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

Download TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC and more Exams Forensics in PDF only on Docsity! TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition 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? 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-assisted intubation and attempted intubation but was unsuccessful. What is the most appropriate immediate next step? 13. within 24 hrs of trauma - Correct answer When is the tertiary survey completed fora trauma pt? 14. pressure - Correct answer An intubated and sedated pt in the ED has multiple extremity injuries with the potential for causing compartment syndrome. What is the most reliable indication of compartment syndrome in a patient who is unconscious? 15. worsening pneumothorax - Correct answer Which of the following is possible complication of positive-pressure ventilation? 16. pelvic stability - Correct answer the most reassuring finding for a male pt with hip pain after a fall is which of the following? 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? 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? 46. a 52 y/o diabetic male with a partial thickness burn to the left lower leg - Correct answer Which of the following patients warrants referral to a burn center? 47. dressing removal - Correct answer A patient arrives with a large open chest wound after being assaulted with a machete. Prehospital providers placed a nonporous dressing over the chest wound and taped it on three sides. he is now showing signs of anxiety, restlessness, severe respiratory distress, cyanosis and decreasing blood pressure. Which of the following is the MOST appropriate immediate intervention? 48. after a physical examination if the pt has no radiologic abnormalities on CT - Correct answer EMS arrives with the intoxicated driver of a car involved in a MVC. EMS reports significant damage to the drivers side of the car. The pt is asking to have the cervical collar removed. When it is appropriate to remove the cervical collar? 49. MARCH - Correct answer Which of the following mnemonics can help the nurse prioritize care for a trauma patient with massive uncontrolled hemorrhage? 50. 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. 51. 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. 52. 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. 53. What is Newton's Second Law? - Correct answer Force equals mass multiplied by acceleration of deceleration. 54. What is kinetic energy (KE)? - Correct answer KE equals 1/2 the mass (M) multiplied by the velocity squared. 55. What is the Mnemonic for the Initial Assessment? - Correct answer A = Airway with simultaneous cervical spine protection 56. B = Breathing 57. C = Circulation 58. D = Disability (neurologic status) 59. E = Expose/Environmental controls (remove clothing and keep the patient warm) 60. 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 61. G = Give comfort measures (verbal reassurance, touch, and pharmacologic and nonpharmacologic management of pain). 62. H = Hx and Head-to-toe assessment 63. I = Inspect posterior surfaces - 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 - I = Injuries sustained - V = Vital Signs - T = Treatment - Pt generated information - PMH - Head-to-toe assessment 81. What is assessed under the Mnemonic "I"? - Correct answer INSPECT POSTERIOR SURFACES - While maintaining C-spine, logroll pt with assistance to inspect back, flanks, buttocks and posterior thighs. - Palpate vertebral column for deformity and areas of tenderness - Assess rectum for presence/absence of tone, presence of blood 82. What she be done after the Secondary Assessment? - Correct answer Reassess: - Primary survey, - VS - Pain - Any injuries 83. 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 84. What medications are used during intubation? - Correct answer LOAD Mnemonic: 85. L = Lidocaine  = Opioids 86. A = Atropine 87. D = Defasiculating agents 88. What are the Rapid Sequence Intubation Steps? - Correct answer PREPARATION: - gather equipment, staffing, etc. 89. PREOXYGENATION: - Use 100% O2 (prevent risk of aspiration). 90. PRETREATMENT: - Decrease S/E's of intubation 91. PARALYSIS WITH INDUCTION: - Pt has LOC, then administer neuromuscular blocking agent 92. PROTECTION AND POSITIONING: - Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration 93. 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. 94. POSTINTUBATION MANAGEMENT: - Secure ET tube - Set ventilator settings - Obtain Chest x-ray - Continue to medicate - Recheck VS and pulse oxtimetry 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. - dysrhythmias - Cardiac Failure 118. 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. 119. 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 120. 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. 121. Spinal shock = areflexia and flaccidity associated with lower motor neuron involvement in complete cord injuries; reflexes return with resolution of spinal shock. 122. Septic shock from bacteremia is distributive shock. Endotoxins and other inflammatory mediators cause vasodilation, shunting of blood in microcirculation, and other perfusion abnormalities. 123. 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. 124. What is renal response? - Correct answer Renal ischemia activates release of renin. 125. Kidneys do not receive adequate blood supply, renin is release into circulation. 126. Renin causes angiotensinogen, normal plasma protein, to release angiotensin I. 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. 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. 159. 2. Central or transtentorial herniation 160. Why does herniation occur? What are the symptoms? - Correct answer Because of uncontrolled increases in ICP. 161. S/E's - Unilateral or bilateral pupillary dilation - AsyDimmetric pupillary reactivity - Abnormal motor posturing - Other evidence of neurologic deterioration 162. 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. 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 - 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 - 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 - 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. - Prolonged hyperventilation NOT RECOMMENDED. - Hypocarbia occurs as result of hyperventilation causes cerebral vasoconstriction, decreased CBF, decreased ICP. And ischemia secondary to severe vasoconstriction. - Hyperoxygenate pt with 100% O2 via bag-mask - Apply direct pressure to bleeding sites except depressed skull fractures - Cannulate 2 large IV's - Hypotension doubles pt's death rate (w/severe head trauma) - Vasopressors used to maintain CPP. - Insert OG or NGT. OG should be used with severe facial trauma. - Position pt, elevate head to decrease ICP (but may also reduce CPP). - Position head midline to facilitate venous drng. Rotate head to compress veins in neck and result in both venous engorgement and decreased drng from brain - Prepare for ICP monitoring device - Administer mannitol as prescribed. - Mannitol, hyperosmolar, volume-depleting diuretic, decreases cerebral edema + ICP by pulling interstitial fluid into intravascular space for eventual excretion by kidneys. - Administer anticonvulsant - Sx should be avoided b/c increases cerebral metabolic rate + ICP. Indications for sz prophylaxis: - Depressed skull fx - Sz at time of injury - Sz on arrival to ED - Hx of sz's - Penetrating brain injury - Acute subdural/epidural hematoma - Administer antipyretic med/Cooling blanket - Hyperthermia may increase cerebral metabolic rate + ICP. Avoid causing shivering during cooling process; increases cerebral metabolic rate + may precipitate rise in ICP - Do not pack ears/nose if CSF leak suspected - Admin tetanus prophylaxis - Wound repair for facial/scalp Lac's - Admin other meds - Analgesics, sedatives, narcan, romazicon, etc. - Admin antibiotics - Pt's w/basilar skull fx need prophylaxis against meningitis - Prepare pt for OR, hospital admin or transfer. 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 - Coexisting chemical burn and swelling of lids 198. What are S/S of penetrating trauma/open or ruptured globe? - Correct answer - Marked visual impairments - Extrusion of intraocular contents - Flattened or shallow anterior chamber - Subconjunctival hemorrhage, hyphema - Decreased intraocular pressure - Restriction of extraocular movements 199. What are the S/S of orbital fracture (orbital blowout fracture)? - Correct answer - Diplopia (double vision) - Loss of vision - Altered extraocular eye movements - Enophthalmos (displacement of the eye backward into the socket) - Subconjunctival hemorrhage or ecchymosis of the eyelid - Infraorbital pain or loss of sensation - Orbital bony deformity 200. 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. 201. S/S: - Slight swelling of maxillary area - Possible lip lac's or fractured teeth - Independent movement of the maxilla from rest of face - Malocclusion 202. 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. 203. S/S: - Massive facial edema - Nasal swelling w/obvious fx of nasal bones - Malocclusion - 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 - 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: - Importance of protective eyewear - No driving w/eye patch on - Wear sunglasses to prevent tearing, aid photophobia - Prepare for admission, OR or transfer 215. What are the nursing interventions for a patient with a maxillofacial or neck injury? - Correct answer - Administer oxygen - For facial trauma, place pt in high-fowler's position if no spinal injury is present. - Insert OG or NGT. OGT should be used if basilar skull fx or severe midface fx's are suspected - Monitor for progressive airway assessment - Prepare for intubation, PRN. - Cannulate 2 large IV's, initiate isotonic crystalloid IV solution - Control external bleeding w/direct pressure - Monitor for continued bleeding + expanding hematomas - Apply cold compresses to face to minimize edema - Assist w/repair of oral lac's, PRN - Admin antibiotics - Stabilize impaled objects - Admin analgesic meds 216. 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 217. What are the most common type of injury associated with chest trauma? - Correct answer blunt; MVC's. Penetrating; firarm injuries or stabbings 218. 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 219. 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. 220. 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. 221. What could a flail chest be associated with? - Correct answer - Ineffective ventilation - Pulmonary contusion - Lacerated lung parenchyma 222. 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. 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 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 237. What are the S/S of pericardial tamponade? - Correct answer A collection of blood in pericardial sac. As blood accumulates, it exerts pressure on the heart, inhibiting or compromising ventricular filling. - Hyotension - Tachycardia or PEA - Dyspnea - Cyanosis - Beck's Triad (hypotension, distended neck veins + muffled heart sounds) - Progressive decreased voltage of conduction complexes on ECG 238. What are aortic injuries S/S? - Correct answer - Hypotension - Decreased LOC - Hypertension in UE's - Decreased quality (amplitude) of femoral pulses compared to UE pulses - Loud systolic murmur in parascapular region - Chest pain - Chest wall ecchymosis - Widened mediastinum on chest xray - Paraplegia 239. How would you assess a pt with a thoracic injury? - Correct answer (Initial assessment) 240. Obtain Hx. 241. PHYSICAL: 242. 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 243. Percussion: - Percuss the chest (Dullness = hemothorax, Hyperresonance = pneumothorax) 244. 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). 245. 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) 246. Diagnostic Procedures: - Xrays - Arteriography - Bronchoscopy and laryngoscopy - CT's - FAST - Labs (cardiac enzymes) - ECG, CVP 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) 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 - Labs, X-rays, CT, Foley, - Family Presence 277. 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 278. What is assessed under the Mnemonic "H"? - Correct answer HISTORY / HEAD- TO-TOE ASSESSMENT - MIVT - M = Mechanism of injury - I = Injuries sustained - V = Vital Signs - T = Treatment - Pt generated information - PMH - Head-to-toe assessment 279. What is assessed under the Mnemonic "I"? - Correct answer INSPECT POSTERIOR SURFACES - While maintaining C-spine, logroll pt with assistance to inspect back, flanks, buttocks and posterior thighs. - Palpate vertebral column for deformity and areas of tenderness - Assess rectum for presence/absence of tone, presence of blood 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: - 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) 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 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. 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. 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. 336. Explain Pulmonary Response. - Correct answer Tachypnea happens for 2 reasons: 337. Maintain acid-base balance 338. 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. 339. 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. 340. How would you assess someone in hypovolemic shock? - Correct answer (Use Initial Assessment) and then: 341. Inspect: - LOC - Rate and quality of respirations - External bleeding? - Skin color and moisture 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 13-15 366. 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 - Depression 371. 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. 372. 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 373. 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. 374. S/S: - Alteration in LOC - Behavior, motor or speech deficits - Abnormal motor posturing - Signs of increased ICP 375. 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 376. 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 377. What is a subdural hematoma and its S/S? - Correct answer A focal brain injury beneath the dura mater that results from acceleration/deceleration. Usually venous, and not necessarily from a fx. Formation may be acute or chronic. 378. Acute pt's hematoma manifest 48 hrs post injury - 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 - Prepare for ICP monitoring device - Administer mannitol as prescribed. - Mannitol, hyperosmolar, volume-depleting diuretic, decreases cerebral edema + ICP by pulling interstitial fluid into intravascular space for eventual excretion by kidneys. - Administer anticonvulsant - Sx should be avoided b/c increases cerebral metabolic rate + ICP. Indications for sz prophylaxis: - Depressed skull fx - Sz at time of injury - Sz on arrival to ED - Hx of sz's - Penetrating brain injury - Acute subdural/epidural hematoma - Administer antipyretic med/Cooling blanket - Hyperthermia may increase cerebral metabolic rate + ICP. Avoid causing shivering during cooling process; increases cerebral metabolic rate + may precipitate rise in ICP - Do not pack ears/nose if CSF leak suspected - Admin tetanus prophylaxis - Wound repair for facial/scalp Lac's - Admin other meds - Analgesics, sedatives, narcan, romazicon, etc. - Admin antibiotics - Pt's w/basilar skull fx need prophylaxis against meningitis - Prepare pt for OR, hospital admin or transfer. 391. What are signs of a serious eye injury? - Correct answer - Visual disturbances - Pain - Redness and ecchymosis of the eye - Periorbital ecchymosis - Increased intraocular pressure 392. 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). 393. S/S: - Blood in anterior chamber - Deep, aching pain - Mild to severe diminished visual acuity - Increased intraocular pressure 394. What are s/s of chemical burns to the eye? - Correct answer Chemical injuries require immediate intervention if it is to be preserved. 395. S/S: - Pain - Corneal Opacification - Coexisting chemical burn and swelling of lids 396. What are S/S of penetrating trauma/open or ruptured globe? - Correct answer - Marked visual impairments - Extrusion of intraocular contents - Flattened or shallow anterior chamber - Subconjunctival hemorrhage, hyphema - Decreased intraocular pressure - Restriction of extraocular movements 397. What are the S/S of orbital fracture (orbital blowout fracture)? - Correct answer - Diplopia (double vision) - Loss of vision - Altered extraocular eye movements - Enophthalmos (displacement of the eye backward into the socket) - Subconjunctival hemorrhage or ecchymosis of the eyelid - Infraorbital pain or loss of sensation - Orbital bony deformity 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. - 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 411. DIAGNOSTIC STUDIES: - Xrays, CT scans, MRI's - Fluorescein staining - Slit-lamp exam - tonometry (measures intraocular pressure) - Bronchoscopy or esophagoscopy 412. What are the nursing interventions for a pt with an ocular injury? - Correct answer - Assess visual acuity & reassess - Elevate HOB to minimize intraocular pressure - Instruct pt not to bend forward, cough or perform Valsalva maneuver b/c these actions may raise intraocular pressure - Assist w/removal of foreign bodies as indicated; stabilize impaled objects - Apply cool packs to decrease pain + periorbital swelling - Admin medications - Instill prescribed topical anesthetic drops for pain - Instill NS drops or artificial tears to keep corneas moist. Cover eyelids w/sterile, moist saline dsg to prevent drying and ulceration - Antibiotics topically or systemically - Admin tetanus prophylactically - Use an eye patch to affected eye - Patch or shield both eyes to reduce movement + photophobia in pt's w/retinal injuries - Patch, shield or cover w/cool pack - Do NOT patch injured eye of pt w/suspected open or ruptured globe or impaled object, patch unaffected eye. Use metal or plastic and do not put pressure on the globe. - Provide psychosocial support - Obtain an ophthalmology consultation - Provide d/c instructions: - Importance of protective eyewear - No driving w/eye patch on - Wear sunglasses to prevent tearing, aid photophobia - Prepare for admission, OR or transfer 413. What are the nursing interventions for a patient with a maxillofacial or neck injury? - Correct answer - Administer oxygen - For facial trauma, place pt in high-fowler's position if no spinal injury is present. - Insert OG or NGT. OGT should be used if basilar skull fx or severe midface fx's are suspected - Monitor for progressive airway assessment - Prepare for intubation, PRN. - Cannulate 2 large IV's, initiate isotonic crystalloid IV solution - Control external bleeding w/direct pressure - Monitor for continued bleeding + expanding hematomas - Apply cold compresses to face to minimize edema - Assist w/repair of oral lac's, PRN - Admin antibiotics - Stabilize impaled objects - Admin analgesic meds 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. 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) 435. What are the S/S of pericardial tamponade? - Correct answer A collection of blood in pericardial sac. As blood accumulates, it exerts pressure on the heart, inhibiting or compromising ventricular filling. - Hyotension - Tachycardia or PEA - Dyspnea - Cyanosis - Beck's Triad (hypotension, distended neck veins + muffled heart sounds) - Progressive decreased voltage of conduction complexes on ECG 436. What are aortic injuries S/S? - Correct answer - Hypotension - Decreased LOC - Hypertension in UE's - Decreased quality (amplitude) of femoral pulses compared to UE pulses - Loud systolic murmur in parascapular region - Chest pain - Chest wall ecchymosis - Widened mediastinum on chest xray - Paraplegia 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: - 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 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 463. Compression: Force from being crushed between objects 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 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 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. 525. U Unresponsive. If the pt. is unresponsive, announce it loudly to the team and direct someone to chk in the pt is pulseless while assessing if the cause of the problem is the airway. - Correct answer Airway and AVPU: 526. ask pt to pen his or her mouth - Correct answer While assessing airway the patient is alert and responds to verbal stimuli you should.. 527. jaw thrust maneuver to open airway and assess for obstruction. If pt has a suspected csi, the jaw thrust procedure should be done by two providers. One provider can maintain c-spine and the other can perform the jaw thrust maneuver. - Correct answer While assessing airway pt is unable to open mouth, responds only to pain, or is unresponsive you should.. 528. The tongue obstructing the airway 529. loose or missing teeth 530. foreign objects 531. blood, vomit, or secretions' 532. edema 533. burns or evidence of inhalation injury 534. Auscultiate or listen for: 535. Obstructive airway sounds such as snoring or gurgling 536. Possible occlusive maxillofacial bony deformity 537. Subcutaneous emphysema - Correct answer Inspect the mouth for: 538. Check the presence of adequate rise and fall of the chest with assisted ventilation 539. Absence of gurgling on auscultation over the epigastrium 540. Bilateral breath sounds present on auscultation 541. Presence of carbon dioxide (CO2) verified by a CO2 device or monitor - Correct answer If the pt has a definitive airway in what should you do? 542. Suction the airway 543. 2, Use care to avoid stimulating the gag reflex 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 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 596. MIST - prehospital report 597. MOI 598. Injuries sustained 599. S s/s in the field 600. T treatment in the field 601. if patients family present get a better hx on them - Correct answer H 602. Sample is part of history 603. S symptoms associated with injury 604. A allergies and tetanus status 605. M meds currently on including anticoagulant therapy 606. P past medical hx 607. L last oral intake 608. E Events and environment factors related to the injury - Correct answer SAMPLE 609. inspect for lacs, abrasions, asymmetry of facial expressions 610. palate for depressions and tenderness 611. look at ears for drainage - Correct answer Head to toe assessment: Head and face 612. immobilize cervical spine, tenderness, tracheal deviation - Correct answer Head to toe assessment: Neck and cervical spine 613. inspect, auscultate, palpate 614. any spontaneous breathing, rate, depth, and degree of effort, use of accessory muscles 615. lacs, contusions, 616. auscilate lung sounds and heart sounds - Correct answer Head to toe assessment: Chest 617. don't forget flanks!!! 618. inspect of lacs, puncture wounds, contusions, 619. auscultate then palpate: 620. bowel sounds? 621. any rigidity, guarding? begin with light palpation start to palpate with side that does not hurt 622. maybe do a fast scan? - Correct answer Head to toe assessment: Abdomen 623. any lacs? deformities? blood at the urtheral meatus 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 and constriction of blood vessels, which causes a rise in heart rate and diastolic blood pressure - Correct answer Baroreceptors: 659. activation: consist of carotid and aortic bodies. ... detect changes in blood oxygen and Co2 and pH. When Co2 rises or oxygen level of pH falls these receptors are activated and information is relayed to the CNS and the cardiorespiratory centers in the medulla , which increases respiratory rage and depth and BP - Correct answer Chemoreceptors: 660. 50 to 150 - Correct answer MAP Range 661. the decrease coagulopathy .. you will you bleed more - Correct answer The colder you are the more acidic you are.. 662. in massive transfusion protocol... responsible for dissolving clots - Correct answer TXA 663. stabilized vital signs, improved mental status, improved urine output - Correct answer What are indicators of increased perfusion? - Correct answer Prehospital shock index pg. 85 664. Flail chest - Correct answer Paradoxical chest wall movement 665. can be caused by blunt trauma. air escapes from injured lung to pleural space and negative intrapleural pressure is lost causing partial or collapsed lung - Correct answer Simple Pneumothorax 666. Dyspnea 667. Tachycardia 668. Decreased or absent breath sounds on the injured side 669. CP - Correct answer Simple Pneumo assessment: 670. Tx is based on size, presence of sx, and stability. For those are aysmpomatic and stable. Observation with or without oxygen. Larger pneumo who are unstable or likely to deteriorate a chest tube is placed. - Correct answer Simple pneumo interventions: 671. can result from penetrating wound through chest wall causing air to be trapped in to the intrapleural place. Might hear "sucking" 672. Tx: nonporous dressing tapes on 3 sided, then Chest tube and would closure surgical repair. - Correct answer Open Pneumo: 673. Air cannot escape intrapleural space.. can begin to compress heart. pt will have sever resp distress, hypotension, JVD. - Correct answer Tension pneumo 674. 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. 675. Prepare for chest tube placement. - Correct answer Tension pneumo intervention 676. Caused by blood in the intrapleural space/ May also occur from lac to live or spleen combined with injury to the diaphragm. 677. Ensure two large bore IVS are placed. 678. Prepare for thoracentesis and chest tube insertion. If open thoracotomy is done chest tube is deferred. - Correct answer Hemothorax: 679. Hypotension 680. JVD 681. Muffled heart sounds - Correct answer Becks Triad: 682. Needle pericardiocentesis, but it is a temp solution. Requires surgical evaluation. 683. (Ultrasound guided) - Correct answer Cardiac Tamponade Intervention: 684. Aortic Dissection - Correct answer Unequal extremity pulse strength possibility of.. 685. pain - hallmark sign, early sign 686. pressure - early sign 687. pallor, pules, paresthesia, paralysis - late sign - Correct answer Six P's of compartment syndrome: 707. What causes the primary effects of blast traumas? - Correct answer The direct blast effects. Types of injuries include last long, tympanic membrane rupture and middle ear damage, abdominal hemorrhage and perforation, global rupture, mild Trumatic brain injury. 708. What causes the secondary effects of blast traumas? - Correct answer Projectiles propelled by the explosion. Injuries include penetrating or blunt injuries or I penetration. 709. What causes the tertiary effects of blast traumas? - Correct answer Results from individuals being thrown by the blast wind. Injuries include hole or partial body translocation from being thrown against a hard service: blunt or penetrating trauma's, fractures, traumatic amputations. 710. What causes quarternary effects of blast traumas? - Correct answer All explosion related injuries, illnesses, or diseases not due to the first three mechanisms. Injuries include external and internal burns, crush injuries, closed and open brain injuries, asthmatic or breathing problems from dust smoke or toxic fumes, angina, or hyper glycemia and hypertension. 711. What causes quinary effects of blasts traumas? - Correct answer Those associated with exposure to hazardous materials from radioactive, biologic, or chemical components of a blast. Injuries include a variety of health effects depending on agent. 712. What are the three processes that transfer oxygen from the air to the lungs and blood stream - Correct answer Ventilation: the active mechanical movement of air into and out of the lungs; diffusion: the passive movement of gases from an area of higher concentration to an area of lower concentration; and perfusion: the movement of blood to and from the lungs as a delivery medium of oxygen to the entire body. 713. When would you use a nasopharyngeal airway versus an oral pharyngeal airway? - Correct answer Nasopharyngeal airways is contraindicated in patients with facial trauma or a suspected basilar skull fracture. Oral pharyngeal airways is used in unresponsive patients unable to maintain their airway, without a gag reflex as a temporary measure to facilitate ventilation with a bag mask device or spontaneous ventilation until the patient can be intubated. 714. Describe the measurement of an NPA - Correct answer Measure from the tip of the patient's nose to the tip of the patients earlobe. 715. Measurement of an OPA - Correct answer Place the proximal end or flange of the airway adjunct at the corner of the mouth to the tip of the mandibular angle. 716. True or false: NPAs and OPAs are definitive airways. - Correct answer False. When placing one of these? One should consider the potential need for a definitive airway. 717. Name the three ways to confirm ETT placement - Correct answer Placement of a CO2 monitoring device, Assessing for equal chest rise and fall, and listening at the epigastrium and four lung fields for equal breath sounds. 718. When capnography measurement reads greater than 45MMHG, the nurse should consider increasing or decreasing the ventilation rate? - Correct answer Increasing the ventilation rate. Doing so would allow the patient to blow off retained CO2. 719. When capnography measurement reads less than 35MMHG, the nurse should consider increasing or decreasing the ventilation rate? - Correct answer Decreasing the ventilation rate. By doing so, the nurse allows the patient to retain CO2. 720. What are the three stages of shock - Correct answer Compensated, decompensated or progressive, and irreversible. 721. What are the signs of compensated shock? - Correct answer Anxiety, confusion, restlessness, increased respiratory rate, narrowing pulse pressure were diastolic increases yet systolic remains unchanged, tachycardia with bounding pulses, and decreased urinary output 722. What are the signs and symptoms of decompensated shock? - Correct answer Decreased level of consciousness, hypertension, narrow pulse pressure, tachycardia with weak pulses, tachypnea, skin that is cool clammy and cyanotic, base access outside the normal range, and serum lactate levels greater than two to 4MMOL/L. 723. What are the signs and symptoms of irreversible shock? - Correct answer Obtunded stuporous or comatose state, marked hypertension and heart failure, bradycardia with possible dysrhythmias, decreased and shallow respiratory rate, pale cool and clammy skin, kidney liver and other organ failure, severe acidosis, elevated lactic acid levels, worsening base access on ABGs, coagulopathies with petechiae purpura or bleeding. 724. What are the four types of shock? - Correct answer Hypovolemic, Cardiogenic, Obstructive, & Distributive 725. What is the trauma triad of death? - Correct answer hypothermia, acidosis, coagulopathy 726. Describe the characteristics of obstructive shock - Correct answer Obstructive shock is it mechanical problem that results from hypoperfusion of the tissue due to an obstruction in either the vasculature or the heart resulting in decreased cardiac output. Some causes include a tension pneumothorax, cardiac tamponade, or venous air embolism on the right side of the heart during systole in the pulmonary artery.Signs include anxiety, muffled heart sounds, JVD, hypertension, chest pain, difficulty breathing, or pulses paradoxes. 727. Describe the characteristics of cardiogenic shock - Correct answer Cardiogenic shock results from pump failure in the presence of adequate intravascular volume. Lack of cardiac output and an organ perfusion occurs secondary to a decrease in myocardial contractility and or valvular insufficiency. This can happen with blunt cardiac trauma or an MI. Symptoms can include low blood pressure increase heart rate and respiratory rate chest pain shortness of breath dysrhythmias increase troponin and pale cool moist skin 728. Describe the characteristics of distributive shock. - Correct answer Distributive shock occurs as a result of Mel distribution of an adequate circulating blood volume with the loss of vascular tone or increased permeability. This can occur with spinal cord