TCAR-POST EXAM WITH VERIFIED QUESTIONS
AND CORRECT ANSWERS LATEST UPDATED
where on the tissue oxygenation cascade do pulmonary contusions cause their
problems - diffusion
all contusions over time - all contusions "blossom" over time. the full extent of the injury
is not initially apparent
important thing to remember when you are evaluating a patient for pulmonary
contusions - 70% of pulmonary contusions aren't initial on the initial CXR
what should you monitor when a pt has trauma to the throax - closely monitor for
pulmonary contustiobs = 70% not present on the initial CXR and "blossom" over time
-monitor for progress e deterioration in hours/days post injury
*might look ok in ER
best parameter of serial monitoring for pt's who have risk factors for pulmonary
contusions - anticipate "blossoming" over time b/c 70% of pulmonary contusions aren't
present on the initial CXR
P:F ratio
bruise on the lungs - pulmonary contusion
causes of pulmonary contusions - high speed blunt or penetrating injury
what happens to the lungs in pulmonary contusions - big boggy bruise on the lungs
diffusion problems
when it becomes contused & edematous, it becomes difficult for oxygen to move from
the alveoli into the capillaries
problem of using CXR as a definitive clinical dx tool - CXR may lag behind clinical status
*b/c 70% of pulmonary contusions aren't present on initial CXR. they "blossom" over
time
,tear in lung tissue - pulmonary laceration
problem of pulmonary lacerations - risk of massive hemothoax b/c those vessels are
very vascular
simple v. tension v. open v. closed. v. hemothorax v. hemopneumothorax -
what is a simple pneumothorax - any air that enters the pleural cavity can also leave at
the same rate. lungs deflated but no increase in intrathroacic pressure. air in/out exits at
the same rate. pt might be able to tolerate a simple pneumothraox causes a problem at
the ventilation point at the tissue oxygen cascade
intrathroacic pressure in simple pneumothorax - air that enters the pleural cavity leaves
at the same rate
lungs are deflated but no increase in pressure air
in/out at the same rate
where is the problem in the tissue oxygenation cascade in simple pneumothroax -
ventilation
what happens in penumothorax - lungs are collapsed/deflated aire
enters space between the visceral & parietal
two layers of the lungs - visceral & parietal
Q - in a pneumothorax, no ligaments attach the lung to the wall. so what holds it up? - A
- a thin layer of pleural fluid & negative pressure. the liquid helps it stick like how a
spilled liquid forms a seal between a glass and a smooth table top
difference between a simple and tension pneumo -
aka chest tube - chest thoacotomy
purpose of using a chest tube in simple pneumothorax - to allow for negative pressure
to reestablish .
tension pnumothorax - air enters under pressure but doesn't exit at the same rate. =
accumulation of air under pressure
example of tension pneumothorax - like using a bicycle pump to put more and more air
into the lungs over time. no escape
*pressure means no lung function on the side of the injury and compromises function on
the un injured heart and great vessel compression
,(decreases preload/CO
increases afterload
effect of tension pneumothorax on heart function - increases intrathoracic pressure
decreases preload/CO
increases afterload
normal pressure in the vena cavas - normally is low
similar to the central venous pressure which is similar to right atrial pressure (2-8mm
hg) so very little increase in pressure to impede venous return to the heart
3 questions to ask in trauma - -what was the dose of energy?
-where did it go?
-what injuries are likely?
2 q's to ask in GSW - caliber type
of gun
# of entrance/exit wounds high/low
velocity
1st question to ask in any traumatic injury? - what was the dose of energy involved?
(was it high or low?)
what is the caliber of a bullet? - diameter
aka diameter of a bullet - caliber
what happens to projectiles when they enter the body - projectiles don't travel in a
straight line
consider temporary cavity wound
what should you consider about tissue a projectile enounters - temporary cavitation
primary goal of GSW surgery - usually damage repair & not bullet removal -if
superficial, it may migrate the surface with time
important thing to remember about retained projectiles - they may migrate over time.
bullett migration might explain unexplained clinical findings
(VP Cheney accidentally shot his friend while hunting in 2006. ICU and did great.
moved to an inpatient unit. had a silent MI bc a shot gun pellets migrated into a canary
artery causing an infract. so had a MI but fibrinolytic not the answer in this case b/c it
was a "projectile embolus"
aka brestbone - sternum
, what attaches the ribs to the sternum - cartliage
what breaks thoracic bones - significant force -1-2nd ribs,
posterior ribs, sternum, scapulae, T2-10 gives us info
about the force aka "dose" of energy received consider
injury to internal structures b/c force
ribs that are the most frequently broken - ribs 4-9 b/c long, thin, and poorly protecte it
is harder to break a short pencil (T1-2) and easier to break a longer one
*ask how many and where to understand the force involved
what is the significance of posterior rib fractures - unusual direction of injury
shorter stubby ribs good muscle profection
**posterior rib fractures have a lot of force so need a high dose.
***PRF need a lot of force so high dose of energy. big red flag for t-spine injury
indication of c-spine injury - to injure c-spine, you don't need a big energy blow. all it
takes is shaking around.
c spine versus t spine fractures - c-spine doesn't need a big energy blow. just some
shaking around
t-spine needs a great strong direct blow (not just a shock_
treatment for rib fractures - largely supportive nursing care like pulmonary toilet
CXR and rib fractures - simple rib fractures are difficult to see on CXR and can be
commonly missed
(1/2 of all rib fractures aren't identified at the POI CXR)
identify a previous rib fracture on CXR - once healed, rib fractures form bony callouses
and become more visible on CXR
how to tell a pt has a pneumonia from a CXR - dark spot that is not equal to the
opposite side
consider if a pt has a lower rib fracture - liver & spleen injury
acts like BBQ/marshmellow skewers
how high does the diaphragm rise on inspiration - level of 4th ICS
AND CORRECT ANSWERS LATEST UPDATED
where on the tissue oxygenation cascade do pulmonary contusions cause their
problems - diffusion
all contusions over time - all contusions "blossom" over time. the full extent of the injury
is not initially apparent
important thing to remember when you are evaluating a patient for pulmonary
contusions - 70% of pulmonary contusions aren't initial on the initial CXR
what should you monitor when a pt has trauma to the throax - closely monitor for
pulmonary contustiobs = 70% not present on the initial CXR and "blossom" over time
-monitor for progress e deterioration in hours/days post injury
*might look ok in ER
best parameter of serial monitoring for pt's who have risk factors for pulmonary
contusions - anticipate "blossoming" over time b/c 70% of pulmonary contusions aren't
present on the initial CXR
P:F ratio
bruise on the lungs - pulmonary contusion
causes of pulmonary contusions - high speed blunt or penetrating injury
what happens to the lungs in pulmonary contusions - big boggy bruise on the lungs
diffusion problems
when it becomes contused & edematous, it becomes difficult for oxygen to move from
the alveoli into the capillaries
problem of using CXR as a definitive clinical dx tool - CXR may lag behind clinical status
*b/c 70% of pulmonary contusions aren't present on initial CXR. they "blossom" over
time
,tear in lung tissue - pulmonary laceration
problem of pulmonary lacerations - risk of massive hemothoax b/c those vessels are
very vascular
simple v. tension v. open v. closed. v. hemothorax v. hemopneumothorax -
what is a simple pneumothorax - any air that enters the pleural cavity can also leave at
the same rate. lungs deflated but no increase in intrathroacic pressure. air in/out exits at
the same rate. pt might be able to tolerate a simple pneumothraox causes a problem at
the ventilation point at the tissue oxygen cascade
intrathroacic pressure in simple pneumothorax - air that enters the pleural cavity leaves
at the same rate
lungs are deflated but no increase in pressure air
in/out at the same rate
where is the problem in the tissue oxygenation cascade in simple pneumothroax -
ventilation
what happens in penumothorax - lungs are collapsed/deflated aire
enters space between the visceral & parietal
two layers of the lungs - visceral & parietal
Q - in a pneumothorax, no ligaments attach the lung to the wall. so what holds it up? - A
- a thin layer of pleural fluid & negative pressure. the liquid helps it stick like how a
spilled liquid forms a seal between a glass and a smooth table top
difference between a simple and tension pneumo -
aka chest tube - chest thoacotomy
purpose of using a chest tube in simple pneumothorax - to allow for negative pressure
to reestablish .
tension pnumothorax - air enters under pressure but doesn't exit at the same rate. =
accumulation of air under pressure
example of tension pneumothorax - like using a bicycle pump to put more and more air
into the lungs over time. no escape
*pressure means no lung function on the side of the injury and compromises function on
the un injured heart and great vessel compression
,(decreases preload/CO
increases afterload
effect of tension pneumothorax on heart function - increases intrathoracic pressure
decreases preload/CO
increases afterload
normal pressure in the vena cavas - normally is low
similar to the central venous pressure which is similar to right atrial pressure (2-8mm
hg) so very little increase in pressure to impede venous return to the heart
3 questions to ask in trauma - -what was the dose of energy?
-where did it go?
-what injuries are likely?
2 q's to ask in GSW - caliber type
of gun
# of entrance/exit wounds high/low
velocity
1st question to ask in any traumatic injury? - what was the dose of energy involved?
(was it high or low?)
what is the caliber of a bullet? - diameter
aka diameter of a bullet - caliber
what happens to projectiles when they enter the body - projectiles don't travel in a
straight line
consider temporary cavity wound
what should you consider about tissue a projectile enounters - temporary cavitation
primary goal of GSW surgery - usually damage repair & not bullet removal -if
superficial, it may migrate the surface with time
important thing to remember about retained projectiles - they may migrate over time.
bullett migration might explain unexplained clinical findings
(VP Cheney accidentally shot his friend while hunting in 2006. ICU and did great.
moved to an inpatient unit. had a silent MI bc a shot gun pellets migrated into a canary
artery causing an infract. so had a MI but fibrinolytic not the answer in this case b/c it
was a "projectile embolus"
aka brestbone - sternum
, what attaches the ribs to the sternum - cartliage
what breaks thoracic bones - significant force -1-2nd ribs,
posterior ribs, sternum, scapulae, T2-10 gives us info
about the force aka "dose" of energy received consider
injury to internal structures b/c force
ribs that are the most frequently broken - ribs 4-9 b/c long, thin, and poorly protecte it
is harder to break a short pencil (T1-2) and easier to break a longer one
*ask how many and where to understand the force involved
what is the significance of posterior rib fractures - unusual direction of injury
shorter stubby ribs good muscle profection
**posterior rib fractures have a lot of force so need a high dose.
***PRF need a lot of force so high dose of energy. big red flag for t-spine injury
indication of c-spine injury - to injure c-spine, you don't need a big energy blow. all it
takes is shaking around.
c spine versus t spine fractures - c-spine doesn't need a big energy blow. just some
shaking around
t-spine needs a great strong direct blow (not just a shock_
treatment for rib fractures - largely supportive nursing care like pulmonary toilet
CXR and rib fractures - simple rib fractures are difficult to see on CXR and can be
commonly missed
(1/2 of all rib fractures aren't identified at the POI CXR)
identify a previous rib fracture on CXR - once healed, rib fractures form bony callouses
and become more visible on CXR
how to tell a pt has a pneumonia from a CXR - dark spot that is not equal to the
opposite side
consider if a pt has a lower rib fracture - liver & spleen injury
acts like BBQ/marshmellow skewers
how high does the diaphragm rise on inspiration - level of 4th ICS
