TNCC Written Exam Review with Solutions 2023., Exams of Nursing

Download TNCC Written Exam Review with Solutions 2023. and more Exams Nursing in PDF only on Docsity! 1 TNCC, Tncc, TNCC Written Exam, TNCC Written Exam, TNCC class, TNCC/TCRN, TNCC Written Exam Review, TNCC, TNCC Skill Demonstration, Tncc, TNCC, TNCC EXAM, TNCC Written Exam, TNCC Written Exam, Tncc, TNCC, Trauma Nursing II, TNCC Primary concern when a person cannot stop coughing/clearing their throat following house fire/smoke? Correct Answer: Airway/Intubate Lab evidence of cellular perfusion Correct Answer: Base Excess (Less than -6 is BAD) Multiple people are in the ER of different ages who all go to the same church. They all have the same symptoms. What is the most likely cause? Correct Answer: Biologic Suspected shock type with a spinal cord injury Correct Answer: Distributive Shock (Includes neurogenic) Patient has GCS of 3, unequal pupils (one sluggish, one blown), and is posturing. What is the cause? Correct Answer: Herniation Middle Meningeal Artery Correct Answer: Epidural Hematoma (results from collection of blood that forms between dura mater and skull) Prior to having a concussion (TBI), the patient had a brain injury that was not fully healed. What is the cause? Correct Answer: 2nd Impact Syndrome Bowel sounds heard in the L chest. What is this a symptom of? Correct Answer: Ruptured diaphragm Symptoms of __________________: include muffled heart sounds and hypotension Correct Answer: Pericardiocentesis How should you dress a severed limb? Correct Answer: Sterile gauze with normal saline THEN put ice on it Amylase level looks at _____________ Correct Answer: Pancreas What should you do if your patient has hyphema (collection of blood inside the front part of the eye?) Correct Answer: Sit HOB up to 30 degrees Principle that people have to take action after suffering a loss in order to decrease severity, seriousness, or painfulness Correct Answer: Mitigation What organ is most at risk following a gunshot Correct Answer: Liver 2 8 year old child with longitudinal thigh lacerations Correct Answer: Sign of child abuse Bleeding around belly button Correct Answer: Cullen's Sign What would cause an inaccurate reading from an 02 saturation probe? Correct Answer: Carboxyhemoglobin (increase FiO2 to 100%) General study of forces and their effects on living tissue and the human body Correct Answer: Biomechanics Study of energy transfer as it applies to identifying actual or potential injuries Correct Answer: Kinematics Refers to the separation of tissue resulting from a sound and/or hydraulic wave force- the effect is a crushing pressure wave which creates a temporary cavity, followed by a rapid and violent closing of the cavity. Correct Answer: Cavitation This rapid motion can lead to crushing, tearing, and shearing forces on tissue Correct Answer: Cavitation Used in OR; does not provide protection against aspiration and not recommended in patients who have eaten recently. It is a supraglottic airway. Correct Answer: Laryngeal Mask Airway Single tube retroglottic device inserted into the esophagus and traps the glottis opening between an esophageal cuff and an oropharyngeal cuff. Designed with 2 ports/lumens each with a separate cuff. Does NOT provide protection against aspiration and is not indicated in children. It is a retroglottic airway. Correct Answer: King Tube Types of Shock (4) Correct Answer: Hypovolemic, Obstructive, Cardiogenic, Distributive Hemorrhage is the leading cause. Can result from vomiting, diarrhea, and burn trauma. Decreased circulating volume --> decreased preload. Therapy includes replacing the type of volume that was lost. Correct Answer: Hypovolemic Shock Results from hypo perfusion of tissue due to an obstruction in either the vasculature or heart. Therapy aimed at relieving the obstruction and improving perfusion. Correct Answer: Obstructive Shock Two classic examples of obstructive shock Correct Answer: Cardiac tamponade and tension pneumothorax Results from pump failure in the presence of adequate intravascular volume. Lack of CO and end-organ perfusion secondary to a decrease in myocardial contractility and/or valvular insufficiency. Therapy includes inotropic support, antidysrhythmic medications, and correction or treatment of underlying cause. Correct Answer: Cardiogenic Shock Results from the misdistribution of an adequate circulating blood volume with the loss of vascular tone or increased permeability. Treatment is to provide volume replacement, increase systemic vascular resistance with medications (pressors) and possible antibiotics. Correct Answer: Distributive Shock 5 ____________ ___________ Injury: shearing or tearing. Diagnosed with MRI. Widespread microscopic hemorrhage. Correct Answer: Diffuse Axonal Injury (Cannot recover from this; shearing/tearing portion DOES NOT heal) Muffled heart sounds Correct Answer: Cardiac tamponade? Pericardial fluid? Most frequently injured organ Correct Answer: Liver Most frequently injured organ from BLUNT trauma Correct Answer: Spleen Pain Ladder: Step 1: Non-opioids for mild pain Step 2: Weak opioids for mild to moderate pain Step 3: Strong opioids for moderate to severe pain Correct Answer: 1: Tylenol, Ibuprofen, Ketorolac 2: Codeine 3: Morphine, Fentanyl, Dilaudid Signs of increased compartment syndrome Correct Answer: Increased pain, feels tight/very painful, but nothing looks wrong Ischemia develops -- Pressure Fasical Development -- Impaired Blood Flow. 6 P's: Pressure, pallor, pulses, paresthesia, paralysis. Extremity goes to level of the ___________!!! NO ______!! Correct Answer: Compartment Syndrome: Level of heart; NO ice!! Control bleeding with direct pressure, elevate, apply tourniquets. Correct Answer: Amputation Wrap in saline gauze, put in bag, then put that bag in another bag filled with ice. Label bag. Correct Answer: Removed limb A ____ and ___ approach is used by all members of the trauma team to provide optimal care for the trauma pt. Correct Answer: Systematic , Organized Trauma is injury to living tissue caused by ... Correct Answer: An extrinsic agent A traumatic incident may be classified as ....(assault or suicide) or ... (falls or collisions) Correct Answer: Intentional;unintentional .... is the study of energy transfer as it applies to identifying actual or potential injuries Correct Answer: Kinematics The general study of forces and their effects Correct Answer: Biomechanics How external forces in the environment are transferred to the body Correct Answer: Mechanism of injury A body at rest will remain at rest, a body in motion will stay in motion Correct Answer: Newton's first law 6 Force = mass x acceleration Correct Answer: Newton's second law For every action there is an equal and opposite reaction Correct Answer: Newton's third law Energy can neither be created nor destroyed but rather I can change form Correct Answer: Law of conservation of energy Kinect is energy is equal to ... Correct Answer: 1/2 the mass x by the velocity squared (v^2) Caused by a sudden stop of the body's motion Correct Answer: Deceleration forces Caused from a sudden and rapid onset of motion ( a Parker car being hit by another vehicle) Correct Answer: Acceleration forces An external force applied time of impact, ex. Steering wheels or dashboards that collide with or push up into a person. Correct Answer: Compression force .... is the major cause of preventable death after injury Correct Answer: Uncontrolled hemorrhage .... is suspected in any patient with multi system trauma. Correct Answer: Cervical spine injury ... shock is from hemorrhage and is the leading cause of preventable deaths in trauma patients. Can also be caused by plasma loss in ... Correct Answer: Hypovolemic; burns ... shock results from hypoperfusion of the tissue due to an obstruction in either the vasculature or heart. Two examples include.... Correct Answer: Obstructive;tension pneumothorax, cardiac tamponade. (With tension pneumo the increase in intrathoracic pressure leads to displacement of the vena cava, obstruction to arrival filling leading to decreased preload and decreased cardiac output) ( with cardiac tamponade there is an accumulation of fluid in the pericardial sac impeding diastolic expansion and filling leading to decreased preload, stroke volume,CO and end organ perfusion) ... shock occurs as a result of maldistribution of an adequate circulation blood volume with the loss of vascular tone or increased permeability. 3 examples. Correct Answer: Distributive; anaphylactic, septic and neurogenic .... 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: Baroreceptor activation; baroreceptors ...activation: consist of carotid and aortic bodies. ... detect changes in blood oxygen and Co2 and pH. When Co2 rises or oxygen level of pH falls these receptors are activated and information is relayed to the CNS and the cardiorespiratory centers in the medulla , which increases respiratory rage and depth and BP Correct Answer: Chemoreceptors 7 In the ... ... response two catecholamines are released ... and ... . Correct Answer: Adrenal gland response; epinephrine and norepinephrine In the adrenal gland response ... is released to raise blood glucose and promote renal retention of water and sodium. Correct Answer: Cortisol ... is the initial post traumatic inflammatory response. ... ... activates this response and ... are sent to the injury sites, activating signaling pathways that mobilize inflammatory cells. Correct Answer: Immune response; tissue hypoxia;neutrophils What stage of shock: anxiety, restless, confused, norm systolic pressure, rising diastolic pressure, slightly tachycardiac, increased RR and decreased urine output Correct Answer: Stage I: compensated What stage of shock:patient is unconscious or intended, normal systolic pressure, narrowing pulse pressure, tachycardia, weak and threads pulses, rapid and shallow respiration, cool and clammy, worsening base excess and increasing Lacoste levels Correct Answer: Stage II: decompensated or progressive shock What stage of shock?: this will lead to death without rapid intervention, obtunded, stuporous or comatose, marked hypotension and heart failure, bradycardia, decreased and shallow respirations, pale, cool and clammy, organ failure and severe acidosis Correct Answer: Stage III: irreversible shock ... is a principle that confuses on prevention rather than intervention. Correct Answer: Damage control resuscitation The components of the neurological system involved with pain transmission include... Correct Answer: Neurons, neuron synapses and neurotransmitters ... pain is persistent and usually lasts longer than 3 to 6 months. Correct Answer: Chronic ... describes the concept of under treatment of pain. Correct Answer: Oligoanalgesia The most reliable and valid tool for pain assessment is ... Correct Answer: Self-report Causes of oligoanalgesia include... Correct Answer: Failure to assess initial pain; failure to implement guidelines and protocols; failure to document pain; failure to meet patients expectations The meninges consist of three layers of protective coverings ... Correct Answer: (PAD) pia matter, arachnoid matter and dura matter Adequate perfusion of oxygen and supply of nutrients to the brain tissue is dependent on ... and ... Correct Answer: CPP; CBF ... is defined as the pressure gradient across the brain tissue, or the difference between the pressures of the cerebral artery and venous vessels. Correct Answer: CPP; CPP = map - icp Normal CPP is ... Acceptable CPP is ... 10 - Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing - Sucking chest wounds - Absent or diminished breath sounds - Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated - Anticipate definitive airway management to support ventilation. Upon initial assessment, what type of oxygen should be used for a pt breathing effectively? Correct Answer: A tight-fitting nonrebreather mask at 12-15 lpm. What intervention should be done if a pt presents with effective circulation? Correct Answer: - Insert 2 large caliber IV's - Administer warmed isotonic crystalloid solution at an appropriate rate What are signs of ineffective circulation? Correct Answer: - Tachycardia - AMS - Uncontrolled external bleeding - Pale, cool, moist skin - Distended or abnormally flattened external jugular veins - Distant heart sounds What are the interventions for Effective/Ineffective Circulation? Correct Answer: - Control any uncontrolled external bleeding by: - Applying direct pressure over bleeding site - Elevating bleeding extremity - Applying pressure over arterial pressure points - Using tourniquet (last resort). - Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution - Use warmed solution - Use pressure bags to increase speed of IVF infusion - Use blood administration tubing for possible administration of blood - Use rapid infusion device based on protocol - Use NS 0.9% in same tubing as blood product - IV = surgical cut-down, central line, or both. - Blood sample to determine ABO and Rh group - IO in sternum, legs, arms or pelvis - Administer blood products - PASG (without interfering with fluid resuscitation) 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 11 What medications are used during intubation? Correct Answer: LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents What are the Rapid Sequence Intubation Steps? Correct Answer: PREPARATION: - gather equipment, staffing, etc. PREOXYGENATION: - Use 100% O2 (prevent risk of aspiration). PRETREATMENT: - Decrease S/E's of intubation PARALYSIS WITH INDUCTION: - Pt has LOC, then administer neuromuscular blocking agent PROTECTION AND POSITIONING: - Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration PLACEMENT WITH PROOF - Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30-60 seconds between attempts. - After intubation, inflate the cuff - Confirm tube placement w/exhaled CO2 detector. POSTINTUBATION MANAGEMENT: - Secure ET tube - Set ventilator settings - Obtain Chest x-ray - Continue to medicate - Recheck VS and pulse oxtimetry What is a Combitube? Correct Answer: A dual-lumen, dual-cuff airway that can be placed blindly into the esophagus to establish an airway. If inadvertently placed into trachea, it can be used as a temporary ET tube. There are only two sizes: small adult and larger adult. What is a Laryngeal Mask Airway? Correct Answer: Looks like an ET tube but is equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to cover the supraglottic area. ILMA, does not require laryngoscopy and visualization of the chords. What is Needle Cricothyrotomy Correct Answer: Percutaneous transtracheal ventilation. (temporary) Complications include: - inadequate ventilation causing hypoxia - hematoma formation - esophageal perforation - aspiration - thyroid perforation - subcutaneous emphysema 12 What is Surgical Cricothyrotomy? Correct Answer: Making an incision in cricothyroid membrane and placing a cuffed endo or trach tube into trachea. This is indicated when other methods of airway management have failed and pt cannot be adequately ventilated and oxygenated. Complications include: - Aspiration - Hemorrhage or hematoma formation or both - Lac to trachea or esophagus - Creation of a false passage - Laryngeal stenosis How do you confirm ET Tube/Alternative Airway Placement? Correct Answer: - Visualization of the chords - Using bronchoscope to confirm placement - Listening to breath sounds over the epigastrum and chest walls while ventilating the pt - CO2 detector - Esophageal detection device - Chest x-ray How do you inspect the chest for adequate ventilation? Correct Answer: Observe: - mental status - RR and pattern - chest wall symmetry - any injuries - patient's skin color (cyanosis?) - JVD or tracheal deviation? (Tension pneumothorax) What are you looking for when auscultating lung sounds? Correct Answer: Absence of BS: - Pneumothorax - Hemothorax - Airway Obstruction Diminished BS: - Splinting or shallow BS may be a result of pain What are you looking for when percussing the chest? Correct Answer: Dullness: - hemothorax Hyperresonance - Pneumothorax What are you looking for when palpating the chest wall, clavicles and neck? Correct Answer: - Tenderness - Swelling - subcutaneous emphysema - step-off deformities = These may indicate: esophageal, pleural, tracheal or bronchial injuries. Palpate trachea above suprasternal notch. Tracheal deviation may indicate a tension pneumothorax or massive hemothorax. 15 - decreased coronary artery perfusion - Membranes of lysosomes breakdown within cells and release digestive enzymes that cause intracellular damage. How would you assess a pt in hypovolemic shock? Correct Answer: (Use Initial Assessment) and then: Inspect: - LOC - Rate and quality of respirations - External bleeding? - Skin color and moisture - Assess jugular veins and peripheral veins Auscultate: - BP - Pulse pressure - Breath sounds - Heart sounds - Bowel sounds Percuss: - Chest and abdomen Palpate: - Central pulse (carotid or femoral) - Positive inotropic effect (force of contraction) may be evidence by a bounding central pulse - Palpate peripheral pulses - Palpate skin temp and moisture Diagnostic Procedures: - Xrays and other studies - Labs Planning and Implementation - Oxygen - IV's with warmed replacement fluids - Control external bleeding with direct pressure - Elevate LE's - NGT - Foley - Monitor and pulse oximeter - Monitor for development of coagulopathies - Surgery? ICP is a reflection of what three volumes? What happens when one increases? Correct Answer: 1. Brain 2. CSF 3. Blood within the nonexpansible cranial vault As volume of one increases, the volume of another decreases to maintain ICP within normal range. As ICP rises, CPP decreases, leading to cerebral ischemia and potential for hypoxia and lethal secondary insult. Hypotensive pt w/marginally elevated ICP can be harmful. 16 Slightly elevated BP could protect against brain ischemia in a pt with high ICP. Cerebral ischemia can lead to increased concentration of CO2 and decreased concentration of O2 in cerebral vessels. CO2 dilates cerebral blood vessels = increase blood volume and ICP. What are the early signs and symptoms of increased ICP? Correct Answer: - Headache - N/V - Amnesia regarding events around the injury - Altered LOC - Restlessness, drowsiness, changes in speech, or loss of judgement What are the late observable signs of symptoms of increased ICP? Correct Answer: - Dilated, nonreactive pupil - Unresponsiveness to verbal or painful stimuli - Abnormal motor posturing patterns - Widening pulse pressure - Increased systolic blood pressure - Changes in RR and pattern - Bradycardia What is Cushing's phenomenon or Cushing's Reflex? Correct Answer: Triad of progressive HTN, bradycardia and diminished respiratory effort. What are the two types of herniation that occurs with ICP? Correct Answer: 1. Uncal herniation 2. Central or transtentorial herniation Why does herniation occur? What are the symptoms? Correct Answer: Because of uncontrolled increases in ICP. S/E's - Unilateral or bilateral pupillary dilation - AsyDimmetric pupillary reactivity - Abnormal motor posturing - Other evidence of neurologic deterioration Define uncal herniation. Correct Answer: The uncus (medial aspect of the temporal lobe) is displaced over the tentorium into the posterior fossa. This herniation is the more common of the two types of herniation syndromes. Define central or transtentorial herniation. Correct Answer: A downward movement of the cerebral hemispheres with herniation of the diencephalon and midbrain through the elongated gap of the tentorium. Disruptions of the bony structures of the skull can result in what? Correct Answer: Displaced or nondisplaced fx's causing CSF leakage b/c of lac to the dura mater, creating a passage for CSF. CSF leaks through the nose (rhinorrhea) or the ears (otorrhea). A potential entrance for invading bacteria. Also: meningitis or encephalitis or brain abscess 17 Define Minor Head Trauma. Correct Answer: GCS 13-15 Define Moderate Head Trauma Correct Answer: Postresuscitative state with GCS 9-13. Define Severe Head Trauma. Correct Answer: Postresuscitative state with GCS score of 8 or less. What is a concussion and its signs and symptoms? Correct Answer: A temporary change in neurologic function that may occur as a result of minor head trauma. S/S: - Transient LOC - H/A - Confusion and disorientation - Dizziness - N/V - Loss of memory - Difficulty with concentration - Irritability - Fatigue What are the signs and symptoms of postconcussive syndrome? Correct Answer: - Persistent H/A - Dizziness - Nausea - Memory impairment - Attention deficit - Irritability - Insomnia - Impaired judgement - Loss of libido - Anxiety - Depression What is diffuse axonal injury and its signs and symptoms? Correct Answer: (DAI) is widespread, rather than localized, through the brain. Diffuse shearing, tearing and compressive stresses from rotational or accerleration/deceleration forces resulting in microscopic damage primarily to axons within the brain. S/S: - Immediate unconsciousness - mild DAI, coma = 6-24 hrs - severe DAI, coma = weeks/months or persistent vegetative state - Elevated ICP - Abnormal posturing - HTN - Hyperthermia - Excessive sweating because of autonomic dysfunction - Mild to severe memory impairment, cognitive, behavioral, and intellectual deficits 20 - Palpate cranial area for: - Point tenderness - Depressions or deformities - Hematomas - Assess all 4 extremities for: - Motor function, muscle strength and abnormal motor posturing - Sensory function DIAGNOSTIC PROCEDURES - Lab Studies PLANNING AND IMPLEMENTATION - (Initial assessment) - Clear airway (stimulation of gag reflex can produce transient increase in ICP or vomiting with subsequent aspiration. - Administer O2 via NRB - Assist with early ET intubation - Administer sedative/neuromuscular blocking agent - Consider hyperventilation - PaCO2 above 45 mm Hg may cause increased cerebral vasodilation, increased CBF, increased ICP. - Prolonged hyperventilation NOT RECOMMENDED. - Hypocarbia occurs as result of hyperventilation causes cerebral vasoconstriction, decreased CBF, decreased ICP. And ischemia secondary to severe vasoconstriction. - Hyperoxygenate pt with 100% O2 via bag-mask - Apply direct pressure to bleeding sites except depressed skull fractures - Cannulate 2 large IV's - Hypotension doubles pt's death rate (w/severe head trauma) - Vasopressors used to maintain CPP. - Insert OG or NGT. OG should be used with severe facial trauma. - Position pt, elevate head to decrease ICP (but may also reduce CPP). - Position head midline to facilitate venous drng. Rotate head to compress veins in neck and result in both venous engorgement and decreased drng from brain - Prepare for ICP monitoring device - Administer mannitol as prescribed. - Mannitol, hyperosmolar, volume-depleting diuretic, decreases cerebral edema + ICP by pulling interstitial fluid into intravascular space for eventual excretion by kidneys. - Administer anticonvulsant - Sx should be avoided b/c increases cerebral metabolic rate + ICP. Indications for sz prophylaxis: - Depressed skull fx - Sz at time of injury - Sz on arrival to ED - Hx of sz's - Penetrating brain injury - Acute subdural/epidural hematoma - Administer antipyretic med/Cooling blanket - Hyperthermia may increase cerebral metabolic rate + ICP. Avoid causing shivering during cooling process; increases cerebral metabolic rate + may precipitate rise in ICP - Do not pack ears/nose if CSF leak suspected - Admin tetanus prophylaxis 21 - Wound repair for facial/scalp Lac's - Admin other meds - Analgesics, sedatives, narcan, romazicon, etc. - Admin antibiotics - Pt's w/basilar skull fx need prophylaxis against meningitis - Prepare pt for OR, hospital admin or transfer. What are signs of a serious eye injury? Correct Answer: - Visual disturbances - Pain - Redness and ecchymosis of the eye - Periorbital ecchymosis - Increased intraocular pressure What is hyphema and its S/S? Correct Answer: Accumulation of blood, mainly RBC's that disperse and layer within the anterior chamber. A severe hymphema obscures entire anterior chamber + will diminish visual acuity severely or completely. Injuries are graded on amount of blood in chamber (Grades I-IV). S/S: - Blood in anterior chamber - Deep, aching pain - Mild to severe diminished visual acuity - Increased intraocular pressure What are s/s of chemical burns to the eye? Correct Answer: Chemical injuries require immediate intervention if it is to be preserved. S/S: - Pain - Corneal Opacification - Coexisting chemical burn and swelling of lids What are S/S of penetrating trauma/open or ruptured globe? Correct Answer: - Marked visual impairments - Extrusion of intraocular contents - Flattened or shallow anterior chamber - Subconjunctival hemorrhage, hyphema - Decreased intraocular pressure - Restriction of extraocular movements What are the S/S of orbital fracture (orbital blowout fracture)? Correct Answer: - Diplopia (double vision) - Loss of vision - Altered extraocular eye movements - Enophthalmos (displacement of the eye backward into the socket) - Subconjunctival hemorrhage or ecchymosis of the eyelid - Infraorbital pain or loss of sensation - Orbital bony deformity What is LeFort I fracture and its S/S? Correct Answer: Transverse maxillary fx that occurs above level of teeth and results in separation of teeth from rest of maxilla. 22 S/S: - Slight swelling of maxillary area - Possible lip lac's or fractured teeth - Independent movement of the maxilla from rest of face - Malocclusion What is LeFort II fracture and its S/S? Correct Answer: Pyramidal maxillary fx=middle facial area. Apex of fx transverses bridge of nose. Two lateral fx's of pyramid extend through the lacrimal bone of the face and ethmoid bone of skull into the median portion of both orbits. Base of the fx extends above level of the upper teeth into maxilla. CSF leak is possible. S/S: - Massive facial edema - Nasal swelling w/obvious fx of nasal bones - Malocclusion - CSF rhinorrhea What is LeFort III fracture and its S/S? Correct Answer: Complete craniofacial separation involving maxilla, zygoma and bones of cranial base. This fx is frequently associated w/leakage of CSF and fx mandible. S/S: - Massive facial edema - Mobility and depression of zygomatic bones - Ecchymosis - Anesthesia of the cheek - Diplopia - Open bite or malocclusion - CSF rhinorrhea What are the mandibular fracture S/S? Correct Answer: - Malocclusion - Inability to open the mouth (trismus) - Pain, especially on movement - Facial asymmetry and a palpable step-off deformity - Edema or hematoma formation at the fracture site - Blood behind, ruptured, tympanic membrane - Anesthesia of the lower lip What are neck injury S/S? Correct Answer: - Dyspnea - Hemoptysis (coughing up blood) - Subcutaneous emphysema in neck, face, or suprasternal area - Decreased or absent breath sounds - Penetrating wounds or impaled objects - Pulsatile or expanding hematoma - Loss of normal anatomic prominence of the laryngeal region - Bruits - Active external bleeding - Neurologic deficit, such as aphasia or hemiplegia - Cranial nerve deficits - Facial sensory or motor nerve deficits 25 - Apply cold compresses to face to minimize edema - Assist w/repair of oral lac's, PRN - Admin antibiotics - Stabilize impaled objects - Admin analgesic meds With any eye injury, what should the evaluation and ongoing assessments be? Correct Answer: - Reassessing visual acuity at reasonable intervals - Reassessing pain, including response to nonpharmacologic + pharmacologic interventions - Monitoring appearance, position, movements of globe and pupillary responses - Monitoring airway patency, respiratory effort and ABG's What are the most common type of injury associated with chest trauma? Correct Answer: blunt; MVC's. Penetrating; firarm injuries or stabbings What are S/S of a rib fracture? Correct Answer: - Dyspnea - Localized pain on movement, palpation, or inspiration - Pt assumes position intended to splint chest wall to reduce pain - Chest wall ecchymosis or sternal contusion - Bony crepitus or deformity What is a flail chest? Correct Answer: A fracture of two or more sites on two or more adjacent ribs, or when rib fractures produce a free-floating sternum. Flail segments may not be clinically evident in the first several hours after injury b/c of muscle spasms that cause splinting. After positive pressure intiated, paradoxical chest wall movement ceases. What could a flail chest be associated with? Correct Answer: - Ineffective ventilation - Pulmonary contusion - Lacerated lung parenchyma What are the S/S of flail chest? Correct Answer: - Dyspnea - Chest wall pain - Paradoxical chest wall movement - the flail segment moves in during inspiration and out during expiration. Define Pneumothorax. Correct Answer: Results when an injury to lung leads to accumulation of air in pleural space w/subsequent loss of negative intrapleural pressure. Partial or total collapse of lung may ensue. An open pneumothorax results from wound through chest wall. Air enters pleural space both through the wound and trachea. What are the S/S of a pneumothorax? Correct Answer: - Dyspnea, tachypnea - Tachycardia - Hyerresonance (increased echo produced by percussion over the lung field) on the injured side - Decreased or absent breath sounds on the injured side - Chest pain 26 - Open, sucking wound on inspiration (open pneumothorax) Define tension pneumothorax. Correct Answer: Life-threatening injury. Air enters pleural space on inspiration, but air cannot escape on expiration. Rising intrathoracic pressure collapses lung on side of injury causing a mediastinal shift that compresses the heart, great vessels, trachea and uninjured lung. Venous return impeded, cardiac output falls, hypotension results. Immediate decompression should be performed. Treatment should not be delayed. What are the S/S of a tension pneumothorax? Correct Answer: - Severe respiratory distress - Markedly diminished or absent breath sounds on affected side - hypotension - Distended neck, head and upper extremity veins-may not be clinically appreciated if significant blood loss present - Tracheal deviation - shift toward uninjured side (LATE sign) - Cyanosis (LATE sign) Define Hemothorax. Correct Answer: Accumulation of blood in the pleural space. What are the S/S of Hemothorax? Correct Answer: - Dyspnea, tachypnea - Chest pain - Signs of shock - Decreased breath sounds on injured side - Dullness to percussion on the injured side What is a pulmonary contusion? Correct Answer: They occur as a result of direct impact, deceleration or high-velocity bullet wounds. It develops when blood leaks into lung parenchyma, causing edema + hemorrhage. This usually develops overtime and not immediately. What are the S/S of pulmonary contusion? Correct Answer: - Dyspnea - Ineffective cough - Hemoptysis - Hypoxia - Chest pain - Chest wall contusion or abrasions What happens to a ruptured diaphragm? Correct Answer: Potentially life-threatening, results from forces that penetrate the body. Left hemidiaphragm is more susceptible to injury because the right side is protected by the liver. - Herniation of abdominal contents - Respiratory compromise b/c impaired lung capacity + displacement of normal tissue. - Mediastinal structures may shift to opposite side of injury What are S/S of a ruptured diaphragm? Correct Answer: (Anything below the nipple line and should be evaluated for potential diaphragmatic injury). - Dyspnea or orthopnea - Dysphagia - Abdominal pain 27 - Sharp epigastric or chest pain radiating to left shoulder (Kehr's sign) - Bowel sounds heard in lower middle chest - Decreased breath sounds on injured side What are S/S with tracheobronchial injury? Correct Answer: Blunt trauma. "Clothesline-type" injuries. - Dyspnea, tachypnea - Hoarseness - Hemoptysis - Subcutaneous emphysema in neck, face, or suprasternal area - Decreased or absent breath sounds - S/S of airway obstruction What are S/S with blunt cardiac injury? Correct Answer: "Cardiac contusion" or "concussion." Common with MVC or falls from heights. - ECG (sinus tach, PVC's, AV blocks) - Chest pain - Chest wall ecchymosis What are the S/S of pericardial tamponade? Correct Answer: A collection of blood in pericardial sac. As blood accumulates, it exerts pressure on the heart, inhibiting or compromising ventricular filling. - Hyotension - Tachycardia or PEA - Dyspnea - Cyanosis - Beck's Triad (hypotension, distended neck veins + muffled heart sounds) - Progressive decreased voltage of conduction complexes on ECG What are aortic injuries S/S? Correct Answer: - Hypotension - Decreased LOC - Hypertension in UE's - Decreased quality (amplitude) of femoral pulses compared to UE pulses - Loud systolic murmur in parascapular region - Chest pain - Chest wall ecchymosis - Widened mediastinum on chest xray - Paraplegia How would you assess a pt with a thoracic injury? Correct Answer: (Initial assessment) Obtain Hx. PHYSICAL: Inspection: - Observe chest wall - Assess breathing effort and RR - Symmetry - Inspect jugular veins (Distended = increased intrathoracic pressure as result of tension pneumothorax or pericardial tamponade. Flat = external jugular veins may reflect hypovolemia) - Inspect upper abdominal region for injury Percussion: 30 -Administer antibiotics, as prescribed -Inspect dressings frequently for continued bleeding -Administer tetanus prophylaxis, as indicated Nsg Interventions for Crush Injury Correct Answer: -Administer intravenous isotonic crystalloid solution to increase urinary output and facilitate excretion of myoglobin -Elevate the injured extremity above the level of the heart to reduce swelling and pain unless compartment syndrome is suspected. For compartment syndrome, maintain at level of the heart -Gently clean open wounds -Prepare the patient for surgical debridement, fasciotomy, or amputation Six Ps of compartment Syndrome Correct Answer: Pain, Pallor, Pulses, Paresthesia, Paralysis, Pressure Nsg Interventions for Compartment Syndrome Correct Answer: -Elevate the limb to the level of the heart to promote venous outflow and prevent further swelling. Elevation above the heart may decrease perfusion to a compromised extremity -Assist with measurement of fascial compartment pressure -Prepare for fasciotomy to preven muscle or neurovascular damage 24 Hour Burn Fluid Calculation Correct Answer: Dosage x Kg x % - ml in first 24 hours -More than 20% of their TBSA burned require: *Adults: 2-4 ml of crystalloid solution x kg x % *Peds: 3-4 ml of crystalloid solution x kg x % *Infants: fluid with 5% dextrose at a maintenance rate in addition to the Peds rate protocol (1/2 the amount should be infused in first 8 hours) What are the late signs of breathing compromise? Correct Answer: - Tracheal deviation - JVD How would you assess a pt in hypovolemic shock? Correct Answer: (Use Initial Assessment) and then: Inspect: - LOC - Rate and quality of respirations - External bleeding? - Skin color and moisture - Assess jugular veins and peripheral veins Auscultate: - BP - Pulse pressure - Breath sounds - Heart sounds - Bowel sounds Percuss: - Chest and abdomen Palpate: - Central pulse (carotid or femoral) - Positive inotropic effect (force of contraction) may be evidence by a bounding central pulse 31 - Palpate peripheral pulses - Palpate skin temp and moisture Diagnostic Procedures: - Xrays and other studies - Labs Planning and Implementation - Oxygen - IV's with warmed replacement fluids - Control external bleeding with direct pressure - Elevate LE's - NGT - Foley - Monitor and pulse oximeter - Monitor for development of coagulopathies - Surgery? What are signs of ineffective breathing? Correct Answer: - AMS - Cyanosis, especially around the mouth - Asymmetric expansion of chest wall - Paradoxical movement of the chest wall during inspiration and expiration - Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing - Sucking chest wounds - Absent or diminished breath sounds - Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated - Anticipate definitive airway management to support ventilation. Upon initial assessment, what type of oxygen should be used for a pt breathing effectively? Correct Answer: A tight-fitting nonrebreather mask at 12-15 lpm. Six Ps of compartment Syndrome Correct Answer: Pain, Pallor, Pulses, Paresthesia, Paralysis, Pressure What intervention should be done if a pt presents with effective circulation? Correct Answer: - Insert 2 large caliber IV's - Administer warmed isotonic crystalloid solution at an appropriate rate What are signs of ineffective circulation? Correct Answer: - Tachycardia - AMS - Uncontrolled external bleeding - Pale, cool, moist skin - Distended or abnormally flattened external jugular veins - Distant heart sounds Nsg Interventions for Compartment Syndrome Correct Answer: -Elevate the limb to the level of the heart to promote venous outflow and prevent further swelling. Elevation above the heart may decrease perfusion to a compromised extremity -Assist with measurement of fascial compartment pressure -Prepare for fasciotomy to preven muscle or neurovascular damage 32 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) 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 24 Hour Burn Fluid Calculation Correct Answer: Dosage x Kg x % - ml in first 24 hours -More than 20% of their TBSA burned require: *Adults: 2-4 ml of crystalloid solution x kg x % *Peds: 3-4 ml of crystalloid solution x kg x % *Infants: fluid with 5% dextrose at a maintenance rate in addition to the Peds rate protocol (1/2 the amount should be infused in first 8 hours) What medications are used during intubation? Correct Answer: LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents What are the Rapid Sequence Intubation Steps? Correct Answer: PREPARATION: - gather equipment, staffing, etc. PREOXYGENATION: - Use 100% O2 (prevent risk of aspiration). PRETREATMENT: 35 Some causes: - Blood loss - Burns, etc. Explain Cardiogenic Shock. Correct Answer: Syndrome that results from ineffective perfusion caused by inadequate contractility of cardiac muscle. Some causes: MI, Blunt cardiac injury, Mitral valve insufficiency, dysrhythmias, Cardiac Failure Explain Obstructive Shock. Correct Answer: Results from inadequate circulating blood volume because of an obstruction or compression of great veins, aorta, pulmonary arteries, or heart itself. Some causes: - Cardiac tamponade (may compress the heart during diastole to such and extent that atria cannot adequately fill, leading to decreased stroke volume). - Tension pneumothorax may lead to inadequate stroke volume by displacing inferior vena cava and obstructing venous return to right atrium. - Air embolus may lead to obstruction of pulmonary artery and subsequent obstruction to right ventricular outflow during systole, with resulting obstructive shock Explain Distributive Shock. Correct Answer: Results from disruption in SNS control of the tone of blood vessels, which leads to vasodilation and maldistribution of blood volume and flow. (Neurogenic and Septic Shock). Neurogenic shock may result from injury to spinal cord in cervical or upper thoracic region. Spinal shock = areflexia and flaccidity associated with lower motor neuron involvement in complete cord injuries; reflexes return with resolution of spinal shock. Septic shock from bacteremia is distributive shock. Endotoxins and other inflammatory mediators cause vasodilation, shunting of blood in microcirculation, and other perfusion abnormalities. What is vascular response? Correct Answer: As blood volume decreases, peripheral blood vessels vasoconstrict as a result of sympathetic stimulation via inhibition of baroreceptors. Arterioles constrict to increase TPR and BP. What is renal response? Correct Answer: Renal ischemia activates release of renin. Kidneys do not receive adequate blood supply, renin is release into circulation. Renin causes angiotensinogen, normal plasma protein, to release angiotensin I. Angiotensin-converting enzyme from the lungs converts into angiotensin II. Angiotensin II causes: - Vasoconstriction of arterioles and some veins - Stimulation of sympathetic nervous system - Retention of water by kidneys - Stimulation of release of aldosterone from the adrenal cortex (sodium retention hormone) 36 *Decreased urinary output = early sign renal hypoperfusion and an indicator that there's systemic hypoperfusion. Explain adrenal gland response. Correct Answer: When adrenal glands are stimulated by SNS, release of catecholamines (epinephrine and norepinephrine) from adrenal medulla will increase. Epi stimulates receptors in heart to increase force of cardiac contraction (positive inotropy) and increase HR (positive chronotropy) to improve cardiac output, BP and tissue perfusion. Shock stimulates hypothalamus to release corticotropin-releasing hormone that stimulates pituitary to release ACTH that stimulates adrenal gland to release cortisol. Effect of cortisol release is elevation in blood sugar and increased insulin resistance and gluconeogenesis, hepatic process to produce more sugar. Cortisol also causes renal retention of water and sodium, a compensatory mechanism to conserve body water. Explain Hepatic Response. Correct Answer: Liver can store excess glucose as glycogen. As shock progresses, glycogenolysis is activated by epi to break down glycogen into glucose. In a compensatory response to shock, hepatic vessels constrict to redirect blood flow to other vital areas. Explain Pulmonary Response. Correct Answer: Tachypnea happens for 2 reasons: 1. Maintain acid-base balance 2. Maintain increased supply of oxygen * Metabolic acidosis from anaerobic metabolism will be a stimulus for the lungs to increase rate of ventilation. Increased RR is an attempt to correct acidosis + augments oxygen supply to maximize oxygen delivery to alveoli. Explain Irreversible Shock. Correct Answer: Shock uncompensated or irreversible stages will cause compromises to most body systems. - Inadequate venous return - inadequate cardiac filling - decreased coronary artery perfusion - Membranes of lysosomes breakdown within cells and release digestive enzymes that cause intracellular damage. ICP is a reflection of what three volumes? What happens when one increases? Correct Answer: 1. Brain 2. CSF 3. Blood within the nonexpansible cranial vault As volume of one increases, the volume of another decreases to maintain ICP within normal range. 37 As ICP rises, CPP decreases, leading to cerebral ischemia and potential for hypoxia and lethal secondary insult. Hypotensive pt w/marginally elevated ICP can be harmful. Slightly elevated BP could protect against brain ischemia in a pt with high ICP. Cerebral ischemia can lead to increased concentration of CO2 and decreased concentration of O2 in cerebral vessels. CO2 dilates cerebral blood vessels = increase blood volume and ICP. What are the early signs and symptoms of increased ICP? Correct Answer: - Headache - N/V - Amnesia regarding events around the injury - Altered LOC - Restlessness, drowsiness, changes in speech, or loss of judgement What are the late observable signs of symptoms of increased ICP? Correct Answer: - Dilated, nonreactive pupil - Unresponsiveness to verbal or painful stimuli - Abnormal motor posturing patterns - Widening pulse pressure - Increased systolic blood pressure - Changes in RR and pattern - Bradycardia What is Cushing's phenomenon or Cushing's Reflex? Correct Answer: Triad of progressive HTN, bradycardia and diminished respiratory effort. What are the two types of herniation that occurs with ICP? Correct Answer: 1. Uncal herniation 2. Central or transtentorial herniation Why does herniation occur? What are the symptoms? Correct Answer: Because of uncontrolled increases in ICP. S/E's - Unilateral or bilateral pupillary dilation - AsyDimmetric pupillary reactivity - Abnormal motor posturing - Other evidence of neurologic deterioration Define uncal herniation. Correct Answer: The uncus (medial aspect of the temporal lobe) is displaced over the tentorium into the posterior fossa. This herniation is the more common of the two types of herniation syndromes. Define central or transtentorial herniation. Correct Answer: A downward movement of the cerebral hemispheres with herniation of the diencephalon and midbrain through the elongated gap of the tentorium. Disruptions of the bony structures of the skull can result in what? Correct Answer: Displaced or nondisplaced fx's causing CSF leakage b/c of lac to the dura mater, creating a passage for CSF. 40 What are intracerebral hematoma's and its S/S? Correct Answer: Occur deep within brain tissue, may be single or multiple and commonly associated with contusions (frontal & temporal lobes). They result in significant mass effect, leading to increased ICP and neurologic deterioration. S/S: - Progressive and often rapid decline in LOC - H/A - Signs of increasing ICP - Pupil abnormalities - Contralateral hemiplegia What are the S/S of a linear skull fx? Correct Answer: - H/A - Possible decreased LOC What are the S/S of a depressed skull fx? Correct Answer: - H/A - Possible decreased LOC - Possible open fx - Palpable depression of skull over the fx site What are the S/S of a basilar skull fx? Correct Answer: - H/A - Altered LOC - Periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle's sign), or blood behind tympanic membrane (hemotympanum) - Facial nerve (VII) palsy - CSF rhinorrhea or otorrhea How would you assess a pt with a cranial injury? Correct Answer: (Initial assessment) INSPECTION: - Assess airway - RR, pattern and effort - Assess pupil size and response to light - Unilateral fixed and dilated pupil = oculomotor nerve compression from increased ICP + herniation syndrome - Bilateral fixed and pinpoint pupils indicate a pontine lesion or effects of opiates - Mildly dilated pupil w/sluggish response may be early sign of herniation syndrome - Widely dilated pupil occasionally occurs w/direct trauma to globe of eye - Determine if pt uses eye meds - Abnormal posturing? - Inspect craniofacial area for ecchymosis/contusions - Periorbital ecchymosis - Mastoid's process ecchymosis - Blood behind tympanic membrane - Inspect nose and ears for drainage - Drng present w/out blood, test drng w/chemical reagant strip. Presence of glucose indicated drng of CSF - If drng present and mixed with blood, test by placing drop of fluid on linen or gauze. If a light outer ring forms around dark inner ring, drng contains CSF - Assess extraocular eye movement (Tests cranial nerves, III, IV, VI) - Performing extraocular eye movements indicates functioning brainstem 41 - Limitation indicates orbital rim fx w/entrapment or paralysis of either a cranial nerve or ocular muscle - Determine LOC with GCS PALPATION - Palpate cranial area for: - Point tenderness - Depressions or deformities - Hematomas - Assess all 4 extremities for: - Motor function, muscle strength and abnormal motor posturing - Sensory function DIAGNOSTIC PROCEDURES - Lab Studies PLANNING AND IMPLEMENTATION - (Initial assessment) - Clear airway (stimulation of gag reflex can produce transient increase in ICP or vomiting with subsequent aspiration. - Administer O2 via NRB - Assist with early ET intubation - Administer sedative/neuromuscular blocking agent - Consider hyperventilation - PaCO2 above 45 mm Hg may cause increased cerebral vasodilation, increased CBF, increased ICP. - Prolonged hyperventilation NOT RECOMMENDED. - Hypocarbia occurs as result of hyperventilation causes cerebral vasoconstriction, decreased CBF, decreased ICP. And ischemia secondary to severe vasoconstriction. - Hyperoxygenate pt with 100% O2 via bag-mask - Apply direct pressure to bleeding sites except depressed skull fractures - Cannulate 2 large IV's - Hypotension doubles pt's death rate (w/severe head trauma) - Vasopressors used to maintain CPP. - Insert OG or NGT. OG should be used with severe facial trauma. - Position pt, elevate head to decrease ICP (but may also reduce CPP). - Position head midline to facilitate venous drng. Rotate head to compress veins in neck and result in both venous engorgement and decreased drng from brain - Prepare for ICP monitoring device - Administer mannitol as prescribed. - Mannitol, hyperosmolar, volume-depleting diuretic, decreases cerebral edema + ICP by pulling interstitial fluid into intravascular space for eventual excretion by kidneys. - Administer anticonvulsant - Sx should be avoided b/c increases cerebral metabolic rate + ICP. Indications for sz prophylaxis: - Depressed skull fx - Sz at time of injury - Sz on arrival to ED - Hx of sz's - Penetrating brain injury - Acute subdural/epidural hematoma - Administer antipyretic med/Cooling blanket 42 - 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. GCS breakdown Correct Answer: What are signs of a serious eye injury? Correct Answer: - Visual disturbances - Pain - Redness and ecchymosis of the eye - Periorbital ecchymosis - Increased intraocular pressure What is hyphema and its S/S? Correct Answer: Accumulation of blood, mainly RBC's that disperse and layer within the anterior chamber. A severe hymphema obscures entire anterior chamber + will diminish visual acuity severely or completely. Injuries are graded on amount of blood in chamber (Grades I-IV). S/S: - Blood in anterior chamber - Deep, aching pain - Mild to severe diminished visual acuity - Increased intraocular pressure Needle decompression insertion site Correct Answer: 2nd intracostal space What are s/s of chemical burns to the eye? Correct Answer: Chemical injuries require immediate intervention if it is to be preserved. S/S: - Pain - Corneal Opacification - Coexisting chemical burn and swelling of lids What are S/S of penetrating trauma/open or ruptured globe? Correct Answer: - Marked visual impairments - Extrusion of intraocular contents - Flattened or shallow anterior chamber - Subconjunctival hemorrhage, hyphema - Decreased intraocular pressure - Restriction of extraocular movements What are the S/S of orbital fracture (orbital blowout fracture)? Correct Answer: - Diplopia (double vision) - Loss of vision 45 - Malocclusion or inability to open + close mouth is highly indicative of maxillary or mandibular fx - Observe for uncontrolled bleeding PALPATION - Palpate periorbital area, face and neck for: - Tenderness - Edema - Step-off defects or depressions - Subcutaneous emphysema (esophageal or tracheal tear) - Palpate trachea above suprasternal notch - Trach deviation = late indication of tension pneumothorax or massive hemothorax - Assess sensory fx of perioribital areas, face and neck - Facial fx's can impinge on infraorbital nerve, causing numbness of inferior eyelid, lateral nose, cheek, or upper lip on affected side. - Check position of trachea DIAGNOSTIC STUDIES: - Xrays, CT scans, MRI's - Fluorescein staining - Slit-lamp exam - tonometry (measures intraocular pressure) - Bronchoscopy or esophagoscopy What are the nursing interventions for a pt with an ocular injury? Correct Answer: - Assess visual acuity & reassess - Elevate HOB to minimize intraocular pressure - Instruct pt not to bend forward, cough or perform Valsalva maneuver b/c these actions may raise intraocular pressure - Assist w/removal of foreign bodies as indicated; stabilize impaled objects - Apply cool packs to decrease pain + periorbital swelling - Admin medications - Instill prescribed topical anesthetic drops for pain - Instill NS drops or artificial tears to keep corneas moist. Cover eyelids w/sterile, moist saline dsg to prevent drying and ulceration - Antibiotics topically or systemically - Admin tetanus prophylactically - Use an eye patch to affected eye - Patch or shield both eyes to reduce movement + photophobia in pt's w/retinal injuries - Patch, shield or cover w/cool pack - Do NOT patch injured eye of pt w/suspected open or ruptured globe or impaled object, patch unaffected eye. Use metal or plastic and do not put pressure on the globe. - Provide psychosocial support - Obtain an ophthalmology consultation - Provide d/c instructions: - Importance of protective eyewear - No driving w/eye patch on - Wear sunglasses to prevent tearing, aid photophobia - Prepare for admission, OR or transfer 46 What are the nursing interventions for a patient with a maxillofacial or neck injury? Correct Answer: - Administer oxygen - For facial trauma, place pt in high-fowler's position if no spinal injury is present. - Insert OG or NGT. OGT should be used if basilar skull fx or severe midface fx's are suspected - Monitor for progressive airway assessment - Prepare for intubation, PRN. - Cannulate 2 large IV's, initiate isotonic crystalloid IV solution - Control external bleeding w/direct pressure - Monitor for continued bleeding + expanding hematomas - Apply cold compresses to face to minimize edema - Assist w/repair of oral lac's, PRN - Admin antibiotics - Stabilize impaled objects - Admin analgesic meds With any eye injury, what should the evaluation and ongoing assessments be? Correct Answer: - Reassessing visual acuity at reasonable intervals - Reassessing pain, including response to nonpharmacologic + pharmacologic interventions - Monitoring appearance, position, movements of globe and pupillary responses - Monitoring airway patency, respiratory effort and ABG's What are the most common type of injury associated with chest trauma? Correct Answer: blunt; MVC's. Penetrating; firarm injuries or stabbings What are S/S of a rib fracture? Correct Answer: - Dyspnea - Localized pain on movement, palpation, or inspiration - Pt assumes position intended to splint chest wall to reduce pain - Chest wall ecchymosis or sternal contusion - Bony crepitus or deformity What is a flail chest? Correct Answer: A fracture of two or more sites on two or more adjacent ribs, or when rib fractures produce a free-floating sternum. Flail segments may not be clinically evident in the first several hours after injury b/c of muscle spasms that cause splinting. After positive pressure intiated, paradoxical chest wall movement ceases. What could a flail chest be associated with? Correct Answer: - Ineffective ventilation - Pulmonary contusion - Lacerated lung parenchyma What are the S/S of flail chest? Correct Answer: - Dyspnea - Chest wall pain - Paradoxical chest wall movement - the flail segment moves in during inspiration and out during expiration. Define Pneumothorax. Correct Answer: Results when an injury to lung leads to accumulation of air in pleural space w/subsequent loss of negative intrapleural pressure. Partial or total collapse of lung may ensue. 47 An open pneumothorax results from wound through chest wall. Air enters pleural space both through the wound and trachea. What are the S/S of a pneumothorax? Correct Answer: - Dyspnea, tachypnea - Tachycardia - Hyerresonance (increased echo produced by percussion over the lung field) on the injured side - Decreased or absent breath sounds on the injured side - Chest pain - Open, sucking wound on inspiration (open pneumothorax) Define tension pneumothorax. Correct Answer: Life-threatening injury. Air enters pleural space on inspiration, but air cannot escape on expiration. Rising intrathoracic pressure collapses lung on side of injury causing a mediastinal shift that compresses the heart, great vessels, trachea and uninjured lung. Venous return impeded, cardiac output falls, hypotension results. Immediate decompression should be performed. Treatment should not be delayed. What are the S/S of a tension pneumothorax? Correct Answer: - Severe respiratory distress - Markedly diminished or absent breath sounds on affected side - hypotension - Distended neck, head and upper extremity veins-may not be clinically appreciated if significant blood loss present - Tracheal deviation - shift toward uninjured side (LATE sign) - Cyanosis (LATE sign) Define Hemothorax. Correct Answer: Accumulation of blood in the pleural space. What are the S/S of Hemothorax? Correct Answer: - Dyspnea, tachypnea - Chest pain - Signs of shock - Decreased breath sounds on injured side - Dullness to percussion on the injured side What is a pulmonary contusion? Correct Answer: They occur as a result of direct impact, deceleration or high-velocity bullet wounds. It develops when blood leaks into lung parenchyma, causing edema + hemorrhage. This usually develops overtime and not immediately. What are the S/S of pulmonary contusion? Correct Answer: - Dyspnea - Ineffective cough - Hemoptysis - Hypoxia - Chest pain - Chest wall contusion or abrasions What happens to a ruptured diaphragm? Correct Answer: Potentially life-threatening, results from forces that penetrate the body. Left hemidiaphragm is more susceptible to injury because the right side is protected by the liver. 50 - Auscultate Heart sounds (muffled = pericardial tamponade) - Auscultate neck vessels for bruits (vascular injury) Diagnostic Procedures: - Xrays - Arteriography - Bronchoscopy and laryngoscopy - CT's - FAST - Labs (cardiac enzymes) - ECG, CVP Cullen sign Correct Answer: bruising around umbilicus What are S/S of Hepatic Injuries? Correct Answer: -Upper Right Quadrant Pain -Abdominal Wall Muscle Rigidity, Spasm, Involuntary Guarding -Rebound Tenderness -Hypoactive or Absent Bowel Sounds -Signs of hemorrhage or hypovolemic shock Grey turner sign Correct Answer: Bruising of the flanks. Between last rib and top of hip What are S/S of Splenic Injuries? Correct Answer: -Signs of hemorrhage or hypovolemic shock -Pain in the left shoulder (Kehr's sign) when lying supine or Trendelenburg -Tenderness in the upper left quadrant -Abdominal wall muscle rigidity, spasm, or involuntary guarding Kehr sign Correct Answer: shoulder pain referred from the diaphragm when it is irritated by blood within the abdominal cavity S/S of Large and Small Bowel Injuries? Correct Answer: -Peritoneal irritation manifested by abdominal wall muscle rigidity, spasm, involuntary guarding, rebound tenderness, or pain -Evisceration of small bowel or stomach -Hypovolemic Shock -Gross blood from rectum AVPU Correct Answer: Alert, Verbal, Pain, Unresponsive S/S of Gastric Injury? Correct Answer: -Abdominal Pain -Peritoneal irritation -Evisceration of stomach -Gross blood in gastric aspirate MATCH Correct Answer: Massive hemorrhage, Airway, Respiration, Circulation, Head Injury/Hypothermia S/S of Esophageal Injury? Correct Answer: -Subcutaneous emphysema -Peritoneal irritation -Pain radiating to the neck, chest, shoulders, or throughout the abdomen 51 -Gross blood in gastric aspirate ABCDEFG(LMNOP)HI Correct Answer: Airway+Alertness Breathing+Ventilation Circulation/Control of Hemorrhage Disability (neuro stat) Exposure/Environmental Control Full set of vitals + family Get resuscitation adjuncts -monitor cardiac rhythm, naso/gastric tube, oxygen, ETCO2, pain History +Head to toe Inspect posterior surface What is the major cause of death after injury? Correct Answer: Uncontrolled external hemorrhage S/S of Renal Injuries? Correct Answer: -Hematuria -Flank or abdominal tenderness elicited during palpation -Ecchymosis over flank may occur, but normally develops 6 to 12 hours after injury What end tidal carbon dioxide ETCO2 measurement shows effective ventilation? Correct Answer: between 35-45 mm Hg note: level above 50 mm Hg signifies depressed ventilation How would you care for a pt with an Abdominal Injury? Correct Answer: (Initial assessment) Obtain Hx. PHYSICAL: Inspection: - Observe the lower chest for asymmetric chest wall movement. -Observe the contour of the abdomen. Distention may indicate bleeding -Inspect lower chest, abdomen, flanks, and back for seat belt abrasions or soft tissue injuries -Inspect pelvic area for soft tissue bruising Percussion: - Percuss for hyperresonance or dullness. Hyperresonance indicates air, dullness indicates fluid. Palpation: - Palpate all four quadrants. Press and quickly release to determine presence of rebound tenderness. -Palpate pelvis for bony instability, asymmetry, or pain. -Palpate flanks for tenderness -Palpate anal sphincter for presence or absence of tone Auscultation: -Auscultate the chest. If bowel sounds heard in chest may have diaphragmatic rupture with herniation of the stomach or small bowel -Auscultate bowel sounds. Absence indicative of visceral injury. Diagnostic Procedures: - Xrays - MRI - IVP and DPL - CT's - FAST 52 - Labs (cardiac enzymes) -Cystogram or urethrogram -Angiography Types of shock Correct Answer: *Hypovolemic*: hemorrhage/burns *Distributive*: Neuro/anaphylactic/Septic *Cardiogenic*: MI/Dysrythmias/blunt cardiac trauma *Obstructive*: Cardiac Tamponade/Tension pneumo/Tension hemo Nsg Interventions for Pelvic Fracture Correct Answer: -Stabilize pelvis by wrapping in folded sheet -Apply a pneumatic antishock garment to splint pelvic fractures -Prepare for application of an external fixator types of distributive shock Correct Answer: neurogenic, anaphylactic, septic Nuerogenic shock Correct Answer: Distributive shock Develops from spinal cord injuries and results in the loss of sympathetic nervous system control of vascular tone, which produces venous and arterial vasodilation. With the loss of SNS unopposed vagal activity may result in bradycardia > atropine or tanscutaneous pacing. Nsg Interventions for Open Fracture Correct Answer: -Irrigate any wound with sterile saline -Cover open wounds with dry, sterile dressings. -Administer antibiotics, as prescribed -Inspect dressings frequently for continued bleeding -Administer tetanus prophylaxis, as indicated anaphylactic shock Correct Answer: Distributive shock A severe reaction that occurs when an allergen is introduced to the bloodstream of an allergic individual. Histamines are released which cause bronchoconstriction, labored breathing, widespread vasodilation, increased vascular permeability, circulatory shock, and sometimes sudden death. Nsg Interventions for Crush Injury Correct Answer: -Administer intravenous isotonic crystalloid solution to increase urinary output and facilitate excretion of myoglobin -Elevate the injured extremity above the level of the heart to reduce swelling and pain unless compartment syndrome is suspected. For compartment syndrome, maintain at level of the heart -Gently clean open wounds -Prepare the patient for surgical debridement, fasciotomy, or amputation septic shock Correct Answer: Distributive shock a serious condition that occurs when an overwhelming bacterial infection affects the body - bacterial endotoxins are released causing increased vascular permeability and vasodilation. Tx: early antibiotics and possibly nor-epinephrine to vasoconstrict the peripheral vasculature, ^ blood volume return to heart, improve cardiac output. What to watch out for in cardiogentic shock regarding tx Correct Answer: Excess of volume administration can cause pulmonary edema and increased myocardial ischemia - reduce after load 55 4. D - disability (neurologic status) 5. F - full set of vitals and Family presence 6. G - Get resuscitation adjuncts L- Lab results (arterial gases, blood type and crossmatch) M- monitor for continuous cardiac rhythm and rate assessment N- naso or orogastric tube consideration O- oxygenation and ventilation analysis: Pulse oxygemetry and end-tidal caron dioxide (ETC02) monitoring and capnopgraphy H- History and head to toe assessment I- Inspect posterior surfaces Correct Answer: ABCDEFGHI Class 4 Hemorrhage Correct Answer: Vasoconstriction is problematic and further impairs tissue perfusion and cellular oxygenation -blood loss greater than 40% and 2,000mL. Effects - Severely decreased mental status or loss of consciousness - lethargic - Marked tachycardia - over 140 -RR over 35 - Ultimately leads to organ failure and death Tracheobronchial injurt Correct Answer: penetrating or clothesline injury, hoarseness or crepitus, difficult intubation Late assessment findings of increased ICP include: Correct Answer: - DILATED, NON-REACTIVE PUPILS - UNRESPONSIVENESS to verbal/painful stimuli - ABNORMAL POSTURING (flexation, extension, flaccidity) - CUSHING RESPONSE Widening pulse pressure Reflex bradycardia Decreased respiratory effort Glascow Coma Scale (GCS) Correct Answer: Neurologic assessment of a patient's BEST verbal response, eye opening, and motor function. Lowest score is a 3, highest is 15, Intubate at 8. In those with traumatic brain injury where should you maintain the systolic pressure? Correct Answer: greater than 90 mmHG The meninges consist of three layers of protective coverings ... Correct Answer: (PAD) pia matter, arachnoid matter and dura matter BLUNT ESOPHAGEAL INJURY Correct Answer: air in the mediastinum with possible widening, sub q emphysema A moderately dilated pupil with sluggish response may be an early sign of what? Correct Answer: herniation syndrome from increased ICP Cushing's triad/response Correct Answer: r/t loss of auto regulation due to ICP 56 Signs of increased intracranial pressure: 1. hypertension 2. bradycardia 3. irregular respirations Correct Answer: Prehospital shock index pg. 85 Normal ICP range Correct Answer: 0-15 mmHg. Maintain below 20 mmHg Rib fractures Correct Answer: doom, anxiety, vascular injuries, heart To maintain cerebral perfusion pressure (CPP) 50- 70 mm Hg Correct Answer: Administer norepinephrine Elevate HOB 0-30 Degrees Drain CSF Beck triad of cardiac tamponade Correct Answer: hypotension, distended neck veins, distant heart sounds Signs of impending herniation Correct Answer: unilateral or bilateral pupillary dilation asymmetric pupillary reactivity abnormal posturing **give brief period of hyperventilation until definitive measures** Adequate perfusion of oxygen and supply of nutrients to the brain tissue is dependent on ... and ... Correct Answer: CPP; CBF Early signs of ICP Correct Answer: Decreased LOC - Amnesia Behavior changes- impaired judgment, restlessness, drowsiness) Pupil changes Vision abnormalities (brain swelling is putting pressure on the optic and oculomotor nerves) Headache Vomiting (pressure on the vagal nerve center of the brain that controls vomiting) Nuchal rigidity Flail chest Correct Answer: 3 or more ribs fractured in 2 or more places, parodoxical rise and fall of chest wall Airway -*6 Correct Answer: -tongue obstruction -loose or missing teeth -foreign objects -blood, vomitus, secretions -edema -snoring, stridor, gurgling trauma its need early supplemental oxygen, start with 15 mL O2 and titrate oxygen delivery. Correct Answer: Oxygen on trauma patients 57 Breathing- *8 Correct Answer: -spontaneous breathing -symmetrical chest rise and fall- flail -depth, pattern, rate of respiration -increase WOB -skin color -open wounds, deformities, sub q emphysema -tracheal deviation, JVD -breath sounds equal and present tension pneumothorax Correct Answer: a pneumothorax with rapid accumulation of air in the pleural space, needle decompress Intubation- post assessment Correct Answer: - secure at the lip, number at the teeth -state need for a vent ... is defined as the pressure gradient across the brain tissue, or the difference between the pressures of the cerebral artery and venous vessels. Correct Answer: CPP; CPP = map - icp Circulation- *3 Correct Answer: -uncontrolled hemorrhage-elevate to heart, pressure, tourniquet -central and peripheral pulses -skin color, temp, moisture, cap refill D- disability Correct Answer: -*GCS- eye opening, verbal response, motor -*pupils -*need for head CT, cspine Unilateral fixed and dilated pupil Correct Answer: herniation with CN III compression from increased ICP pulmonary contusion Correct Answer: Injury or bruising of lung tissue that results in hemorrhage. swelling, blood and fluids in area, watch fluids, ECG shows PVCs, tach Bilaterally fixed and pinpoint pupils may indicate an injury where? Correct Answer: @ the pons or be from the effects of opioids H- hx and head to toe Correct Answer: -hx: MIST, past medical hx -head to toe can result from penetrating wound through chest wall causing air to be trapped in to the intrapleural place. Might hear "sucking" Tx: nonporous dressing tapes on 3 sided, then Chest tube and would closure surgical repair. Correct Answer: Open Pneumo: Becks triad Correct Answer: hypotension, JVD, muffled heart sounds pericardial surgery or aspiration of fluids What degree should the patients' head be placed to reduce ICP Correct Answer: 30 degrees, also keep the head midline to help with venous flow. 60 Consider a pelvic binder for pelvic fractures consider a tourniquet cannulate two veins with large caliber IV - if unable to gain assess consider IO a. obtain labs, type and cross b. infuse warm isotonic fluids c. consider balanced resuscitation d. use rapid infusion device Correct Answer: C Interventions: B-breathing and ventilation Correct Answer: -*determine effectiveness of breathing using inspection, palpation, auscultation -*state need for BVM (10-12/min) Obese hypo-ventilation Correct Answer: Increase airway resistance Decrease chest wall compliance Increase intra-abd pressure Adrenal response Correct Answer: Release of catecholamines (epi and norepi) that increase contractility and HR ... pain originates from organs and may lead to referred pain. (Trauma) Correct Answer: Visceral Intubation with RSI-assess 5 Correct Answer: -assess placement with CO2 detector, bilateral chest rise and fall, auscultation of breath sounds and epigastrium, 5-6 breaths CO2, skin color Facial Fx Correct Answer: CSF What is diffuse axonal injury and its signs and symptoms? Correct Answer: (DAI) is widespread, rather than localized, through the brain. Diffuse shearing, tearing and compressive stresses from rotational or accerleration/deceleration forces resulting in microscopic damage primarily to axons within the brain. S/S: - Immediate unconsciousness - mild DAI, coma = 6-24 hrs - severe DAI, coma = weeks/months or persistent vegetative state - Elevated ICP - Abnormal posturing - HTN - Hyperthermia - Excessive sweating because of autonomic dysfunction - Mild to severe memory impairment, cognitive, behavioral, and intellectual deficits C-circulation and hemorrhage Correct Answer: -*determine adequacy of circulation using inspection, auscultation, palpation -assess medic line -*2nd large bore IV, warm crystalloid infusing at controlled rate if not shocky Tamponade Correct Answer: Muffled heart tones 61 JVD Hypo-tension If injury causes the CPP to fall outside the range of 50 - 160, the brain loses its ability to ... and CBF is directly dependent on ... for perfusion Correct Answer: Auto regulate ; MAP Tamponade Tx Correct Answer: Peri-cardio-centesis E-exposure Correct Answer: -*need to remove all clothing and inspect for hemorrhage, injury, deformity -warm patient- blankets, fluids, temp -forensics Disability - Neurologic Status 1. Assess pupils for equality, shape, and reactivity (PERRL) 2. Assess GCS (eye opening, verbal response, and motor response) Correct Answer: D F- full set of vitals and family presence Correct Answer: - full set of vitals -liaison for family What fluid not given in TBI Correct Answer: D5W and NA Hr 146 RR increased BP decreased Moan to pain Correct Answer: Decomp shock Intracerebral hematoma Correct Answer: deep in brain tissue, HA, increased ICP, LOC, pupil changes, frontal lobe more risk for sig herniation G- LMNOP Correct Answer: - labs- lactate, ABG, type and cross, glucose -m-monitor -n-NG/OG -o-pulse ox -p-pain- pharma and nonpharm Normal Co2 ... Correct Answer: 35-45 Herniation syndrome Correct Answer: uncontrolled increases in ICP, uncal and central (shift down) or transtentorial, midline shift is seen with uncal herniation Early sign of Increased ICP Correct Answer: N/V MIST Correct Answer: Mechanism of action Injuries S/S Treatment 62 Diffuse anoxal Correct Answer: sweating, posturing, sym storm, HTN, hyperthermia shearing and tearing immediate unconciousness Linear Correct Answer: nondisplaced fx Six Ps of compartment Syndrome Correct Answer: Pain, Pallor, Pulses, Paresthesia, Paralysis, Pressure Head to toe Correct Answer: -face -neck- c-spine -chest- lung and heart -abdomen and flanks -pelvis and perineum- gentle pressure over iliac crest, pubic symphysis, foley -extremities- neurovascular -posterior- spinal board maxillary fracture Correct Answer: Lefort I, II, III Diplopia Correct Answer: Lefort III Lefort I Correct Answer: transverse maxillary (above the teeth) Disaster management - Vulnerable Correct Answer: Mitigation Revaluation adjuncts Correct Answer: -cspine CT, -CXR, pelvis XR -CTA -reverse trauma score -FAST -clean and dress wounds -tetnus, abx Co2 ... causes dilation of cerebral arterial vasculature and increased blood flood and increased ICP. ... causes constriction and decreased blood flow.! Correct Answer: Hypercapnia; hypocapnia Wrap up Correct Answer: -Identify all injuries, reevaluate primary assessment, VS, injuries, interventions -Transfer to trauma center, OR, ICU, burns Meningeal artery Correct Answer: Epidural hematoma 1. Get a CT 2. Consider ABG 's if decreased LOC 3. Consider glucose check Correct Answer: D Interventions SpO2 Correct Answer: percent of o2 saturation 65 -pressors, dop, epi, NO FLUIDS .... can produce bleeding that may not be evident until several hours after injury Correct Answer: Basilar skull fractures Obstructive Correct Answer: -inadequate circulating blood volume bc of obstruction of the great veins, aorta, pulm arteries, heart -cardiac tamponade (muffled heart sounds, tachy), tension pneumo (deviated trachea), tension hemo Occular nursing intervention Correct Answer: Elevate HOB 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. Trauma pt DvT Correct Answer: Pelvic fx The three areas of basilar skull fractures include ... Correct Answer: Periodontal D.C. my Isra (raccoon eyes - fossa fracture) Mastoid process ecchymoses (behind the ear) Hemotympanum (blood in the tympanic membrane/middle ear) Obese Increase abd pressure Decrease venous return Correct Answer: Emboli Anaphylactic Correct Answer: Vasodilation due to allergens, IM epi Full set of vitals and family presence Correct Answer: F Compensated stage Correct Answer: -SBP is normal, rising DBP, tachy bounding, lactate builds up Baby ok Then decrease LOC Weak cry Correct Answer: Hypoglycemia ... is a test that requires fluid to be sent to the lab and is considered the gold standard for identifying CSF Correct Answer: Beta2-Transferrin Irreversible damage Correct Answer: obtunded comatose, sbp 50-60, brady, shallow resp death 66 Young girl does not remember Correct Answer: Head CT Cerebral response Correct Answer: -brain autoregulates so blood is shunted from other organs to brain -SBP >50 cerebral ischemia occurs and the increase in CO2 in the brain stimulates the CNS response 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. Renal response Correct Answer: Vasoconstriction of arterioles and some veins, reabsorption of Na and H20 MVA diff breathing Tachycardia Correct Answer: Liver lac What are two quick tests for general suspicion of CSF leak? Correct Answer: Halo sign and glucose Inflammatory response Correct Answer: activated by hypoxia, neutrophils travel to injury site Decrease cranial calcification Correct Answer: CT normal without radio graphic abnormality Pulmonary response Correct Answer: Increase RR to improve O2 and remove CO2 Get Resuscitation Adjuncts L - Labs (maybe a lactic acid), a b g 's, blood type M - monitors N - naso or oro gastric tubes O Oxygen and ETC02 monitors P - pain assessment and management Correct Answer: G Trauma triad of death Correct Answer: hypothermia, coagulopathy, acidosis AVPU Correct Answer: ID pt Need intubation MTP Correct Answer: 1:1:1 monitor Ca bc citrate inhibits clotting cascade ... is damaged brain tissue usually caused by blunt trauma Correct Answer: Cerebral contusion TXA Correct Answer: antifibtinolytic, slow down the dissolution of established clots Sudden stop/fall Correct Answer: Deceleration ICP Correct Answer: normal is 0-15, >20 BAD 24 Hour Burn Fluid Calculation Correct Answer: Dosage x Kg x % - ml in first 24 hours -More than 20% of their TBSA burned require: 67 *Adults: 2-4 ml of crystalloid solution x kg x % *Peds: 3-4 ml of crystalloid solution x kg x % *Infants: fluid with 5% dextrose at a maintenance rate in addition to the Peds rate protocol (1/2 the amount should be infused in first 8 hours) `CPP Correct Answer: MAP-ICP Cardiogenic shock Correct Answer: Antiarrythmics Hypotension and cerebral blood flow Correct Answer: -CO2 causes dialation, if CPP outside of 50-160, regulation fails and flow relies on MAP, MAP <60 hypoxic <60 edema Where are most cerebral contusions found Correct Answer: Frontal and temporal lobes Early signs of ICP increase, CPP decrease Correct Answer: NV, Ha, amnesia, AMS, LOC Dry chem exposure Correct Answer: Remove pt clothing Late signs of ICP increase Correct Answer: non reactive pupils, cushins, posturing Reevaluation and Consider the need to Transfer Correct Answer: Final step in primary survey Cushing Correct Answer: pressure on brain stem causes wide pulse pressure, brady, decreased RR GSW chest Correct Answer: Thoracic injury Signs and symptoms of intracerebral hematoma include ... Correct Answer: Progressive and rapid decline, headache, signs of increasing ICP, pupil abnormalities Cerebral contusion Correct Answer: -damage to capillary vasculature, 18-36 hours after time of injury Family presence Correct Answer: Clear policies 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 Epidural hematoma Correct Answer: temporal or parietal skull that lacerate the meningeal artery younger population, with skull fx, rapid accumulation of arterial blood in space transient LOC, rapid deterioation Flail chest Correct Answer: Intubate Subdural hematoma Correct Answer: accel or decell injury, venous in nature, acute or chronic, elderly, alcoholics, anticaogulants, 72 hrs-2 wks, seizures, aphaisa unilateral fixed dialated pupil 70 L last oral intake E Events and environment factors related to the injury Correct Answer: SAMPLE demonstrates and describes techniques for determining latency of airway using inspection, ausculataton, and palpation. Identifies at least FOUR Correct Answer: -is tongue obstructing airway -are there any lose or missing teeth -are there any foreign bodies is there any blood, vomitus or other secretions -is there any edema -is there any snoring, gurgling, or stridor ... refers to a condition that occurs when the patient suffers a second milks TBI before recovery from the first Correct Answer: Second impact syndrome B Correct Answer: -Determine breathing effectiveness -state need for assisted ventilation with bag-valve mask device -assess ET placement -Et secure, number at teeth documented -need for manuel ventilation 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) B Demonstrates and describes techniques for determining breathing effectiveness using components of inspection, auscultation, and palpation. identifies at least FOUR Correct Answer: -is there spontaneous breathing -is there symmetrical chest rise -what are the depth, pattern and rate of respirations -is there increased work of breathing -skin color -open wounds or deformities, subcutaneous emphysema -tracheal deviation or jugular venous distention -great sounds present and equal 71 Patients who sustain a mild TBI may develop .... . Typically it will manifest several days or moths after head trauma. Correct Answer: Postconcussive syndrome C Correct Answer: circulation and control of hemorrhage -3 inspects for uncontrolled hemorrhage, palates central pulse, inspects and palpates skin for color, temp and moisture. -assess patency of prehospital IV -need 2nd IV -warmed isotonic crystalloid with blood tubing at controlled rate inspect for lacs, abrasions, asymmetry of facial expressions palate for depressions and tenderness look at ears for drainage Correct Answer: Head to toe assessment: Head and face D Correct Answer: disability (neurologic status) -GCS (best eye opening, best verbal response, best motor reaponse) -assess pupils -states need for CT of head and cervical spine A ... fracture is a complete craniofacial separation Correct Answer: Lefort III E Correct Answer: Exposure and environmental control -remove all clothing and inspect for uncontrolled bleeding or obvious injury -keep pt warm (blankets, warming lights, increased room temp, warmed fluids, warmed oxygen Six Ps of compartment Syndrome Correct Answer: Pain, Pallor, Pulses, Paresthesia, Paralysis, Pressure F Correct Answer: full set of vitals facilitate family presence Assessment findings with maxillary fractures include Correct Answer: Facial edema, ecchymoses and diplopoa (lefort III) G Correct Answer: GET resuscitation adjuncts LMNOP immobilize cervical spine, tenderness, tracheal deviation Correct Answer: Head to toe assessment: Neck and cervical spine LMNOP Correct Answer: Labs (blood samples, blood gas) Monitor (attaches pt to cardiac monitor N-naso/orogastric tube Oximeter and calnography. Pain -pharmacological and nonpharmacologcial pain measu 72 What are some interventions for the patient with a brain, cranial or macillofacial trauma Correct Answer: Elevation of patients head of bed by 30 degrees to decrease ICP, position head midline, ICP monitoring device H Correct Answer: History MIST Mechanism of injury Injuries sustained Signs and symptoms in field Treatment in field 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 Head to toe assessment Correct Answer: 1) Inspects AND palpates face/neck 2) inspects AND palpates neck for injuries, demonstrate removal AND replacement of cervical collar for assessment 3) Inspects AND palpates chest 4) auscultate heart and lung sounds 5) inspects abdomen and flanks 6) auscultate and palpates abdomen 7)inspects pelvis and perineum 8) applies gentle pressure over iliac crests downward and medially 9)gentle pressure to symphysis pubis 10)urinary catheter unless contraindicated 11) Inspects AND palpates 4 extremities Treatment of corneal abrasion includes Correct Answer: Topical antibiotics, oral analgesics NO patching , topical anti inflammatory P Correct Answer: Posterior surfaces -states need to maintain cervical spine -Inspects AND palpates posterior surfaces -consider removal of spinal cord inspect, auscultate, palpate any spontaneous breathing, rate, depth, and degree of effort, use of accessory muscles lacs, contusions, 75 - After intubation, inflate the cuff - Confirm tube placement w/exhaled CO2 detector. POSTINTUBATION MANAGEMENT: - Secure ET tube - Set ventilator settings - Obtain Chest x-ray - Continue to medicate - Recheck VS and pulse oxtimetry For every action there is an equal and opposite reaction Correct Answer: Newton's third law A an unrestrained driver was involved in a frontal collision without airbag deployment. he is hypotensive and tachycardic with shallow respirations, distended JVD and muffled heart tones the nurse prepare for what Correct Answer: pericardiocentesis Energy can neither be created nor destroyed but rather I can change form Correct Answer: Law of conservation of energy any deformities? bleeding? contusions, lacs? skin temp?? place splints on deformities, pulses Correct Answer: Head to toe assessment: Extremities Kinect is energy is equal to ... Correct Answer: 1/2 the mass x by the velocity squared (v^2) D An unrestrained driver is brought into the emergency department following a frontal impact MVC. she is pale, anxious, and c/o SOB. what is the potential injury Correct Answer: Lumbar fx 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. Caused from a sudden and rapid onset of motion ( a Parker car being hit by another vehicle) Correct Answer: Acceleration forces B pt to ER after being pinned to brick retaining wall. knwoing crushing injuries can result to significant damage to muslces the priority asessment for trauma nruse is for Correct Answer: myoglobinemia nd renal failure An external force applied time of impact, ex. Steering wheels or dashboards that collide with or push up into a person. Correct Answer: Compression force inspect posterior surfaces blogroll with at least 3 people. maintain c spine take out backboard Rectal tone per MD Correct Answer: I 76 .... is the major cause of preventable death after injury Correct Answer: Uncontrolled hemorrhage A the nurse is preparing to cleanse an extensive abrasion contaminated with dirt and gravel. which of the following intervention is indicated Correct Answer: us copious amounts of NS .... is suspected in any patient with multi system trauma. Correct Answer: Cervical spine injury 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. ... shock is from hemorrhage and is the leading cause of preventable deaths in trauma patients. Can also be caused by plasma loss in ... Correct Answer: Hypovolemic; burns A when providing care for the pedicatric pt with burns the post resuscitation care, how are fluids delivered Correct Answer: parkland formula with maintainence fluidss ... shock results from hypoperfusion of the tissue due to an obstruction in either the vasculature or heart. Two examples include.... Correct Answer: Obstructive;tension pneumothorax, cardiac tamponade. (With tension pneumo the increase in intrathoracic pressure leads to displacement of the vena cava, obstruction to arrival filling leading to decreased preload and decreased cardiac output) ( with cardiac tamponade there is an accumulation of fluid in the pericardial sac impeding diastolic expansion and filling leading to decreased preload, stroke volume,CO and end organ perfusion) labs, wound care, tetanus, administer meds, prepare for transfer Correct Answer: Secondary Reval Adjuncts ... shock occurs as a result of maldistribution of an adequate circulation blood volume with the loss of vascular tone or increased permeability. 3 examples. Correct Answer: Distributive; anaphylactic, septic and neurogenic B thinning skin and diminished autonomic response in older adult can have what effect on primary assessment Correct Answer: compromised thermoregulation .... 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: Baroreceptor activation; baroreceptors Nsg Interventions for Compartment Syndrome Correct Answer: -Elevate the limb to the level of the heart to promote venous outflow and prevent further swelling. Elevation above the heart may decrease perfusion to a compromised extremity -Assist with measurement of fascial compartment pressure -Prepare for fasciotomy to preven muscle or neurovascular damage ...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 77 the CNS and the cardiorespiratory centers in the medulla , which increases respiratory rage and depth and BP Correct Answer: Chemoreceptors A in mass casualty "doing the greatest good for the greatest number of people refers to a situation where Correct Answer: there may be more patients than resources In the ... ... response two catecholamines are released ... and ... . Correct Answer: Adrenal gland response; epinephrine and norepinephrine Vital signs Interventions Primary survey Pain Correct Answer: Post resuscitation care parameters that are continuously evaluated: In the adrenal gland response ... is released to raise blood glucose and promote renal retention of water and sodium. Correct Answer: Cortisol C effective pain management in hte pt iwth rib fxwill promote what Correct Answer: cough with ability to clear secretions ... is the initial post traumatic inflammatory response. ... ... activates this response and ... are sent to the injury sites, activating signaling pathways that mobilize inflammatory cells. Correct Answer: Immune response; tissue hypoxia;neutrophils What is a Laryngeal Mask Airway? Correct Answer: Looks like an ET tube but is equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to cover the supraglottic area. ILMA, does not require laryngoscopy and visualization of the chords. What stage of shock: anxiety, restless, confused, norm systolic pressure, rising diastolic pressure, slightly tachycardiac, increased RR and decreased urine output Correct Answer: Stage I: compensated Bduring the primary survery which of the following has the greatest priority Correct Answer: cervical spine injury What stage of shock:patient is unconscious or intended, normal systolic pressure, narrowing pulse pressure, tachycardia, weak and threads pulses, rapid and shallow respiration, cool and clammy, worsening base excess and increasing Lacoste levels Correct Answer: Stage II: decompensated or progressive shock Capnography monitors numeric value, as well as continuous waveform, indicating real-time measurement and trending over time. Correct Answer: Quantitative: What stage of shock?: this will lead to death without rapid intervention, obtunded, stuporous or comatose, marked hypotension and heart failure, bradycardia, decreased and shallow respirations, pale, cool and clammy, organ failure and severe acidosis Correct Answer: Stage III: irreversible shock 80 A which of the following structures would be hte most affected by teh concept of caviation Correct Answer: Liver 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 B the most common cause of shock in the trauma pt is Correct Answer: loss of circ volume results from hypo perfusion to the tissue due to an obstruction in either vasculature or heart. Goal is to relieve obstruction and improve perfusion. Ex: tension pneumo or cardiac tamponade are two classic examples that may result from trauma. Correct Answer: Obstructive Shock B a pt with injury to the middle meningeal artery is at risk for which of the following Correct Answer: epidural hematoma 24 Hour Burn Fluid Calculation Correct Answer: Dosage x Kg x % - ml in first 24 hours -More than 20% of their TBSA burned require: *Adults: 2-4 ml of crystalloid solution x kg x % *Peds: 3-4 ml of crystalloid solution x kg x % *Infants: fluid with 5% dextrose at a maintenance rate in addition to the Peds rate protocol (1/2 the amount should be infused in first 8 hours) C what organ might be injured in left lower rib fx Correct Answer: spleen Results from pump failure in the presence of adequate intravascular volume. There is a lack of cardiac output and end organ perfusion secondary to a decrease in myocardial contractility and/or valvular insufficiency. Ex: MI's or dysrhythmia are common causes Correct Answer: Cariogenic Shock D pt with amputation of an index finger with a knife. amputaiton is brought in with pt. it is wrapped in sterile gauze with saline and sealed in a plastic bag. the next step amputation care is Correct Answer: place the bag on ice 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?) 81 - JVD or tracheal deviation? (Tension pneumothorax) D which physiological change in airway of an odler adult pt places the pt at risk for difficult intubation Correct Answer: cervical arthritis occurs as a result of maldistribution of an adequate circulating blood volume with the loss of vascular tone or increased permeability. Ex: Anaphylactic - release of antihistamines Septic Shock - systemic release of bacterial endotoxins, resulting in increased vascular permeability and vasodilation. Neurogenic shock - spinal cord injury results of loss in sympathetic nervous system control of vascular tone. Goal: Volume replacement and vasoconstriction Correct Answer: Distributive Shock Cthe term worried well when refering to disaster preparedness planning refers to: Correct Answer: individuals hwo think they have been affected by the event but are asymptomatic 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) C which of the following would be priority intervention for a pt with multiple rib fractures and chest wall instability follwoing a mvc collision Correct Answer: assist with endotracheal intubation A breath every 5 to 6 seconds: 10-12 ventilations per minute Correct Answer: Bag mask ventilation A a 22 yr old was struck by a vehicle while crossing the street, sustaining multiple fx she is alert and answering qestions and crying what is the best method for initial pain assessment for this pt Correct Answer: self report scale What are you looking for when auscultating lung sounds? Correct Answer: Absence of BS: - Pneumothorax - Hemothorax 82 - Airway Obstruction Diminished BS: - Splinting or shallow BS may be a result of pain D which of the following diagnostic intervention is most appropriate for the unstable pt with a suspectedinternal hemorrhage Correct Answer: focused assessment with sonography for trauma Stroke Volume X HR Correct Answer: Cardiac Output = C an adult pt involved in a brush fire arrives to the er. upon initial assessment in the er the most concerning finding is Correct Answer: hoarse voice and repeatedly decides to clear throat. What are you looking for when percussing the chest? Correct Answer: Dullness: - hemothorax Hyperresonance - Pneumothorax C a college student presents to the er stating afterarriving at a party , she awoke in a dorm rom. she didnt recognize with no memory of the previous evening the trauma nurse prepare for what exam. Correct Answer: sexual assult .. 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: B when assessing a pt following a MVC the nurses asks how fsat the car was going Correct Answer: when volocity is doubled speed is quadroupled 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 B which of hte following significant assessment findigns is frequently found in a patient with complete cransiofacial separation involving the maxilla, zygoma, orbits, and bones of the cranial base. Correct Answer: diplopia 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 85 POSTINTUBATION MANAGEMENT: - Secure ET tube - Set ventilator settings - Obtain Chest x-ray - Continue to medicate - Recheck VS and pulse oxtimetry A which of hte following nursing interventions would be best for traumitc __________ Correct Answer: HOB 30 degrees Flail chest Correct Answer: Paradoxical chest wall movement B an unrestrained driver inlvolved in a MVC in which alcohol was involed. he denies any pain and numbness and tinlging. according to NEXUS critera which factors indicate need for radiological Correct Answer: suspected alcohol abuse Explain Obstructive Shock. Correct Answer: Results from inadequate circulating blood volume because of an obstruction or compression of great veins, aorta, pulmonary arteries, or heart itself. Some causes: - Cardiac tamponade (may compress the heart during diastole to such and extent that atria cannot adequately fill, leading to decreased stroke volume). - Tension pneumothorax may lead to inadequate stroke volume by displacing inferior vena cava and obstructing venous return to right atrium. - Air embolus may lead to obstruction of pulmonary artery and subsequent obstruction to right ventricular outflow during systole, with resulting obstructive shock C 32 wk pregnant lady arrives in er after trapped in a car that flipped. the initial assessment reveals s/s of shock, vaginal bleeding, a palpable asymmetrical uterus, and slowing fetal heart tones what is the most likely cause Correct Answer: uterine rupture 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 B a pt father arrives in teh ER and needs to be told his son was severely injured in a MVC and is in surgery, the father si agitated, yelling, and smells of alcohol. in planning to talk with the father the trauma nurse will Correct Answer: deliver information regarding the son;s care in a calm voice Explain Distributive Shock. Correct Answer: Results from disruption in SNS control of the tone of blood vessels, which leads to vasodilation and maldistribution of blood volume and flow. (Neurogenic and Septic Shock). Neurogenic shock may result from injury to spinal cord in cervical or upper thoracic region. Spinal shock = areflexia and flaccidity associated with lower motor neuron involvement in complete cord injuries; reflexes return with resolution of spinal shock. Septic shock from bacteremia is distributive shock. Endotoxins and other inflammatory mediators cause vasodilation, shunting of blood in microcirculation, and other perfusion abnormalities. 86 1. Preparation and Triage 2. Primary Survery (ABCDE) with resuscitation adjuncts (F,G) 3. Reevaluation (consideration of transfer) 4. Secondary Survey (HI) with reevaluation adjuncts 5. Reevaluation and post resuscitation care 6. Definitive care of transfer to an appropriate trauma nurse Correct Answer: Initial Assessment 1. Dyspnea 2. Tachycardia 3. Decreased or absent breath sounds on the injured side 4. CP Correct Answer: Simple Pneumo assessment: 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. Before the arrival of the pt Correct Answer: When should PPE be placed: 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: Pt is at hospital in the right amount of time, right care, right trauma facility, right resources Correct Answer: Safe Care: 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. Uncontrolled Hemorrhage Correct Answer: Major cause of preventable death: What is renal response? Correct Answer: Renal ischemia activates release of renin. Kidneys do not receive adequate blood supply, renin is release into circulation. Renin causes angiotensinogen, normal plasma protein, to release angiotensin I. Angiotensin-converting enzyme from the lungs converts into angiotensin II. Angiotensin II causes: - Vasoconstriction of arterioles and some veins - Stimulation of sympathetic nervous system - Retention of water by kidneys - Stimulation of release of aldosterone from the adrenal cortex (sodium retention hormone) *Decreased urinary output = early sign renal hypoperfusion and an indicator that there's systemic hypoperfusion. 87 reorganize care to C-ABC Correct Answer: If uncontrolled hemorrhage .. Air cannot escape intrapleural space.. can begin to compress heart. pt will have sever resp distress, hypotension, JVD. Correct Answer: Tension pneumo Used at the beginning of the initial assessment 1. A Alert. If the pt is alert he or she will be able to maintain his or her airway once it is clear. 2. V responds to verbal stimuli responds to pain. If the patient needs verbal stimulation to respond, an airway adjunct may be needed to keep the tongue from obstructing the airway. 3. P responds to pain. If the pt. responds only to pain, he or she may not be able to maintain his or her airway adjunct may need to be placed while further assessment is made to determine the need for intubation. 4. U Unresponsive. If the pt. is unresponsive, announce it loudly to the team and direct someone to chk in the pt is pulseless while assessing if the cause of the problem is the airway. Correct Answer: Airway and AVPU: What is a Laryngeal Mask Airway? Correct Answer: Looks like an ET tube but is equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to cover the supraglottic area. ILMA, does not require laryngoscopy and visualization of the chords. ask pt to pen his or her mouth Correct Answer: While assessing airway the patient is alert and responds to verbal stimuli you should.. A 14 gauge needle that is inserted into the 2nd intercostal space in the midclavicular line on the affected side over the top of the rib to avoid neuromuscular bundle that runs under the rib. Prepare for chest tube placement. Correct Answer: Tension pneumo intervention 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.. Explain adrenal gland response. Correct Answer: When adrenal glands are stimulated by SNS, release of catecholamines (epinephrine and norepinephrine) from adrenal medulla will increase. Epi stimulates receptors in heart to increase force of cardiac contraction (positive inotropy) and increase HR (positive chronotropy) to improve cardiac output, BP and tissue perfusion. Shock stimulates hypothalamus to release corticotropin-releasing hormone that stimulates pituitary to release ACTH that stimulates adrenal gland to release cortisol. Effect of cortisol release is elevation in blood sugar and increased insulin resistance and gluconeogenesis, hepatic process to produce more sugar. 90 1. bony fractures and possible rib fractures, which may impact ventilation 2. palpate for crepitus 3. subcutaneous emphysema which may be a sign for a pneumothorax 4. soft tissue injury Correct Answer: Palpate the chest for 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. 1. open the airway, use jaw thrust 2. insert an oral airway 3. assist ventilations with a bag mask 4. prepare for definitive airway Correct Answer: If breathing is absent.. 1. pain - hallmark sign, early sign 2. pressure - early sign 3. pallor, pules, paresthesia, paralysis - late sign Correct Answer: Six P's of compartment syndrome: What is Surgical Cricothyrotomy? Correct Answer: Making an incision in cricothyroid membrane and placing a cuffed endo or trach tube into trachea. This is indicated when other methods of airway management have failed and pt cannot be adequately ventilated and oxygenated. Complications include: - Aspiration - Hemorrhage or hematoma formation or both - Lac to trachea or esophagus - Creation of a false passage - Laryngeal stenosis Pediatric Assessment Triangle 1. General appearance - muscle tone, interactiveness, consoloability, poor or gaze, speech or cry 2. Work of breathing - inadequate or excessive, accessory muscle use, retractions, tripod position, abnormal upper airway sounds 3. Circulation of the skin - color, mottling or central or peripheral cyanosis, diaphoresis Correct Answer: PAT How would you assess a pt in hypovolemic shock? Correct Answer: (Use Initial Assessment) and then: Inspect: - LOC - Rate and quality of respirations - External bleeding? - Skin color and moisture - Assess jugular veins and peripheral veins Auscultate: 91 - BP - Pulse pressure - Breath sounds - Heart sounds - Bowel sounds Percuss: - Chest and abdomen Palpate: - Central pulse (carotid or femoral) - Positive inotropic effect (force of contraction) may be evidence by a bounding central pulse - Palpate peripheral pulses - Palpate skin temp and moisture Diagnostic Procedures: - Xrays and other studies - Labs Planning and Implementation - Oxygen - IV's with warmed replacement fluids - Control external bleeding with direct pressure - Elevate LE's - NGT - Foley - Monitor and pulse oximeter - Monitor for development of coagulopathies - Surgery? brachial pulse Correct Answer: Under age of 1 where do you find a pulse ICP is a reflection of what three volumes? What happens when one increases? Correct Answer: 1. Brain 2. CSF 3. Blood within the nonexpansible cranial vault As volume of one increases, the volume of another decreases to maintain ICP within normal range. As ICP rises, CPP decreases, leading to cerebral ischemia and potential for hypoxia and lethal secondary insult. Hypotensive pt w/marginally elevated ICP can be harmful. Slightly elevated BP could protect against brain ischemia in a pt with high ICP. Cerebral ischemia can lead to increased concentration of CO2 and decreased concentration of O2 in cerebral vessels. CO2 dilates cerebral blood vessels = increase blood volume and ICP. 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 92 What are the early signs and symptoms of increased ICP? Correct Answer: - Headache - N/V - Amnesia regarding events around the injury - Altered LOC - Restlessness, drowsiness, changes in speech, or loss of judgement What are the late observable signs of symptoms of increased ICP? Correct Answer: - Dilated, nonreactive pupil - Unresponsiveness to verbal or painful stimuli - Abnormal motor posturing patterns - Widening pulse pressure - Increased systolic blood pressure - Changes in RR and pattern - Bradycardia How do you inspect the chest for adequate ventilation? Correct Answer: Observe: - mental status - RR and pattern - chest wall symmetry - any injuries - patient's skin color (cyanosis?) - JVD or tracheal deviation? (Tension pneumothorax) What is Cushing's phenomenon or Cushing's Reflex? Correct Answer: Triad of progressive HTN, bradycardia and diminished respiratory effort. What are the two types of herniation that occurs with ICP? Correct Answer: 1. Uncal herniation 2. Central or transtentorial herniation What are you looking for when auscultating lung sounds? Correct Answer: Absence of BS: - Pneumothorax - Hemothorax - Airway Obstruction Diminished BS: - Splinting or shallow BS may be a result of pain Why does herniation occur? What are the symptoms? Correct Answer: Because of uncontrolled increases in ICP. S/E's - Unilateral or bilateral pupillary dilation - AsyDimmetric pupillary reactivity - Abnormal motor posturing - Other evidence of neurologic deterioration 95 S/S: - Alteration in LOC - Behavior, motor or speech deficits - Abnormal motor posturing - Signs of increased ICP What is an epidural hematoma and its S/S? Correct Answer: Results when a collection of blood forms between the skull and the dura mater. Bleeding is arterial=blood accumulates rapidly: - Compression of underlying brain - rapid increase in ICP - Decreased CBF - Secondary brain injury * Usually requires surgical intervention S/S: - Transient LOC - Lucid period lasting a few minutes to several hours - Rapid deterioration in neurologic status - Severe H/A - Sleepiness - Dizziness - N/V - Hemiparesis or hemiplegia on opposite side of hematoma - Unilateral fixed and dilated pupil on same side of hematoma Explain Obstructive Shock. Correct Answer: Results from inadequate circulating blood volume because of an obstruction or compression of great veins, aorta, pulmonary arteries, or heart itself. Some causes: - Cardiac tamponade (may compress the heart during diastole to such and extent that atria cannot adequately fill, leading to decreased stroke volume). - Tension pneumothorax may lead to inadequate stroke volume by displacing inferior vena cava and obstructing venous return to right atrium. - Air embolus may lead to obstruction of pulmonary artery and subsequent obstruction to right ventricular outflow during systole, with resulting obstructive shock What is a subdural hematoma and its S/S? Correct Answer: A focal brain injury beneath the dura mater that results from acceleration/deceleration. Usually venous, and not necessarily from a fx. Formation may be acute or chronic. Acute pt's hematoma manifest 48 hrs post injury S/S: - Altered LOC or steady decline in LOC - S/S of increased ICP - Hemiparesis or hemiplegia on opposite side of hematoma - Unilateral fixed and dilated pupil on same side of hematoma Chronic pt's " " up to 2 wks post injury - H/A 96 - Progressive decrease in LOC - Ataxia - Incontinence - Sz's What are intracerebral hematoma's and its S/S? Correct Answer: Occur deep within brain tissue, may be single or multiple and commonly associated with contusions (frontal & temporal lobes). They result in significant mass effect, leading to increased ICP and neurologic deterioration. S/S: - Progressive and often rapid decline in LOC - H/A - Signs of increasing ICP - Pupil abnormalities - Contralateral hemiplegia Explain Distributive Shock. Correct Answer: Results from disruption in SNS control of the tone of blood vessels, which leads to vasodilation and maldistribution of blood volume and flow. (Neurogenic and Septic Shock). Neurogenic shock may result from injury to spinal cord in cervical or upper thoracic region. Spinal shock = areflexia and flaccidity associated with lower motor neuron involvement in complete cord injuries; reflexes return with resolution of spinal shock. Septic shock from bacteremia is distributive shock. Endotoxins and other inflammatory mediators cause vasodilation, shunting of blood in microcirculation, and other perfusion abnormalities. What are the S/S of a linear skull fx? Correct Answer: - H/A - Possible decreased LOC What are the S/S of a depressed skull fx? Correct Answer: - H/A - Possible decreased LOC - Possible open fx - Palpable depression of skull over the fx site What is vascular response? Correct Answer: As blood volume decreases, peripheral blood vessels vasoconstrict as a result of sympathetic stimulation via inhibition of baroreceptors. Arterioles constrict to increase TPR and BP. What are the S/S of a basilar skull fx? Correct Answer: - H/A - Altered LOC - Periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle's sign), or blood behind tympanic membrane (hemotympanum) - Facial nerve (VII) palsy - CSF rhinorrhea or otorrhea How would you assess a pt with a cranial injury? Correct Answer: (Initial assessment) INSPECTION: - Assess airway 97 - RR, pattern and effort - Assess pupil size and response to light - Unilateral fixed and dilated pupil = oculomotor nerve compression from increased ICP + herniation syndrome - Bilateral fixed and pinpoint pupils indicate a pontine lesion or effects of opiates - Mildly dilated pupil w/sluggish response may be early sign of herniation syndrome - Widely dilated pupil occasionally occurs w/direct trauma to globe of eye - Determine if pt uses eye meds - Abnormal posturing? - Inspect craniofacial area for ecchymosis/contusions - Periorbital ecchymosis - Mastoid's process ecchymosis - Blood behind tympanic membrane - Inspect nose and ears for drainage - Drng present w/out blood, test drng w/chemical reagant strip. Presence of glucose indicated drng of CSF - If drng present and mixed with blood, test by placing drop of fluid on linen or gauze. If a light outer ring forms around dark inner ring, drng contains CSF - Assess extraocular eye movement (Tests cranial nerves, III, IV, VI) - Performing extraocular eye movements indicates functioning brainstem - Limitation indicates orbital rim fx w/entrapment or paralysis of either a cranial nerve or ocular muscle - Determine LOC with GCS PALPATION - Palpate cranial area for: - Point tenderness - Depressions or deformities - Hematomas - Assess all 4 extremities for: - Motor function, muscle strength and abnormal motor posturing - Sensory function DIAGNOSTIC PROCEDURES - Lab Studies PLANNING AND IMPLEMENTATION - (Initial assessment) - Clear airway (stimulation of gag reflex can produce transient increase in ICP or vomiting with subsequent aspiration. - Administer O2 via NRB - Assist with early ET intubation - Administer sedative/neuromuscular blocking agent - Consider hyperventilation - PaCO2 above 45 mm Hg may cause increased cerebral vasodilation, increased CBF, increased ICP. - Prolonged hyperventilation NOT RECOMMENDED. - Hypocarbia occurs as result of hyperventilation causes cerebral vasoconstriction, decreased CBF, decreased ICP. And ischemia secondary to severe vasoconstriction. - Hyperoxygenate pt with 100% O2 via bag-mask - Apply direct pressure to bleeding sites except depressed skull fractures - Cannulate 2 large IV's - Hypotension doubles pt's death rate (w/severe head trauma)