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A adult patient with a knife injury to the neck has an intact airway and is hemodynamically stable. They complain of difficulty swallowing and speaking. In the primary survey, further assessment is indicated next for which of the following conditions? a. Damage to the cervical spine b. An expanding pneumothorax c. Laceration of the carotid artery d. Injury to the thyroid gland - ansa. Damage to the cervical spine
A patient arrives at the emergency department by private vehicle after sustaining an injury to the right lower extremity while using a saw. There is a large gaping wound to the right thigh area with significant bleeding. What is the priority intervention? a. Elevate the extremity to the level of the heart b. Initiate direct pressure c. Apply a tourniquet d. Cover the open wound with sterile saline dressings - ansb. Initiate direct pressure
A patient fell two weeks ago, striking their head. Today, the patient presented with a persistent headache and nausea and was diagnosed with a small subdural hematoma. The patient has been in the ED for 24 hours awaiting an inpatient bed. The night shift nurse reports the patient has been anxious, restless, shaky, and vomited twice during the night. The patient states they couldn't sleep because a young child kept coming into the room. What is the most likely cause for these signs and symptoms? a. increase intracranial pressure b. alcohol withdrawal c. rhabdomyolysis d. pulmonary embolus - ansb. alcohol withdrawal
A patient involved in a MVC has sustained a fracture to the second rib of the anterior left chest. Which concurrent injury is most commonly associated with this fracture? a. Blunt cardiac injury b. Brachial plexus injury c. Pneumothorax d. Hemothorax - ansb. Brachial plexus injury
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A patient with a spinal cord injury at C5 is being cared for in the emergency department while awaiting transport to a trauma center. Which of the following represents the highest priority for ongoing assessment and management for this patient? a. maintain adequate respiratory status. b. administer balanced resuscitation fluid c. perform serial assessments of neurologic function d. maintain core temperature - ansa. maintain adequate respiratory status
A trauma nurse cared for a child with devastating burns two weeks ago. The nurse called in sick for a couple of days and is now back working on the team. Which of the following behaviors would indicate this nurse is coping well? a. They are talking about taking the emergency nursing certification examination. b. They keep requesting to be assigned to the walk-in/ambulatory area c. They are impatient and snap at their coworkers. d. They are thinking about transferring out of the emergency department. - ansa. They are talking about taking the emergency nursing certification examination.
Following a bomb explosion, fragmentation injuries from the bomb or objects in the environment are examples of which phase of injury? a. primary b. secondary c. tertiary d. quaternary - ansb. secondary
In a patient with severe traumatic brain injury, hypocapnia causes which condition? a. Respiratory acidosis b. Metabolic acidosis c. Neurogenic shock d. Cerebral vasoconstriction - ansd. Cerebral vasoconstriction
The general impression step in the initial assessment provides the opportunity to do which of the following? a. Assess for uncontrolled internal hemorrhage b. Accurately triage the patient c. Reprioritize circulation before airway or breathing. d. Activate the trauma team - ansc. Reprioritize circulation before airway or breathing.
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What is the best measure of the adequacy of cellular perfusion and can help to predict the outcome of resuscitation? a. End-tidal carbon dioxide b. Hematocrit level c. Base deficit d. Oxygen saturation - ansc. Base deficit
What is the best position for maintaining an open airway in the obese patient? a. Prone b. Supine c. Reverse Trendelenburg d. Right lateral recumbent - ansc. Reverse Trendelenburg
What is the leading cause of preventable death for the trauma patient in the prehospital environment? a. Airway compromise b. Ineffective ventilation c. Secondary head injury d. Uncontrolled external hemorrhage - ansd. Uncontrolled external hemorrhage
Which of the following accurately describes ventilation principles associated with use of a bag-mask device for an adult? a. Compress the bag-mask device at a rate of one breath every 6 seconds. b. Delivers 100% oxygen. c. Squeeze the bag-mask device completely for each breath. d. Maintain the oxygen saturation levels between 92% and 94%. - ansa. Compress the bag-mask device at a rate of one breath every 6 seconds.
Which of the following is considered a cornerstone of a high-performance trauma team? a. Individual goals b. Use of TeamSTEPPS c. Identification of a single decision maker d. Effective communication - ansd. Effective communication
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While performing an assessment on a 13-month-old involved in a motor vehicle collision, the nurse identifies which of the following findings from the patient as a sign of possible altered mental status? a. Sunken fontanel b. Crying, but consolable c. Spontaneous movement of arms and legs d. Cooperation with the assessment - ansd. Cooperation with the assessment
A (AVPU) - ansAlert. Will be able to maintain airway once clear.
A (Primary Survey) - ansAirway and alertness with simultaneous cervical spinal stabilization.
Airway Assessment - ansInspect: tongue obstruction, loose/missing teeth, foreign objects, blood, vomitus, secretions, edema, burns or evidence of inhalation injury
Auscultate: listen for obstructive airway sounds (ie. snoring, gurgling, stridor)
Palpate: palpate for possible occlusive maxillofacial bony deformity, subcutaneous emphysema
Airway Interventions: - ansSuction Remove foreign body if noted Jaw thrust maneuver (maintain cspine) Nasopharyngeal airway (can be conscious) Oropharyngeal airway (no gag) Consider definitive airway
Alertness Assessment - ansA-Alert V-Verbal P-Painful U-Unresponsive
B (Primary Survey) - ansBreathing and Ventilation
Breathing and Ventilation Assessment - ansInspect: spontaneous breathing, symmetrical rise and fall, depth/pattern/rate of respirations, accessory muscle use, diaphragmatic breathing, skin color (normal, pale, flushed, cyanotic),
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Auscultate: Muffled heart sounds - may indicate pericardial tamponade
Palpate: carotid and/or femoral pulses for rate, rhythm, strength
Circulation and Control of Hemorrhage Interventions - ansControl and treat external bleeding: apply direct pressure, elevate bleeding extremity, apply pressure over arterial sites, consider use of a tourniquet.
2 large bore IVs, if unable consider IO, obtain labs and crossmatch.
Initiate IVF of warmed isotonic crystalloid solution. Consider blood products after 2L.
**Large volumes of fluid lead to dilution coagulopathy which worsens metabolic acidosis and may cause hypothermia. Component therapy, including administering RBC, plasma and platelets is a balanced approach so that O2 delivery is optimized, acidosis corrected and coagulopathy prevented.
Classifications of Shock - ansHypovolemic - decrease in the amount of circulating blood volume
Obstructive - obstruction in either the vasculature or heart
Cardiogenic - pump failure in the presence of adequate intravascular volume
Distributive - maldistribution of an adequate circulating blood volume (septic, anaphylactic, neurogenic)
Corneal Abrasion - ansDamage to the corneal epithelium. Easy to evaluate with fluorescein.
Findings: photophobia, tearing, pain, injected conjunctiva (redness), lid swelling, irritation
Treatment: Ophthalmic ABX, Cycloplegic agent to decrease spasms and pain, ophthalmic NSAIDS to decrease swelling, oral analgesics, Ophthalmic f/u in 24 hours. (Do NOT patch - increases infection)
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Corneal Foreign Body - ansRoutinely metal, plastic or wood.
Findings: photophobia, pain, injected conjunctiva (redness), lid swelling
Treatment: topical anesthetic, removal of foreign body, ophthalmic ABX, cycloplegics, oral analgesia
Corneal Laceration - ansInvolves one or more layers of the cornea. Visualized with a slit lamp.
Findings: similar to abrasion, pain out of proportion to findings, decreased vision
Treatment: treat small lacerations similar to an abrasion, larger lacerations need ophthalmology referral and possible surgery
Cycloplegic agent - ansCycloplegia is paralysis of the ciliary muscle of the eye, resulting in a loss of accommodation. Because of the paralysis of the ciliary muscle, the curvature of the lens can no longer be adjusted to focus on nearby objects.
D (Primary Survey) - ansDisability (Neurologic Status)
Disability Assessment - ansAssess GCS on arrival and repeat per policy.
Assess pupils for equality, shape and reactivity (PERRL)
Disability interventions - ansEvaluate for need for CT. Assume AMS to be the result of CNS injury until proven otherwise.
Consider ABGs - AMS may be indicator of decreased cerebral perfusion, hypoventilation or acid-base imbalance.
Consider bedside glucose.
Distributive Shock - ansOccurs as a result of maldistribution of an adequate circulating volume with a loss of vascular tone or increased permeability.
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GCS - ansGCS
EYES 1: Does not open eyes 2: Opens eyes in response to pain 3: Opens eyes in response to voice 4: Opens eyes spontaneously
VERBAL
- Makes no sounds
- Makes sounds
- Words
- Confused, disoriented
- Oriented, converses normally
MOTOR
- Makes no movements
- Extension to painful stimuli (decerebrate)
- Abnormal flexion to painful stimuli (decorticate)
- Withdrawal to painful stimuli
- Localizes painful stimuli
- Obeys commands
H (Secondary Survey) - ansHistory Prehospital Report (MIST) M: MOI I: Injuries sustained S: Signs and symptoms in the field T: Treatment in field
Patient History (SAMPLE): S: Symptoms A: Allergies and tetanus status M: Medications P: Past medical history L: Last oral intake E: Events and Environmental factors related to injury.
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H: Head and Face Head to Toe Assessment (secondary survey) - ansSOFT TISSUE:
Inspect: lacerations, puncture wounds, abrasions, contusions, edema, ecchymosis, impaled objects.
Palpate: areas of tenderness, step-offs, crepitus
BONY DEFORMITIES:
Inspect: asymmetry of facial expressions, exposed tissue or bone for brain matter
Palpate: depressions, angulations, tenderness
Hepatic Injuries - ansIn blunt trauma the liver may lacerate from increased abdominal pressure.
Hematoma - bleeding contained within the capsule
Laceration - the capsule is disrupted
Findings: Cullen sign (ecchymosis around the umbilicus or RUQ), tenderness, guarding or rigidity RUQ, 9-12 rib FXs, elevated LFT
Graded I-VI, I = minor trauma
Nonoperative management is standard of care in hemodynamically stable patient. Observed with serial abdominal exams.
Findings of contrast extravasation may be embolized by IR.
For surgical patients - fluid resuscitation is essential. Risks of surgery include disruption of the natural tamponade process due to the evacuation of large amounts of blood resulting in hypovolemia.
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The liver filters out toxins, takes the nutrients and returns the blood to the heart via the hepatic veins.
Hepatocyte cells are capable of regeneration allowing the liver to repair its own tissue.
Functions: Store and metabolize lipids, transport nutrients, produce glucose and bilirubin, convert ammonia to urea, secrete electrolytes, lipids, lecithin, cholesterol and bile. Metabolizes vitamin K and produces thrombin and fibrinogen (all necessary for clotting).
Obstructive Shock - ansResults from hypo perfusion of the tissue due to an obstruction in either the vasculature or heart.
Tension pneumothorax - increased thoracic pressure leads to displacement of the vena cava, obstruction to atrial filling, decreased preload and decreased cardiac output.
Cardiac tamponade - impedes diastolic expansion and filling leads to decreased preload, strokes volume and cardiac output and ultimately end organ perfusion.
P (AVPU) - ansPainful. Responds only to painful stimuli. (Airway adjunct may be needed while determining need for intubation)
Reevaluation - ansPortable radiograph - AP chest, pelvis. Can quickly identify potentially life-threatening injuries such as pneumothorax or pelvic fracture with uncontrolled internal hemorrhage. Can also confirm placement of ET tubes, chest tubes and gastric tubes.
Consider need for transfer.
shock - ansInadequate tissue perfusion.
Spleen - ansEncapsulated organ LUQ level of 9th-11th ribs and curves around a portion of the stomach. Minimal elasticity and flexibility - most frequent injured organ in blunt trauma.
Secondary lymph organ that filters and cleanses the blood. Removes old RBCs and holds a reserve of blood. It recycles iron. It removes antibody-coated bacteria. Supplies
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lymphocytes to stimulate an immune response to blood borne microorganisms. Stores 200-300ml of blood and leads to hemodynamic instability quickly if damaged.
Splenic Injuries - ansIn blunt trauma the spleen may lacerate from increased abdominal pressure.
Graded I-V, I = minor trauma
Assessment findings: signs of trauma LUQ, abdominal distention, asymmetry, abnormal contour, tenderness, guarding, rigidity, pain left shoulder when supine.
CT: Hemoperitoneum. Hypodensity - represents parenchymal disruption, intraparenchymal hematoma or subcapsular hematoma. Contrast blush or extravasation
- hyperdense area that represent traumatic disruption. Active extravasation implies ongoing bleeding.
Nonoperative management is preferred if hemodynamically stable, stable H/H x 12- hours, minimal transfusion requirements (<2units), grade I or II without blush, age <55, alert able to assist in assessment of abdomen.
Surgical options: total splenectomy for severe injury, for less severe - direct pressure packing, embolization, splenorrhaphy (suturing spleen), partial removal.
Asplenic patients have difficulty destroying encapsulated bacteria - Streptococcus pneumonia, Neisseria meningitides and Haemophilus influenza. At risk for pneumococcal sepsis. Need annual flu shot and q5yr meningococcal and pneumococcal vaccines.
U (AVPU) - ansUnresponsive. Does not respond to any stimuli.
V (AVPU) - ansVerbal. Needs verbal stimuli to respond. (Airway adjunct may be needed to prevent tongue obstruction) A (AVPU) - ansAlert. Will
be able to maintain airway once clear.
A (Primary Survey) - ansAirway and alertness with simultaneous cervical spinal stabilization.
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Breathing and Ventilation Intervention - ansBreathing absent: jaw-thrust maneuver, oral airway adjunct, assist ventilation with bag-mask device, prepare for definitive airway
Breathing present: NRB. Determine if ventilation effective: etCO2 35-45, SpO2 94% or higher. If ineffective: assist with bag-mask and determine need for definitive airway
C (Primary Survey) - ansCirculation and Control of Hemorrhage
Cardiogenic Shock - ansResults from pump failure in the presence of adequate intravascular volume. There is a lack of cardiac output and end-organ perfusion secondary to a decrease in myocardial contractility and/or valvular insufficiency.
Acute causes - myocardial infarction, dysrhythmias or toxicologic pathologies. Heart failure is a chronic cause.
Blunt cardiac injury may present similar to MI.
Excess of volume administration or increased after load can result in pulmonary edema and increased myocardial ischemia.
Inotropic support to improve contractility.
Circulation and Control of Hemorrhage Assessment - ansInspect: Uncontrolled external bleeding, skin color
Auscultate: Muffled heart sounds - may indicate pericardial tamponade
Palpate: carotid and/or femoral pulses for rate, rhythm, strength
Circulation and Control of Hemorrhage Interventions - ansControl and treat external bleeding: apply direct pressure, elevate bleeding extremity, apply pressure over arterial sites, consider use of a tourniquet.
2 large bore IVs, if unable consider IO, obtain labs and crossmatch.
Initiate IVF of warmed isotonic crystalloid solution. Consider blood products after 2L.
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**Large volumes of fluid lead to dilution coagulopathy which worsens metabolic acidosis and may cause hypothermia. Component therapy, including administering RBC, plasma and platelets is a balanced approach so that O2 delivery is optimized, acidosis corrected and coagulopathy prevented.
Classifications of Shock - ansHypovolemic - decrease in the amount of circulating blood volume
Obstructive - obstruction in either the vasculature or heart
Cardiogenic - pump failure in the presence of adequate intravascular volume
Distributive - maldistribution of an adequate circulating blood volume (septic, anaphylactic, neurogenic)
Corneal Abrasion - ansDamage to the corneal epithelium. Easy to evaluate with fluorescein.
Findings: photophobia, tearing, pain, injected conjunctiva (redness), lid swelling, irritation
Treatment: Ophthalmic ABX, Cycloplegic agent to decrease spasms and pain, ophthalmic NSAIDS to decrease swelling, oral analgesics, Ophthalmic f/u in 24 hours. (Do NOT patch - increases infection)
Corneal Foreign Body - ansRoutinely metal, plastic or wood.
Findings: photophobia, pain, injected conjunctiva (redness), lid swelling
Treatment: topical anesthetic, removal of foreign body, ophthalmic ABX, cycloplegics, oral analgesia
Corneal Laceration - ansInvolves one or more layers of the cornea. Visualized with a slit lamp.
Findings: similar to abrasion, pain out of proportion to findings, decreased vision
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input in spinal cord injury, unopposed vagal activity may result in decreased cardiac output through bradycardia.
TREATMENT: increase systemic resistance, controlled volume replacement. Vasoconstriction and in some cases (neurogenic) Atropine to counteract bradycardia.
E (Primary Survey) - ansExposure and Environmental Control
Exposure and Environmental Control - ansCarefully and completely undress the patient. Inspect for uncontrolled bleeding and note any obvious injuries.
Prevent heat loss. Hypothermia combined with hypotension and acidosis is a potentially lethal combination in the injured patient. Consider: warm blankets, keep ambient temperature warm, warm IVF, forced air warmers, radiant warming lights.
F (Primary Survey) - ansFull Set of VS & Family Presence
G (Primary Survey) - ansGet Resuscitation Adjuncts: (LMNOP) L: Labs M: Monitor cardiac rate and rhythm N: Naso or orogastric tube consideration O: Oxygenation - SpO2 and/or etCO2 monitor P: Pain assessment and management
GCS - ansGCS
EYES 1: Does not open eyes 2: Opens eyes in response to pain 3: Opens eyes in response to voice 4: Opens eyes spontaneously
VERBAL
- Makes no sounds
- Makes sounds
- Words
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- Confused, disoriented
- Oriented, converses normally
MOTOR
- Makes no movements
- Extension to painful stimuli (decerebrate)
- Abnormal flexion to painful stimuli (decorticate)
- Withdrawal to painful stimuli
- Localizes painful stimuli
- Obeys commands
H (Secondary Survey) - ansHistory Prehospital Report (MIST) M: MOI I: Injuries sustained S: Signs and symptoms in the field T: Treatment in field
Patient History (SAMPLE): S: Symptoms A: Allergies and tetanus status M: Medications P: Past medical history L: Last oral intake E: Events and Environmental factors related to injury.
H: Head and Face Head to Toe Assessment (secondary survey) - ansSOFT TISSUE:
Inspect: lacerations, puncture wounds, abrasions, contusions, edema, ecchymosis, impaled objects.
Palpate: areas of tenderness, step-offs, crepitus
BONY DEFORMITIES:
Inspect: asymmetry of facial expressions, exposed tissue or bone for brain matter
