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Questions and Answers

What is the primary focus of the primary survey in trauma assessment?

Evaluating the patient's medical history

Performing a full physical examination

Identifying and stabilizing life-threatening conditions (correct)

Assessing psychological status of the patient

Which of the following symptoms indicates a compromised airway?

Gasping breaths and inability to speak (correct)

Rapid swelling of the limbs

Sudden dizziness and fainting

High fever and chills

What is the least invasive intervention for managing a compromised airway?

Insert oral/nasal airway

Chin lift/jaw thrust maneuver (correct)

Suction or remove foreign bodies

Intubate the patient

Which of the following is NOT a common cause of airway obstruction?

Severe migraines Signup and view all the answers

In the context of trauma assessment, what does the 'E' in ABCDE stand for?

Exposure Signup and view all the answers

What is the most efficient method to rapidly reduce the core temperature in cases of heat stroke?

Immersion in a cold water bath Signup and view all the answers

What key characterization indicates severe heat stroke?

Hot, dry skin with no sweating Signup and view all the answers

Which symptom is NOT typically associated with heat stroke?

Cool, moist skin Signup and view all the answers

When assessing a patient with heat stroke, which intervention is important to prevent complications?

Monitoring for rhabdomyolysis Signup and view all the answers

What is the critical core temperature indicating hypothermia when assessing a patient?

95℉ Signup and view all the answers

What color code indicates a life-threatening injury that requires immediate intervention?

Red Signup and view all the answers

Which of the following is NOT a common cause of seizures?

Low blood pressure Signup and view all the answers

In which phase do sensory warnings typically occur before a seizure?

Prodromal phase Signup and view all the answers

Which neurologic disorder can be caused by metabolic impairment such as toxicity from kidney dysfunction?

Seizures Signup and view all the answers

What does the 'Yellow' color code signify in triage scenarios?

Urgent but not life threatening injuries Signup and view all the answers

Which symptom may occur during the 'Ictal phase' of a seizure?

Convulsions Signup and view all the answers

What is one factor that can lead to seizures specifically in women of childbearing age?

Malignant hypertension Signup and view all the answers

Which of the following is true about the aural phase in seizures?

It occurs as a sensory warning before the seizure. Signup and view all the answers

What is the most common type of brain edema?

Vasogenic edema Signup and view all the answers

Which type of brain injury is characterized by bruising of the brain tissue?

Contusion Signup and view all the answers

What is a key sign of a basilar skull fracture?

Raccoon eyes Signup and view all the answers

Which of the following complications is NOT associated with skull fractures?

Herniation Signup and view all the answers

What type of hematoma occurs between the dura mater and the skull?

Epidural hematoma Signup and view all the answers

What does the presence of rhinorrhea indicate in the context of a head injury?

CSF leakage and potential fracture Signup and view all the answers

Which statement about cytotoxic edema is true?

It results from disruption of cell membranes. Signup and view all the answers

What complication is most directly associated with a traumatic brain injury (TBI)?

Seizures Signup and view all the answers

What condition typically results from an obstruction of cerebrospinal fluid (CSF) flow?

Hydrocephalus Signup and view all the answers

Which complication may develop from a scalp laceration?

Blood loss Signup and view all the answers

What is the recommended position for a patient with spinal injuries?

Supine position Signup and view all the answers

Which of the following is an important intervention for respiratory management post-emergency stabilization?

Monitor for signs of infection Signup and view all the answers

What indicates a potentially fatal injury level in cervical spine injuries?

C2-C3 injury Signup and view all the answers

What is a key concern when managing patients with autonomic dysreflexia?

Avoiding vagal stimulation Signup and view all the answers

What is the purpose of traction in managing cervical injuries?

To maintain body alignment and relieve pressure Signup and view all the answers

Which medication is primarily used to prevent stress ulcers in patients with spinal injuries?

PPI and H2 blockers Signup and view all the answers

What method is recommended for assessing abdominal status post-injury?

Assess abdomen for signs of retention Signup and view all the answers

What intervention is crucial for managing potential complications in patients with lumbar injuries?

Assessing for respiratory problems Signup and view all the answers

What should be included in post-op care following a decompression laminectomy?

Frequent monitoring of vital signs and neuro checks Signup and view all the answers

How often should a patient prone to skin integrity issues be turned?

Every two hours Signup and view all the answers

In the management of patients with neurogenic bladder, what is crucial?

Implementing a bladder control program Signup and view all the answers

During the assessment of an unconscious patient, which finding is significant?

Unarousable state Signup and view all the answers

What characterizes an abnormal state of awareness in an unconscious patient?

Complete or partial unawareness of self or environment Signup and view all the answers

Which approach is appropriate for a patient requiring spinal immobilization?

Logroll to maintain spinal alignment Signup and view all the answers

Study Notes

Emergency Severity Index (ESI)

ESI-5, Stable: Not life-threatening, requires examination only. Examples include cold symptoms, minor burns, poison ivy, prescription refills.

Primary Survey

Aims to identify and stabilize life-threatening conditions in this order: Airway, Breathing, Circulation, Disability, Exposure.
If uncontrolled external hemorrhage is present, the usual ABC order changes to ABC, C, to prioritize controlling catastrophic hemorrhage.

Airway Assessment

Airway obstruction is a major cause of immediate trauma deaths.
Hypoxia (lack of oxygen) can lead to death.
Signs of a compromised airway include dyspnea, inability to speak, gasping breaths, foreign body presence, and trauma to the face or neck.
Causes of airway obstruction include saliva, blood, vomit, laryngeal trauma, dentures, facial trauma, fractures, and dentures.
Risk factors for airway obstruction include seizures, drowning, anaphylaxis, foreign body obstruction, and cardiopulmonary arrest.

Airway Interventions

Maintain cervical spine stabilization during airway management.
Start with least invasive interventions and progress as needed:
- Oxygen administration.
- Suction or removal of foreign bodies.
- Chin lift/jaw thrust maneuver to open the airway.
- Insertion of oral/nasal airway.
- Intubation (if necessary).
Acute confusion from stroke can cause a fall or head injury from tripping.

Environmental Emergencies

Include heat, cold, submersion, stings/bites, poisonings, violence, and terrorism.

Heat Stroke

A medical emergency and the most severe form of heat stress.
Failure of the body's heat regulation mechanisms (hypothalamic thermoregulatory system).
Increased sweating, vasodilation, and increased respiration deplete fluids and electrolytes, especially sodium.
Can be non-exertional (without significant physical activity) or exertional (during physical activity).
Heat injury at the cellular level leads to cerebral edema and hemorrhage, causing death.

Heat Stroke Assessment

Profound central nervous system dysfunction: altered mental status, confusion, weakness, progressing to coma.
Body temperature above 105°F.
Hot, dry skin with no sweat.
Tachypnea (rapid breathing) and tachycardia (rapid heart rate).

Heat Stroke Management

Stabilize ABCs (Airway, Breathing, Circulation) with 100% oxygen, cardiac monitoring, and electrolyte/coagulation correction.
Rapid temperature reduction to 102°F.
Immersion in cold water bath (most effective).
Remove clothing, cover with cool, wet sheets.
Place a large fan in front of the patient.
Apply ice to the neck, groin, chest, and axillae.
Monitor for temperature changes and control shivering with chlorpromazine (shivering increases core temperature).
Monitor for rhabdomyolysis (which carries a risk of kidney injury) and disseminated intravascular coagulation (DIC).

Hypothermia

Core temperature below 95°F.
Occurs when heat production by the body cannot compensate for heat loss to the environment.
Types:
- Primary: Environmental exposure.
- Secondary: Conditions like cardiac arrest or massive head trauma.
Red: Life-threatening injuries needing immediate intervention (severe bleeding, airway obstruction, respiratory distress).
Yellow: Urgent, but not life-threatening injuries (fractures, significant but stable injuries).
Green: Minor injuries (minor cuts, abrasions, sprains).

Seizures

Sudden abnormal, excessive electrical discharge between brain cells causing temporary abnormalities in muscle tone, movements, behavior, sensations, or awareness.
Causes:
- Stroke: Direct or indirect (scar tissue).
- Metabolic impairments: Uremia (toxin buildup due to kidney dysfunction), encephalopathy, poisoning.
- Blood sugar dysregulation (hyperglycemia or hypoglycemia).
- High fever (especially in children).
- Drug or alcohol withdrawal (starting 4-6 hours after the last drink).
- Hypertension (especially malignant hypertension), particularly in women of childbearing age.
- Idiopathic: Sometimes people experience a single seizure without further occurrences.
- Genetics, CNS infection (meningitis).

Seizure Phases

Not all patients experience all phases:
- Prodromal phase: Sensory or behavioral changes that precede a seizure by hours or days.
- Aural phase: Sensory warning that is similar each time a seizure occurs and is part of the seizure activity.
- Ictal phase: From the onset of symptoms to the end of seizure activity.

Post Seizure Assessment

Assess respiratory status and maintain an airway (ABCs).
Prevent head flexion, rotation, or extension (presume head trauma unless it's proven otherwise).
Immobilize spine with a rigid cervical collar and supportive backboard with straps.
Maintain traction.
Logroll the patient to keep the spine intact.
Position in supine or reverse Trendelenburg (no sitting position).

General Interventions Post Emergency Stabilization

Respiratory System:
- Assess respiratory status (patterns, sounds, secretions).
- Monitor ABGs (arterial blood gases).
- Encourage deep breathing and use of an incentive spirometer.
- Monitor for signs of infection.
- Maintain mechanical ventilation if needed.
Cardiovascular System:
- Monitor for cardiac dysrhythmias (avoid vagal stimulation, pacemaker may be needed, treat symptomatic bradycardia).
- Assess for signs of shock (neurogenic).
- Assess for DVT (tenderness may not be present).
- Monitor for orthostatic hypotension.
Neuromuscular System:
- Assess neurological status, motor, and sensory function.
- Monitor for autonomic dysreflexia and spinal shock.
- Immobilize.
- Assess pain.
- Provide operative care as needed.
- Encourage exercise techniques and use assistive devices to prevent problems.
Gastrointestinal System:
- Assess the abdomen.
- Prevent bowel retention (enemas, digital removal).
- initiate a bowel control program (especially for those with lack of sensation).
- Use PPIs and H2 blockers to prevent stress ulcers.
- Maintain adequate nutrition (start within 72 hours of injury).
- Consider enteral (EN) or parenteral (PN) nutrition if needed. Provide high protein and high calorie diet.
Renal System:
- Prevent urinary retention (foley catheter or self-catheterization).
- Manage neurogenic bladder with a bladder control program.
- Maintain fluid and electrolyte balance.
- Monitor for infection.
Integumentary System:
- Assess skin integrity (especially bony prominences).
- Turn the patient every two hours.
- Provide daily bathing.
Psychosocial:
- Assess psychosocial status.
- Prevent sensory deprivation with conversations, music, reading, television viewing. Promote good sleep and rest.
- Encourage self-expression and offer a safe space to discuss concerns.
- Promote rehabilitation and access to community resources.
- Educate family/caregivers.

Cervical Level Injuries

Injury at C2 to C3 is often fatal.
C4: Diaphragm affected.
Injury above C4: Respiratory difficulty and paralysis from the neck down.
Injury at C5-C8: May have movement of the shoulder.

Interventions for Cervical Injuries: Spine Traction

Skull Tongs:
- Traction is applied to the skull using tongs.
- Weights are attached to the tongs.
- Monitor neurological status (level of consciousness, motor function, sensation).
- Monitor for increased intracranial pressure (ICP): Nausea, vomiting, neurological changes.
- Ensure weights hang freely.
- Maintain body alignment.
- Turn the patient every two hours.
- Assess pin insertion sites for signs of infection.
- Provide pin care (clean twice daily with chlorhexidine gluconate, apply antibiotic ointment).
Halo Traction:
- A headpiece with four pins inserted into the skull.
- A metal halo is attached to a vest or jacket.
- Monitor neurological status.
- Monitor for increased ICP: Nausea, vomiting, neurological changes.
- Never move the client using the Halo.
- Assess for tightness of the halo.
- Assess skin integrity.
- Provide pin care (clean twice daily with chlorhexidine gluconate, apply antibiotic ointment).

Thoracic Level Injuries

Loss of movement depends on the level of injury.
Leg paralysis may occur.
Autonomic dysreflexia may occur in those with injuries above T6.

Lumbar & Sacral Level Injuries

Loss of movement and sensation may occur.
Injury below S2-S3 results in a neurogenic bladder.
Injury above S2: Male erection may be possible, but ejaculation is not.
Injury between S2-S4 damages both the sympathetic and parasympathetic nervous system responses leading to the inability to achieve erection or ejaculation.

Interventions for Thoracic/Lumbar/Sacral Injuries

Bed rest.
Immobilization.
Assess for respiratory problems.
Use a brace when the patient is out of bed.

Surgical Interventions for Thoracic/Lumbar/Sacral Injuries

Decompression Laminectomy:
- Relief of spinal cord pressure by removing part or all of the lamina (the roof of the spinal canal).
Spinal Fusion:
- Permanently joins two or more vertebrae.

Post-Operative Care for Thoracic/Lumbar/Sacral Injuries

Monitor respiratory status.
Monitor vital signs and neurological checks.
Encourage deep breathing and incentive spirometer use (to prevent atelectasis and pneumonia).
Assess for fluid and electrolyte imbalance.
Monitor intake and output.
Assess for immobility problems (keep patient in a prescribed position, log rolling).
Provide cast care as needed.
Administer pain medication.
Fracture bedpan.
Start with NPO then progress diet (liquids, soft, solids).

Medications for Spinal Cord Injuries

Dexamethasone (corticosteroid)
Dextran (plasma volume expander)
Dantrolene (for malignant hyperthermia and chronic spasticity)
Pain medication (avoid opioids if possible due to the risk of constipation).
Antidepressants.
Inotropes (dobutamine).
Gabapentin (may help with paresthesias).

Unconscious Patient

An abnormal state of complete or partial unawareness of self or environment, unresponsive to stimulation.
Causes include head trauma, toxins, shock, hemorrhage, tumor, and infection.
Assessment findings:
- Unarousable.
- Altered response to painful stimuli and altered respirations.
- Decreased cranial nerve activity.

Interventions for Unconscious Patient

Secure the airway.
Monitor vital signs.
Assess neurological status.
Auscultate lung sounds.
Position appropriately.
Monitor fluid status and nutrition.
Treat any underlying causes.

Increased Intracranial Pressure (ICP)

ICP is the pressure within the skull.
Increased ICP can be life-threatening.
Types:
- Vasogenic (most common): Disruption of the blood-brain barrier, occurring primarily in the white matter. Treatment includes diuretics and steroids.
- Cytotoxic: Disruption of cell membranes, leading to direct fluid build-up within cells (intact blood-brain barrier).
- Interstitial: Ventricular enlargement due to excess cerebrospinal fluid (CSF) production, obstruction of flow, or inability to reabsorb CSF. Often a result of hydrocephalus (CSF buildup in the brain).

Causes of Increased ICP

Mass lesions (tumors).
Head injuries surgery.
Infections.
Vascular insult.
Toxic or metabolic conditions.

Herniation

An abnormal protrusion of the brain through a defect or opening, compressing the brain due to a shifting of pressure from a higher pressure space to a lower pressure space.
A late sign of increased ICP.

Head Injury

Injury or trauma to the scalp, skull, or brain.
Serious form of head injury: Traumatic brain injury (TBI).
Complications: Cerebral bleed, hematomas, increased ICP, infections, seizures, personality changes, and cranial nerve damage.

Types of Head Injuries

Scalp lacerations: External head trauma with potential complications such as blood loss and infection.
Skull fractures:
- Complications: Intracranial infections, hematoma, meningeal and brain tissue damage.
Head Trauma: Can be diffuse (generalized) or focal (localized).

Hematomas and Hemorrhage

Hematoma:
- Epidural: Bleeding between the dura and the arachnoid space.
- Subdural: Bleeding between the skull and the dura mater.
Hemorrhage:
- Intracerebral: Bleeding within the brain tissue, deep, and large.
- Subarachnoid: Bleeding in the space between the arachnoid membrane and the pia mater.

Skull Fractures

Location of the fracture determines the manifestations:
- Raccoon Eyes: Periorbital bruising.
- Battle Sign: Postauricular bruising.
- Halo Sign: Fluid on a white gauze pad that coalesces into the center with a yellowish ring around the blood (due to the presence of CSF).
- Rhinorrhea: CSF leakage from the nose.
- Otorrhea: CSF leakage from the ear.
  - Confirms a fracture has traversed the dura.
  - Test fluid with Dextrostix: If no blood present, and glucose test is positive, it confirms the presence of CSF.

Specific Skull Fracture Locations

Basilar: Location: Base of the skull. Involves the frontal and temporal lobes. Manifestations: Raccoon eyes, Battle sign, halo sign, rhinorrhea, partial/total loss of vision, smell loss, eye movement defects, frontal and middle fossa involvement, conductive hearing loss, loss of balance. Monitor for CSF leaks.
Anterior Fossa: Location: Frontobasilar. Manisfestations: Raccoon eyes, halo sign, rhinorrhea, partial/total loss of vision, smell loss. Avoid nose blowing.
Middle Fossa: Location: Temporal lobe. Manifestations: Battle sign, otorrhea or rhinorrhea, cranial nerve injury, conductive hearing loss. Watch for cranial nerve injury.
Posterior Fossa: Location: Cervical spine injury. Manifestations: Vertebral artery injury, damage to lower cranial nerves, loss of balance.

Focal Brain Injury

Laceration: Tearing of the cortical surface of the brain.
- Severe tissue damage, usually seen in open fractures and injuries due to penetration.
- Management: Antibiotics (until meningitis is ruled out) and prevention of secondary injury from ICP.
Contusion: Bruising of brain tissue within a focal area.
- Often associated with closed head injuries.
- Usually occurs at a fracture site.
- Coup-contrecoup: Injury occurs at the site of direct impact (coup) and a second area of damage on the opposite side (contrecoup) leading to multiple contused areas.

Complications of Brain Injuries

Epidural Hematoma: Bleeding between the skull and dura mater. Associated with temporal or parietal skull fractures.
Subdural Hematoma: Bleeding between the dura and arachnoid space. Associated with acceleration-deceleration injury.
Intracerebral Hematoma: Bleeding within brain tissue. Deep, large, associated with contusions. Can be caused by an evolving hematoma.

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