Module - 6 - Trauma & Burns Flashcards
1
Q
- You are on the scene where a thirty-five-year-old man having gunshot wound to the left chest. The left chest has been decompressed with a needle prior to your arrival. The patient is intubated and continues to desaturate. Your assessment reveals an increase in SQ air to the chest and neck. The next intervention would be to
A. Reneedle the left chest
B. Advance ET tube below the level of the injury; right main stem intubation
C. Decrease respiratory rate down to 10 per minute
D. Insert a chest tube
A
- B: Tracheobronchial injury (TBI) is damage to the tracheobronchial tree (the structure of airways involving the trachea and bronchi). It can result from blunt or penetrating neck or chest trauma, causing a tear in the trachea or bronchus, allowing air to enter the pleural space or mediastinum. These injuries are characterized by palpable subcutaneous emphysema (in the neck, face, and thorax), dyspnea, hemoptysis (coughing up blood), and absent breath sounds to the affected side. Hamman’s sign, which is a crunching sound auscultated to the anterior chest that is synchronized to the patient’s heart beat, may also be present. A pneumothorax that reaccumulates after needle decompression has been performed or chest tube has been placed, should heighten the suspicion for tracheobronchial injury. The airways may also be injured by inhaling harmful fumes or aspirating liquids or objects. Intubation with placement of the tube distal to the injury site should be accomplished (right mainstem intubation in most cases). These patients should be closely monitored for development of a tension pneumothorax during transport.
2
Q
- You are managing a burn patient who weighs 90 kg with a 65% burn surface area (BSA). How much fluid should this patient receive in the first eight hours when using the Parkland formula?
A. 23,400 mL
B. 11,700 mL
C. 8,450 mL
D. 5,850 mL
A
- B: Once the burning process has been stopped, the patient should be volume resuscitated according to the Parkland formula. This formula dictates the amount of Lactated Ringer’s solution or Hartmann’s solution to deliver in the first twenty-four hours after the time of injury. Half of this volume is given in the first eight hours with the remaining half to be administered in the subsequent sixteen hours. This formula excludes first-degree burns, so erythema (redness of the skin) alone is discounted.
3
Q
- What does the clinical presentation of abnormal posturing generally indicate?
A. Frontal lobe dysfunction
B. Upper motor neuron dysfunction
C. Severe injury/damage to the brain and brainstem
D. Lower motor neuron dysfunction
A
- C: Abnormal posturing is an involuntary flexion or extension of the arms and legs, indicating severe brain injury. It occurs when one set of muscles becomes incapacitated, while the opposing set is not, and an external stimulus, such as pain, causes the working set of muscles to contract. Patients with decorticate posturing present with the arms flexed, or bent inward on the chest, the hands clenched into fists, and the legs extended, and feet turned inward. Progression from decorticate posturing to decerebrate posturing is often indicative of uncal (transtentorial) or tonsilar brain herniation. In decerebrate posturing, the head is arched back, the arms are extended by the sides, and the legs are extended. A hallmark of decerebrate posturing is extended elbows. The arms and legs are extended and rotated internally. The patient is rigid, with the teeth clenched.
4
Q
- Using the Consensus formula, calculate how much fluid this 70-kg patient with a 50% BSA would receive in the first 8 hours of care?
A. 2,000-4,000 mL
B. 7,000-14,000 mL
C. 3,500-7,000 mL
D. 5,000-8,000 mL
A
- C: The burn formulas are a guide only and infusions must be tailored to the urine output and central venous pressure. Inadequate fluid resuscitation causes renal failure and death, but over-resuscitation also causes morbidity and mortality. Consensus Formula (Parkland and modified Brook formulas combined) [(2-4 mL × weight in kg) × % TBSA] = Total fluids in twenty-four hours with half of the total fluids calculated administered in the first eight hours and the rest in the subsequent sixteen hours.
5
Q
- The most commonly abused organ orsystem is?
A. Head
B. Orthopedic
C. Integumentary
D. Genitourinary
A
- C: The integumentary system is the largest organ system that protects the body from damage, comprising the skin and its appendages (including hair, scales, feathers, and nails). The integumentary system has a variety of functions; it may serve as waterproof, cushion, and protect the deeper tissues, excrete wastes, regulate temperature, and is the attachment site for sensory receptors to detect pain, sensation, pressure, and temperature. In humans, the integumentary system also provides vitamin D synthesis.
6
Q
- You are transporting a twenty-year-old man involved in a high-speed motor vehicle accident with a history of being ejected from the vehicle two hours prior to your arrival. The patient has been intubated and remains unconscious, with abnormal posturing noted. Mechanisms of injury associated with acceleration and deceleration that occurs with high-speed motor vehicle accidents or ejection from a vehicle can cause which type of brain injury?
A. Cerebral contusion
B. Concussion
C. Diffuse axonal injury
D. Depressed skull fracture
A
- C: Diffuse axonal injury occurs when the delicate axons of the brain are stretched and damaged as a result of rapid movement of the brain, involving mechanism of injury associated with acceleration and deceleration that occurs with high-speed motor vehicle accidents or ejection from a vehicle. This type of brain
7
Q
- When inserting a chest tube, correct insertion site recommended is
A. 2nd ICS midclavicular
B. 5th ICS anterior midaxillary
C. 5th ICS midaxillary
D. 4th ICS midaxillary
A
- B: All pneumothoraces greater than 20% or any pneumothorax present in patients requiring positive pressure ventilation should be treated with tube thoracostomy prior to transport. Treatment consists of placement of an appropriate-sized chest tube to the fifth intercostal space, at the anterior midaxillary line of the affected side. An alternate site for chest tube placement is the second intercostal space at the midclavicular line of the affected hemothorax. The anterior approach (alternate site) is inappropriate if both air and fluid are suspected in the pleural space.
8
Q
- You are transporting a twenty-three-year-old man, with a diagnosis of left-sided hemothorax. Guidelines for tube clamping suggest that the chest tube be clamped after how many milliliters of blood have been removed in the adult patient?
A. 100 mL
B. 1,000 mL
C. 1,500 mL
D. 500 mL
A
- B: Hemothorax occurs when blood accumulates in the pleural space. When more than 1,500 mL of blood accumulates in the pleural space, a hemothorax is deemed massive. Clinical presentation can include dyspnea, chest pain, decreased or absent breath sounds over the affected side, and dullness to percussion of the affected hemothorax. Signs of shock, which would be related to the blood loss, may be evident. Advanced Trauma Life Support (ATLS) guidelines state the tube should be clamped after 1,000 mL of blood is removed in adult patients. Pediatric patients have a circulating volume of 80 mL/kg. The 1,000 mL in adults represents one fifth of the circulating volume, so a similar 20% loss in children may require thoracostomy tube clamping. It is important to remember that tube clamping is a temporizing measure until open thoracotomy can be performed.
9
Q
- You arrive on the scene to manage a fall victim. She presents with a BP 80/50, HR 128, RR 36, SaO2 90%. Ground EMS reports that upon their physical examination, the patient revealed decreased bowel-like breath sounds on the left side of the chest. The patient is complaining of difficulty in breathing and severe left shoulder pain. The most likely diagnosis of this patient is
A. Diaphragmatic rupture and spleen injury
B. Neurogenic shock and tension pneumothorax
C. Hypovolemic shock and cardiac tamponade
D. Hemothorax and liver injury
A
- A: Blunt injury to the diaphragm, resulting in rupture or partial tear, occurs when a tremendous force is applied to the abdomen. Diaphragmatic tears can occur without herniation of bowel into the chest cavity. If an intestinal herniation into the pleural space does occur, intestinal strangulation may develop. The left diaphragm is injured more often than the right because the liver absorbs the impact of the force on the right side. If a right-sided tear has occurred, liver injury will probably accompany it. Spleen injuries often occur with left-sided diaphragmatic trauma. Specific treatment for a known or suspected diaphgramatic tear with possible herniation should focus on airway management, oxygenation, and ventilation because of the potentially decreased lung capacity.
10
Q
- You are preparing to transport a seventy-two-kg patient presenting with second and third degree burns to his entire face, anterior torso, and complete left arm. How much fluid should the patient receive in the first eight hours using the Parkland formula?
A. 4,600 mL
B. 9,200 mL
C. 3,066 mL
D. 2,300 mL
A
- A: The assessment of the patient with burn injuries begins with the ABCs of the primary assessment. Burn wounds are often very dramatic in appearance and can lure the transport team’s attention away from more immediate life-threatening problems. The goal of initial fluid resuscitation is to restore and maintain adequate tissue perfusion and vital organ function, in addition to preserving heat-injured but viable tissue in the zone of stasis. Parkland Formula [(4 mL × weight in kg) × % TBSA] = Total fluids in 24 Hours 4 × 72 = 288 × 32 = 9,216 mL in twenty-five hours with half of the total amount of fluids calculated is administered in the first eight hours. Answer: 4,600 mL in the first eight hours
11
Q
- A sixty-year-old male patient has been trapped under a tractor for almost six hours. Once extricated, he is most likely to experience
A. Tension pneumothorax
B. Massive hemothorax
C. Rhabdomyolysis
D. Compartment syndrome
A
- C: Rhabdomyolysis is the rapid breakdown (lysis) of skeletal muscle (rhabdomyo) due to injury to muscle tissue. The muscle damage may be caused by physical (e.g., crush injury), chemical, or biological factors. The destruction of the muscle leads to the release of the breakdown products of damaged muscle cells into the bloodstream; some of these, such as myoglobin (a protein), are harmful to the kidney and may lead to acute kidney failure. Treatment is with intravenous fluids, and dialysis or hemofiltration, if necessary. Swelling of the damaged muscle occasionally leads to compartment syndrome, the compression by swollen muscle of surrounding tissues in the same fascial compartment (such as nerves and blood vessels), leading to damage or loss of function in the part of the body, supplied by these structures. Symptoms of this complication include, decreased blood supply, decrease in sensation, or pain in the affected limb. Release of the components of muscle tissue into the bloodstream, leads to disturbances in electrolytes, causing, nausea, vomiting, confusion, coma, and cardiac arrhythmias. Furthermore, damage to the kidneys may lead to dark (tea-colored) urine or a marked decrease (oliguria) or absence (anuria) of urine production, usually about 12-24 hours after the initial muscle damage. Finally, disruptions in blood clotting may lead to the development of a state called disseminated intravascular coagulation (DIC). The most reliable test in the diagnosis of rhabdomyolysis is the level of creatine kinase (CK) in the blood. CPK levels greater than 20,000 are ominous and are indicative of later DIC, acute kidney failure, and potentially dangerous hyperkalemia.
12
Q
- Your patient was struck from behind while driving. The most common area of injury from a rear-end collision is
A. Ankle fracture
B. Coup Contrecoup injury pattern
C. C2 fracture
D. T12-L1 injuries
A
- D: An automobile hit from behind rapidly accelerates, causing the car to move forward under the patient. Predictable injuries are to the back with T12-L1 being the common area of injury, femur fractures, tibia/fibula fractures, ankle fractures, cervical strain, and C2 fractures caused by hyperextension if the head restraint is not in the proper position.
13
Q
- The clotting cascade can be triggered through an extrinsic pathway. The triggering mechanism is the release of
A. Fibrinogen
B. Prothrombin
C. Basophils
D. Tissue thromboplastin
A
- D: Thromboplastin is the combination of both phospholipids and tissue factor, both needed in the activation of the extrinsic pathway. However, partial thromboplastin is just phospholipids and not tissue factor. Tissue factor is not needed to activate the intrinsic pathway. Partial thromboplastin is used to measure the intrinsic pathway. This test is called the aPTT, or activated partial thromboplastin time.
14
Q
- A patient in early shock most probably would present with which of the following acid-base imbalance?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
A
- D: Rapid and shallow respirations are seen with a shock patient, which is due to sympathetic nervous system stimulation and acidosis.
15
Q
- Which blood component does not require typing and crossmatching before administration?
A. Platelets
B. Fresh frozen plasma
C. Cyropercipitate
D. Albumin
A
- D: A blood product is any component of the blood, which is collected from a donor for use in a blood transfusion. Whole blood is uncommonly used in transfusion medicine at present; most blood products consist of specific processed components, such as red blood cells, blood plasma, or platelets. Type and crossmatch refers to the complex testing that is performed prior to a blood transfusion to determine if the donor’s blood is compatible with the blood of an intended recipient, or to identify matches for organ transplants. Crossmatching is usually performed only after other less complex tests have not excluded compatibility. Blood compatibility has many aspects and is determined not only by the blood types (O, A, B, AB), but also by blood factors (Rh, Kell, etc.). Albumin is a blood protein that is mainly produced in the liver and helps maintain volume of the blood by maintaining the oncotic pressure. Albumin IV is a plasma volume expander made from pooled human venous plasma, which does require type and crossmatching. Indications of Albumin IV include hypovolemia and hypoalbuminemia, which can be caused by burns, major injury, hemorrhage, pancreatitis, infection, liver failure, or liver cirrhosis.
16
Q
- You are transporting a twenty-five-year-old female that presents with the following 12-lead ECG. What does the following 12-lead ECG show? [image]
A. U waves
B. Electrical alternans
C. Osborne wave
D. Prolonged QT interval
A
- B: Electrical alternans is an electrocardiographic phenomenon of alternation of QRS complex amplitude or axis between beats (high, low, high). Also a wandering baseline may be seen. It is seen in cardiac tamponade and is thought to be related to changes in the ventricular electrical axis due to fluid in the pericardium.
17
Q
- Platelets are considered low at
A. <150
B. <450
C. <240
D. <150
A
- D: In an adult, a normal count is about 150,000-400,000 (150-450) platelets per microliter of blood. If platelet levels fall below 20,000 per microliter, massive bleeding may occur and is considered a life-threatening risk.
18
Q
- Electrical alternans may be caused by a
A. Pulmonary embolus
B. Pericardial effusion
C. Tension pneumothorax
D. Diaphragmatic rupture
A
- B: Pericardial effusion (“fluid around the heart”) is an abnormal accumulation of fluid in the pericardial cavity. Because of the limited amount of space in the pericardial cavity, fluid accumulation will lead to an increased intrapericardial pressure, and this can negatively affect heart function. When there is a pericardial effusion, with enough pressure to adversely affect heart function, this is called cardiac tamponade. Normal levels of pericardial fluid are from 15 to 50 mL. The so-called “water-bottle heart” is a radiographic sign of pericardial effusion, in which the cardiopericardial silhouette is enlarged and assumes the shape of a flask or water bottle. Electrical alternans is seen in cardiac tamponade and is thought to be related to changes in the ventricular electrical axis due to fluid in the pericardium.
19
Q
- Normal K+ value is
A. 3.0-4.0
B. 3.5-4.5
C. 4.0-5.0
D. 1.5-2.5
A
- B: Normal range of K+ is 3.5-4.5. Some laboratories go as high as 5.5 for upper normal range.
20
Q
- You are managing a twenty-five-year-old man with burns to the entire face, left forearm, right hand, and anterior portion of the entire left leg. His BSA would be
A. 12%
B. 19%
C. 24%
D. 30%
A
- B: Entire face 4.5%, left forearm 4.5%, right hand 1%, and anterior portion of the entire left leg 9% = BSA of 19%
21
Q
- A twenty-one-year-old patient with history of stab wounds to the chest, presenting with a drop in the systolic blood pressure of 20 mmHg during inspiration, a narrowing pulse pressure, and clear equal breath sounds bilaterally would most likely be managed with all of the following, except
A. Intravenous fluid bolus
B. Pericardiocentesis
C. Rapid transport
D. Needle thoracostomy
A
- D: Cardiac tamponade also known as pericardial tamponade, is an emergency condition in which fluid accumulates in the pericardium (the sac in which the heart is enclosed). If the fluid significantly elevates the pressure on the heart, it will prevent the heart’s ventricles from filling properly. This, in turn, leads to a low-stroke volume. The end result is ineffective pumping of blood, shock, and often death. Clinical presentation can include; tachycardia, bradycardia, Beck’s triad (muffled heart tones, hypotension, jugular venous distension), pulsus paradoxus, and the presence of electrical alternans on the ECG. Management of a cardiac tamponade in the prehospital setting includes rapid transport to the closest, most appropriate facility, intravenous fluids (this measure improves filling pressures and temporarily improves cardiac output) until pericardiocentesis can be performed. Landmark for performing a pericardiocentesis is the infrasternal angle or subcostal angle, into the apex of which the xiphoid process projects with the needle and syringe directed toward the left shoulder/scapula. A needle placed into the pericardial sac, with aspiration of as little as 15-20 mL of blood can improve the patient’s condition. Pericardial blood will generally not clot because it has been defibrinated by heart motion.
22
Q
- A patient presenting with Beck’s triad is most likely experiencing
A. Tension pneumothorax
B. Increased ICP
C. Cardiac tamponade
D. Intra-abdominal bleeding
A
- C: Beck’s triad is a collection of three medical signs associated with acute cardiac tamponade, an emergency condition wherein fluid accumulates around the heart and impairs its ability to pump blood. The result is the triad of low arterial blood pressure, jugular venous distention (unless the patient is hypovolemic), and distant, muffled heart sounds. Pulsus paradoxus, a fall in the systolic blood pressure >15 mmHg during normal inspiration and a narrowing pulse pressure may also be observed prior to hypotension.
23
Q
- Immediate release of intrapleural pressure should be performed where
A. Fourth intercostal space, anterior axillary line
B. Fifth intercostal space, anterior midaxillary line)
C. Fourth intercostal space, midclavicular line
D. Second intercostal space, midclavicular line
A
- D: A pneumothorax can lead to severe oxygen shortage and low blood pressure, progressing to cardiac arrest unless treated; this situation is termed as tension pneumothorax. Clinical presentation can include dyspnea, tachycardia, altered mentation, narrowing pulse pressure, pulsus paradoxus, jugular venous distension, hypotension, diminished/absent breath sounds on the affected side, shock, and cardiac arrest. Initial treatment of a tension pneumothorax is performing a needle thoracostomy, with definitive treatment to include placement of a chest tube. To release intrapleural pressure, a large-bore needle should be placed into the second intercostal space, two-finger breadths lateral to the sternal border on the affected side. The needle should then be placed superior to the rib margin to avoid the intercostal artery. The anterior site should be used for avoidance of the internal mammary vessels.
24
Q
- An object in motion will remain in motion and an object at rest will remain at rest unless acted upon by a force; this law is known as
A. Newton’s first law
B. Newton’s second law
C. Newton’s third law
D. Ohm’s law
A
- A: Newton’s laws of motion are three physical laws that form the basis for classical mechanics. They describe the relationship between the forces acting on a body and its motion due to those forces.
25
Q
- Your patient was involved in a single car roll-over and is complaining of neck and left shoulder pain. You note bruising to the left chest wall. Vital signs are BP 80/48, HR 130, RR 28, SpO2 96%. The most likely cause is
A. Cardiac tamponade
B. Tension pneumothorax
C. Splenic injury
D. Intra-abdominal bleeding
A
- C: Injury to the spleen is the most common serious complication of abdominal injury, resulting from trauma. Kehr’s sign is the 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 classical symptom of a ruptured spleen. It may result from diaphragmatic or peridiaphragmatic lesions, renal calculi, splenic injury, or ectopic pregnancy. Kehr’s sign is a classical example of referred pain: irritation of the diaphragm is signaled by the phrenic nerve as pain in the area above the collarbone. This is due to the fact that the supraclavicular nerves have the same cervical nerves origin as the phrenic nerve, C3 and C4.
26
Q
- What is a common problem associated with electrical injuries?
A. Myoglobinuria
B. Ventricular fibrillation
C. Diabetes insipidus
D. Hypokalemia
A
- A: Electrical injuries occurs upon contact of a human body with any source of voltage high enough to cause sufficient current through the skin, muscles, or hair. Voltage is defined as the force with which the electrical movement occurs. High voltage injuries (>1,000 volts) and low voltage injures (<1,000 volts) are both common, and either type can cause death. The higher the voltage, the more significant the injury. The type of current, alternating (AC) or direct (DC), can also determine the significance of the injury. Alternating current produces a tetanic contraction of muscles that “freezes” the victim to the source and has a greater potential in causing ventricular fibrillation. This is not seen with direct current. Low voltage AC can be more dangerous than a low voltage DC. Lactic acidosis is common because of the significant muscle damage caused by electrical injury. It is essential to maintain higher rates of urinary output because hemoglobinuria and myoglobinuria are common with electrical injuries.
27
Q
- When managing a patient with an electrical injury that presents with hematochromagen urine, you should maintain a urine output of
A. 30-50 mL/hr
B. 50-100 mL/hr
C. 1-2 mL/kg/hr
D. A minimum 100 mL/hr
A
- D: The fluid resuscitation must be based on actual urine flow. A minimum of 50-100 mL/hour of urine must be maintained. If blood-colored urine is present, then the fluid volume must be sufficient enough to maintain a minimum output of 100 mL/hr.
28
Q
- Normal cerebral perfusion pressure is at least?
A. 80-100 mmHg
B. 50-60 mmHg
C. 70-90 mmHg
D. >100 mmHg
A
- C: Cerebral perfusion pressure, or CPP, is the net pressure gradient, causing blood flow to the brain (brain perfusion). It must be maintained within narrow limits because too little pressure could cause brain tissue to become ischemic (having inadequate blood flow) and too much could raise ICP.
29
Q
- Your patient presents with following parameters: CVP 0, CI 1, PA S/D 8/4, wedge 3, and SVR 1,800. What is your diagnosis?
A. Hypovolemic shock
B. Right ventricular infarction
C. CHF
D. Sepsis
A
- A: Careful interpretation of the CVP is important! Central venous pressure (CVP) describes the pressure of blood in the thoracic vena cava, near the right atrium of the heart. CVP reflects the amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system. It is a good approximation of right atrial pressure, which is a major determinant of right ventricular end-diastolic volume. The CVP should always be considered in conjunction with other cardiovascular parameters. Under normal circumstances, the right-sided heart pressures should indirectly reflect left-sided pressures, and the left-sided filling pressure may be an indicator of left ventricular function. Preload (end-diastolic volume) is the pressure stretching the ventricle of the heart at the beginning of systole after passive filling of the ventricle and subsequent atrial contraction. Afterload (end-systolic volume) is the ventricular pressure at the end of systole.
30
Q
- Normal ICP is
A. 0-10 mmHg
B. 10-20 mmHg
C. 20-30 mmHg
D. > 30 mmHg
A
- A: ICP monitoring uses a device placed inside the head, which senses the pressure inside the skull and sends its measurements to a recording device. The intraventricular catheter is thought to be the most accurate method, but if immediate access is needed, a subarachnoid bolt is typically used. Normal value ranges may vary slightly among different laboratories (upper limits of the range can go as high as 15 mmHg).
31
Q
- The formula used to calculate mean arterial pressure is:
A. 2/3 DBP × SBP
B. [(DBP × 2) + SBP] divided by 3
C. 2 × SBP + DBP
D. [(2 + DBP) × SBP] divided by 3
A
- B [(DBP × 2) + SBP] divided by 3
32
Q
- What is the formula used when calculating cerebral perfusion pressure?
A. [(2 × DBP) + SBP] divided by 3
B. MAP − ICP
C. ICP − DBP
D. [(2 + DBP) × SBP] divided by 3
A
- B MAP − ICP
33
Q
- Grey Turner’s sign may indicate
A. Meningitis
B. Splenic injury
C. Retroperitoneal bleed
D. Gallbladder
A
- C: Grey Turner’s sign refers to bruising of the flanks and can indicate retroperitoneal or intra-abdominal bleeding, which can take up to 24-48 hours to show up on assessment. It can be caused by acute pancreatitis, blunt abdominal trauma, ruptured abdominal aortic aneurysm, or ruptured/hemorrhagic ectopic pregnancy. It may be accompanied by Cullen’s sign (superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus), which may then be indicative of pancreatic necrosis, with retroperitoneal or intra-abdominal bleeding. Murphy’s sign is useful for differentiating pain in the right upper quadrant. Typically, it is positive in cholecystitis (gallbladder disease). Kernig’s and Brudzinski’s signs when elicited can indicate meningitis. Kehr’s sign (referred shoulder pain) can be indicative of a spleen injury or ectopic pregnancy.
34
Q
- Most commonly seen injuries with side impact or “lay it down” motorcycle crashes include all of the following, except
A. Open fracture of the femur
B. Pelvic fractures
C. Abrasions to the affected side
D. Tibia/fibula or malleolus fractures
A
- B: Injuries associated with a side-impact motorcycle crash are related to the body parts crushed between the cycle and the second object. Most commonly seen injuries involve the leg and foot on the impact side. Open fracture of the femur, tibia/fibula, and malleolus are predictable. Motorcycle riders have learned the technique of laying down the bike and sliding off to the side before colliding with another object. Commonly seen are abrasions on the affected side.
35
Q
- Predictable injuries that can occur with falls can include all of the following, except
A. Calcaneus fractures
B. C2 fracture
C. T12-L1 back injuries
D. Bilateral wrist fractures
A
- B: Falls from heights greater than 15-20 feet are associated with severe injuries. Three predictable injuries are seen with falls. The forces involved are deceleration and compression. The first injury, calcaneus fractures, is caused by compression of the feet on impact. Second, as the energy dissipates after impact and the top of the body pushes down toward the point of impact, compression fractures to T12-L1 are seen. Finally, as the body moves forward and the patient puts both arms out to complete the fall, bilateral wrist fractures occur. It is important to estimate the distance fallen and what the patient landed on. A soft-landing surface (dirt or sand) will absorb much more energy than a hard surface, such as concrete.
36
Q
- Dry chemicals such as lime should be
A. Brushed off before irrigation
B. Neutralized with a special agent before irrigation
C. Irrigated immediately with water or physiologic saline
D. Wrapped in a dressing and not irrigated
A
- A: Chemical burns differ from thermal burns in that the burning process continues until the agent is inactivated by reaction of tissues: neutralized or diluted with water. Dry chemicals, such as lime, should be brushed off before irrigation. Water and physiologic saline are fluids of choice for wound irrigation.
37
Q
- Hamman’s sign may indicate the presence of
A. Tension pneumothorax
B. Tracheobronchial injury
C. Aortic rupture
D. Cardiac tamponade
A
- B: Tracheobronchial injuries occur when blunt or penetrating trauma causes a tear in the trachea or bronchus, allowing air to enter the pleural space or mediastinum. These injuries are characterized by palpable subcutaneous emphysema in the neck, face, and thorax. Other clinical findings include dyspnea, hemoptysis (coughing up blood), and absent breath sounds on the affected side. Hamman’s sign is a crunching sound auscultated on the anterior chest wall and is synchronized to the patient’s heartbeat. A pneumothorax that reaccumulates after chest tube insertion and placement to water seal drainage and suction should heighten the transport team’s suspicion for tracheobronchial injuries. Treatment is intubation, with placement of the tube distal to the injury site, which most often can involve an intentional right mainstem intubation.
38
Q
- Recommended urinary output when managing a burn patient without an electrical injury is
A. 100 mL/hr
B. 10-20 mL/hr
C. 30-50 mL/hr
D. >100 mL/hr
A
- C: Urinary output is perhaps the most accurate method of evaluating the effectiveness of fluid replacement. Adult burn patients should have an hourly urine output of 30-50 mL/hr, and in the pediatric patient, it should be maintained at 1-2 mL/kg/hr/% BSA below 30 kg. Oliguria is an indication of inadequate fluid volume and should be easily corrected by increasing the rate of fluid administration. An osmotic diuretic, such as mannitol can be administered to avoid acute renal failure when fluid administration has been ineffective.
39
Q
- Hydrofluoric burns can be managed with copious amounts of water and
A. Calcium gluconate
B. Osmotic diuretics
C. Glucagon
D. Pyroxidine
A
- A: Hydrofluoric acid (HF) is an extremely corrosive liquid and is a contact poison. Because of the ability of hydrofluoric acid to penetrate tissue, poisoning can occur readily through exposure of skin or eyes, or when inhaled or swallowed. Symptoms of exposure to hydrofluoric acid may not be immediately evident. HF interferes with nerve function, meaning that burns may not initially be painful. Once absorbed into blood through the skin, it reacts with blood calcium and may cause cardiac arrest. Formation of insoluble calcium fluoride is proposed as the etiology for both precipitous fall in serum calcium and the severe pain associated with tissue toxicity. In some cases, exposures can lead to hypocalcemia. Thus, hydrofluoric acid exposure is often treated with calcium gluconate, a source of Ca2+ that sequesters the fluoride ions. HF chemical burns can be treated with a water wash and 2.5% calcium gluconate gel or special rinsing solutions. However, because it is absorbed, medical treatment is necessary; rinsing off is not enough and in some cases, amputation may be necessary.
40
Q
- The management approach for a patient experiencing brain herniation can include all of the following, except
A. Serum sodium goal 155
B. Serum osmolality less than 320
C. Hypertonic saline, mannitol
D. Hyperventilation to maintain EtCO2 at 20-30 mmHg
A
- D: Cushing’s triad is the triad of widening pulse pressure (rising systolic, declining diastolic), change in respiratory pattern (irregular respirations), and bradycardia. It is a sign of increased ICP, and it occurs as a result of the Cushing reflex. Brain herniation, also known as cistern obliteration, is a deadly side effect of very high ICP that occurs when the brain shifts across structures within the skull. Brain herniation frequently presents with abnormal posturing a characteristic positioning of the limbs indicative of severe brain damage. These patients have a lowered level of consciousness, with Glasgow Coma Scores of three to five. One or both pupils may be dilated and fail to constrict in response to light. Vomiting can also occur due to compression of the vomiting center in the medulla oblongata. Routine hyperventilation is not longer recommended in the initial management of the patient with traumatic brain injury. The patient’s EtCO2 should be maintained between 35-45 mmHg. Mannitol may be used to treat increasing ICP manifested by deterioration in the patient’s neurologic status.
41
Q
- Classic picture of neurogenic shock presents with
A. Hypertension
B. Absence of tachycardia
C. Cool skin
D. Pallor
A
- B: Neurogenic shock, also known as a type of distributive shock or vasogenic shock, is an imbalance between parasympathetic and sympathetic nervous stimulation of vascular smooth muscle, resulting in sustained vasodilatation typically, and the heart rate does not increase in the neurogenic shock patient due to loss of sympathetic impulses/stimulation. Vasomotor paralysis below the level of the injury occurs resulting in decreased peripheral vascular resistance. Sympathetic impulses, which would normally stimulate vasoconstriction, are interrupted, leading to widespread vasodilation. Blood collects in the capillary beds, reducing venous return, cardiac output, and blood pressure. Refer to the table for review of compensatory mechanisms.
42
Q
- Your patient presents with motor loss, numbness to touch, vibration on the same side of the spinal injury, loss of pain, and temperature sensation on the opposite side. You suspect that the most likely spinal cord syndrome present is
A. Brown-Séquard
B. Central cord
C. Anterior cord syndrome
D. Neurogenic shock
A
- Brown-Séquard
43
Q
- When should escharotomies ideally be performed?
A. Circumferential burns are present in the chest or extremities and transport time exceeds greater than thirty minutes
B. Circumferential burns to the extremities or digits have adequate circulatory stability
C. Circumferential burns to the chest decrease chest wall compliance
D. Circumferential burns are present on any pediatric patient
A
- C: Circumferential burns to the chest or extremities represent the more easily recognizable complications of burn care. Circumferential burns to the chest wall decrease chest wall compliance, creating respiratory insufficiency and hypoxia, especially in the pediatric patient. The treatment for this problem is an escharotomy, which allows the chest to expand fully for more efficient ventilation. Circumferential burns to the extremities or digits can be equally threatening to the circulatory stability of the affected limb, producing the “five Ps” that represent the signs and symptoms of an arterial injury: pain, pallor, pulselessness, paresthesias, and paralysis. Escharotomies ideally should be performed before transport of the patient and should be performed only under the direction of a medical physician.
44
Q
- A patient presents with a further drop in MAP of 20% with an increase in fluid loss of over 1,800 mL. Vasoconstriction continues and leads to oxygen deficiency. Physiologically, the body switches to anaerobic metabolism, forming lactic acid as a waste product. The patient would most likely be in which stage of shock?
A. Early reversible and compensated shock
B. Late shock
C. Intermediate or progressive and decompensated shock
D. Refractory or irreversible shock
A
- C: Shock is a clinical syndrome which results in a systemic imbalance between oxygen supply and demand. Inadequate blood flow to body organs and tissue causes life-threatening cellular dysfunction.
45
Q
- Calculate the following patient’s cerebral perfusion pressure (CPP): BP 180/90, HR 120, RR 24, SpO2 98%, CVP 2, ICP 25.
A. 80
B. 120
C. 65
D. 95
A
- D:
90 × 2 = 180
180 × 2 = 360
360 divided by 3 = 120
120-25 = 95
MAP-ICP = CPP
46
Q
- All of the following conditions are considered a form of obstructive shock, except
A. Cardiac
B. ICP
C. Tension pneumothorax
D. Massive pulmonary embolism
A
- B: Cardiac tamponade, tension pneumothorax, massive pulmonary embolism, and aortic stenosis are classified as forms of obstructive shock. In these situations, the flow of blood is obstructed, which impedes circulation and can result in circulatory arrest.
47
Q
- You are managing a 100-kg burned patient with 70% BSA. How much fluid will the patient receive in the first eight hours using the Consensus formula?
A. 14,000-28,000 mL
B. 7,000-14,000 mL
C. 3,500-7,000
D. 28,000 mL
A
- B: 2 × 100 = 200; 200 × 70 = 14,000; half is administered in the first eight hours = 7,000 mL (is the lower end of the Consensus formula). Answer = 7,000-14,000 mL Consensus formula (Parkland and modified Brook formulas combined) [(2-4 mL × weight in kg) × % TBSA] = Total fluids in twenty-four hours with half of the total fluids calculated administered
48
Q
- Late signs and symptoms of a tension pneumothorax can include all of the following, except
A. Narrowing pulse pressure
B. Hypotension
C. Bradycardia
D. Tracheal shift away from the affected side
A
- A: Early signs and symptoms of a tension pneumothorax can be characterized by increased work of breathing, tachycardia, pulsus paradoxus, narrowing pulse pressure, and breath’s sounds diminished on the affected side. Late signs and symptoms of decompensated obstructive shock include cyanosis, hypoxemia hypotension, bradycardia, and confusion. The affected side of the chest may be hyper-expanded and show decreased movement, with increased movement on the other side. The breath sounds may be diminished or absent on the affected side, as air in the pleural space dampens sound and percussion of the chest may sound hyperresonant (higher pitched). In very severe cases, the respiratory rate falls sharply, which may result in further shock and coma. Recent studies have shown that the development of tension features may not always be as rapid as previously thought. Particular clinical signs may also be less useful in the recognition of tension pneumothorax, such as the deviation of the trachea away from the affected side and the presence of increased jugular venous pressure.
49
Q
- The most common cause of pulseless electrical activity in a trauma patient is
A. Hypoxia
B. Hypovolemia
C. Tension pneumothorax
D. Cardiac tamponade
A
- B: Pulseless electrical activity (PEA), also known by the older term electromechanical dissociation or nonperfusing rhythm, refers to any heart rhythm observed on the ECG that should be producing a pulse, but is not. The most common cause of PEA is hypovolemia. The approach in treatment of PEA is to treat the underlying cause. These possible causes are remembered as the 6 Hs and the 6 Ts or by using the mneumonic PATCH4MD. Refer to the tables for review of causes for PEA. Where an underlying systemic cause cannot be determined rapidly enough, pulseless electrical activity should be treated as if the patient were in asystole. Treatment is intravenous delivery epinephrine (1:10,000) 1 mg every 3-5 minutes, and, if the underlying rhythm is bradycardia (<60 BPM), Atropine 1 mg IV up to 0.04 mg/kg. Both these drugs should be administered along with appropriate CPR techniques. Defibrillators are not used for this rhythm as the problem lies in the response of the myocardial tissue to electrical impulses.
50
Q
- You have responded to a fire in a building with five victims. You notice that a large portion of the synthetic carpet has been burned in the room where you are treating the patients. The patients are exhibiting increasing signs of respiratory distress and coughingafter high oxygen has been applied. What may be causing the patients’ signs and symptoms?
A. Cyanide
B. Ammonia
C. Carbon dioxide
D. Hydrocarbon
A
- A: Cyanide makes the cells of an organism unable to use oxygen, primarily through the inhibition of cytochrome oxidase. Inhalation of high concentrations of cyanide causes coma with seizures, apnea, and cardiac arrest, with death following in a matter of minutes. At lower doses, loss of consciousness may be preceded by general weakness, giddiness, headaches, vertigo, confusion, and perceived difficulty in breathing. A fatal dose for a patient can be as low as 1.5 mg/kg body weight. Blood cyanide concentrations may be measured as a means of confirming the diagnosis in hospitalized patients or to assist in the forensic investigation of a criminal poisoning. Cyanide toxicity can occur following ingestion of amygdalin (found in almonds and apricot kernels), prolonged administration of nitroprusside, and after exposure to gases produced by the combustion of synthetic materials. The United States standard cyanide antidote kit first uses a small inhaled dose of amyl nitrite, followed by intravenous sodium nitrite, followed by intravenous sodium thiosulfate. Hydroxocobalamin is newly approved in the US at doses from 2.5 to 10 mg per injection and is available in Cyanokit antidote kits. Hydroxocobalamin (OHCbl, or B12a) is a natural form of vitamin B12. Pharmaceutically, hydroxycobalamin is usually produced as a sterile injectable solution; it is used for treatment of the vitamin deficiency and also (because of its affinity for cyanide ion) as a treatment for cyanide poisoning. Hydroxocobalamin will bind circulating and cellular cyanide molecules to form cyanocobalamin, which is excreted in the urine.
76
Q
Electrical alternans
A
is an electrocardiographic phenomenon of alternation of QRS complex amplitude or axis between beats (high, low, high). It is thought to be related to changes in the ventricular electrical axis due to fluid in the pericardium.
- wandering baseline may be seen
- seen in cardiac tamponade
78
Q
Pericardial effusion
A
“fluid around the heart” is an abnormal accumulation of fluid in the pericardial cavity.
- Because of the limited amount of space in the pericardial cavity, fluid accumulation will lead to an increased intrapericardial pressure, and this can negatively affect heart function.
- When there is a pericardial effusion, with enough pressure to adversely affect heart function, this is called cardiac tamponade.
- Normal levels of pericardial fluid are from 15 to 50 mL.
- Electrical alternans is seen in cardiac tamponade and is thought to be related to changes in the ventricular electrical axis due to fluid in the pericardium.
96
Q
Landmark for performing a pericardiocentesis
A
is the infrasternal angle or subcostal angle, into the apex of which the xiphoid process projects with the needle and syringe directed toward the left shoulder/scapula.
A needle placed into the pericardial sac, with aspiration of as little as 15-20 mL of blood can improve the patient’s condition.
99
Q
Kehr’s sign is
A
a classical example of referred pain: irritation of the diaphragm is signaled by the phrenic nerve as pain in the area above the collarbone.
This is due to the fact that the supraclavicular nerves have the same cervical nerves origin as the phrenic nerve, C3 and C4.
108
Q
Grey Turner’s sign refers to
A
bruising of the flanks and can indicate retroperitoneal or intra-abdominal bleeding, which can take up to 24-48 hours to show up on assessment.
- It can be caused by acute pancreatitis, blunt abdominal trauma, ruptured abdominal aortic aneurysm, or ruptured/hemorrhagic ectopic pregnancy.
- It may be accompanied by Cullen’s sign (superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus), which may then be indicative of pancreatic necrosis, with retroperitoneal or intra-abdominal bleeding.
110
Q
Kernig’s and Brudzinski’s signs when elicited can indicate
A
meningitis
