TNCC 8th edition exam with complete solution 2022

TNCC 8th edition exam with complete solution 2022 1. The major cause of preventable death after injury - ✔✔Uncontrolled hemorrhage

2. The best measure of the adequacy of cellular perfusion and helps to predict the outcome of resuscitation - ✔✔Base deficit

3. Examples of primary blast injuries - ✔✔Blast lung, ruptured tympanic membrane, TBI, abdominal hemorrhage

4. Examples of secondary blast injuries - ✔✔Wounds from debris and bomb fragments

5. Examples of tertiary blast injuries - ✔✔Blunt or penetrating trauma from the body being thrown by the blast

6. Examples of quaternary blast injuries - ✔✔Injuries or illness related to explosion: burns, toxic injury from chemicals

7. Examples of quinary blast injuries - ✔✔Injuries associated with exposure to hazardous materials from the components of the blast

8. Questions to ask for airway assessment (need 4) ✔✔ Is the tongue obstructing?

Are there any foreign objects?

Is there any edema?

Are there loose or missing teeth?

Is there snoring, gurgling, or stridor?

Is there bony deformity?

Is there blood, vomit, or secretions?

9. Questions to ask during breathing assessment. (Need 4) - ✔✔Is there symmetrical chest rise?

Is there spontaneous breathing?

Is there tracheal deviation or JVD?

What is their skin color?

Are there open wounds or deformities in the chest?

What's the depth, pattern, and rate of respirations?

Is there increased work of breathing?

Are breath sounds present and equal?

10. 3 ways to assess ETT placement - ✔✔ 1. Apply end tidal, assess CO2 after 5-6 breaths 2. Assess for symmetrical chest wall rise and fall 3. Auscultation over the epigastrium for gurgling and bilateral breath sounds.

11. What do you document after placing an ETT? - ✔✔ETT placement at teeth or gums

12. Situations that require a definitive airway - ✔✔GCS 8 or less Apnea Inhalation injury Increased risk of aspiration Anticipate decreased neuro status Severe maxo fractures Laryngeal/tracheal injury

13. Where do you listen for breath sounds? - ✔✔2nd intercostal space at midclavicular line and 5th intercostal space at anterior axillary line

14. King airway - ✔✔A multidimensional esophageal airway that traps the glottis opening between an esophageal cuff and an oropharyngeal cuff

15. 3 things to assess for circulation - ✔✔Palpate central pulse Assess (again) for external hemorrhage Inspect and palpate skin for color, temp, and moisture.

16. When do you establish IV access? - ✔✔Right after the circulatory assessment

17. At what point to you evaluate need for transfer or definitive care? - ✔✔After the primary survey

18. How do you palpate the iliac crests? - ✔✔Downward and medially

19. The 3 components of the pediatric assessment triangle - ✔✔Skin circulation, work of breathing, general appearance

20. What type of fluids should you give kids with normal blood glucose? - ✔✔Fluids with dextrose to prevent hypoglycemia

21. How much fluid do you give a kid? - ✔✔20mL/kg

22. What assessment finding gives concern for severe brain injury? - ✔✔Bulging fontanels

23. Parkland formula - ✔✔3mL x the weight in kg x % TBSA = the fluid to go over 24 hours

24. How do you give the fluid over 24 hours in parkland formula? - ✔✔First half over 8 hours and second half over 16 hours

25. Normal baseline FHR - ✔✔120-160

26. What does Kleihaver-Betke test for? - ✔✔Tests for fetal RBCs I. Maternal circulation, which is abnormal and could indicate fetomaternal hemorrhage has occurred

27. Symptoms of abruptly placentae - ✔✔Dark red bleeding, sudden sharp abdominal pain, "boardlike" uterus, increased FHR

28. Symptoms of uterine rupture - ✔✔Sudden sharp abdominal or suprapibic pain, asymmetry of uterus, decreased FHR

29. What degree to you tilt the supine pregnant patient to prevent supine hypotension? - ✔✔15 degrees

30. 3 parts of the trauma triad of death - ✔✔Hypothermia, coagulopathy, metabolic acidosise

31. Examples of obstructive shock - ✔✔Tension pneumo, cardiac tamponade, pulmonary artery embolism

32. Symptoms of stage 1 of shock - ✔✔Change in neuro status, increased DBP, decreased UO, tachycardia

33. Symptoms of stage 2 of shock - ✔✔Declining neuro status, tachycardia, narrow pulse pressure, weak thready pulse, cool skin, abnormal base deficit, increased lactate

34. symptoms of epidural hematoma - ✔✔Transient LOC with a lucid period, HA, N/V, rapidly declining neuro status

35. For what reasons would you not give mannitol? - ✔✔An active bleed or hypotension

36. What is Beck triad for cardiac tamponade? - ✔✔Hypotension, distended neck veins, muffled heart sounds

37. Solid abdominal organs and what are they prone to? - ✔✔Liver, spleen, gallbladder, pancreas, prone to lacerations

38. Hollow abdominal organs and what are they prone to - ✔✔Stomach, bowels, uterus, bladder, prone to rupture

39. Big symptom of splenic injury - ✔✔Left shoulder pain

40. Where do you secure a pelvic binder? - ✔✔At the level of the greater trochanter and symphysis pubis

41. What is Turners sign? - ✔✔Ecchymosis over the flank at the 11th and 12th ribs, in renal injury

42. What organs do you ultrasound in a FAST exam? - ✔✔Bladder, liver, spleen

43. What kind of dressing do you apply to an open pneumo? - ✔✔Nonporous dressing (petroleum gauze or plastic wrap) and tape on 3 sides

TNCC 8th Edition Questions and Answers (Updated 2022) 52 Questions with 100% Correct Answers 1. What are the greatest risks for transport? - ✔✔Loss of airway patency, displaced obstructive tubes lines or catheters, dislodge splinting devices, need to replace or reinforce dressings, deterioration in patient status change in vital signs or level of consciousness, injury to the patient and/or team members

2. According to newtons law which of these two force is greater: size or force? - ✔✔Neither. For each force there is an equal and opposite reaction.

3. What is the relationship between mass and velocity to kinetic energy? - ✔✔Kinetic energy is equal to 1/2 the mass multiplied the square of its velocity therefore when mass is doubled so is the net energy, however, when velocity is doubled energy is quadrupled.

4. What is tension? - ✔✔stretching force by pulling at opposite ends

5. What is compression? - ✔✔Crushing by squeezing together

6. What is bending? - ✔✔Loading about an axis. Bending causes compression on the side the person is bending toward intention to the opposite side

7. What is shearing? - ✔✔Damage by tearing or bending by exerting faucet different parts in opposite directions at the same time.

8. What is torsion? - ✔✔Torsion forces twist ends in opposite directions.

9. What is combined loading? - ✔✔Any combination of tension compression torsion bending and/or shear.

10. What are the four types of trauma related injuries? - ✔✔Blunt, penetrating, thermal, or blast.

11. What are contributing factors to injuries related to blunt traumas? - ✔✔The point of impact on the patient's body, the type of surface that is hit, the tissues ability to resist (bone versus soft tissue, air-filled versus solid organs), and the trajectory of force.

12. What are the seven patterns of pathway injuries related to motor vehicle accidents? - ✔✔Up and over, down and under, lateral, rotational, rear, roll over, and ejection.

13. Differentiate between the three impacts of motor vehicle impact sequence. - ✔✔The first impact occurs when the vehicle collided with another object. The second impact occurs after the initial impact when the occupant continues to move in the original direction of travel until they collide with the interior of the vehicle or meet resistance. The third impact occurs when internal structures collide within the body cavity.

14. What are the three factors that contribute to the damage caused by penetrating trauma's? ✔✔The point of impact, the velocity and speed of impact, and the proximity to the object.

15. What causes the primary effects of blast traumas? - ✔✔The direct blast effects. Types of injuries include last long, tympanic membrane rupture and middle ear damage, abdominal hemorrhage and perforation, global rupture, mild Trumatic brain injury.

16. What causes the secondary effects of blast traumas? - ✔✔Projectiles propelled by the explosion. Injuries include penetrating or blunt injuries or I penetration.

17. What causes the tertiary effects of blast traumas? - ✔✔Results from individuals being thrown by the blast wind. Injuries include hole or partial body translocation from being thrown against a hard service: blunt or penetrating trauma's, fractures, traumatic amputations.

18. What causes quarternary effects of blast traumas? - ✔✔All explosion related injuries, illnesses, or diseases not due to the first three mechanisms. Injuries include external and internal burns, crush injuries, closed and open brain injuries, asthmatic or breathing problems from dust smoke or toxic fumes, angina, or hyper glycemia and hypertension.

19. What causes quinary effects of blasts traumas? - ✔✔Those associated with exposure to hazardous materials from radioactive, biologic, or chemical components of a blast. Injuries include a variety of health effects depending on agent.

20. What are the three processes that transfer oxygen from the air to the lungs and blood stream ✔✔Ventilation: the active mechanical movement of air into and out of the lungs; diffusion: the passive movement of gases from an area of higher concentration to an area of lower concentration; and perfusion: the movement of blood to and from the lungs as a delivery medium of oxygen to the entire body.

21. When would you use a nasopharyngeal airway versus an oral pharyngeal airway? ✔✔Nasopharyngeal airways is contraindicated in patients with facial trauma or a suspected basilar skull fracture. Oral pharyngeal airways is used in unresponsive patients unable to maintain their airway, without a gag reflex as a temporary measure to facilitate ventilation with a bag mask device or spontaneous ventilation until the patient can be intubated.

22. Describe the measurement of an NPA - ✔✔Measure from the tip of the patient's nose to the tip of the patients earlobe.

23. Measurement of an OPA - ✔✔Place the proximal end or flange of the airway adjunct at the corner of the mouth to the tip of the mandibular angle.

24. True or false: NPAs and OPAs are definitive airways. - ✔✔False. When placing one of these? One should consider the potential need for a definitive airway.

25. Name the three ways to confirm ETT placement - ✔✔Placement of a CO2 monitoring device, Assessing for equal chest rise and fall, and listening at the epigastrium and four lung fields for equal breath sounds.

26. When capnography measurement reads greater than 45MMHG, the nurse should consider increasing or decreasing the ventilation rate? - ✔✔Increasing the ventilation rate. Doing so would allow the patient to blow off retained CO2.

27. When capnography measurement reads less than 35MMHG, the nurse should consider increasing or decreasing the ventilation rate? - ✔✔Decreasing the ventilation rate. By doing so, the nurse allows the patient to retain CO2.

28. What are the three stages of shock - ✔✔Compensated, decompensated or progressive, and irreversible.

29. What are the signs of compensated shock? - ✔✔Anxiety, confusion, restlessness, increased respiratory rate, narrowing pulse pressure were diastolic increases yet systolic remains unchanged, tachycardia with bounding pulses, and decreased urinary output

30. What are the signs and symptoms of decompensated shock? - ✔✔Decreased level of consciousness, hypertension, narrow pulse pressure, tachycardia with weak pulses, tachypnea, skin that is cool clammy and cyanotic, base access outside the normal range, and serum lactate levels greater than two to 4MMOL/L.

31. What are the signs and symptoms of irreversible shock? - ✔✔Obtunded stuporous or comatose state, marked hypertension and heart failure, bradycardia with possible dysrhythmias, decreased and shallow respiratory rate, pale cool and clammy skin, kidney liver and other organ failure, severe acidosis, elevated lactic acid levels, worsening base access on ABGs, coagulopathies with petechiae purpura or bleeding.

32. What are the four types of shock? - ✔✔Hypovolemic, Cardiogenic, Obstructive, & Distributive

33. What is the trauma triad of death? - ✔✔hypothermia, acidosis, coagulopathy

34. Describe the characteristics of obstructive shock - ✔✔Obstructive shock is it mechanical problem that results from hypoperfusion of the tissue due to an obstruction in either the vasculature or the heart resulting in decreased cardiac output. Some causes include a tension pneumothorax, cardiac tamponade, or venous air embolism on the right side of the heart during systole in the pulmonary artery.Signs include anxiety, muffled heart sounds, JVD, hypertension, chest pain, difficulty breathing, or pulses paradoxes.

35. Describe the characteristics of cardiogenic shock - ✔✔Cardiogenic shock results from pump failure in the presence of adequate intravascular volume. Lack of cardiac output and an organ

perfusion occurs secondary to a decrease in myocardial contractility and or valvular insufficiency. This can happen with blunt cardiac trauma or an MI. Symptoms can include low blood pressure increase heart rate and respiratory rate chest pain shortness of breath dysrhythmias increase troponin and pale cool moist skin

36. Describe the characteristics of distributive shock. - ✔✔Distributive shock occurs as a result of Mel distribution of an adequate circulating blood volume with the loss of vascular tone or increased permeability. This can occur with spinal cord injuries, sepsis, or anaphylaxis.

Symptoms include low blood pressure heart rate respiratory rate preload and afterload, spinal tenderness, difficulty breathing, warm pink and dry skin with a cool core temperature.

37. Describe the characteristics of hypovolemic shock - ✔✔Hypovolemia is caused by a decrease in the amount of circulating volume usually caused by massive bleeding, but also can be from vomiting and diarrhea. Characteristics include low blood pressure and preload, increase heart rate respiratory rate and afterload, with contractility unchanged. Signs include obvious bleeding, weak peripheral pulses, pale cool and moist skin, distended abdomen, pelvic fracture, or bruise swollen and deformed extremities especially long bones.

38. What is the recommended fluid bolus for a trauma? - ✔✔500 ML's of warmed isotonic crystalloid. Ongoing fluid boluses of 500 ML's should be given judiciously with constant reassessments after administration.

39. What is the minimum permissive hypertension and a trauma patient? - ✔✔A systolic of greater than or equal to 90 MMHG

40. What is the minimum permissive oxygenation level of a trauma patient? - ✔✔Greater than or equal to 94%

41. What is Cullen's sign and its significance? - ✔✔Cullens sign is periumbilical bruising and is indicative of intraperitoneal bleeding

42. Define Cushing's triad - ✔✔Bradycardia, progressive hypertension (widening pulse pressure), and decreased respiratory effort

43. What are the early signs of increased Intracranial pressure - ✔✔headache, vomiting, behavioral changes that begin with restlessness and may progress to confusion, drowsiness, or impaired judgment

44. What are the late signs of Increased intracranial pressure - ✔✔dilated, non-reactive pupil(s); abnormal motor posturing (flexion, extension, flaccidity); Cushing's triad, Unresponsive to per verbal and painful stimuli, bradycardia and decreased respiratory effort

45. What are the symptoms of a subdural hematoma? - ✔✔Decreased LOC, nausea vomiting headache and ipsilateral pupillary changes

46. What is a trademark symptom of an epidural hematoma - ✔✔Loss of consciousness then awake and alert then loss of consciousness

47. Define the characteristics of neurogenic shock - ✔✔Distributive shock with a T6 or higher injury results and vasodilation, bradycardia, flushed warm dry skin. Risk for temperature instability.

Nursing interventions include maintaining warmth and spinal stabilization.

48. Define the characteristics of spinal shock - ✔✔Transient loss of function can include loss of reflexes and muscle tone below the level of industry with possible vascular response.

49. Describe the four types of spinal cord injury - ✔✔Central cord injury results in greater weakness distally, anterior injury includes motor loss or weakness below the cord level of injury yet sensory is intact, Brown-Sequard (hemicord) is weak on one side with sensory deficit on opposite side, posterior cord syndrome although rare is when the patient is unable to use sense vibration in proprioception

50. Describe one fat embolism syndrome is most likely to occur in its characteristics - ✔✔With longform fractures. Tachycardia, Thrombocytopenia, and petechiae rash.

51. What is the Munro-Kellie doctrine? - ✔✔Within the skull 80% his brain, 10% is blood, and 10% is CSF. Any increase of any of the products results in increased intracranial pressure.

52. What are the treatment goals for a TBI? - ✔✔O2 saturation > or equal to 95%, systolic blood pressure > or equal to 100 MMHG, ICP < 15 MMHG, CPP > or equal to 60 MMHG, normal glycemia, hemoglobin > or equal to 7 g/DL, sodium 135-145, osmotic diuretics, anti-emetics, sedatives, anticonvulsants, head of bed at 30°, and neck at midline

TNCC Final Exam Test 2022 Open Book 50 Questions with 100% Correct Answers BEST LAYOUT 1. Why is a measure of serum lactate obtained in the initial assessment of the trauma patient?

a) to measure oxygenation and ventilation b) to quantify the base deficit for the adequacy of cellular perfusion c) *to gauge end-organ perfusion and tissue hypoxia ** d) to determine the underlying cause of shock

2. A trauma patient is restless and repeatedly asking "where am I?" vital signs upon arrival were BP 100/60 mm Hg, HR 96 beats/min, and RR 24 breaths/min. Her skin is cool and dry. Current vital signs are BP 104/84mm Hg, HR 108, RR 28 breaths/min. The patient is demonstrating signs and symptoms of which stage of shock?

A) compensated ** B) Progressive C) irreversible D) decompensated

3. An elderly patient with a history of anticoagulant use presents after a fall at home that day. she denies any loss of consciousness. She has a hematoma to her forehead and complains of headache, dizziness, and nausea. Which is a most likely cause of her symptoms?

A) epidural hematoma B) diffuse axonal injury C) post-concussive syndrome D) subdural hematoma ***

4. EMS brings a patient who fell riding his bicycle. Using the American College of Surgeons screening guidelines, which assessment finding would prompt the nurse to prepare the patient for radiologic spine clearance?

A) Alert with no neurologic deficits B) Multiple abrasions to the extremities C) Multiple requests of water D) Smell of alcohol on breath ***

5. Which of the following occurs during the third impact of a motor vehicle crash?

A) The driver of the vehicle collides with the steering wheel B) the vehicle collides with a tree C) the aorta is torn at its attachment with the ligamentum arteriosum D) the airbag deploys and strikes the front seat passenger ***

6. A passenger is brought to the emergency department of a rural hospital following a high-speed MVC. When significant abdominal and pelvic injuries are noted in the primary survey, which of the following is the priority interventions?

A) initiate transfer to a trauma center ** B) provide report to the operating room nurse C) Obtained imaging studies D) Place a gastric tube

7. Which of the following injuries is LEAST likely to be promptly identified?

A) spleen B) lung C) bowel *** D) brain

8. Patients with a crush injury should be monitored for which of the following conditions?

A) Hypernatremia B) Hypercalcemia C) Dysrhthmias ** D) polyuria

9. What finding raises suspicion of complete spinal cord injury?

A) Weakness in the lower extremities B) Priapism *** C) voluntary anal sphincter tone D) intact reflexes distal to the injury

10. A patient with a complete spinal cord injury in neurogenic shock will demonstrate hypotension and which other clinical signs?

A) Bradycardia and ipsilateral absences of motor function B) Tachycardia and respiratory depression C) Tachycardia and absent motor function below the level of injury D) Bradycardia and absent motor function below the level of the injury ***

11. A 5-year old child presents to the ED with bruises to the upper arms and buttocks in various stages of healing and multiple small, clean, round burns to the back. There are no abnormalities found based on the pediatric assessment triangle or primary survey. Which of the following is the priority nursing intervention?

A) report your suspicion of the maltreatment in accordance with local regulations *** B) apply ice to the bruises and consult wound care C) engage in therapeutic communication to determine the MOI D) provide the family with injury prevention resourse

12. A patient with lower extremity fracture complains of severe pain and tightness in his calf, minimally relieved by pain medications. Which of the following is the priority nursing intervention?

A) elevating the extremity above the level of the heart B) repositioning and apply ice C) Elevating the extremity to the level of the heart *** D) Preparing the patient for ultrasound

13. A 36-year old female has a deformity of the left wrist after a fall. She is reluctant to move her hand due to pain. Which of the following is the most appropriate intervention?

A) apply a sling and elevate the extremity to the level of the heart.

B) apply a splint and ELEVATE ABOVE THE LEVEL OF THE HEART *** C) Apply a sling and elevate the extremity above the level of the heart D) apply a splint and elevate the extremity to the level of the heart.

14. Which of the following is a late sign of increased intracranial pressure?

Cushing Response Widening pulse pressure Reflex bradycardia Decreased RR A) Restlessness or drowsiness B) Nausea and vomiting C) Decreased respiratory effort** D) amnesia and anxiety

15. Which of the following mnemonics can help the nurse prioritize care for a trauma patient with massive uncontrolled hemorrhage?

A) ABC B) MARCH*** C) AVPU D) VIPP

16. A patient is thrown against a car during a tornado and presents with obvious bilateral femoral fractures. The patient is pale, alert, disoriented, and has delayed cap refill. Which of the following interventions would be most appropriate for this patient based on the disaster triage principle?

A) initiate two large caliber intravenous lines for Ringers lactate solution administration *** B) Administer Dilaudid for pain control and provide comfort care C) Place the patient in an observation area for care within the next few hours

D) Contact the command center for the personnel to notify next of kin.

17. A patient arrives with a large open chest wound after being assault ed with a machete, Prehospital providers placed a nonporous dressing over the chest wound and tapes it on 3 sides.

He is now showing signs of anxiety, restlessness, severe respiratory distress, cyanosis, and decreasing blood pressure. Which of the following is the MOST appropriate interventions?

A) needle decompression B) tube thoracostomy C) dressing removal ** D) surgical repair

18. A patient is found lying on the floor after falling 13 hours ago. Which of the following lab values is expected with a musculoskeletal complication associated with this presentation?

A) elevated creatine kinase *** B) decreased potassium level C) decreased WBC D) elevated GFR

19. A 56-year- male patient involved in a MVC is brought to the ED of a rural critical access facility.

He c/o neck pain, SOB, and diffuse abd pain. His GCS is 15. His vitals are as follows: BP 98/71 HR 125 beats/min RR 26 breaths/min SpO2 94% on high flow O2 via NRB mask

which of the following is the priority intervention for this patient?

A) Expedite transport to the CT scanner B) prepare the patient for spinal radiographs C) expedite transfer to the closest trauma center *** D) notify the patients family

20. Caregivers carry a 2-year old into the ED who fell out of 2nd story window. The patient is awake and crying with increased work of breathing and pale skin. which of the following interventions has the highest priority?

A) padding the upper back while stabilizing the cervical spine *** B) applying a tight-fitting NRB mask with an attached resevior C) establishing intravenous access and administering a 20mL/kg bolus D) preparing for drug assisted intubation

21. Which of the following is a component of the trauma triad of death?

hypothermia, metabolic acidosis, coagulopathy A) Acidosis ** B) hyperthermia C) hemorrhage D) sepsis

22. A 35-year old male presents with facial trauma after bring struck inthe face with a baseball. a tear-drop shaped left pupil is noted on exam. What type of injury is suspected?

A) oculomotor nerve palsy B) globe rupture *** C) uncal herniation D) retinal detachment

23. Which of the following is true about the log roll maneuver?

A) it causes less spinal motion than the lift and slide manuever B) it is recommended for patients with unstable pelvic fractures C) it can worsen cord damage from an unstable spinal injury *** D) it does not increases the risk of life threatening hemorrhage from unstable injuries

24. EMS arrives with the intoxicated driver of a car involved in a MVC. EMS reports significant damage to the drivers side of the car. The patient is asking to have the cervical color removed. when is it appropriate to remove the cervical collar?

A) after a physical examination if the patient has no radiologic abnormalities on a computed tomography scan *** B) after physician evaluation if the patient has not neurologic abnormalities on exam C) after palpation of the spine if the patient has no point tenderness the the vertebral column D) after physical examination if the patient has not neck pain with movement

25. Tearing of the bridging veins is most frequently associated with which brain injury?

A) epidural hematoma B) subdural hematoma *** C) diffuse axonal injury D) intracerebral hematoma

26. If a patient has received multiple transfusions of banked blood preserved with citrate, which electrolyte is most likely to drop and require supplementation?

A) potassium B) magnesium C) sodium D) calcium ***

27. A trauma patient is en route to a rural ED. Radiology notifies the charge nurse that the CT scanner will be out of service for several of hours. The team gathers to plan accordingly. Which of the following terms best describes this trauma teams communication?

A) Brief B) loop C) debrief D) huddle ***

28. The nurse is caring for a 120 kg male is brought in after a warehouse fire and is calculating the patient's fluid resuscitation needs. He has painful red blistering to the entire surface of both upper extremities and superficial burns to the anterior chest. Using the modified Lund and Browder chart to calculate the total BSA burned, how much IV fluids would be administered in the first 8 hours?

(upper arm 4+4 / lower arm 3+3 / hand 2.5+2.5) = 19% TBSA.

120 kg x (2 mL) x (19% TBSA) = 4560 mL

4560 / 2 (half of fluids given in first 8 hours) = 2280 mL

A) 2280 mL *** B) 3840 mL C) 4560 mL D) 7680 mL

29. Which of the following assessment findings differentiates a tension PTX from a simple PTX?

Assessment findings associated with tension pneumothorax include anxiety, severe restlessness, severe respiratory distress, and absent breath sounds on the injured side. Hypotension due to compression of the heart and great vessels is consistent with obstructive shock. Hypotension worsens with inspiration due to increased intrathoracic pressure. Late signs include distended neck veins, tracheal deviation, and cyanosis. A) increased work of breathing B) unilaterally diminished breath sounds C) pleuritic chest pain D) hypotension that worsens with inspiration ***

30. Which of the following considerations is most important when caring for a geriatric trauma patient?

A) head to to exam B) medical history ** C) incontinence D) falls

31. An intubated trauma patient is being transferred to a tertiary care center. After moving the patient to the stretcher for transport, a drop in pulse oximetry to 85% is noted. Which of the following is the priority interventions?

A) call for a portable CXR stat B) chest to make sure the ventilator is plugged in C) suction the ET tube D) confirm ET tube placement

32. What factor contributes most the kinetic energy of a body in motion?

A) acceleration B) mass C) velocity *** D) inertia

33. During the primary survey of an unconscious patient with multi-system trauma, the nurse notes snoring respirations. Which priority nursing interventions should be performed next?

A) open the airway with the head-tilt/chin lift maneuver B) auscultate bilateral breath sounds to assess ventilatory status C) assist respirations using a BVM D) insert an oropharyngeal airway if there is no gag reflex ***

34. Following a review of recent drills and a real disaster event, a hospital has identified deficiencies and is taking steps to minimize the impact of future disaster. Which phase of the disaster life cycle does this describe?

A) mitigation *** B) preparedness

C) response D) recovery

35. Which pulse pressure description is an indication of early hypovolemic shock?

A) widened B) narrowed *** C) bounding D) weak

36. The most reassuring finding for a male patient with hop pain after a fall is which of the following?

A) a normal prostate exam B) absence of abdominal distension C) a normal fast exam D) pelvic stability ***

37. A 49-year old restrained driver involved in a MVC presents to the trauma center c/o abd, pelvic, and bil lower extremity pain Vitals signs are stable. The nurse can anticipate all of these negative fast exam except which of the following?

The FAST exam is done at the bedside to identify pathological fluid in the abdominal and pelvic cavities. FAST exams reduce the use of more invasive diagnostic peritoneal lavage and can be repeated if clinical changes or hemodynamic changes occur. A negative FAST study does not rule out injury and may warrant a follow-up computed tomography scan. Serial FAST exams can identify increasing abdominal fluid collections from hemorrhage. Diagnostic peritoneal lavage/diagnostic peritoneal aspiration is performed by the surgical team to rapidly identify the presence of hemorrhage in patients who are hemodynamically unstable after trauma. A) diagnostic peritoneal lavage *** B) serial fast exams C) abdominal and pelvic CT scans D) serial abdominal assessments

38. Which of the following is an expected finding in a patient with a thoracostomy connected to a chest drainage system?

A) output of 200 mL/hr B) tubing clamp closed for transport C) dependent loops in the tubing to promote drainage D) fluctuations in the water serial chamber ***

39. Which of the following patients warrants referral to a burn center?

A) a 21- year old female with a partial thickness burn to the right forearm B) a 40-year old hypertensive male with a superficial burn to the back C) a 52-year old diabetic male with partial thickness burn to the left lower leg *** D) a 35-year old hyperlipidemic female with superficial burns to the anterior thorax.

40. A patient has been in the ED for several hours waiting to be admitted. He sustained multiple rib fractures and a femur fracture after a fall. He has been awake, alert, and c/o leg pain. His wife reported suddenly becoming anxious and confused. Upon reassessment, the patient is restless, with respiratory distress and petechiae to his neck. the patient is exhibiting signs of symptoms commonly associated with which of the following conditions?

A) acute lung injury B) fat embolism *** C) PTX D) pulmonary contusion

41. Which is the effect of hypothermia on the oxyhemoglobin dissociation curve?

A) Hemoglobin does not readily release oxygen for use by the tissues *** B) The amount of oxygen available to the tissues increases C) Tissue oxygenation (PaO2) increases D) Hemoglobin molecule saturation (SaO2) decreases

42. A 20-year old male presents to the ED c/o severe lower abd pain after landing hard on the bicycle cross bars which performing an aerial BMX maneuver. Secondary assessment reveals

lower abd tenderness and scrotal ecchymosis. Which of the following orders would the nurse questions?

A) Fast exam B) CT scan C) straight cath for urine sample *** D) ice and elevation of the scrotum

43. You are treating a 27-year old male in respiratory distress who was involved in a house fire.

Calculating TBSA burned is deferred d/t the need for emergent intubation. At what rate should you begin fluid resuscitation?

A) 1000 mL/hr B) 500 mL/hr *** C) 250 mL/hr D) 125 mL/hr

44. Which of the following is possible complication of positive-pressure ventilation?

A) worsening pneumothorax B) worsening flail chest C) reabsorption of pleural air D) negative intrapleural pressure

45. Which of the following is NOT considered goal-directed therapy of cardiogenic shock?

A) controlled fluid boluses B) antidysrhythmic administration C) pericardiocentesis *** D) cardiac cath

46. What bedside monitoring parameters are used to assess for adequacy of oxygenation and effectiveness of ventilation?

A) pulse oximetry and capnogaphy ** B) respiratory rate and capnography C) pulse oximetry and respiratory rate D) capnography and capnometry

47. Which if the following values indicates the need for alcohol withdrawal interventions?

A) CIWA-Ar of 36 *** B) GCS 13 C) ETCo2 of 48 mm Hg D) heart rate of 45 beats/min

48. An unresponsive trauma patient has an oropharyngeal airway in place, shallow and labored respiratory, and dusky skin. the trauma team has administered medications for drug assisted intubation and attempted intubation but was unsuccessful. What is the most appropriate immediate next step?

A) Ventilate with a BVM *** B) Prepare for cricothyroidotomy C) administer reversal medications D) contact anesthesia for assistance

49. The trauma nurse knows that placing a bariatric patients in a "ramped position" provides better visualization during the insertion of which device?

A) Intraosseous line B) orogastric tube C) ET tube *** D) urinary catheter

50. You are caring for a patient who was involved in a MVA and is 32 weeks pregnant. Findings of your secondary survey include abd pain on palpation, fundal high at the costal margin, and some dark bloody show. Varying, accelerations and decelerations are noted on the cardiotocography.

These findings are most consistent with which of the following?

A) placental abruption *** B) preterm labor C) uterine rupture D) fetal demise

TNCC Physical Assessments 2022/23 What is the Trauma Assessment Mnemonic?

- ✔✔ A = Airway with simultaneous cervical spine stabilization/immobilization B = Breathing C = Circulation D = Disability (neurologic status) E = Expose patient/Environmental Control F = Full set of VS/Focused Adjuncts/Facilitate Family Presence G = Give comfort measures H = History/Head-to-toe assessment I = Inspect posterior surfaces

What is assessed in Airway while simultaneously protecting the cervical spine?

- Assess: - Vocalization - Tongue obstructing airway - Loose teeth, foreign objects - Blood, vomitus, other secretions - Edema Interventions: - Position pt - Jaw thrust/Chin lift - Remove foreign objects - Suction blood, vomitus, secretions - Insert oropharyngeal or nasopharyngeal airway - Needle or surgical cricothyrotomy

What is assessed in Breathing? - ✔✔Assess:

- Spontaneous breathing - Rise and fall of chest - Rate and pattern of breathing - Use of accessory muscles/Diaphragmatic breathing - Skin color - Integrity of soft tissue and bony structures of chest wall - Bilateral breath sounds Interventions: - Supplemental oxygen - Bag-Mask ventilation - Needle thoracentesis/Decompression - Chest tube - Nonporous dsg taped on 3 sides

What is assessed in Circulation? - ✔✔Assess: - Palpates central pulse for rate and quality - Skin color, temperature and moisture - External bleeding Interventions: - Direct pressure over uncontrolled bleeding sites - Insert 2 large caliber IV's with warmed isotonic crystalloid solution - Infuses fluid rapidly with blood tubing - Blood sampling for typing - Blood administration - Pericardiocentesis - Emergency thoracotomy - Surgery - Cardiopulmonary resuscitation and advanced life support measures

What is assessed in Disability? - ✔✔Assess: - AVPU (LOC) - Pupils (PERRL) Interventions: - Perform further investigation - Hyperventilation, if indicated

What is assessed in Trauma Mnemonic under "E?" - ✔✔EXPOSE PATIENT AND ENVIRONMENTAL CONTROL (remove clothing and keep patient warm) Assess: - Obvious wounds/Deformities - Temperature Control Interventions: - Remove clothing - Preserve clothing for evidence if indicated (don't cut through bullet wounds, use paper bags) - Cover with blankets - Warming lights - Increase ambient temperature

What is assessed in Trauma Mnemonic under "F?" - ✔✔FULL SET OF VS/FOCUSED ADJUNCTS/FACILITATE FAMILY PRESENCE Assess: - Obtain a complete set of vital signs - Consider the focused adjuncts - Cardiac Monitor - Pulse Oximeter - Urinary catheter if not contraindicated - Gastric tube - Laboratory studies

- Facilitate family presence

What is assessed in Trauma Mnemonic under "G?" - ✔✔- Assesses pain using an appropriate pain scale - Verbal reassurance - Initiates a nonpharmacologic pain intervention - Considers obtaining order for pain medication

What is assessed for History? - ✔✔- MIVT - Patient-generated information - PMH

What is assessed under Head-to-toe assessment? - ✔✔HEAD AND FACE - Inspect for wounds, ecchymosis, deformities, drainage from nose and ears, and check pupils - Palpate for tenderness, note bony crepitus, deformity NECK - Remove anterior portion of the rigid cervical collar to inspect and palpate the neck - Another team member must hold the pt's head while the collar is being removed and replaced - Inspect for wounds, ecchymosis, deformities, and distended neck veins - Palpate for tenderness, note bony crepitus, deformity, subcutaneous emphysema, and tracheal postion CHEST - Inspect for breathing rate and depth, wounds, deformities, ecchymosis, use of accessory muscles, paradoxical movement - Auscultate breath sounds and heart sounds - Palpate for tenderness, note bony crepitus, subcutaneous emphysema, and deformity ABDOMEN AND FLANKS - Inspect for wounds, distention, ecchymosis, and scars - Auscultate bowel sounds - Palpate all four quadrants for tenderness, rigidity, guarding, masses, and femoral pulses

PELVIS AND PERINEUM - Inspect for wounds, deformities, ecchymosis, priapism, blood at the urinary meatus or in the perineal area - Palpate the pelvis and anal sphincter tone EXTREMITIES - Inspect for ecchymosis, movement, wounds, and deformities - Palpate for pulses, skin temperature, sensation, tenderness, deformities, and note bony crepitus

How do you Inspect Posterior Services? - ✔✔- Maintain cervical spine protection and support injured extremities while the pt is log-rolled.

- Inspect the posterior surfaces for wounds, deformities, and ecchymosis - Palpate the posterior surfaces for tenderness and deformities - Palpate anal sphincter tone (if not performed previously)

Planning and Implementation in General: - ✔✔Studies: - Laboratory Studies - T&S or crossmatch - H&H - ETOH - Serum lactate level - Serum pregnancy test as indicated - Kleihauer-Betke test as indicated - ABG's Interventions: - OR intervention - Admission or Transfer - GCS and Revised Trauma Score - Psychosocial support of pt and family - Pain control

- Nonpharmacological pain intervention - Meds as indicated: - Tetanus prophylaxis - Antibiotics - Pain meds - Neuromuscular blockers - Sedation

Planning and Implementation for Head and Face: - ✔✔Studies: - Plain X-ray's - CT scan - MRI's - Angiography Interventions: - Position pt - Meds, as prescribed - ICP monitoring - Suctioning

Planning and Implementation for the Neck: - ✔✔Studies: - Plain X-ray's - CT scan - MRI's - Angiography Interventions: - Spinal protection with vertebral column immobilization - Steroids, per institutional protocols

Planning and Implementation for the Chest: - ✔✔Studies:

- Plain X-ray's - CT scan - MRI - Arteriography or aortography - Focused assessment sonography for trauma (FAST) - Bronchoscopy - Esophagoscopy - EKG - Hemodynamic monitoring Interventions: - Chest tube - Autotransfusion - Needle thoracentesis/decompression - Pericardiocentesis - Prepare for possible thoracotomy

Planning and Implementation for Abdomen and Flanks: - ✔✔Studies: - Plain X-rays - CT scan - MRI - FAST - IVP - DPL - Cystogram or urethrogram - Angiography Interventions: - Foley - Gastric tube - Consider pelvic antishock garment for intraabdominal or pelvic bleeding

Planning and Implementation for Pelvis and Perineum: - ✔✔Studies: - Plain X-rays - CT scan - MRI - FAST Interventions: - Foley - Pneumatic antishock garment for splinting - External pelvic stabilization device

Planning and Implementation for Extremities: - ✔✔Studies: - X-rays - CT scan - MRI - Measurement of compartment pressures Interventions: - Immobilization/traction devices - Elevation - Ice

Planning and Implementation for Posterior Services: - ✔✔Studies: - X-rays - CT scan - MRI Interventions: - Spinal protection with vertebral column immobilization

Planning and Implementation for Surface Trauma: - ✔✔Interventions: - Irrigation - Wound care - Ice - Care for amputated parts - Tetanus prophylaxis - Antibiotics

TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition 2022 Solution Guide 415 Questions with 100% Correct Answers Expedite transfer to the closest trauma center- 👈👈Correct Answer - A 56 y/o M pt involved in a motor vehicle crash is brought to the ED of a rural critical access facility. He complains of neck pain, 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 priority intervention for this patient?

a pertinent medical hx is crucial- 👈👈Correct Answer - Which of the following considerations is the most important when caring for a geriatric trauma pt?

Mitigation- 👈👈Correct Answer - Following a review of recent drills and a real disaster event, a hospital has identified deficiencies and is taking steps to minimize the impact of a future disaster . Which phase of the disaster life cycle does this describe?

Multiple requests for water- 👈👈Correct Answer - EMS brings a pt who fell while riding his bicycle.

Using the American College of Surgeobs screening guidelines, which assessment finding would prompt the RN to prepare the pt for a radiologic spine clearance?

hemoglobin does not readily release O2 for use by the tissues- 👈👈Correct Answer - What is the effect of hypothermia on the oxyhemoglobin dissociation curve?

acidosis- 👈👈Correct Answer - Which of the following is a component of the trauma triad of death?

Complete- 👈👈Correct Answer - EMS brings a pt from MVC. VS: BP 90/49, HR 48, RR 12, temp 97.2F (36.2 C). The pt exhibits urinary incontinence and priapism. These assessment findings are most consistent with which of the following types of spinal cord injury?

flucuation in the water seal chamber- 👈👈Correct Answer - Which of the following is an expected finding in a pt with a tube thoracstomy connected to a chest drainage system?

insert an oropharyngeal airway if there is no gag reflex- 👈👈Correct Answer - During the primary survey of an unconscious pt with multi-system trauma, the nurse notes snoring respirations. What priority nursing interventions should be preformed next?

globe rupture- 👈👈Correct Answer - A 35 y/o M presents with facial trauma after being struck in the face with a baseball. A teardrop-shaped left pupil is noted on exam. What type of injury is suspected?

compensated- 👈👈Correct Answer - A trauma pt is restless and repeatedly asking "where am i?" VS upon arrival: BP 110/60, HR96, RR 24. Her skin is cool and dry. Current VS are BP 104/84, HR 108, RR 28.

The pt is demonstrating s/sx of which stage of shock?

ventilate with a bag mask device- 👈👈Correct Answer - An unresponsive trauma pt has an oropharygeal airway in place, shallow and labored respirations, and dusky skin. The trauma team has administered medications for drug-assisted intubation and attempted intubation but was unsuccessful.

What is the most appropriate immediate next step?

within 24 hrs of trauma- 👈👈Correct Answer - When is the tertiary survey completed fora trauma pt?

pressure- 👈👈Correct Answer - An intubated and sedated pt in the ED has multiple extremity injuries with the potential for causing compartment syndrome. What is the most reliable indication of compartment syndrome in a patient who is unconscious?

worsening pneumothorax- 👈👈Correct Answer - Which of the following is possible complication of positive-pressure ventilation?

pelvic stability- 👈👈Correct Answer - the most reassuring finding for a male pt with hip pain after a fall is which of the following?

narrowed- 👈👈Correct Answer - Which of the following pulse pressures indicate early hypovolemic shock?

dysrhythmias- 👈👈Correct Answer - Patients with a crush injury should be monitored for which of the following conditions?

subdural hematoma- 👈👈Correct Answer - Tearing of the bridging veins is most frequently associated with which brain injury?

straight cath for urine sample- 👈👈Correct Answer - A 20 y/o M presents to the ED complaining of severe lower abd pain after landing hard on the bicycle cross bars while preforming an aerial BMX maneuver. Secondary assessment reveals lower abd tenderness and scrotal ecchymosis. Which of the following orders would the RN question?

placental abruption- 👈👈Correct Answer - You are caring for a pt who was involved in a MVC and is 32 weeks pregnant. Findings of your secondary survey include abd pain on palpation, fundal ht at the costal margin, and some dark bloody show. Varying accelerations and decelerations are noted on cariocgraphy. These findings are most consistent with which of the following?

it can worsen cord damage from an unstable spinal injury- 👈👈Correct Answer - Which of the following is true about the log-roll?

defusings- 👈👈Correct Answer - All of these are considered a critical communication point in trauma care EXCEPT which of the following?

pulse oximetry and capnography- 👈👈Correct Answer - What bedside monitoring parameters are used to assess for adequacy of O2 and effectiveness of ventilation?

padding the upper back while stabilizing the cervical spine- 👈👈Correct Answer - Caregivers carry in a 2 y/o into the ED who fell out of a second-story window. The pt is awake and crying with increased work of breathing and pale skin. Which of the following interventions has the highest priority?

bowel- 👈👈Correct Answer - Which of the following injuries is LEAST likely to be promptly identified?

Initiate transfer to a trauma center- 👈👈Correct Answer - A pt is brought to the ED of a rural hospital following a high-speed MVC. When significant abd and pelvic injuries are noted in the primary survey, which of the following is the priority interventions?

bardycardia and absent motor function below the level of injury- 👈👈Correct Answer - A pt with a complete spinal cord injury in neurogenic shock will demonstrate hypotension and which other clinical signs?

apply splint and elevate above the level of the heart- 👈👈Correct Answer - a 37 y/o F has a deformity of the L wrist after a fall. She is reluctant to move her hand due to pain. Which of the following is the most appropriate intervention?

the aorta is torn at its attachment with the ligamentum arteriosum- 👈👈Correct Answer - which of the following occurs during the third impact of a motor vehicle crash?

Report your suspicion of maltreatment in accordance with local regulations- 👈👈Correct Answer - a 5 y/o child presents to the ED with bruises to the upper arm and buttocks in various stages of healing and multiple small, clean, round burns to the back. There are no abnormalities found based on the pediatric assessment triangle or primary survey. Which of the following is the priority survey. Which of the following is the priority nursing intervention?

to guage end-organ perfusion and tissue hypoxia- 👈👈Correct Answer - Why is a measure of serum lactate obtained in the initial assessment of a trauma patient?

elevating the extremity to the level of the heart- 👈👈Correct Answer - A pt with a lower extremity fracture complains of severe pain and tightness in his calf, minimally by pain medications. Which of the following is the priority nursing intervention?

velocity- 👈👈Correct Answer - What factor contributes most to the kinetic energy of a body in motion?

subdural hematoma- 👈👈Correct Answer - An elderly patient with a history of anticoagulant use presents after a fall at home today. She denies any loss of consciousness. She has a hematoma to her forehead and complains of headache, dizziness, and nausea. What is the most likely cause of her symptoms?

fat embolism- 👈👈Correct Answer - a pt has been in the ED for several hrs waiting to be admitted. He sustained 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 anxious and confused. Upon

reassessment, the pt is restless with respiratory distress and petechiae to his neck. The pt is exhibiting s/sx most commonly associated with which of the following conditions?

nausea and vomiting- 👈👈Correct Answer - Which of the following is a late sign of increased intracranial pressure?

serial FAST exams- 👈👈Correct Answer - a 49 y/o restrained driver involved in a MVC presents to the trauma center complaining of abd, pelvic, and bilateral lower extremity pain. VS are stable. The nurse can anticipate all of these after a negative FAST exam EXCEPT which of the following?

pericardiocentesis- 👈👈Correct Answer - Which of the following is NOT considered goal-directed therapy for cardiogenic shock?

endotracheal tube- 👈👈Correct Answer - The trauma nurse knows that placing a bariatric patient in a ramped position providers better visualization during the insertion of which device?

increased work of breathing?- 👈👈Correct Answer - which of the following assessment findings differentiates a tension pneumothorax from a simple pneumothorax?

calcium- 👈👈Correct Answer - if a pt has received multiple transfusions of banked blood preserved with citrate, which electrolyte is most likely to drop and require supplementation?

identifying individuals who made mistakes during the traumatic event- 👈👈Correct Answer - Which of the following is NOT considered a benefit of debriefings?

500 mL/hr- 👈👈Correct Answer - You are treating a 27 y/o M in respiratory distress who was involved in a house fire. Calculating TBSA burned is deferred due to the need for emergent intubation. At what rate should you begin fluid resuscitation?

advanced age- 👈👈Correct Answer - Which of the following is most likely to contribute to inadequate oxygenation and ventilation?

a 52 y/o diabetic male with a partial thickness burn to the left lower leg- 👈👈Correct Answer - Which of the following patients warrants referral to a burn center?

dressing removal- 👈👈Correct Answer - A patient arrives with a large open chest wound after being assaulted with a machete. Prehospital providers placed a nonporous dressing over the chest wound and taped it on three sides. he is now showing signs of anxiety, restlessness, severe respiratory distress, cyanosis and decreasing blood pressure. Which of the following is the MOST appropriate immediate intervention?

after a physical examination if the pt has no radiologic abnormalities on CT- 👈👈Correct Answer - EMS arrives with the intoxicated driver of a car involved in a MVC. EMS reports significant damage to the drivers side of the car. The pt is asking to have the cervical collar removed. When it is appropriate to remove the cervical collar?

MARCH- 👈👈Correct Answer - Which of the following mnemonics can help the nurse prioritize care for a trauma patient with massive uncontrolled hemorrhage?

What is kinematics?- 👈👈Correct Answer - A branch of mechanics (energy transfer) that refers to motion and does not consider the concepts of force and mass of the object or body.

What is Newton's First Law?- 👈👈Correct Answer - A body at rest will remain at rest. A body in motion will remain in motion until acted on by an outside force.

What is the Law of Conservation of Energy?- 👈👈Correct Answer - Energy can neither be created nor destroyed. It is only changed from one form to another.

What is Newton's Second Law?- 👈👈Correct Answer - Force equals mass multiplied by acceleration of deceleration.

What is kinetic energy (KE)?- 👈👈Correct Answer - KE equals 1/2 the mass (M) multiplied by the velocity squared.

What is the Mnemonic for the Initial Assessment?- 👈👈Correct Answer - A = Airway with simultaneous cervical spine protection B = Breathing C = Circulation D = Disability (neurologic status) E = Expose/Environmental controls (remove clothing and keep the patient warm)

What is the Mnemonic for the Secondary Assessment?- 👈👈Correct Answer - F = Full set of VS/Focused adjuncts (includes cardiac monitor, urinary catheter, and gastric tube)/Family presence G = Give comfort measures (verbal reassurance, touch, and pharmacologic and nonpharmacologic management of pain).

H = Hx and Head-to-toe assessment I = Inspect posterior surfaces

Where do you listen to auscultate breath sounds?- 👈👈Correct Answer - Auscultate the lungs bilaterally at the second intercostal space midclavicular line and at the fifth intercostal space at the anterior axillary line.

What are the late signs of breathing compromise?- 👈👈Correct Answer - - Tracheal deviation - JVD

What are signs of ineffective breathing?- 👈👈Correct Answer - - AMS - Cyanosis, especially around the mouth - Asymmetric expansion of chest wall - Paradoxical movement of the chest wall during inspiration and expiration - Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing - Sucking chest wounds - Absent or diminished breath sounds - Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated - Anticipate definitive airway management to support ventilation.

Upon initial assessment, what type of oxygen should be used for a pt breathing effectively?👈👈Correct Answer - A tight-fitting nonrebreather mask at 12-15 lpm.

What intervention should be done if a pt presents with effective circulation?- 👈👈Correct Answer - Insert 2 large caliber IV's - Administer warmed isotonic crystalloid solution at an appropriate rate

What are signs of ineffective circulation?- 👈👈Correct Answer - - Tachycardia - AMS - Uncontrolled external bleeding - Pale, cool, moist skin - Distended or abnormally flattened external jugular veins - Distant heart sounds

What are the interventions for Effective/Ineffective Circulation?- 👈👈Correct Answer - - Control any uncontrolled external bleeding by: - Applying direct pressure over bleeding site - Elevating bleeding extremity - Applying pressure over arterial pressure points - Using tourniquet (last resort).

- Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution - Use warmed solution - Use pressure bags to increase speed of IVF infusion - Use blood administration tubing for possible administration of blood - Use rapid infusion device based on protocol - Use NS 0.9% in same tubing as blood product - IV = surgical cut-down, central line, or both.

- Blood sample to determine ABO and Rh group - IO in sternum, legs, arms or pelvis

- Administer blood products - PASG (without interfering with fluid resuscitation)

How do you assess Mnemonic "D"?- 👈👈Correct Answer - DISABILITY A = Alert V = Verbal P = Pain U = Unresponsive - GCS - PERRL? - Determine presence of lateralizing signs including: - Unilateral deterioration in motor movements or unequal pupils - Symptoms that help to locate area of injury in brain

What are the interventions for Disability?- 👈👈Correct Answer - - If assessment indicates a decreased LOC, conduct further investigation during secondary focused assessments - If pt is not alert or verbal, continue to monitor for any compromise to ABC's - If pt demonstrates signs of herniation or neurologic deterioration, consider hyperventilation.

What is assessed and intervened for Expose/Environmental Controls?- 👈👈Correct Answer - - Remove clothing - Ensure appropriate decontamination if exposed to hazardous material - Keep pt warm - Keep clothing for evidence

What is the first thing assessed under the Secondary Assessment?- 👈👈Correct Answer - FULL SET VS / FOCUSED ADJUNCTS / FAMILY PRESENCE - ABCDE should be completed - Labs, X-rays, CT, Foley, - Family Presence

What is the second thing assessed under the Secondary Assessment?- 👈👈Correct Answer - GIVE COMFORT MEASURES - Talking to pt - Pharmacologic/Nonpharmacologic pain management - Observe for physical signs of pain

What is assessed under the Mnemonic "H"?- 👈👈Correct Answer - HISTORY / HEAD-TO-TOE ASSESSMENT - MIVT - M = Mechanism of injury - I = Injuries sustained - V = Vital Signs - T = Treatment - Pt generated information - PMH - Head-to-toe assessment

What is assessed under the Mnemonic "I"?- 👈👈Correct Answer - INSPECT POSTERIOR SURFACES - While maintaining C-spine, logroll pt with assistance to inspect back, flanks, buttocks and posterior thighs.

- Palpate vertebral column for deformity and areas of tenderness - Assess rectum for presence/absence of tone, presence of blood

What she be done after the Secondary Assessment?- 👈👈Correct Answer - Reassess: - Primary survey, - VS - Pain - Any injuries

What are factors that contribute to ineffective ventilation?- 👈👈Correct Answer - - AMS - LOC - Neurologic injury - Spinal Cord Injury - Intracranial Injury - Blunt trauma - Pain caused by rib fractures - Penetrating Trauma - Preexisting hx of respiratory diseases - Increased age

What medications are used during intubation?- 👈👈Correct Answer - LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents

What are the Rapid Sequence Intubation Steps?- 👈👈Correct Answer - PREPARATION: - gather equipment, staffing, etc.

PREOXYGENATION: - Use 100% O2 (prevent risk of aspiration).

PRETREATMENT: - Decrease S/E's of intubation PARALYSIS WITH INDUCTION: - Pt has LOC, then administer neuromuscular blocking agent PROTECTION AND POSITIONING: - Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration PLACEMENT WITH PROOF

- Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30-60 seconds between attempts.

- After intubation, inflate the cuff - Confirm tube placement w/exhaled CO2 detector.

POSTINTUBATION MANAGEMENT: - Secure ET tube - Set ventilator settings - Obtain Chest x-ray - Continue to medicate - Recheck VS and pulse oxtimetry

What is a Combitube?- 👈👈Correct Answer - A dual-lumen, dual-cuff airway that can be placed blindly into the esophagus to establish an airway. If inadvertently placed into trachea, it can be used as a temporary ET tube. There are only two sizes: small adult and larger adult.

What is a Laryngeal Mask Airway?- 👈👈Correct Answer - Looks like an ET tube but is equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to cover the supraglottic area.

ILMA, does not require laryngoscopy and visualization of the chords.

What is Needle Cricothyrotomy- 👈👈Correct Answer - Percutaneous transtracheal ventilation. (temporary)

Complications include: - inadequate ventilation causing hypoxia - hematoma formation - esophageal perforation - aspiration - thyroid perforation - subcutaneous emphysema

What is Surgical Cricothyrotomy?- 👈👈Correct Answer - Making an incision in cricothyroid membrane and placing a cuffed endo or trach tube into trachea. This is indicated when other methods of airway management have failed and pt cannot be adequately ventilated and oxygenated.

Complications include: - Aspiration - Hemorrhage or hematoma formation or both - Lac to trachea or esophagus - Creation of a false passage - Laryngeal stenosis

How do you confirm ET Tube/Alternative Airway Placement?- 👈👈Correct Answer - - Visualization of the chords - Using bronchoscope to confirm placement - Listening to breath sounds over the epigastrum and chest walls while ventilating the pt - CO2 detector - Esophageal detection device - Chest x-ray

How do you inspect the chest for adequate ventilation?- 👈👈Correct Answer - Observe: - mental status - RR and pattern - chest wall symmetry - any injuries - patient's skin color (cyanosis?)

- JVD or tracheal deviation? (Tension pneumothorax)

What are you looking for when auscultating lung sounds?- 👈👈Correct Answer - Absence of BS: - Pneumothorax

- Hemothorax - Airway Obstruction Diminished BS: - Splinting or shallow BS may be a result of pain

What are you looking for when percussing the chest?- 👈👈Correct Answer - Dullness: - hemothorax Hyperresonance - Pneumothorax

What are you looking for when palpating the chest wall, clavicles and neck?- 👈👈Correct Answer - Tenderness - Swelling - subcutaneous emphysema - step-off deformities = These may indicate: esophageal, pleural, tracheal or bronchial injuries.

Palpate trachea above suprasternal notch. Tracheal deviation may indicate a tension pneumothorax or massive hemothorax.

What is the DOPE mnemonic?- 👈👈Correct Answer - D - Displaced tube O - Obstruction: Check secretions or pt biting tube P - Pneumothorax: Condition may occur from original trauma or barotrauma from ventilator E - Equipment failure: pt may have become detached from equipment or there's a kink in the tubing

Explain Hypovolemic Shock.- 👈👈Correct Answer - Most common to affect a trauma pt cause by hypovolemia.. Hypovolemia, a decrease in amount of circulating blood volume, may result from significant loss of whole blood because of hemorrhage or from loss of semipermeable integrity of cellular membrane leading to leakage of plasma and protein from intravascular space to the interstitial space (as in a burn).

Some causes:

- Blood loss - Burns, etc.

Explain Cardiogenic Shock.- 👈👈Correct Answer - Syndrome that results from ineffective perfusion caused by ineffective perfusion caused by inadequate contractility of cardiac muscle.

Some causes: - MI - Blunt cardiac injury - Mitral valve insufficiency - dysrhythmias - Cardiac Failure

Explain Obstructive Shock.- 👈👈Correct Answer - Results from inadequate circulating blood volume because of an obstruction or compression of great veins, aorta, pulmonary arteries, or heart itself.

Some causes: - Cardiac tamponade (may compress the heart during diastole to such and extent that atria cannot adequately fill, leading to decreased stroke volume).

- Tension pneumothorax may lead to inadequate stroke volume by displacing inferior vena cava and obstructing venous return to right atrium.

- Air embolus may lead to obstruction of pulmonary artery and subsequent obstruction to right ventricular outflow during systole, with resulting obstructive shock

Explain Distributive Shock.- 👈👈Correct Answer - Results from disruption in SNS control of the tone of blood vessels, which leads to vasodilation and maldistribution of blood volume and flow. (Neurogenic and Septic Shock). Neurogenic shock may result from injury to spinal cord in cervical or upper thoracic region.

Spinal shock = areflexia and flaccidity associated with lower motor neuron involvement in complete cord injuries; reflexes return with resolution of spinal shock.

Septic shock from bacteremia is distributive shock. Endotoxins and other inflammatory mediators cause vasodilation, shunting of blood in microcirculation, and other perfusion abnormalities.

What is vascular response?- 👈👈Correct Answer - As blood volume decreases, peripheral blood vessels vasoconstrict as a result of sympathetic stimulation via inhibition of baroreceptors. Arterioles constrict to increase TPR and BP.

What is renal response?- 👈👈Correct Answer - Renal ischemia activates release of renin.

Kidneys do not receive adequate blood supply, renin is release into circulation.

Renin causes angiotensinogen, normal plasma protein, to release angiotensin I.

Angiotensin-converting enzyme from the lungs converts into angiotensin II.

Angiotensin II causes: - Vasoconstriction of arterioles and some veins - Stimulation of sympathetic nervous system - Retention of water by kidneys - Stimulation of release of aldosterone from the adrenal cortex (sodium retention hormone)

*Decreased urinary output = early sign renal hypoperfusion and an indicator that there's systemic hypoperfusion.

Explain adrenal gland response.- 👈👈Correct Answer - When adrenal glands are stimulated by SNS, release of catecholamines (epinephrine and norepinephrine) from adrenal medulla will increase.

Epi stimulates receptors in heart to increase force of cardiac contraction (positive inotropy) and increase HR (positive chronotropy) to improve cardiac output, BP and tissue perfusion.

Shock stimulates hypothalamus to release corticotropin-releasing hormone that stimulates pituitary to release ACTH that stimulates adrenal gland to release cortisol.

Effect of cortisol release is elevation in blood sugar and increased insulin resistance and gluconeogenesis, hepatic process to produce more sugar.

Cortisol also causes renal retention of water and sodium, a compensatory mechanism to conserve body water.

Explain Hepatic Response.- 👈👈Correct Answer - Liver can store excess glucose as glycogen.

As shock progresses, glycogenolysis is activated by epi to break down glycogen into glucose.

In a compensatory response to shock, hepatic vessels constrict to redirect blood flow to other vital areas.

Explain Pulmonary Response.- 👈👈Correct Answer - Tachypnea happens for 2 reasons: 1. Maintain acid-base balance 2. Maintain increased supply of oxygen

* Metabolic acidosis from anaerobic metabolism will be a stimulus for the lungs to increase rate of ventilation. Increased RR is an attempt to correct acidosis + augments oxygen supply to maximize oxygen delivery to alveoli.

Explain Irreversible Shock.- 👈👈Correct Answer - Shock uncompensated or irreversible stages will cause compromises to most body systems.

- Inadequate venous return - inadequate cardiac filling - decreased coronary artery perfusion - Membranes of lysosomes breakdown within cells and release digestive enzymes that cause intracellular damage.

How would you assess someone in hypovolemic shock?- 👈👈Correct Answer - (Use Initial Assessment) and then: Inspect: - LOC - Rate and quality of respirations - External bleeding?

- Skin color and moisture - Assess jugular veins and peripheral veins Auscultate: - BP - Pulse pressure - Breath sounds - Heart sounds - Bowel sounds Percuss: - Chest and abdomen Palpate: - Central pulse (carotid or femoral) - Positive inotropic effect (force of contraction) may be evidence by a bounding central pulse - Palpate peripheral pulses - Palpate skin temp and moisture Diagnostic Procedures: - Xrays and other studies - Labs Planning and Implementation - Oxygen - IV's with warmed replacement fluids - Control external bleeding with direct pressure

- Elevate LE's - NGT - Foley - Monitor and pulse oximeter - Monitor for development of coagulopathies - Surgery?

ICP is a reflection of what three volumes? What happens when one increases?- 👈👈Correct Answer - 1.

Brain 2. CSF 3. Blood within the nonexpansible cranial vault

As volume of one increases, the volume of another decreases to maintain ICP within normal range.

As ICP rises, CPP decreases, leading to cerebral ischemia and potential for hypoxia and lethal secondary insult. Hypotensive pt w/marginally elevated ICP can be harmful.

Slightly elevated BP could protect against brain ischemia in a pt with high ICP. Cerebral ischemia can lead to increased concentration of CO2 and decreased concentration of O2 in cerebral vessels. CO2 dilates cerebral blood vessels = increase blood volume and ICP.

What are the early signs and symptoms of increased ICP?- 👈👈Correct Answer - - Headache - N/V - Amnesia regarding events around the injury - Altered LOC - Restlessness, drowsiness, changes in speech, or loss of judgement

What are the late observable signs of symptoms of increased ICP?- 👈👈Correct Answer - - Dilated, nonreactive pupil - Unresponsiveness to verbal or painful stimuli

- Abnormal motor posturing patterns - Widening pulse pressure - Increased systolic blood pressure - Changes in RR and pattern - Bradycardia

What is Cushing's phenomenon or Cushing's Reflex?- 👈👈Correct Answer - Triad of progressive HTN, bradycardia and diminished respiratory effort.

What are the two types of herniation that occurs with ICP?- 👈👈Correct Answer - 1. Uncal herniation 2. Central or transtentorial herniation

Why does herniation occur? What are the symptoms?- 👈👈Correct Answer - Because of uncontrolled increases in ICP.

S/E's - Unilateral or bilateral pupillary dilation - AsyDimmetric pupillary reactivity - Abnormal motor posturing - Other evidence of neurologic deterioration

Define uncal herniation.- 👈👈Correct Answer - The uncus (medial aspect of the temporal lobe) is displaced over the tentorium into the posterior fossa. This herniation is the more common of the two types of herniation syndromes.

Define central or transtentorial herniation.- 👈👈Correct Answer - A downward movement of the cerebral hemispheres with herniation of the diencephalon and midbrain through the elongated gap of the tentorium.

Disruptions of the bony structures of the skull can result in what?- 👈👈Correct Answer - Displaced or nondisplaced fx's causing CSF leakage b/c of lac to the dura mater, creating a passage for CSF.

CSF leaks through the nose (rhinorrhea) or the ears (otorrhea). A potential entrance for invading bacteria.

Also: meningitis or encephalitis or brain abscess

Define Minor Head Trauma.- 👈👈Correct Answer - GCS 13-15

Define Moderate Head Trauma- 👈👈Correct Answer - Postresuscitative state with GCS 9-13.

Define Severe Head Trauma.- 👈👈Correct Answer - Postresuscitative state with GCS score of 8 or less.

What is a concussion and its signs and symptoms?- 👈👈Correct Answer - A temporary change in neurologic function that may occur as a result of minor head trauma.

S/S: - Transient LOC - H/A - Confusion and disorientation - Dizziness - N/V - Loss of memory - Difficulty with concentration - Irritability - Fatigue

What are the signs and symptoms of postconcussive syndrome?- 👈👈Correct Answer - - Persistent H/A - Dizziness - Nausea - Memory impairment - Attention deficit

- Irritability - Insomnia - Impaired judgement - Loss of libido - Anxiety - Depression

What is diffuse axonal injury and its signs and symptoms?- 👈👈Correct Answer - (DAI) is widespread, rather than localized, through the brain. Diffuse shearing, tearing and compressive stresses from rotational or accerleration/deceleration forces resulting in microscopic damage primarily to axons within the brain.

S/S: - Immediate unconsciousness - mild DAI, coma = 6-24 hrs - severe DAI, coma = weeks/months or persistent vegetative state - Elevated ICP - Abnormal posturing - HTN - Hyperthermia - Excessive sweating because of autonomic dysfunction - Mild to severe memory impairment, cognitive, behavioral, and intellectual deficits

What is a cerebral contusion and its S/S?- 👈👈Correct Answer - A common focal brain injury in which brain tissue is bruised and damaged in a local area. Mainly located in frontal and temporal lobes. May cause hemorrhage, infarction, necrosis and edema. Max effects of bleeding & edema peak 18-36 post injury.

S/S: - Alteration in LOC - Behavior, motor or speech deficits - Abnormal motor posturing - Signs of increased ICP

What is an epidural hematoma and its S/S?- 👈👈Correct Answer - Results when a collection of blood forms between the skull and the dura mater. Bleeding is arterial=blood accumulates rapidly: - Compression of underlying brain - rapid increase in ICP - Decreased CBF - Secondary brain injury * Usually requires surgical intervention S/S: - Transient LOC - Lucid period lasting a few minutes to several hours - Rapid deterioration in neurologic status - Severe H/A - Sleepiness - Dizziness - N/V - Hemiparesis or hemiplegia on opposite side of hematoma - Unilateral fixed and dilated pupil on same side of hematoma

What is a subdural hematoma and its S/S?- 👈👈Correct Answer - A focal brain injury beneath the dura mater that results from acceleration/deceleration. Usually venous, and not necessarily from a fx.

Formation may be acute or chronic.

Acute pt's hematoma manifest 48 hrs post injury S/S: - Altered LOC or steady decline in LOC - S/S of increased ICP - Hemiparesis or hemiplegia on opposite side of hematoma - Unilateral fixed and dilated pupil on same side of hematoma

Chronic pt's " " up to 2 wks post injury - H/A - Progressive decrease in LOC - Ataxia - Incontinence - Sz's

What are intracerebral hematoma's and its S/S?- 👈👈Correct Answer - Occur deep within brain tissue, may be single or multiple and commonly associated with contusions (frontal & temporal lobes). They result in significant mass effect, leading to increased ICP and neurologic deterioration.

S/S: - Progressive and often rapid decline in LOC - H/A - Signs of increasing ICP - Pupil abnormalities - Contralateral hemiplegia

What are the S/S of a linear skull fx?- 👈👈Correct Answer - - H/A - Possible decreased LOC

What are the S/S of a depressed skull fx?- 👈👈Correct Answer - - H/A - Possible decreased LOC - Possible open fx - Palpable depression of skull over the fx site

What are the S/S of a basilar skull fx?- 👈👈Correct Answer - - H/A - Altered LOC - Periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle's sign), or blood behind tympanic membrane (hemotympanum) - Facial nerve (VII) palsy

- CSF rhinorrhea or otorrhea

How would you assess a pt with a cranial injury?- 👈👈Correct Answer - (Initial assessment) INSPECTION: - Assess airway - RR, pattern and effort - Assess pupil size and response to light - Unilateral fixed and dilated pupil = oculomotor nerve compression from increased ICP + herniation syndrome - Bilateral fixed and pinpoint pupils indicate a pontine lesion or effects of opiates - Mildly dilated pupil w/sluggish response may be early sign of herniation syndrome - Widely dilated pupil occasionally occurs w/direct trauma to globe of eye - Determine if pt uses eye meds - Abnormal posturing?

- Inspect craniofacial area for ecchymosis/contusions - Periorbital ecchymosis - Mastoid's process ecchymosis - Blood behind tympanic membrane - Inspect nose and ears for drainage - Drng present w/out blood, test drng w/chemical reagant strip. Presence of glucose indicated drng of CSF - If drng present and mixed with blood, test by placing drop of fluid on linen or gauze. If a light outer ring forms around dark inner ring, drng contains CSF - Assess extraocular eye movement (Tests cranial nerves, III, IV, VI) - Performing extraocular eye movements indicates functioning brainstem - Limitation indicates orbital rim fx w/entrapment or paralysis of either a cranial nerve or ocular muscle - Determine LOC with GCS PALPATION - Palpate cranial area for: - Point tenderness

- Depressions or deformities - Hematomas - Assess all 4 extremities for: - Motor function, muscle strength and abnormal motor posturing - Sensory function DIAGNOSTIC PROCEDURES - Lab Studies PLANNING AND IMPLEMENTATION - (Initial assessment) - Clear airway (stimulation of gag reflex can produce transient increase in ICP or vomiting with subsequent aspiration.

- Administer O2 via NRB - Assist with early ET intubation - Administer sedative/neuromuscular blocking agent - Consider hyperventilation - PaCO2 above 45 mm Hg may cause increased cerebral vasodilation, increased CBF, increased ICP. - Prolonged hyperventilation NOT RECOMMENDED. - Hypocarbia occurs as result of hyperventilation causes cerebral vasoconstriction, decreased CBF, decreased ICP. And ischemia secondary to severe vasoconstriction.

- Hyperoxygenate pt with 100% O2 via bag-mask - Apply direct pressure to bleeding sites except depressed skull fractures - Cannulate 2 large IV's - Hypotension doubles pt's death rate (w/severe head trauma) - Vasopressors used to maintain CPP. - Insert OG or NGT. OG should be used with severe facial trauma.

- Position pt, elevate head to decrease ICP (but may also reduce CPP).

- Position head midline to facilitate venous drng. Rotate head to compress veins in neck and result in both venous engorgement and decreased drng from brain - Prepare for ICP monitoring device - Administer mannitol as prescribed.

- Mannitol, hyperosmolar, volume-depleting diuretic, decreases cerebral edema + ICP by pulling interstitial fluid into intravascular space for eventual excretion by kidneys.

- Administer anticonvulsant - Sx should be avoided b/c increases cerebral metabolic rate + ICP. Indications for sz prophylaxis: - Depressed skull fx - Sz at time of injury - Sz on arrival to ED - Hx of sz's - Penetrating brain injury - Acute subdural/epidural hematoma

- Administer antipyretic med/Cooling blanket - Hyperthermia may increase cerebral metabolic rate + ICP. Avoid causing shivering during cooling process; increases cerebral metabolic rate + may precipitate rise in ICP - Do not pack ears/nose if CSF leak suspected - Admin tetanus prophylaxis - Wound repair for facial/scalp Lac's - Admin other meds - Analgesics, sedatives, narcan, romazicon, etc.

- Admin antibiotics - Pt's w/basilar skull fx need prophylaxis against meningitis - Prepare pt for OR, hospital admin or transfer.

What are signs of a serious eye injury?- 👈👈Correct Answer - - Visual disturbances - Pain - Redness and ecchymosis of the eye - Periorbital ecchymosis - Increased intraocular pressure

What is hyphema and its S/S?- 👈👈Correct Answer - Accumulation of blood, mainly RBC's that disperse and layer within the anterior chamber. A severe hymphema obscures entire anterior chamber + will diminish visual acuity severely or completely. Injuries are graded on amount of blood in chamber (Grades I-IV).

S/S: - Blood in anterior chamber - Deep, aching pain - Mild to severe diminished visual acuity - Increased intraocular pressure

What are s/s of chemical burns to the eye?- 👈👈Correct Answer - Chemical injuries require immediate intervention if it is to be preserved.

S/S: - Pain - Corneal Opacification - Coexisting chemical burn and swelling of lids

What are S/S of penetrating trauma/open or ruptured globe?- 👈👈Correct Answer - - Marked visual impairments - Extrusion of intraocular contents - Flattened or shallow anterior chamber - Subconjunctival hemorrhage, hyphema - Decreased intraocular pressure - Restriction of extraocular movements

What are the S/S of orbital fracture (orbital blowout fracture)?- 👈👈Correct Answer - - Diplopia (double vision) - Loss of vision - Altered extraocular eye movements - Enophthalmos (displacement of the eye backward into the socket) - Subconjunctival hemorrhage or ecchymosis of the eyelid

- Infraorbital pain or loss of sensation - Orbital bony deformity

What is LeFort I fracture and its S/S?- 👈👈Correct Answer - Transverse maxillary fx that occurs above level of teeth and results in separation of teeth from rest of maxilla.

S/S: - Slight swelling of maxillary area - Possible lip lac's or fractured teeth - Independent movement of the maxilla from rest of face - Malocclusion

What is LeFort II fracture and its S/S?- 👈👈Correct Answer - Pyramidal maxillary fx=middle facial area.

Apex of fx transverses bridge of nose. Two lateral fx's of pyramid extend through the lacrimal bone of the face and ethmoid bone of skull into the median portion of both orbits. Base of the fx extends above level of the upper teeth into maxilla. CSF leak is possible.

S/S: - Massive facial edema - Nasal swelling w/obvious fx of nasal bones - Malocclusion - CSF rhinorrhea

What is LeFort III fracture and its S/S?- 👈👈Correct Answer - Complete craniofacial separation involving maxilla, zygoma and bones of cranial base. This fx is frequently associated w/leakage of CSF and fx mandible.

S/S: - Massive facial edema - Mobility and depression of zygomatic bones - Ecchymosis - Anesthesia of the cheek - Diplopia - Open bite or malocclusion

- CSF rhinorrhea

What are the mandibular fracture S/S?- 👈👈Correct Answer - - Malocclusion - Inability to open the mouth (trismus) - Pain, especially on movement - Facial asymmetry and a palpable step-off deformity - Edema or hematoma formation at the fracture site - Blood behind, ruptured, tympanic membrane - Anesthesia of the lower lip

What are neck injury S/S?- 👈👈Correct Answer - - Dyspnea - Hemoptysis (coughing up blood) - Subcutaneous emphysema in neck, face, or suprasternal area - Decreased or absent breath sounds - Penetrating wounds or impaled objects - Pulsatile or expanding hematoma - Loss of normal anatomic prominence of the laryngeal region - Bruits - Active external bleeding - Neurologic deficit, such as aphasia or hemiplegia - Cranial nerve deficits - Facial sensory or motor nerve deficits - Dysphonia (hoarseness) - Dysphagia (difficulty swallowing)

How would you assess a patient with ocular, maxillofacial and neck trauma?- 👈👈Correct Answer (Initial assessment) HISTORY - MOI?

- Acceleration/Deceleration?

- What was it caused by?

- Pt restrained? Airbags deployed? Etc. - What are the pt's complaints?

- Pt normally wear glasses or contacts?

- Pt have hx of eye problems?

- Pt ever have eye surgery?

- Pt have visual or ocular changes associated with chronic illness?

PHYSICAL INSPECTION: - Inspect eye, orbits, face and neck - Check for symmetry, edema, ecchymosis, ptosis, lacerations and hematomas - Inspect globe for lacerations, large corneal abrasions, hyphema, and extrusion or prolapse of intraocular contents - Determine whether lid lac's - Assess pupil's (PERRL) - Unilateral fixed and dilated pupil may indicate oculomotor nerve compression as a result of ICP + herniation syndrome - Bilateral fixed and pinpoint pupils = pontine lesion or drugs - Mildly dilated pupil w/sluggish response may early sign of herniation syndrome - Widely dilated pupil occasionally occurs w/direct trauma to globe of eye - Assess for consensual response - Assess redness, eye watering, blepharospasm - Assess extraocular movement, except when an open globe injury is known or suspected.

- Limitation range of ocular motion may indicate orbital rim fx w/entrapment or paralysis of cranial nerve or ocular muscle - Perform visual acuity exam - Use Snellen or handheld chart. Check uninjured eye first - Assess for blurred or double vision with injured eye and then with both eyes open - Inspect for rhinorrhea or otorrhea

- If drng present, may indicate CSF leak - Observe for impaled objects - Assess occlusion of mandible and maxilla - Malocclusion or inability to open + close mouth is highly indicative of maxillary or mandibular fx - Observe for uncontrolled bleeding PALPATION - Palpate periorbital area, face and neck for: - Tenderness - Edema - Step-off defects or depressions - Subcutaneous emphysema (esophageal or tracheal tear) - Palpate trachea above suprasternal notch - Trach deviation = late indication of tension pneumothorax or massive hemothorax - Assess sensory fx of perioribital areas, face and neck - Facial fx's can impinge on infraorbital nerve, causing numbness of inferior eyelid, lateral nose, cheek, or upper lip on affected side.

- Check position of trachea DIAGNOSTIC STUDIES: - Xrays, CT scans, MRI's - Fluorescein staining - Slit-lamp exam - tonometry (measures intraocular pressure) - Bronchoscopy or esophagoscopy

What are the nursing interventions for a pt with an ocular injury?- 👈👈Correct Answer - - Assess visual acuity & reassess - Elevate HOB to minimize intraocular pressure - Instruct pt not to bend forward, cough or perform Valsalva maneuver b/c these actions may raise intraocular pressure - Assist w/removal of foreign bodies as indicated; stabilize impaled objects

- Apply cool packs to decrease pain + periorbital swelling - Admin medications - Instill prescribed topical anesthetic drops for pain - Instill NS drops or artificial tears to keep corneas moist. Cover eyelids w/sterile, moist saline dsg to prevent drying and ulceration - Antibiotics topically or systemically - Admin tetanus prophylactically - Use an eye patch to affected eye - Patch or shield both eyes to reduce movement + photophobia in pt's w/retinal injuries - Patch, shield or cover w/cool pack - Do NOT patch injured eye of pt w/suspected open or ruptured globe or impaled object, patch unaffected eye. Use metal or plastic and do not put pressure on the globe.

- Provide psychosocial support - Obtain an ophthalmology consultation - Provide d/c instructions: - Importance of protective eyewear - No driving w/eye patch on - Wear sunglasses to prevent tearing, aid photophobia - Prepare for admission, OR or transfer

What are the nursing interventions for a patient with a maxillofacial or neck injury?- 👈👈Correct Answer - - Administer oxygen - For facial trauma, place pt in high-fowler's position if no spinal injury is present.

- Insert OG or NGT. OGT should be used if basilar skull fx or severe midface fx's are suspected - Monitor for progressive airway assessment - Prepare for intubation, PRN. - Cannulate 2 large IV's, initiate isotonic crystalloid IV solution - Control external bleeding w/direct pressure - Monitor for continued bleeding + expanding hematomas - Apply cold compresses to face to minimize edema

- Assist w/repair of oral lac's, PRN - Admin antibiotics - Stabilize impaled objects - Admin analgesic meds

With any eye injury, what should the evaluation and ongoing assessments be?- 👈👈Correct Answer - Reassessing visual acuity at reasonable intervals - Reassessing pain, including response to nonpharmacologic + pharmacologic interventions - Monitoring appearance, position, movements of globe and pupillary responses - Monitoring airway patency, respiratory effort and ABG's

What are the most common type of injury associated with chest trauma?- 👈👈Correct Answer - blunt; MVC's. Penetrating; firarm injuries or stabbings

What are S/S of a rib fracture?- 👈👈Correct Answer - - Dyspnea - Localized pain on movement, palpation, or inspiration - Pt assumes position intended to splint chest wall to reduce pain - Chest wall ecchymosis or sternal contusion - Bony crepitus or deformity

What is a flail chest?- 👈👈Correct Answer - A fracture of two or more sites on two or more adjacent ribs, or when rib fractures produce a free-floating sternum.

Flail segments may not be clinically evident in the first several hours after injury b/c of muscle spasms that cause splinting. After positive pressure intiated, paradoxical chest wall movement ceases.

What could a flail chest be associated with?- 👈👈Correct Answer - - Ineffective ventilation - Pulmonary contusion - Lacerated lung parenchyma

What are the S/S of flail chest?- 👈👈Correct Answer - - Dyspnea - Chest wall pain - Paradoxical chest wall movement - the flail segment moves in during inspiration and out during expiration.

Define Pneumothorax.- 👈👈Correct Answer - Results when an injury to lung leads to accumulation of air in pleural space w/subsequent loss of negative intrapleural pressure. Partial or total collapse of lung may ensue.

An open pneumothorax results from wound through chest wall. Air enters pleural space both through the wound and trachea.

What are the S/S of a pneumothorax?- 👈👈Correct Answer - - Dyspnea, tachypnea - Tachycardia - Hyerresonance (increased echo produced by percussion over the lung field) on the injured side - Decreased or absent breath sounds on the injured side - Chest pain - Open, sucking wound on inspiration (open pneumothorax)

Define tension pneumothorax.- 👈👈Correct Answer - Life-threatening injury. Air enters pleural space on inspiration, but air cannot escape on expiration. Rising intrathoracic pressure collapses lung on side of injury causing a mediastinal shift that compresses the heart, great vessels, trachea and uninjured lung. Venous return impeded, cardiac output falls, hypotension results.

Immediate decompression should be performed. Treatment should not be delayed.

What are the S/S of a tension pneumothorax?- 👈👈Correct Answer - - Severe respiratory distress - Markedly diminished or absent breath sounds on affected side - hypotension - Distended neck, head and upper extremity veins-may not be clinically appreciated if significant blood loss present

- Tracheal deviation - shift toward uninjured side (LATE sign) - Cyanosis (LATE sign)

Define Hemothorax.- 👈👈Correct Answer - Accumulation of blood in the pleural space.

What are the S/S of Hemothorax?- 👈👈Correct Answer - - Dyspnea, tachypnea - Chest pain - Signs of shock - Decreased breath sounds on injured side - Dullness to percussion on the injured side

What is a pulmonary contusion?- 👈👈Correct Answer - They occur as a result of direct impact, deceleration or high-velocity bullet wounds. It develops when blood leaks into lung parenchyma, causing edema + hemorrhage. This usually develops overtime and not immediately.

What are the S/S of pulmonary contusion?- 👈👈Correct Answer - - Dyspnea - Ineffective cough - Hemoptysis - Hypoxia - Chest pain - Chest wall contusion or abrasions

What happens to a ruptured diaphragm?- 👈👈Correct Answer - Potentially life-threatening, results from forces that penetrate the body. Left hemidiaphragm is more susceptible to injury because the right side is protected by the liver.

- Herniation of abdominal contents - Respiratory compromise b/c impaired lung capacity + displacement of normal tissue.

- Mediastinal structures may shift to opposite side of injury

What are S/S of a ruptured diaphragm?- 👈👈Correct Answer - (Anything below the nipple line and should be evaluated for potential diaphragmatic injury).

- Dyspnea or orthopnea - Dysphagia - Abdominal pain - Sharp epigastric or chest pain radiating to left shoulder (Kehr's sign) - Bowel sounds heard in lower middle chest - Decreased breath sounds on injured side

What are S/S with tracheobronchial injury?- 👈👈Correct Answer - Blunt trauma. "Clothesline-type" injuries.

- Dyspnea, tachypnea - Hoarseness - Hemoptysis - Subcutaneous emphysema in neck, face, or suprasternal area - Decreased or absent breath sounds - S/S of airway obstruction

What are S/S with blunt cardiac injury?- 👈👈Correct Answer - "Cardiac contusion" or "concussion."

Common with MVC or falls from heights.

- ECG (sinus tach, PVC's, AV blocks) - Chest pain - Chest wall ecchymosis

What are the S/S of pericardial tamponade?- 👈👈Correct Answer - A collection of blood in pericardial sac. As blood accumulates, it exerts pressure on the heart, inhibiting or compromising ventricular filling.

- Hyotension - Tachycardia or PEA - Dyspnea - Cyanosis

- Beck's Triad (hypotension, distended neck veins + muffled heart sounds) - Progressive decreased voltage of conduction complexes on ECG

What are aortic injuries S/S?- 👈👈Correct Answer - - Hypotension - Decreased LOC - Hypertension in UE's - Decreased quality (amplitude) of femoral pulses compared to UE pulses - Loud systolic murmur in parascapular region - Chest pain - Chest wall ecchymosis - Widened mediastinum on chest xray - Paraplegia

How would you assess a pt with a thoracic injury?- 👈👈Correct Answer - (Initial assessment) Obtain Hx. PHYSICAL: Inspection: - Observe chest wall - Assess breathing effort and RR - Symmetry - Inspect jugular veins (Distended = increased intrathoracic pressure as result of tension pneumothorax or pericardial tamponade. Flat = external jugular veins may reflect hypovolemia) - Inspect upper abdominal region for injury Percussion: - Percuss the chest (Dullness = hemothorax, Hyperresonance = pneumothorax) Palpation: - Palpate chest wall, clavicles and neck for: - Tenderness - Swelling or hematoma

- Subcutaneous emphysema - Note presence of bony crepitus - Palpate central and peripheral pulses and compare quality between: - Right and left extremities - Upper and lower extremities - Palpate the trachea (above suprasternal notch. Trach shift may indicate late sign of tension pneumothorax or massive hemothorax) - Palpate extremities for motor and sensory function (lower extremitiy paresis or paralysis may indicate aortic injury).

Auscultation: - Auscultate compare BP in both UE's and LE's - Auscultate breath sounds (decreased or absent breath = pneumo or hemothorax. Diminshed BS = splinting. Shallow = b/c of pain).

- Auscultate chest for presence of BS (diaphragmatic rupture) - Auscultate Heart sounds (muffled = pericardial tamponade) - Auscultate neck vessels for bruits (vascular injury) Diagnostic Procedures: - Xrays - Arteriography - Bronchoscopy and laryngoscopy - CT's - FAST - Labs (cardiac enzymes) - ECG, CVP

What is the planning and implementation for thoracic injury?- 👈👈Correct Answer - p. 142

What is kinematics?- 👈👈Correct Answer - A branch of mechanics (energy transfer) that refers to motion and does not consider the concepts of force and mass of the object or body.

What is Newton's First Law?- 👈👈Correct Answer - A body at rest will remain at rest. A body in motion will remain in motion until acted on by an outside force.

What is the Law of Conservation of Energy?- 👈👈Correct Answer - Energy can neither be created nor destroyed. It is only changed from one form to another.

What is Newton's Second Law?- 👈👈Correct Answer - Force equals mass multiplied by acceleration of deceleration.

What is kinetic energy (KE)?- 👈👈Correct Answer - KE equals 1/2 the mass (M) multiplied by the velocity squared.

What is the Mnemonic for the Initial Assessment?- 👈👈Correct Answer - A = Airway with simultaneous cervical spine protection B = Breathing C = Circulation D = Disability (neurologic status) E = Expose/Environmental controls (remove clothing and keep the patient warm)

What is the Mnemonic for the Secondary Assessment?- 👈👈Correct Answer - F = Full set of VS/Focused adjuncts (includes cardiac monitor, urinary catheter, and gastric tube)/Family presence G = Give comfort measures (verbal reassurance, touch, and pharmacologic and nonpharmacologic management of pain).

H = Hx and Head-to-toe assessment I = Inspect posterior surfaces

Where do you listen to auscultate breath sounds?- 👈👈Correct Answer - Auscultate the lungs bilaterally at the second intercostal space midclavicular line and at the fifth intercostal space at the anterior axillary line.

What are the late signs of breathing compromise?- 👈👈Correct Answer - - Tracheal deviation

- JVD

What are signs of ineffective breathing?- 👈👈Correct Answer - - AMS - Cyanosis, especially around the mouth - Asymmetric expansion of chest wall - Paradoxical movement of the chest wall during inspiration and expiration - Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing - Sucking chest wounds - Absent or diminished breath sounds - Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated - Anticipate definitive airway management to support ventilation.

Upon initial assessment, what type of oxygen should be used for a pt breathing effectively?👈👈Correct Answer - A tight-fitting nonrebreather mask at 12-15 lpm.

What intervention should be done if a pt presents with effective circulation?- 👈👈Correct Answer - Insert 2 large caliber IV's - Administer warmed isotonic crystalloid solution at an appropriate rate

What are signs of ineffective circulation?- 👈👈Correct Answer - - Tachycardia - AMS - Uncontrolled external bleeding - Pale, cool, moist skin - Distended or abnormally flattened external jugular veins - Distant heart sounds

What are the interventions for Effective/Ineffective Circulation?- 👈👈Correct Answer - - Control any uncontrolled external bleeding by: - Applying direct pressure over bleeding site

- Elevating bleeding extremity - Applying pressure over arterial pressure points - Using tourniquet (last resort).

- Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution - Use warmed solution - Use pressure bags to increase speed of IVF infusion - Use blood administration tubing for possible administration of blood - Use rapid infusion device based on protocol - Use NS 0.9% in same tubing as blood product - IV = surgical cut-down, central line, or both.

- Blood sample to determine ABO and Rh group - IO in sternum, legs, arms or pelvis - Administer blood products - PASG (without interfering with fluid resuscitation)

How do you assess Mnemonic "D"?- 👈👈Correct Answer - DISABILITY A = Alert V = Verbal P = Pain U = Unresponsive - GCS - PERRL? - Determine presence of lateralizing signs including: - Unilateral deterioration in motor movements or unequal pupils - Symptoms that help to locate area of injury in brain

What are the interventions for Disability?- 👈👈Correct Answer - - If assessment indicates a decreased LOC, conduct further investigation during secondary focused assessments - If pt is not alert or verbal, continue to monitor for any compromise to ABC's

- If pt demonstrates signs of herniation or neurologic deterioration, consider hyperventilation.

What is assessed and intervened for Expose/Environmental Controls?- 👈👈Correct Answer - - Remove clothing - Ensure appropriate decontamination if exposed to hazardous material - Keep pt warm - Keep clothing for evidence

What is the first thing assessed under the Secondary Assessment?- 👈👈Correct Answer - FULL SET VS / FOCUSED ADJUNCTS / FAMILY PRESENCE - ABCDE should be completed - Labs, X-rays, CT, Foley, - Family Presence

What is the second thing assessed under the Secondary Assessment?- 👈👈Correct Answer - GIVE COMFORT MEASURES - Talking to pt - Pharmacologic/Nonpharmacologic pain management - Observe for physical signs of pain

What is assessed under the Mnemonic "H"?- 👈👈Correct Answer - HISTORY / HEAD-TO-TOE ASSESSMENT - MIVT - M = Mechanism of injury - I = Injuries sustained - V = Vital Signs - T = Treatment - Pt generated information - PMH - Head-to-toe assessment

What is assessed under the Mnemonic "I"?- 👈👈Correct Answer - INSPECT POSTERIOR SURFACES - While maintaining C-spine, logroll pt with assistance to inspect back, flanks, buttocks and posterior thighs.

- Palpate vertebral column for deformity and areas of tenderness - Assess rectum for presence/absence of tone, presence of blood

What she be done after the Secondary Assessment?- 👈👈Correct Answer - Reassess: - Primary survey, - VS - Pain - Any injuries

What are factors that contribute to ineffective ventilation?- 👈👈Correct Answer - - AMS - LOC - Neurologic injury - Spinal Cord Injury - Intracranial Injury - Blunt trauma - Pain caused by rib fractures - Penetrating Trauma - Preexisting hx of respiratory diseases - Increased age

What medications are used during intubation?- 👈👈Correct Answer - LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents

What are the Rapid Sequence Intubation Steps?- 👈👈Correct Answer - PREPARATION: - gather equipment, staffing, etc.

PREOXYGENATION: - Use 100% O2 (prevent risk of aspiration).

PRETREATMENT: - Decrease S/E's of intubation PARALYSIS WITH INDUCTION: - Pt has LOC, then administer neuromuscular blocking agent PROTECTION AND POSITIONING: - Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration PLACEMENT WITH PROOF - Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30-60 seconds between attempts.

- After intubation, inflate the cuff - Confirm tube placement w/exhaled CO2 detector.

POSTINTUBATION MANAGEMENT: - Secure ET tube - Set ventilator settings - Obtain Chest x-ray - Continue to medicate - Recheck VS and pulse oxtimetry

What is a Combitube?- 👈👈Correct Answer - A dual-lumen, dual-cuff airway that can be placed blindly into the esophagus to establish an airway. If inadvertently placed into trachea, it can be used as a temporary ET tube. There are only two sizes: small adult and larger adult.

What is a Laryngeal Mask Airway?- 👈👈Correct Answer - Looks like an ET tube but is equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to cover the supraglottic area.

ILMA, does not require laryngoscopy and visualization of the chords.

What is Needle Cricothyrotomy- 👈👈Correct Answer - Percutaneous transtracheal ventilation. (temporary)

Complications include: - inadequate ventilation causing hypoxia - hematoma formation - esophageal perforation - aspiration - thyroid perforation - subcutaneous emphysema

What is Surgical Cricothyrotomy?- 👈👈Correct Answer - Making an incision in cricothyroid membrane and placing a cuffed endo or trach tube into trachea. This is indicated when other methods of airway management have failed and pt cannot be adequately ventilated and oxygenated.

Complications include: - Aspiration - Hemorrhage or hematoma formation or both - Lac to trachea or esophagus - Creation of a false passage - Laryngeal stenosis

How do you confirm ET Tube/Alternative Airway Placement?- 👈👈Correct Answer - - Visualization of the chords - Using bronchoscope to confirm placement - Listening to breath sounds over the epigastrum and chest walls while ventilating the pt - CO2 detector - Esophageal detection device

- Chest x-ray

How do you inspect the chest for adequate ventilation?- 👈👈Correct Answer - Observe: - mental status - RR and pattern - chest wall symmetry - any injuries - patient's skin color (cyanosis?)

- JVD or tracheal deviation? (Tension pneumothorax)

What are you looking for when auscultating lung sounds?- 👈👈Correct Answer - Absence of BS: - Pneumothorax - Hemothorax - Airway Obstruction Diminished BS: - Splinting or shallow BS may be a result of pain

What are you looking for when percussing the chest?- 👈👈Correct Answer - Dullness: - hemothorax Hyperresonance - Pneumothorax

What are you looking for when palpating the chest wall, clavicles and neck?- 👈👈Correct Answer - Tenderness - Swelling - subcutaneous emphysema - step-off deformities = These may indicate: esophageal, pleural, tracheal or bronchial injuries.

Palpate trachea above suprasternal notch. Tracheal deviation may indicate a tension pneumothorax or massive hemothorax.

What is the DOPE mnemonic?- 👈👈Correct Answer - D - Displaced tube O - Obstruction: Check secretions or pt biting tube P - Pneumothorax: Condition may occur from original trauma or barotrauma from ventilator E - Equipment failure: pt may have become detached from equipment or there's a kink in the tubing

Explain Hypovolemic Shock.- 👈👈Correct Answer - Most common to affect a trauma pt cause by hypovolemia.. Hypovolemia, a decrease in amount of circulating blood volume, may result from significant loss of whole blood because of hemorrhage or from loss of semipermeable integrity of cellular membrane leading to leakage of plasma and protein from intravascular space to the interstitial space (as in a burn).

Some causes: - Blood loss - Burns, etc.

Explain Cardiogenic Shock.- 👈👈Correct Answer - Syndrome that results from ineffective perfusion caused by ineffective perfusion caused by inadequate contractility of cardiac muscle.

Some causes: - MI - Blunt cardiac injury - Mitral valve insufficiency - dysrhythmias - Cardiac Failure

Explain Obstructive Shock.- 👈👈Correct Answer - Results from inadequate circulating blood volume because of an obstruction or compression of great veins, aorta, pulmonary arteries, or heart itself.

Some causes: - Cardiac tamponade (may compress the heart during diastole to such and extent that atria cannot adequately fill, leading to decreased stroke volume).

- Tension pneumothorax may lead to inadequate stroke volume by displacing inferior vena cava and obstructing venous return to right atrium.

- Air embolus may lead to obstruction of pulmonary artery and subsequent obstruction to right ventricular outflow during systole, with resulting obstructive shock

Explain Distributive Shock.- 👈👈Correct Answer - Results from disruption in SNS control of the tone of blood vessels, which leads to vasodilation and maldistribution of blood volume and flow. (Neurogenic and Septic Shock). Neurogenic shock may result from injury to spinal cord in cervical or upper thoracic region.

Spinal shock = areflexia and flaccidity associated with lower motor neuron involvement in complete cord injuries; reflexes return with resolution of spinal shock.

Septic shock from bacteremia is distributive shock. Endotoxins and other inflammatory mediators cause vasodilation, shunting of blood in microcirculation, and other perfusion abnormalities.

What is vascular response?- 👈👈Correct Answer - As blood volume decreases, peripheral blood vessels vasoconstrict as a result of sympathetic stimulation via inhibition of baroreceptors. Arterioles constrict to increase TPR and BP.

What is renal response?- 👈👈Correct Answer - Renal ischemia activates release of renin.

Kidneys do not receive adequate blood supply, renin is release into circulation.

Renin causes angiotensinogen, normal plasma protein, to release angiotensin I.

Angiotensin-converting enzyme from the lungs converts into angiotensin II.

Angiotensin II causes:

- Vasoconstriction of arterioles and some veins - Stimulation of sympathetic nervous system - Retention of water by kidneys - Stimulation of release of aldosterone from the adrenal cortex (sodium retention hormone)

*Decreased urinary output = early sign renal hypoperfusion and an indicator that there's systemic hypoperfusion.

Explain adrenal gland response.- 👈👈Correct Answer - When adrenal glands are stimulated by SNS, release of catecholamines (epinephrine and norepinephrine) from adrenal medulla will increase.

Epi stimulates receptors in heart to increase force of cardiac contraction (positive inotropy) and increase HR (positive chronotropy) to improve cardiac output, BP and tissue perfusion.

Shock stimulates hypothalamus to release corticotropin-releasing hormone that stimulates pituitary to release ACTH that stimulates adrenal gland to release cortisol.

Effect of cortisol release is elevation in blood sugar and increased insulin resistance and gluconeogenesis, hepatic process to produce more sugar.

Cortisol also causes renal retention of water and sodium, a compensatory mechanism to conserve body water.

Explain Hepatic Response.- 👈👈Correct Answer - Liver can store excess glucose as glycogen.

As shock progresses, glycogenolysis is activated by epi to break down glycogen into glucose.

In a compensatory response to shock, hepatic vessels constrict to redirect blood flow to other vital areas.

Explain Pulmonary Response.- 👈👈Correct Answer - Tachypnea happens for 2 reasons:

1. Maintain acid-base balance 2. Maintain increased supply of oxygen

* Metabolic acidosis from anaerobic metabolism will be a stimulus for the lungs to increase rate of ventilation. Increased RR is an attempt to correct acidosis + augments oxygen supply to maximize oxygen delivery to alveoli.

Explain Irreversible Shock.- 👈👈Correct Answer - Shock uncompensated or irreversible stages will cause compromises to most body systems.

- Inadequate venous return - inadequate cardiac filling - decreased coronary artery perfusion - Membranes of lysosomes breakdown within cells and release digestive enzymes that cause intracellular damage.

How would you assess someone in hypovolemic shock?- 👈👈Correct Answer - (Use Initial Assessment) and then: Inspect: - LOC - Rate and quality of respirations - External bleeding?

- Skin color and moisture - Assess jugular veins and peripheral veins Auscultate: - BP - Pulse pressure - Breath sounds - Heart sounds - Bowel sounds Percuss:

- Chest and abdomen Palpate: - Central pulse (carotid or femoral) - Positive inotropic effect (force of contraction) may be evidence by a bounding central pulse - Palpate peripheral pulses - Palpate skin temp and moisture Diagnostic Procedures: - Xrays and other studies - Labs Planning and Implementation - Oxygen - IV's with warmed replacement fluids - Control external bleeding with direct pressure - Elevate LE's - NGT - Foley - Monitor and pulse oximeter - Monitor for development of coagulopathies - Surgery?

ICP is a reflection of what three volumes? What happens when one increases?- 👈👈Correct Answer - 1.

Brain 2. CSF 3. Blood within the nonexpansible cranial vault

As volume of one increases, the volume of another decreases to maintain ICP within normal range.

As ICP rises, CPP decreases, leading to cerebral ischemia and potential for hypoxia and lethal secondary insult. Hypotensive pt w/marginally elevated ICP can be harmful.

Slightly elevated BP could protect against brain ischemia in a pt with high ICP. Cerebral ischemia can lead to increased concentration of CO2 and decreased concentration of O2 in cerebral vessels. CO2 dilates cerebral blood vessels = increase blood volume and ICP.

What are the early signs and symptoms of increased ICP?- 👈👈Correct Answer - - Headache - N/V - Amnesia regarding events around the injury - Altered LOC - Restlessness, drowsiness, changes in speech, or loss of judgement

What are the late observable signs of symptoms of increased ICP?- 👈👈Correct Answer - - Dilated, nonreactive pupil - Unresponsiveness to verbal or painful stimuli - Abnormal motor posturing patterns - Widening pulse pressure - Increased systolic blood pressure - Changes in RR and pattern - Bradycardia

What is Cushing's phenomenon or Cushing's Reflex?- 👈👈Correct Answer - Triad of progressive HTN, bradycardia and diminished respiratory effort.

What are the two types of herniation that occurs with ICP?- 👈👈Correct Answer - 1. Uncal herniation 2. Central or transtentorial herniation

Why does herniation occur? What are the symptoms?- 👈👈Correct Answer - Because of uncontrolled increases in ICP.

S/E's

- Unilateral or bilateral pupillary dilation - AsyDimmetric pupillary reactivity - Abnormal motor posturing - Other evidence of neurologic deterioration

Define uncal herniation.- 👈👈Correct Answer - The uncus (medial aspect of the temporal lobe) is displaced over the tentorium into the posterior fossa. This herniation is the more common of the two types of herniation syndromes.

Define central or transtentorial herniation.- 👈👈Correct Answer - A downward movement of the cerebral hemispheres with herniation of the diencephalon and midbrain through the elongated gap of the tentorium.

Disruptions of the bony structures of the skull can result in what?- 👈👈Correct Answer - Displaced or nondisplaced fx's causing CSF leakage b/c of lac to the dura mater, creating a passage for CSF.

CSF leaks through the nose (rhinorrhea) or the ears (otorrhea). A potential entrance for invading bacteria.

Also: meningitis or encephalitis or brain abscess

Define Minor Head Trauma.- 👈👈Correct Answer - GCS 13-15

Define Moderate Head Trauma- 👈👈Correct Answer - Postresuscitative state with GCS 9-13.

Define Severe Head Trauma.- 👈👈Correct Answer - Postresuscitative state with GCS score of 8 or less.

What is a concussion and its signs and symptoms?- 👈👈Correct Answer - A temporary change in neurologic function that may occur as a result of minor head trauma.

S/S: - Transient LOC - H/A

- Confusion and disorientation - Dizziness - N/V - Loss of memory - Difficulty with concentration - Irritability - Fatigue

What are the signs and symptoms of postconcussive syndrome?- 👈👈Correct Answer - - Persistent H/A - Dizziness - Nausea - Memory impairment - Attention deficit - Irritability - Insomnia - Impaired judgement - Loss of libido - Anxiety - Depression

What is diffuse axonal injury and its signs and symptoms?- 👈👈Correct Answer - (DAI) is widespread, rather than localized, through the brain. Diffuse shearing, tearing and compressive stresses from rotational or accerleration/deceleration forces resulting in microscopic damage primarily to axons within the brain.

S/S: - Immediate unconsciousness - mild DAI, coma = 6-24 hrs - severe DAI, coma = weeks/months or persistent vegetative state - Elevated ICP - Abnormal posturing

- HTN - Hyperthermia - Excessive sweating because of autonomic dysfunction - Mild to severe memory impairment, cognitive, behavioral, and intellectual deficits

What is a cerebral contusion and its S/S?- 👈👈Correct Answer - A common focal brain injury in which brain tissue is bruised and damaged in a local area. Mainly located in frontal and temporal lobes. May cause hemorrhage, infarction, necrosis and edema. Max effects of bleeding & edema peak 18-36 post injury.

S/S: - Alteration in LOC - Behavior, motor or speech deficits - Abnormal motor posturing - Signs of increased ICP

What is an epidural hematoma and its S/S?- 👈👈Correct Answer - Results when a collection of blood forms between the skull and the dura mater. Bleeding is arterial=blood accumulates rapidly: - Compression of underlying brain - rapid increase in ICP - Decreased CBF - Secondary brain injury * Usually requires surgical intervention S/S: - Transient LOC - Lucid period lasting a few minutes to several hours - Rapid deterioration in neurologic status - Severe H/A - Sleepiness - Dizziness - N/V

- Hemiparesis or hemiplegia on opposite side of hematoma - Unilateral fixed and dilated pupil on same side of hematoma

What is a subdural hematoma and its S/S?- 👈👈Correct Answer - A focal brain injury beneath the dura mater that results from acceleration/deceleration. Usually venous, and not necessarily from a fx.

Formation may be acute or chronic.

Acute pt's hematoma manifest 48 hrs post injury S/S: - Altered LOC or steady decline in LOC - S/S of increased ICP - Hemiparesis or hemiplegia on opposite side of hematoma - Unilateral fixed and dilated pupil on same side of hematoma

Chronic pt's " " up to 2 wks post injury - H/A - Progressive decrease in LOC - Ataxia - Incontinence - Sz's

What are intracerebral hematoma's and its S/S?- 👈👈Correct Answer - Occur deep within brain tissue, may be single or multiple and commonly associated with contusions (frontal & temporal lobes). They result in significant mass effect, leading to increased ICP and neurologic deterioration.

S/S: - Progressive and often rapid decline in LOC - H/A - Signs of increasing ICP - Pupil abnormalities - Contralateral hemiplegia

What are the S/S of a linear skull fx?- 👈👈Correct Answer - - H/A - Possible decreased LOC

What are the S/S of a depressed skull fx?- 👈👈Correct Answer - - H/A - Possible decreased LOC - Possible open fx - Palpable depression of skull over the fx site

What are the S/S of a basilar skull fx?- 👈👈Correct Answer - - H/A - Altered LOC - Periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle's sign), or blood behind tympanic membrane (hemotympanum) - Facial nerve (VII) palsy - CSF rhinorrhea or otorrhea

How would you assess a pt with a cranial injury?- 👈👈Correct Answer - (Initial assessment) INSPECTION: - Assess airway - RR, pattern and effort - Assess pupil size and response to light - Unilateral fixed and dilated pupil = oculomotor nerve compression from increased ICP + herniation syndrome - Bilateral fixed and pinpoint pupils indicate a pontine lesion or effects of opiates - Mildly dilated pupil w/sluggish response may be early sign of herniation syndrome - Widely dilated pupil occasionally occurs w/direct trauma to globe of eye - Determine if pt uses eye meds - Abnormal posturing?

- Inspect craniofacial area for ecchymosis/contusions

- Periorbital ecchymosis - Mastoid's process ecchymosis - Blood behind tympanic membrane - Inspect nose and ears for drainage - Drng present w/out blood, test drng w/chemical reagant strip. Presence of glucose indicated drng of CSF - If drng present and mixed with blood, test by placing drop of fluid on linen or gauze. If a light outer ring forms around dark inner ring, drng contains CSF - Assess extraocular eye movement (Tests cranial nerves, III, IV, VI) - Performing extraocular eye movements indicates functioning brainstem - Limitation indicates orbital rim fx w/entrapment or paralysis of either a cranial nerve or ocular muscle - Determine LOC with GCS PALPATION - Palpate cranial area for: - Point tenderness - Depressions or deformities - Hematomas - Assess all 4 extremities for: - Motor function, muscle strength and abnormal motor posturing - Sensory function DIAGNOSTIC PROCEDURES - Lab Studies PLANNING AND IMPLEMENTATION - (Initial assessment) - Clear airway (stimulation of gag reflex can produce transient increase in ICP or vomiting with subsequent aspiration.

- Administer O2 via NRB - Assist with early ET intubation - Administer sedative/neuromuscular blocking agent - Consider hyperventilation

- PaCO2 above 45 mm Hg may cause increased cerebral vasodilation, increased CBF, increased ICP. - Prolonged hyperventilation NOT RECOMMENDED. - Hypocarbia occurs as result of hyperventilation causes cerebral vasoconstriction, decreased CBF, decreased ICP. And ischemia secondary to severe vasoconstriction.

- Hyperoxygenate pt with 100% O2 via bag-mask - Apply direct pressure to bleeding sites except depressed skull fractures - Cannulate 2 large IV's - Hypotension doubles pt's death rate (w/severe head trauma) - Vasopressors used to maintain CPP. - Insert OG or NGT. OG should be used with severe facial trauma.

- Position pt, elevate head to decrease ICP (but may also reduce CPP).

- Position head midline to facilitate venous drng. Rotate head to compress veins in neck and result in both venous engorgement and decreased drng from brain - Prepare for ICP monitoring device - Administer mannitol as prescribed.

- Mannitol, hyperosmolar, volume-depleting diuretic, decreases cerebral edema + ICP by pulling interstitial fluid into intravascular space for eventual excretion by kidneys.

- Administer anticonvulsant - Sx should be avoided b/c increases cerebral metabolic rate + ICP. Indications for sz prophylaxis: - Depressed skull fx - Sz at time of injury - Sz on arrival to ED - Hx of sz's - Penetrating brain injury - Acute subdural/epidural hematoma

- Administer antipyretic med/Cooling blanket - Hyperthermia may increase cerebral metabolic rate + ICP. Avoid causing shivering during cooling process; increases cerebral metabolic rate + may precipitate rise in ICP - Do not pack ears/nose if CSF leak suspected

- Admin tetanus prophylaxis - Wound repair for facial/scalp Lac's - Admin other meds - Analgesics, sedatives, narcan, romazicon, etc.

- Admin antibiotics - Pt's w/basilar skull fx need prophylaxis against meningitis - Prepare pt for OR, hospital admin or transfer.

What are signs of a serious eye injury?- 👈👈Correct Answer - - Visual disturbances - Pain - Redness and ecchymosis of the eye - Periorbital ecchymosis - Increased intraocular pressure

What is hyphema and its S/S?- 👈👈Correct Answer - Accumulation of blood, mainly RBC's that disperse and layer within the anterior chamber. A severe hymphema obscures entire anterior chamber + will diminish visual acuity severely or completely. Injuries are graded on amount of blood in chamber (Grades I-IV).

S/S: - Blood in anterior chamber - Deep, aching pain - Mild to severe diminished visual acuity - Increased intraocular pressure

What are s/s of chemical burns to the eye?- 👈👈Correct Answer - Chemical injuries require immediate intervention if it is to be preserved.

S/S: - Pain - Corneal Opacification - Coexisting chemical burn and swelling of lids

What are S/S of penetrating trauma/open or ruptured globe?- 👈👈Correct Answer - - Marked visual impairments - Extrusion of intraocular contents - Flattened or shallow anterior chamber - Subconjunctival hemorrhage, hyphema - Decreased intraocular pressure - Restriction of extraocular movements

What are the S/S of orbital fracture (orbital blowout fracture)?- 👈👈Correct Answer - - Diplopia (double vision) - Loss of vision - Altered extraocular eye movements - Enophthalmos (displacement of the eye backward into the socket) - Subconjunctival hemorrhage or ecchymosis of the eyelid - Infraorbital pain or loss of sensation - Orbital bony deformity

What is LeFort I fracture and its S/S?- 👈👈Correct Answer - Transverse maxillary fx that occurs above level of teeth and results in separation of teeth from rest of maxilla.

S/S: - Slight swelling of maxillary area - Possible lip lac's or fractured teeth - Independent movement of the maxilla from rest of face - Malocclusion

What is LeFort II fracture and its S/S?- 👈👈Correct Answer - Pyramidal maxillary fx=middle facial area.

Apex of fx transverses bridge of nose. Two lateral fx's of pyramid extend through the lacrimal bone of the face and ethmoid bone of skull into the median portion of both orbits. Base of the fx extends above level of the upper teeth into maxilla. CSF leak is possible.

S/S:

- Massive facial edema - Nasal swelling w/obvious fx of nasal bones - Malocclusion - CSF rhinorrhea

What is LeFort III fracture and its S/S?- 👈👈Correct Answer - Complete craniofacial separation involving maxilla, zygoma and bones of cranial base. This fx is frequently associated w/leakage of CSF and fx mandible.

S/S: - Massive facial edema - Mobility and depression of zygomatic bones - Ecchymosis - Anesthesia of the cheek - Diplopia - Open bite or malocclusion - CSF rhinorrhea

What are the mandibular fracture S/S?- 👈👈Correct Answer - - Malocclusion - Inability to open the mouth (trismus) - Pain, especially on movement - Facial asymmetry and a palpable step-off deformity - Edema or hematoma formation at the fracture site - Blood behind, ruptured, tympanic membrane - Anesthesia of the lower lip

What are neck injury S/S?- 👈👈Correct Answer - - Dyspnea - Hemoptysis (coughing up blood) - Subcutaneous emphysema in neck, face, or suprasternal area - Decreased or absent breath sounds

- Penetrating wounds or impaled objects - Pulsatile or expanding hematoma - Loss of normal anatomic prominence of the laryngeal region - Bruits - Active external bleeding - Neurologic deficit, such as aphasia or hemiplegia - Cranial nerve deficits - Facial sensory or motor nerve deficits - Dysphonia (hoarseness) - Dysphagia (difficulty swallowing)

How would you assess a patient with ocular, maxillofacial and neck trauma?- 👈👈Correct Answer (Initial assessment) HISTORY - MOI? - Acceleration/Deceleration?

- What was it caused by?

- Pt restrained? Airbags deployed? Etc. - What are the pt's complaints?

- Pt normally wear glasses or contacts?

- Pt have hx of eye problems?

- Pt ever have eye surgery?

- Pt have visual or ocular changes associated with chronic illness?

PHYSICAL INSPECTION: - Inspect eye, orbits, face and neck - Check for symmetry, edema, ecchymosis, ptosis, lacerations and hematomas - Inspect globe for lacerations, large corneal abrasions, hyphema, and extrusion or prolapse of intraocular contents

- Determine whether lid lac's - Assess pupil's (PERRL) - Unilateral fixed and dilated pupil may indicate oculomotor nerve compression as a result of ICP + herniation syndrome - Bilateral fixed and pinpoint pupils = pontine lesion or drugs - Mildly dilated pupil w/sluggish response may early sign of herniation syndrome - Widely dilated pupil occasionally occurs w/direct trauma to globe of eye - Assess for consensual response - Assess redness, eye watering, blepharospasm - Assess extraocular movement, except when an open globe injury is known or suspected.

- Limitation range of ocular motion may indicate orbital rim fx w/entrapment or paralysis of cranial nerve or ocular muscle - Perform visual acuity exam - Use Snellen or handheld chart. Check uninjured eye first - Assess for blurred or double vision with injured eye and then with both eyes open - Inspect for rhinorrhea or otorrhea - If drng present, may indicate CSF leak - Observe for impaled objects - Assess occlusion of mandible and maxilla - Malocclusion or inability to open + close mouth is highly indicative of maxillary or mandibular fx - Observe for uncontrolled bleeding PALPATION - Palpate periorbital area, face and neck for: - Tenderness - Edema - Step-off defects or depressions - Subcutaneous emphysema (esophageal or tracheal tear) - Palpate trachea above suprasternal notch - Trach deviation = late indication of tension pneumothorax or massive hemothorax

- Assess sensory fx of perioribital areas, face and neck - Facial fx's can impinge on infraorbital nerve, causing numbness of inferior eyelid, lateral nose, cheek, or upper lip on affected side.

- Check position of trachea DIAGNOSTIC STUDIES: - Xrays, CT scans, MRI's - Fluorescein staining - Slit-lamp exam - tonometry (measures intraocular pressure) - Bronchoscopy or esophagoscopy

What are the nursing interventions for a pt with an ocular injury?- 👈👈Correct Answer - - Assess visual acuity & reassess - Elevate HOB to minimize intraocular pressure - Instruct pt not to bend forward, cough or perform Valsalva maneuver b/c these actions may raise intraocular pressure - Assist w/removal of foreign bodies as indicated; stabilize impaled objects - Apply cool packs to decrease pain + periorbital swelling - Admin medications - Instill prescribed topical anesthetic drops for pain - Instill NS drops or artificial tears to keep corneas moist. Cover eyelids w/sterile, moist saline dsg to prevent drying and ulceration - Antibiotics topically or systemically - Admin tetanus prophylactically - Use an eye patch to affected eye - Patch or shield both eyes to reduce movement + photophobia in pt's w/retinal injuries - Patch, shield or cover w/cool pack - Do NOT patch injured eye of pt w/suspected open or ruptured globe or impaled object, patch unaffected eye. Use metal or plastic and do not put pressure on the globe.

- Provide psychosocial support

- Obtain an ophthalmology consultation - Provide d/c instructions: - Importance of protective eyewear - No driving w/eye patch on - Wear sunglasses to prevent tearing, aid photophobia - Prepare for admission, OR or transfer

What are the nursing interventions for a patient with a maxillofacial or neck injury?- 👈👈Correct Answer - - Administer oxygen - For facial trauma, place pt in high-fowler's position if no spinal injury is present.

- Insert OG or NGT. OGT should be used if basilar skull fx or severe midface fx's are suspected - Monitor for progressive airway assessment - Prepare for intubation, PRN. - Cannulate 2 large IV's, initiate isotonic crystalloid IV solution - Control external bleeding w/direct pressure - Monitor for continued bleeding + expanding hematomas - Apply cold compresses to face to minimize edema - Assist w/repair of oral lac's, PRN - Admin antibiotics - Stabilize impaled objects - Admin analgesic meds

With any eye injury, what should the evaluation and ongoing assessments be?- 👈👈Correct Answer - Reassessing visual acuity at reasonable intervals - Reassessing pain, including response to nonpharmacologic + pharmacologic interventions - Monitoring appearance, position, movements of globe and pupillary responses - Monitoring airway patency, respiratory effort and ABG's

What are the most common type of injury associated with chest trauma?- 👈👈Correct Answer - blunt; MVC's. Penetrating; firarm injuries or stabbings

What are S/S of a rib fracture?- 👈👈Correct Answer - - Dyspnea - Localized pain on movement, palpation, or inspiration - Pt assumes position intended to splint chest wall to reduce pain - Chest wall ecchymosis or sternal contusion - Bony crepitus or deformity

What is a flail chest?- 👈👈Correct Answer - A fracture of two or more sites on two or more adjacent ribs, or when rib fractures produce a free-floating sternum.

Flail segments may not be clinically evident in the first several hours after injury b/c of muscle spasms that cause splinting. After positive pressure intiated, paradoxical chest wall movement ceases.

What could a flail chest be associated with?- 👈👈Correct Answer - - Ineffective ventilation - Pulmonary contusion - Lacerated lung parenchyma

What are the S/S of flail chest?- 👈👈Correct Answer - - Dyspnea - Chest wall pain - Paradoxical chest wall movement - the flail segment moves in during inspiration and out during expiration.

Define Pneumothorax.- 👈👈Correct Answer - Results when an injury to lung leads to accumulation of air in pleural space w/subsequent loss of negative intrapleural pressure. Partial or total collapse of lung may ensue.

An open pneumothorax results from wound through chest wall. Air enters pleural space both through the wound and trachea.

What are the S/S of a pneumothorax?- 👈👈Correct Answer - - Dyspnea, tachypnea

- Tachycardia - Hyerresonance (increased echo produced by percussion over the lung field) on the injured side - Decreased or absent breath sounds on the injured side - Chest pain - Open, sucking wound on inspiration (open pneumothorax)

Define tension pneumothorax.- 👈👈Correct Answer - Life-threatening injury. Air enters pleural space on inspiration, but air cannot escape on expiration. Rising intrathoracic pressure collapses lung on side of injury causing a mediastinal shift that compresses the heart, great vessels, trachea and uninjured lung. Venous return impeded, cardiac output falls, hypotension results.

Immediate decompression should be performed. Treatment should not be delayed.

What are the S/S of a tension pneumothorax?- 👈👈Correct Answer - - Severe respiratory distress - Markedly diminished or absent breath sounds on affected side - hypotension - Distended neck, head and upper extremity veins-may not be clinically appreciated if significant blood loss present - Tracheal deviation - shift toward uninjured side (LATE sign) - Cyanosis (LATE sign)

Define Hemothorax.- 👈👈Correct Answer - Accumulation of blood in the pleural space.

What are the S/S of Hemothorax?- 👈👈Correct Answer - - Dyspnea, tachypnea - Chest pain - Signs of shock - Decreased breath sounds on injured side - Dullness to percussion on the injured side

What is a pulmonary contusion?- 👈👈Correct Answer - They occur as a result of direct impact, deceleration or high-velocity bullet wounds. It develops when blood leaks into lung parenchyma, causing edema + hemorrhage. This usually develops overtime and not immediately.

What are the S/S of pulmonary contusion?- 👈👈Correct Answer - - Dyspnea - Ineffective cough - Hemoptysis - Hypoxia - Chest pain - Chest wall contusion or abrasions

What happens to a ruptured diaphragm?- 👈👈Correct Answer - Potentially life-threatening, results from forces that penetrate the body. Left hemidiaphragm is more susceptible to injury because the right side is protected by the liver.

- Herniation of abdominal contents - Respiratory compromise b/c impaired lung capacity + displacement of normal tissue.

- Mediastinal structures may shift to opposite side of injury

What are S/S of a ruptured diaphragm?- 👈👈Correct Answer - (Anything below the nipple line and should be evaluated for potential diaphragmatic injury).

- Dyspnea or orthopnea - Dysphagia - Abdominal pain - Sharp epigastric or chest pain radiating to left shoulder (Kehr's sign) - Bowel sounds heard in lower middle chest - Decreased breath sounds on injured side

What are S/S with tracheobronchial injury?- 👈👈Correct Answer - Blunt trauma. "Clothesline-type" injuries.

- Dyspnea, tachypnea - Hoarseness

- Hemoptysis - Subcutaneous emphysema in neck, face, or suprasternal area - Decreased or absent breath sounds - S/S of airway obstruction

What are S/S with blunt cardiac injury?- 👈👈Correct Answer - "Cardiac contusion" or "concussion."

Common with MVC or falls from heights.

- ECG (sinus tach, PVC's, AV blocks) - Chest pain - Chest wall ecchymosis

What are the S/S of pericardial tamponade?- 👈👈Correct Answer - A collection of blood in pericardial sac. As blood accumulates, it exerts pressure on the heart, inhibiting or compromising ventricular filling.

- Hyotension - Tachycardia or PEA - Dyspnea - Cyanosis - Beck's Triad (hypotension, distended neck veins + muffled heart sounds) - Progressive decreased voltage of conduction complexes on ECG

What are aortic injuries S/S?- 👈👈Correct Answer - - Hypotension - Decreased LOC - Hypertension in UE's - Decreased quality (amplitude) of femoral pulses compared to UE pulses - Loud systolic murmur in parascapular region - Chest pain - Chest wall ecchymosis - Widened mediastinum on chest xray - Paraplegia

How would you assess a pt with a thoracic injury?- 👈👈Correct Answer - (Initial assessment) Obtain Hx. PHYSICAL: Inspection: - Observe chest wall - Assess breathing effort and RR - Symmetry - Inspect jugular veins (Distended = increased intrathoracic pressure as result of tension pneumothorax or pericardial tamponade. Flat = external jugular veins may reflect hypovolemia) - Inspect upper abdominal region for injury Percussion: - Percuss the chest (Dullness = hemothorax, Hyperresonance = pneumothorax) Palpation: - Palpate chest wall, clavicles and neck for: - Tenderness - Swelling or hematoma - Subcutaneous emphysema - Note presence of bony crepitus - Palpate central and peripheral pulses and compare quality between: - Right and left extremities - Upper and lower extremities - Palpate the trachea (above suprasternal notch. Trach shift may indicate late sign of tension pneumothorax or massive hemothorax) - Palpate extremities for motor and sensory function (lower extremitiy paresis or paralysis may indicate aortic injury).

Auscultation: - Auscultate compare BP in both UE's and LE's - Auscultate breath sounds (decreased or absent breath = pneumo or hemothorax. Diminshed BS = splinting. Shallow = b/c of pain).

- Auscultate chest for presence of BS (diaphragmatic rupture) - Auscultate Heart sounds (muffled = pericardial tamponade) - Auscultate neck vessels for bruits (vascular injury) Diagnostic Procedures: - Xrays - Arteriography - Bronchoscopy and laryngoscopy - CT's - FAST - Labs (cardiac enzymes) - ECG, CVP

What is the planning and implementation for thoracic injury?- 👈👈Correct Answer - p. 142

Kinematics- 👈👈Correct Answer - Is the study of energy transfer as it applies to identifying actual or potential injuries.

Biomechanics- 👈👈Correct Answer - Is the general study of forces and their effects.

Mechanism of Injury- 👈👈Correct Answer - Is how external forces are transferred to the body, resulting in injury

Newton's First Law of Motion- 👈👈Correct Answer - an object in motion will remain in motion unless acted upon by another force

Newton's Second Law of Motion- 👈👈Correct Answer - The acceleration of an object depends on the mass of the object and the amount of force applied.

Newton's Third Law of Motion- 👈👈Correct Answer - For every action there is an equal and opposite reaction

Law of Conservation of Energy- 👈👈Correct Answer - Matter is neither created nor destroyed (but may change form)

What are the five forms in which energy exist?- 👈👈Correct Answer - 1. Mechanical 2. Thermal 3. Chemical 4. Electrical 5. Radiant

Describe the 3 types of Internal forces of energy transfer in the context of trauma.- 👈👈Correct Answer - Compression: The ability of the tissue to resist crush injury or force

Tension: The ability to resist being pulled apart when stretched

Shear: The ability to resist a force applied parallel to the tissue

Describe the 3 types of external forces of energy transfer in the context of trauma.- 👈👈Correct Answer - Deceleration: Force from a sudden stop in the body's motion Acceleration: Force from a sudden onset in the body's motion Compression: Force from being crushed between objects

List the four main types of traumatic injury and give an example of each- 👈👈Correct Answer - Blunt: The result of a broad energy impact across a large surface area.

Penetrating: The

What 4 environmental and pathophysiologic factors are considered when the mechanism of injury is a fall?- 👈👈Correct Answer -

Describe the three impacts in the motor vehicle impact sequence- 👈👈Correct Answer - 1. First Impact: Vehicle hits another object 2. Second Impact: Occupant hits the interior of the vehicle 3. Third Impact: Organcs hit other internal structures

Define the five mechanisms of injury in blast trauma.- 👈👈Correct Answer - 1. Primary: Found in patients who were closest to the blast. Injuries are most commonly associated with air-filled organs 2. Secondary: Include fragment injuries, puncture wounds, lacerations, and impaled objects. Generally, these cause the most casualties 3. Tertiary: Result from the patient being blown into a large object. Injuries include pelvic or femur fractures an thoracic injuries.

4. Quaternary: Result from heat, flame, gas, and smoke and cause burn injuries.

5. Quinary: Injuries associated with radioactive, biological or chemical elements that may be present in the explosion.

Describe the usefulness of the Haddon Matrix in prevention and reduction of injury- 👈👈Correct Answer - Looks at 3 phases of the event: Pre-event, event, and post-event.

Looks at 4 factors involved in the event: The host (patient), the agent (cause), the physical evironment, and the socioeconomic environment.

Countermeasures can be applied at each phase to help reduce injury.

What assessment findings differentiate a placental abruption from a uterine rupture?- 👈👈Correct Answer -

What intervention is used to treat hypotension from aortocaval compression?- 👈👈Correct Answer -

Describe the activities and associated factors related to low-energy trauma in the older adult.👈👈Correct Answer -

List common injuries from falls in the older adult population.- 👈👈Correct Answer -

What condition is associated with a fall from which the older adult cannot rise? What complications result from this condition?- 👈👈Correct Answer -

Review the age-related anatomic and physiologic change of the older adult in relation to the components of the initial assessment.- 👈👈Correct Answer -

Describe the fluid resuscitation of an older adult patient related to fluid overload, when to administer red blood cells, and the use of anticoagulant medication.- 👈👈Correct Answer -

Describe effects of common medications in relation to the older adult trauma patient.- 👈👈Correct Answer -

Describe common patterns and severity of injuries in the bariatric trauma patient.- 👈👈Correct Answer -

Which comorbid conditions factor into the risks of the bariatric trauma patient? And how?- 👈👈Correct Answer -

Describe the pathophysiologic changes of the systems of the bariatric patient and the effects on trauma resuscitation efforts.- 👈👈Correct Answer -

Describe techniques to improve the intubation process for the bariatric trauma patient.- 👈👈Correct Answer -

Discuss the use and insertion of nasogastric tubes in the bariatric patient.- 👈👈Correct Answer -

Differentiate family and intimate partner violence from community violence.- 👈👈Correct Answer -

List the populations at higher risk for interpersonal violence.- 👈👈Correct Answer -

Describe the types of abuse and the associated signs of each.- 👈👈Correct Answer -

What cues to abuse may be obtained during the history portion of the initial assessment?- 👈👈Correct Answer -

Describe specific injuries associated with interpersonal violence and abuse.- 👈👈Correct Answer -

List the basic components of evidence collection.- 👈👈Correct Answer -

Describe steps to maintain the forensic chain of custody.- 👈👈Correct Answer -

1. Preparation and Triage 2. Primary Survery (ABCDE) with resuscitation adjuncts (F,G) 3. Reevaluation (consideration of transfer) 4. Secondary Survey (HI) with reevaluation adjuncts 5. Reevaluation and post resuscitation care 6. Definitive care of transfer to an appropriate trauma nurse- 👈👈Correct Answer - Initial Assessment

1. A- airway and Alertness with simultaneous cervical spinal stabilization 2. B- breathing and Ventilation 3. circulation and control of hemorrhage 4. D - disability (neurologic status) 5. F - full set of vitals and Family presence 6. G - Get resuscitation adjuncts L- Lab results (arterial gases, blood type and crossmatch) M- monitor for continuous cardiac rhythm and rate assessment N- naso or orogastric tube consideration

O- oxygenation and ventilation analysis: Pulse oxygemetry and end-tidal caron dioxide (ETC02) monitoring and capnopgraphy H- History and head to toe assessment I- Inspect posterior surfaces- 👈👈Correct Answer - ABCDEFGHI

Before the arrival of the pt- 👈👈Correct Answer - When should PPE be placed:

Pt is at hospital in the right amount of time, right care, right trauma facility, right resources👈👈Correct Answer - Safe Care:

Uncontrolled Hemorrhage- 👈👈Correct Answer - Major cause of preventable death:

reorganize care to C-ABC- 👈👈Correct Answer - If uncontrolled hemorrhage ..

Used at the beginning of the initial assessment

1. A Alert. If the pt is alert he or she will be able to maintain his or her airway once it is clear.

2. V responds to verbal stimuli responds to pain. If the patient needs verbal stimulation to respond, an airway adjunct may be needed to keep the tongue from obstructing the airway.

3. P responds to pain. If the pt. responds only to pain, he or she may not be able to maintain his or her airway adjunct may need to be placed while further assessment is made to determine the need for intubation.

4. U Unresponsive. If the pt. is unresponsive, announce it loudly to the team and direct someone to chk in the pt is pulseless while assessing if the cause of the problem is the airway.- 👈👈Correct Answer Airway and AVPU:

ask pt to pen his or her mouth- 👈👈Correct Answer - While assessing airway the patient is alert and responds to verbal stimuli you should..

jaw thrust maneuver to open airway and assess for obstruction. If pt has a suspected csi, the jaw thrust procedure should be done by two providers. One provider can maintain c-spine and the other can

perform the jaw thrust maneuver.- 👈👈Correct Answer - While assessing airway pt is unable to open mouth, responds only to pain, or is unresponsive you should..

1. The tongue obstructing the airway 2. loose or missing teeth 3. foreign objects 4. blood, vomit, or secretions' 5. edema 6. burns or evidence of inhalation injury

Auscultiate or listen for: 1. Obstructive airway sounds such as snoring or gurgling 2. Possible occlusive maxillofacial bony deformity 3. Subcutaneous emphysema- 👈👈Correct Answer - Inspect the mouth for:

1. Check the presence of adequate rise and fall of the chest with assisted ventilation 2. Absence of gurgling on auscultation over the epigastrium 3. Bilateral breath sounds present on auscultation 4. Presence of carbon dioxide (CO2) verified by a CO2 device or monitor- 👈👈Correct Answer - If the pt has a definitive airway in what should you do?

1. Suction the airway 2, Use care to avoid stimulating the gag reflex 3. If the airway is obstructed by blood or vomitus secretions, use a rigid suction device If foreign body is noted, remove it carefully with forceps or another appropriate method- 👈👈Correct Answer - If Airway is not patent

1. Apnea 2. GCS 8 or less 3. Maxillary fractures

4. Evidence of inhalation injury (facial burns) 5. Laryngeal or tracheal injury or neck hematoma 6. High risk of aspiration and patients inability to protect the airway 7. Compromised or ineffective ventilation- 👈👈Correct Answer - Following conditions might require a definitive airway

Breathing: To assess breathing expose the chest: 1. Inspect for a. spontaneous breathing b. symmetrical rise and fall c. depth, pattern, and rate of respiration d. signs of difficulty breathing such as accessory muscle use e. skin color (normal, pale, flushed, cyanotic) f. contusions, abrasions, deformities (flail chest) g. open pneumothoraces (sucking chest wounds) h. JVD i. signs of inhalation injury (singed nasal hairs, carbonaceous sputum)- 👈👈Correct Answer - B

tracheal deviation and jvd- 👈👈Correct Answer - Late signs of tension pneumo:

1. equal breath sounds bilaterally at the second intercostal space midclavicular line and the bases for fifth intercostal space at the axillary line- 👈👈Correct Answer - Auscultate the chest for:

1. bony fractures and possible rib fractures, which may impact ventilation 2. palpate for crepitus 3. subcutaneous emphysema which may be a sign for a pneumothorax 4. soft tissue injury- 👈👈Correct Answer - Palpate the chest for

1. open the airway, use jaw thrust

2. insert an oral airway 3. assist ventilations with a bag mask 4. prepare for definitive airway- 👈👈Correct Answer - If breathing is absent..

trauma its need early supplemental oxygen, start with 15 mL O2 and titrate oxygen delivery.👈👈Correct Answer - Oxygen on trauma patients

Circulation and Control of Hemorrhage

Inspect first for any uncontrolled bleeding Skin color

palpate for central pulses - carotid and femoral - rate, rhythm, and strength Skin temp: cool, diaphoretic, or warm and dry- 👈👈Correct Answer - C

apply direct pressure to bleeding

elevate extremity

apply pressure over arterial sites

Consider a pelvic binder for pelvic fractures

consider a tourniquet

cannulate two veins with large caliber IV - if unable to gain assess consider IO a. obtain labs, type and cross b. infuse warm isotonic fluids c. consider balanced resuscitation

d. use rapid infusion device- 👈👈Correct Answer - C Interventions:

Disability - Neurologic Status

1. Assess pupils for equality, shape, and reactivity (PERRL) 2. Assess GCS (eye opening, verbal response, and motor response)- 👈👈Correct Answer - D

1. Get a CT 2. Consider ABG 's if decreased LOC 3. Consider glucose check- 👈👈Correct Answer - D Interventions

Exposure and Environmental Control

Remove all clothes and assess for any obvious injuries and uncontrolled bleeding- 👈👈Correct Answer E

IF clothing is needed for evidence preserve in paper bag.

Maintain body temp - cover the pt, turn up heat in room, administer warm fluids- 👈👈Correct Answer E Interventions:

Full set of vitals and family presence- 👈👈Correct Answer - F

Get Resuscitation Adjuncts L - Labs (maybe a lactic acid), a b g 's, blood type M - monitors N - naso or oro gastric tubes O Oxygen and ETC02 monitors P - pain assessment and management- 👈👈Correct Answer - G

Reevaluation and Consider the need to Transfer- 👈👈Correct Answer - Final step in primary survey

H,I- 👈👈Correct Answer - Secondary Survery

History and Head to toe MIST - prehospital report MOI Injuries sustained S s/s in the field T treatment in the field if patients family present get a better hx on them- 👈👈Correct Answer - H

Sample is part of history S symptoms associated with injury A allergies and tetanus status M meds currently on including anticoagulant therapy P past medical hx L last oral intake E Events and environment factors related to the injury- 👈👈Correct Answer - SAMPLE

inspect for lacs, abrasions, asymmetry of facial expressions

palate for depressions and tenderness

look at ears for drainage- 👈👈Correct Answer - Head to toe assessment: Head and face

immobilize cervical spine, tenderness, tracheal deviation- 👈👈Correct Answer - Head to toe assessment: Neck and cervical spine

inspect, auscultate, palpate

any spontaneous breathing, rate, depth, and degree of effort, use of accessory muscles

lacs, contusions,

auscilate lung sounds and heart sounds- 👈👈Correct Answer - Head to toe assessment: Chest

don't forget flanks!!!

inspect of lacs, puncture wounds, contusions,

auscultate then palpate:

bowel sounds?

any rigidity, guarding? begin with light palpation start to palpate with side that does not hurt

maybe do a fast scan?- 👈👈Correct Answer - Head to toe assessment: Abdomen

any lacs? deformities? blood at the urtheral meatus

palpate pelvis with high pressure over the iliac wings downward and medially- 👈👈Correct Answer Head to toe assessment: pelvis and perineum

any deformities? bleeding? contusions, lacs? skin temp?? place splints on deformities, pulses👈👈Correct Answer - Head to toe assessment: Extremities

inspect posterior surfaces

blogroll with at least 3 people. maintain c spine

take out backboard

Rectal tone per MD- 👈👈Correct Answer - I

labs, wound care, tetanus, administer meds, prepare for transfer- 👈👈Correct Answer - Secondary Reval Adjuncts

Vital signs Interventions Primary survey Pain- 👈👈Correct Answer - Post resuscitation care parameters that are continuously evaluated:

Capnography monitors numeric value, as well as continuous waveform, indicating real-time measurement and trending over time.- 👈👈Correct Answer - Quantitative:

Colorimetric CO2 detectors provide info about the presence or absence of CO2. A chemically treated indicator strip changes color revealing the presence or absence of exhaled CO2- 👈👈Correct Answer Qualitative

D displaced tube O obstructed or kinked P pneumothorax E equipment failure , such as becoming detached from the equipment or loss of capnopgrahy👈👈Correct Answer - DOPE

1. Preparation 2. Preoxygenation 3. Pretreatment 4. Paralysis and Induction 5. Protecting and positioning - v 6. Placement of proof - secure the tube 7. Post intubation - secure ETT Tube, get X-ray for placement- 👈👈Correct Answer - Steps of Rapid Sequence Intubation

from hemorrhage is leading cause. Hypovolemia is caused by decrease in the amount of circulating volume. Goal is to replace volume.- 👈👈Correct Answer - Hypovolemic Shock

results from hypo perfusion to the tissue due to an obstruction in either vasculature or heart. Goal is to relieve obstruction and improve perfusion.

Ex: tension pneumo or cardiac tamponade are two classic examples that may result from trauma.👈👈Correct Answer - Obstructive Shock

Results 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.

Ex: MI's or dysrhythmia are common causes- 👈👈Correct Answer - Cariogenic Shock

occurs as a result of maldistribution of an adequate circulating blood volume with the loss of vascular tone or increased permeability.

Ex: Anaphylactic - release of antihistamines Septic Shock - systemic release of bacterial endotoxins, resulting in increased vascular permeability and vasodilation. Neurogenic shock - spinal cord injury results of loss in sympathetic nervous system control of vascular tone.

Goal: Volume replacement and vasoconstriction- 👈👈Correct Answer - Distributive Shock

A breath every 5 to 6 seconds: 10-12 ventilations per minute- 👈👈Correct Answer - Bag mask ventilation

Stroke Volume X HR- 👈👈Correct Answer - Cardiac Output =

.. activation: .... are found in the carotid sinus and along the aortic arch, are sensitive to the degree of stretch in the arterial wall. When the receptors sense a decrease in stretch, they stimulate the sympathetic nervous system to release Epi, norepi, causing stimulation of cardiac activity and constriction of blood vessels, which causes a rise in heart rate and diastolic blood pressure- 👈👈Correct Answer - Baroreceptors:

activation: consist of carotid and aortic bodies. ... detect changes in blood oxygen and Co2 and pH. When Co2 rises or oxygen level of pH falls these receptors are activated and information is relayed to the CNS and the cardiorespiratory centers in the medulla , which increases respiratory rage and depth and BP- 👈👈Correct Answer - Chemoreceptors:

50 to 150- 👈👈Correct Answer - MAP Range

the decrease coagulopathy .. you will you bleed more- 👈👈Correct Answer - The colder you are the more acidic you are..

in massive transfusion protocol... responsible for dissolving clots- 👈👈Correct Answer - TXA

stabilized vital signs, improved mental status, improved urine output- 👈👈Correct Answer - What are indicators of increased perfusion?

- 👈👈Correct Answer - Prehospital shock index pg. 85

Flail chest- 👈👈Correct Answer - Paradoxical chest wall movement

can be caused by blunt trauma. air escapes from injured lung to pleural space and negative intrapleural pressure is lost causing partial or collapsed lung- 👈👈Correct Answer - Simple Pneumothorax

1. Dyspnea 2. Tachycardia 3. Decreased or absent breath sounds on the injured side 4. CP- 👈👈Correct Answer - Simple Pneumo assessment:

Tx is based on size, presence of sx, and stability. For those are aysmpomatic and stable. Observation with or without oxygen. Larger pneumo who are unstable or likely to deteriorate a chest tube is placed.👈👈Correct Answer - Simple pneumo interventions:

can result from penetrating wound through chest wall causing air to be trapped in to the intrapleural place. Might hear "sucking"

Tx: nonporous dressing tapes on 3 sided, then Chest tube and would closure surgical repair.👈👈Correct Answer - Open Pneumo:

Air cannot escape intrapleural space.. can begin to compress heart. pt will have sever resp distress, hypotension, JVD.- 👈👈Correct Answer - Tension pneumo

A 14 gauge needle that is inserted into the 2nd intercostal space in the midclavicular line on the affected side over the top of the rib to avoid neuromuscular bundle that runs under the rib.

Prepare for chest tube placement.- 👈👈Correct Answer - Tension pneumo intervention

Caused by blood in the intrapleural space/ May also occur from lac to live or spleen combined with injury to the diaphragm.

Ensure two large bore IVS are placed.

Prepare for thoracentesis and chest tube insertion. If open thoracotomy is done chest tube is deferred.👈👈Correct Answer - Hemothorax:

1. Hypotension 2. JVD 3. Muffled heart sounds- 👈👈Correct Answer - Becks Triad:

Needle pericardiocentesis, but it is a temp solution. Requires surgical evaluation.

(Ultrasound guided)- 👈👈Correct Answer - Cardiac Tamponade Intervention:

Aortic Dissection- 👈👈Correct Answer - Unequal extremity pulse strength possibility of..

1. pain - hallmark sign, early sign 2. pressure - early sign 3. pallor, pules, paresthesia, paralysis - late sign- 👈👈Correct Answer - Six P's of compartment syndrome:

Pediatric Assessment Triangle 1. General appearance - muscle tone, interactiveness, consoloability, poor or gaze, speech or cry 2. Work of breathing - inadequate or excessive, accessory muscle use, retractions, tripod position, abnormal upper airway sounds 3. Circulation of the skin - color, mottling or central or peripheral cyanosis, diaphoresis- 👈👈Correct Answer - PAT

brachial pulse- 👈👈Correct Answer - Under age of 1 where do you find a pulse

What are the greatest risks for transport?- 👈👈Correct Answer - Loss of airway patency, displaced obstructive tubes lines or catheters, dislodge splinting devices, need to replace or reinforce dressings, deterioration in patient status change in vital signs or level of consciousness, injury to the patient and/or team members

According to newtons law which of these two force is greater: size or force?- 👈👈Correct Answer Neither. For each force there is an equal and opposite reaction.

What is the relationship between mass and velocity to kinetic energy?- 👈👈Correct Answer - Kinetic energy is equal to 1/2 the mass multiplied the square of its velocity therefore when mass is doubled so is the net energy, however, when velocity is doubled energy is quadrupled.

What is tension?- 👈👈Correct Answer - stretching force by pulling at opposite ends

What is compression?- 👈👈Correct Answer - Crushing by squeezing together

What is bending?- 👈👈Correct Answer - Loading about an axis. Bending causes compression on the side the person is bending toward intention to the opposite side

What is shearing?- 👈👈Correct Answer - Damage by tearing or bending by exerting faucet different parts in opposite directions at the same time.

What is torsion?- 👈👈Correct Answer - Torsion forces twist ends in opposite directions.

What is combined loading?- 👈👈Correct Answer - Any combination of tension compression torsion bending and/or shear.

What are the four types of trauma related injuries?- 👈👈Correct Answer - Blunt, penetrating, thermal, or blast.

What are contributing factors to injuries related to blunt traumas?- 👈👈Correct Answer - The point of impact on the patient's body, the type of surface that is hit, the tissues ability to resist (bone versus soft tissue, air-filled versus solid organs), and the trajectory of force.

What are the seven patterns of pathway injuries related to motor vehicle accidents?- 👈👈Correct Answer - Up and over, down and under, lateral, rotational, rear, roll over, and ejection.

Differentiate between the three impacts of motor vehicle impact sequence.- 👈👈Correct Answer - The first impact occurs when the vehicle collided with another object. The second impact occurs after the initial impact when the occupant continues to move in the original direction of travel until they collide with the interior of the vehicle or meet resistance. The third impact occurs when internal structures collide within the body cavity.

What are the three factors that contribute to the damage caused by penetrating trauma's?👈👈Correct Answer - The point of impact, the velocity and speed of impact, and the proximity to the object.

What causes the primary effects of blast traumas?- 👈👈Correct Answer - The direct blast effects. Types of injuries include last long, tympanic membrane rupture and middle ear damage, abdominal hemorrhage and perforation, global rupture, mild Trumatic brain injury.

What causes the secondary effects of blast traumas?- 👈👈Correct Answer - Projectiles propelled by the explosion. Injuries include penetrating or blunt injuries or I penetration.

What causes the tertiary effects of blast traumas?- 👈👈Correct Answer - Results from individuals being thrown by the blast wind. Injuries include hole or partial body translocation from being thrown against a hard service: blunt or penetrating trauma's, fractures, traumatic amputations.

What causes quarternary effects of blast traumas?- 👈👈Correct Answer - All explosion related injuries, illnesses, or diseases not due to the first three mechanisms. Injuries include external and internal burns, crush injuries, closed and open brain injuries, asthmatic or breathing problems from dust smoke or toxic fumes, angina, or hyper glycemia and hypertension.

What causes quinary effects of blasts traumas?- 👈👈Correct Answer - Those associated with exposure to hazardous materials from radioactive, biologic, or chemical components of a blast. Injuries include a variety of health effects depending on agent.

What are the three processes that transfer oxygen from the air to the lungs and blood stream👈👈Correct Answer - Ventilation: the active mechanical movement of air into and out of the lungs; diffusion: the passive movement of gases from an area of higher concentration to an area of lower

concentration; and perfusion: the movement of blood to and from the lungs as a delivery medium of oxygen to the entire body.

When would you use a nasopharyngeal airway versus an oral pharyngeal airway?- 👈👈Correct Answer Nasopharyngeal airways is contraindicated in patients with facial trauma or a suspected basilar skull fracture. Oral pharyngeal airways is used in unresponsive patients unable to maintain their airway, without a gag reflex as a temporary measure to facilitate ventilation with a bag mask device or spontaneous ventilation until the patient can be intubated.

Describe the measurement of an NPA- 👈👈Correct Answer - Measure from the tip of the patient's nose to the tip of the patients earlobe.

Measurement of an OPA- 👈👈Correct Answer - Place the proximal end or flange of the airway adjunct at the corner of the mouth to the tip of the mandibular angle.

True or false: NPAs and OPAs are definitive airways.- 👈👈Correct Answer - False. When placing one of these? One should consider the potential need for a definitive airway.

Name the three ways to confirm ETT placement- 👈👈Correct Answer - Placement of a CO2 monitoring device, Assessing for equal chest rise and fall, and listening at the epigastrium and four lung fields for equal breath sounds.

When capnography measurement reads greater than 45MMHG, the nurse should consider increasing or decreasing the ventilation rate?- 👈👈Correct Answer - Increasing the ventilation rate. Doing so would allow the patient to blow off retained CO2.

When capnography measurement reads less than 35MMHG, the nurse should consider increasing or decreasing the ventilation rate?- 👈👈Correct Answer - Decreasing the ventilation rate. By doing so, the nurse allows the patient to retain CO2.

What are the three stages of shock- 👈👈Correct Answer - Compensated, decompensated or progressive, and irreversible.

What are the signs of compensated shock?- 👈👈Correct Answer - Anxiety, confusion, restlessness, increased respiratory rate, narrowing pulse pressure were diastolic increases yet systolic remains unchanged, tachycardia with bounding pulses, and decreased urinary output

What are the signs and symptoms of decompensated shock?- 👈👈Correct Answer - Decreased level of consciousness, hypertension, narrow pulse pressure, tachycardia with weak pulses, tachypnea, skin that is cool clammy and cyanotic, base access outside the normal range, and serum lactate levels greater than two to 4MMOL/L.

What are the signs and symptoms of irreversible shock?- 👈👈Correct Answer - Obtunded stuporous or comatose state, marked hypertension and heart failure, bradycardia with possible dysrhythmias, decreased and shallow respiratory rate, pale cool and clammy skin, kidney liver and other organ failure, severe acidosis, elevated lactic acid levels, worsening base access on ABGs, coagulopathies with petechiae purpura or bleeding.

What are the four types of shock?- 👈👈Correct Answer - Hypovolemic, Cardiogenic, Obstructive, & Distributive

What is the trauma triad of death?- 👈👈Correct Answer - hypothermia, acidosis, coagulopathy

Describe the characteristics of obstructive shock- 👈👈Correct Answer - Obstructive shock is it mechanical problem that results from hypoperfusion of the tissue due to an obstruction in either the vasculature or the heart resulting in decreased cardiac output. Some causes include a tension pneumothorax, cardiac tamponade, or venous air embolism on the right side of the heart during systole in the pulmonary artery.Signs include anxiety, muffled heart sounds, JVD, hypertension, chest pain, difficulty breathing, or pulses paradoxes.

Describe the characteristics of cardiogenic shock- 👈👈Correct Answer - Cardiogenic shock results from pump failure in the presence of adequate intravascular volume. Lack of cardiac output and an organ perfusion occurs secondary to a decrease in myocardial contractility and or valvular insufficiency. This can happen with blunt cardiac trauma or an MI. Symptoms can include low blood pressure increase heart rate and respiratory rate chest pain shortness of breath dysrhythmias increase troponin and pale cool moist skin

Describe the characteristics of distributive shock.- 👈👈Correct Answer - Distributive shock occurs as a result of Mel distribution of an adequate circulating blood volume with the loss of vascular tone or

increased permeability. This can occur with spinal cord injuries, sepsis, or anaphylaxis. Symptoms include low blood pressure heart rate respiratory rate preload and afterload, spinal tenderness, difficulty breathing, warm pink and dry skin with a cool core temperature.

Describe the characteristics of hypovolemic shock- 👈👈Correct Answer - Hypovolemia is caused by a decrease in the amount of circulating volume usually caused by massive bleeding, but also can be from vomiting and diarrhea. Characteristics include low blood pressure and preload, increase heart rate respiratory rate and afterload, with contractility unchanged. Signs include obvious bleeding, weak peripheral pulses, pale cool and moist skin, distended abdomen, pelvic fracture, or bruise swollen and deformed extremities especially long bones.

What is the recommended fluid bolus for a trauma?- 👈👈Correct Answer - 500 ML's of warmed isotonic crystalloid. Ongoing fluid boluses of 500 ML's should be given judiciously with constant reassessments after administration.

What is the minimum permissive hypertension and a trauma patient?- 👈👈Correct Answer - A systolic of greater than or equal to 90 MMHG

What is the minimum permissive oxygenation level of a trauma patient?- 👈👈Correct Answer - Greater than or equal to 94%

What is Cullen's sign and its significance?- 👈👈Correct Answer - Cullens sign is periumbilical bruising and is indicative of intraperitoneal bleeding

Define Cushing's triad- 👈👈Correct Answer - Bradycardia, progressive hypertension (widening pulse pressure), and decreased respiratory effort

What are the early signs of increased Intracranial pressure- 👈👈Correct Answer - headache, vomiting, behavioral changes that begin with restlessness and may progress to confusion, drowsiness, or impaired judgment

What are the late signs of Increased intracranial pressure- 👈👈Correct Answer - dilated, non-reactive pupil(s); abnormal motor posturing (flexion, extension, flaccidity); Cushing's triad, Unresponsive to per verbal and painful stimuli, bradycardia and decreased respiratory effort

What are the symptoms of a subdural hematoma?- 👈👈Correct Answer - Decreased LOC, nausea vomiting headache and ipsilateral pupillary changes

What is a trademark symptom of an epidural hematoma- 👈👈Correct Answer - Loss of consciousness then awake and alert then loss of consciousness

Define the characteristics of neurogenic shock- 👈👈Correct Answer - Distributive shock with a T6 or higher injury results and vasodilation, bradycardia, flushed warm dry skin. Risk for temperature instability. Nursing interventions include maintaining warmth and spinal stabilization.

Define the characteristics of spinal shock- 👈👈Correct Answer - Transient loss of function can include loss of reflexes and muscle tone below the level of industry with possible vascular response.

Describe the four types of spinal cord injury- 👈👈Correct Answer - Central cord injury results in greater weakness distally, anterior injury includes motor loss or weakness below the cord level of injury yet sensory is intact, Brown-Sequard (hemicord) is weak on one side with sensory deficit on opposite side, posterior cord syndrome although rare is when the patient is unable to use sense vibration in proprioception

Describe one fat embolism syndrome is most likely to occur in its characteristics- 👈👈Correct Answer With longform fractures. Tachycardia, Thrombocytopenia, and petechiae rash.

What is the Munro-Kellie doctrine?- 👈👈Correct Answer - Within the skull 80% his brain, 10% is blood, and 10% is CSF. Any increase of any of the products results in increased intracranial pressure.

What are the treatment goals for a TBI?- 👈👈Correct Answer - O2 saturation > or equal to 95%, systolic blood pressure > or equal to 100 MMHG, ICP < 15 MMHG, CPP > or equal to 60 MMHG, normal glycemia, hemoglobin > or equal to 7 g/DL, sodium 135-145, osmotic diuretics, anti-emetics, sedatives, anticonvulsants, head of bed at 30°, and neck at midline

TNCC Written Exam 2022 (92 Questions with 100% Correct Answers) 1. What is the best measure of the adequacy of cellular perfusion and helps predict the outcome of resuscitation? - ✔✔Base deficit used in conjunction with serum lactate

2. Will hypocapnia cause vasoconstriction or vasodilation, especially in the cerebral vasculature? ✔✔Vasoconstriction

3. What results from tissue hypo perfusion and oxygen deficit? - ✔✔Metabolic acidosis

4. What type of shock results in generalized vasodilation? - ✔✔Neurogenic shock

5. Spinal cord injuries at C3-C5 causes loss of what nerves function, resulting in what? - ✔✔Phrenic nerve; paralyzed diaphragm and inability to breath

6. Extremity elevation AT the level of the heart is beneficial for what type of injury? ✔✔Compartment Syndrome

7. What is a high risk of frostbite? - ✔✔Thrombus formation

8. What two medications can be administered to maintain perfusion after a frostbite injury along with rewarming? - ✔✔Tissue plasminogen activator or non steroidal anti-inflammatory medication (NSAIDS)

9. An rise in diastolic blood pressures is a sign of increasing what? - ✔✔Peripheral resistance

10. What position will benefit the airway and work of breathing for the bariatric patient? ✔✔Reverse Trendelenburg

11. Which phase of a blast results from flying debris, projectiles, and bomb fragments causing lacerations or penetrating injuries? - ✔✔Secondary Phase

12. What phase of a blast results from any explosion-related illness or injury including hyperglycemia, hypertension, angina, asthma, COPD, or sepsis? - ✔✔Quaternary Phase

13. What phase of a blast results from individuals being thrown by the blast and impacting walls, ground, or any hard object? - ✔✔Tertiary Phase

14. What phase of a blast results from impact of the over and under pressurization wave with body surfaces. Injuries include blast lung, tympanic membrane rupture, abdominal hemorrhage, globe rupture, and mild traumatic brain injury? - ✔✔Primary Phase

15. Signs of what include muscle pain or weakness, dark red or brown urine, general weakness or malaise, and elevated creatinine kinase levels? - ✔✔Rhabdomyolosis

16. Signs of what include anxiety, pleuritic chest pain, dyspnea, hypoxemia, hemoptysis, cough, orthopnea, adventitious lung sounds, decreased lung sounds, jugular vein distention, or hypotension? - ✔✔Pulmonary Embolus

17. Signs of what include headache, nausea and vomiting, amnesia, behavioral changes, altered level of consciousness? - ✔✔Increased intracranial pressure

18. Signs of what include asymmetric pupillary reactivity, unilateral dilation, widening pulse pressure, abnormal motor posturing, bradycardia, and decreased respiratory effort? - ✔✔Late signs of increased ICP with Herniation Syndrome

19. What is caused by the tear of the bridging veins or middle meningeal artery? - ✔✔Subdural and Epidural Hematoma

20. Affect concentration, memory, sleep, mode, and libido. Causes headaches, dizziness and nausea.

- ✔✔Postconcussive Syndrome/ Mild Traumatic Brain Injury

21. Signs and symptoms similar to early signs of increased ICP but do not worsen. ✔✔Postconcussive Syndrome/ Mild Traumatic Brain Injury

22. Cerebral Perfusion Pressure = ______-______ - ✔✔MAP - ICP

23. What is the range for CO2 to maximize perfusion? - ✔✔35-45

24. Does hypoventilation cause dilation or constriction? Increase or decrease ICP? - ✔✔Dilation and increase in ICP due to high CO2

25. Hyperventilation cause dilation or constriction? - ✔✔Constriction d/t low CO2

26. Pupils with pressure on cranial nerve - ✔✔Fixed and dilated

27. Pupils with opiates vs stimulants - ✔✔small; large

28. Pupils with anticholinergics such as atropine, ipratropium, and scopolamine - ✔✔large

29. Sluggish reaction of pupils is an early sign of what? - ✔✔Increasing ICP

30. Glasgow Coma Score with Mild, Moderate, and Severe TBI - ✔✔Mild = 13-15 Moderate = 9-12 Severe = 3-8

31. Goal value for ICP - ✔✔<15

32. Goal value for Cerebral Perfusion Pressure (CPP) - ✔✔>60

33. Le Fort Fracture - ✔✔Fracture of the maxilla

34. What decrease ICP by decreasing cellular edema? - ✔✔Osmotic diuretics (such as 3% saline and mannitol)

35. Becks Triad is a sign of what? And includes what three symptoms? - ✔✔Cardiac Tamponade; 1. Hypotension 2. JVD 3. Muffled heart sounds

36. What is pulsus paradoxus? And what is it a sign of? - ✔✔Drop in blood pressure with inspiration, sign of cardiac tamponade

37. Tachycarida, weak pulses, hypotension, cool periphery, delayed cap refill, anxiety and agitation are signs of what type of shock? Seen with what? - ✔✔Obstructive Shock; Cardiac Tamponade

38. Persistent blood loss following chest tube insertion is a sign of what? - ✔✔Hemothorax

39. Ipsilateral diminished breath sounds and chest movement is a sign of what? - ✔✔Hemothorax

40. Tearing chest/back pain, unequal blood pressure and pulses are a sign of what? Caused by a high mechanism of injury. - ✔✔Thoracic Aortic Disruption

41. Dysrhythmia, ischemic changes, and persistent unexplained tachycardia are signs of what? ✔✔Myocardial contusion from Blunt Cardiac Injury

42. Decreased/absent breath sounds ipsilaterally, JVD, hypotension, and tracheal deviation to the contralateral side (late sign) is seen with what? Can lead to what? - ✔✔Tension Pneumothorax; PEA

43. Hemoptysis, ineffective cough, crackles in affected lung, hypoxia/hypercapnia, and alveolar opacities are signs of what? - ✔✔Pulmonary Contusion

44. Paradoxical chest wall movement, bony crepitus, rib segment depressed with inhalation and elevated with exhalation are signs of what? - ✔✔Flail Chest (caused by chest wall injury)

45. Open wound on chest wall resulting in sucking sound, decreased breath sounds, chest movement, and hyper-resonance ipsilaterally, subcutaneous emphysema, and tachycardia are signs of what? - ✔✔Open Pneumothorax

46. Hear bowel sounds in chest and Kehr's sign seen with what? - ✔✔Traumatic Diaphragmatic Tear

47. Referred pain down the left shoulder; indicative of a ruptured spleen. - ✔✔Kehr's Sign

48. Diaphragmatic Tears are seen with what types of injuries? - ✔✔Penetrating injuries between T4T12, or rapid deceleration causing severe blunt trauma to the torso.

49. Incision with blood clot, edges approximated with suture closer, and results in a fine scar. This is __________ Intention. - ✔✔Primary

50. Irregular large wound with blood clot, no closure, granulation tissue fills in the wound, results in large scar. This is ________ Intention. - ✔✔Secondary

51. Contaminated wound, granulation tissue, delayed closure with suture. This is _______ Intention.

- ✔✔Tertiary

52. Soft, dry, red wound with intact skin that blanches with pressure. No blistering or sloughing.

What degree burn? - ✔✔First degree; superficial

53. Moist wound, weeping, red or pink edematous skin that blanches with pressure, some blisters.

What degree burn? - ✔✔Second degree; superficial partial thickness

54. Wet, waxy, red to pale skin that does not blanch, multiple sisters. What degree burn? ✔✔Second degree; deep partial thickness

55. Waxy white to leathery gray to charred skin that is dry and firm with absent hair, no blanching.

What degree burn? - ✔✔Third degree; full thickness

56. Burn extends into the fascia and/or muscle. What degree burn? - ✔✔Fourth degree; full thickness

57. Zones of burn injury (3) - ✔✔Zone of coagulation Zone of stasis Zone of hyperemia

58. What syndrome occurs most often in burns greater than 20% BSA and lasts for approximately 612 hours? - ✔✔Capillary Leak Syndrome

59. Fluid replacement goals/calculation - ✔✔2mL/kg LR x TBSA% (give 1/2 over first 8 hours (minus transport time) and 1/2 over next 16 hours)

60. Urine Output goals for fluid replacement therapy - ✔✔0.5 mL/kg (30-50mL/hr)

61. Disaster Definition - ✔✔A sudden calamitous event that seriously disrupts the functioning of a community or society and causes human, material, and economic losses that exceed the community's or society's ability to cope using its own resources.

62. Mitigation - ✔✔A foundation to limit the potential impact of a disaster

63. Triage colors and meanings: - ✔✔Green - minor, walking wounded Yellow - delayed Red - immediate Black - expectant, deceased

64. When should the decision to transfer be made? - ✔✔When the patient's needs outweigh the capabilities of your facility

65. Tertiary care facility, teaching hospital, comprehensive care from resuscitation or rehabilitation, research, injury prevention. - ✔✔Level 1 Trauma Center

66. Trauma rescucitation and definitive trauma care. Specialty and rehabilitation care may not be as comprehensive, may not conduct research. - ✔✔Level 2 Trauma Center

67. Provides ATLS assessment, intervention, resuscitation and emergency surgery. Generally does not accept transfers. - ✔✔Level 3 Trauma Center

68. Provides ATLS assessment, intervention, and resuscitation. May be in a remote area, has 24 hour physician and NP coverage. - ✔✔Level 4 Trauma Center

69. Greatest risk to the patient during interfaculty transfer/transport? - ✔✔Loss of airway and respiratory compromise

70. What survey is a complete exam within 24 hours of arrival and identified injuries missed during primary assessment, reviews radiology studies, orders more studies, and assesses for hidden injuries? - ✔✔Tertiary Survey

71. Stages of shock - ✔✔1. Compensatory Shock 2. Decompensatory Shock (progressive, hypotensive) 3. Irreversible Shock

72. Anxiety, confusion, restlessness, narrowing pulse pressure, tachycardia, bounding pulse, and decreasing urinary output are signs of what? - ✔✔Compensated Shock

73. Decreased level of consciousness, hypotension, narrowed pulse pressure, tachycardia with weak pulse, tachypnea, and cool, clammy, cyanotic skin are signs of what? ✔✔Decompensated/Progressive shock

74. Obtunded/comatose, profound hypotension, bradycardia, dysrhythmias, slow shallow respirations, petechiae/purpura are signs of what? - ✔✔Irreversible shock

75. Benefits of the trauma nursing process - ✔✔Systematic approach to the evaluation of each trauma patient. Identifies life-threatening conditions, determines priorities of care.

76. Efficient production of ATP, which maintains cellular metabolic function, is seen with what type of metabolism? - ✔✔Aerobic metabolism

77. Inefficient production of ATP, byproduct is lactic acid, leads to metabolic acidosis, cellular dysfunction leads to cell death with what type of metabolism? - ✔✔Anaerobic metabolism

78. The cellular process in which oxygen is used to metabolize glucose. Energy is produced in an efficient manner with minimal waste products. - ✔✔Aerobic metabolism

79. The cellular process in which glucose is metabolized into energy without oxygen. Energy is produced in an inefficient manner with many waste products. - ✔✔Anaerobic metabolism

80. What is included in the Trauma Triad of Death? - ✔✔Coagulopathy Acidosis Hypothermia

81. Pump failure, caused by blunt cardiac injury, dysrhythmias, or myocardial infarction is what type of shock? - ✔✔Cardiogenic Shock

82. What type of shock is caused by cardiac tamponade or tension pneumothorax? Ventricular failure is seen. - ✔✔Obstructive Shock

83. Reservoir depletion and hemorrhage cause which type of shock? - ✔✔Hypovolemic Shock

84. Vasodilation, anaphylaxis, sepsis, and spinal cord injuries cause which type of shock? ✔✔Distributive Shock

85. Options for hemorrhage - ✔✔Pressure at site, tourniquet, hemostatic dressings, Massive Transfusion Protocol, Tranexamic Acid (clotting promoter)

86. Treatment for cariogenic shock - ✔✔inotropic support, anti-dysrhythmic medications, treat myocardial infarction or other underlying cause

87. Treatment for obstructive shock - ✔✔pericardiocentesis, cardiac window, needle decompression, position pregnant patient on L side

88. Treatment for distributive shock - ✔✔Support ventilations, vasopressors, pain management, apply warming methods

89. Treatment for hypovolemic shock - ✔✔Tourniquet, 1:1:1 blood products, massive transfusion protocol, TXA, surgical repair

90. Subdural hematoma is caused by tearing of the ______ veins and symptoms usually present within ____ hours of the accident. - ✔✔Bridging; 72

91. Epidural hematoma is caused by an arterial or venous bleed? Sx are transient LOC followed by a lucid period. - ✔✔Arterial

92. Hyperventilation causes cerebral blood vessels to do what? - ✔✔Constrict

TNCC - Trauma Nursing Core Course Exam 2022 Study Guide 1. Preparation and Triage 2. Primary Survery (ABCDE) with resuscitation adjuncts (F,G) 3. Reevaluation (consideration of transfer) 4. Secondary Survey (HI) with reevaluation adjuncts 5. Reevaluation and post resuscitation care 6. Definitive care of transfer to an appropriate trauma nurse - ✔✔Initial Assessment

1. A- airway and Alertness with simultaneous cervical spinal stabilization 2. B- breathing and Ventilation 3. circulation and control of hemorrhage 4. D - disability (neurologic status) 5. F - full set of vitals and Family presence 6. G - Get resuscitation adjuncts L- Lab results (arterial gases, blood type and crossmatch) M- monitor for continuous cardiac rhythm and rate assessment N- naso or orogastric tube consideration O- oxygenation and ventilation analysis: Pulse oxygemetry and end-tidal caron dioxide (ETC02) monitoring and capnopgraphy H- History and head to toe assessment I- Inspect posterior surfaces - ✔✔ABCDEFGHI

Before the arrival of the pt - ✔✔When should PPE be placed:

Pt is at hospital in the right amount of time, right care, right trauma facility, right resources - ✔✔Safe Care:

Uncontrolled Hemorrhage - ✔✔Major cause of preventable death:

reorganize care to C-ABC - ✔✔If uncontrolled hemorrhage ..

Used at the beginning of the initial assessment

1. A Alert. If the pt is alert he or she will be able to maintain his or her airway once it is clear.

2. V responds to verbal stimuli responds to pain. If the patient needs verbal stimulation to respond, an airway adjunct may be needed to keep the tongue from obstructing the airway.

3. P responds to pain. If the pt. responds only to pain, he or she may not be able to maintain his or her airway adjunct may need to be placed while further assessment is made to determine the need for intubation.

4. U Unresponsive. If the pt. is unresponsive, announce it loudly to the team and direct someone to chk in the pt is pulseless while assessing if the cause of the problem is the airway. - ✔✔Airway and AVPU:

ask pt to pen his or her mouth - ✔✔While assessing airway the patient is alert and responds to verbal stimuli you should..

jaw thrust maneuver to open airway and assess for obstruction. If pt has a suspected csi, the jaw thrust procedure should be done by two providers. One provider can maintain c-spine and the other can perform the jaw thrust maneuver. - ✔✔While assessing airway pt is unable to open mouth, responds only to pain, or is unresponsive you should..

1. The tongue obstructing the airway 2. loose or missing teeth 3. foreign objects 4. blood, vomit, or secretions' 5. edema 6. burns or evidence of inhalation injury

Auscultiate or listen for: 1. Obstructive airway sounds such as snoring or gurgling

2. Possible occlusive maxillofacial bony deformity 3. Subcutaneous emphysema - ✔✔Inspect the mouth for:

1. Check the presence of adequate rise and fall of the chest with assisted ventilation 2. Absence of gurgling on auscultation over the epigastrium 3. Bilateral breath sounds present on auscultation 4. Presence of carbon dioxide (CO2) verified by a CO2 device or monitor - ✔✔If the pt has a definitive airway in what should you do?

1. Suction the airway 2, Use care to avoid stimulating the gag reflex 3. If the airway is obstructed by blood or vomitus secretions, use a rigid suction device If foreign body is noted, remove it carefully with forceps or another appropriate method - ✔✔If Airway is not patent

1. Apnea 2. GCS 8 or less 3. Maxillary fractures 4. Evidence of inhalation injury (facial burns) 5. Laryngeal or tracheal injury or neck hematoma 6. High risk of aspiration and patients inability to protect the airway 7. Compromised or ineffective ventilation - ✔✔Following conditions might require a definitive airway

Breathing: To assess breathing expose the chest: 1. Inspect for a. spontaneous breathing b. symmetrical rise and fall c. depth, pattern, and rate of respiration d. signs of difficulty breathing such as accessory muscle use

e. skin color (normal, pale, flushed, cyanotic) f. contusions, abrasions, deformities (flail chest) g. open pneumothoraces (sucking chest wounds) h. JVD i. signs of inhalation injury (singed nasal hairs, carbonaceous sputum) - ✔✔B

tracheal deviation and jvd - ✔✔Late signs of tension pneumo:

1. equal breath sounds bilaterally at the second intercostal space midclavicular line and the bases for fifth intercostal space at the axillary line - ✔✔Auscultate the chest for:

1. bony fractures and possible rib fractures, which may impact ventilation 2. palpate for crepitus 3. subcutaneous emphysema which may be a sign for a pneumothorax 4. soft tissue injury - ✔✔Palpate the chest for

1. open the airway, use jaw thrust 2. insert an oral airway 3. assist ventilations with a bag mask 4. prepare for definitive airway - ✔✔If breathing is absent..

trauma its need early supplemental oxygen, start with 15 mL O2 and titrate oxygen delivery. ✔✔Oxygen on trauma patients

Circulation and Control of Hemorrhage

Inspect first for any uncontrolled bleeding Skin color

palpate for central pulses - carotid and femoral - rate, rhythm, and strength Skin temp: cool, diaphoretic, or warm and dry - ✔✔C

apply direct pressure to bleeding

elevate extremity

apply pressure over arterial sites

Consider a pelvic binder for pelvic fractures

consider a tourniquet

cannulate two veins with large caliber IV - if unable to gain assess consider IO a. obtain labs, type and cross b. infuse warm isotonic fluids c. consider balanced resuscitation d. use rapid infusion device - ✔✔C Interventions:

Disability - Neurologic Status

1. Assess pupils for equality, shape, and reactivity (PERRL) 2. Assess GCS (eye opening, verbal response, and motor response) - ✔✔D

1. Get a CT 2. Consider ABG 's if decreased LOC 3. Consider glucose check - ✔✔D Interventions

Exposure and Environmental Control

Remove all clothes and assess for any obvious injuries and uncontrolled bleeding - ✔✔E

IF clothing is needed for evidence preserve in paper bag.

Maintain body temp - cover the pt, turn up heat in room, administer warm fluids - ✔✔E Interventions:

Full set of vitals and family presence - ✔✔F

Get Resuscitation Adjuncts L - Labs (maybe a lactic acid), a b g 's, blood type M - monitors N - naso or oro gastric tubes O Oxygen and ETC02 monitors P - pain assessment and management - ✔✔G

Reevaluation and Consider the need to Transfer - ✔✔Final step in primary survey

H,I - ✔✔Secondary Survery

History and Head to toe MIST - prehospital report MOI Injuries sustained S s/s in the field T treatment in the field if patients family present get a better hx on them - ✔✔H

Sample is part of history S symptoms associated with injury A allergies and tetanus status M meds currently on including anticoagulant therapy P past medical hx L last oral intake E Events and environment factors related to the injury - ✔✔SAMPLE

inspect for lacs, abrasions, asymmetry of facial expressions

palate for depressions and tenderness

look at ears for drainage - ✔✔Head to toe assessment: Head and face

immobilize cervical spine, tenderness, tracheal deviation - ✔✔Head to toe assessment: Neck and cervical spine

inspect, auscultate, palpate

any spontaneous breathing, rate, depth, and degree of effort, use of accessory muscles

lacs, contusions,

auscilate lung sounds and heart sounds - ✔✔Head to toe assessment: Chest

don't forget flanks!!!

inspect of lacs, puncture wounds, contusions,

auscultate then palpate:

bowel sounds?

any rigidity, guarding? begin with light palpation start to palpate with side that does not hurt

maybe do a fast scan? - ✔✔Head to toe assessment: Abdomen

any lacs? deformities? blood at the urtheral meatus

palpate pelvis with high pressure over the iliac wings downward and medially - ✔✔Head to toe assessment: pelvis and perineum

any deformities? bleeding? contusions, lacs? skin temp?? place splints on deformities, pulses - ✔✔Head to toe assessment: Extremities

inspect posterior surfaces

blogroll with at least 3 people. maintain c spine

take out backboard

Rectal tone per MD - ✔✔I

labs, wound care, tetanus, administer meds, prepare for transfer - ✔✔Secondary Reval Adjuncts

Vital signs

Interventions Primary survey Pain - ✔✔Post resuscitation care parameters that are continuously evaluated:

Capnography monitors numeric value, as well as continuous waveform, indicating real-time measurement and trending over time. - ✔✔Quantitative:

Colorimetric CO2 detectors provide info about the presence or absence of CO2. A chemically treated indicator strip changes color revealing the presence or absence of exhaled CO2 - ✔✔Qualitative

D displaced tube O obstructed or kinked P pneumothorax E equipment failure , such as becoming detached from the equipment or loss of capnopgrahy - ✔✔DOPE

1. Preparation 2. Preoxygenation 3. Pretreatment 4. Paralysis and Induction 5. Protecting and positioning - v 6. Placement of proof - secure the tube 7. Post intubation - secure ETT Tube, get X-ray for placement - ✔✔Steps of Rapid Sequence Intubation

from hemorrhage is leading cause. Hypovolemia is caused by decrease in the amount of circulating volume. Goal is to replace volume. - ✔✔Hypovolemic Shock

results from hypo perfusion to the tissue due to an obstruction in either vasculature or heart. Goal is to relieve obstruction and improve perfusion.

Ex: tension pneumo or cardiac tamponade are two classic examples that may result from trauma. ✔✔Obstructive Shock

Results 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.

Ex: MI's or dysrhythmia are common causes - ✔✔Cariogenic Shock

occurs as a result of maldistribution of an adequate circulating blood volume with the loss of vascular tone or increased permeability.

Ex: Anaphylactic - release of antihistamines Septic Shock - systemic release of bacterial endotoxins, resulting in increased vascular permeability and vasodilation. Neurogenic shock - spinal cord injury results of loss in sympathetic nervous system control of vascular tone.

Goal: Volume replacement and vasoconstriction - ✔✔Distributive Shock

A breath every 5 to 6 seconds: 10-12 ventilations per minute - ✔✔Bag mask ventilation

Stroke Volume X HR - ✔✔Cardiac Output =

.. activation: .... are found in the carotid sinus and along the aortic arch, are sensitive to the degree of stretch in the arterial wall. When the receptors sense a decrease in stretch, they stimulate the sympathetic nervous system to release Epi, norepi, causing stimulation of cardiac activity and constriction of blood vessels, which causes a rise in heart rate and diastolic blood pressure ✔✔Baroreceptors:

activation: consist of carotid and aortic bodies. ... detect changes in blood oxygen and Co2 and pH. When Co2 rises or oxygen level of pH falls these receptors are activated and information is relayed to the CNS and the cardiorespiratory centers in the medulla , which increases respiratory rage and depth and BP - ✔✔Chemoreceptors:

50 to 150 - ✔✔MAP Range

the decrease coagulopathy .. you will you bleed more - ✔✔The colder you are the more acidic you are..

in massive transfusion protocol... responsible for dissolving clots - ✔✔TXA

stabilized vital signs, improved mental status, improved urine output - ✔✔What are indicators of increased perfusion?

- ✔✔Prehospital shock index pg. 85

Flail chest - ✔✔Paradoxical chest wall movement

can be caused by blunt trauma. air escapes from injured lung to pleural space and negative intrapleural pressure is lost causing partial or collapsed lung - ✔✔Simple Pneumothorax

1. Dyspnea 2. Tachycardia 3. Decreased or absent breath sounds on the injured side 4. CP - ✔✔Simple Pneumo assessment:

Tx is based on size, presence of sx, and stability. For those are aysmpomatic and stable. Observation with or without oxygen. Larger pneumo who are unstable or likely to deteriorate a chest tube is placed. ✔✔Simple pneumo interventions:

can result from penetrating wound through chest wall causing air to be trapped in to the intrapleural place. Might hear "sucking"

Tx: nonporous dressing tapes on 3 sided, then Chest tube and would closure surgical repair. - ✔✔Open Pneumo:

Air cannot escape intrapleural space.. can begin to compress heart. pt will have sever resp distress, hypotension, JVD. - ✔✔Tension pneumo

A 14 gauge needle that is inserted into the 2nd intercostal space in the midclavicular line on the affected side over the top of the rib to avoid neuromuscular bundle that runs under the rib.

Prepare for chest tube placement. - ✔✔Tension pneumo intervention

Caused by blood in the intrapleural space/ May also occur from lac to live or spleen combined with injury to the diaphragm.

Ensure two large bore IVS are placed.

Prepare for thoracentesis and chest tube insertion. If open thoracotomy is done chest tube is deferred. ✔✔Hemothorax:

1. Hypotension 2. JVD 3. Muffled heart sounds - ✔✔Becks Triad:

Needle pericardiocentesis, but it is a temp solution. Requires surgical evaluation.

(Ultrasound guided) - ✔✔Cardiac Tamponade Intervention:

Aortic Dissection - ✔✔Unequal extremity pulse strength possibility of..

1. pain - hallmark sign, early sign

2. pressure - early sign 3. pallor, pules, paresthesia, paralysis - late sign - ✔✔Six P's of compartment syndrome:

Pediatric Assessment Triangle 1. General appearance - muscle tone, interactiveness, consoloability, poor or gaze, speech or cry 2. Work of breathing - inadequate or excessive, accessory muscle use, retractions, tripod position, abnormal upper airway sounds 3. Circulation of the skin - color, mottling or central or peripheral cyanosis, diaphoresis - ✔✔PAT

brachial pulse - ✔✔Under age of 1 where do you find a pulse