Trauma and Burns

A 30-year-old male is evaluated in the trauma center shortly after sustaining a stab wound to the left anterior abdomen during an altercation. On arrival, he is lethargic and diaphoretic. Vital signs are temperature 36.7°C (98.1°F), pulse 142/min, and blood pressure 72/40 mmHg. His airway is secure, and breath sounds are present and equal bilaterally. The abdomen is rigid with severe, diffuse guarding and rebound tenderness. Intravenous access is rapidly obtained and isotonic fluid resuscitation is initiated. Which of the following is the most appropriate next step in the management of this patient?

A 34-year-old male construction worker is brought to the emergency department via ambulance after being crushed by a heavy concrete pipe. On arrival, he is confused and agitated. His temperature is 36.5°C (97.7°F), blood pressure is 78/40 mm Hg, pulse is 135/min, and respirations are 24/min. Pulse oximetry shows 96% on room air. Primary survey reveals a patent airway and equal breath sounds bilaterally. Heart sounds are rapid but normal in intensity. The abdomen is soft, nondistended, and without guarding. The pelvis is mechanically unstable to gentle lateral compression. A prominent scrotal hematoma and blood at the urethral meatus are noted. Intravenous access is established, a pelvic binder is applied, and a massive transfusion protocol with uncrossmatched blood products in a $1:1:1$ ratio is initiated. Ten minutes later, his blood pressure is 80/42 mm Hg and pulse is 132/min. A focused assessment with sonography for trauma (FAST) exam demonstrates no fluid in the pericardial sac, hepatorenal recess, splenorenal recess, or rectovesical pouch. Anteroposterior chest radiograph is unremarkable. Which of the following is the most appropriate next step in management?

A 35-year-old male is transported to the emergency department after his motorcycle struck a concrete barrier at high speed. Upon arrival, he is lethargic and visibly pale. Vital signs show a heart rate of 142/min, a blood pressure of 76/40 mm Hg, and a respiratory rate of 24/min. Oxygen saturation is 96% on a non-rebreather mask. The airway is patent, and breath sounds are crisp and equal bilaterally. The abdomen is tense, distended, and dull to percussion. The pelvis is stable to manual compression. Focused assessment with sonography for trauma demonstrates significant free anechoic fluid in the splenorenal and hepatorenal recesses. Two large-bore intravenous lines are established, and resuscitation with balanced crystalloids and uncrossmatched blood is initiated. Which of the following is the most appropriate next step in management?

Match the following thoracic trauma clinical presentations to their most appropriate immediate next step in management or diagnostic evaluation.

Following a fall from a second-story residential roof, a 54-year-old male is evaluated in the trauma center. He was reportedly cleaning gutters when he lost his balance and fell approximately 20 feet (6 meters) onto the grass below. The patient is awake, alert, and secured to a rigid backboard with a cervical collar.

Vital signs are:
Temperature: 36.6°C (97.9°F)
Heart rate: 122/min
Blood pressure: 80/50 mm Hg
Respiratory rate: 22/min
Oxygen saturation: 96% on room air

Physical examination reveals a patent airway with midline trachea. Breath sounds are clear and equal bilaterally. Heart sounds are normal without murmurs, rubs, or gallops. His abdomen is soft, non-distended, and non-tender to deep palpation, though he notes he cannot feel the examiner's hands well. The pelvis is stable to anterior-posterior and lateral compression. Neurologic examination reveals flaccid paralysis and areflexia of both lower extremities, with a complete loss of pain, temperature, and light touch sensation below the level of the umbilicus. Upper extremity strength and sensation are intact. Two large-bore peripheral intravenous lines are established, and a bolus of warm isotonic crystalloid is initiated.

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

A 25-year-old male is brought to the emergency department via ambulance after a high-speed motorcycle collision. Upon arrival, his airway is patent and his breathing is spontaneous but rapid. His blood pressure is 75/40 mmHg, heart rate is 135/min, and respiratory rate is 24/min. Physical examination reveals a distended and rigidly tense abdomen with diffuse tenderness. Intravenous access is established, and 1 liter of warmed crystalloid solution is administered rapidly without improvement in his blood pressure. A Focused Assessment with Sonography for Trauma (FAST) examination reveals a large amount of free fluid in the hepatorenal and splenorenal recesses. Which of the following is the most appropriate next step in management?

Match each classic clinical presentation following acute trauma with its most likely associated diagnosis.

Paramedics arrive at the trauma center with a 34-year-old construction worker who fell approximately 20 feet from a roof. The patient is moaning and clutching his abdomen. His temperature is 36.8°C (98.2°F), blood pressure is 82/45 mmHg, pulse is 128/min, and respirations are 22/min. Peripheral intravenous lines are placed, and fluid resuscitation is initiated. His airway is clear, and breath sounds are equal bilaterally. A bedside ultrasound evaluation of the abdomen demonstrates an anechoic fluid collection between the liver and right kidney. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old male is brought to the emergency department immediately after a high-speed motor vehicle collision. He is visibly distressed, tachycardic, and has multiple contusions on his chest and abdomen. According to the Advanced Trauma Life Support (ATLS) protocol, arrange the following initial assessment and management steps in the correct chronological order.

A 42-year-old woman is brought to the trauma bay by helicopter emergency medical services after crashing her snowmobile into a fence at high speed. She complains of severe abdominal pain. Her temperature is 36.5°C (97.7°F), blood pressure is 76/45 mm Hg, and pulse is 128/min. She is lethargic but appropriately answers questions. The airway is clear, and the trachea is midline. Breath sounds are clear and equal bilaterally. Jugular venous pressure is not elevated. The abdomen is distended, rigid, and exhibits diffuse guarding. A bedside focused assessment with sonography for trauma (FAST) demonstrates a significant anechoic stripe in the hepatorenal recess. Two large-bore intravenous lines are established, and crystalloid fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

Emergency medical services transport a 30-year-old factory worker to the regional trauma center after an industrial flash fire. The primary survey confirms a patent airway, symmetric breath sounds, and stable hemodynamics. Secondary evaluation of the patient's integumentary system reveals partial-thickness and full-thickness burns covering the entire anterior aspect of his trunk as well as the entire anterior aspect of his left leg. The genital region, head, posterior torso, arms, right leg, and posterior left leg are completely spared. Based on the standard adult Rule of Nines, what is the estimated percentage of total body surface area affected by these burns?

A 24-year-old man is brought to the emergency department after sustaining a stab wound to the right upper quadrant of his abdomen during a physical altercation. On arrival, he appears confused, pale, and profusely diaphoretic. Vital signs are temperature 36.8°C (98.2°F), heart rate 138/min, blood pressure 75/40 mm Hg, and respiratory rate 22/min. Physical examination reveals a 3-cm linear laceration just below the right costal margin. The abdomen is notably distended with diffuse guarding and marked rebound tenderness in all four quadrants. Peripheral pulses are weak and thready. Which of the following is the most appropriate next step in the management of this patient?

Match the following classic trauma presentations with their most appropriate immediate next step in management or diagnosis.

A 33-year-old construction worker is brought to the emergency department after falling approximately 20 feet from scaffolding. On arrival, he is in severe respiratory distress and is unable to answer questions. His blood pressure is 74/42 mm Hg, and his heart rate is 138/min. Physical examination reveals severely distended jugular veins, a trachea that is deviated to the right, and completely absent breath sounds over the left hemithorax. Which of the following is the most appropriate immediate next step in the management of this patient?

During a severe thunderstorm, a 52-year-old male is struck by a heavy falling tree branch and sustains significant blunt force trauma to his torso. On presentation to the trauma bay, his blood pressure is 78/52 mm Hg and pulse is 132/min. He is tachypneic with a respiratory rate of 26/min and oxygen saturation of 94% on room air. The primary survey reveals equal breath sounds bilaterally and no tracheal deviation. His abdomen is rigid with severe, diffuse tenderness to palpation. A bedside ultrasound demonstrates an anechoic stripe between the right kidney and the liver. Which of the following is the most appropriate next step in the management of this patient?

A 31-year-old woman, G1P0 at 35 weeks gestation, is brought to the emergency department via ambulance following a high-speed frontal motor vehicle collision. She was the restrained driver. Upon arrival, her blood pressure is 78/42 mmHg, pulse is 128/min, and respirations are 24/min. She is pale, diaphoretic, and lethargic. Physical examination reveals a transverse ecchymosis across the lower abdomen. The abdomen is diffusely tender with involuntary guarding. The uterus is firm and exquisitely tender to palpation. Fetal heart rate monitoring demonstrates a baseline of 110/min with absent variability and recurrent late decelerations. An extended focused assessment with sonography for trauma (E-FAST) reveals a large volume of anechoic fluid in the hepatorenal space (Morison pouch). Which of the following is the most appropriate next step in the management of this patient?

Match each classic burn trauma or post-resuscitation clinical presentation with its most appropriate immediate diagnostic or therapeutic next step in management.

A 19-year-old male is brought to the emergency department after a collision during a rugby match. While running, he was struck forcefully in the left upper quadrant of the abdomen by an opposing player's knee. He initially tried to continue playing but collapsed on the sideline due to lightheadedness and severe abdominal pain.

On presentation, his temperature is 36.6°C (97.9°F), blood pressure is 82/48 mm Hg, heart rate is 134/min, and respiratory rate is 22/min. He appears pale and diaphoretic. The airway is intact, and breath sounds are equal bilaterally. Cardiac examination reveals sinus tachycardia. His abdomen is rigid and diffusely tender with guarding and rebound tenderness, most pronounced in the left upper quadrant. The pelvis is stable to compression.

A focused assessment with sonography for trauma (FAST) examination demonstrates anechoic free fluid in the splenorenal recess and the rectovesical pouch. Two large-bore peripheral intravenous lines are established. Despite a 1-liter bolus of warmed isotonic crystalloid and initiation of an uncrossmatched blood transfusion, his blood pressure remains 84/50 mm Hg.

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

A 45-year-old man is brought to the emergency department after a propane tank explosion at his home. He is awake, alert, and complaining of severe pain. Physical examination reveals deep partial-thickness (second-degree) and full-thickness (third-degree) burns involving his entire posterior trunk and both of his entire upper extremities. There are also superficial (first-degree) burns involving his entire face and neck. The remainder of his body is unaffected. Based on the Rule of Nines, what is the estimated total body surface area (TBSA) percentage that should be used to calculate his initial fluid resuscitation requirements?

A $22$-year-old man is brought to the emergency department by ambulance $15$ minutes after sustaining a stab wound to the left side of his chest during an altercation. On arrival, the patient is agitated and diaphoretic. His temperature is $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure is $82/40 \text{ mmHg}$, pulse is $132/\text{min}$, and respiratory rate is $26/\text{min}$. Pulse oximetry shows $94\%$ on room air. Primary survey reveals a $3 \text{ cm}$ linear laceration in the left $6^{\text{th}}$ intercostal space at the midaxillary line. The trachea is midline. Breath sounds are markedly diminished on the left side of the chest. The abdomen is slightly distended and diffusely tender to palpation. A left-sided tube thoracostomy is placed, draining $400 \text{ mL}$ of gross blood and a small amount of bubbling air. Five minutes after chest tube placement, breath sounds are equal bilaterally, and oxygen saturation improves to $99\%$. However, his blood pressure remains $80/42 \text{ mmHg}$ and pulse is $135/\text{min}$ despite rapid intravenous infusion of $1 \text{ L}$ of warmed crystalloid solution. A bedside focused assessment with sonography for trauma (FAST) demonstrates a large anechoic fluid collection in the splenorenal recess, with no pericardial effusion identified. Which of the following is the most appropriate next step in management?