TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC, Exams of Nursing

Download TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC and more Exams Nursing in PDF only on Docsity! 1 [Date] TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition Verified Questions And Answers Latest Update Best Rated A+ 1. Expedite transfer to the closest trauma center - Correct answer A 56 y/o M pt involved in a motor vehicle crash is brought to the ED of a rural critical access facility. He complains of neck pain, SOB, and diffuse abd pain. His GCS is 15. His VS: BP 98/71, HR 125, RR 26, SpO2 94% on high-flow O2 via NRB mask. Which of the following is the priority intervention for this patient? 2. a pertinent medical hx is crucial - Correct answer Which of the following considerations is the most important when caring for a geriatric trauma pt? 3. Mitigation - Correct answer Following a review of recent drills and a real disaster event, a hospital has identified deficiencies and is taking steps to minimize the impact of a future disaster . Which phase of the disaster life cycle does this describe? 4. Multiple requests for water - Correct answer EMS brings a pt who fell while riding his bicycle. Using the American College of Surgeobs screening guidelines, which assessment finding would prompt the RN to prepare the pt for a radiologic spine clearance? 5. hemoglobin does not readily release O2 for use by the tissues - Correct answer What is the effect of hypothermia on the oxyhemoglobin dissociation curve? 2 [Date] 6. acidosis - Correct answer Which of the following is a component of the trauma triad of death? 7. Complete - Correct answer EMS brings a pt from MVC. VS: BP 90/49, HR 48, RR 12, temp 97.2F (36.2 C). The pt exhibits urinary incontinence and priapism. These assessment findings are most consistent with which of the following types of spinal cord injury? 8. flucuation in the water seal chamber - Correct answer Which of the following is an expected finding in a pt with a tube thoracstomy connected to a chest drainage system? 9. insert an oropharyngeal airway if there is no gag reflex - Correct answer During the primary survey of an unconscious pt with multi-system trauma, the nurse notes snoring respirations. What priority nursing interventions should be preformed next? 10.globe rupture - Correct answer A 35 y/o M presents with facial trauma after being struck in the face with a baseball. A teardrop-shaped left pupil is noted on exam. What type of injury is suspected? 11.compensated - Correct answer A trauma pt is restless and repeatedly asking "where am i?" VS upon arrival: BP 110/60, HR96, RR 24. Her skin is cool and dry. Current VS are BP 104/84, HR 108, RR 28. The pt is demonstrating s/sx of which stage of shock? 12.ventilate with a bag mask device - Correct answer An unresponsive trauma pt has an oropharygeal airway in place, shallow and labored respirations, and dusky skin. The trauma team has administered medications for drug- 5 [Date] 27.Initiate transfer to a trauma center - Correct answer A pt is brought to the ED of a rural hospital following a high-speed MVC. When significant abd and pelvic injuries are noted in the primary survey, which of the following is the priority interventions? 28.bardycardia and absent motor function below the level of injury - Correct answer A pt with a complete spinal cord injury in neurogenic shock will demonstrate hypotension and which other clinical signs? 29.apply splint and elevate above the level of the heart - Correct answer a 37 y/o F has a deformity of the L wrist after a fall. She is reluctant to move her hand due to pain. Which of the following is the most appropriate intervention? 30.the aorta is torn at its attachment with the ligamentum arteriosum - Correct answer which of the following occurs during the third impact of a motor vehicle crash? 31.Report your suspicion of maltreatment in accordance with local regulations - Correct answer a 5 y/o child presents to the ED with bruises to the upper arm and buttocks in various stages of healing and multiple small, clean, round burns to the back. There are no abnormalities found based on the pediatric assessment triangle or primary survey. Which of the following is the priority survey. Which of the following is the priority nursing intervention? 32.to guage end-organ perfusion and tissue hypoxia - Correct answer Why is a measure of serum lactate obtained in the initial assessment of a trauma patient? 6 [Date] 33.elevating the extremity to the level of the heart - Correct answer A pt with a lower extremity fracture complains of severe pain and tightness in his calf, minimally by pain medications. Which of the following is the priority nursing intervention? 34.velocity - Correct answer What factor contributes most to the kinetic energy of a body in motion? 35.subdural hematoma - Correct answer An elderly patient with a history of anticoagulant use presents after a fall at home today. She denies any loss of consciousness. She has a hematoma to her forehead and complains of headache, dizziness, and nausea. What is the most likely cause of her symptoms? 36.fat embolism - Correct answer a pt has been in the ED for several hrs waiting to be admitted. He sustained multiple rib fractures and a femur fracture after a fall. He has been awake, alert, and complaining of leg pain. His wife reported that he suddenly became anxious and confused. Upon reassessment, the pt is restless with respiratory distress and petechiae to his neck. The pt is exhibiting s/sx most commonly associated with which of the following conditions? 37.nausea and vomiting - Correct answer Which of the following is a late sign of increased intracranial pressure? 38.serial FAST exams - Correct answer a 49 y/o restrained driver involved in a MVC presents to the trauma center complaining of abd, pelvic, and bilateral lower extremity pain. VS are stable. The nurse can anticipate all of these after a negative FAST exam EXCEPT which of the following? 7 [Date] 39.pericardiocentesis - Correct answer Which of the following is NOT considered goal-directed therapy for cardiogenic shock? 40.endotracheal tube - Correct answer The trauma nurse knows that placing a bariatric patient in a ramped position providers better visualization during the insertion of which device? 41.increased work of breathing? - Correct answer which of the following assessment findings differentiates a tension pneumothorax from a simple pneumothorax? 42.calcium - Correct answer if a pt has received multiple transfusions of banked blood preserved with citrate, which electrolyte is most likely to drop and require supplementation? 43.identifying individuals who made mistakes during the traumatic event - Correct answer Which of the following is NOT considered a benefit of debriefings? 44.500 mL/hr - Correct answer You are treating a 27 y/o M in respiratory distress who was involved in a house fire. Calculating TBSA burned is deferred due to the need for emergent intubation. At what rate should you begin fluid resuscitation? 45.advanced age - Correct answer Which of the following is most likely to contribute to inadequate oxygenation and ventilation? 10 [Date] 65.What are the late signs of breathing compromise? - Correct answer - Tracheal deviation - JVD 66.What are signs of ineffective breathing? - Correct answer - AMS - Cyanosis, especially around the mouth - Asymmetric expansion of chest wall - Paradoxical movement of the chest wall during inspiration and expiration - Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing - Sucking chest wounds - Absent or diminished breath sounds - Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated - Anticipate definitive airway management to support ventilation. 67.Upon initial assessment, what type of oxygen should be used for a pt breathing effectively? - Correct answer A tight-fitting nonrebreather mask at 12-15 lpm. 68.What intervention should be done if a pt presents with effective circulation? - Correct answer - Insert 2 large caliber IV's - Administer warmed isotonic crystalloid solution at an appropriate rate 69.What are signs of ineffective circulation? - Correct answer - Tachycardia - AMS - Uncontrolled external bleeding - Pale, cool, moist skin - Distended or abnormally flattened external jugular veins 11 [Date] - Distant heart sounds 70.What are the interventions for Effective/Ineffective Circulation? - Correct answer - Control any uncontrolled external bleeding by: - Applying direct pressure over bleeding site - Elevating bleeding extremity - Applying pressure over arterial pressure points - Using tourniquet (last resort). - Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution - Use warmed solution - Use pressure bags to increase speed of IVF infusion - Use blood administration tubing for possible administration of blood - Use rapid infusion device based on protocol - Use NS 0.9% in same tubing as blood product - IV = surgical cut-down, central line, or both. - Blood sample to determine ABO and Rh group - IO in sternum, legs, arms or pelvis - Administer blood products - PASG (without interfering with fluid resuscitation) 71.How do you assess Mnemonic "D"? - Correct answer DISABILITY 72.A = Alert 73.V = Verbal 74.P = Pain 75.U = Unresponsive - GCS - PERRL? - Determine presence of lateralizing signs including: - Unilateral deterioration in motor movements or unequal pupils - Symptoms that help to locate area of injury in brain 12 [Date] 76.What are the interventions for Disability? - Correct answer - If assessment indicates a decreased LOC, conduct further investigation during secondary focused assessments - If pt is not alert or verbal, continue to monitor for any compromise to ABC's - If pt demonstrates signs of herniation or neurologic deterioration, consider hyperventilation. 77.What is assessed and intervened for Expose/Environmental Controls? - Correct answer - Remove clothing - Ensure appropriate decontamination if exposed to hazardous material - Keep pt warm - Keep clothing for evidence 78.What is the first thing assessed under the Secondary Assessment? - Correct answer FULL SET VS / FOCUSED ADJUNCTS / FAMILY PRESENCE - ABCDE should be completed - Labs, X-rays, CT, Foley, - Family Presence 79.What is the second thing assessed under the Secondary Assessment? - Correct answer GIVE COMFORT MEASURES - Talking to pt - Pharmacologic/Nonpharmacologic pain management - Observe for physical signs of pain 80.What is assessed under the Mnemonic "H"? - Correct answer HISTORY / HEAD-TO-TOE ASSESSMENT - MIVT - M = Mechanism of injury 15 [Date] 95.What is a Combitube? - Correct answer A dual-lumen, dual-cuff airway that can be placed blindly into the esophagus to establish an airway. If inadvertently placed into trachea, it can be used as a temporary ET tube. There are only two sizes: small adult and larger adult. 96.What is a Laryngeal Mask Airway? - Correct answer Looks like an ET tube but is equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to cover the supraglottic area. 97.ILMA, does not require laryngoscopy and visualization of the chords. 98.What is Needle Cricothyrotomy - Correct answer Percutaneous transtracheal ventilation. (temporary) 99.Complications include: - inadequate ventilation causing hypoxia - hematoma formation - esophageal perforation - aspiration - thyroid perforation - subcutaneous emphysema 100. What is Surgical Cricothyrotomy? - Correct answer Making an incision in cricothyroid membrane and placing a cuffed endo or trach tube into trachea. This is indicated when other methods of airway management have failed and pt cannot be adequately ventilated and oxygenated. 101. Complications include: - Aspiration 16 [Date] - Hemorrhage or hematoma formation or both - Lac to trachea or esophagus - Creation of a false passage - Laryngeal stenosis 102. How do you confirm ET Tube/Alternative Airway Placement? - Correct answer - Visualization of the chords - Using bronchoscope to confirm placement - Listening to breath sounds over the epigastrum and chest walls while ventilating the pt - CO2 detector - Esophageal detection device - Chest x-ray 103. How do you inspect the chest for adequate ventilation? - Correct answer Observe: - mental status - RR and pattern - chest wall symmetry - any injuries - patient's skin color (cyanosis?) - JVD or tracheal deviation? (Tension pneumothorax) 104. What are you looking for when auscultating lung sounds? - Correct answer Absence of BS: - Pneumothorax - Hemothorax - Airway Obstruction 105. Diminished BS: - Splinting or shallow BS may be a result of pain 17 [Date] 106. What are you looking for when percussing the chest? - Correct answer Dullness: - hemothorax 107. Hyperresonance - Pneumothorax 108. What are you looking for when palpating the chest wall, clavicles and neck? - Correct answer - Tenderness - Swelling - subcutaneous emphysema - step-off deformities 109. = These may indicate: esophageal, pleural, tracheal or bronchial injuries. 110. Palpate trachea above suprasternal notch. Tracheal deviation may indicate a tension pneumothorax or massive hemothorax. 111. What is the DOPE mnemonic? - Correct answer D - Displaced tube  - Obstruction: Check secretions or pt biting tube 112. P - Pneumothorax: Condition may occur from original trauma or barotrauma from ventilator 113. E - Equipment failure: pt may have become detached from equipment or there's a kink in the tubing 114. Explain Hypovolemic Shock. - Correct answer Most common to affect a trauma pt cause by hypovolemia.. Hypovolemia, a decrease in amount of circulating blood volume, may result from significant loss of whole blood because of hemorrhage or from loss of semipermeable integrity of cellular membrane leading to leakage of plasma and protein from intravascular space to the interstitial space (as in a burn). 115. Some causes: 20 [Date] 127. Angiotensin-converting enzyme from the lungs converts into angiotensin II. 128. 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) 129. *Decreased urinary output = early sign renal hypoperfusion and an indicator that there's systemic hypoperfusion. 130. Explain adrenal gland response. - Correct answer When adrenal glands are stimulated by SNS, release of catecholamines (epinephrine and norepinephrine) from adrenal medulla will increase. 131. 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. 132. Shock stimulates hypothalamus to release corticotropin-releasing hormone that stimulates pituitary to release ACTH that stimulates adrenal gland to release cortisol. 133. Effect of cortisol release is elevation in blood sugar and increased insulin resistance and gluconeogenesis, hepatic process to produce more sugar. 21 [Date] 134. Cortisol also causes renal retention of water and sodium, a compensatory mechanism to conserve body water. 135. Explain Hepatic Response. - Correct answer Liver can store excess glucose as glycogen. 136. As shock progresses, glycogenolysis is activated by epi to break down glycogen into glucose. 137. In a compensatory response to shock, hepatic vessels constrict to redirect blood flow to other vital areas. 138. Explain Pulmonary Response. - Correct answer Tachypnea happens for 2 reasons: 139. Maintain acid-base balance 140. 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. 141. Explain Irreversible Shock. - Correct answer Shock uncompensated or irreversible stages will cause compromises to most body systems. - Inadequate venous return - inadequate cardiac filling - decreased coronary artery perfusion - Membranes of lysosomes breakdown within cells and release digestive enzymes that cause intracellular damage. 22 [Date] 142. How would you assess someone in hypovolemic shock? - Correct answer (Use Initial Assessment) and then: 143. Inspect: - LOC - Rate and quality of respirations - External bleeding? - Skin color and moisture - Assess jugular veins and peripheral veins 144. Auscultate: - BP - Pulse pressure - Breath sounds - Heart sounds - Bowel sounds 145. Percuss: - Chest and abdomen 146. 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 147. Diagnostic Procedures: - Xrays and other studies - Labs 148. 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 25 [Date] 163. Define central or transtentorial herniation. - Correct answer A downward movement of the cerebral hemispheres with herniation of the diencephalon and midbrain through the elongated gap of the tentorium. 164. Disruptions of the bony structures of the skull can result in what? - Correct answer Displaced or nondisplaced fx's causing CSF leakage b/c of lac to the dura mater, creating a passage for CSF. 165. CSF leaks through the nose (rhinorrhea) or the ears (otorrhea). A potential entrance for invading bacteria. 166. Also: meningitis or encephalitis or brain abscess 167. Define Minor Head Trauma. - Correct answer GCS 13-15 168. Define Moderate Head Trauma - Correct answer Postresuscitative state with GCS 9-13. 169. Define Severe Head Trauma. - Correct answer Postresuscitative state with GCS score of 8 or less. 170. What is a concussion and its signs and symptoms? - Correct answer A temporary change in neurologic function that may occur as a result of minor head trauma. 171. S/S: - Transient LOC - H/A - Confusion and disorientation - Dizziness - N/V 26 [Date] - Loss of memory - Difficulty with concentration - Irritability - Fatigue 172. What are the signs and symptoms of postconcussive syndrome? - Correct answer - Persistent H/A - Dizziness - Nausea - Memory impairment - Attention deficit - Irritability - Insomnia - Impaired judgement - Loss of libido - Anxiety - Depression 173. What is diffuse axonal injury and its signs and symptoms? - Correct answer (DAI) is widespread, rather than localized, through the brain. Diffuse shearing, tearing and compressive stresses from rotational or accerleration/deceleration forces resulting in microscopic damage primarily to axons within the brain. 174. 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 27 [Date] - Mild to severe memory impairment, cognitive, behavioral, and intellectual deficits 175. What is a cerebral contusion and its S/S? - Correct answer A common focal brain injury in which brain tissue is bruised and damaged in a local area. Mainly located in frontal and temporal lobes. May cause hemorrhage, infarction, necrosis and edema. Max effects of bleeding & edema peak 18- 36 post injury. 176. S/S: - Alteration in LOC - Behavior, motor or speech deficits - Abnormal motor posturing - Signs of increased ICP 177. What is an epidural hematoma and its S/S? - Correct answer Results when a collection of blood forms between the skull and the dura mater. Bleeding is arterial=blood accumulates rapidly: - Compression of underlying brain - rapid increase in ICP - Decreased CBF - Secondary brain injury  Usually requires surgical intervention 178. 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 30 [Date] - 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 190. 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 191. DIAGNOSTIC PROCEDURES - Lab Studies 192. 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. 31 [Date] - Prolonged hyperventilation NOT RECOMMENDED. - Hypocarbia occurs as result of hyperventilation causes cerebral vasoconstriction, decreased CBF, decreased ICP. And ischemia secondary to severe vasoconstriction. - Hyperoxygenate pt with 100% O2 via bag-mask - Apply direct pressure to bleeding sites except depressed skull fractures - Cannulate 2 large IV's - Hypotension doubles pt's death rate (w/severe head trauma) - Vasopressors used to maintain CPP. - Insert OG or NGT. OG should be used with severe facial trauma. - Position pt, elevate head to decrease ICP (but may also reduce CPP). - Position head midline to facilitate venous drng. Rotate head to compress veins in neck and result in both venous engorgement and decreased drng from brain - Prepare for ICP monitoring device - Administer mannitol as prescribed. - Mannitol, hyperosmolar, volume-depleting diuretic, decreases cerebral edema + ICP by pulling interstitial fluid into intravascular space for eventual excretion by kidneys. - Administer anticonvulsant - Sx should be avoided b/c increases cerebral metabolic rate + ICP. Indications for sz prophylaxis: - Depressed skull fx - Sz at time of injury - Sz on arrival to ED - Hx of sz's - Penetrating brain injury - Acute subdural/epidural hematoma - Administer antipyretic med/Cooling blanket - Hyperthermia may increase cerebral metabolic rate + ICP. Avoid causing shivering during cooling process; increases cerebral metabolic rate + may precipitate rise in ICP 32 [Date] - 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. 193. What are signs of a serious eye injury? - Correct answer - Visual disturbances - Pain - Redness and ecchymosis of the eye - Periorbital ecchymosis - Increased intraocular pressure 194. What is hyphema and its S/S? - Correct answer Accumulation of blood, mainly RBC's that disperse and layer within the anterior chamber. A severe hymphema obscures entire anterior chamber + will diminish visual acuity severely or completely. Injuries are graded on amount of blood in chamber (Grades I-IV). 195. S/S: - Blood in anterior chamber - Deep, aching pain - Mild to severe diminished visual acuity - Increased intraocular pressure 196. What are s/s of chemical burns to the eye? - Correct answer Chemical injuries require immediate intervention if it is to be preserved. 197. S/S: - Pain - Corneal Opacification 35 [Date] - 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) 208. How would you assess a patient with ocular, maxillofacial and neck trauma? - Correct answer (Initial assessment) 209. 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? 210. PHYSICAL 211. 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) 36 [Date] - 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 212. 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 37 [Date] - 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 213. DIAGNOSTIC STUDIES: - Xrays, CT scans, MRI's - Fluorescein staining - Slit-lamp exam - tonometry (measures intraocular pressure) - Bronchoscopy or esophagoscopy 214. What are the nursing interventions for a pt with an ocular injury? - Correct answer - Assess visual acuity & reassess - Elevate HOB to minimize intraocular pressure - Instruct pt not to bend forward, cough or perform Valsalva maneuver b/c these actions may raise intraocular pressure - Assist w/removal of foreign bodies as indicated; stabilize impaled objects - Apply cool packs to decrease pain + periorbital swelling - Admin medications - Instill prescribed topical anesthetic drops for pain - Instill NS drops or artificial tears to keep corneas moist. Cover eyelids w/sterile, moist saline dsg to prevent drying and ulceration - Antibiotics topically or systemically - Admin tetanus prophylactically - Use an eye patch to affected eye - Patch or shield both eyes to reduce movement + photophobia in pt's w/retinal injuries - Patch, shield or cover w/cool pack - Do NOT patch injured eye of pt w/suspected open or ruptured globe or impaled object, patch unaffected eye. Use metal or plastic and do not put pressure on the globe. - Provide psychosocial support - Obtain an ophthalmology consultation - Provide d/c instructions: 40 [Date] 223. Define Pneumothorax. - Correct answer Results when an injury to lung leads to accumulation of air in pleural space w/subsequent loss of negative intrapleural pressure. Partial or total collapse of lung may ensue. 224. An open pneumothorax results from wound through chest wall. Air enters pleural space both through the wound and trachea. 225. What are the S/S of a pneumothorax? - Correct answer - Dyspnea, tachypnea - Tachycardia - Hyerresonance (increased echo produced by percussion over the lung field) on the injured side - Decreased or absent breath sounds on the injured side - Chest pain - Open, sucking wound on inspiration (open pneumothorax) 226. Define tension pneumothorax. - Correct answer Life-threatening injury. Air enters pleural space on inspiration, but air cannot escape on expiration. Rising intrathoracic pressure collapses lung on side of injury causing a mediastinal shift that compresses the heart, great vessels, trachea and uninjured lung. Venous return impeded, cardiac output falls, hypotension results. 227. Immediate decompression should be performed. Treatment should not be delayed. 228. What are the S/S of a tension pneumothorax? - Correct answer - Severe respiratory distress - Markedly diminished or absent breath sounds on affected side - hypotension 41 [Date] - 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) 229. Define Hemothorax. - Correct answer Accumulation of blood in the pleural space. 230. What are the S/S of Hemothorax? - Correct answer - Dyspnea, tachypnea - Chest pain - Signs of shock - Decreased breath sounds on injured side - Dullness to percussion on the injured side 231. What is a pulmonary contusion? - Correct answer They occur as a result of direct impact, deceleration or high-velocity bullet wounds. It develops when blood leaks into lung parenchyma, causing edema + hemorrhage. This usually develops overtime and not immediately. 232. What are the S/S of pulmonary contusion? - Correct answer - Dyspnea - Ineffective cough - Hemoptysis - Hypoxia - Chest pain - Chest wall contusion or abrasions 233. What happens to a ruptured diaphragm? - Correct answer Potentially life-threatening, results from forces that penetrate the body. Left 42 [Date] 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 234. What are S/S of a ruptured diaphragm? - Correct answer (Anything below the nipple line and should be evaluated for potential diaphragmatic injury). - Dyspnea or orthopnea - Dysphagia - Abdominal pain - Sharp epigastric or chest pain radiating to left shoulder (Kehr's sign) - Bowel sounds heard in lower middle chest - Decreased breath sounds on injured side 235. What are S/S with tracheobronchial injury? - Correct answer Blunt trauma. "Clothesline-type" injuries. - Dyspnea, tachypnea - Hoarseness - Hemoptysis - Subcutaneous emphysema in neck, face, or suprasternal area - Decreased or absent breath sounds - S/S of airway obstruction 236. What are S/S with blunt cardiac injury? - Correct answer "Cardiac contusion" or "concussion." Common with MVC or falls from heights. - ECG (sinus tach, PVC's, AV blocks) - Chest pain - Chest wall ecchymosis 45 [Date] 247. What is the planning and implementation for thoracic injury? - Correct answer p. 142 248. What is kinematics? - Correct answer A branch of mechanics (energy transfer) that refers to motion and does not consider the concepts of force and mass of the object or body. 249. What is Newton's First Law? - Correct answer A body at rest will remain at rest. A body in motion will remain in motion until acted on by an outside force. 250. What is the Law of Conservation of Energy? - Correct answer Energy can neither be created nor destroyed. It is only changed from one form to another. 251. What is Newton's Second Law? - Correct answer Force equals mass multiplied by acceleration of deceleration. 252. What is kinetic energy (KE)? - Correct answer KE equals 1/2 the mass (M) multiplied by the velocity squared. 253. What is the Mnemonic for the Initial Assessment? - Correct answer A = Airway with simultaneous cervical spine protection 254. B = Breathing 255. C = Circulation 256. D = Disability (neurologic status) 257. E = Expose/Environmental controls (remove clothing and keep the patient warm) 46 [Date] 258. What is the Mnemonic for the Secondary Assessment? - Correct answer F = Full set of VS/Focused adjuncts (includes cardiac monitor, urinary catheter, and gastric tube)/Family presence 259. G = Give comfort measures (verbal reassurance, touch, and pharmacologic and nonpharmacologic management of pain). 260. H = Hx and Head-to-toe assessment 261. I = Inspect posterior surfaces 262. Where do you listen to auscultate breath sounds? - Correct answer Auscultate the lungs bilaterally at the second intercostal space midclavicular line and at the fifth intercostal space at the anterior axillary line. 263. What are the late signs of breathing compromise? - Correct answer - Tracheal deviation - JVD 264. What are signs of ineffective breathing? - Correct answer - AMS - Cyanosis, especially around the mouth - Asymmetric expansion of chest wall - Paradoxical movement of the chest wall during inspiration and expiration - Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing - Sucking chest wounds - Absent or diminished breath sounds - Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated - Anticipate definitive airway management to support ventilation. 47 [Date] 265. Upon initial assessment, what type of oxygen should be used for a pt breathing effectively? - Correct answer A tight-fitting nonrebreather mask at 12-15 lpm. 266. What intervention should be done if a pt presents with effective circulation? - Correct answer - Insert 2 large caliber IV's - Administer warmed isotonic crystalloid solution at an appropriate rate 267. What are signs of ineffective circulation? - Correct answer - Tachycardia - AMS - Uncontrolled external bleeding - Pale, cool, moist skin - Distended or abnormally flattened external jugular veins - Distant heart sounds 268. What are the interventions for Effective/Ineffective Circulation? - Correct answer - Control any uncontrolled external bleeding by: - Applying direct pressure over bleeding site - Elevating bleeding extremity - Applying pressure over arterial pressure points - Using tourniquet (last resort). - Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution - Use warmed solution - Use pressure bags to increase speed of IVF infusion - Use blood administration tubing for possible administration of blood - Use rapid infusion device based on protocol - Use NS 0.9% in same tubing as blood product - IV = surgical cut-down, central line, or both. - Blood sample to determine ABO and Rh group 50 [Date] 280. What she be done after the Secondary Assessment? - Correct answer Reassess: - Primary survey, - VS - Pain - Any injuries 281. What are factors that contribute to ineffective ventilation? - Correct answer - AMS - LOC - Neurologic injury - Spinal Cord Injury - Intracranial Injury - Blunt trauma - Pain caused by rib fractures - Penetrating Trauma - Preexisting hx of respiratory diseases - Increased age 282. What medications are used during intubation? - Correct answer LOAD Mnemonic: 283. L = Lidocaine  = Opioids 284. A = Atropine 285. D = Defasiculating agents 286. What are the Rapid Sequence Intubation Steps? - Correct answer PREPARATION: - gather equipment, staffing, etc. 287. PREOXYGENATION: - Use 100% O2 (prevent risk of aspiration). 288. PRETREATMENT: 51 [Date] - Decrease S/E's of intubation 289. PARALYSIS WITH INDUCTION: - Pt has LOC, then administer neuromuscular blocking agent 290. PROTECTION AND POSITIONING: - Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration 291. 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. 292. POSTINTUBATION MANAGEMENT: - Secure ET tube - Set ventilator settings - Obtain Chest x-ray - Continue to medicate - Recheck VS and pulse oxtimetry 293. What is a Combitube? - Correct answer A dual-lumen, dual-cuff airway that can be placed blindly into the esophagus to establish an airway. If inadvertently placed into trachea, it can be used as a temporary ET tube. There are only two sizes: small adult and larger adult. 294. What is a Laryngeal Mask Airway? - Correct answer Looks like an ET tube but is equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to cover the supraglottic area. 295. ILMA, does not require laryngoscopy and visualization of the chords. 296. What is Needle Cricothyrotomy - Correct answer Percutaneous transtracheal ventilation. (temporary) 52 [Date] 297. Complications include: - inadequate ventilation causing hypoxia - hematoma formation - esophageal perforation - aspiration - thyroid perforation - subcutaneous emphysema 298. What is Surgical Cricothyrotomy? - Correct answer Making an incision in cricothyroid membrane and placing a cuffed endo or trach tube into trachea. This is indicated when other methods of airway management have failed and pt cannot be adequately ventilated and oxygenated. 299. Complications include: - Aspiration - Hemorrhage or hematoma formation or both - Lac to trachea or esophagus - Creation of a false passage - Laryngeal stenosis 300. How do you confirm ET Tube/Alternative Airway Placement? - Correct answer - Visualization of the chords - Using bronchoscope to confirm placement - Listening to breath sounds over the epigastrum and chest walls while ventilating the pt - CO2 detector - Esophageal detection device - Chest x-ray 55 [Date] 316. Explain Obstructive Shock. - Correct answer Results from inadequate circulating blood volume because of an obstruction or compression of great veins, aorta, pulmonary arteries, or heart itself. 317. 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 318. Explain Distributive Shock. - Correct answer Results from disruption in SNS control of the tone of blood vessels, which leads to vasodilation and maldistribution of blood volume and flow. (Neurogenic and Septic Shock). Neurogenic shock may result from injury to spinal cord in cervical or upper thoracic region. 319. Spinal shock = areflexia and flaccidity associated with lower motor neuron involvement in complete cord injuries; reflexes return with resolution of spinal shock. 320. Septic shock from bacteremia is distributive shock. Endotoxins and other inflammatory mediators cause vasodilation, shunting of blood in microcirculation, and other perfusion abnormalities. 56 [Date] 321. What is vascular response? - Correct answer As blood volume decreases, peripheral blood vessels vasoconstrict as a result of sympathetic stimulation via inhibition of baroreceptors. Arterioles constrict to increase TPR and BP. 322. What is renal response? - Correct answer Renal ischemia activates release of renin. 323. Kidneys do not receive adequate blood supply, renin is release into circulation. 324. Renin causes angiotensinogen, normal plasma protein, to release angiotensin I. 325. Angiotensin-converting enzyme from the lungs converts into angiotensin II. 326. 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) 327. *Decreased urinary output = early sign renal hypoperfusion and an indicator that there's systemic hypoperfusion. 57 [Date] 328. Explain adrenal gland response. - Correct answer When adrenal glands are stimulated by SNS, release of catecholamines (epinephrine and norepinephrine) from adrenal medulla will increase. 329. 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. 330. Shock stimulates hypothalamus to release corticotropin-releasing hormone that stimulates pituitary to release ACTH that stimulates adrenal gland to release cortisol. 331. Effect of cortisol release is elevation in blood sugar and increased insulin resistance and gluconeogenesis, hepatic process to produce more sugar. 332. Cortisol also causes renal retention of water and sodium, a compensatory mechanism to conserve body water. 333. Explain Hepatic Response. - Correct answer Liver can store excess glucose as glycogen. 334. As shock progresses, glycogenolysis is activated by epi to break down glycogen into glucose. 335. In a compensatory response to shock, hepatic vessels constrict to redirect blood flow to other vital areas. 60 [Date] 351. 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. 352. 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. 353. What are the early signs and symptoms of increased ICP? - Correct answer - Headache - N/V - Amnesia regarding events around the injury - Altered LOC - Restlessness, drowsiness, changes in speech, or loss of judgement 354. What are the late observable signs of symptoms of increased ICP? - Correct answer - Dilated, nonreactive pupil - Unresponsiveness to verbal or painful stimuli - Abnormal motor posturing patterns - Widening pulse pressure - Increased systolic blood pressure - Changes in RR and pattern - Bradycardia 355. What is Cushing's phenomenon or Cushing's Reflex? - Correct answer Triad of progressive HTN, bradycardia and diminished respiratory effort. 356. What are the two types of herniation that occurs with ICP? - Correct answer 1. Uncal herniation 61 [Date] 357. 2. Central or transtentorial herniation 358. Why does herniation occur? What are the symptoms? - Correct answer Because of uncontrolled increases in ICP. 359. S/E's - Unilateral or bilateral pupillary dilation - AsyDimmetric pupillary reactivity - Abnormal motor posturing - Other evidence of neurologic deterioration 360. Define uncal herniation. - Correct answer The uncus (medial aspect of the temporal lobe) is displaced over the tentorium into the posterior fossa. This herniation is the more common of the two types of herniation syndromes. 361. Define central or transtentorial herniation. - Correct answer A downward movement of the cerebral hemispheres with herniation of the diencephalon and midbrain through the elongated gap of the tentorium. 362. Disruptions of the bony structures of the skull can result in what? - Correct answer Displaced or nondisplaced fx's causing CSF leakage b/c of lac to the dura mater, creating a passage for CSF. 363. CSF leaks through the nose (rhinorrhea) or the ears (otorrhea). A potential entrance for invading bacteria. 364. Also: meningitis or encephalitis or brain abscess 365. Define Minor Head Trauma. - Correct answer GCS 13-15 62 [Date] 366. Define Moderate Head Trauma - Correct answer Postresuscitative state with GCS 9-13. 367. Define Severe Head Trauma. - Correct answer Postresuscitative state with GCS score of 8 or less. 368. What is a concussion and its signs and symptoms? - Correct answer A temporary change in neurologic function that may occur as a result of minor head trauma. 369. S/S: - Transient LOC - H/A - Confusion and disorientation - Dizziness - N/V - Loss of memory - Difficulty with concentration - Irritability - Fatigue 370. What are the signs and symptoms of postconcussive syndrome? - Correct answer - Persistent H/A - Dizziness - Nausea - Memory impairment - Attention deficit - Irritability - Insomnia - Impaired judgement - Loss of libido - Anxiety 65 [Date] - H/A - Progressive decrease in LOC - Ataxia - Incontinence - Sz's 381. What are intracerebral hematoma's and its S/S? - Correct answer Occur deep within brain tissue, may be single or multiple and commonly associated with contusions (frontal & temporal lobes). They result in significant mass effect, leading to increased ICP and neurologic deterioration. 382. S/S: - Progressive and often rapid decline in LOC - H/A - Signs of increasing ICP - Pupil abnormalities - Contralateral hemiplegia 383. What are the S/S of a linear skull fx? - Correct answer - H/A - Possible decreased LOC 384. What are the S/S of a depressed skull fx? - Correct answer - H/A - Possible decreased LOC - Possible open fx - Palpable depression of skull over the fx site 385. What are the S/S of a basilar skull fx? - Correct answer - H/A - Altered LOC - Periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle's sign), or blood behind tympanic membrane (hemotympanum) - Facial nerve (VII) palsy 66 [Date] - CSF rhinorrhea or otorrhea 386. How would you assess a pt with a cranial injury? - Correct answer (Initial assessment) 387. INSPECTION: - Assess airway - RR, pattern and effort - Assess pupil size and response to light - Unilateral fixed and dilated pupil = oculomotor nerve compression from increased ICP + herniation syndrome - Bilateral fixed and pinpoint pupils indicate a pontine lesion or effects of opiates - Mildly dilated pupil w/sluggish response may be early sign of herniation syndrome - Widely dilated pupil occasionally occurs w/direct trauma to globe of eye - Determine if pt uses eye meds - Abnormal posturing? - Inspect craniofacial area for ecchymosis/contusions - Periorbital ecchymosis - Mastoid's process ecchymosis - Blood behind tympanic membrane - Inspect nose and ears for drainage - Drng present w/out blood, test drng w/chemical reagant strip. Presence of glucose indicated drng of CSF - If drng present and mixed with blood, test by placing drop of fluid on linen or gauze. If a light outer ring forms around dark inner ring, drng contains CSF - Assess extraocular eye movement (Tests cranial nerves, III, IV, VI) - Performing extraocular eye movements indicates functioning brainstem - Limitation indicates orbital rim fx w/entrapment or paralysis of either a cranial nerve or ocular muscle - Determine LOC with GCS 67 [Date] 388. 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 389. DIAGNOSTIC PROCEDURES - Lab Studies 390. PLANNING AND IMPLEMENTATION - (Initial assessment) - Clear airway (stimulation of gag reflex can produce transient increase in ICP or vomiting with subsequent aspiration. - Administer O2 via NRB - Assist with early ET intubation - Administer sedative/neuromuscular blocking agent - Consider hyperventilation - PaCO2 above 45 mm Hg may cause increased cerebral vasodilation, increased CBF, increased ICP. - Prolonged hyperventilation NOT RECOMMENDED. - Hypocarbia occurs as result of hyperventilation causes cerebral vasoconstriction, decreased CBF, decreased ICP. And ischemia secondary to severe vasoconstriction. - Hyperoxygenate pt with 100% O2 via bag-mask - Apply direct pressure to bleeding sites except depressed skull fractures - Cannulate 2 large IV's - Hypotension doubles pt's death rate (w/severe head trauma) - Vasopressors used to maintain CPP. - Insert OG or NGT. OG should be used with severe facial trauma. - Position pt, elevate head to decrease ICP (but may also reduce CPP). - Position head midline to facilitate venous drng. Rotate head to compress veins in neck and result in both venous engorgement and decreased drng from brain 70 [Date] - Altered extraocular eye movements - Enophthalmos (displacement of the eye backward into the socket) - Subconjunctival hemorrhage or ecchymosis of the eyelid - Infraorbital pain or loss of sensation - Orbital bony deformity 398. What is LeFort I fracture and its S/S? - Correct answer Transverse maxillary fx that occurs above level of teeth and results in separation of teeth from rest of maxilla. 399. S/S: - Slight swelling of maxillary area - Possible lip lac's or fractured teeth - Independent movement of the maxilla from rest of face - Malocclusion 400. What is LeFort II fracture and its S/S? - Correct answer Pyramidal maxillary fx=middle facial area. Apex of fx transverses bridge of nose. Two lateral fx's of pyramid extend through the lacrimal bone of the face and ethmoid bone of skull into the median portion of both orbits. Base of the fx extends above level of the upper teeth into maxilla. CSF leak is possible. 401. S/S: - Massive facial edema - Nasal swelling w/obvious fx of nasal bones - Malocclusion - CSF rhinorrhea 402. What is LeFort III fracture and its S/S? - Correct answer Complete craniofacial separation involving maxilla, zygoma and bones of cranial base. This fx is frequently associated w/leakage of CSF and fx mandible. 403. S/S: - Massive facial edema - Mobility and depression of zygomatic bones 71 [Date] - Ecchymosis - Anesthesia of the cheek - Diplopia - Open bite or malocclusion - CSF rhinorrhea 404. What are the mandibular fracture S/S? - Correct answer - Malocclusion - Inability to open the mouth (trismus) - Pain, especially on movement - Facial asymmetry and a palpable step-off deformity - Edema or hematoma formation at the fracture site - Blood behind, ruptured, tympanic membrane - Anesthesia of the lower lip 405. What are neck injury S/S? - Correct answer - Dyspnea - Hemoptysis (coughing up blood) - Subcutaneous emphysema in neck, face, or suprasternal area - Decreased or absent breath sounds - Penetrating wounds or impaled objects - Pulsatile or expanding hematoma - Loss of normal anatomic prominence of the laryngeal region - Bruits - Active external bleeding - Neurologic deficit, such as aphasia or hemiplegia - Cranial nerve deficits - Facial sensory or motor nerve deficits - Dysphonia (hoarseness) - Dysphagia (difficulty swallowing) 406. How would you assess a patient with ocular, maxillofacial and neck trauma? - Correct answer (Initial assessment) 72 [Date] 407. 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? 408. PHYSICAL 409. 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 75 [Date] - 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 414. With any eye injury, what should the evaluation and ongoing assessments be? - Correct answer - Reassessing visual acuity at reasonable intervals - Reassessing pain, including response to nonpharmacologic + pharmacologic interventions - Monitoring appearance, position, movements of globe and pupillary responses - Monitoring airway patency, respiratory effort and ABG's 415. What are the most common type of injury associated with chest trauma? - Correct answer blunt; MVC's. Penetrating; firarm injuries or stabbings 416. What are S/S of a rib fracture? - Correct answer - Dyspnea - Localized pain on movement, palpation, or inspiration - Pt assumes position intended to splint chest wall to reduce pain - Chest wall ecchymosis or sternal contusion - Bony crepitus or deformity 417. What is a flail chest? - Correct answer A fracture of two or more sites on two or more adjacent ribs, or when rib fractures produce a free-floating sternum. 76 [Date] 418. 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. 419. What could a flail chest be associated with? - Correct answer - Ineffective ventilation - Pulmonary contusion - Lacerated lung parenchyma 420. What are the S/S of flail chest? - Correct answer - Dyspnea - Chest wall pain - Paradoxical chest wall movement - the flail segment moves in during inspiration and out during expiration. 421. Define Pneumothorax. - Correct answer Results when an injury to lung leads to accumulation of air in pleural space w/subsequent loss of negative intrapleural pressure. Partial or total collapse of lung may ensue. 422. An open pneumothorax results from wound through chest wall. Air enters pleural space both through the wound and trachea. 423. What are the S/S of a pneumothorax? - Correct answer - Dyspnea, tachypnea - Tachycardia - Hyerresonance (increased echo produced by percussion over the lung field) on the injured side - Decreased or absent breath sounds on the injured side - Chest pain - Open, sucking wound on inspiration (open pneumothorax) 77 [Date] 424. Define tension pneumothorax. - Correct answer Life-threatening injury. Air enters pleural space on inspiration, but air cannot escape on expiration. Rising intrathoracic pressure collapses lung on side of injury causing a mediastinal shift that compresses the heart, great vessels, trachea and uninjured lung. Venous return impeded, cardiac output falls, hypotension results. 425. Immediate decompression should be performed. Treatment should not be delayed. 426. What are the S/S of a tension pneumothorax? - Correct answer - Severe respiratory distress - Markedly diminished or absent breath sounds on affected side - hypotension - Distended neck, head and upper extremity veins-may not be clinically appreciated if significant blood loss present - Tracheal deviation - shift toward uninjured side (LATE sign) - Cyanosis (LATE sign) 427. Define Hemothorax. - Correct answer Accumulation of blood in the pleural space. 428. What are the S/S of Hemothorax? - Correct answer - Dyspnea, tachypnea - Chest pain - Signs of shock - Decreased breath sounds on injured side - Dullness to percussion on the injured side 80 [Date] - Chest pain - Chest wall ecchymosis - Widened mediastinum on chest xray - Paraplegia 437. How would you assess a pt with a thoracic injury? - Correct answer (Initial assessment) 438. Obtain Hx. 439. PHYSICAL: 440. 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 441. Percussion: - Percuss the chest (Dullness = hemothorax, Hyperresonance = pneumothorax) 442. Palpation: - Palpate chest wall, clavicles and neck for: - Tenderness - Swelling or hematoma - Subcutaneous emphysema - Note presence of bony crepitus - Palpate central and peripheral pulses and compare quality between: - Right and left extremities - Upper and lower extremities - Palpate the trachea (above suprasternal notch. Trach shift may indicate late sign of tension pneumothorax or massive hemothorax) - Palpate extremities for motor and sensory function (lower extremitiy paresis or paralysis may indicate aortic injury). 443. Auscultation: 81 [Date] - 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) 444. Diagnostic Procedures: - Xrays - Arteriography - Bronchoscopy and laryngoscopy - CT's - FAST - Labs (cardiac enzymes) - ECG, CVP 445. What is the planning and implementation for thoracic injury? - Correct answer p. 142 446. Kinematics - Correct answer Is the study of energy transfer as it applies to identifying actual or potential injuries. 447. Biomechanics - Correct answer Is the general study of forces and their effects. 448. Mechanism of Injury - Correct answer Is how external forces are transferred to the body, resulting in injury 449. Newton's First Law of Motion - Correct answer an object in motion will remain in motion unless acted upon by another force 82 [Date] 450. Newton's Second Law of Motion - Correct answer The acceleration of an object depends on the mass of the object and the amount of force applied. 451. Newton's Third Law of Motion - Correct answer For every action there is an equal and opposite reaction 452. Law of Conservation of Energy - Correct answer Matter is neither created nor destroyed (but may change form) 453. What are the five forms in which energy exist? - Correct answer 1. Mechanical 454. 2. Thermal 455. 3. Chemical 456. Electrical 457. Radiant 458. Describe the 3 types of Internal forces of energy transfer in the context of trauma. - Correct answer Compression: The ability of the tissue to resist crush injury or force 459. Tension: The ability to resist being pulled apart when stretched 460. Shear: The ability to resist a force applied parallel to the tissue 461. Describe the 3 types of external forces of energy transfer in the context of trauma. - Correct answer Deceleration: Force from a sudden stop in the body's motion 462. Acceleration: Force from a sudden onset in the body's motion 85 [Date] 487. Describe effects of common medications in relation to the older adult trauma patient. - Correct answer 488. Describe common patterns and severity of injuries in the bariatric trauma patient. - Correct answer 489. Which comorbid conditions factor into the risks of the bariatric trauma patient? And how? - Correct answer 490. Describe the pathophysiologic changes of the systems of the bariatric patient and the effects on trauma resuscitation efforts. - Correct answer 491. Describe techniques to improve the intubation process for the bariatric trauma patient. - Correct answer 492. Discuss the use and insertion of nasogastric tubes in the bariatric patient. - Correct answer 493. Differentiate family and intimate partner violence from community violence. - Correct answer 494. List the populations at higher risk for interpersonal violence. - Correct answer 495. Describe the types of abuse and the associated signs of each. - Correct answer 86 [Date] 496. What cues to abuse may be obtained during the history portion of the initial assessment? - Correct answer 497. Describe specific injuries associated with interpersonal violence and abuse. - Correct answer 498. List the basic components of evidence collection. - Correct answer 499. Describe steps to maintain the forensic chain of custody. - Correct answer 500. Preparation and Triage 501. Primary Survery (ABCDE) with resuscitation adjuncts (F,G) 502. Reevaluation (consideration of transfer) 503. Secondary Survey (HI) with reevaluation adjuncts 504. Reevaluation and post resuscitation care 505. Definitive care of transfer to an appropriate trauma nurse - Correct answer Initial Assessment 506. A- airway and Alertness with simultaneous cervical spinal stabilization 507. B- breathing and Ventilation 508. circulation and control of hemorrhage 509. D - disability (neurologic status) 510. F - full set of vitals and Family presence 511. G - Get resuscitation adjuncts 512. L- Lab results (arterial gases, blood type and crossmatch) 513. M- monitor for continuous cardiac rhythm and rate assessment 514. N- naso or orogastric tube consideration 87 [Date] 515. O- oxygenation and ventilation analysis: Pulse oxygemetry and end- tidal caron dioxide (ETC02) monitoring and capnopgraphy 516. H- History and head to toe assessment I- Inspect posterior surfaces - Correct answer ABCDEFGHI 517. Before the arrival of the pt - Correct answer When should PPE be placed: 518. Pt is at hospital in the right amount of time, right care, right trauma facility, right resources - Correct answer Safe Care: 519. Uncontrolled Hemorrhage - Correct answer Major cause of preventable death: 520. reorganize care to C-ABC - Correct answer If uncontrolled hemorrhage .. 521. Used at the beginning of the initial assessment 522. A Alert. If the pt is alert he or she will be able to maintain his or her airway once it is clear. 523. 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. 524. 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. 90 [Date] 555. tracheal deviation and jvd - Correct answer Late signs of tension pneumo: 556. equal breath sounds bilaterally at the second intercostal space midclavicular line and the bases for fifth intercostal space at the axillary line - Correct answer Auscultate the chest for: 557. bony fractures and possible rib fractures, which may impact ventilation 558. palpate for crepitus 559. subcutaneous emphysema which may be a sign for a pneumothorax 560. soft tissue injury - Correct answer Palpate the chest for 561. open the airway, use jaw thrust 562. insert an oral airway 563. assist ventilations with a bag mask 564. prepare for definitive airway - Correct answer If breathing is absent.. 565. trauma its need early supplemental oxygen, start with 15 mL O2 and titrate oxygen delivery. - Correct answer Oxygen on trauma patients 566. Circulation and Control of Hemorrhage 567. Inspect first for any uncontrolled bleeding 568. Skin color 569. palpate for central pulses - carotid and femoral - rate, rhythm, and strength 570. Skin temp: cool, diaphoretic, or warm and dry - Correct answer C 91 [Date] 571. apply direct pressure to bleeding 572. elevate extremity 573. apply pressure over arterial sites 574. Consider a pelvic binder for pelvic fractures 575. consider a tourniquet 576. cannulate two veins with large caliber IV - if unable to gain assess consider IO a. obtain labs, type and cross b. infuse warm isotonic fluids c. consider balanced resuscitation d. use rapid infusion device - Correct answer C Interventions: 577. Disability - Neurologic Status 578. Assess pupils for equality, shape, and reactivity (PERRL) 579. Assess GCS (eye opening, verbal response, and motor response) - Correct answer D 580. Get a CT 581. Consider ABG 's if decreased LOC 92 [Date] 582. Consider glucose check - Correct answer D Interventions 583. Exposure and Environmental Control 584. Remove all clothes and assess for any obvious injuries and uncontrolled bleeding - Correct answer E 585. IF clothing is needed for evidence preserve in paper bag. 586. Maintain body temp - cover the pt, turn up heat in room, administer warm fluids - Correct answer E Interventions: 587. Full set of vitals and family presence - Correct answer F 588. Get Resuscitation Adjuncts 589. L - Labs (maybe a lactic acid), a b g 's, blood type 590. M - monitors 591. N - naso or oro gastric tubes  Oxygen and ETC02 monitors 592. P - pain assessment and management - Correct answer G 593. Reevaluation and Consider the need to Transfer - Correct answer Final step in primary survey 594. H,I - Correct answer Secondary Survery 595. History and Head to toe 95 [Date] 625. any deformities? bleeding? contusions, lacs? skin temp?? place splints on deformities, pulses - Correct answer Head to toe assessment: Extremities 626. inspect posterior surfaces 627. blogroll with at least 3 people. maintain c spine 628. take out backboard 629. Rectal tone per MD - Correct answer I 630. labs, wound care, tetanus, administer meds, prepare for transfer - Correct answer Secondary Reval Adjuncts 631. Vital signs 632. Interventions 633. Primary survey 634. Pain - Correct answer Post resuscitation care parameters that are continuously evaluated: 635. Capnography monitors numeric value, as well as continuous waveform, indicating real-time measurement and trending over time. - Correct answer Quantitative: 96 [Date] 636. Colorimetric CO2 detectors provide info about the presence or absence of CO2. A chemically treated indicator strip changes color revealing the presence or absence of exhaled CO2 - Correct answer Qualitative 637. D displaced tube  obstructed or kinked 638. P pneumothorax 639. E equipment failure , such as becoming detached from the equipment or loss of capnopgrahy - Correct answer DOPE 640. Preparation 641. Preoxygenation 642. Pretreatment 643. Paralysis and Induction 644. Protecting and positioning - v 645. Placement of proof - secure the tube 646. Post intubation - secure ETT Tube, get X-ray for placement - Correct answer Steps of Rapid Sequence Intubation 647. from hemorrhage is leading cause. Hypovolemia is caused by decrease in the amount of circulating volume. Goal is to replace volume. - Correct answer Hypovolemic Shock 648. results from hypo perfusion to the tissue due to an obstruction in either vasculature or heart. Goal is to relieve obstruction and improve perfusion. 649. Ex: tension pneumo or cardiac tamponade are two classic examples that may result from trauma. - Correct answer Obstructive Shock 97 [Date] 650. 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. 651. Ex: MI's or dysrhythmia are common causes - Correct answer Cariogenic Shock 652. occurs as a result of maldistribution of an adequate circulating blood volume with the loss of vascular tone or increased permeability. 653. Ex: Anaphylactic - release of antihistamines 654. 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. 655. Goal: Volume replacement and vasoconstriction - Correct answer Distributive Shock 656. A breath every 5 to 6 seconds: 10-12 ventilations per minute - Correct answer Bag mask ventilation 657. Stroke Volume X HR - Correct answer Cardiac Output = 658. .. activation: .... are found in the carotid sinus and along the aortic arch, are sensitive to the degree of stretch in the arterial wall. When the receptors sense a decrease in stretch, they stimulate the sympathetic nervous system to release Epi, norepi, causing stimulation of cardiac activity