Module - 6 - Trauma & Burns Flashcards

Question

25. Your patient was involved in a single car roll-over and is complaining of neck and left shoulder pain. You note bruising to the left chest wall. Vital signs are BP 80/48, HR 130, RR 28, SpO2 96%. The most likely cause is A. Cardiac tamponade B. Tension pneumothorax C. Splenic injury D. Intra-abdominal bleeding

Answer 1

25. C: Injury to the spleen is the most common serious complication of abdominal injury, resulting from trauma. Kehr’s sign is the occurrence of acute pain in the tip of the shoulder due to the presence of blood or other irritants in the peritoneal cavity when a person is lying down and the legs are elevated. Kehr’s sign in the left shoulder is considered a classical symptom of a ruptured spleen. It may result from diaphragmatic or peridiaphragmatic lesions, renal calculi, splenic injury, or ectopic pregnancy. Kehr’s sign is a classical example of referred pain: irritation of the diaphragm is signaled by the phrenic nerve as pain in the area above the collarbone. This is due to the fact that the supraclavicular nerves have the same cervical nerves origin as the phrenic nerve, C3 and C4.

Answer 2

26. A: Electrical injuries occurs upon contact of a human body with any source of voltage high enough to cause sufficient current through the skin, muscles, or hair. Voltage is defined as the force with which the electrical movement occurs. High voltage injuries (\>1,000 volts) and low voltage injures (\<1,000 volts) are both common, and either type can cause death. The higher the voltage, the more significant the injury. The type of current, alternating (AC) or direct (DC), can also determine the significance of the injury. Alternating current produces a tetanic contraction of muscles that “freezes” the victim to the source and has a greater potential in causing ventricular fibrillation. This is not seen with direct current. Low voltage AC can be more dangerous than a low voltage DC. Lactic acidosis is common because of the significant muscle damage caused by electrical injury. It is essential to maintain higher rates of urinary output because hemoglobinuria and myoglobinuria are common with electrical injuries.

Answer 3

27. D: The fluid resuscitation must be based on actual urine flow. A minimum of 50-100 mL/hour of urine must be maintained. If blood-colored urine is present, then the fluid volume must be sufficient enough to maintain a minimum output of 100 mL/hr.

Answer 4

28. C: Cerebral perfusion pressure, or CPP, is the net pressure gradient, causing blood flow to the brain (brain perfusion). It must be maintained within narrow limits because too little pressure could cause brain tissue to become ischemic (having inadequate blood flow) and too much could raise ICP.

Answer 5

29. A: Careful interpretation of the CVP is important! Central venous pressure (CVP) describes the pressure of blood in the thoracic vena cava, near the right atrium of the heart. CVP reflects the amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system. It is a good approximation of right atrial pressure, which is a major determinant of right ventricular end-diastolic volume. The CVP should always be considered in conjunction with other cardiovascular parameters. Under normal circumstances, the right-sided heart pressures should indirectly reflect left-sided pressures, and the left-sided filling pressure may be an indicator of left ventricular function. Preload (end-diastolic volume) is the pressure stretching the ventricle of the heart at the beginning of systole after passive filling of the ventricle and subsequent atrial contraction. Afterload (end-systolic volume) is the ventricular pressure at the end of systole.

Answer 6

30. A: ICP monitoring uses a device placed inside the head, which senses the pressure inside the skull and sends its measurements to a recording device. The intraventricular catheter is thought to be the most accurate method, but if immediate access is needed, a subarachnoid bolt is typically used. Normal value ranges may vary slightly among different laboratories (upper limits of the range can go as high as 15 mmHg).

Answer 7

31. B [(DBP × 2) + SBP] divided by 3

Answer 8

32. B MAP − ICP

Answer 9

33. C: Grey Turner’s sign refers to bruising of the flanks and can indicate retroperitoneal or intra-abdominal bleeding, which can take up to 24-48 hours to show up on assessment. It can be caused by acute pancreatitis, blunt abdominal trauma, ruptured abdominal aortic aneurysm, or ruptured/hemorrhagic ectopic pregnancy. It may be accompanied by Cullen’s sign (superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus), which may then be indicative of pancreatic necrosis, with retroperitoneal or intra-abdominal bleeding. Murphy’s sign is useful for differentiating pain in the right upper quadrant. Typically, it is positive in cholecystitis (gallbladder disease). Kernig’s and Brudzinski’s signs when elicited can indicate meningitis. Kehr’s sign (referred shoulder pain) can be indicative of a spleen injury or ectopic pregnancy.

Answer 10

34. B: Injuries associated with a side-impact motorcycle crash are related to the body parts crushed between the cycle and the second object. Most commonly seen injuries involve the leg and foot on the impact side. Open fracture of the femur, tibia/fibula, and malleolus are predictable. Motorcycle riders have learned the technique of laying down the bike and sliding off to the side before colliding with another object. Commonly seen are abrasions on the affected side.

Answer 11

35. B: Falls from heights greater than 15-20 feet are associated with severe injuries. Three predictable injuries are seen with falls. The forces involved are deceleration and compression. The first injury, calcaneus fractures, is caused by compression of the feet on impact. Second, as the energy dissipates after impact and the top of the body pushes down toward the point of impact, compression fractures to T12-L1 are seen. Finally, as the body moves forward and the patient puts both arms out to complete the fall, bilateral wrist fractures occur. It is important to estimate the distance fallen and what the patient landed on. A soft-landing surface (dirt or sand) will absorb much more energy than a hard surface, such as concrete.

Answer 12

36. A: Chemical burns differ from thermal burns in that the burning process continues until the agent is inactivated by reaction of tissues: neutralized or diluted with water. Dry chemicals, such as lime, should be brushed off before irrigation. Water and physiologic saline are fluids of choice for wound irrigation.

Answer 13

37. B: Tracheobronchial injuries occur when blunt or penetrating trauma causes a tear in the trachea or bronchus, allowing air to enter the pleural space or mediastinum. These injuries are characterized by palpable subcutaneous emphysema in the neck, face, and thorax. Other clinical findings include dyspnea, hemoptysis (coughing up blood), and absent breath sounds on the affected side. Hamman’s sign is a crunching sound auscultated on the anterior chest wall and is synchronized to the patient’s heartbeat. A pneumothorax that reaccumulates after chest tube insertion and placement to water seal drainage and suction should heighten the transport team’s suspicion for tracheobronchial injuries. Treatment is intubation, with placement of the tube distal to the injury site, which most often can involve an intentional right mainstem intubation.

Answer 14

38. C: Urinary output is perhaps the most accurate method of evaluating the effectiveness of fluid replacement. Adult burn patients should have an hourly urine output of 30-50 mL/hr, and in the pediatric patient, it should be maintained at 1-2 mL/kg/hr/% BSA below 30 kg. Oliguria is an indication of inadequate fluid volume and should be easily corrected by increasing the rate of fluid administration. An osmotic diuretic, such as mannitol can be administered to avoid acute renal failure when fluid administration has been ineffective.

Answer 15

39. A: Hydrofluoric acid (HF) is an extremely corrosive liquid and is a contact poison. Because of the ability of hydrofluoric acid to penetrate tissue, poisoning can occur readily through exposure of skin or eyes, or when inhaled or swallowed. Symptoms of exposure to hydrofluoric acid may not be immediately evident. HF interferes with nerve function, meaning that burns may not initially be painful. Once absorbed into blood through the skin, it reacts with blood calcium and may cause cardiac arrest. Formation of insoluble calcium fluoride is proposed as the etiology for both precipitous fall in serum calcium and the severe pain associated with tissue toxicity. In some cases, exposures can lead to hypocalcemia. Thus, hydrofluoric acid exposure is often treated with calcium gluconate, a source of Ca2+ that sequesters the fluoride ions. HF chemical burns can be treated with a water wash and 2.5% calcium gluconate gel or special rinsing solutions. However, because it is absorbed, medical treatment is necessary; rinsing off is not enough and in some cases, amputation may be necessary.

Answer 16

40. D: Cushing’s triad is the triad of widening pulse pressure (rising systolic, declining diastolic), change in respiratory pattern (irregular respirations), and bradycardia. It is a sign of increased ICP, and it occurs as a result of the Cushing reflex. Brain herniation, also known as cistern obliteration, is a deadly side effect of very high ICP that occurs when the brain shifts across structures within the skull. Brain herniation frequently presents with abnormal posturing a characteristic positioning of the limbs indicative of severe brain damage. These patients have a lowered level of consciousness, with Glasgow Coma Scores of three to five. One or both pupils may be dilated and fail to constrict in response to light. Vomiting can also occur due to compression of the vomiting center in the medulla oblongata. Routine hyperventilation is not longer recommended in the initial management of the patient with traumatic brain injury. The patient’s EtCO2 should be maintained between 35-45 mmHg. Mannitol may be used to treat increasing ICP manifested by deterioration in the patient’s neurologic status.

Answer 17

41. B: Neurogenic shock, also known as a type of distributive shock or vasogenic shock, is an imbalance between parasympathetic and sympathetic nervous stimulation of vascular smooth muscle, resulting in sustained vasodilatation typically, and the heart rate does not increase in the neurogenic shock patient due to loss of sympathetic impulses/stimulation. Vasomotor paralysis below the level of the injury occurs resulting in decreased peripheral vascular resistance. Sympathetic impulses, which would normally stimulate vasoconstriction, are interrupted, leading to widespread vasodilation. Blood collects in the capillary beds, reducing venous return, cardiac output, and blood pressure. Refer to the table for review of compensatory mechanisms.

Answer 18

42. Brown-Séquard

Answer 19

43. C: Circumferential burns to the chest or extremities represent the more easily recognizable complications of burn care. Circumferential burns to the chest wall decrease chest wall compliance, creating respiratory insufficiency and hypoxia, especially in the pediatric patient. The treatment for this problem is an escharotomy, which allows the chest to expand fully for more efficient ventilation. Circumferential burns to the extremities or digits can be equally threatening to the circulatory stability of the affected limb, producing the “five Ps” that represent the signs and symptoms of an arterial injury: pain, pallor, pulselessness, paresthesias, and paralysis. Escharotomies ideally should be performed before transport of the patient and should be performed only under the direction of a medical physician.

Answer 20

44. C: Shock is a clinical syndrome which results in a systemic imbalance between oxygen supply and demand. Inadequate blood flow to body organs and tissue causes life-threatening cellular dysfunction.

Answer 21

45. D: 90 × 2 = 180 180 × 2 = 360 360 divided by 3 = 120 120-25 = 95 MAP-ICP = CPP

Answer 22

46. B: Cardiac tamponade, tension pneumothorax, massive pulmonary embolism, and aortic stenosis are classified as forms of obstructive shock. In these situations, the flow of blood is obstructed, which impedes circulation and can result in circulatory arrest.

Answer 23

47. B: 2 × 100 = 200; 200 × 70 = 14,000; half is administered in the first eight hours = 7,000 mL (is the lower end of the Consensus formula). Answer = 7,000-14,000 mL Consensus formula (Parkland and modified Brook formulas combined) [(2-4 mL × weight in kg) × % TBSA] = Total fluids in twenty-four hours with half of the total fluids calculated administered

Answer 24

48. A: Early signs and symptoms of a tension pneumothorax can be characterized by increased work of breathing, tachycardia, pulsus paradoxus, narrowing pulse pressure, and breath’s sounds diminished on the affected side. Late signs and symptoms of decompensated obstructive shock include cyanosis, hypoxemia hypotension, bradycardia, and confusion. The affected side of the chest may be hyper-expanded and show decreased movement, with increased movement on the other side. The breath sounds may be diminished or absent on the affected side, as air in the pleural space dampens sound and percussion of the chest may sound hyperresonant (higher pitched). In very severe cases, the respiratory rate falls sharply, which may result in further shock and coma. Recent studies have shown that the development of tension features may not always be as rapid as previously thought. Particular clinical signs may also be less useful in the recognition of tension pneumothorax, such as the deviation of the trachea away from the affected side and the presence of increased jugular venous pressure.

Answer 25

49. B: Pulseless electrical activity (PEA), also known by the older term electromechanical dissociation or nonperfusing rhythm, refers to any heart rhythm observed on the ECG that should be producing a pulse, but is not. The most common cause of PEA is hypovolemia. The approach in treatment of PEA is to treat the underlying cause. These possible causes are remembered as the 6 Hs and the 6 Ts or by using the mneumonic PATCH4MD. Refer to the tables for review of causes for PEA. Where an underlying systemic cause cannot be determined rapidly enough, pulseless electrical activity should be treated as if the patient were in asystole. Treatment is intravenous delivery epinephrine (1:10,000) 1 mg every 3-5 minutes, and, if the underlying rhythm is bradycardia (\<60 BPM), Atropine 1 mg IV up to 0.04 mg/kg. Both these drugs should be administered along with appropriate CPR techniques. Defibrillators are not used for this rhythm as the problem lies in the response of the myocardial tissue to electrical impulses.

Answer 26

50. A: Cyanide makes the cells of an organism unable to use oxygen, primarily through the inhibition of cytochrome oxidase. Inhalation of high concentrations of cyanide causes coma with seizures, apnea, and cardiac arrest, with death following in a matter of minutes. At lower doses, loss of consciousness may be preceded by general weakness, giddiness, headaches, vertigo, confusion, and perceived difficulty in breathing. A fatal dose for a patient can be as low as 1.5 mg/kg body weight. Blood cyanide concentrations may be measured as a means of confirming the diagnosis in hospitalized patients or to assist in the forensic investigation of a criminal poisoning. Cyanide toxicity can occur following ingestion of amygdalin (found in almonds and apricot kernels), prolonged administration of nitroprusside, and after exposure to gases produced by the combustion of synthetic materials. The United States standard cyanide antidote kit first uses a small inhaled dose of amyl nitrite, followed by intravenous sodium nitrite, followed by intravenous sodium thiosulfate. Hydroxocobalamin is newly approved in the US at doses from 2.5 to 10 mg per injection and is available in Cyanokit antidote kits. Hydroxocobalamin (OHCbl, or B12a) is a natural form of vitamin B12. Pharmaceutically, hydroxycobalamin is usually produced as a sterile injectable solution; it is used for treatment of the vitamin deficiency and also (because of its affinity for cyanide ion) as a treatment for cyanide poisoning. Hydroxocobalamin will bind circulating and cellular cyanide molecules to form cyanocobalamin, which is excreted in the urine.

Answer 27

* **Parkland Formula** [(4 mL × weight in kg) × % of TBSA] = * **Modified Brooke Formula** [(2 mL × weight in kg) × % TBSA] = * **Consensus Formula** ( [(2-4 mL Total fluids in twenty-four hours Half of the total fluids calculated administered in the first eight hours and the rest in the subsequent sixteen hours.

Answer 28

the delicate axons of the brain are stretched and damaged as a result of rapid movement of the brain, involving mechanism of injury associated with acceleration and deceleration that occurs with high-speed motor vehicle accidents or ejection from a vehicle. This type of brain injury is generally severe with a high morbidity and mortality.

Answer 29

tube thoracostomy prior to transport. * Treatment consists of placement of an appropriate-sized chest tube to the fifth intercostal space, at the anterior midaxillary line of the affected side. * An alternate site for chest tube placement is the second intercostal space at the midclavicular line of the affected hemothorax. * The anterior approach (alternate site) is inappropriate if both air and fluid are suspected in the pleural space.

Answer 30

1,500 mL of blood accumulates in the pleural space, a hemothorax is deemed massive. * Advanced Trauma Life Support (ATLS) guidelines state the tube should be clamped after 1,000 mL of blood is removed in adult patients. * Pediatric patients have a circulating volume of 80 mL/kg. The 1,000 mL in adults represents one fifth of the circulating volume, so a similar 20% loss in children may require thoracostomy tube clamping.

Answer 31

* Caused blunt injury to the diaphragm, resulting in rupture or partial tear, * Diaphragmatic tears can occur without herniation of bowel into the chest cavity. * If an intestinal herniation into the pleural space does occur, intestinal strangulation may develop. * The left diaphragm is injured more often than the right because the liver absorbs the impact of the force on the right side. Sp**L**een injuries often occur with left-sided diaphragmatic trauma. * If a right-sided tear has occurred, live**R** injury will probably accompany it. * Focus on airway management, oxygenation, and ventilation because of the potentially decreased lung capacity.

Answer 32

the rapid breakdown (lysis) of skeletal muscle (rhabdomyo) due to injury to muscle tissue. * The muscle damage may be caused by physical (e.g., crush injury), chemical, or biological factors. * destruction of the muscle leads to the release of the breakdown products of damaged muscle cells into the bloodstream; some of these, such as myoglobin (a protein), are harmful to the kidney and may lead to acute kidney failure. * Treatment is with intravenous fluids, and dialysis or hemofiltration, if necessary. * Swelling of the damaged muscle occasionally leads to compartment syndrome * disruptions in blood clotting may lead to the development of a state called disseminated intravascular coagulation (DIC).

Answer 33

the level of creatine kinase (CK) in the blood. CPK levels greater than 20,000 are ominous and are indicative of later DIC, acute kidney failure, and potentially dangerous hyperkalemia.

Answer 34

* Fractured ribs - pneumothorax, hemopneumothorax * concussion, skull fractures * patella & femur fractures, dislocated hips, acetabular fractures, * ruptured spleen, lacerated liver, and ruptured/torn thoracic aorta.

Answer 35

* Clavicles * ribs, femur fracture * tibia/fibula fractures * ruptured spleens.

Answer 36

Potential for multisystem injuries. ## Footnote

Answer 37

Falls from heights greater than 15-20 feet are associated with severe injuries. * Calcaneus fractures * compression fractures to T 12-L1 * bilateral wrist fractures.

Answer 38

**Head-on:** fractured femurs, tibias and fibulas; chest and abdominal injuries; head and neck injuries. **Side impact:** most commonly seen injuries are fractures of the femur, tibia/fibula, and malleolus. **Laying down the motorcycle:** commonly seen are abrasions to the affected side and fractures may occur if the patient hits the road hard or comes in contact with another object.

Answer 39

Automobile rapidly accelerates causing the car to move forward under the patient. * back with T12-L1 * femur fractured, tibia/fibula fractures, ankle fractures, * cervical strain * C2 fractures caused by hyperextension if the head restraint is not in the proper position.

Answer 40

is called the aPTT, or activated partial thromboplastin time. Thromboplastin is the combination of both phospholipids and tissue factor, both needed in the activation of the extrinsic pathway. However, partial thromboplastin is just phospholipids and not tissue factor. Tissue factor is not needed to activate the intrinsic pathway. Partial thromboplastin is used to measure the intrinsic pathway.

Answer 41

Hemodynamic findings: SVR \> 1,200, CVP low Clinical findings: * Rapid, weak, thready pulse due to decreased blood flow combined with tachycardia; * cool, clammy skin due to vasoconstriction and stimulation of vasoconstriction; * increased thirst, * altered mentation, and hypotension.

Answer 42

Hemodynamic findings: SVR \> 1,200, CVP high, PAWP high Clinical findings: * Distended jugular veins due to increased jugular venous pressure; * crackles; * weak or absent distal pulses; * hypotension * arrhythmias, often tachycardia.

Answer 43

Hemodynamic findings: SVR\< 800, CI low, and heart rate is either normal or bradycardia is present. Clinical findings: * Hypotension * may be accompanied by profound bradycardia due to loss of the cardiac accelerating nerve fibers from the sympathetic nervous system at T1-T4 * the skin is warm and dry or a clear sweat line exists, above which the skin is diaphoretic * priapism due to peripheral nervous system stimulation.

Answer 44

Hemodynamic findings: SVR \< 800, CI high Clinical findings: * Pyrexia (fever) due to increased level of cytokines; * systemic vasodilation resulting in hypotension; * warm and sweaty skin due to vasodilation; * activation of the coagulation pathways, resulting in DIC

Answer 45

Hemodynamic findings: SVR \< 800, CI low, and tachycardia Clinical findings: * Erythema (red skin), urticaria (hives), and pruritis (itching); * localized edema, especially around the face and tongue; * weak and rapid pulse; * breathlessness and cough due to narrowing of airways and swelling of the throat; * wheezing due to bronchoconstriction secondary to the histamine release; * hypotension.

Answer 46

Hemodynamic findings: N/A? Clinical findings: * Distended jugular veins due to increased jugular venous pressure * pulsus paradoxus in the presence of tamponade or tension pneumothorax. * Other causes are aortic stenosis and massive pulmonary embolism.

Answer 47

a blood protein that is mainly produced in the liver and helps maintain volume of the blood by maintaining the oncotic pressure. * Albumin IV is a plasma volume expander made from pooled human venous plasma, which does require type and crossmatching. * **Indications** of Albumin IV include hypovolemia and hypoalbuminemia, which can be caused by burns, major injury, hemorrhage, pancreatitis, infection, liver failure, or liver cirrhosis.

Answer 48

Is a frozen blood product prepared from plasma and each 15 mL unit typically contains : * 100 IU of factor VIII, and 250 mg of fibrinogen. * Use for hemophilia, Von Willebrand’s disease, hypofibrinogenemia (low fibrinogen levels), DIC.

Answer 49

Also known as thrombocytes, play a fundamental role in hemostasis, which leads to the formation of blood clots. * If the number of platelets are too low (thrombocytopenia), excessive bleeding can occur. * If the number of platelets are too high, blood clots can form (thrombosis).

Answer 50

PRBCs are a preparation of red blood cells that are transfused to correct low blood levels in anemic patients. * This increases the amount of hemoglobin in the blood that can carry oxygen perfused from alveoli of the lungs to tissues. * One unit of PRBCs typically will raise * the hematocrit by 3-4% and the * blood hemoglobin concentration by 1 gm/dL.

Answer 51

Refers to the liquid portion of human blood that has been frozen and preserved quickly after a blood donation and will be used for blood transfusion. * Indications for use are limited to the treatment of deficiencies of coagulation proteins for which specific factor concentrates are unavailable or undesirable; * reversal of Coumadin (warfarin); * massive blood transfusion.

Answer 52

is an electrocardiographic phenomenon of alternation of QRS complex amplitude or axis between beats (high, low, high). It is thought to be related to changes in the ventricular electrical axis due to fluid in the pericardium. * wandering baseline may be seen * seen in cardiac tamponade

Answer 53

150,000-400,000 (150-450) per microliter of blood If platelet levels fall below 20,000 per microliter, massive bleeding may occur and is considered a life-threatening risk.

Answer 54

“fluid around the heart” is an abnormal accumulation of fluid in the pericardial cavity. * Because of the limited amount of space in the pericardial cavity, fluid accumulation will lead to an increased intrapericardial pressure, and this can negatively affect heart function. * When there is a pericardial effusion, with enough pressure to adversely affect heart function, this is called cardiac tamponade. * Normal levels of pericardial fluid are from 15 to 50 mL. * Electrical alternans is seen in cardiac tamponade and is thought to be related to changes in the ventricular electrical axis due to fluid in the pericardium.

Answer 55

135-145 \<120 or \>160 can cause seizures.

Answer 56

3.5-4.5 \>7 can cause ventricular dysrhythmias; ECG findings peaked/tented T wave \> 5 mm in height.

Answer 57

8.8-10.4 Trouseau’s and Chvostek’s signs can indicate hypocalcemia.

Answer 58

24-30 \<20 can indicate acidosis, look for cause calculate anion gap [Na - (Cl+HCO3)]

Answer 59

6-23 Elevated BUN can indicate: dehydration, blood in the gut, or renal failure.

Answer 60

0.6-1.4 Elevated reading indicates renal failure; BUN elevated.

Answer 61

70-110 Assess for changes in behavior

Answer 62

285-295 Maintain \<320 in the head-injured patient.

Answer 63

1.5-2.5 * Levels of 4-8 are therapeutic levels in the preeclampsia obstetrical patient to prevent seizures. * Levels \>10 can be toxic and may require the administration of calcium.

Answer 64

Adult: 15-45 Pediatric: 40-80 Increased levels with Reye’s syndrome and hepatic encepholapathy. Evacuate the bowel of any blood (blood contains protein, which increases ammonia levels).

Answer 65

\<100 Measurable peptide used to diagnose CHF but can be nonspecific. Levels \>500 CHF diagnosis.

Answer 66

12-18 Low indicates anemia; high many causes

Answer 67

36-52% Low indicates anemia; high can indicate dehydration and other conditions.

Answer 68

150-400 Low platelets (thrombocytopenia), high platelets (thrombosis).

Answer 69

4.5-10.5 Are more elevated in the pediatric patient but is considered normal range.

Answer 70

60-400 * \>20,000 are ominous and are indicative of later DIC, * acute renal failure, * and potentially dangerous hyperkalemia in heatstroke.

Answer 71

**Presentation:** tachycardia, bradycardia, Beck’s triad (muffled heart tones, hypotension, jugular venous distension), pulsus paradoxus, and the presence of electrical alternans on the ECG. **MGMT:** in the prehospital setting - rapid transport, intravenous fluids (this measure improves filling pressures and temporarily improves cardiac output), until pericardial centesis can be preformed.

Answer 72

is the infrasternal angle or subcostal angle, into the apex of which the xiphoid process projects with the needle and syringe directed toward the left shoulder/scapula. ## Footnote A needle placed into the pericardial sac, with aspiration of as little as 15-20 mL of blood can improve the patient’s condition.

Answer 73

a collection of three medical signs associated with acute cardiac tamponade * low arterial blood pressure * JVD (unless the patient is hypovolemic) * distant, muffled heart sounds. Pulsus paradoxus, a fall in the systolic blood pressure \>15 mmHg during normal inspiration and a narrowing pulse pressure may also be observed prior to hypotension.

Answer 74

**First law** - Inertia - object in motion will stay in motion **Second law** - F=mA **Third law** - Equal and opposite reaction

Answer 75

a classical example of referred pain: irritation of the diaphragm is signaled by the phrenic nerve as pain in the area above the collarbone. This is due to the fact that the supraclavicular nerves have the same cervical nerves origin as the phrenic nerve, C3 and C4.

Answer 76

* It is essential to maintain higher rates of urinary output because hemoglobinuria and myoglobinuria are common with electrical injuries. * A minimum of 50-100 mL/hour of urine must be maintained. The fluid volume must be sufficient enough to maintain a minimum output of 100 mL/hr. * Lactic acidosis is common because of the significant muscle damage caused by electrical injury. * AC produces a tetanic contraction of muscles that “freezes” the victim to the source and has a greater potential in causing ventricular fibrillation. This is not seen with direct current.

Answer 77

MAP - ICP Normal: 70-90 * the net pressure gradient, causing blood flow to the brain. * must be maintained within narrow limits because too little could cause brain tissue to become ischemic, too much could raise ICP.

Answer 78

describes the pressure of blood in the thoracic vena cava, near the right atrium of the heart. * CVP reflects the amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system. * It is a good approximation of right atrial pressure, which is a major determinant of right ventricular end-diastolic volume. * CVP should always be considered in conjunction with other cardiovascular parameters. Under normal circumstances, the right-sided heart pressures should indirectly reflect left-sided pressures, and the left-sided filling pressure may be an indicator of left ventricular function.

Answer 79

**Preload** (end-diastolic volume) is the pressure stretching the ventricle of the heart at the beginning of systole after passive filling of the ventricle and subsequent atrial contraction. **Afterload** (end-systolic volume) is the ventricular pressure at the end of systole.

Answer 80

Preload of the right side of the heart ## Footnote

Answer 81

Preload of the left side of the heart

Answer 82

Afterload of the right side of the heart

Answer 83

Afterload of the left side of the heart

Answer 84

bruising of the flanks and can indicate retroperitoneal or intra-abdominal bleeding, which can take up to 24-48 hours to show up on assessment. * It can be caused by acute **pancreatitis**, blunt abdominal trauma, ruptured abdominal aortic aneurysm, or ruptured/hemorrhagic ectopic pregnancy. * It may be accompanied by Cullen’s sign (superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus), which may then be indicative of **pancreatic** necrosis, with retroperitoneal or intra-abdominal bleeding.

Answer 85

differentiating pain in the right upper quadrant. Typically, it is positive in cholecystitis (gallbladder disease), Appendicitis,

Answer 86

meningitis

Answer 87

(referred shoulder pain) can be indicative of a spleen injury or ectopic pregnancy.

Answer 88

Adults 30-50 mL/hr, Pediatric 1-2 mL/kg/hr/% BSA below 30 kg. An osmotic diuretic, such as mannitol can be administered to avoid acute renal failure when fluid administration has been ineffective.

Answer 89

* an extremely corrosive liquid and is a contact poison. * Once absorbed into blood through the skin, it reacts with blood calcium and may cause cardiac arrest. * In some cases, exposures can lead to hypocalcemia. Thus, hydrofluoric acid exposure is often treated with calcium gluconate, a source of Ca2+ that sequesters the fluoride ions.

Answer 90

is a deadly side effect of very high ICP that occurs when the brain shifts across structures within the skull. * frequently presents with abnormal posturing a characteristic positioning of the limbs indicative of severe brain damage. * Cushing’s triad is the triad of widening pulse pressure (rising systolic, declining diastolic), change in respiratory pattern (irregular respirations), and bradycardia. * Vomiting can also occur due to compression of the vomiting center in the medulla oblongata. * EtCO2 should be maintained between 35-45 mmHg. * Mannitol may be used to treat increasing ICP manifested by deterioration in the patient’s neurologic status.

Answer 91

an imbalance between parasympathetic and sympathetic nervous stimulation of vascular smooth muscle Presents with: * sustained vasodilatation * heart rate does not increase due to loss of sympathetic impulses/stimulation. * Vasomotor paralysis below the level of the injury occurs resulting in decreased peripheral vascular resistance. * Blood collects in the capillary beds, reducing venous return, cardiac output, and blood pressure.

Answer 92

Circumferential burns to the chest wall * decrease chest wall compliance, creating respiratory insufficiency and hypoxia, especially in the pediatric patient. * The treatment for this problem is an escharotomy, which allows the chest to expand fully for more efficient ventilation.

Answer 93

* can threaten the circulatory stability of the affected limb, * Monitor for the “five Ps” * pain, * pallor, * pulselessness, * paresthesias, * paralysis.

Answer 94

* Cardiac tamponade, * tension pneumothorax, * massive pulmonary embolism, * aortic stenosis In these situations, the flow of blood is obstructed, which impedes circulation and can result in circulatory arrest.

Answer 95

should be producing a pulse, but is not The most common cause of PEA is hypovolemia.

Answer 96

**P**ulmonary embolism **A**cidosis **T**ension pneumothorax **C**ardiac tamponade **H**ypovolemia **H**ypoxia **H**yper/hypokalemia, hypoglycemia **H**ypothermia **M**I **D**rugs - Overdose

Answer 97

Treat as if in asystole - it is not a shockable rhythm CPR & epinephrine (1:10,000) 1 mg every 3-5 minutes,

Answer 98

Cyanide makes the cells of an organism unable to use oxygen, primarily through the inhibition of **cytochrome oxidase**. ## Footnote

Answer 99

* ingestion of amygdalin (found in almonds and apricot kernels) * prolonged administration of nitroprusside * after exposure to gases produced by the combustion of synthetic materials. A fatal dose for a patient can be as low as 1.5 mg/kg body weight.

Answer 100

The United States standard cyanide antidote kit * first uses a small inhaled dose of amyl nitrite * followed by intravenous sodium nitrite * followed by intravenous sodium thiosulfate.

Answer 101

newly approved in the US at doses from 2.5 to 10 mg per injection and is available in Cyanokit antidote kits. * is a natural form of vitamin B12 * will bind circulating and cellular cyanide molecules to form cyanocobalamin, which is excreted in the urine.