Trauma and Surgical Management

Question 1

Model trauma care systems

Answer 1

• Prevention
• Access
• Acute hospital care
• Rehabilitation
• Research activities

Question 2

regional resource, state-of-the-science care, education, outreach, and research

Answer 2

Level I

Question 3

provides care for trauma patients and transfer to Level I if needed

Answer 3

Level II

Question 4

community hospital where no Level I or II exists

Answer 4

Level III

Question 5

provides advanced trauma life support (ATLS)

and transfer

Answer 5

Level IV

Question 6

Primary prevention

Answer 6

prevent the event
• Driving safety classes
• Speed limits
• Campaigns to not drink and drive

Question 7

Secondary prevention

Answer 7

minimize the impact of the traumatic event
• Seat belt use 
• Airbags
• Car seats
• Helmets

Question 8

Tertiary prevention

Answer 8

maximize patient outcomes after a traumatic event through emergency response systems, medical care, and rehabilitation

Question 9

Trauma Team

Answer 9

• Similar to code team
  • Team members preassigned
  • Trauma surgeons, emergency department physicians, and specialists
  • Nurses
  • Ancillary services: radiologic technologists, laboratory
  technicians, respiratory therapists, and social workers

Question 10

TRAUMA TRIAGE

Answer 10

• Essential for determining if patient needs to be transferred to a Level I trauma center
• Made by prehospital personnel
• Criteria in place to guide decision
• ABCs and lifesaving interventions
• Ground versus air transport

Question 11

DISASTER AND MASS CASUALTY MANAGEMENT

Answer 11

• A sudden event that overwhelms EMS, hospitals, community resources
• Environmental, man-made, terrorism-related
• Internal disaster
• Disaster protocols
• Disaster debriefing

Question 12

MECHANISMS OF INJURY

Answer 12

• Knowledge helps to identify potential problems
• Uncontrolled source of energy
• Kinetic energy
• Thermal, chemical, electrical, radiation, blast

Question 13

BLUNT TRAUMA

Answer 13

• Severity depends on kinetic energy dissipated to the body
• Common vehicular trauma, assault with blunt objects, falls, and sports
- Acceleration
- Deceleration
- Shearing
- Crushing
- Compression

Question 14

PENETRATING TRAUMA

Answer 14

• Impalement of foreign objects into the body
• Stab wounds are low-velocity injuries
• Ballistic trauma (e.g., gunshot injuries)
• Medium velocity: handguns, some rifles
• High velocity: assault and hunting rifles
• Velocity and missile (bullet) determine tissue damage
• Cavitation

Question 15

BLAST TRAUMA

Answer 15

• Blunt and penetrating trauma
• Tissue and organ injury
• Gas-containing organ injury (e.g., eardrums, lungs,
intestines)
• Blast injury: 
  • Primary
  • Secondary 
  • Tertiary
  • Quaternary

Question 16

PREHOSPITAL CARE/TRANSPORT

Answer 16

• Emergency stabilization and quick transport
• ABCs (with cervical stabilization)
• IV access and fluid administration
• Hemorrhage control
• Fracture stabilization

Question 17

EMERGENCY CARE PHASE

Answer 17

• Prehospital data obtained
• Trauma unit in emergency department must always be
in a state of readiness
• Trauma surgeon must be present upon patient arrival, in the operating room, and during critical care interventions

Question 18

PRIMARY SURVEY

Answer 18

• Done in 1 to 2 minutes
• Airway patency (with C-spine immobile)
• Breathing effectiveness
• Circulation, including hemorrhage and pulses
• Disability (overview of neurological status)
• Expose the patient, remove clothing, warm patient and trauma room
• Identify life-threatening injuries accurately to establish priorities

Question 19

SECONDARY SURVEY

Answer 19

• Performed after life-threatening injuries are identified and treated
• Examination of all body systems:
• Full set of vital signs; focused interventions, family
presence
• Give comfort measures
• History and more thorough head-to-toe assessment
• Inspect posterior surfaces
• Maintain C-spine immobilization until cleared by x-ray
• X-ray studies (as determined by injury)
• Laboratory studies
• Tetanus toxoid administration
• Specialty physician consults

Question 20

RESUSCITATION PHASE

Answer 20

• Time from injury to stabilization
• Focus: To establish effective circulatory volume
• ABCDEs

Question 21

MAINTAIN AIRWAY PATENCY

Answer 21

• Many factors affect the airway (e.g., facial fractures, bleeding, vomiting, decreased sensorium)
• Open airway
• Jaw thrust or chin lift
• Nasopharyngeal or oropharyngeal airways
• Laryngeal mask airways (LMA)
• Endotracheal intubation
• Cricothyrotomy
• Facial fracture
• Unable to intubate
• Facial or upper airway burns
• Oropharyngeal hemorrhage

Question 22

INEFFECTIVE BREATHING

Answer 22

• Ongoing assessment is essential
• Respiratory status
• Arterial blood gases (ABGs)
• Chest x-rays
• Computed tomography (CT) imaging
• Improve ventilation and gas exchange

Question 23

Ineffective Breathing: Tension pneumothorax Interventions

Answer 23

• Needle decompression

- Prepare for chest tube insertion on affected side.

Question 24

Ineffective Breathing: Pneumothorax interventions

Answer 24

Prepare for chest tube insertion on affected side.

Question 25

Ineffective Breathing: Open chest wound interventions

Answer 25

- Seal the wound with an occlusive dressing and tape on three sides. - Prepare for chest tube insertion on affected side.

Question 26

Pulmonary contusion interventions

Answer 26

Prepare for early intubation and mechanical ventilation.

Question 27

Flail chest interventions

Answer 27

- Prepare for early intubation and mechanical ventilation. | - Administer analgesics as ordered.

Question 28

Spinal cord injury interventions

Answer 28

1) Avoid hyperextension or rotation of the patient’s neck. 2) Observe ventilatory effort and use of accessory muscles. 3) Maintain complete spinal immobilization. 4) Monitor for signs of distributive (neurogenic) shock.

Question 29

Decreased level of consciousness interventions

Answer 29

1) Position the patient’s head midline with the head of the bed elevated. 2) Anticipate a computed tomography scan. 3) Implement interventions to prevent aspiration. 4) Prepare for intubation and mechanical ventilation.

Question 30

Massive hemothorax interventions

Answer 30

1) Prepare for chest tube insertion on affected side. 2) Administer blood or blood products as ordered. 3) Anticipate and prepare for emergency open thoracotomy.

Question 31

IMPAIRED GAS EXCHANGE • Supplemental oxygen or mechanical ventilation • Ongoing assessment:

Answer 31

* Oxygen saturation * Respiratory status (rate, work of breathing, depth of ventilation, breath sounds) * Secretion removal

Question 32

CIRCULATION: HYPOVOLEMIA

Answer 32

``` • Hypovolemic shock: Acute blood loss - External hemorrhage - Internal hemorrhage • Ongoing assessment of vital signs, urine output, mental status, and hemodynamic parameters • Early rapid identification of cause ```

Question 33

Treatment of hypovolemia

Answer 33

1) Stop bleeding 2) Venous access • Two large-bore IVs • Intraosseous IV access • Central line may be needed 3) Administration of crystalloids and blood products • Lactated Ringer’s is fluid of choice • Blood administration is based on response to initial fluid resuscitation and laboratory values • Autotransfusion an option

Question 34

RESPONSE TO TREATMENT

Answer 34

* Rapid responders * Transient responders: Patient is still bleeding; surgery needed * Minimal or no responders: Emergent surgical intervention is needed to stop bleeding

Question 35

ONGOING SIGNS AND SYMPTOMS OF SHOCK

Answer 35

* Tachycardia, tachypnea * Narrowing pulse pressure * Falling PaO2 * Decreasing urine output * Increased serum lactate levels * Falling hematocrit