TNCC 8th Edition test prep, TNCC Notes for Written Exam, TNCC EXAM, Exams of Nursing

Download TNCC 8th Edition test prep, TNCC Notes for Written Exam, TNCC EXAM and more Exams Nursing in PDF only on Docsity! TNCC 8th Edition test prep, TNCC Notes for Written Exam, TNCC EXAM 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? - Correct answer Expedite transfer to the closest trauma center Which of the following considerations is the most important when caring for a geriatric trauma pt? - Correct answer a pertinent medical hx is crucial 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? - Correct answer Mitigation 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? - Correct answer Multiple requests for water What is the effect of hypothermia on the oxyhemoglobin dissociation curve? - Correct answer hemoglobin does not readily release O2 for use by the tissues Which of the following is a component of the trauma triad of death? - Correct answer acidosis 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? - Correct answer Complete Which of the following is an expected finding in a pt with a tube thoracstomy connected to a chest drainage system? - Correct answer flucuation in the water seal chamber 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? - Correct answer insert an oropharyngeal airway if there is no gag reflex 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? - Correct answer globe rupture 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? - Correct answer compensated 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? - Correct answer ventilate with a bag mask device When is the tertiary survey completed fora trauma pt? - Correct answer within 24 hrs of trauma 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? - Correct answer pressure Which of the following is possible complication of positive-pressure ventilation? - Correct answer worsening pneumothorax the most reassuring finding for a male pt with hip pain after a fall is which of the following? - Correct answer pelvic stability to her forehead and complains of headache, dizziness, and nausea. What is the most likely cause of her symptoms? - Correct answer subdural hematoma 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? - Correct answer fat embolism Which of the following is a late sign of increased intracranial pressure? - Correct answer nausea and vomiting 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? - Correct answer serial FAST exams Which of the following is NOT considered goal-directed therapy for cardiogenic shock? - Correct answer pericardiocentesis The trauma nurse knows that placing a bariatric patient in a ramped position providers better visualization during the insertion of which device? - Correct answer endotracheal tube which of the following assessment findings differentiates a tension pneumothorax from a simple pneumothorax? - Correct answer increased work of breathing? if a pt has received multiple transfusions of banked blood preserved with citrate, which electrolyte is most likely to drop and require supplementation? - Correct answer calcium Which of the following is NOT considered a benefit of debriefings? - Correct answer identifying individuals who made mistakes during the traumatic event 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? - Correct answer 500 mL/hr Which of the following is most likely to contribute to inadequate oxygenation and ventilation? - Correct answer advanced age Which of the following patients warrants referral to a burn center? - Correct answer a 52 y/o diabetic male with a partial thickness burn to the left lower leg 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? - Correct answer dressing removal 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? - Correct answer after a physical examination if the pt has no radiologic abnormalities on CT Which of the following mnemonics can help the nurse prioritize care for a trauma patient with massive uncontrolled hemorrhage? - Correct answer MARCH 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. - Correct answer What is kinematics? A body at rest will remain at rest. A body in motion will remain in motion until acted on by an outside force. - Correct answer What is Newton's First Law? Energy can neither be created nor destroyed. It is only changed from one form to another. - Correct answer What is the Law of Conservation of Energy? Force equals mass multiplied by acceleration of deceleration. - Correct answer What is Newton's Second Law? KE equals 1/2 the mass (M) multiplied by the velocity squared. - Correct answer What is kinetic energy (KE)? 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) - Correct answer What is the Mnemonic for the Initial Assessment? 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 - Correct answer What is the Mnemonic for the Secondary Assessment? Auscultate the lungs bilaterally at the second intercostal space midclavicular line and at the fifth intercostal space at the anterior axillary line. - Correct answer Where do you listen to auscultate breath sounds? - Tracheal deviation - JVD - Correct answer What are the late signs of breathing compromise? - 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 - I = Injuries sustained - V = Vital Signs - T = Treatment - Pt generated information - PMH - Head-to-toe assessment - Correct answer What is assessed under the Mnemonic "H"? 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 - Correct answer What is assessed under the Mnemonic "I"? Reassess: - Primary survey, - VS - Pain - Any injuries - Correct answer What she be done after the Secondary Assessment? - 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 - Correct answer What are factors that contribute to ineffective ventilation? LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents - Correct answer What medications are used during intubation? 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 - Correct answer What are the Rapid Sequence Intubation Steps? 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. - Correct answer What is a Combitube? 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. - Correct answer What is a Laryngeal Mask Airway? Percutaneous transtracheal ventilation. (temporary) Complications include: - inadequate ventilation causing hypoxia - hematoma formation - esophageal perforation - aspiration - thyroid perforation - subcutaneous emphysema - Correct answer What is Needle Cricothyrotomy 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 - Correct answer What is Surgical Cricothyrotomy? - 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 - Correct answer How do you confirm ET Tube/Alternative Airway Placement? Observe: - mental status - RR and pattern - chest wall symmetry - any injuries - patient's skin color (cyanosis?) - JVD or tracheal deviation? (Tension pneumothorax) - Correct answer How do you inspect the chest for adequate ventilation? Absence of BS: - Pneumothorax - Hemothorax 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. - Correct answer What is renal response? 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. - Correct answer Explain adrenal gland response. 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. - Correct answer Explain Hepatic Response. 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. - Correct answer Explain Pulmonary Response. 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. - Correct answer Explain Irreversible Shock. (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? - Correct answer How would you assess someone in hypovolemic shock? 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. - Correct answer ICP is a reflection of what three volumes? What happens when one increases? - Anxiety - Depression - Correct answer What are the signs and symptoms of postconcussive syndrome? (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 - Correct answer What is diffuse axonal injury and its signs and symptoms? 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 - Correct answer What is a cerebral contusion and its S/S? 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 - Correct answer What is an epidural hematoma and its S/S? 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 - Correct answer What is a subdural hematoma and its S/S? 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 - Correct answer What are intracerebral hematoma's and its S/S? - H/A - Possible decreased LOC - Correct answer What are the S/S of a linear skull fx? - H/A - Possible decreased LOC - Possible open fx - Palpable depression of skull over the fx site - Correct answer What are the S/S of a depressed skull fx? - 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 - Correct answer What are the S/S of a basilar skull fx? (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 - 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 - Correct answer What are the mandibular fracture S/S? - 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) - Correct answer What are neck injury S/S? (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 dila - Correct answer How would you assess a patient with ocular, maxillofacial and neck trauma? - 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 d - Correct answer What are the nursing interventions for a pt with an ocular injury? - 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 - Correct answer What are the nursing interventions for a patient with a maxillofacial or neck injury? - 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 - Correct answer With any eye injury, what should the evaluation and ongoing assessments be? blunt; MVC's. Penetrating; firarm injuries or stabbings - Correct answer What are the most common type of injury associated with chest trauma? - 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 - Correct answer What are S/S of a rib fracture? 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. - Correct answer What is a flail chest? - Ineffective ventilation - Pulmonary contusion - Lacerated lung parenchyma - Correct answer What could a flail chest be associated with? - Dyspnea - Decreased breath sounds on injured side - Correct answer What are S/S of a ruptured diaphragm? 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 - Correct answer What are S/S with tracheobronchial injury? "Cardiac contusion" or "concussion." Common with MVC or falls from heights. - ECG (sinus tach, PVC's, AV blocks) - Chest pain - Chest wall ecchymosis - Correct answer What are S/S with blunt cardiac injury? 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 - Correct answer What are the S/S of pericardial tamponade? - 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 - Correct answer What are aortic injuries S/S? (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 extremi - Correct answer How would you assess a pt with a thoracic injury? p. 142 - Correct answer What is the planning and implementation for thoracic injury? 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. - Correct answer What is kinematics? A body at rest will remain at rest. A body in motion will remain in motion until acted on by an outside force. - Correct answer What is Newton's First Law? Energy can neither be created nor destroyed. It is only changed from one form to another. - Correct answer What is the Law of Conservation of Energy? Force equals mass multiplied by acceleration of deceleration. - Correct answer What is Newton's Second Law? KE equals 1/2 the mass (M) multiplied by the velocity squared. - Correct answer What is kinetic energy (KE)? 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) - Correct answer What is the Mnemonic for the Initial Assessment? 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 - Correct answer What is the Mnemonic for the Secondary Assessment? Auscultate the lungs bilaterally at the second intercostal space midclavicular line and at the fifth intercostal space at the anterior axillary line. - Correct answer Where do you listen to auscultate breath sounds? - Tracheal deviation - JVD - Correct answer What are the late signs of breathing compromise? - 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 - MIVT - M = Mechanism of injury - I = Injuries sustained - V = Vital Signs - T = Treatment - Pt generated information - PMH - Head-to-toe assessment - Correct answer What is assessed under the Mnemonic "H"? 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 - Correct answer What is assessed under the Mnemonic "I"? Reassess: - Primary survey, - VS - Pain - Any injuries - Correct answer What she be done after the Secondary Assessment? - 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 - Correct answer What are factors that contribute to ineffective ventilation? LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents - Correct answer What medications are used during intubation? 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 - Correct answer What are the Rapid Sequence Intubation Steps? 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. - Correct answer What is a Combitube? 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. - Correct answer What is a Laryngeal Mask Airway? Percutaneous transtracheal ventilation. (temporary) Complications include: - inadequate ventilation causing hypoxia - hematoma formation - esophageal perforation - aspiration - thyroid perforation - subcutaneous emphysema - Correct answer What is Needle Cricothyrotomy 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 - Correct answer What is Surgical Cricothyrotomy? - 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 - Correct answer How do you confirm ET Tube/Alternative Airway Placement? Observe: - mental status - RR and pattern - chest wall symmetry - any injuries - patient's skin color (cyanosis?) - JVD or tracheal deviation? (Tension pneumothorax) - Correct answer How do you inspect the chest for adequate ventilation? Absence of BS: constrict to increase TPR and BP. - Correct answer What is vascular response? 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. - Correct answer What is renal response? 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. - Correct answer Explain adrenal gland response. 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. - Correct answer Explain Hepatic Response. 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. - Correct answer Explain Pulmonary Response. 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. - Correct answer Explain Irreversible Shock. (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? - Correct answer How would you assess someone in hypovolemic shock? 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 - Irritability - Insomnia - Impaired judgement - Loss of libido - Anxiety - Depression - Correct answer What are the signs and symptoms of postconcussive syndrome? (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 - Correct answer What is diffuse axonal injury and its signs and symptoms? 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 - Correct answer What is a cerebral contusion and its S/S? 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 - Correct answer What is an epidural hematoma and its S/S? 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 - Correct answer What is a subdural hematoma and its S/S? 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 - Correct answer What are intracerebral hematoma's and its S/S? - H/A - Possible decreased LOC - Correct answer What are the S/S of a linear skull fx? - H/A - Possible decreased LOC - Possible open fx - Palpable depression of skull over the fx site - Correct answer What are the S/S of a depressed skull fx? - 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 - Correct answer What are the S/S of a basilar skull fx? (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 - 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 - Correct answer What are the mandibular fracture S/S? - 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) - Correct answer What are neck injury S/S? (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 dila - Correct answer How would you assess a patient with ocular, maxillofacial and neck trauma? - 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 d - Correct answer What are the nursing interventions for a pt with an ocular injury? - 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 - Correct answer What are the nursing interventions for a patient with a maxillofacial or neck injury? - 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 - Correct answer With any eye injury, what should the evaluation and ongoing assessments be? blunt; MVC's. Penetrating; firarm injuries or stabbings - Correct answer What are the most common type of injury associated with chest trauma? - 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 - Correct answer What are S/S of a rib fracture? 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. - Correct answer What is a flail chest? - Ineffective ventilation - Pulmonary contusion - 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 - Correct answer What are S/S of a ruptured diaphragm? 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 - Correct answer What are S/S with tracheobronchial injury? "Cardiac contusion" or "concussion." Common with MVC or falls from heights. - ECG (sinus tach, PVC's, AV blocks) - Chest pain - Chest wall ecchymosis - Correct answer What are S/S with blunt cardiac injury? 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 - Correct answer What are the S/S of pericardial tamponade? - 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 - Correct answer What are aortic injuries S/S? (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 extremi - Correct answer How would you assess a pt with a thoracic injury? p. 142 - Correct answer What is the planning and implementation for thoracic injury? Is the study of energy transfer as it applies to identifying actual or potential injuries. - Correct answer Kinematics Is the general study of forces and their effects. - Correct answer Biomechanics Is how external forces are transferred to the body, resulting in injury - Correct answer Mechanism of Injury an object in motion will remain in motion unless acted upon by another force - Correct answer Newton's First Law of Motion The acceleration of an object depends on the mass of the object and the amount of force applied. - Correct answer Newton's Second Law of Motion For every action there is an equal and opposite reaction - Correct answer Newton's Third Law of Motion Matter is neither created nor destroyed (but may change form) - Correct answer Law of Conservation of Energy 1. Mechanical 2. Thermal 3. Chemical 4. Electrical 5. Radiant - Correct answer What are the five forms in which energy exist? 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 - Correct answer Describe the 3 types of Internal forces of energy transfer in the context of trauma. 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 - Correct answer Describe the 3 types of external forces of energy transfer in the context of trauma. Blunt: The result of a broad energy impact across a large surface area. Penetrating: The - Correct answer List the four main types of traumatic injury and give an example 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. Initial Assessment - 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 ABCDEFGHI - Correct answer 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 When should PPE be placed: - Correct answer Before the arrival of the pt Safe Care: - Correct answer Pt is at hospital in the right amount of time, right care, right trauma facility, right resources Major cause of preventable death: - Correct answer Uncontrolled Hemorrhage If uncontrolled hemorrhage .. - Correct answer reorganize care to C-ABC Airway and AVPU: - Correct answer 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. While assessing airway the patient is alert and responds to verbal stimuli you should.. - Correct answer ask pt to pen his or her mouth While assessing airway pt is unable to open mouth, responds only to pain, or is unresponsive you should.. - Correct answer 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. Inspect the mouth for: - Correct answer 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 If the pt has a definitive airway in what should you do? - Correct answer 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 Airway is not patent - Correct answer 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 Following conditions might require a definitive airway - Correct answer 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 B - Correct answer 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) Late signs of tension pneumo: - Correct answer tracheal deviation and jvd Auscultate the chest for: - Correct answer 1. equal breath sounds bilaterally at the second intercostal space midclavicular line and the bases for fifth intercostal space at the axillary line if patients family present get a better hx on them SAMPLE - Correct answer 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 Head to toe assessment: Head and face - Correct answer inspect for lacs, abrasions, asymmetry of facial expressions palate for depressions and tenderness look at ears for drainage Head to toe assessment: Neck and cervical spine - Correct answer immobilize cervical spine, tenderness, tracheal deviation Head to toe assessment: Chest - Correct answer 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: Abdomen - Correct answer 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: pelvis and perineum - Correct answer any lacs? deformities? blood at the urtheral meatus palpate pelvis with high pressure over the iliac wings downward and medially Head to toe assessment: Extremities - Correct answer any deformities? bleeding? contusions, lacs? skin temp?? place splints on deformities, pulses I - Correct answer inspect posterior surfaces blogroll with at least 3 people. maintain c spine take out backboard Rectal tone per MD Secondary Reval Adjuncts - Correct answer labs, wound care, tetanus, administer meds, prepare for transfer Post resuscitation care parameters that are continuously evaluated: - Correct answer Vital signs Interventions Primary survey Pain Quantitative: - Correct answer Capnography monitors numeric value, as well as continuous waveform, indicating real-time measurement and trending over time. Qualitative - Correct answer 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 DOPE - Correct answer D displaced tube O obstructed or kinked P pneumothorax E equipment failure , such as becoming detached from the equipment or loss of capnopgrahy Steps of Rapid Sequence Intubation - Correct answer 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 Hypovolemic Shock - Correct answer from hemorrhage is leading cause. Hypovolemia is caused by decrease in the amount of circulating volume. Goal is to replace volume. Obstructive Shock - Correct answer 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. Cariogenic Shock - Correct answer 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 Distributive Shock - Correct answer 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. Cardiac Tamponade Intervention: - Correct answer Needle pericardiocentesis, but it is a temp solution. Requires surgical evaluation. (Ultrasound guided) Unequal extremity pulse strength possibility of.. - Correct answer Aortic Dissection Six P's of compartment syndrome: - Correct answer 1. pain - hallmark sign, early sign 2. pressure - early sign 3. pallor, pules, paresthesia, paralysis - late sign PAT - Correct answer 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 Under age of 1 where do you find a pulse - Correct answer brachial pulse 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 - Correct answer What are the greatest risks for transport? Neither. For each force there is an equal and opposite reaction. - Correct answer According to newtons law which of these two force is greater: size or force? 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. - Correct answer What is the relationship between mass and velocity to kinetic energy? stretching force by pulling at opposite ends - Correct answer What is tension? Crushing by squeezing together - Correct answer What is compression? Loading about an axis. Bending causes compression on the side the person is bending toward intention to the opposite side - Correct answer What is bending? Damage by tearing or bending by exerting faucet different parts in opposite directions at the same time. - Correct answer What is shearing? Torsion forces twist ends in opposite directions. - Correct answer What is torsion? Any combination of tension compression torsion bending and/or shear. - Correct answer What is combined loading? Blunt, penetrating, thermal, or blast. - Correct answer What are the four types of trauma related injuries? 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. - Correct answer What are contributing factors to injuries related to blunt traumas? Up and over, down and under, lateral, rotational, rear, roll over, and ejection. - Correct answer What are the seven patterns of pathway injuries related to motor vehicle accidents? 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. - Correct answer Differentiate between the three impacts of motor vehicle impact sequence. The point of impact, the velocity and speed of impact, and the proximity to the object. - Correct answer What are the three factors that contribute to the damage caused by penetrating trauma's? 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. - Correct answer What causes the primary effects of blast traumas? Projectiles propelled by the explosion. Injuries include penetrating or blunt injuries or I penetration. - Correct answer What causes the secondary 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. - Correct answer What causes the tertiary 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. - Correct answer What causes quarternary effects of blast 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. - Correct answer What causes quinary effects of blasts traumas? 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. - Correct answer What are the three processes that transfer oxygen from the air to the lungs and blood stream 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. - Correct answer When would you use a nasopharyngeal airway versus an oral pharyngeal airway? 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. - Correct answer Describe the characteristics of hypovolemic shock 500 ML's of warmed isotonic crystalloid. Ongoing fluid boluses of 500 ML's should be given judiciously with constant reassessments after administration. - Correct answer What is the recommended fluid bolus for a trauma? A systolic of greater than or equal to 90 MMHG - Correct answer What is the minimum permissive hypertension and a trauma patient? Greater than or equal to 94% - Correct answer What is the minimum permissive oxygenation level of a trauma patient? Cullens sign is periumbilical bruising and is indicative of intraperitoneal bleeding - Correct answer What is Cullen's sign and its significance? Bradycardia, progressive hypertension (widening pulse pressure), and decreased respiratory effort - Correct answer Define Cushing's triad headache, vomiting, behavioral changes that begin with restlessness and may progress to confusion, drowsiness, or impaired judgment - Correct answer What are the early 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 - Correct answer What are the late signs of Increased intracranial pressure Decreased LOC, nausea vomiting headache and ipsilateral pupillary changes - Correct answer What are the symptoms of a subdural hematoma? Loss of consciousness then awake and alert then loss of consciousness - Correct answer What is a trademark symptom of an epidural hematoma 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. - Correct answer Define the characteristics of neurogenic shock Transient loss of function can include loss of reflexes and muscle tone below the level of industry with possible vascular response. - Correct answer Define the characteristics of spinal shock 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 - Correct answer Describe the four types of spinal cord injury With longform fractures. Tachycardia, Thrombocytopenia, and petechiae rash. - Correct answer Describe one fat embolism syndrome is most likely to occur in its characteristics 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. - Correct answer What is the Munro-Kellie doctrine? 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 - Correct answer What are the treatment goals for a TBI?