ERDX Exam 399 Questions with Verified Answers
What is a collection of excess fluid between the visceral pericardium and the parietal pericardium? -
... [Show More] CORRECT ANSWER Pericardial Tamponade
What are the classic signs and symptoms of a pericardial tamponade? - CORRECT ANSWER Beck's Triad
What are the 3 findings in Beck's Triad? - CORRECT ANSWER Muffled heart tones
Systemic Hypotension
Distended Neck Veins (may not be present with hypovolemia)
What are the cardiovascular effects of Pericardial Tamponade? - CORRECT ANSWER Elevated CVP
Narrowed Pulse Pressure
Rapidly falling cardiac output
Tachycardia
Pulsus alternans
Blunting of the QRS complex
Pulseless Electrical Activity
Pulsus paradoxus or paradoxical pulse
What is Pulsus Alternans? - CORRECT ANSWER Alternating morphology of the QRS complex
What is pulsus paradoxus or paradoxical pulse? - CORRECT ANSWER A change of more than 10 mmHg in arterial pressure during inspiration
How is pulsus paradoxus or paradoxical pulse found? - CORRECT ANSWER Usually seen as a decreased amplitude on the arterial waveform, but may also be palpated as a reduction in the strength of the radial pulse during inspiration.
What are the non-cardiac indications of a pericardial tamponade? - CORRECT ANSWER Grey, death-like appearance
Extreme anxiety
Inability to lie supine
Dyspnea
Cyanosis
How is pericardial tamponade diagnosed? - CORRECT ANSWER Clinically or via FAST exam
What is the treatment for pericardial tamponade? - CORRECT ANSWER Pericardiocentesis
Observe monitor for ventricular irritation during insertion
How do you determine if blood aspirated from a pericardiocentesis is pericardial blood or ventricular blood? - CORRECT ANSWER Pericardial blood WILL NOT clot
Ventricular blood WILL clot
In blunt cardiac injury, what part of the heart is most likely to be injured? - CORRECT ANSWER Right ventricle (anterior chest)
Blunt cardiac injury is frequently associated with _____ and _____. - CORRECT ANSWER External chest wall trauma
Fractures of the sternum or ribs overlying the heart
What are the symptoms of blunt cardiac injury? - CORRECT ANSWER Electrical disturbances
Chest Pain
Heart Failure
Describe electrical disturbances associated with blunt cardiac injury. - CORRECT ANSWER PVC's
A-Fib
Atrioventricular blocks
S-T segment changes
What is the treatment for electrical disturbances associated with blunt cardiac injury? - CORRECT ANSWER Continuous ECG monitoring
Antiarrhythmics for clinically significant arrhythmias
Describe chest pain associated with blunt cardiac injury and its treatment. - CORRECT ANSWER Does not radiate or respond to standard treatment for chest pain.
Treatments: analgesia and treat as per MI
Describe heart failure associated with blunt cardiac injury. - CORRECT ANSWER Right sided heart failure (JVD, Hypotension, Tachycardia)
What is the treatment for heart failure associated with blunt cardiac injury? - CORRECT ANSWER IV fluids per hemodynamic parameters
Inotropic drugs
List the Great Vessels - CORRECT ANSWER Aorta
3 branches of the aorta: brachiocephalic, left common carotid, left subclavian
Pulmonary artery and veins
Superior Vena Cava
What percentage of aortic injuries die on scene? - CORRECT ANSWER 80%
Of the patients with aortic injuries that make it to the hospital, how many will die within 6 hours? - CORRECT ANSWER 30%
Of the patients with aortic injuries that make it to the hospital, how many will die with 24 hours? - CORRECT ANSWER 40%
What is the mortality rate in patients with pulmonary vascular trauma? - CORRECT ANSWER 60%
Of patients with great vessel injuries, what percentage are asymptomatic? - CORRECT ANSWER 30-50%
What are the subjective symptoms of great vessel injuries? - CORRECT ANSWER Chest pain (ripping or tearing)
Radiates through to the back
Difficulty breathing
Vagal complaints
Dysphagia
What are the objective symptoms of great vessel injuries? - CORRECT ANSWER Signs of hemorrhagic shock
Dyspnea
Asymmetric pulse pressure (stronger upper extremity pulses as opposed to femoral pulses)
Vascular bruits over precordium or intrascapular region
Focal neurological findings
Hoarseness
What injury does asymmetric pulse pressure indicate? - CORRECT ANSWER Vascular injury to the descending aorta
What are the treatments for great vessel injuries? - CORRECT ANSWER Keep the patient calm and quiet
Type and cross 10 units of blood (assure blood is readily available)
Beta-blockade with a goal of: SBP: 80-100 and HR 60-80
Operative management
Describe fractures of upper ribs (1st and 2nd). - CORRECT ANSWER Protected by surrounding tissue and requires great force to fracture.
Fractures of 1st and 2nd ribs are usually associated with what other injuries? - CORRECT ANSWER Lungs, trachea, aortic arch, great vessels, vertebral column
Describe fractures of ribs 3 through 9. - CORRECT ANSWER Challenges include pain management, ineffective ventilation and secretion retention.
What injures are frequently associated with fractures of ribs 3 through 9? - CORRECT ANSWER Pulmonary contusions
Pneumothorax
What injuries are commonly associated with sternum fractures? - CORRECT ANSWER Blunt cardiac injury and great vessel injury
What injuries are commonly associated with left sided ribs 9-12 fractures? - CORRECT ANSWER Pulmonary injury, splenic injury, left kidney injury
What injuries are commonly associated with right sided ribs 9-12 fractures? - CORRECT ANSWER Pulmonary injury, liver injury, right kidney injury
Define a flail chest segment - CORRECT ANSWER Three or more rib fractures in two or more locations causing a free floating segment of the rib cage
Define paradoxical chest wall movement. - CORRECT ANSWER Sinking of the flail segment during inspiration when the remainder of the chest bulges; bulging of the flail segment during exhalation when the remainder of the chest sinks.
List some common symptoms of flail chest. - CORRECT ANSWER Paradoxical chest wall movement
Decreased tidal volume
Increased respiratory effort
Verying degrees of hypoxia
What types of pain management are used in flail chest? - CORRECT ANSWER IV analgesia
Epidural anesthesia (for 3 or more rib fractures)
Intercostal nerve block
Intrapleural anesthesia
TENS
List the treatments for flail chest. - CORRECT ANSWER Pain management
Judicious use of crystalloids (goal of euvolemia)
Appropriate ventilator support (adjusted to insure normal blood gases, pulse ox and respiratory effort)
Aggressive chest physiotherapy (postural drainage, percussion, vibration)
Suctioning
Early mobilization
Position to insure optimal ventilation, oxygenation and chest wall stability
What should be considered with rib fractures in children? - CORRECT ANSWER Rib fractures in children are often associated with abuse
What should be considered with rib fractures in the older population? - CORRECT ANSWER Rib fractures occur frequently in the elderly and often lead to respiratory complications, therefore, admission with aggressive pain control may be necessary.
After trauma, symptoms of pulmonary contusions evolve when? - CORRECT ANSWER 6-48 hours after the trauma
List the symptoms of pulmonary contusions - CORRECT ANSWER Reduction of PaO2 (below 60 mmHg on room air)
Signs of respiratory distress (increased HR and RR)
Pleuritic chest pain
Crackles on auscultation
Severe hypoxemia and respiratory acidosis
Cough/inability to clear secretions
Local areas of wheezing
Increasing plateau pressures
What are the treatment goals of pulmonary contusions? - CORRECT ANSWER Pain relief
Maintain euvolemia
Adequate respiratory gas exchange (application of oxygen and non-invasive or invasive ventilation if needed)
What are the long term treatments for pulmonary contusions? - CORRECT ANSWER Mobilize and clear blood and secretions (chest physiotherapy, postural drainage, mobilization)
What is the term for excess air in the pleural space? - CORRECT ANSWER Pneumotherax
What are the sources of pneumothorax and their frequency? - CORRECT ANSWER Pulmonary laceration (71%)
Tracheobronchial Injury (13%)
Esophagus (7%)
External wound or open pneumothorax (7%)
What are the symptoms of an open pneumothorax? - CORRECT ANSWER Sucking sound on inhalation
Bubbling on exhalation
May cause subcutaneous emphysema
Emergent treatment is a three-sided occlusive dressing
What are the symptoms of a tension pneumothorax? - CORRECT ANSWER Severe respiratory distress
Significantly diminished or absent breath sounds on the affected side
Signs of obstructive shock
What are the signs of obstructive shock associated with a tension pneumothorax? - CORRECT ANSWER anxiety or severe restlessness
hypotension
distended neck, head or upper extremity veins (absent if the patient has hypovolemia)
tracheal deviation toward uninjured side
cyanosis
What is the treatment for tension pneumothorax? - CORRECT ANSWER Needle decompression
Describe the process of needle decompression. - CORRECT ANSWER 2nd intercostal space at midclavicular line
Use a large bore needle darted directly above the third rib on the opposite side of tracheal deviation
What is the term for a collection of blood in the pleural space? - CORRECT ANSWER Hemothorax
What is the term for more than 1500 mL of blood, or more than 200 mL/hr of blood over 2-4 hours in the collection chamber? - CORRECT ANSWER Massive Hemothorax
What are some key considerations with a massive hemothorax? - CORRECT ANSWER May cause hypovolemic and obstructive shock
Consider autotransfusion
List the advantages of autotransfusion. - CORRECT ANSWER Immediately available
No incompatibility concerns
Elimination of complications related to storage (hyperkalemia, hypocalcemia, metabolic acidosis)
Blood is at body temperature
May be more acceptable to patients with religious objections to blood transfusion
List the disadvantages of autotransfusion. - CORRECT ANSWER Limited to non-contaminated wounds
Requires special equipment and some operator training
Cannot be used with wounds <4-6 hours old
What are the differences in pain between a pneumothorax and a hemothorax? - CORRECT ANSWER Hemothorax - dull ache on side of fluid
Pneumothorax - sharp pain which may radiate to the shoulder on the side of the pneumothorax
Describe the differences in fremitus of a hemothorax and pneumothorax - CORRECT ANSWER Hemothorax - fremitus is absent over fluid
Pneumothorax - fremitus is decreased over air
Describe the differences in breath sounds between a hemothorax and pneumothroax. - CORRECT ANSWER Breath sounds are decreased over both.
Describe the differences in percussion of a hemothorax and percussion of a pneumothorax. - CORRECT ANSWER Hemothorax - hypo-resonance
Pneumothorax - hyper-resonance
How are treatments of hemothorax and pneumothroax determined? - CORRECT ANSWER Based on size, symptoms and patient stability
What is the treatment for an asymptomatic and stable pneumothorax? - CORRECT ANSWER Supplemental oxygen (promotes reabsorption of pleural air)
Observe for deterioration
What is the treatment for an asymptomatic and stable hemothorax? - CORRECT ANSWER IV
Encourage deep breathing
Observe for deterioration
What are the treatments for a patient with indications of instability in a pneumothorax? - CORRECT ANSWER Support oxygenation / ventilation (oxygen administration)
Chest Tube placement
Consider Thoracotomy
What are the treatments for a patient with indications of instability in a hemothorax? - CORRECT ANSWER Support oxygenation/ventilation
Chest Tube Placement
Consider Thoracotomy
Treat hypovolemic shock
Blood loss replacement / autotransfusion
List the factors of care for the chest drainage set. - CORRECT ANSWER Maintain the drainage set below the level of the chest.
Keep the unit upright
Prevent dependent loops
Describe bubbling in a patent system. - CORRECT ANSWER Bubbling should be noted in the suction control chamber with intermittent bubbling in the water seal chamber. There should be no bubbling in the collection chamber.
If the fluctuation or bubbling in the water seal chamber suddenly ceases, what are the likely causes? - CORRECT ANSWER Tubing is kinked
Obstruction (clot in the tubing)
Pneumothorax has re-expanded
What is the pneumonic FOCA and what is it used for? - CORRECT ANSWER FOCA is used for problem solving for chest tubes.
F - presnece of fluctuation
O - Output
C - Color
A - Presence of Air Leak
Chest Tube drainage of more than 1000 mL initially or 200 mL/hour over 2-4 hours will likely need _____. - CORRECT ANSWER Thoracotomy
Sudden increase in bright red blood may indicate _____. - CORRECT ANSWER New arterial bleeding
Continuous bubbling noted in water seal chamber is indicative of _____. - CORRECT ANSWER Presence of air leak
What are the possible causes of a chest tube air leak? - CORRECT ANSWER Expected in an unexpanded lung
Check for air leak at insertion site
Check for hole in tubing
Change out the chest drainage set
Consider large internal leak
What is ARDS? - CORRECT ANSWER Acute Respiratory Distress Syndrome: non-cardiogenic pulmonary edema
What are the symptoms of ARDS? - CORRECT ANSWER Hypoxemia
Non-cardiogenic pulmonary edema
Pulmonary hypertension
Intrapulmonary shunting
ARDS mneumonic symptoms: - CORRECT ANSWER A - Acute in onset
R - Ratio of PaO2 to FiO2 (P/F ratio) less than 20 regardless of PEEP
D - Diffuse bilateral pulmonary infiltrates on CXR
S - Swan-Ganz pulmonary artery wedge pressure less than 18 mmHg or no clinical evidence of left atrial hypertension
Describe ARDS related to the PF ratio. (PaO2 to FiO2). - CORRECT ANSWER Healthy adult: >400
Mild ARDS: 200-300
Moderate ARDS: 100-200
Severe ARDS: < 100
List the risk factors for ARDS: - CORRECT ANSWER Occurs more frequently in patients with any type of shock
Multi-system trauma with extensive tissue destruction
Pulmonary contusion
Multiple orthopedic injuries (especially pelvic or long bone fractures)
Massive transfusions
Thoracic trauma
Bacterial Pneumonia
Sepsis
Near-Drowning
Gastric aspiration
Major head injuries
What are some physiological symptoms of impending insufficiency in ARDS? - CORRECT ANSWER Physical assessment normal initially
Dyspnea (although relatively normal PaO2)
Decreased PaCO2 and respiratory alkalosis
CXR may be normal
In ARDS, impending insufficiency usually leads to clinical insufficiency which includes symptoms like_____. - CORRECT ANSWER Usually starts within 24 hours
Markedly decreased oxygenation
Significant dyspnea
Hyperdynamic state with elevated Cl
Patchy infiltrates on CXR
Physiological deadspace increases
High levels of PEEP required for oxygenation
What are the late symptoms of ARDS? - CORRECT ANSWER Frequently irreversible with fibrosis, atelectasis and recurrent pneumonia
Hypoxemia is refractory to increased oxygenation
Decreased lung compliance
Patient often dies within two weeks with multi-organ dysfunction syndrome
Many ARDS survivors have _____. - CORRECT ANSWER Lasting lung damage
In treatment of ARDS, vent settings: Tidal volume should be_____. - CORRECT ANSWER 6-10 mL/kg
Permissive hypercapnia PaCO2 65-85 tolerated unless there is increased ICP
In treatment of ARDS, vent settings for end-expiratory plateau pressure should be _____. - CORRECT ANSWER <30 cm H2O
Barotrauma and air leaks above this limit
In the treatment of ARDS, vent settings for PEEP (positive end-expiratory pressure) should be _____. - CORRECT ANSWER 10-15 cm H2O
Consider early prone positioning
In treatment of ARDS, vent settings for RR should be _____. - CORRECT ANSWER 18-24 breaths per minute
Higher than normal limits, hypercapnia
In treatment of ARDS, vent settings inspiratory:expiratory ratio should be _____ - CORRECT ANSWER 1:2 to 1:1
Check for inadvertent PEEP
In treatment of ARDS, vent settings FiO2 should be _____. - CORRECT ANSWER <60-80%
Goal PaO2 40-60
Goal SpO2 85-95%
Lowest possible to reduce O2 toxicity
What are the vent settings on high frequency oscillatory ventilation in treatment of ARDS? - CORRECT ANSWER Amplitude pressure (30-50 cmH2O)
Mean airway pressure (15-30 cmH2O)
Respiratory rate (3-10)
FiO2 (<60-80%)
What are the symptoms of a ruptured diaphragm? - CORRECT ANSWER Heart sounds shifted to the right side of the chest
Signs of obstructive shock
Dysphagia
Dyspnea
Decreased breath sounds on the affected side
Bowel sounds in the middle to lower chest
Lower chest, abdominal or epigastric pain that radiates to left shoulder
In 66% of abdominal trauma, the _____ is the only damaged intraperitoneal structure. - CORRECT ANSWER Spleen
Organs most likely affected in penetrating abdominal trauma are: - CORRECT ANSWER 1. Small Intestine
2. Colon
3. Liver
Organs most likely affected in blunt abdominal trauma are: - CORRECT ANSWER 1. Spleen
2. Liver
3. Small Bowel
_____ are more likely but less lethal than gunshot wounds. - CORRECT ANSWER Stab wounds
Which abdominal quadrant is most likely to be affected in stab wounds? - CORRECT ANSWER Left Upper Quadrant [Show Less]