Trauma and Burns

A $31$-year-old woman, G2P1, at $34$ weeks gestation is evaluated in the emergency department after a high-speed motor vehicle collision. She was an unrestrained driver. On arrival, she is unresponsive with a Glasgow Coma Scale score of $7$. She is rapidly intubated for airway protection. Vital signs are temperature $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure $72/40\text{ mm Hg}$, and pulse $142/\text{min}$. Breath sounds are equal bilaterally. Her abdomen is gravid, tense, and diffusely tender. Uterine tone is markedly increased. A focused assessment with sonography for trauma exam demonstrates a large amount of free fluid in the hepatorenal and splenorenal recesses. External fetal monitoring reveals a baseline fetal heart rate of $105/\text{min}$ with recurrent late decelerations and absent variability. A massive transfusion protocol is initiated. Which of the following is the most appropriate next step in management?

A 38-year-old male motorcyclist is brought to the emergency department after colliding with a guardrail. On presentation, he is awake but groggy. His temperature is 36.2°C (97.1°F), blood pressure is 78/45 mm Hg, pulse is 132/min, and respirations are 22/min. Oxygen saturation is 97% on a nonrebreather mask. Airway is patent. Breath sounds are equal bilaterally, and the trachea is midline. The abdomen is soft and non-distended without guarding. There is a scrotal hematoma, and blood is noted at the urethral meatus. Anteroposterior compression of the iliac crests reveals mechanical instability. Intravenous access is established, and a 1-liter bolus of warmed lactated Ringer solution is rapidly infused, but the blood pressure remains 80/48 mm Hg. A bedside focused assessment with sonography for trauma (FAST) demonstrates no free intraperitoneal or pericardial fluid. A pelvic binder is immediately applied. Which of the following is the most appropriate next step in management?

Match each specific clinical presentation of thoracic trauma with its most appropriate immediate definitive intervention or diagnostic modality.

A 25-year-old man is brought to the emergency department via ambulance 20 minutes after being shot during an altercation. He sustained a single gunshot wound to the right anterior chest, located in the fifth intercostal space at the midclavicular line. There is no visible exit wound. The patient is pale, diaphoretic, and lethargic. Vital signs include a blood pressure of 76/40 mm Hg, heart rate of 132/min, and respiratory rate of 22/min. Oxygen saturation is 97% on high-flow oxygen. The trachea is midline, and neck veins are flat. Auscultation of the chest reveals clear and equal breath sounds bilaterally. The abdomen is visibly distended and demonstrates diffuse rigidity and guarding. Two large-bore intravenous lines are placed, and fluid resuscitation is initiated. Which of the following is the most appropriate next step in the management of this patient?

A series of patients arrive at the trauma bay following various traumatic incidents. Match each patient's clinical presentation with the most appropriate next step in management according to Advanced Trauma Life Support (ATLS) protocols.

A $45$-year-old man is brought to the emergency department by emergency medical services after a high-speed motor vehicle collision. He was an unrestrained driver and was ejected from the vehicle. On arrival, he is agitated, pale, and diaphoretic. His blood pressure is $76/40 \text{ mm Hg}$, heart rate is $138\text{/min}$, and respiratory rate is $24\text{/min}$. The airway is patent, and the trachea is midline. Breath sounds are present and equal bilaterally. Heart sounds are normal. The abdomen is distended and diffusely tender with mild rigidity. The pelvis is mechanically stable to anteroposterior and lateral compression. Intravenous access is established, and the mass transfusion protocol is initiated. Following the administration of $1 \text{ L}$ of warmed crystalloid and $1 \text{ unit}$ of uncrossmatched packed red blood cells, his blood pressure is $82/45 \text{ mm Hg}$. A focused assessment with sonography for trauma (FAST) reveals a large amount of anechoic fluid in the hepatorenal and splenorenal recesses; there is no fluid in the pericardial sac. A portable anteroposterior chest radiograph demonstrates clear lung fields but a noticeably widened mediastinum with blurring of the aortic knob. Which of the following is the most appropriate next step in the management of this patient?

Burn victims often present with complex, life-threatening complications that require immediate recognition and targeted intervention. Match each clinical presentation of a burn or inhalation injury to the most appropriate next step in management or specific antidote.

A 42-year-old construction worker is transported to the trauma bay shortly after falling from a height of approximately 20 feet (6 meters). On arrival, his airway is secure, and breath sounds are present and equal bilaterally. His heart rate is 135/min, and blood pressure is 78/50 mm Hg. Oxygen saturation is 97% on ambient air. The patient is confused and appropriately localizes to painful stimuli. Two large-bore intravenous catheters are placed, and warmed isotonic crystalloid fluids are rapidly infused. Physical examination reveals a rigid, distended abdomen with diffuse tenderness. The pelvis is mechanically stable to anteroposterior and lateral compression. A focused assessment with sonography for trauma (FAST) reveals a significant collection of anechoic fluid in the hepatorenal recess. Which of the following is the most appropriate next step in the management of this patient?

A 52-year-old woman is brought to the emergency department by emergency medical services after being involved in a head-on motor vehicle collision. She is confused, tachypneic, and has blood on her face from a scalp laceration. Her vital signs show a blood pressure of 90/50 mmHg, a heart rate of 118/min, and a respiratory rate of 26/min. According to the Advanced Trauma Life Support (ATLS) protocol, arrange the following initial management steps in the correct chronological order.

A 42-year-old man is brought to the emergency department via helicopter following a structural fire. The injury occurred exactly 2 hours prior to arrival. He weighs $90 \text{ kg}$. Physical examination reveals deep partial-thickness and full-thickness burns involving his entire anterior trunk, his entire right arm, and the entire anterior surface of his right leg. The remainder of his skin is intact. During transport, paramedics administered $480 \text{ mL}$ of intravenous lactated Ringer solution. The trauma team initiates fluid resuscitation using the traditional Parkland formula ($4 \text{ mL} \times \text{weight in kg} \times \% \text{TBSA}$). At what rate (in $\text{mL/hr}$) should the lactated Ringer infusion be set for the remainder of the first 8-hour period following the injury?

A 48-year-old male construction worker is brought to the emergency department after being crushed between a concrete barrier and a moving vehicle at the level of his hips. On arrival, he is pale, diaphoretic, and confused. Vital signs are blood pressure 75/40 mm Hg, heart rate 138/min, and respiratory rate 24/min. The airway is patent, and breath sounds are clear and equal bilaterally. A portable chest radiograph shows no abnormalities. The abdomen is soft, non-distended, and mildly tender to deep palpation. Anteroposterior compression of the pelvis reveals severe mechanical instability, and a pelvic binder is immediately applied in the trauma bay. A focused assessment with sonography for trauma (FAST) exam demonstrates no anechoic free fluid in the pericardium, hepatorenal recess, splenorenal recess, or retrovesical space. The patient receives 2 units of uncrossmatched type O-negative packed red blood cells and 1 L of isotonic crystalloid. Reassessment reveals a blood pressure of 78/42 mm Hg and a heart rate of 135/min. Which of the following is the most appropriate next step in management?

Emergency medical services arrive at the trauma bay with a 22-year-old college student who crashed his mountain bike at high speed, striking his torso against the handlebars. He is awake but lethargic, complaining of severe pain in his left upper abdomen and left shoulder.

Vital signs include a heart rate of 135/min, blood pressure of 82/48 mm Hg, and respiratory rate of 22/min. Oxygen saturation is 96% on room air.

Physical examination reveals a large contusion over the left lower rib cage with marked tenderness and guarding in the left upper quadrant.

Intravenous access is established, and a bolus of warmed isotonic crystalloid is initiated. A focused assessment with sonography for trauma (FAST) demonstrates a large anechoic stripe between the spleen and the left kidney.

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

Match each acute trauma clinical presentation with the most appropriate next step in management.

A 28-year-old man arrives at the emergency department following a violent collision during a rugby match. Paramedics report he was struck aggressively in the mid-abdomen by another player's helmet. Upon arrival, he appears pale and lethargic. His temperature is 36.6°C (97.9°F), pulse is 135/min, respirations are 24/min, and blood pressure is 78/45 mm Hg. Pulse oximetry is 95% on room air. The airway is clear, and breath sounds are symmetric bilaterally. Abdominal examination reveals severe distension, diffuse rigidity, and rebound tenderness. A bedside focused assessment with sonography for trauma (FAST) demonstrates a large volume of anechoic fluid in the hepatorenal recess. Which of the following is the most appropriate next step in management?

Emergency medical services transport a 39-year-old unrestrained driver to the trauma bay following a high-speed collision with a concrete barrier. Upon arrival, he is unresponsive and is immediately intubated for airway protection. His heart rate is 142/min and blood pressure is 74/40 mm Hg. Physical examination shows extensive bruising across the sternum. Breath sounds are diminished on the left side. A left-sided chest tube is inserted, yielding 250 mL of gross blood. Bedside ultrasonography (FAST) demonstrates normal cardiac motion without pericardial effusion and no free fluid in the peritoneal cavity. Anteroposterior radiographs of the chest and pelvis are obtained. The pelvic film is unremarkable. The chest radiograph demonstrates a widened mediastinum, obscured aortic contour, and a left apical pleural cap. The patient's hemodynamics do not improve despite the initiation of a massive transfusion protocol. Which of the following is the most appropriate next step in the evaluation of this patient?

A $34$-year-old man is brought to the emergency department after a severe industrial fire. He sustained deep, full-thickness circumferential burns to his anterior and posterior torso, as well as his bilateral lower extremities. The total body surface area burned is estimated at $55\%$. Due to marked oropharyngeal edema and carbonaceous sputum, he was intubated at the scene. Intravenous fluid resuscitation with lactated Ringer solution was initiated based on standard weight-based formulas.

Upon arrival, his temperature is $36.7^\circ\text{C}$ ($98.1^\circ\text{F}$), blood pressure is $112/68 \text{ mm Hg}$, and heart rate is $110/\text{min}$.

Four hours later, the patient's urine output has decreased to $10 \text{ mL/hr}$. Repeat vital signs show a blood pressure of $78/48 \text{ mm Hg}$ and a heart rate of $142/\text{min}$. The mechanical ventilator frequently alarms for high airway pressures.

Current ventilator parameters and central line measurements are as follows:
- Peak inspiratory pressure: $65 \text{ cm H}_2\text{O}$
- Plateau pressure: $55 \text{ cm H}_2\text{O}$
- Central venous pressure: $18 \text{ mm Hg}$

Bedside echocardiography demonstrates a small, underfilled, and hyperdynamic left ventricle. There is no evidence of pericardial effusion. An arterial blood gas analysis reveals a pH of $7.18$, $p\text{CO}_2$ of $72 \text{ mm Hg}$, and $p\text{O}_2$ of $62 \text{ mm Hg}$.

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

A 33-year-old male is transported to the trauma bay by paramedics after sustaining a gunshot wound to the left lower quadrant of his abdomen. On arrival, he appears pale and diaphoretic. His temperature is 36.5°C (97.7°F), blood pressure is 82/50 mm Hg, pulse is 135/min, and respirations are 24/min. Physical examination reveals a single penetrating wound just lateral to the umbilicus. The abdomen is distended, rigid, and diffusely tender to palpation with involuntary guarding. Intravenous access is established and fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

Following a severe industrial accident where he fell approximately three stories, a 51-year-old male worker is evaluated in the trauma bay. He is deeply comatose, exhibiting a Glasgow Coma Scale score of 6. Initial vitals demonstrate a blood pressure of 72/38 mm Hg, a pulse of 142/min, and a respiratory rate of 36/min. During the primary evaluation, the clinician notes tracheal deviation toward the right side and a complete lack of breath sounds on the left. Furthermore, the patient's abdomen is markedly distended with guarding on palpation, and the pelvic ring demonstrates obvious mechanical instability.

Arrange the following interventions in the most appropriate chronological sequence for this patient's acute resuscitation, in accordance with standard trauma protocols.

A 38-year-old female is brought to the emergency department after a snowmobile collision in which she struck a tree at high speed. On arrival, she is lethargic and pale. Her temperature is 36.1°C (97.0°F), blood pressure is 74/42 mmHg, heart rate is 136/min, and respiratory rate is 24/min. Oxygen saturation is 96% on a non-rebreather mask. Two large-bore intravenous lines are established, and she receives 1 L of warmed lactated Ringer solution and 1 unit of uncrossmatched type O-negative packed red blood cells. Reassessment reveals a blood pressure of 76/40 mmHg and a heart rate of 132/min. Primary survey shows a patent airway and equal breath sounds bilaterally. A portable chest radiograph demonstrates a widened mediastinum and blurring of the aortic knob but no pneumothorax or hemothorax. A focused assessment with sonography for trauma (FAST) examination reveals a large amount of anechoic fluid in the hepatorenal recess (Morison pouch). An anteroposterior pelvic radiograph shows an intact pelvic ring with no fractures. Which of the following is the most appropriate next step in management?

A 24-year-old male is brought to the emergency department via ambulance following a high-speed motorcycle collision. He was found approximately 30 feet from his motorcycle. On arrival, he is moaning but not following commands. His blood pressure is 80/40 mmHg, and his heart rate is 132/min. Arrange the following steps of his initial trauma evaluation and management in the most appropriate chronological order.