Casefiles 3: blunt trauma, hemorrhagic shock, penetrating abd. trauma, burns

Question 1

FAST

Answer 1

Focused Abdominal Sonography for Trauma
a quick US designed to detect pericardial effusion and intra-abdominal free fluid
especially helpful for evaluation of the hemodyamically unstable, multiple trauma patient.

Question 2

four areas evaluated in the FAST

Answer 2

pericardial space, right upper quadrant subhepatic space, left upper quadrant perisplenic space, and pelvis.

Question 3

diagnostic peritoneal lavage (DPL) helps to identify ?

Answer 3

intraperitoneal bleeding as the cause of the hypotension. Positive results can be based on aspiration of greater than 10 mL of blood or enteric contents from the peritoneal cavity
-get cell count analysis if no blood, positive lavage is WBC count more than 500 cells/mm3 or RBC count of more than 100,000 cells/mm3

Question 4

what is abdominal CT scan good for in the blunt trauma patient?

Answer 4

solid organ injuries, retroperitoneal injuries, and peritoneal fluid

• don’t use for unstable trauma pt
• lacks sensitivity or specificity for hollow viscous injury identification

Question 5

the Pan-scan includes ?

Answer 5

CT imaging of the brain, c-spine, chest, abdomen, and pelvis

Question 6

? is rarely the cause of hemodynamic instability in a trauma patient; therefore, the evaluation should be directed toward identification of a ?

Answer 6

rarely TBI

bleeding source or mechanical source (such as tension pneumothorax).

Question 7

what clinical feature in a TBI patient contributes to secondary brain injury and worse neurologic outcomes?

Answer 7

Persistent hypotension

Question 8

prioritization of his injuries example

Answer 8

treatment of the pneumothorax (airway)
to supportive care and monitoring of his TBI
to reduction of the fractured left lower extremity to improve the circulatory status to the left lower extremity
to repair of his superficial scalp lacerations

Question 9

Laboratory tests are an adjunct to the s/s of shock and include the use of ?

Answer 9

base deficit calculated from arterial or venous blood gas or lactate

Question 10

Rotational thromboelastometry (ROTEM) and thromboelastography (TEGS) assesses ?

Answer 10

the quality of the clot formation in the injured patient.

allows the physician to decide if the patient needs PRBCs, FFP, platelets, or cryoprecipitate.

Question 11

hemostatic resuscitation

Answer 11

packed red blood cell:FFP:platelets in a ratio of 1:1:1

Question 12

several conditions mandate operative interventions after penetrating trauma include ?

Answer 12

peritonitis, evisceration, and hemorrhagic shock

Question 13

The use of ? can reverse the coagulopathy associated with the use of Coumadin

Answer 13

factor IX prothrombin concentrates

-essential for patients who are bleeding and have no margin for expansion of the process like in a closed head injury.

Question 14

If the patient is in shock with distended neck veins and midline trachea, what is the diagnosis?

Answer 14

pericardial tamponade

Question 15

The early administration of this anti-fibrinolytic agent soon after major injuries (within 3 hours of injury) has been shown to produce lower transfusion requirement and improved survival in a randomized controlled clinical trial (CRASH-II Trial)

Answer 15

tranexamic acid (TXA)

Question 16

massive transfusion generally defined as ?

Answer 16

greater than or equal to 10 units of PRBC transfusion over a 24-hour period

Question 17

patients that may require massive transfusion

Answer 17

systolic BP less than 110 mm Hg, HR greater than 105, hematocrit less than 32%, and pH less than 7.25 in a trauma patient with high injury mechanism (high-speed motor vehicle crash, penetrating truncal injury, fall from height, and auto vs pedestrian crash).

Question 18

“lethal triad”

often associated with severe injuries and large volume blood losses

Answer 18

hypothermia, acidosis, and coagulopathy

Question 19

initial negative FAST examinations do not reliably rule-out ?

Answer 19

intra-abdominal injuries in stable patients with abdominal penetrating trauma.

Question 20

single SW to the epigastric region and signs of shock that include diaphoresis, tachycardia, and marginally low blood pressure + diffuse abdominal tenderness that is suggestive of peritonitis
best next step?

Answer 20

exploratory laparotomy

Question 21

SW to RLQ with +DPL (7000 RBC/mm3 and 750 WBC/mm3)

what is next best step?

Answer 21

laparotomy

NOT diagnostic laparoscopy

Question 22

immediate and late complications of major burn trauma

Answer 22

early: Airway compromise and tissue hypoperfusion
late: wound sepsis, functional loss, and psychological trauma

Question 23

what are the most critical interventions during initial management of severe burn victims

Answer 23

intubation and the initiation of mechanical ventilation

Question 24

two 2nd degree burn types and treatments

Answer 24

Superficial partial-thickness: topical wound care such as silver sulfadiazine
Deep partial-thickness: often treated by excision and skin-grafting

Question 25

3rd degree burns

Answer 25

Full-thickness burn of the skin involving the entire epidermis and dermis layers
painless, appear white or black with a leather-like appearance

Question 26

Parkland Formula

Answer 26

(Affected TBSA%) × (4 mL of Lactated Ringer) × (weight of patient in kg).
1/2 of the calculated volume is given over the first 8 hours and the remainder given over the subsequent 16 hours.
The rate and volume of administration are adjusted to keep urine output between 0.5 and 1.0 mL/kg/h.

Question 27

Modified Brooke Formula

Answer 27

lactated Ringer 2 to 4 mL/kg×% TBSA during the first 24 hours, with 1/2 of the volume given in the first 8 hours and the remaining fluid in the subsequent 16 hours.
During the second 24 hours, colloid fluid (5% albumin in lactated ringer) is given at 0.3 to 0.5 ml/kg×% TBSA titrated to maintain urine output of more than 0.5 mL/kg/h.

Question 28

escharotomy

Answer 28

incision made in the “leathery” and nonexpansive full-thickness burn sites to help improve tissue perfusion if there is a circumferential burn wound in the extremities
-can be made in truncal region

Question 29

A topical agent most useful for full-thickness, infected burns which can penetrate eschars

Answer 29

Sulfamylon (Mafenide)

drawbacks: pain with application and metabolic acidosis relating to its carbonic anhydrase inhibition activities

Question 30

Silver Sulfadiazine (SS)

Answer 30

most commonly applied topical agent for superficial burn wounds
soothing, but can’t penetrate eschars or help infected burns

Question 31

Silver Nitrate

Answer 31

topical burn wound agent. It has limited eschar penetrance and turns tissues a black color; also leaches Na+ and Cl- from tissue

Question 32

Major burn wounds are generally defined as injuries with ? TBSA involvement

Answer 32

more than 20%
if this large will produce systemic inflammatory responses and interstitial edema in tissues and organs away from the injured areas

Question 33

All victims rescued from the scene of closed-space fires should have their ? levels measured. level of greater than 30% can produce permanent central nervous system (CNS) dysfunction, and a COHgb level greater than 60% can produce coma and death.

Answer 33

carboxyhemoglobin (COHgb)
level of greater than 30% can produce permanent (CNS) dysfunction, and a COHgb level greater than 60% can produce coma and death.

Question 34

The half-life of CO in the blood in a patient receiving room air is ?; whereas, the half-life of CO in a patient receives 100% oxygen delivered through an endotracheal tube by a ventilator, is ?

Answer 34

250 minutes

reduced to 40 to 60 minutes

Question 35

Inflammatory mediators such as prostaglandins, thromboxane A2, and reactive oxygen radicals are released from injured burned tissues, which produce ?

Answer 35

local edema, increased capillary permeability, decreased tissue perfusion, and end-organ dysfunction

Question 36

rule of 9’s adult

Answer 36

whole head: 9
front chest: 9
back chest: 9
front abdomen: 9
back abdomen: 9
whole arm: 9
front leg: 9
back leg: 9
genitalia: 1

Question 37

rule of 9’s infant

Answer 37

front head: 9
back head: 9
front chest: 9
back chest: 9
front abdomen: 9
back abdomen: 9
whole arm: 9
front leg: 7
back leg: 7

Question 38

desired UOP

Answer 38

adults: UOP of 0.5 mL/kg/h is sufficient
children: UOP of 0.5 to 1.0 mL/kg/h is desirable
infants: UOP of 1 to 2 mL/kg/h is strived for

Question 39

what are indications of abdominal compartment syndrome and are potential indications for abdominal decompression?

Answer 39

Bladder pressures greater than 20 mm Hg plus at least one additional organ dysfunction

Question 40

signs of extremity hypoperfusion and suggest the need for decompressive procedures such as escharotomies and/or fasciotomies

Answer 40

Impaired capillary refill, increasing pain, and paresthesias

Question 41

major types of biologic dressings applied for temporary wound coverage

Answer 41

Porcine or bovine xenografts, cadaver skin, and acellular dermal matrix

Question 42

after the resuscitation phase, the optimal goal in the management of burn wounds is to ?

Answer 42

excise the burn wounds and provide early coverage with autologous split-thickness skin graft to facilitate early wound coverage and to minimize the risk of wound sepsis

Question 43

systemic burn complications

Answer 43

• hypermetabolic state
• activation of the complement and coagulation pathways leading to microvascular thromboses, capillary leak, and interstitial edema
• subsequent counter-regulatory anti-inflammatory response that produces immune-suppression and susceptibility to nosocomial infections and sepsis

Question 44

other burn complications

Answer 44

AMS, pneumonia/resp. failure, myocardial depression, VTEs, GI ulcers, acalculous cholecystitis, pancreatitis, and hepatic dysfunction, infection, corneal abrasions/ulcerations, burn scars, psychosocial trauma

Question 45

patients recommended for transfer to burn center

Answer 45

• younger than 10 y or older than 50 y with full-thickness burn more than 10% TBSA
• Any age with TBSA burn more than 20%
• Partial- or full-thickness burn involving face, eyes, ears, hands, genitalia, perineum, and over joints
• Burn injury complicated by chemical, electrical, or other forms of significant trauma
• Any patient requiring special social, emotional, and long-term rehabilitative support

Question 46

Candidates for outpatient burn treatments

Answer 46

some adults with partial-thickness burns measuring less than 10% TBSA, children and elderly patients with less than 5% TBSA burns, and adults with full-thickness burns measuring less than 2% TBSA.

Question 47

burn degrees

Answer 47

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