Module 7 (Propofol Papi's)

Question 1

Airway management is tailored to the type of injury, the nature and degree of airway compromise, and the patient’s hemodynamic and _______(1) status.
Generally diagnosis of suspected cervical spine injury is reliably done for most patients by thin cut multidetector _______(2) scanning.
Generally it is _______(3) to allow some relaxation of the _______(4) inline stabilization of the cervical spine to improve the glottic view when visualization of the larynx is restricted.
A linear correlation exists between the rib score and _______(5) of pneumonia, acute respiratory failure, and need for tracheostomy.
A systolic blood pressure of 110 mmHg is accepted as a prehospital triage threshold for delivery to a Level I trauma center for trauma patients older than 65 years; systolic blood pressure of _______(6) remains a triage threshold for young patients.
The method of resuscitation of the hemorrhaging patient has changed since the Iraq and Afghanistan wars. The concept of _______(7) control resuscitation has replaced the classic crystalloid resuscitation.
Damage control resuscitation consists of _______(8) hypotension; rapid control of any bleeding source; minimal _______(9) infusion; early administration of plasma and other blood products in a balanced ratio (preferably 1:1:1) of _______(10), _______(11), and _______(12) by activation of the massive transfusion protocol; early administration of _______(13) acid; and, if indicated, damage control surgery to control bleeding and sources of contamination. Definitive surgery is deferred until after normalization of the patient’s physiologic condition.
Management strategies in the diagnosis and treatment of blunt aortic injuries have gone through major changes in the past 10 years with substantially improved early outcomes. In the area of diagnosis, _______(14) replaced aortography, and, in the area of treatment, _______(15) stenting practically replaced open repair, although in grade 3 or 4 blunt aortic injuries, open repair in the form of mostly “clamp and saw” technique is done.

Answer 1

1. oxygenation
2. computed tomography
3. reasonable
4. manual
5. development
6. 90 mmHg
7. damage
8. brief permissive
9. crystalloid
10. packed red blood cells
11. plasma
12. platelets
13. tranexamic
14. computed tomography angiography
15. endovascular

Question 2

9. Clinically, burn injury is manifested in two phases: _______(1), which is characterized by continued plasma loss from the intravascular space into burned, and often into intact, tissues for about the first day or two after injury, and the subsequent _______(2) or _______(3) phase, which may last for months.
10. In burn-injured patients, intravascular volume should be restored with utmost care to prevent excessive edema formation in both damaged and intact tissues which results from the generalized increase in _______(4) caused by the injury. Edema from overaggressive resuscitation has many deleterious and potentially life-threatening effects.
11. Of the many resuscitation formulas available, the _______(5) (Baxter) and modified Brooke formulas are tailored to the clinical condition of the patient and are accepted in most centers. Parkland formula uses crystalloid whereas Brooke formula uses combination of crystalloid and _______(6) during the first 24 hours. The addition of glucose is not necessary except in children, especially those weighing less than _______(7). _______(8) may be administered after the first day following injury at a rate of 0.3, 0.4, or 0.5 mL/kg/24 hours for burns of 30% to 50%, 50% to 70%, or 70% to 100% of total body surface area, respectively.
12. Traditionally, monitoring of fluid therapy for burn injury is limited to hourly urine output, heart rate, systemic blood pressure, and base deficit. Indeed, there is some evidence to suggest that _______(9) as an end point of resuscitation compared to sophisticated hemodynamic monitoring provides similar outcomes in terms of mortality, organ function, length of hospital or intensive care stay, duration of mechanical ventilation, and burn-related complications such as pulmonary edema, compartment syndromes, or infection.
13. The _______(10) technique most commonly used in the trauma setting involves obtaining images through the subcostal long axis, subcostal inferior vena cava, parasternal long axis, parasternal short axis, and apical four-chamber windows. Placement of a phased-array, low-frequency (5 to 2 MHz) probe in these locations provides ideal views that are sufficient to inform the clinician of an underlying hemodynamic problem. TTE can be used in the emergency department, operating room, or intensive care unit and provides rapid information about the etiology of hypotension or other hemodynamic complications.

Answer 2

1. burn shock
2. hypermetabolic
3. hyperdynamic
4. capillary permeability
5. Parkland
6. colloid
7. 20 kg
8. Albumin 5%
9. hourly monitoring of urine output
10. transthoracic echocardiography (TTE)

Question 3

Questions:
14. Unrecognized hypoperfusion may lead to splanchnic ischemia with resulting acidosis in the intestinal wall, permitting the passage of luminal _______(1) into the circulation and release of inflammatory mediators, causing sepsis and multiorgan failure. _______(2) and _______(3) are considered acceptable markers of organ hypoperfusion in the apparently resuscitated patient and may be used intraoperatively to set the optimal end points of resuscitation.
15. Although trauma center laboratories cannot provide results of the standard coagulation tests rapidly, at least international normalized ratio can be monitored with a point-of-care device and provide some information. _______(4) and rotation transmission electron microscopy are point-of-care devices that provide a relatively rapid, comprehensive, and quantitative graphic evaluation of clotting function.
16. Anesthetic and adjunct drugs for general anesthesia need to be tailored to five major clinical conditions: airway compromise, _______(5), head or open eye injuries, cardiac injury, and burns. The varying contribution of these conditions to the clinical picture of a given patient necessitates priority-oriented planning.
17. Reducing or eliminating anesthesia to avoid abolishing the hemodynamic balance in hypovolemic patients is a natural and often utilized practice, especially when _______(6) is part of damage control resuscitation, to limit bleeding is employed. This approach provides high pressure and low flow to the organs. Another concept, aggressive titrated administration of anesthetics and blood products to produce a high-flow and low-pressure hemodynamic state with vasodilation to improve organ flow and oxygenation and to reduce fibrinolytic activity and inflammation, has been proposed recently.
18. Component resuscitation therapy, mainly universally available trauma, is _______(7) to the whole blood transfusion practiced by the military. During the preparation of platelets and fresh frozen plasma, 100 mL of nonhemostatic anticoagulants is put in each bag. This additional fluid _______(8) factors levels by 20%. Similarly 100 mL of solution is added to packed red blood cells for storage injury protection in addition to 100 mL of anticoagulant. Fresh frozen plasma will _______(9) the hematocrit and platelet count. Likewise, packed red blood cells _______(10) coagulation factors and platelet counts. Thus a 1:1:1 ratio cannot be compared with whole blood in its hemostatic ability.
19. Death is a much greater threat during emergency trauma surgery than it is in any other operative procedure. Approximately _______(11) of patients admitted for acute trauma die in the OR, accounting for approximately 8% of postinjury deaths. Uncontrollable _______(12) is the cause of approximately 80% of intraoperative mortality; brain herniation and _______(13) are the most common causes of death in the remaining patients.
20. Recent advances in the management of acute trauma and critical care, such as _______(14) crystalloid infusion, hemostatic resuscitation, damage control, and open abdomen strategies, have substantially decreased the incidence of postinjury abdominal _______(15) syndrome.

Answer 3

1. microorganisms
2. Base deficit
3. blood lactate level
4. Thromboelastography
5. hypovolemia
6. permissive hypotension
7. inferior
8. lowers
9. decrease
10. lower
11. 0.7%
12. bleeding
13. air embolism
14. limiting
15. compartment

Question 4

Questions:
- A rapid overview in trauma assessment _______(1) to determine whether the patient is stable, unstable, dying, or dead.
- The primary survey is a rapid evaluation of functions that are _______(2) to survival, including the ABCs of _______(3), _______(4), and _______(5).
- During the primary survey, a brief _______(6) examination is performed and the patient is examined for any _______(7) that might have been overlooked.
- The phrase “Airway, Neck Rotation, Allergies, Baseline Neuro Exam, have they been using _______(8)” helps remember some aspects of the initial assessment.
- The secondary survey is an elaborate systematic examination of the entire body to identify _______(9).
- _______(10) (focused assessment with sonography), computed tomography [CT], _______(11), interventional radiologic procedures, and magnetic resonance imaging [MRI] are some diagnostic procedures used.
- The Tertiary Survey occurs within the first _______(12) hours after admission and may include a period of anesthesia.
- A note on trauma cases: They should never last more than a few _______(13).

Answer 4

Answers:
1. takes only a few seconds
2. crucial
3. airway patency
4. breathing
5. circulation
6. neurologic
7. external injuries
8. drugs
9. additional injuries
10. Radiography
11. Angiography
12. 24
13. hours

Question 5

Questions:
- _______(1) obstruction is probably the most frequent cause of asphyxia after trauma.
- Bleeding into the _______(2) region may produce airway obstruction not only because of compression by the _______(3), but also from venous _______(4) and upper airway _______(5) as a result of compression of neck veins.
- No _______(6) intubations for any trauma; all traumas are considered _______(7).
- In the case of a Basilar Skull Fracture, there should be NO _______(8) or _______(9) due to the risk of complications.

Answer 5

Answers:
1. Airway
2. cervical
3. hematoma
4. congestion
5. edema
6. blind
7. full stomachs
8. NG (nasogastric)
9. OG (orogastric)

Question 6

Questions:
- Intracranial pressure elevation can lead to _______(1) Herniation.
- Intraocular pressure elevation may result in the _______(2) of eye contents.
- Intravascular pressure elevation might cause the _______(3) of a Hemostatic Clot from an injured vessel.
- The preferred anesthetic sequence for patients who are not hemodynamically compromised includes _______(4), _______(5) loading, and relatively large doses of an intravenous anesthetic and _______(6) relaxant, followed by rapid treatment of _______(7).
- Cerebral Perfusion Pressure is calculated as _______(8) minus _______(9).
- Ketamine is advantageous in this setting because it maintains the systemic _______(10) pressure and does not cause an appreciable increase in _______(11) and _______(12).
- It was once thought to be contraindicated in patients with head and open eye injuries because it may potentially increase both _______(13) and _______(14).
- Ketamine could cause dislodgement of a _______(15) plug, initiating bleeding in vascular injuries.
- If ketamine causes a BIG increase in Pressure
- _______(16) may be used as long as the fasciculation is inhibited by giving a defasciculating dose of a _______(17) muscle relaxant.

Answer 6

Answers:
1. Brain
2. Extrusion
3. Dislodgement
4. Preoxygenation
5. Opioid
6. muscle
7. Hypertension
8. MAP (Mean Arterial Pressure)
9. ICP (Intracranial Pressure)
10. blood
11. ICP
12. IOP (Intraocular Pressure)
13. intracranial
14. IOP
15. hemostatic
16. Succinylcholine
17. nondepolarizing

Question 7

Questions:
- Manual _______(1) stabilization is the standard of care for these patients in the _______(2) stage.
- It can result in some degree of _______(3) movement.
- A hard cervical _______(4) alone does not provide absolute protection, especially against _______(5) movements of the neck.
- This is what is _______(6) placed.
- _______(7) operators in addition to the physician who is managing the _______(8) are needed.
- The first operator stabilizes and aligns the head in _______(9) position without applying _______(10) traction.
- The second operator stabilizes both _______(11) by holding them against the table or _______(12).
- The anterior portion of the hard collar may be removed after _______(13).
- Collar limits _______(14) opening.

Answer 7

Answers:
1. inline
2. acute
3. C-spine
4. collar
5. rotational
6. routinely
7. Two
8. airway
9. neutral
10. cephalad
11. shoulders
12. stretcher
13. immobilization
14. mouth

Question 8

Questions:
- _______(1) and _______(2) patients require immediate insertion of a 14-gauge _______(3) through the fourth or fifth intercostal space in the _______(4) line OR through the second intercostal space at the _______(5) line is essential.
- There is no time for _______(6) confirmation in this setting.

Answer 8

Answers:
1. Hypoxemic
2. hypotensive
3. angiocatheter
4. midaxillary
5. midclavicular
6. radiologic

Question 9

Questions:
- Flail Chest results from fractures at two or more sites of at least three _______(1) ribs or rib fractures associated with _______(2) separation or _______(3) fracture.
- Consider underlying _______(4) contusion.
- Increased _______(5) (WOB).
- Respiratory _______(6).
- _______(7).
- Often develops over a _______(8) to _______(9)-hour period.
- Evidence: worsening chest _______(10) and _______(11).
- Major Risk of _______(12).
- Risk increase abruptly when contusion exceeds _______(13)% of lung volume.
- Rib Fractures: Increased chance of _______(14) development.
- Severe pain prevents Deep _______(15) and _______(16).
- Pneumonia Prevention: _______(17), thoracic paravertebral block, _______(18), incentive spirometers, Chest _______(19).

Answer 9

Answers:
1. adjacent
2. costochondral
3. sternal
4. pulmonary
5. Work of Breathing
6. Failure
7. Hypoxemia
8. 3
9. 6
10. x-rays
11. ABG’s (Arterial Blood Gases)
12. ARDS (Acute Respiratory Distress Syndrome)
13. 20
14. Pneumonia
15. Breaths
16. Coughing
17. Epidural
18. opiates
19. PT (Physical Therapy)

Question 10

Questions:
- Flail Chest results from fractures at two or more sites of at least three _______(1) ribs, or rib fractures associated with _______(2) separation or _______(3) fracture.
- Consider underlying _______(4) contusion.
- Often develops over a _______(5)- to _______(6)-hour period.
- Evidence: worsening chest _______(7) and _______(8).
- Major Risk of _______(9).
- Risk increases abruptly when contusion exceeds _______(10)% of lung volume.
- Rib Fractures: Increased chance of _______(11) development.
- Severe pain prevents Deep _______(12) and _______(13).
- Pneumonia Prevention: _______(14), thoracic paravertebral block, _______(15), incentive spirometers, Chest _______(16).

Answer 10

Answers:
1. adjacent
2. costochondral
3. sternal
4. pulmonary
5. 3
6. 6
7. x-rays
8. ABG’s (Arterial Blood Gases)
9. ARDS (Acute Respiratory Distress Syndrome)
10. 20
11. Pneumonia
12. Breaths
13. Coughing
14. Epidural
15. opiates
16. PT (Physical Therapy)

Question 11

Questions:
- Tachycardia is traditionally used as an index of _______(1), but may be absent in up to _______(2)% of hypotensive trauma patients because of:
- activated _______(3) reflex,
- a protective mechanism to prevent excessive _______(4) filling.
- Trigger: Blood pooling in _______(5), stretching of heart _______(6).
- Response: _______(7), _______(8), _______(9), and increased _______(10) tone.
- Chronic _______(11) use is detectable for _______(12) hours after use and results in depleted _______(13) stores at your synapses.
- The only thing that works is _______(14) or _______(15).
- Thus: equating a normal heart rate and systemic blood pressure with normovolemia (and warm!) during initial resuscitation may lead to loss of valuable time for treating underlying occult _______(16) or _______(17).

Answer 11

Answers:
1. hypovolemia
2. 30
3. Bezold–Jarisch
4. cardiac
5. ventricles
6. walls
7. Bradycardia
8. Hypotension
9. Vasodilation
10. vagal
11. cocaine
12. 12-48
13. norepinephrine
14. Vasopressin
15. Epi (Epinephrine)
16. hypovolemia
17. hypoperfusion

Question 12

Questions:
- Classic Crystalloid Resuscitation involves fluids: _______(1) Lactated Ringer’s (LR) or normal saline in adults; _______(2) mL/kg in children.
- BP Response: Transient or no BP increase indicates the need for _______(3).
- Damage Control Resuscitation (DCR) utilizes _______(4) Hypotension: Intentional low BP (e.g., systolic _______(5)-_______(6) mmHg) for a limited period to reduce hemorrhage.
- Blood Products: Immediate administration via Massive Transfusion Protocol (MTP); _______(7) ratio of PRBCs, plasma, platelets.
- Tranexamic Acid: Administered within _______(8) hours to reduce clot breakdown, acting as an _______(9).

Answer 12

Answers:
1. 2L
2. 20
3. blood products
4. Permissive
5. 70
6. 90
7. 1:1:1
8. 3
9. anti-fibrinolytic

Question 13

• Issues with Crystalloid Use: Elevates blood _______(1) (LR) and increases base _______(2) (normal saline).
• Targets: Affects _______(3) and _______(4)-1, which stabilize _______(5) membrane integrity.
• Mechanism: Massive hemorrhage already damages endothelial _______(6); crystalloids exacerbate this, worsening _______(7) dysfunction.
• Dilution: Weakens _______(8) factors and _______(9).
• Withholding Fluids can be as harmful as _______(10).

Answer 13

Answers:
1. lactate
2. deficit
3. glycocalyx
4. syndecan
5. endothelial
6. glycocalyx
7. endothelial
8. clotting
9. platelets
10. over-resuscitation

Question 14

• Base deficit and blood lactate are the MOST useful and practical markers during all phases of _______(1), including the earliest.
• Base Deficit indicators include the severity of shock, _______(2) debt, O2 _______(3), fluid _______(4), likelihood of _______(5), and _______(6).
• Prognostic value of base deficit is better than _______(7) pH.
• Scales for Base Deficit in Mild Shock: _______(8) to _______(9) mmol/L.
• Moderate Shock: _______(10) to _______(11) mmol/L.
• Severe Shock: >_______(12) mmol/L.
• Increased Mortality is associated with a base deficit below _______(13) to _______(14) mmol/L.
• Resuscitation Endpoint is the normalization of _______(15) deficit.
• Blood lactate is less specific than base deficit for _______(16) hypoxia but correlates with other signs of _______(17).
• It is an important marker of _______(18).
• Resuscitation Endpoint for lactate is when an elevated lactate level is considered an endpoint to guide _______(19) efforts.
• Non-hypoxic causes of elevated lactate include _______(20)-induced glycolysis and _______(21) oxidation.
• Normal blood lactate level: _______(22) to _______(23) mmol/L.
• Lactic Acidosis is indicated by levels >_______(24) mmol/L.
• The half-life of lactate is _______(25) mins, meaning the level decreases rather rapidly after correction of the cause.
• Increased Mortality is noted if there is a failure to clear lactate within _______(26) hrs post-shock reversal.

Answer 14

Answers:
1. shock
2. oxygen
3. delivery
4. adequacy
5. MOF (Multiple Organ Failure)
6. survival
7. arterial
8. −2
9. −5
10. −6
11. −9
12. 10
13. −5
14. −8
15. base
16. tissue
17. hypoperfusion
18. dysoxia
19. resuscitation
20. Epinephrine
21. pyruvate
22. 0.5
23. 1.5
24. 5
25. 15-30
26. 24

Question 15

Questions:
- Hemoglobin (Hgb) / Hematocrit (Hct) as Transfusion Threshold has a utility that is _______(1).
- The target Hgb level is _______(2) to _______(3) g/dL, even in brain injuries (some say _______(4)-_______(5) for brains - Dr. H).
- Increased morbidity and mortality in trauma when Hct is < _______(6) (Hgb < _______(7) g/dL).
- Age Factor: Risks are higher if red cells are >_______(8) days old.
- Type O Rh-positive PRBCs and AB-negative FFP are satisfactory in _______(9) situations.
- Controversy surrounds the use of uncrossmatched type O PRBCs due to concerns of _______(10) and allergic reactions.
- Majority of trauma patients are _______(11) on admission.
- A minority of 10-15% enter in a _______(12) state or rapidly develop it.
- One unit of FFP contains approximately _______(13)% coagulation factor activity of a 70-kg man.

Answer 15

Answers:
1. unclear
2. 7
3. 9
4. 9
5. 10
6. 30
7. 10
8. 14
9. urgent
10. alloantibodies
11. hypercoagulable
12. hypocoagulable
13. 7

Question 16

Questions:
- Pediatric Massive Hemorrhage is defined as a transfusion volume > _______(1) mL/kg or _______(2)% of blood volume over _______(3) hours.
- Adult definitions/treatments don’t apply to pediatric cases due to differences in _______, _______, _______, and _______(4).
- The circulating blood volume in an infant is _______(5) mL/kg.
- For children older than _______(6) months, the circulating blood volume is _______(7) mL/kg.
- In children, the 1:1:1 ratio of blood components translates to _______(8) mL/kg PRBCs, _______(9) mL/kg FFP, and _______(10) mL/kg platelets.

Answer 16

Answers:
1. 40
2. 50
3. 24
4. size, physiology, nature of injury, demographics
5. 90
6. 3
7. 70
8. 20
9. 20
10. 10

Question 17

Questions:
- The lethal triad to avoid in trauma consists of _______(1), _______(2), and _______(3).
- _______(4) and _______(5) are major inducers of Trauma-Induced Coagulopathy.
- Coagulopathy is an independent predictor of _______(6) and _______(7).
- This predictor is not dependent on _______(8), _______(9), or the presence of _______(10).

Answer 17

Answers:
1. Acidosis
2. Hypothermia
3. Dilutional coagulopathy
4. Acidosis
5. Hypothermia
6. Multiple Organ Failure (MOF)
7. Mortality
8. Shock
9. Injury severity
10. Lethal triad

Question 18

Questions:
- Hypotension is a major cause of death, with SBP < _______(1) mmHg linked to a _______(2)% mortality increase.
- To support blood pressure, _______(3) and vasopressors (preferably _______(4)) should be used.
- Pupillary dilatation and sluggish response indicate _______(5) nerve compression by the medial portion of the _______(6) lobe (uncus).
- A “blown” pupil suggests _______(7) herniation under the _______(8).
- Pupillary light response is usually more sluggish in _______(9)-injured patients.
- A CT Scan in acute head injuries showing midline shift, distortion of ventricles and cisterns, effacement of sulci in the uninjured hemisphere, and the presence of hematoma suggests _______(10).

Answer 18

Answers:
1. 90
2. 50
3. Fluids
4. Phenylephrine
5. Oculomotor
6. Temporal
7. Uncal
8. Falx cerebri
9. Head
10. Positive findings

Question 19

Questions:
- Before instrumentation, _______(1) and atropine (_______(2) to _______(3) mg) should be administered for the management of bradycardia/dysrhythmias.
- If additional treatment is needed, more atropine, _______(4), _______(5), and _______(6) may be required.
- For injuries at _______(7) or lower, usually normal tidal volumes are maintained because the _______(8) function is intact.
- Injuries at _______(9) or above may require permanent _______(10) assistance.
- The mnemonic “_______(11)-_______(12)-_______(13), keep the diaphragm alive” helps to remember the spinal cord level necessary for diaphragm function.
- A severe surge of _______(14) occurs post-acute spinal cord trauma.

Answer 19

Answers:
1. Preoxygenation
2. 0.4
3. 0.6
4. Glycopyrrolate
5. Isoproterenol
6. Cardiac pacing
7. C5
8. Diaphragm
9. C4
10. Ventilatory
11. C3
12. 4
13. 5
14. Catecholamine

Question 20

Questions:
- Diagnostic signs of cervical arterial injury include absent or decreased _______(1) pulses or distal _______(2) pulses.
- A _______(3) or _______(4) is indicative of a cervical arterial (vascular) injury.
- Penetrating neck injury in Zone I extends from the _______(5) to the _______(6).
- Zone _______(7) of a penetrating neck injury is located between the _______(8) and the angle of the _______(9).
- Zone _______(10) extends from the angle of the _______(11) to the base of the _______(12).
- Zones _______(13) and _______(14) are less frequent and more difficult to manage surgically compared to Zone II, which is the most common.

Answer 20

Answers:
1. Upper extremity
2. Carotid
3. Bruit
4. Thrill
5. Clavicles
6. Sternal notch
7. II
8. Cricoid cartilage
9. Mandible
10. III
11. Mandible
12. Cranial
13. I
14. III

Question 21

Questions:
- Brown Séquard Syndrome involves a _______(1) transection resulting in _______(2) motor dysfunction and _______(3) sensory deficit below the level of injury.
- A _______(4) transection of the spinal cord can lead to _______(5) or _______(6), with a high likelihood of _______(7) shock.

Answer 21

Answers:
1. Partial
2. Ipsilateral
3. Contralateral
4. Complete
5. Paraplegia
6. Quadriplegia
7. Neurogenic

Question 22

Questions:
- Blunt Cervical Vascular Injuries may present with a hematoma compressing _______(1) and causing _______(2) displacement.
- Symptoms can include cervical _______(3), _______(4) mental status, and _______(5) neurologic deficits.
- _______(6) may occur, characterized by temporary loss of vision due to lack of blood flow to the retina.
- _______(7) syndrome may be evidenced by _______, _______, and _______.

Answer 22

Answers:
1. cervical veins
2. airway
3. bruit
4. altered
5. lateralizing
6. Amaurosis fugax
7. Horner; Ptosis; miosis; anhidrosis

Question 23

Questions:
- The _______(1) is best for detecting pneumothorax.
- _______(2) is used for emergency diagnosis, placing the probe longitudinally over the _______(3) space.
- Normal findings on this include _______(4) and vertical “_______(5)”.
- The absence of these signs suggests _______(6).
- “B lines” on an ultrasound are _______(7) artifacts from echo-dense lung areas, while “A lines” are _______(8) echogenic lines.
- “Comet Tails” are produced by movement and are _______(9) in the presence of a pneumothorax.
- M-mode on an ultrasound shows a _______(10) appearance for lung and a horizontal line pattern for _______(11).
- A _______(12) is the definitive test for pneumothorax diagnosis.

Answer 23

Answers:
1. Chest radiograph
2. Transthoracic ultrasound
3. intercostal
4. pleural sliding
5. B lines
6. pneumothorax
7. vertical
8. horizontal
9. absent
10. granular
11. pneumothorax
12. Chest CT

Question 24

Questions:
- Pericardial tamponade is characterized by signs known as _______(1) Triad which include _______, _______(2), and _______(3).

Answer 24

Answers:
1. Beck’s
2. Hypotension
3. Jugular Venous Distension (JVD), Muffled heart sounds

Question 25

Questions:
- Thoracic aortic injury from _______(1) trauma can injure any part of the thoracic aorta and its branches, whereas _______(2) trauma is most common at the _______(3), distal to the left subclavian artery origin.
- The _______(4) is particularly vulnerable to _______(5) and tearing because it is anchored by the ligamentum arteriosum and left main stem bronchus.
- The aortic _______(6) is fixed by the diaphragm and vulnerable to _______(7) forces.
- Associated injuries are likely with various _______(8) and _______(9) visceral injuries.
- Grade 1 aortic injury includes Intramural hematoma, limited _______(10), and mural thrombus.
- Grade 2 involves _______(11) rupture and altered aortic geometry, sometimes with a small _______(12).
- Grade 3 aortic injury is characterized by _______(13), massive blood extravasation, and intraluminal obstruction causing pseudocoarctation and _______(14).
- The majority of thoracic aortic injuries are managed with _______(15), while open left thoracotomy is still done occasionally using techniques like lung isolation via double-lumen tube or bronchial blocker, and possibly partial left heart bypass for “clamp and sew” technique.

Answer 25

Answers:
1. Penetrating
2. Blunt
3. aortic isthmus
4. Isthmus
5. traction
6. Root
7. shearing
8. thoracic
9. abdominal
10. intimal flap
11. Subadventitial
12. hemomediastinum
13. Transsection
14. ischemia
15. endovascular stents

Question 26

Questions:
- For endovascular procedures, the radial artery cannula should be placed on the _______ (1) side, as the left subclavian artery may be covered by the _______ (2).
- During aortography and stent placement, there may be a need to stop _______ (3).
- To facilitate these procedures, systemic blood pressure is lowered to a mean of _______ (4) mmHg.

Answer 26

Answers:
1. right
2. stent
3. ventilation
4. 60

Question 27

Questions:
- Hemodynamically unstable patients with abdominal and pelvic injuries are taken _______ (1) for surgery, bypassing a _______ (2) scan.
- A hemodynamically stable patient can have further evaluation by _______ (3) scan.
- The absence of abdominal distention does not rule out _______ (4), as a minimum of _______ (5) L of blood can accumulate before visible changes in girth.
- The diaphragm’s ability to move _______ (6) allows for more blood loss without an increase in abdominal size.

Answer 27

Answers:
1. directly
2. CT
3. CT
4. intra-abdominal bleeding
5. 1
6. cephalad

Question 28

Questions:
- Open fractures that remain unrepaired for more than _______ (1) hours are likely to become _______ (2).
- The classic syndrome indicative of vascular trauma includes _______ (3), pulselessness, pallor, _______ (4), and paresis, collectively known as the “5 Ps”.
- The definitive diagnosis of vascular trauma is made via _______ (5).
- Compartment Syndrome is characterized by severe pain in the _______ (6) extremity.
- Early recognition of Compartment Syndrome is crucial for the effectiveness of an emergency _______ (7).
- A diagnosis of Compartment Syndrome is confirmed when compartment pressures exceed _______ (8) cm H2O, indicating the need for _______ (9).

Answer 28

Answers:
1. 6
2. septic
3. Pain
4. paresthesias
5. Arteriography
6. affected
7. fasciotomy
8. 30
9. immediate surgery

Question 29

Questions:
- The lethal dose for burns is considered to be _______% Total Body Surface Area (TBSA) (1).
- Name three risk factors for death due to burns: _______ injury (2), burns covering _______% TBSA (3), and age greater than _______ (4).
- Mortality rates increase to _______% (5), _______% (6), _______% (7), and _______% (8) with 0, 1, 2, and 3 risk factors respectively.
- Major burns are defined as full-thickness burns greater than _______% TBSA (9) and partial-thickness burns greater than _______% TBSA in adults (10) or greater than _______% in individuals at the extremes of age (11).
- Major burns also include those that involve the _______ (12), hands, feet, _______ (13), or are due to inhalation, chemical, or electrical causes.

Answer 29

Answers:
1. 90
2. Inhalation
3. 40
4. 60
5. 0.3
6. 3
7. 33
8. 90
9. 10
10. 25
11. 20
12. face
13. perineum

Question 30

Questions:
- _______ (1) and _______ (2) are inflammatory mediators that cause wound edema and systemic issues.
- Burns covering more than _______% Total Body Surface Area (TBSA) (3) can lead to consistent catabolism and weight loss for up to _______ (4).
- Pharmacological measures to address the catabolism include recombinant human _______ hormone (5), insulin-like _______ factor 1 (6), low-dose _______ (7), β-blockade (8), and the synthetic testosterone analogue _______ (9).

Answer 30

Answers:
1. Interleukins
2. tumor necrosis factor
3. 40
4. 1 year
5. growth
6. growth
7. insulin
8. (Accepting general answer since the prompt does not specify a particular β-blocker)
9. oxandrolone

Question 31

Questions:
- Partial-thickness burns are red, blanch with pressure, and are sensitive to _______ (1) and _______ (2).
- Superficial burns, also known as _______ degree burns (3), involve the _______ (4) and upper _______ (5) and heal spontaneously.
- Deep burns, known as _______ degree burns (6), affect the deep _______ (7) and typically require _______ (8) and grafting.
- Full-thickness burns, or _______ degree burns (9), do not _______ (10) with pressure and are insensate, indicating complete destruction of the _______ (11).
- Fourth-degree burns involve _______ (12), _______, (13) and _______, (14) often requiring complete _______ (15) and leading to limited function post-surgery.
- Laser _______ imaging (16) is used as a diagnostic aid for determining burn _______ (17).
- The “Rule of Nines” for TBSA in adults allocates _______ % (18) to the head, _______ % (19) to upper extremity, _______ % (20) to the trunk, and _______ % (21) to each lower extremity.

Answer 31

Answers:
1. touch
2. heat
3. first
4. epidermis
5. dermis
6. second
7. dermis
8. excision
9. third
10. blanch
11. dermis
12. muscle
13. fascia
14. bone
15. excision
16. Doppler
17. depth
18. 9
19. 18
20. 36
21. 36

Question 32

Questions:
- Parenchymal lung injury can develop within _______ (1) to _______ (2) days after a burn and often presents as _______ (3).
- Late complications after a burn can occur after more than _______ (4) days and include conditions such as _______ (5) and Pulmonary _______ (6).
- If a lung injury is present, the fluid requirement for a burn patient increases by _______ (7) to _______ (8) percent.
- The presence of a lung injury after a burn _______ (9) the mortality risk.

Answer 32

Answers:
1. 1
2. 5
3. ARDS (Acute Respiratory Distress Syndrome)
4. 5+
5. Pneumonia
6. Embolism
7. 30
8. 50
9. increases

Question 33

Questions:
- For moderate to severe burns with a patent airway, the initial treatment includes the administration of O2 at the highest possible _______ (1) concentration via a face mask.
- Using _______ (2) from the start can help prevent pulmonary edema due to the loss of autopeep.
- _______ (3) and _______ (4) are part of the management to help maintain clear airways.
- Indications for immediate intubation include _______ (5) burns.
- The preferred intubation technique for adults, if feasible, is an _______ (6) intubation.
- In pediatric patients, intubation is typically conducted after inhalation induction with O2 and _______ (7), followed by intubation via _______ (8) or a conventional laryngoscope.

Answer 33

Answers:
1. FiO2
2. PEEP (Positive End-Expiratory Pressure)
3. Bronchodilators
4. Pulmonary toilet
5. massive
6. awake fiberoptic
7. sevoflurane
8. FOB (Fiber-Optic Bronchoscope)

Question 34

Questions:
- Mechanisms of CO Toxicity include CO having a _______(1) greater affinity for hemoglobin than _______(2).
- CO _______(3)-shifts hemoglobin dissociation curve, altering its _______(4).
- It impairs _______(5) function.
- CO uncouples _______(6) phosphorylation.
- It reduces _______(7) production.
- Causes _______(8).
- Treatment includes maximizing inspired _______(9) concentration until CO toxicity is ruled out by blood _______(10) measurement.
- _______(11) O2 is recommended for COHb > _______(12)% at admission, unless contraindicated due to other life-threatening conditions like shock, neurologic injury, _______(13), myocardial ischemia, infarction, or arrhythmias.

Answer 34

Answers:
1. 200x
2. O2
3. Left
4. shape
5. mitochondrial
6. oxidative
7. ATP
8. metabolic acidosis
9. O2
10. COHb
11. Hyperbaric
12. 30
13. metabolic acidosis

Question 35

Questions:
- Blood COHb Level <15-20% is associated with symptoms such as _______, _______, and occasional _______(1).
- A COHb Level of 20-40% may cause _______, _______, disorientation, and _______(2).
- Symptoms like _______, combativeness, _______(3), coma, and shock are observed with a COHb Level of 40-60%.
- A Blood COHb Level of >60% is typically associated with _______(4).

Answer 35

Answers:
1. Headache, dizziness, confusion
2. Nausea, vomiting, visual impairment
3. hallucinations
4. Death

Question 36

Questions:
- Cyanide or hydrocyanic acid is produced by incomplete combustion of _______(1) materials and may be inhaled or absorbed through _______(2) membranes.
- The usual clinical presentation is unexplained _______(3) in the absence of _______(4).
- Nonspecific neurologic symptoms such as _______(5), _______(6), or coma are also common findings.
- Elevated _______(7) lactate levels in severe burns may result from _______(8) or CO or CN− toxicity.
- However, _______(9) after smoke inhalation in a patient without a major burn suggests CN− toxicity.
- The definitive diagnosis can be made only by determination of the blood _______(10) level, which is toxic above _______(11) mg/L and lethal at levels beyond _______(12) mg/L.
- Nevertheless, exogenous _______(13) combined with fast-acting _______(14) can be administered to facilitate conversion to thiocyanate and cyanocobalamin, which are excreted in the _______(15).

Answer 36

Answers:
1. synthetic
2. mucous
3. metabolic acidosis
4. cyanosis
5. agitation
6. confusion
7. plasma
8. hypovolemia
9. lactic acidosis
10. cyanide
11. 0.2
12. 1
13. thiosulfate
14. hydroxycobalamin (vitamin B12)
15. urine

Question 37

Questions:
- Abdominal edema may also occur, and when resuscitation volume exceeds _______(1) mL/kg/24 hours, increased intra-abdominal pressure may produce abdominal _______(2) syndrome with impedance of venous return.
- _______(3) solutions are preferred for resuscitation during the _______(4) following a burn injury; leakage of colloids during this phase may increase edema.
- The Parkland Formula recommends _______(5) mL crystalloid/kg% burn for the first 24 h and _______(6)% of calculated volume as colloid during the second 24 h to maintain adequate urine output.
- The Modified Brooke Formula suggests _______(7) mL lactated Ringer’s/kg% burn for the first 24 h and _______(8) mL/kg% burn during the second 24 h.
- For children <20 kg, _______(9) mL/kg% burn for the first 24 h and crystalloid with 5% dextrose at maintenance rate of _______(10) mL/kg for the first 10 kg and _______(11) mL/kg for the next 10 kg for 24 h.
- Clinical End Points of Burn Resuscitation include urine output of _______(12), pulse of _______(13) beats per minute (age dependent), and systolic BP of _______(14) mmHg (infants); children _______(15) mmHg plus 2x age in years; adults MAP > _______(16) mmHg.
- Base deficit should be less than _______(17).

Answer 37

Answers:
1. 300
2. compartment
3. Crystalloid
4. first day
5. 4.0
6. 20-60
7. 2.0
8. 0.3–0.5
9. 2–3
10. 100
11. 50
12. 0.5–1 mL
13. 80–140
14. 60
15. 70–90
16. 60
17. 2

Question 38

Questions:
- Dark, cola-colored urine in the trauma patient suggests either _______(1) resulting from incompatible blood transfusion or _______(2) caused by massive skeletal muscle destruction after blunt or electrical trauma.
- Pink-stained serum suggests _______(3), whereas unstained serum indicates _______(4).
- Both of these conditions may result in _______(5).
- _______(6)-colored urine usually is caused by hematuria, which, in the traumatized patient, suggests _______(7) injury.

Answer 38

Answers:
1. hemoglobinuria
2. myoglobinuria
3. hemoglobinuria
4. myoglobinuria
5. acute renal failure
6. Red
7. urinary tract

Question 39

Questions:
- The R and K values are indices of formation, buildup, and crosslinking of _______(1) and depend on the function of _______(2) factors.
- The maximum _______(3) aka the MA is the widest portion of the curve and indicates the absolute strength of the _______(4) clot.
- It represents _______(5) function.
- The α-angle is the slope of the external divergence of the tracing from the R-value point, indicating the speed of _______(6) formation and _______(7) crosslinking.
- The value of this parameter is determined by both _______(8) factors and _______(9).
- Hypothermia can cause _______(10) by interfering with both _______(11) and _______(12) factors.

Answer 39

Answers:
1. fibrin
2. coagulation
3. amplitude
4. fibrin
5. platelet
6. clot
7. fibrin
8. coagulation
9. platelets
10. coagulopathy
11. platelets
12. coagulation

Question 40

Questions:
- Maintenance of anesthesia in the hypovolemic trauma patient raises concerns similar to those pertaining to _______(1). Hemorrhagic shock decreases minimum alveolar concentration (MAC) by approximately _______(2)%.
- All intravenous anesthetics including _______(3) cause comparable degrees of cerebrovascular constriction and _______(4) reduction.
- Use Whole Blood (WB) if available. FDA-approved cold stored WB is preferred over _______(5) WB (non-FDA approved).
- Initiate infusion of _______(6) gm Tranexamic Acid (TXA) over _______(7) hours if TXA _______(8) gm administered preoperatively.
- Carefully follow _______(9) concentration during massive transfusion.
- Consider giving empiric _______(10) chloride if hypotensive (citrate will bind the calcium –> _______(11)).
- Give calcium every _______(12) units.
- Stronger evidence exists for use of _______(13) in hemorrhagic shock.
- Consider _______(14) bolus of _______(15) units followed by a _______(16) infusion (0.04 U/min) in cases of refractory shock.

Answer 40

Answers:
1. induction
2. 25
3. ketamine
4. ICP (Intracranial Pressure)
5. fresh
6. 1
7. 8
8. 1
9. calcium
10. calcium
11. hypocalcemia
12. 2-4
13. vasopressin
14. vasopressin
15. 2-4
16. vasopressin

Question 41

Questions:
- Guide maintenance of anesthesia and resuscitation to a mean arterial pressure goal, generally MAP > _______(1) mm Hg.
- Maintain systolic blood pressure > _______(2) mm Hg in patients with documented or suspect _______(3).
- Havenstein verbalizes >_______(4) with traumatic brain injury.
- Tranexamic acid dose of _______(5) g over _______(6) minutes within _______(7) hours of injury has demonstrated a survival benefit.
- If Initial dose of _______(8) gm administered follow by an infusion of _______(9) gm over _______(10) hours.
- Hydrocortisone dose of _______(11) mg can improve vasopressor responsiveness in critically ill trauma patients.
- Citrate preservative in blood decreases calcium through _______(12).
- Ionized calcium less than _______(13) –> decrease pH and increase lactate.
- _______(14) gram calcium chloride, corrects calcium and hypotension.
- Follow up with ionized calcium _______(15).
- _______(16) gram Ca++ CL with every _______(17) units of blood.

Answer 41

Answers:
1. 55
2. 90
3. TB (Traumatic Brain Injury)
4. 110
5. 2
6. 10
7. 3
8. 1
9. 1
10. 8
11. 100
12. chelation
13. 9
14. 1
15. levels
16. 1
17. 4

Question 42

Questions:
- Consider agent effective against skin flora, which typically involves _______(1) bacteria.
- Common antibiotics used for _______(2) coverage include Cefazolin (Ancef, Kefzol), Vancomycin, and _______(3).
- Consider agents effective against gi/bowel injury flora, which typically involves _______(4) bacteria.
- Antibiotics like Cefoxitin (Mefoxin), _______(5), and Ceftriaxone (Rocephin) are used for _______(6) coverage.
- In hypotensive resuscitation, maintain a systolic blood pressure > _______(7) without CNS injury.
- A systolic blood pressure range of _______(8)-_______(9) is ideal to avoid hydrostatic changes.
- With CNS injury, the goal is a systolic blood pressure > _______(10).
- The drug of choice for Hemorrhagic Shock prevention is _______(11).
- TXA is most effective when given within _______(12) hours of injury.
- The initial dose of TXA is _______(13) gram in _______(14) saline over _______(15) minutes.
- Then, TXA is given as _______(16) gram IV over _______(17) hours.
- Side effect of TXA includes _______(18) Hypotension when flushed quickly.
- Post-operative/Emergence recommendation for ARDS patients is low lung volume ventilation, _______(19) mL/kg, which can decrease _______(20).

Answer 42

Answers:
1. gram-positive (gram +)
2. gram-positive
3. Clindamycin
4. gram-negative (gram -)
5. Gentamicin
6. gram-negative
7. 100
8. 90
9. 110
10. 110
11. TXA (Tranexamic Acid)
12. 3
13. 1
14. 100ml
15. 10
16. 1
17. 8
18. Transient
19. 6
20. mortality

Question 43

Questions:
- Consider agent effective against skin flora, which typically involves _______(1) bacteria.
- Common antibiotics used for _______(2) coverage include Cefazolin (Ancef, Kefzol), Vancomycin, and _______(3).
- Consider agents effective against gi/bowel injury flora, which typically involves _______(4) bacteria.
- Antibiotics like Cefoxitin (Mefoxin), _______(5), and Ceftriaxone (Rocephin) are used for _______(6) coverage.
- In hypotensive resuscitation, maintain a systolic blood pressure > _______(7) without CNS injury.
- A systolic blood pressure range of _______(8)-_______(9) is ideal to avoid hydrostatic changes.
- With CNS injury, the goal is a systolic blood pressure > _______(10).
- The drug of choice for Hemorrhagic Shock prevention is _______(11).
- TXA is most effective when given within _______(12) hours of injury.
- The initial dose of TXA is _______(13) gram in _______(14) saline over _______(15) minutes.
- Then, TXA is given as _______(16) gram IV over _______(17) hours.
- Side effect of TXA includes _______(18) Hypotension when flushed quickly.
- Post-operative/Emergence recommendation for ARDS patients is low lung volume ventilation, _______(19) mL/kg, which can decrease _______(20).

Answer 43

Answers:
1. gram-positive (gram +)
2. gram-positive
3. Clindamycin
4. gram-negative (gram -)
5. Gentamicin
6. gram-negative
7. 100
8. 90
9. 110
10. 110
11. TXA (Tranexamic Acid)
12. 3
13. 1
14. 100ml
15. 10
16. 1
17. 8
18. Transient
19. 6
20. mortality