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Expedite transfer to the closest trauma center- A 56 y/o M pt involved in a motorvehiclecrashisbroughttotheEDofaruralcritical accessfacility.Hecomplainsofneckpain, SOB, and diffuse abd pain. His GCS is 15. His VS: BP 98/71, HR 125, RR 26,SpO2 94% on high-flow O2 via NRB mask. Which of the following is the priorityintervention for this patient? apertinentmedicalhxiscrucial - Whichofthefollowingconsiderationsisthemostimportant when caring for a geriatric trauma pt? Mitigation-Followinga reviewofrecentdrillsandarealdisasterevent,ahospitalhasidentified deficiencies and is taking steps to minimize the impact of a future disaster .Which phase of the disaster life cycle does this describe? Multiplerequestsforwater-EMSbringsaptwhofellwhileridinghisbicycle.UsingtheAmerican College of Surgeobs screening guidelines, which assessment finding wouldprompt the RN to prepare the pt for a radiologic spine clearance? hemoglobindoesnotreadilyreleaseO2forusebythetissues - Whatistheeffectofhypothermia on the oxyhemoglobin dissociation curve? acidosis-Whichofthefollowingisacomponentof thetraumatriadofdeath? Complete-EMSbringsaptfromMVC.VS:BP90/49,HR48,RR12,temp97.2F(36.2C). The pt exhibits urinary incontinence and priapism. These assessment findings aremost consistent with which of the following types of spinal cord injury? flucuationinthewaterseal chamber - Whichof thefollowingisanexpectedfindinginapt with a tube thoracstomy connected to a chest drainage system? insertanoropharyngealairwayif thereisnogagreflex - Duringtheprimarysurveyofanunconscious pt with multi-system trauma, the nurse notes snoring respirations. Whatpriority nursing interventions should be preformed next? globerupture-A35y/o Mpresentswithfacialtraumaafterbeingstruckinthefacewitha baseball. A teardrop-shaped left pupil is noted on exam. What type of injury issuspected?
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compensated - A trauma pt is restless and repeatedly asking "where am i?" VS uponarrival:BP110/60,HR96,RR24.Herskiniscoolanddry.CurrentVSareBP104/84,HR 108, RR 28. The pt is demonstrating s/sx of which stage of shock? ventilate with a bag mask device - An unresponsive trauma pt has an oropharygealairwayinplace,shallowandlaboredrespirations,andduskyskin.Thetrauma teamhasadministeredmedicationsfordrug- assistedintubationandattemptedintubationbutwasunsuccessful.What is the most appropriate immediate next step? within24 hrsoftrauma-Whenisthetertiarysurveycompletedforatraumapt? pressure-AnintubatedandsedatedptintheEDhasmultipleextremityinjurieswiththepotential for causing compartment syndrome. What is the most reliable indication ofcompartment syndrome in a patient who is unconscious? worseningpneumothorax-Whichofthefollowingispossiblecomplicationofpositive-pressure ventilation? pelvicstability-themostreassuringfindingforamaleptwithhippainafterafalliswhich of the following? narrowed - Whichofthefollowingpulsepressuresindicateearlyhypovolemic shock? dysrhythmias-Patientswithacrushinjuryshouldbemonitoredforwhichofthefollowing conditions? subduralhematoma-Tearingofthebridgingveinsismostfrequentlyassociatedwithwhich brain injury? straight cath for urine sample - A 20 y/o M presents to the ED complaining of severelowerabdpainafterlandinghardonthebicyclecrossbarswhilepreforminganaerialBM X maneuver. Secondary assessment reveals lower abd tenderness and scrotalecchymosis. Which of the following orders would the RN question? placental abruption - You are caring for a pt who was involved in a MVC and is 32weeks pregnant. Findings of your secondary survey include abd pain on palpation,fundal ht at the costal margin, and some dark bloody show. Varying accelerations anddecelerationsarenotedoncariocgraphy.Thesefindingsaremostconsistentwithwhichof the following? itcanworsencorddamagefromanunstablespinalinjury - Whichofthefollowingistrueabout the log-roll? defusings-AlloftheseareconsideredacriticalcommunicationpointintraumacareEXCEPT which of the following?
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fat embolism - a pt has been in the ED for several hrs waiting to be admitted. Hesustained multiple rib fractures and a femur fracture after a fall. He has been awake,alert, and complaining of leg pain. His wife reported that he suddenly became anxiousand confused. Upon reassessment, the pt is restless with respiratory distress andpetechiaetohisneck.Theptisexhibitings/sxmostcommonlyassociatedwithwhichofthe following conditions? nauseaandvomiting-Whichofthefollowingisalatesignofincreasedintracranialpressure? serial FAST exams - a 49 y/o restrained driver involved in a MVC presents to thetraumacentercomplainingofabd,pelvic,andbilaterallowerextremitypain.VSarestable. The nurse can anticipate all of these after a negative FAST exam EXCEPTwhich of the following? pericardiocentesis-WhichofthefollowingisNOTconsideredgoal- directedtherapyforcardiogenic shock? endotrachealtube - Thetraumanurseknowsthatplacingabariatricpatientinarampedposition providers better visualization during the insertion of which device? increasedworkofbreathing?-whichofthefollowingassessmentfindingsdifferentiatesa tension pneumothorax from a simple pneumothorax? calcium-ifapthasreceivedmultipletransfusionsofbankedbloodpreservedwithcitrate, which electrolyte is most likely to drop and require supplementation? identifyingindividualswhomademistakesduringthetraumaticevent - Whichofthefollowing is NOT considered a benefit of debriefings? 500mL/hr-Youaretreatinga27y/oMinrespiratorydistresswhowasinvolvedinahouse fire. Calculating TBSA burned is deferred due to the need for emergentintubation. At what rate should you begin fluid resuscitation? advancedage - Whichof thefollowingismostlikelytocontributetoinadequateoxygenation and ventilation? a52y/odiabeticmalewithapartialthicknessburntotheleftlowerleg - Whichof thefollowing patients warrants referral to a burn center? dressing removal - A patient arrives with a large open chest wound after beingassaultedwithamachete.Prehospitalprovidersplacedanonporousdressingoverthech est wound and taped it on three sides. he is now showing signs of anxiety,restlessness, severe respiratory distress, cyanosis and decreasing blood pressure. WhichofthefollowingistheMOSTappropriateimmediateintervention?
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after a physical examination if the pt has no radiologic abnormalities on CT - EMSarriveswiththeintoxicateddriverofacarinvolvedinaMVC.EMSreportssignificantdamag e to the drivers side of the car. The pt is asking to have the cervical collarremoved. When it is appropriate to remove the cervical collar? MARCH-Whichofthefollowingmnemonicscanhelpthenurseprioritize careforatrauma patient with massive uncontrolled hemorrhage? Whatiskinematics? - Abranchofmechanics(energytransfer)thatreferstomotionanddoes not consider the concepts of force and mass of the object or body. WhatisNewton'sFirstLaw? - Abodyatrestwill remainatrest.Abodyinmotion willremain in motion until acted on by an outside force. WhatistheLawofConservationofEnergy? - Energycanneitherbecreatednordestroyed. It is only changed from one form to another. WhatisNewton'sSecondLaw? - Forceequalsmassmultipliedbyaccelerationofdeceleration. Whatiskineticenergy(KE)?-KEequals1/2themass(M) multipliedbythevelocitysquared. WhatistheMnemonicfortheInitialAssessment? - A=Airwaywith simultaneouscervical spine protection B = Breathing C=Circulation D=Disability(neurologicstatus) E=Expose/Environmentalcontrols(removeclothingandkeepthepatientwarm) What is the Mnemonic for the Secondary Assessment? - F = Full set of VS/Focusedadjuncts(includescardiacmonitor,urinarycatheter,andgastrictube)/Familypr esenceG = Give comfort measures (verbal reassurance, touch, and pharmacologic andnonpharmacologic management of pain). H=HxandHead-to-toeassessmentI = Inspect posterior surfaces Where do you listen to auscultate breath sounds? - Auscultate the lungs bilaterally atthesecondintercostalspacemidclavicularlineandatthefifthintercostal spaceattheanterior axillary line. Whatarethelatesignsofbreathingcompromise?--Tracheal deviation
- JVD Whataresignsofineffectivebreathing?--AMS
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- Asymmetricexpansionofchestwall
- Paradoxicalmovementofthechestwallduringinspirationandexpiration
- Useofaccessorymusclesorabdominalmusclesorbothordiaphragmaticbreathing
- Suckingchestwounds
- Absentordiminishedbreathsounds
- AdministerO2viaNRBorassistventilationswithabag-maskdevice,asindicated
- Anticipatedefinitiveairwaymanagementtosupportventilation. Uponinitialassessment,whattypeofoxygenshouldbeusedforaptbreathingeffectively? - A tight-fitting nonrebreather mask at 12-15 lpm. Whatinterventionshouldbedoneifaptpresentswitheffectivecirculation? --Insert2large caliber IV's
- Administerwarmedisotoniccrystalloidsolutionatanappropriaterate Whataresignsofineffectivecirculation?- - Tachycardia
- AMS
- Uncontrolledexternalbleeding
- Pale,cool,moist skin
- Distendedorabnormallyflattenedexternaljugularveins
- Distantheartsounds WhataretheinterventionsforEffective/IneffectiveCirculation? --Controlanyuncontrolled external bleeding by:
- Applyingdirectpressureoverbleedingsite
- Elevatingbleedingextremity
- Applyingpressureoverarterialpressurepoints
- Usingtourniquet(lastresort).
- Cannulate2large-caliberIV'sandinitiateinfusionsofanisotoniccrystalloidsolution
- Usewarmedsolution
- UsepressurebagstoincreasespeedofIVFinfusion
- Usebloodadministrationtubingforpossibleadministrationofblood
- Userapidinfusiondevicebasedonprotocol
- UseNS0.9%insametubingasblood product
- IV=surgicalcut-down,centralline,orboth.
- BloodsampletodetermineABOandRhgroup
- IOinsternum, legs,armsorpelvis
- Administerbloodproducts
- PASG(withoutinterferingwithfluidresuscitation) HowdoyouassessMnemonic"D"?-DISABILITYA = Alert V=VerbalP = Pain U= Unresponsive
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- GCS
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WhatshebedoneaftertheSecondaryAssessment?-Reassess:
- Primarysurvey,
- VS
- Pain
- Anyinjuries Whatarefactorsthatcontributetoineffectiveventilation?--AMS
- LOC
- Neurologicinjury
- SpinalCordInjury
- IntracranialInjury
- Blunttrauma
- Paincausedbyribfractures
- PenetratingTrauma
- Preexistinghxofrespiratorydiseases
- Increasedage Whatmedicationsareusedduringintubation?-LOADMnemonic: L =Lidocaine O=Opioids A=Atropine D=Defasiculatingagents WhataretheRapidSequenceIntubationSteps?-PREPARATION:
gatherequipment,staffing,etc.PREO XYGENATION:
Use100%O2(preventriskofaspiration).PRETREAT MENT: - Decrease S/E's of intubationPARALYSISWITHINDUC TION:
- PthasLOC,thenadministerneuromuscularblockingagentPROTECTION AND POSITIONING:
Applypressureovercricoidcartilage(minimizeslikelihoodofvomitingandaspirationPLACEM ENT WITH PROOF
- EachattemptNOTtoexceed30seconds,maxof 3attempts.Ventilatept30-60seconds between attempts.
- Afterintubation,inflatethecuff
- Confirmtubeplacementw/exhaledCO2detector.POSTINTUBATION MANAGEMENT:
- SecureETtube
- Setventilatorsettings
- ObtainChestx-ray
- Continuetomedicate
- RecheckVSandpulseoxtimetry
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WhatisaCombitube?-Adual-lumen,dual-cuff airwaythatcanbeplacedblindlyintothe esophagus to establish an airway. If inadvertently placed into trachea, it can beused as a temporary ET tube.There are only two sizes: small adult and larger adult. What is a Laryngeal Mask Airway? - Looks like an ET tube but is equipped with aninflatable,elliptical,siliconerubbercollaratthedistalend.Itisdesignedtocoverthesupraglot tic area. ILMA,doesnotrequirelaryngoscopyandvisualizationofthechords. WhatisNeedleCricothyrotomy-Percutaneoustranstrachealventilation.(temporary) Complications include:
- inadequateventilationcausinghypoxia
- hematomaformation
- esophagealperforation
- aspiration
- thyroidperforation
- subcutaneousemphysema What is Surgical Cricothyrotomy? - Making an incision in cricothyroid membrane andplacingacuffedendoortrachtubeintotrachea.Thisisindicatedwhenothermethodsof airway management have failed and pt cannot be adequately ventilated andoxygenated. Complications include:
- Aspiration
- Hemorrhageorhematomaformationorboth
- Lactotracheaoresophagus
- Creationofafalsepassage
- Laryngeal stenosis HowdoyouconfirmETTube/AlternativeAirwayPlacement? --Visualizationofthechords
- Usingbronchoscopetoconfirmplacement
- Listeningtobreathsoundsovertheepigastrumandchestwallswhileventilatingthept
- CO2detector
- Esophagealdetectiondevice
- Chestx-ray Howdoyouinspectthechestforadequateventilation?-Observe:
- mentalstatus
- RRandpattern
- chestwallsymmetry
- anyinjuries
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- JVDortrachealdeviation?(Tensionpneumothorax) Whatareyoulookingforwhenauscultatinglungsounds?-AbsenceofBS:
- Pneumothorax
- Hemothorax
AirwayObstructionDimin ished BS:
- SplintingorshallowBSmaybearesultofpain Whatareyoulookingforwhen percussingthechest?-Dullness:
hemothoraxHyperreson ance
- Pneumothorax Whatareyoulookingforwhenpalpatingthechestwall,claviclesandneck? --Tenderness
- Swelling
- subcutaneousemphysema
- step-offdeformities =Thesemayindicate:esophageal,pleural,trachealorbronchialinjuries. Palpatetracheaabovesuprasternalnotch.Trachealdeviationmayindicateatensionpneumot horax or massive hemothorax. WhatistheDOPEmnemonic?-D-Displacedtube O-Obstruction:Checksecretionsorptbitingtube P-Pneumothorax:Conditionmayoccurfromoriginaltraumaorbarotraumafromventilator E-Equipmentfailure:ptmayhavebecomedetachedfromequipmentorthere'sakinkin the tubing Explain Hypovolemic Shock. - Most common to affect a trauma pt cause byhypovolemia.. Hypovolemia, a decrease in amount of circulating blood volume, mayresult from significant loss of whole blood because of hemorrhage or from loss ofsemipermeableintegrityofcellularmembraneleadingtoleakageofplasmaandproteinfrom intravascular space to the interstitial space (as in a burn). Some causes:
- Bloodloss
- Burns,etc. ExplainCardiogenicShock.-Syndromethatresultsfromineffectiveperfusioncausedby ineffective perfusion caused by inadequate contractility of cardiac muscle. Some causes:
- MI
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hormone)
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*Decreasedurinaryoutput=earlysignrenalhypoperfusionandanindicatorthatthere'ssystem ic hypoperfusion. Explainadrenalglandresponse. - WhenadrenalglandsarestimulatedbySNS,releaseofcatecholamines(epinephrineandnore pinephrine)fromadrenalmedullawillincrease. Epi stimulates receptors in heart to increase force of cardiac contraction (positiveinotropy)andincreaseHR(positivechronotropy)toimprovecardiacoutput,BPandtis sue perfusion. Shock stimulates hypothalamus to release corticotropin-releasing hormone thatstimulatespituitarytoreleaseACTHthatstimulatesadrenalglandtoreleasecortisol. Effectofcortisolreleaseiselevationinbloodsugarandincreasedinsulinresistanceandglucone ogenesis, hepatic process to produce more sugar. Cortisolalsocausesrenalretention ofwaterandsodium,acompensatorymechanismto conserve body water. ExplainHepaticResponse.-Livercanstoreexcessglucoseasglycogen. Asshockprogresses,glycogenolysisisactivatedbyepitobreakdownglycogenintoglucose. Inacompensatoryresponsetoshock,hepaticvesselsconstricttoredirectbloodflowtoother vital areas. ExplainPulmonaryResponse.-Tachypneahappensfor2reasons: 1.Maintainacid-basebalance 2.Maintainincreasedsupplyofoxygen
- Metabolic acidosis from anaerobic metabolism will be a stimulus for the lungs toincreaserateofventilation.IncreasedRRisanattempttocorrectacidosis+augmentsoxygen supply to maximize oxygen delivery to alveoli. ExplainIrreversibleShock.- Shockuncompensatedorirreversiblestageswillcausecompromises to most body systems.
- Inadequatevenousreturn
- inadequatecardiacfilling
- decreasedcoronaryarteryperfusion
- Membranesoflysosomesbreakdownwithincellsandreleasedigestiveenzymesthatcause intracellular damage. Howwouldyouassesssomeoneinhypovolemicshock?-(UseInitialAssessment)and
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Inspect:
- LOC
- Rateandqualityofrespirations
- Externalbleeding?
- Skincolorandmoisture
- AssessjugularveinsandperipheralveinsAuscultate:
- BP
- Pulsepressure
- Breathsounds
- Heartsounds
- BowelsoundsPercuss:
ChestandabdomenPalp ate:
- Centralpulse(carotidorfemoral)
- Positiveinotropiceffect(forceofcontraction)maybeevidencebyaboundingcentralpulse
- Palpateperipheralpulses
PalpateskintempandmoistureDiagno stic Procedures:
- Xraysandotherstudies
- Labs PlanningandImplementation
- Oxygen
- IV'swithwarmedreplacementfluids
- Controlexternalbleedingwithdirectpressure
- Elevate LE's
- NGT
- Foley
- Monitorandpulseoximeter
- Monitorfordevelopmentofcoagulopathies
- Surgery? ICPisareflectionofwhatthreevolumes?Whathappenswhenoneincreases? - 1.Brain 2.CSF 3.Bloodwithinthenonexpansiblecranialvault Asvolumeofoneincreases,thevolumeofanotherdecreasestomaintainICPwithinnormal range. As ICP rises, CPP decreases, leading to cerebral ischemia and potential for hypoxiaandlethalsecondaryinsult.Hypotensiveptw/marginallyelevatedICPcanbeharmful.
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Slightlyelevated BP could protectagainst brain ischemia ina pt with high ICP. Cerebralischemia can lead to increased concentration of CO2 and decreased concentration ofO2incerebralvessels.CO2dilatescerebralbloodvessels=increasebloodvolumeandICP. WhataretheearlysignsandsymptomsofincreasedICP?--Headache
- N/V
- Amnesiaregardingeventsaroundtheinjury
- AlteredLOC
- Restlessness,drowsiness,changesinspeech,orlossofjudgement WhatarethelateobservablesignsofsymptomsofincreasedICP? --Dilated,nonreactive pupil
- Unresponsivenesstoverbalorpainfulstimuli
- Abnormalmotorposturingpatterns
- Increasedsystolicbloodpressure
- ChangesinRRandpattern
- Bradycardia WhatisCushing'sphenomenonorCushing'sReflex? - TriadofprogressiveHTN,bradycardia and diminished respiratory effort. Whatarethetwotypesof herniationthatoccurswithICP?-1.Uncalherniation 2.Centralortranstentorial herniation Whydoesherniationoccur?Whatarethesymptoms? - Becauseofuncontrolledincreases in ICP. S/E's
- Unilateralorbilateralpupillarydilation
- AsyDimmetricpupillaryreactivity
- Abnormalmotorposturing
- Otherevidenceofneurologicdeterioration Defineuncalherniation. - Theuncus(medialaspectofthetemporallobe)isdisplacedoverthe tentoriumintotheposteriorfossa.Thisherniationisthemore commonof thetwo types of herniation syndromes. Define central or transtentorial herniation. - A downward movement of the cerebralhemisphereswithherniationofthediencephalonandmidbrainthroughtheelongated gap of the tentorium. Disruptions of the bony structures of the skull can result in what? - Displaced ornondisplacedfx'scausingCSFleakageb/coflactotheduramater,creatingapassage
