TCRN Abdominal Trauma Exam 86 Questions with Verified Answers
Kehr's Sign - CORRECT ANSWER Referred shoulder tip pain
Lloyd's Sign - CORRECT ANSWER
... [Show More] Costovertebral angle tenderness, percussion on the back between 12th rib and the spine.
Quadrant system of the abdomen - CORRECT ANSWER Four regions and periumbilical area (around the naval)
A&P of the mouth - CORRECT ANSWER Consists of parotids, submandibulars and sublinguals. Has paired glands for salivating and digesting food.
A&P of the pharynx - CORRECT ANSWER Consists of throat to grasps food, and propels forward
A&P of esophagus - CORRECT ANSWER For muscular peristalsis and consists of a cricopharyngeal sphincer upper border.
A&P of the stomach - CORRECT ANSWER A reservoir for food and begins digestion. Consists of cardiac sphincter at entry of stomach and pyloric sphincter at exit to small intestine. Allows food to be broken down to semi-liquid chyme, and produces intrinsic factor for absorption of vitamin B12.
A&P of small intestine - CORRECT ANSWER For digestion and nutrient absorption. Consists of duodenum (superior segment), jejunum (middle, shortest segment), and ileum (most inferior, longest segment). Has villi (microvilli to increase absorption of molecules, water, and vitamins into blood), crpyts of lieberkuhn (glands in grooves of villi), Peyer's patches (lymphatic tissue in submucosa), Brunner's glands (secreting mucus), and other hormones secreted for controlling bile, pancreatic, and ntestinal juices.
A&P of large intestine - CORRECT ANSWER Consists of cecum (connects to ileocecal pouch), ascending colon on right (hepatic flexure), transverse colon (above small intestine, left colic flexure), descending colon (on left into pelvis), signmoid colon (through pelvis to become rectum), and rectum (terminates in anus). These are used to absorb excess water and electrolytes, store food residue, and eliminate waste in form of feces.
A&P of Liver - CORRECT ANSWER Located in the right upper quadrant. Consists of left, right, caudate, and quatrate lobes. Made up of functional unit lobule with hepatocytes (for metabolic, endocrine, and secretory functions), and Kupffer cells (reticuloendothelial macrophages that remove bacteria and toxins from intestinal capillaries). The liver metabolizes carbohydrates, fats, and proteins; synthesizes plasma proteins, and vitamin A; stores nutrients of iron, vitamins D, K, and B12; regulates blood glucose; and secretes bile.
A&P of gallbladder - CORRECT ANSWER This is a pear shaped organ under right lobe of liver. It stores and concentrates bile created by liver. This is a blue-green liquid of water cholesterol, bile salts and phospholipids that emulsifies/breaks down fats and promotes intestinal absorption of fatty acids, cholesterol, and other lipids. This organ releases the bile into the common bile duct for delivery to duodenum in response to contraction/relaxation of sphincter of Oddi.
A&P of pancreas - CORRECT ANSWER This is in the abdomen behind the stomach. It has exocrine functions and endocrine functions. Exocrine includes secreting 1000mL digestive enzymes daily that causes vagal stimulation and release of hormones secretin and cholecystokinin in a control rate and amount. Clustered lobes/lobules (acini) or enzyme-producing cells release into pancreatic duct that joins the bile duct from the gallbladder before entering the duodenum. Endocrine functions with blood glucose. Consists of Islets of Langerhans between aciner cells. Beta cells secrete insulin for carbohydrate metabolism and alpha cells secrete glucagon that stimulates glycogenolyisis.
A&P of digestion - CORRECT ANSWER Starts with the mouth, chewing and salivating (starch digestion). Swallowing consists of the hypopharyngeal sphincter that relaxes as food as it enters the esophagus, mucus lubricates bolus.Glossopharyngeal nerve activates peristalsis. Food enters through the cardiac sphincter, stomach wall stretches, hydrochloric acid and pepsin is stimulated, gastrin released from gastric glands, intrinsic factor, and proteolytic enzymes. Peristalsis and enzymes break down food, forming chyme that enter the pyloric sphincter into duodenum.
A&P of absorption - CORRECT ANSWER Alcohol is absorbed from stomach, small intestine completes digestion, small intestine absorption into bloodstream (consits of carbohydrates, fats, proteins, water, and electrolyte absorption). Large intestine absorption through lymph vessels has no hormones or digestive enzymes, absorbs all but 100mL of remaining water, absorbs sodium and chloride, and bacteria aid in synthesizing vitamin K and breaking down cellulose into usable carbohydrates.
A&P of elimination - CORRECT ANSWER Has normal bacteria such as E. coli, enterbacter aerogenes, clostridium perfringens, and lactobacillus bifidus. Alkaline mucus of colon lubricates intestnal walls and protects mucosa from acidic bacterial action. Bacterial action produces flatus, which helps propel food toward rectum. Contractions casue propulsive waves. Internal sphincter contains thick circular smooth muscle movement underautomic control. External sphincter contains skeletal muscle under voluntart control.
Physical examination of abdomen - CORRECT ANSWER Mouth (condition of teeth, dentures, tongue, lesions) and abdomen (inspect, auscultate, percuss, and then palpate).
Physical examination: inspect - CORRECT ANSWER Skin: Discoloration, rashes, purpura, petechia, surgical scars, scleara for jaundice, oral mucosa, nail beds, etc. Peristaltic waves may be seen with bowel obstruction.
Physical examination: auscultate - CORRECT ANSWER Start lower right quadrant and then clockwise. Turn off suction, and use diaphragm of stethoscope. Listen two minutes each; bell of stethoscope for vascular sounds. No vascular sounds is normal; if any heard, don't palpate. Normal bowel sounds are high-pitched, gurgling causes by air mixing with fluid during peristalsis, loudest before meals. Hypoactive is sounds heard infreqently, caused by ileus, bowel obstruction, peritonitis, and the use of opioids. Hyperactive is loud, high-pitched, tinkling sounds usually meaning diarrhea, constipation, and laxative use.
Physical examination: percussion - CORRECT ANSWER Tympany is a hallow sound, air over the stomach, or bowels. Dullness is over organs such as the liver, kidney, or feces filled bowel.
Physical examination: palpation - CORRECT ANSWER Light to determine size, shape, and tenderness. Deep is 1 1/2 inches deep and looking for any rebound tenderness upon release. Guarding for peritonitis or other inflmammatory process. Usually cannot palpate liver unless hepatomegaly (have patient take deep breath and hold, liver at 5th to 7th intercostal space. Rectal exam if indicated. .
Abdominal injuries - CORRECT ANSWER Ranked 3rd as a cause of death, 1/5th of all trauma patients require abdominal operative intervention. Most common injury are from blunt trauma injuring the liver and spleen the most. Liver most fatal, spleen most common.
Grey-Turn's sign - CORRECT ANSWER Bruising of the flanks, the part of the body between the last rib and the top of the hip. Sign of retroperitoneal hemorrhage.
Cullen's sign - CORRECT ANSWER Superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus. Associated with retroperitoneal or intra-abdominal bleeding.
Abdominal trauma assessment - CORRECT ANSWER Requires assesment pre-transport to determine blood loss since it is difficult to recognize but may cause life-threatening hemorrhage and serious organ damage. Inspect, palpate, FAST, CT, and baseline hematrocrit and hemoglobin levels and perfomr serial H&H checks if time allows.
FAST - CORRECT ANSWER Focused Assessment with Sonogram for Trauma
Signs and symptoms of abdominal trauma - CORRECT ANSWER Altered mental status; tachycardia and absence of palpable pulses; pale, moist, and mottled skin with poor peripheral perfusion; hypotension; abdominal pain; distended, round and firm abdomen (late sign of internal bleeding).
Hollow organs during trauma - CORRECT ANSWER These leak contents when injured (peritonitis). These include stomach, intestines, gallbladder, urinary bladder, ureters, uterus, and great vessels.
Solid organs during trauma - CORRECT ANSWER Bleed when injured. These include liver, spleen, pancreas, and kidneys.
Trauma to spleen - CORRECT ANSWER Most commonly injured abdominal organ, highly vascular; Kehr's sign.
Trauma to liver - CORRECT ANSWER This is the largest, most vascular organ; Kehr's sign.
Trauma to large and small intestines - CORRECT ANSWER Penetrating trauma most common; seatbelt injury from blunt trauma.
Trauma to stomach - CORRECT ANSWER Damage from trauma is rare
Trauma to doudenum - CORRECT ANSWER This is well-protected; may not produce symptoms of injury
Trauma to jejunum and ileum - CORRECT ANSWER Frequently injured by gunshot and stab wounds
Vascular injuries - CORRECT ANSWER Usually life-threatening, vessels may include the aorta, inferior vena cava, renal artery, mesenteric artery, and iliac artery. Transfer immediately to trauma center for surgery. These patients will most likely be in need of mass resuscitation during transportation.
Abdominal compartment syndrome - CORRECT ANSWER Tissue edema within the abdomen. Intra-abdominal pressures are >20 mmHg. Pain and decreased or absent urinary output. Organ ischemia and dysfunction. Common with volume resuscitation and vascular leak. Can be treated with abdominal decompression through lapartotomy, paracentesis, etc.
Retroperitoneal injuries - CORRECT ANSWER Usually femoral or abdominal vascular injuries. Femoral artery or viens, loss ofintravscular volume. Treated with IV fluids and treat any bradydysrhythmias.
Diaphragmatic rupture - CORRECT ANSWER This is caused by both blunt and penetrating trauma. C3-C5 keep the diaphragm alive (phrenic nerve). Positive Kehr's sign. This is often identified by auscultation of bowel sounds in the chest or dullness on percussion of the chest. Positive pressure ventilation.
How will a swallowed coin appear on the x-ray? - CORRECT ANSWER Coin in the esophagus lie in the frontal plane. Coins in the trachea lie in the sagittal plane because it is turned on end by vocal chords.
Foreign bodies in upper GI - CORRECT ANSWER Usually swallowed. Young children put objects into mouth. Food that does not pass through the esophagus because of underlying mechanical problems, toothpicks and dentures commonly seen, self-harm in psychiatric patients, and criminal activity.
Foreign body in oropharynx - CORRECT ANSWER Well-innervated so patient usually can describe location of object, especially after eating. Can cause abrasions, lacerations, and punctures resulting in abscesses, perforation, and soft-tissue infections. Variable degree of discomfort from minor to severe.Inability to swallow or handle secretions but airway compromise rarely seen.
Foreign bodies in the esophagus - CORRECT ANSWER The esophagus at the level of the hypopharynx is the most common site for the location of a foreign body, the ileocecal region is the most frequent site of perforation. Object easily sensed in upper third as narrow areas easily entrap object. Dysphagia (difficult swallowing) followed by odynophagia (painful
swallowing), choking and drooling. The patient usually cannot identify the exact location of the foreign body. Large esophageal foreign bodies can cause tracheal impingement with
resultant stridor or respiratory compromise. Adults usually present acutely, with a history of ingestion or vague discomfort in epigastrium. Results in abrasions, punctures, and perforations resulting in abscess, pneumomediastinum, mediastinitis, pneumothorax, pericarditis or vascular injury to aorta. Button batteries can cause rapid esophageal necrosis.
Foreign bodies in the stomach - CORRECT ANSWER If object reaches stomach, 90% chance it will pass into intestine if <2mc diameter. If >2cm diameter or >6cm long, likely will be trapped in pylorus or duodenum. May cause perforation and peritonitis.
Foreign bodies in rectum - CORRECT ANSWER Causes by body packing. Drug-filled condoms or baggies swallowed or inserted in rectum. Suspect in patient with drug-induced toxic effects with recent travel. Or caused by sexual stimulation.
Foreign body, esophageal assessment in children - CORRECT ANSWER May be asymptomatic, adult who witnessed child with object suspects child may have swallowed it. Gagging vomiting and neck or throat pain are common presentations.
Foreign body, stomach or colon assessment in children - CORRECT ANSWER History of swallowing an object which has passed through esophagus, vague symptoms such as fever, abdominal pain, or vomiting.
Diagnostic interventions for foreign bodies - CORRECT ANSWER Laboratory studies rarely required. CT scan yields highest accuracy. Radiographs useful only if onject is radiopaque. Barium or gastrografin swallow.
Removal techniques for foreign bodies - CORRECT ANSWER Foley catheter (insert past object, inflate and pull out), bougienage (dilation of esophagus).
Treatment options for foreign bodies - CORRECT ANSWER Emergency endoscopy if foreign object is sharp, nonradiopaque, elongated, multiple in number or there are suspected esophageal injuries. Admit for observation or discharge will close follow-up
Ostomy - CORRECT ANSWER A portion of the large or small intestine is brought to the skin surface and turned back on itself like a cuff. It creates an opening on abdomen called stoma, wastes pass out of body for collection, bypass diseased or removed portion of colon, stoma has no nerve endings to transmit pain, rich with blood vessels, "beefy red" normal color, colostomy or ileostomy, clean technique for bag changes, does no prevent sexual relations.
Causes for bowel obstruction - CORRECT ANSWER Tumors, foreign body, strictures, hernias, postoperative adhesions, paralytic ileus, and neurogenic condtions.
Assessment for vowel obstruction - CORRECT ANSWER Pain (colicky, crampy, intermittent, wavelike, poorly localized, rapid onset in small bowel, gradual onset in large bowel, may feel relief after vomiting). Change in bowel habits. History of abdominal surgery. Fever, tachycardia, moderate to severe distress, abdominal distention, vomiting (bilious, fecal material may be present), high-pitched perstaltic rush sounds, hyperactive bowel sounds, absent bowel sounds is late finding.
Diagnosis of bowel obstruction - CORRECT ANSWER CBC, serum chemistries, serum lipase and amylase, type and crossmatch, stool for occult blood, urinalysis, flat and upright abdominal radiographs, abdominal CT, and barium studies
Management of bowel obstructions - CORRECT ANSWER NPO, insert gastric tube to suction, cardiac and pulse oximetry monitoring, insert urinary catheter, IV access, antiemetrics, antibiotics, and analgesics.
Blunt abdominal trauma - CORRECT ANSWER Leading causes of morbidity and mortality among all age groups, identification of serious intra-abdominal pathology is challenging because injuries may not manifest during initial assessment and treatment period. Missed intra-abdominal injuries and concealed hemorrhage increased morbidity and mortality of patients who survive initial phase after injury.
Causes of blunt abdominal trauma - CORRECT ANSWER MVCs, assaults, recreational accidents, and falls.
Most common injured areas in blunt abdominal trauma are - CORRECT ANSWER Liver, pancreas, spleen, small and large bowel.
Abdominal penetrating trauma - CORRECT ANSWER Involves the violation of the abdominal cavity, usually by gunshot or stab wound.
Gunshot wounds in abdomin - CORRECT ANSWER High energy transfer, unpredictable pattern of injuries, secondary missiles, such as bullet and bone fragments, inflict additional damage.
Stab wounds in abdomin - CORRECT ANSWER More predictable pattern of organ injury and occult injuries may be overlooked.
Abdominal trauma in pediatric patients - CORRECT ANSWER Acidosis develops more rapidly, children can accommodate up to 25% blood loss by increasing heart rate and peripheral vascular resistance to maintain systolic blood pressure (BP is unreliable indictor of shock; children have greater fluid needs related to body surface area; fluid, electrolyte and acid-base balance precarious). Abdominal walls are thinner, weaker, less developed. Liver more easily damaged, kidneys are mobile and not protected by fat, intra-abdominal injury can result from air bag deployment, abdominal injuries may be result of child maltreatment.
Abdominal trauma in older (geriatric) patients - CORRECT ANSWER Any degree of hypoxemia is detrimental to elderly. Cardiovascular system less responsive, decreased ability to adjust to external temperature (maintain normothermia), peristalsis and gastric motility decrease with age, shock may be present despite normal vital signs, decreased ability to concentrate urine (urine output unreliable indicator of tissue perfusion).
Liver trauma - CORRECT ANSWER Blunt trauma is usual cause, injury damages functions (blood storage and filtration, bile secretion, conversion of glucose to glycogen, synthesis of serum proteins and clotting factors). Injury ranges from minor laceration to parenchymal tissue damage (blood flow at any time is approximately 30% of cardiac output, risk of rapid blood loss if injured). Suspect injury in any patient with lower chest, abdominal or right-sided trauma.
Assessment of liver trauma - CORRECT ANSWER History or mechanism of injury, past medical history (bleeding disorders, liver disease or enlarged liver), assess level of consciousness, for possible hypotension/tachycardia, level of distress, presence of abrasions, contusions, open wounds, and look for ecchymosis over right chest wall, RUQ abdomen. Observe for abdominal distention and abdominal tenderness with rebound tenderness, decreased or absent bowel and breath sounds, and right lower chest wall tenderness.
Diagnosis of liver trauma - CORRECT ANSWER CBC, type and crossmatch, coagulation profile, serum chemistries, liver enzymes, abdominal radiograph (flat plate), chest radiograph (right pneumothorax or fractured ribs), FAST scan (rapid evaulation of intraperitoneal hemmorrhage), abdominal CT, and angiography
Management of liver trauma - CORRECT ANSWER Initiate 2 large bore IVs (warmed normal saline infusions, warmed blood products as ordered), cardiac and pulse oximetry, insert gastric tube to suction, urinary catheter, maintain normothermic body temperature, analgesics, and antibiotics.
Pancreas trauma - CORRECT ANSWER Retroperitoneal location protects it from injury. Associated injury to liver, stomach, spleen, great vessels, and duodenum. Isolated injury from penetrating trauma to mid-back.
Symptoms to pancreas trauma - CORRECT ANSWER Onset may be delayed 24-72 hours post injury. Retroperitoneal symptoms may be absent, laboratory studies may stay within normal ranges, imaging studies lack precision, endoscopic retrograde cholangiopancreatography (ERCP) during surgicalexploration shows promise as more accurtate diagnostic tool, injury will disrupt function (digestion and nutrient absorption, production of enzymes, insulin, electrolytes, carbohydrate metabolism, and insulin and glucagon secretion). Post injury complications (pancreatitis, and diabetes).
Assessment of pancreatic trauma - CORRECT ANSWER May be asymptomatic until peritoneal irritation occurs. Symptoms may vary depending on the mechanism of injury, look for past medical history of bleeding disorders, hypotension and tachycardia, abrasions, contusions, open wounds, ecchymosis over epigastric area, abdominal tenderness.
Diagnosis of pancreas trauma - CORRECT ANSWER CBC, serum chemistries, serum amylase and lipase, type and crossmatch, imaging studies such as abdominal and chest radiographs, abdominal CT scan, MRI, ERCP.
Management of pancreas trauma - CORRECT ANSWER Initiate 2 large bore IVs, warmed normal saline, warmed blood products, cardiac and pulse oximentry monitoring, gastric tube to suction, urinary catheter, maintain normothermic body temperature, analgesis, and antibiotics.
Spleen - CORRECT ANSWER Protected under boney rib cage. Highly vascular organ, filters 10-15% of total blood volume every minute. It can pool significant amounts of blood, increasing risk of hemorrhage after injury, holds 25% of body's platelets, and its role is supporting immune systems directs efforts to preserve rather than remove injured spleen.
Spleen trauma - CORRECT ANSWER Caused by blunt trauma, motor vehicle collision, bicycling, direct blow to abdomen, colonoscopy,.
Assessment of spleen trauma - CORRECT ANSWER Assess type and location of pain, left upper quadrant, referred to left shoulder (Kehr's sign), assess the mechanism of injury and past medical history (history of bleeding tendencies, level of consciousness, hypotension, and tachycardia, ecchymosis over left lower chest wall/LUQ abdomen, decreased or absent bowel and breath sounds, lower left chest wall tenderness, abdominal tenderness with rebound, and rigid abdomen.
Diagnosis spleen trauma - CORRECT ANSWER CBC, type and crossmatch, chest radiograph (pneumothorax or fractured left 10th-12th ribs), abdominal radiograph (flat plate), FAST, abdominal CT, and angiography.
Management of spleen trauma - CORRECT ANSWER Initiate 2 large bore IVs, warmed normal saline and warmed blood products as needed. Cardiac and pulse oximetry monitoring, gastric tube to suction, urinary catheter, maintain normothermic body temperature.
Treatment of spleen trauma (surgical) - CORRECT ANSWER Hemodynamically unstable patients to fluid chanllenge and no other signs of external hemorrhage should be considered to have a life threatening injury. Patients who respond to initial fluid bolus then deteriorate with hypotension and tachycardia are likely to have ongoing hemorrhage. These patients should undergo exploratory laparotomy and splenic repair or removal. Do not delay surgery for imaging studies.
Treatment of spleen trauma (medical) - CORRECT ANSWER CT scanning provides the most ideal noninvasive means for evaluating the spleen in a stable patient (SBP >90 and heart rate is <120). Stable hemoglobin levels, minimal transfusion requirements (<2 units), angioembolization has been reported as a safe method of splenic salvage when immediately available in the treating facility (consider when CT scan images show arterial contrast blush or active extravasation).
Small bowel trauma - CORRECT ANSWER Causes by crushed between applied force and spinal column, shearing from rapid deceleration, penetrating trauma (gunshot, knife). may have non-specific symptoms until peritonitis develops.
Large bowel trauma - CORRECT ANSWER Transverse and sigmoid colon more mobile within peritoneum (gross fecal contamination leads to sepsis).
Assessment of bowel trauma - CORRECT ANSWER Pain (generalized with nausea and vomiting), hypotension and tachycardia, moderate to severe distress, ecchymosis over abdomen (seat belt sign) and abdominal distension. Decreased or absent bowel and breath sounds, abdominal tenderness with rebound, and rigid abdomen in epigastric/LUQ.
Diagnosis of bowel trauma - CORRECT ANSWER CBC, serum chemistries, serum amylase, urinalysis, type and crossmatch, abdominal radiograph (flat plate) (free air or fluid, pneumoperitoneum does not always correlate to bowel injury), FAST (free intraperitoneal fluid), abdominal CT (preferred imaging study, accuracy in detecting injury >95%), and angiography (only if looking for visceral bleeding site).
Pelvic trauma - CORRECT ANSWER Pelvic fractures are the 3rd leading cause from MVCs (46%). Results from significant force (may involve additional injuries to the ureters and bladder). Can lead to catastrophic hemorrhage. Includes open-book fracture (pelvis separated at symphysis pubis).
Types of pelvis injuries - CORRECT ANSWER Pelvic ring fractures, acetabular fracture, and avulsion injuries
Pelvic trauma complications - CORRECT ANSWER High energy trauma increases the likelihood of concomitant injuries, involving the abdominal and pelvic viscera. The majority of pelvis injuries are due to high energy blunt trauma, frail and elderly patients may sustain such injuries from a low energy mechanism such as a fall.
Management of pelvic trauam - CORRECT ANSWER Although the type of pelvic fracture may be unknown at the time of transport, prepare and anticipate a life-threatening type of injury. Close the potential space or apply a pelvic binder by using a commercial device or bed sheet. [Show Less]