounds, abrasions, contusions, edema, ecchymoses, impaled objects - Palpate for areas of tenderness, step-offs, and crepitus - Bone deformities - Asymmetry of facial expression - Any exposed tissue or bone that may suggest disruption of CNS - Palpate for depressions, angulations, tenseness Head-to-toe Assessment: Eyes - Gross visual acuity; " how many fingers am I holding up" - Prescription glasses or contacts? ~ Remove contacts before edema begins - PERRL - Muscle function; ask pt to follow moving finger in six cardinal positions Head-to-toe Assessment: Ears - Unusual drainage - Test otorrhea for CSF ~ Halo sign and glucose testing ~ Don't pack ear with suspected CSF leak - Ecchymosis behind the ear - Ear avulsions or lacerations Head-to-toe Assessment: Nose - Unusual drainage - Test rhinorrhea for CSF ~ Do not pack or insert NG tube if CSF leak suspected - Note position of nasal septum Head-to-toe Assessment: Neck and Cervical Spine - Presume pts with maxillofacial or head trauma may also have unstable CSI until proven otherwise; IMMOBILIZE - Sign of penetrating or surface trauma - Position of trachea and appearance of jugular veins - Palpate for cervical tenderness or deformities, tracheal deviation, SQ emphysema and areas tenderness Head-to-toe Assessment: Chest - Spontaneous breathing - Resp rate, depth, and effort; use of accessory or abd muscles and any paradoxical chest movement - Lacerations, puncture wounds, abrasions, contusions, avulsions, ecchymoses, edema, impaled objects, scars that may indicate previous chest surgery - Expansion and excursion of chest - Pain with breathing - Lung sounds - Heart sounds for presence of murmurs, friction rubs, or muffled heart tones - SQ edema - Bony crepitus or deformities (step offs or areas of tenderness) to the clavicles, sternum, and ribs Head-to-toe Assessment: Abdomen/Flanks - Lacerations, puncture wounds, abrasions, contusions, avulsions, ecchymoses, edema, impaled objects, and scars indicating previous abdominal surgery - Evisceration - Distention - Bowel sounds - Palpate for rigidity, guarding, masses, tenderness Head-to-toe Assessment: Pelvis/Perineum - Lacerations, puncture wounds, abrasions, contusions, avulsions, ecchymoses, edema, impaled objects, and scars - Bone deformities or exposed bone - Blood at urethral meatus, vagina, rectum - Priapism - Pain and/or urge, but inability to void - Palpate for instability if pelvis by applying gentle pressure over iliac wings downward and medially or on symphysis pubis Discuss why the insertion of a urinary catheter is no longer part of primary survey? Due to risk of UTI; alternate methods should be considered prior to placement Head-to-toe Assessment: Extremities - Lacerations, puncture wounds, abrasions, contusions, avulsions, ecchymoses, edema, impaled objects, deformity, and any open wounds - Bleeding - Angulation, deformity, and open wounds with evidence of protruding bone fragments, edema - Correct placement of previously applied splints - Skin color - Presence of dialysis catheters, PICCs, or other signs of complex medical hx - Skin temp and moisture - Pulses ~ Always compare sides - Crepitus - Deformity and areas of tenderness - Sensation - Spontaneous movement of all extremities - Motor strength and ROM in all extremities - Test equality of strength in bilateral extremities Inspect Posterior Surfaces - Maintain cervical spinal protection - Logroll pt with assistance from trauma team - Lacerations, puncture wounds, abrasions, contusions, avulsions, ecchymoses, edema, impaled objects, and scars - Presence of blood around rectum - Palpate for deformity and areas of tenderness - DRE (per MD) or ask alert pt to squeeze buttocks ~ Presence or absence of rectal tone ~ Presence of high-riding prostrate gland - Promote timely removal of or from spine board if no contraindications Describe the endpoints of resuscitation and their normal values. ... Define SaO2 Percentage of hgb saturated with oxygen; determined by ABG Define SpO2 Pulse oximetry reading of arterial oxygen saturation (SaO2) Define PaO2 Partial pressure of oxygen dissolved in arterial blood; reflection of tissue oxygenation Define PaCO2 Partial pressure or carbon dioxide dissolved in blood Define FiO2 Inspired concentration of oxygen measured in fraction; more commonly referred to as percentage *Room air is approx. 0.21 or 21% FiO2 Define hypoxemia Oxygen deficiency within arterial blood; measured by SpO2, SaO2, or PaO2 Define hypoxia Deficiency in oxygen deficiency to tissues; not directly measures or but considered to be present in decreased PaO2 Define ventilation Movement of air in and out of lungs Define diffusion Passive movement of gases from area of high concentration to area of lower concentration Define perfusion 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 AMS? The tongue Identify contributing factors to ineffective ventilation. - AMS from brain injury, prolonged loss of consciousness, increased ICP, hypoxia, or medication, substance or alcohol use - Trauma in the high cervical spine with disruption of sympathetic pathways - SCI with possible involvement of phrenic nerve - Blunt thoracic trauma with rib fractures and chest wall instability - Penetrating thoracic trauma resulting in hemo or pneumothorax - Preexisting history of respiratory disease - Increased age with decreased pulmonary reserve - Tachypnea as compensation for diminished oxygenation and perfusion Identify the criteria for use and measurement of the airway adjuncts. Temporary measure to keep airway patent; definitive airway may be necessary With nasopharyngeal airway, select correct length by measuring from top of the patient's nose to tip of the earlobe; insert with bevel facing nasal septum With oropharyngeal airway, measure correct size by placing proximal end of airway adjunct at corner or the mouth. If distal end reaches the tip of the earlobe, it is a correct fit. When is use of nasopharyngeal airway contraindicated? Facial trauma or suspected basilar skull fracture When is use of oropharyngeal airway contraindicated? Patient responsive or gag reflex intact What are the three indications for definitive airway management? - Failure to maintain or protect the airway - Failure to maintain oxygenation or ventilation - A specific anticipated clinical course What are two types of rescue airways and what is their major risk when used? Supraglottic and retroglottic airways Supraglottic airways do not provide protection against aspiration and is not recommended in patients who have recently eaten List, in order, the seven steps of verifying ETT placement 1. Attacth a CO2 detection device and begin assisted ventilations 2. Watch for symmetric rise and fall of chest AND AT THE SAME TIME, listen for presence of gurgling over epigastrium, which may indicate tube is in esophagus 3. Listen for presence of BBS at midaxillary and midclavicular lines 4. Secure ETT, note the number at the lip for positioning, and document 5. Prepare for mechanical ventilation 6. Note patient's color for improvement 7. Obtain CXR for verification Identify and explain the circumstances in which the pulse oximetry reading may be unreliable and why. - Poor peripheral perfusion caused by vasoconstriction, hypotension, or hypothermia - BP cuff inflated above sensor - CO poisoning - Methemoglobinemia - Severe dehydration In terms of the oxyhemoglobin-dissociation curve, what does a "shift to the right mean" and when does it occur? A shift to the right means hemoglobins affinity for oxygen has decreased, making it easier to release the bound oxygen to the tissues. This occurs in an environment of high metabolic demand (increased CO2, temperature, 2,3-diphosphoglycerate and decreased pH). In terms of the oxyhemoglobin-dissociation curve, what does a "shift to the left mean" and when does it occur? A shift to the left means hemoglobins affinity for oxygen has increased, making it harder to release the bound oxygen to the tissues. This occurs in an environment of low metabolic demand (decreased CO2, temperature, 2,3-diphosphoglycerate; increased pH; CO poisoning and methemoglobinemia) Differentiate between qualitative and quantitative end-tidal carbon dioxide. Quantitative provides a numeric value while qualitative informs on presence or absence of exhaled CO2 through color changing strips DOPE mnemonic to troubleshoot ventilator or capnography alarms - D: Displaced tube - O: Obstructed or linked tube - P: Pneumothorax - E: Equipment Failure Define hyperoxia and the pulse oximetry parameters used to monitor it. 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. Seven P's of RSI - Preparation - Preoxygenation ~ Provide oxygen at highest concentration ~ To prepare pt to tolerate the period of apnea without desaturation - Pretreatment ~ L: Lidocaine ~ O: Opioids ~ A: Atropine ~ D: Defasciculating dose of neuromuscular blocking agents - Paralysis with induction ~ Give sedative prior ~ Depolarizing (succinylcholine) and nondepolarizing (rocuronium and vecuronium) agents used ~ Nondepolarizing agents have fewer side effects but are longer acting ~ Short-acting medications preferred - Protection and Positioning ~ Protect airway from aspiration ~ Assist ventilation with bag-mask device if SpO2 falls below normal limits ~ Maintain cervical spinal stabilization - Placement with Proof - Post intubation management Etiology and pathophysiology of hypovolemic shock Due to loss of circulating blood volume; from hemorrhage, vomiting, diarrhea, burns Decreased circulating volume results in decreased preload; ventricles stretch less with filling; Starling's law states less stretch = less force = diminished CO Etiology and pathophysiology of obstructive shock Due to obstruction in either vasculature or heart; from tension pneumothorax and cardiac tamponade; results in obstruction to atrial filling Etiology and pathophysiology of 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 Etiology and pathophysiology of 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 components of CO - CO = SV x HR - Stroke volume is affected by preload (venous return) and afterload (peripheral vascular resistance) and contractility Compensated Shock - Anxiety, lethargy, confusion, and restlessness from oxygen being shunted to brainstem, maintaining survival function, and away from areas responsible for higher brain function - SBP usually WNL - Rising DBP, results in narrowed pulse pressure; reflection of peripheral vasoconstriction - Bounding or slightly tachycardic pulse - Increased respiratory rate - Decreased urinary output as kidneys work to retain fluid Decompensated Shock Compensatory mechanisms begin to fail - LOC deteriorates - Normal or slightly decreased SBP - Narrowing pulse pressure - Tachycardia - Weak and thready pulses - Rapid and shallow respirations as lungs try to correct acidosis - Cool, clammy, cyanotic skin as blood shunts to vital organs - Base excess not within normal range of -2 to +2 mEq/L - Serum lactate levels greater than 4 mmol/L Irreversible Shock Will lead to death without rapid intervention - Obtunded, stuporous, or comatose - Marked hypotension and heart failure - Bradycardia with possible dysrhythmias - Decreased and shallow respirations - Pale, cool, clammy skin - Kidney, liver, other organ failure - Severe acidosis, elevated lactic acid levels, and worsening base excess - Coagulopathies with petechia, purpura, or bleeding List the three components of the trauma triad of death. - Hypothermia - Acidosis - Coagulopathy List the components of a massive transfusion protocol. - 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? 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 Define damage control surgery and it's purpose. - Intended to stop bleeding, restore normothermia, and treat coagulopathy and acidosis; in other words resuscitation from the trauma triad - Recommended last no longer than 90 minutes - Definitive injury repair is accomplished later What is considered adequate urinary output? 0.5mL/kg per hour Are vasoconstrictors and vasopressors indicated in hemorrhagic shock? NO Describe the interventions, in order, for control of hemorrhage with extremity injuries. ...