Trauma and Burns

An $18$-year-old male is brought to the emergency department $30$ minutes after falling from a $15$-foot scaffolding. He is groggy and responsive only to painful stimuli. Vital signs show a temperature of $36.5^\circ$ C, a heart rate of $142$/min, a blood pressure of $78/45$ mmHg, and a respiratory rate of $24$/min. An intravenous line is established, and $1$ L of warm crystalloid fluid is rapidly administered. Following resuscitation, his blood pressure remains $82/50$ mmHg. Primary survey reveals equal breath sounds bilaterally and a stable pelvis. There is extensive bruising over the left upper quadrant of the abdomen. Point-of-care abdominal ultrasonography reveals a significant amount of anechoic fluid in the hepatorenal and splenorenal spaces. Which of the following is the most appropriate next step in management?

Match each clinical presentation following severe thoracic trauma to its most likely diagnosis.

A 24-year-old male is brought to the emergency department by helicopter after colliding with a tree while skiing at high speed. On arrival, his blood pressure is $76/40$ mmHg, heart rate is $138$/min, and respiratory rate is $26$/min. The patient is confused, pale, and diaphoretic. The trachea is midline, and breath sounds are equal bilaterally without chest wall crepitus. The abdomen is distended with diffuse tenderness and involuntary guarding. The pelvis is mechanically stable to gentle anteroposterior and lateral compression. Bilateral large-bore peripheral intravenous lines are placed, and resuscitation with type O negative packed red blood cells is initiated. A bedside Focused Assessment with Sonography for Trauma (FAST) reveals a large anechoic collection in the splenorenal recess and the rectovesical pouch. Which of the following is the most appropriate next step in management?

A 32-year-old male is brought to the emergency department after being rescued from a structure fire. He sustained deep partial-thickness and full-thickness thermal burns involving his entire anterior chest and abdomen, his entire right lower extremity, and his entire right upper extremity. The patient currently weighs $80\text{ kg}$. The injury occurred exactly $2\text{ hours}$ prior to his arrival at the emergency department. Two large-bore peripheral intravenous lines are placed. Following current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns (which recommend $2\text{ mL/kg/\%TBSA}$), what should be the initial continuous intravenous infusion rate of lactated Ringer solution in $\text{mL/hr}$?

A 19-year-old female university student is rushed to the trauma center by helicopter after a high-speed collision while riding an electric scooter. She was not wearing a helmet and struck a concrete barrier. Upon arrival, her airway is clear, and breath sounds are present bilaterally. Vital signs show a blood pressure of 72/40 mm Hg, a heart rate of 144/min, and a respiratory rate of 22/min. Her abdomen is bruised across the lower quadrants, distended, and rigid to palpation. Bedside ultrasonography (FAST) demonstrates a significant accumulation of anechoic fluid in the hepatorenal recess and the rectouterine pouch. A pelvic binder is placed by emergency medical services, and a portable chest radiograph is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation of blunt pelvic and genitourinary trauma with the most appropriate next step in management or diagnosis.

A 41-year-old man is brought to the emergency department after a motorcycle collision. He is unresponsive but opens his eyes to painful stimuli. Vital signs are temperature $36.2^\circ\text{C}$, blood pressure $78/48 \text{ mm Hg}$, heart rate $132/\text{min}$, and respiratory rate $24/\text{min}$. The airway is patent, and breath sounds are equal bilaterally. A properly positioned pelvic binder was placed by emergency medical services. Extended focused assessment with sonography for trauma (eFAST) demonstrates no intraperitoneal fluid and no pericardial effusion. There is normal lung sliding bilaterally. An anteroposterior pelvic radiograph reveals a severe diastasis of the pubic symphysis and a right sacroiliac joint disruption. After receiving $1\text{ L}$ of warmed intravenous crystalloids and $2\text{ units}$ of uncrossmatched type O-negative blood, the patient's blood pressure is $82/50 \text{ mm Hg}$ and heart rate is $128/\text{min}$. Which of the following is the most appropriate next step in management?

A 29-year-old male arrives at the trauma center after a severe crush injury caused by a tractor rolling over his lower body. He is awake and in significant pain. Vital signs reveal a blood pressure of $115/75$ mm Hg, heart rate of $98$/min, and respiratory rate of $18$/min. Primary survey is intact, and a FAST examination is negative for intraperitoneal fluid. Pelvic radiography confirms a displaced butterfly fracture of the pubic rami. On genitourinary examination, there is severe perineal ecchymosis and frank blood visible at the urethral meatus. The patient reports a strong urge to urinate but is unable to void. A digital rectal examination demonstrates a high-riding, nonpalpable prostate. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for managing this patient's genitourinary injuries.

A 28-year-old warehouse worker is rushed to the emergency department after being pinned against a loading dock by a reversing forklift. He is in severe respiratory distress and profusely diaphoretic. His temperature is 37.0°C (98.6°F), blood pressure is 70/30 mm Hg, pulse is 142/min, and respirations are 36/min. Oxygen saturation is 82% on high-flow oxygen via a non-rebreather mask. Physical examination reveals marked jugular venous distention. The trachea is visibly deviated to the right. The left chest wall has a large, developing contusion. Auscultation reveals completely absent breath sounds on the left side, and percussion of the left hemithorax is hyperresonant. Heart sounds are rapid but distinct. Which of the following is the most appropriate initial step in the management of this patient?

A 30-year-old woman, gravida 2, para 1, at 32 weeks gestation is brought to the emergency department after falling approximately 8 feet (2.4 meters) from a ladder. She complains of severe, generalized abdominal pain. On presentation, she is pale, diaphoretic, and lethargic. Her temperature is 36.6°C (97.9°F), blood pressure is 78/45 mm Hg, and pulse is 132/min. Her respiratory rate is 24/min and oxygen saturation is 97% on face mask oxygen. Cardiopulmonary auscultation is unremarkable. Abdominal examination reveals a gravid, distended abdomen that is diffusely tender with involuntary guarding. A focused assessment with sonography for trauma (FAST) scan shows a significant volume of anechoic fluid in the hepatorenal recess (Morison's pouch). Fetal heart tones are present at 145/min. Which of the following is the most appropriate next step in management?

Carefully review the following clinical vignettes of patients presenting after major thoracic or thoracoabdominal trauma. Match each patient presentation with the most appropriate next step in their diagnosis or management.

A 52-year-old man is brought to the emergency department by ambulance after a high-speed motor vehicle collision. He was the unrestrained driver and was ejected from the vehicle. On arrival, the patient is lethargic and confused. His blood pressure is 78/48 mm Hg, and his pulse is 132/min and thready. His respiratory rate is 24/min, and oxygen saturation is 96% on a non-rebreather face mask. Physical examination reveals equal breath sounds bilaterally and normal heart sounds with no murmurs. The abdomen is distended, tympanitic, and diffusely tender with involuntary guarding. The pelvis is stable to anterior-posterior and lateral compression. Extremities show multiple abrasions but no obvious deformities. An arterial blood gas analysis shows a pH of 7.22, pCO2 of 32 mm Hg, and HCO3- of 12 mEq/L. Which of the following is the most appropriate next step in the management of this patient?

Emergency medical personnel bring a 35-year-old female to the trauma center after she was struck by a fast-moving delivery van while riding her bicycle. She is in severe distress and gasping for air.

Vital signs on arrival are:
Temperature: 36.4°C (97.5°F)
Blood pressure: 78/42 mmHg
Pulse: 142/min
Respirations: 34/min
Oxygen saturation: 86% on room air

Initial evaluation reveals an intact and patent airway. Examination of the chest shows asymmetrical expansion, with absent breath sounds and hyperresonance to percussion over the right hemithorax. The trachea appears deviated toward the left side, and the jugular veins are significantly distended. The abdomen is diffusely tender and distended. A focused assessment with sonography for trauma (FAST) demonstrates a substantial accumulation of free fluid in the hepatorenal recess.

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

Match each clinical presentation of a trauma patient to the most appropriate next step in management based on standard trauma evaluation principles.

A $28$-year-old man is brought to the emergency department $30$ minutes after crashing his all-terrain vehicle (ATV) into a tree. The paramedics report that he was thrown approximately $20$ feet and landed in a muddy ditch. On arrival, he is lethargic and confused. His medical history is significant for an appendectomy at age $10$. His estranged wife is present in the emergency department demanding to make all medical decisions, although his electronic medical record clearly lists his brother as his legally appointed healthcare proxy. The brother is currently $45$ minutes away. Vital signs are temperature $36.1^\circ\text{C}$ ($97.0^\circ\text{F}$), blood pressure $78/40\text{ mm Hg}$, pulse $138\text{/min}$, and respirations $24\text{/min}$. Physical examination reveals diffuse abdominal distension, rigidity, and rebound tenderness. There is a large area of ecchymosis over the left upper quadrant. A focused assessment with sonography for trauma (FAST) exam demonstrates a significant amount of anechoic fluid in the splenorenal and hepatorenal recesses. Which of the following is the most appropriate next step in the management of this patient?

Paramedics transport a $32$-year-old male to the trauma center following ejection from a tumbling vehicle on the interstate. On arrival, the patient is unresponsive, cyanotic, and producing audible gurgling respiratory sounds. Vital signs are blood pressure $75/40$ mmHg, heart rate $142$/min, and respiratory rate $32$/min. Physical examination demonstrates a lack of breath sounds over the right hemithorax, markedly distended neck veins, and tracheal deviation to the left. His abdomen is rigid and diffusely tender to palpation. Arrange the following interventions in the most appropriate chronological order according to standard trauma resuscitation principles.

A 48-year-old male ski instructor is airlifted to the trauma bay after colliding with a tree at high speed. During transport, he received $1$ L of lactated Ringer solution. Upon arrival, the patient appears pale, diaphoretic, and confused. His temperature is $36.1^\circ\text{C}$ ($97.0^\circ\text{F}$), pulse is $135$/min, respirations are $24$/min, and blood pressure is $78/42$ mm Hg. Pulse oximetry shows $95\%$ on room air. The trachea is midline, and breath sounds are present and equal bilaterally. Heart sounds are rapid but normal in intensity, with no jugular venous distention. The abdomen is tense with significant left upper quadrant tenderness and involuntary guarding. The pelvis is mechanically stable to gentle compression. Bedside focused assessment with sonography for trauma (FAST) demonstrates a well-defined anechoic stripe in the splenorenal recess. Which of the following is the most appropriate next step in the management of this patient?

A 35-year-old man is brought to the emergency department after being rescued from a burning building. The fire department successfully extracted him from the fire 2 hours ago. On examination, the patient is hemodynamically stable and weighs 90 kg ($198.4$ lbs). He has severe deep partial-thickness and full-thickness burns involving his entire anterior trunk, his entire right arm, and the anterior aspect of his left leg. The remainder of his skin, including his face, neck, and posterior surfaces, is unaffected. Large-bore intravenous access is obtained. Using the traditional Parkland formula ($4$ mL/kg/% total body surface area), at what rate (in mL/hr) should intravenous lactated Ringer solution be administered to this patient initially?

Match each of the following clinical trauma presentations with the single most appropriate next step in management.

A 28-year-old woman, G1P0, at 32 weeks gestation is brought to the emergency department via ambulance after a high-speed motor vehicle collision. She was the unrestrained driver. Upon arrival, she is lethargic and pale. Her blood pressure is 78/45 mm Hg, pulse is 132/min, and respiratory rate is 26/min. Physical examination reveals a gravid, distended abdomen with diffuse tenderness and rebound guarding. The uterus is palpated, but no vaginal bleeding is noted. Fetal heart rate is 145/min. A bedside Focused Assessment with Sonography for Trauma (FAST) reveals a large volume of free intraperitoneal fluid in the hepatorenal recess. Arterial blood gas analysis on room air shows a pH of 7.25, pCO2 of 30 mm Hg, and HCO3- of 14 mEq/L. Two large-bore intravenous lines are established, and a massive transfusion protocol is initiated. Which of the following is the most appropriate next step in the management of this patient?