TNCC Test Preparation Notes for Written Exam: 415Q & AS TNCC Prep, Exams of Health sciences

Download TNCC Test Preparation Notes for Written Exam: 415Q & AS TNCC Prep and more Exams Health sciences in PDF only on Docsity! TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] Expedite transfer to the closest trauma center - CORRECT ANSWERS 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 ANSWERS Which of the following considerations is the most important when caring for a geriatric trauma pt? Mitigation - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS What is the effect of hypothermia on the oxyhemoglobin dissociation curve? acidosis - CORRECT ANSWERS Which of the following is a component of the trauma triad of death? Complete - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS 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? TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] globe rupture - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS When is the tertiary survey completed fora trauma pt? pressure - CORRECT ANSWERS 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 ANSWERS Which of the following is possible complication of positive-pressure ventilation? pelvic stability - CORRECT ANSWERS the most reassuring finding for a male pt with hip pain after a fall is which of the following? narrowed - CORRECT ANSWERS Which of the following pulse pressures indicate early hypovolemic shock? dysrhythmias - CORRECT ANSWERS Patients with a crush injury should be monitored for which of the following conditions? subdural hematoma - CORRECT ANSWERS Tearing of the bridging veins is most frequently associated with which brain injury? TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] nausea and vomiting - CORRECT ANSWERS Which of the following is a late sign of increased intracranial pressure? serial FAST exams - CORRECT ANSWERS 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 ANSWERS Which of the following is NOT considered goal-directed therapy for cardiogenic shock? endotracheal tube - CORRECT ANSWERS 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 ANSWERS which of the following assessment findings differentiates a tension pneumothorax from a simple pneumothorax? calcium - CORRECT ANSWERS 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 ANSWERS Which of the following is NOT considered a benefit of debriefings? 500 mL/hr - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS Which of the following patients warrants referral to a burn center? TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] dressing removal - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS Which of the following mnemonics can help the nurse prioritize care for a trauma patient with massive uncontrolled hemorrhage? What is kinematics? - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS Energy can neither be created nor destroyed. It is only changed from one form to another. What is Newton's Second Law? - CORRECT ANSWERS Force equals mass multiplied by acceleration of deceleration. What is kinetic energy (KE)? - CORRECT ANSWERS KE equals 1/2 the mass (M) multiplied by the velocity squared. What is the Mnemonic for the Initial Assessment? - CORRECT ANSWERS A = Airway with simultaneous cervical spine protection B = Breathing C = Circulation TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] D = Disability (neurologic status) E = Expose/Environmental controls (remove clothing and keep the patient warm) What is the Mnemonic for the Secondary Assessment? - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS - Tracheal deviation - JVD What are signs of ineffective breathing? - CORRECT ANSWERS - 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 ANSWERS A tight-fitting nonrebreather mask at 12-15 lpm. TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] What is the second thing assessed under the Secondary Assessment? - CORRECT ANSWERS GIVE COMFORT MEASURES - Talking to pt - Pharmacologic/Nonpharmacologic pain management - Observe for physical signs of pain What is assessed under the Mnemonic "H"? - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS Reassess: - Primary survey, - VS - Pain - Any injuries TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] What are factors that contribute to ineffective ventilation? - CORRECT ANSWERS - 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 ANSWERS LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents What are the Rapid Sequence Intubation Steps? - CORRECT ANSWERS 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 TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - 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 ANSWERS 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 ANSWERS 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 ANSWERS Percutaneous transtracheal ventilation. (temporary) Complications include: - inadequate ventilation causing hypoxia - hematoma formation - esophageal perforation - aspiration - thyroid perforation - subcutaneous emphysema TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] Some causes: - Blood loss - Burns, etc. Explain Cardiogenic Shock. - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS 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. TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] 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 ANSWERS 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 ANSWERS 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 ANSWERS When adrenal glands are stimulated by SNS, release of catecholamines (epinephrine and norepinephrine) from adrenal medulla will increase. TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] 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 ANSWERS 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 ANSWERS 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 ANSWERS Shock uncompensated or irreversible stages will cause compromises to most body systems. - Inadequate venous return - inadequate cardiac filling TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] What are the late observable signs of symptoms of increased ICP? - CORRECT ANSWERS - 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 ANSWERS Triad of progressive HTN, bradycardia and diminished respiratory effort. What are the two types of herniation that occurs with ICP? - CORRECT ANSWERS 1. Uncal herniation 2. Central or transtentorial herniation Why does herniation occur? What are the symptoms? - CORRECT ANSWERS 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 ANSWERS 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. TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] Define central or transtentorial herniation. - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS GCS 13-15 Define Moderate Head Trauma - CORRECT ANSWERS Postresuscitative state with GCS 9-13. Define Severe Head Trauma. - CORRECT ANSWERS Postresuscitative state with GCS score of 8 or less. What is a concussion and its signs and symptoms? - CORRECT ANSWERS 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 TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] What are the signs and symptoms of postconcussive syndrome? - CORRECT ANSWERS - 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 ANSWERS (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 ANSWERS 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 TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED 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 ANSWERS - 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 ANSWERS (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 TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - 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. TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - 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 TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] 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 ANSWERS 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 ANSWERS - 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 ANSWERS - Dyspnea - Hemoptysis (coughing up blood) - Subcutaneous emphysema in neck, face, or suprasternal area TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - 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 ANSWERS (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 TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - 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) TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - Monitoring airway patency, respiratory effort and ABG's What are the most common type of injury associated with chest trauma? - CORRECT ANSWERS blunt; MVC's. Penetrating; firarm injuries or stabbings What are S/S of a rib fracture? - CORRECT ANSWERS - 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 ANSWERS 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 ANSWERS - Ineffective ventilation - Pulmonary contusion - Lacerated lung parenchyma What are the S/S of flail chest? - CORRECT ANSWERS - Dyspnea - Chest wall pain - Paradoxical chest wall movement - the flail segment moves in during inspiration and out during expiration. Define Pneumothorax. - CORRECT ANSWERS 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. TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] 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 ANSWERS - 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 ANSWERS 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 ANSWERS - 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 ANSWERS Accumulation of blood in the pleural space. What are the S/S of Hemothorax? - CORRECT ANSWERS - Dyspnea, tachypnea - Chest pain - Signs of shock TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - Decreased breath sounds on injured side - Dullness to percussion on the injured side What is a pulmonary contusion? - CORRECT ANSWERS 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 ANSWERS - Dyspnea - Ineffective cough - Hemoptysis - Hypoxia - Chest pain - Chest wall contusion or abrasions What happens to a ruptured diaphragm? - CORRECT ANSWERS 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 ANSWERS (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 TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - 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 ANSWERS p. 142 What is kinematics? - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS Energy can neither be created nor destroyed. It is only changed from one form to another. TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] What is Newton's Second Law? - CORRECT ANSWERS Force equals mass multiplied by acceleration of deceleration. What is kinetic energy (KE)? - CORRECT ANSWERS KE equals 1/2 the mass (M) multiplied by the velocity squared. What is the Mnemonic for the Initial Assessment? - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS - Tracheal deviation - JVD What are signs of ineffective breathing? - CORRECT ANSWERS - AMS - Cyanosis, especially around the mouth - Asymmetric expansion of chest wall TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - 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 ANSWERS A tight-fitting nonrebreather mask at 12-15 lpm. What intervention should be done if a pt presents with effective circulation? - CORRECT ANSWERS - Insert 2 large caliber IV's - Administer warmed isotonic crystalloid solution at an appropriate rate What are signs of ineffective circulation? - CORRECT ANSWERS - 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 ANSWERS - 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 TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - 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 ANSWERS Reassess: - Primary survey, - VS - Pain - Any injuries What are factors that contribute to ineffective ventilation? - CORRECT ANSWERS - 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 ANSWERS LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents What are the Rapid Sequence Intubation Steps? - CORRECT ANSWERS PREPARATION: - gather equipment, staffing, etc. TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] 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 ANSWERS 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 ANSWERS 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. TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] What is Needle Cricothyrotomy - CORRECT ANSWERS Percutaneous transtracheal ventilation. (temporary) Complications include: - inadequate ventilation causing hypoxia - hematoma formation - esophageal perforation - aspiration - thyroid perforation - subcutaneous emphysema What is Surgical Cricothyrotomy? - CORRECT ANSWERS 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 ANSWERS - 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 TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - 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 ANSWERS 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 ANSWERS 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 ANSWERS 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 TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - 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 ANSWERS 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 ANSWERS 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 ANSWERS Tachypnea happens for 2 reasons: 1. Maintain acid-base balance TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] 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 ANSWERS 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 ANSWERS (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 TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - AsyDimmetric pupillary reactivity - Abnormal motor posturing - Other evidence of neurologic deterioration Define uncal herniation. - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS GCS 13-15 Define Moderate Head Trauma - CORRECT ANSWERS Postresuscitative state with GCS 9-13. Define Severe Head Trauma. - CORRECT ANSWERS Postresuscitative state with GCS score of 8 or less. What is a concussion and its signs and symptoms? - CORRECT ANSWERS A temporary change in neurologic function that may occur as a result of minor head trauma. S/S: - Transient LOC - H/A TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED 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 ANSWERS - 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 ANSWERS (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 TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - 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 ANSWERS 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 ANSWERS 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 TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - 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. TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - 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 TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - 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 ANSWERS - Visual disturbances - Pain - Redness and ecchymosis of the eye - Periorbital ecchymosis - Increased intraocular pressure What is hyphema and its S/S? - CORRECT ANSWERS 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 TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - Blood behind, ruptured, tympanic membrane - Anesthesia of the lower lip What are neck injury S/S? - CORRECT ANSWERS - 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 ANSWERS (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? TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - 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 TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] 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 ANSWERS - 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 TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - Chest wall pain - Paradoxical chest wall movement - the flail segment moves in during inspiration and out during expiration. Define Pneumothorax. - CORRECT ANSWERS 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 ANSWERS - 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 ANSWERS 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 ANSWERS - 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) TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - Cyanosis (LATE sign) Define Hemothorax. - CORRECT ANSWERS Accumulation of blood in the pleural space. What are the S/S of Hemothorax? - CORRECT ANSWERS - 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 ANSWERS 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 ANSWERS - Dyspnea - Ineffective cough - Hemoptysis - Hypoxia - Chest pain - Chest wall contusion or abrasions What happens to a ruptured diaphragm? - CORRECT ANSWERS 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 ANSWERS (Anything below the nipple line and should be evaluated for potential diaphragmatic injury). TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] - 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 ANSWERS 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 ANSWERS "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 ANSWERS 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) TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] Biomechanics - CORRECT ANSWERS Is the general study of forces and their effects. Mechanism of Injury - CORRECT ANSWERS Is how external forces are transferred to the body, resulting in injury Newton's First Law of Motion - CORRECT ANSWERS an object in motion will remain in motion unless acted upon by another force Newton's Second Law of Motion - CORRECT ANSWERS 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 ANSWERS For every action there is an equal and opposite reaction Law of Conservation of Energy - CORRECT ANSWERS Matter is neither created nor destroyed (but may change form) What are the five forms in which energy exist? - CORRECT ANSWERS 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 ANSWERS 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 TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] Describe the 3 types of external forces of energy transfer in the context of trauma. - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS Describe the three impacts in the motor vehicle impact sequence - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS 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. TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] Countermeasures can be applied at each phase to help reduce injury. What assessment findings differentiate a placental abruption from a uterine rupture? - CORRECT ANSWERS What intervention is used to treat hypotension from aortocaval compression? - CORRECT ANSWERS Describe the activities and associated factors related to low-energy trauma in the older adult. - CORRECT ANSWERS List common injuries from falls in the older adult population. - CORRECT ANSWERS What condition is associated with a fall from which the older adult cannot rise? What complications result from this condition? - CORRECT ANSWERS Review the age-related anatomic and physiologic change of the older adult in relation to the components of the initial assessment. - CORRECT ANSWERS 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 ANSWERS Describe effects of common medications in relation to the older adult trauma patient. - CORRECT ANSWERS Describe common patterns and severity of injuries in the bariatric trauma patient. - CORRECT ANSWERS TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] 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 ANSWERS Airway and AVPU: ask pt to pen his or her mouth - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS Inspect the mouth for: 1. Check the presence of adequate rise and fall of the chest with assisted ventilation TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] 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 ANSWERS 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 ANSWERS 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 ANSWERS 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) TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] h. JVD i. signs of inhalation injury (singed nasal hairs, carbonaceous sputum) - CORRECT ANSWERS B tracheal deviation and jvd - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS If breathing is absent.. trauma its need early supplemental oxygen, start with 15 mL O2 and titrate oxygen delivery. - CORRECT ANSWERS 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 ANSWERS C TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] 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 ANSWERS SAMPLE inspect for lacs, abrasions, asymmetry of facial expressions palate for depressions and tenderness look at ears for drainage - CORRECT ANSWERS Head to toe assessment: Head and face immobilize cervical spine, tenderness, tracheal deviation - CORRECT ANSWERS 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 ANSWERS Head to toe assessment: Chest don't forget flanks!!! inspect of lacs, puncture wounds, contusions, TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] 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 ANSWERS 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 ANSWERS Head to toe assessment: pelvis and perineum any deformities? bleeding? contusions, lacs? skin temp?? place splints on deformities, pulses - CORRECT ANSWERS 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 ANSWERS I labs, wound care, tetanus, administer meds, prepare for transfer - CORRECT ANSWERS Secondary Reval Adjuncts TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] Vital signs Interventions Primary survey Pain - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS Hypovolemic Shock TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] 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 ANSWERS Open Pneumo: Air cannot escape intrapleural space.. can begin to compress heart. pt will have sever resp distress, hypotension, JVD. - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS Hemothorax: 1. Hypotension 2. JVD 3. Muffled heart sounds - CORRECT ANSWERS Becks Triad: Needle pericardiocentesis, but it is a temp solution. Requires surgical evaluation. (Ultrasound guided) - CORRECT ANSWERS Cardiac Tamponade Intervention: TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] Aortic Dissection - CORRECT ANSWERS Unequal extremity pulse strength possibility of.. 1. pain - hallmark sign, early sign 2. pressure - early sign 3. pallor, pules, paresthesia, paralysis - late sign - CORRECT ANSWERS 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 ANSWERS PAT brachial pulse - CORRECT ANSWERS Under age of 1 where do you find a pulse What are the greatest risks for transport? - CORRECT ANSWERS 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 ANSWERS Neither. For each force there is an equal and opposite reaction. What is the relationship between mass and velocity to kinetic energy? - CORRECT ANSWERS 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 ANSWERS stretching force by pulling at opposite ends What is compression? - CORRECT ANSWERS Crushing by squeezing together TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] What is bending? - CORRECT ANSWERS Loading about an axis. Bending causes compression on the side the person is bending toward intention to the opposite side What is shearing? - CORRECT ANSWERS Damage by tearing or bending by exerting faucet different parts in opposite directions at the same time. What is torsion? - CORRECT ANSWERS Torsion forces twist ends in opposite directions. What is combined loading? - CORRECT ANSWERS Any combination of tension compression torsion bending and/or shear. What are the four types of trauma related injuries? - CORRECT ANSWERS Blunt, penetrating, thermal, or blast. What are contributing factors to injuries related to blunt traumas? - CORRECT ANSWERS 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 ANSWERS Up and over, down and under, lateral, rotational, rear, roll over, and ejection. Differentiate between the three impacts of motor vehicle impact sequence. - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS 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. TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] What are the four types of shock? - CORRECT ANSWERS Hypovolemic, Cardiogenic, Obstructive, & Distributive What is the trauma triad of death? - CORRECT ANSWERS hypothermia, acidosis, coagulopathy Describe the characteristics of obstructive shock - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS 500 ML's of warmed isotonic crystalloid. Ongoing fluid boluses of 500 ML's should be given judiciously with constant reassessments after administration. TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] What is the minimum permissive hypertension and a trauma patient? - CORRECT ANSWERS A systolic of greater than or equal to 90 MMHG What is the minimum permissive oxygenation level of a trauma patient? - CORRECT ANSWERS Greater than or equal to 94% What is Cullen's sign and its significance? - CORRECT ANSWERS Cullens sign is periumbilical bruising and is indicative of intraperitoneal bleeding Define Cushing's triad - CORRECT ANSWERS Bradycardia, progressive hypertension (widening pulse pressure), and decreased respiratory effort What are the early signs of increased Intracranial pressure - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS Decreased LOC, nausea vomiting headache and ipsilateral pupillary changes What is a trademark symptom of an epidural hematoma - CORRECT ANSWERS Loss of consciousness then awake and alert then loss of consciousness Define the characteristics of neurogenic shock - CORRECT ANSWERS 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 ANSWERS Transient loss of function can include loss of reflexes and muscle tone below the level of industry with possible vascular response. TNCC TEST PREPA, TNCC NOTES FOR WRITTEN EXAM, 415Q & AS TNCC PREP, TNCC EXAM, TNCC 8TH EDITION[,GRADED A+] Describe the four types of spinal cord injury - CORRECT ANSWERS 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 ANSWERS With longform fractures. Tachycardia, Thrombocytopenia, and petechiae rash. What is the Munro-Kellie doctrine? - CORRECT ANSWERS 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 ANSWERS 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