Trauma and Burns

A 25-year-old man is brought to the trauma bay via ambulance after being ejected from a vehicle during a high-speed collision. On arrival, he is comatose with gurgling respirations. Vital signs are temperature 36.1°C (97.0°F), blood pressure 65/35 mm Hg, pulse 145/min, and respirations 8/min. Physical examination reveals a trachea deviated to the left, absent breath sounds on the right hemithorax, and dramatically distended neck veins. Anteroposterior compression of the pelvis reveals mechanical instability. Arrange the following critical interventions in the exact sequential order they should be performed according to Advanced Trauma Life Support (ATLS) priority protocols.

A 52-year-old man is brought to the emergency department after falling 20 feet from a roof. On arrival, he is confused and diaphoretic. His blood pressure is 82/50 mmHg and his pulse is 130/min. His airway is patent, and breath sounds are clear and equal bilaterally. A rigid cervical collar is in place. Physical examination reveals significant ecchymosis and guarding over the left upper quadrant of the abdomen. The pelvis is mechanically stable to anteroposterior and lateral compression. Intravenous fluid resuscitation with warmed crystalloid is initiated. A bedside focused assessment with sonography for trauma (FAST) demonstrates a large amount of anechoic fluid in the splenorenal recess. Which of the following is the most appropriate next step in management?

Emergency medical services arrive at the hospital with a 42-year-old man who was rescued from a structural fire in an enclosed basement. The patient sustained full-thickness burns over his entire anterior torso, both upper extremities, and the anterior aspect of both thighs, yielding an estimated 45% total body surface area involvement. Although awake and agitated, he exhibits a noticeably hoarse voice, and inspection of the oropharynx reveals carbonaceous sputum and soot. Vital signs include a blood pressure of 110/70 mm Hg, heart rate of 118/min, and respiratory rate of 26/min. His oxygen saturation reads 94% while receiving high-flow oxygen. Arrange the following acute management interventions in the most appropriate chronological sequence.

A 34-year-old female is brought to the emergency department via helicopter after being rescued from a residential house fire. The burn injury occurred at 14:00, and she arrives at the trauma bay at 17:00. Her weight is $90 \text{ kg}$. Physical examination reveals deep partial-thickness and full-thickness burns involving her entire anterior trunk (chest and abdomen), her entire right arm (circumferential), and the anterior surface of her left leg. The remainder of her skin is uninjured. En route to the hospital, paramedics successfully intubated her for airway protection and administered $740 \text{ mL}$ of lactated Ringer solution intravenously. According to current Advanced Trauma Life Support (ATLS) guidelines ($2 \text{ mL/kg/\%TBSA}$ for adult thermal burns), what should be the intravenous fluid infusion rate in $\text{mL/hr}$ for the remainder of the first 8-hour post-injury period?

Paramedics transport a 32-year-old man to the trauma resuscitation bay following an altercation outside a restaurant. The patient sustained a single stab wound to the left lower abdominal quadrant. He is awake, alert, and conversant. Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), heart rate of $92/\text{min}$, respiratory rate of $16/\text{min}$, and blood pressure of $128/82 \text{ mm Hg}$. Physical examination reveals a $3\text{-cm}$ laceration in the left lower quadrant with a segment of omentum actively protruding through the defect. The remainder of the abdomen is soft and non-tender. Two large-bore intravenous lines are established. Which of the following is the most appropriate next step in the management of this patient?

A $27$-year-old male construction worker is brought to the trauma bay after falling approximately $20\text{ feet}$ from scaffolding. On arrival, he is confused and profusely diaphoretic. His temperature is $36.2^\circ\text{C}$, heart rate is $128\text{ /min}$, blood pressure is $82/50\text{ mm Hg}$, and respiratory rate is $26\text{ /min}$. A rigid cervical collar is in place. The airway is patent, and breath sounds are vesicular and equal bilaterally. The trachea is midline. Heart sounds are rapid but regular without murmurs. The abdomen is flat, soft, and non-distended. Anteroposterior compression of the anterior superior iliac spines reveals abnormal mobility and elicits crepitus. A focused assessment with sonography for trauma (FAST) exam demonstrates no intraperitoneal free fluid and no pericardial effusion. Two large-bore intravenous lines are established, and $1\text{ L}$ of warmed crystalloid is rapidly infusing. Which of the following is the most appropriate next step in management?

A 19-year-old male collegiate rugby player is evaluated in the emergency department immediately after a severe on-field collision. During the match, he was struck forcefully in the left flank by an opponent's shoulder. En route to the hospital, he received 1 L of intravenous lactated Ringer solution. Upon arrival, he appears pale, diaphoretic, and lethargic. His temperature is 36.5°C (97.7°F), blood pressure is 78/40 mm Hg, and pulse is 138/min. Oxygen saturation is 99% on room air. The trachea is midline, and breath sounds are clear and symmetric bilaterally. Heart sounds are rapid but normal in intensity, with no jugular venous distention. The abdomen is distended, rigid, and diffusely tender, with significant guarding in the left upper quadrant. The patient also reports worsening pain in his left shoulder while lying supine. A focused assessment with sonography for trauma (FAST) examination reveals an anechoic stripe in the splenorenal recess. What is the most appropriate next step in the management of this patient?

Match the following clinical presentations of acute trauma to the most appropriate initial diagnostic or therapeutic intervention according to standard trauma protocols.

A 28-year-old female is brought to the emergency department by emergency medical services after a high-speed motorcycle collision. She was found approximately 30 feet from her vehicle. On arrival, her temperature is 36.5°C (97.7°F), blood pressure is 76/40 mm Hg, pulse is 138/min, and respirations are 28/min. The patient is lethargic and pale. The airway is intact, and breath sounds are present and equal bilaterally. A rigid cervical collar is in place. Abdominal examination reveals diffuse tenderness and guarding. The patient receives 1 L of warmed intravenous crystalloid solution and 1 unit of uncrossmatched packed red blood cells, but her blood pressure only improves to 82/45 mm Hg. A portable chest radiograph shows a widened mediastinum but no evidence of pneumothorax or hemothorax. A focused assessment with sonography for trauma (FAST) examination reveals a large anechoic fluid collection in the hepatorenal recess (Morison's pouch). An anteroposterior pelvic radiograph shows no fractures. Which of the following is the most appropriate next step in management?

Following the primary survey and initial resuscitation in the trauma bay, the next steps in management diverge significantly based on the patient's hemodynamic status, mechanism of injury, and bedside diagnostic findings. Match each clinical presentation below with the most appropriate immediate diagnostic or therapeutic next step.

A 28-year-old carpenter is brought to the emergency department after accidentally severing his right index finger with a table saw. The amputated digit was recovered at the scene and brought to the hospital by coworkers in a dry tissue paper. The patient is hemodynamically stable, and a trauma primary survey reveals no other injuries. The emergency department team is preparing the amputated digit for transport with the patient to a specialized microsurgery center. Arrange the following steps for the proper preservation and transport of the amputated digit in the correct chronological sequence.

A 34-year-old man is brought to the emergency department 30 minutes after being involved in a high-speed motor vehicle collision. He was the unrestrained driver of a vehicle that struck a concrete barrier. On arrival, he is groaning and withdrawing from painful stimuli.

Vital signs are temperature 36.5°C (97.7°F), blood pressure 78/45 mmHg, pulse 135/min, and respirations 22/min.

Primary survey reveals a patent airway and a midline trachea. Breath sounds are clear and equal bilaterally. Jugular venous distention is absent.

The abdomen is distended, with significant guarding and rebound tenderness. The pelvis is stable to anterior-posterior and lateral compression.

Two large-bore intravenous lines are placed, and warmed isotonic crystalloid fluid resuscitation is initiated. A bedside ultrasound examination demonstrates an anechoic stripe between the liver and right kidney.

Which of the following is the most appropriate next step in the management of this patient?

An emergency medical services team transports a 42-year-old male construction worker to the trauma center after he fell approximately $6\text{ meters}$ ($20\text{ feet}$) from a scaffold. On arrival, the patient is confused and complains of severe left-sided abdominal pain and chest wall tenderness. His airway is patent. Initial vital signs demonstrate a temperature of $36.2^\circ\text{C}$ ($97.2^\circ\text{F}$), heart rate of $135/\text{min}$, respiratory rate of $26/\text{min}$, and blood pressure of $78/50\text{ mmHg}$. Symmetrical breath sounds are auscultated bilaterally. He receives a rapid intravenous infusion of $1\text{ L}$ of warmed crystalloid solution and $1\text{ unit}$ of uncrossmatched type O-negative packed red blood cells. Fifteen minutes later, his blood pressure improves to $112/68\text{ mmHg}$ and heart rate decreases to $98/\text{min}$. However, during the secondary survey, he becomes progressively more lethargic. Repeat vital signs show a heart rate of $138/\text{min}$ and a blood pressure of $82/45\text{ mmHg}$. An extended focused assessment with sonography for trauma (E-FAST) reveals a large anechoic collection in the splenorenal recess and no evidence of pneumothorax. Pelvic radiography shows no fractures. Arterial blood gas analysis on room air reveals a pH of $7.21$, $p\text{CO}_2$ of $34\text{ mmHg}$, and calculated bicarbonate of $14\text{ mEq/L}$. Which of the following is the most appropriate next step in the management of this patient?

A 45-year-old industrial worker is rapidly brought to the emergency department after being trapped in a structural fire. On arrival, he has obvious soot in his oropharynx, marked hoarseness, and inspiratory stridor. Physical examination reveals deep, leathery, charred skin completely encircling his anterior and posterior thorax. His respiratory rate is 34/min, and he is demonstrating poor breathing efforts with minimal chest wall expansion. Oxygen saturation is 86% on a high-flow oxygen mask. Blood pressure is 98/60 mm Hg, and pulse is 128/min. Arrange the following interventions in the most appropriate chronological sequence based on prioritized trauma and burn life support principles.

A 35-year-old electrical lineman is brought to the emergency department after sustaining a high-voltage electrical injury from a power transformer. The accident occurred exactly 2 hours prior to his arrival due to extrication difficulties. He is awake but confused. His blood pressure is 140/85 mm Hg and his heart rate is 112/min. A Foley catheter is placed and immediately drains dark, tea-colored urine. He weighs 90 kg. Physical examination reveals deep entry and exit wounds on his upper extremities, as well as associated full-thickness thermal burns covering exactly 20% of his total body surface area (TBSA).

According to the current Advanced Trauma Life Support (ATLS) guidelines for electrical burns, what should be the initial intravenous fluid infusion rate (in mL/hr) of lactated Ringer solution upon his arrival?

A 10-year-old boy is brought to the emergency department via ambulance after falling forcefully onto the handlebars of his bicycle. He is pale and intermittently responsive. Heart rate is $155\text{ /min}$, and blood pressure is $72/40\text{ mm Hg}$. Capillary refill time is $4\text{ seconds}$. Intravenous access is rapidly obtained, and an initial bolus of $20\text{ mL/kg}$ of warm isotonic crystalloid is administered, but his vital signs do not improve. Primary survey reveals equal breath sounds bilaterally and no external bleeding. His abdomen is tightly distended with diffuse tenderness. Bedside focused assessment with sonography for trauma (FAST) demonstrates significant free fluid in the splenorenal and hepatorenal recesses.

Which of the following is the most appropriate next step in the management of this patient?

A 52-year-old woman is evaluated in the emergency department after a severe motor vehicle collision. She was the restrained driver of a vehicle that struck a concrete retaining wall at highway speeds. Upon arrival, she is lethargic but her airway is patent. She appears pale and diaphoretic. Vital signs are a temperature of 36.6°C (97.9°F), a pulse of 135/min, a blood pressure of 78/48 mmHg, and a respiratory rate of 28/min. Oxygen saturation is 96% on supplemental oxygen.

Breath sounds are clear and equal bilaterally, and the trachea is midline. Heart sounds are normal. The abdomen is soft, nondistended, and mildly tender to deep palpation in the lower quadrants. There is marked ecchymosis over the suprapubic region. Anteroposterior pelvic radiography performed in the trauma bay demonstrates a symphyseal diastasis of $4 \text{ cm}$ and a displaced fracture of the left sacroiliac joint. A pelvic binder is immediately applied, and she receives rapid intravenous transfusion of uncrossmatched blood products and crystalloid.

Following initial resuscitation, her blood pressure is 82/50 mmHg and pulse is 128/min. A bedside focused assessment with sonography for trauma (FAST) exam demonstrates no pericardial effusion and no intraperitoneal free fluid.

Which of the following is the most appropriate next step in management?

A $45$-year-old man is brought to the emergency department following a high-speed motor vehicle collision. The patient was an unrestrained driver and was ejected from the vehicle. His body mass index is $42 \text{ kg/m}^2$. Upon arrival, he is confused and diaphoretic. His temperature is $36.5^\circ\text{C}$, blood pressure is $76/40 \text{ mmHg}$, pulse is $138\text{ /min}$, and respiratory rate is $24\text{ /min}$. Pulse oximetry shows $97\%$ on high-flow oxygen. Primary survey reveals an intact airway. The trachea is midline, and breath sounds are clear and equal bilaterally. Neck veins are flat. The abdomen is obese with a visible seatbelt sign, but deep palpation is limited; there is mild diffuse tenderness without obvious rigidity. Anteroposterior compression of the pelvis does not elicit instability. Chest and pelvic radiographs show no abnormalities. A bedside focused assessment with sonography for trauma (FAST) is attempted but is technically inadequate and indeterminate due to severe obesity and obscuring bowel gas. Intravenous fluid resuscitation with isotonic crystalloids is initiated. Which of the following is the most appropriate next step in management?

A 22-year-old man is transported to the emergency department after falling approximately 20 feet from a roof. Upon arrival, he is moaning in pain and clutching his left torso. His airway is unobstructed, and breath sounds are clear and symmetric bilaterally. His heart rate is 142/min and his blood pressure is 78/40 mmHg. Supplemental oxygen is applied, and two large-bore intravenous catheters are placed. Following a 1-liter infusion of warmed crystalloid, his blood pressure remains 80/42 mmHg. A bedside ultrasonographic evaluation of the abdomen reveals a significant anechoic fluid collection in the splenorenal recess. Radiographic evaluation of the chest and pelvis demonstrates no acute fractures or abnormalities. Which of the following is the most appropriate next step in the management of this patient?

A 30-year-old man is brought to the trauma bay after a high-speed motorcycle collision. On arrival, he has active, pulsatile bleeding from a partially amputated right lower extremity. He is moaning, his eyes remain closed, and he exhibits abnormal flexion posturing to painful stimuli. His respiratory rate is 32/min, and oxygen saturation is 84% on room air. Auscultation of the chest reveals absent breath sounds on the right side. Arrange the following initial management steps in the most appropriate chronological order according to current trauma resuscitation protocols.