Trauma and Burns

A 35-year-old man is brought to the emergency department after being rescued from a closed-space house fire. He is coughing up carbonaceous sputum and has a hoarse voice. He has sustained deep partial-thickness and full-thickness burns covering his entire anterior trunk and bilateral upper extremities. According to standard trauma and burn management principles, arrange the following clinical interventions in the most appropriate chronological sequence.

A 38-year-old male pedestrian is brought to the emergency department after being struck by a delivery truck at highway speeds. Upon arrival, he has agonal respirations. Physical examination reveals massive midfacial crush injuries with active oropharyngeal hemorrhage. His vital signs are temperature 35.5°C (95.9°F), blood pressure 68/35 mmHg, pulse 142/min, and respiratory rate 6/min. There are absent breath sounds over the right hemithorax and pronounced jugular venous distention. The pelvis is mechanically unstable on manual compression, and a rapidly expanding scrotal hematoma is noted. Based on Advanced Trauma Life Support (ATLS) protocols, arrange the following management steps in the most appropriate chronological order.

Match each classic thoracic trauma presentation with its most appropriate initial specific management step.

A 38-year-old male construction worker is brought to the emergency department after falling approximately 25 feet from a scaffold. On arrival, his blood pressure is 72/40 mmHg, heart rate is 138/min, and respiratory rate is 24/min. He is lethargic but maintaining his airway. Bilateral breath sounds are clear and equal. The abdomen is soft, non-distended, and lacks rebound tenderness or guarding. Gentle anteroposterior compression of the iliac crests reveals abnormal outward mobility of the pelvis. Intravenous access is established, and resuscitation with uncrossmatched blood is initiated. A bedside focused assessment with sonography for trauma (FAST) examination demonstrates no free fluid in the pericardial, hepatorenal, splenorenal, or rectovesical spaces. Which of the following is the most appropriate next step in management?

A 48-year-old construction worker arrives at the emergency department via helicopter after being crushed by a steel beam across his hips. He is confused, pale, and diaphoretic. Vital signs demonstrate a heart rate of 138/min and a blood pressure of 72/40 mm Hg. His airway is patent and lungs are clear to auscultation bilaterally. Emergency medical personnel placed a circumferential pelvic sheet prior to transport. On evaluation, his abdomen is non-distended and soft to palpation. Inspection of the perineum reveals a scrotal hematoma and blood at the urethral meatus. Point-of-care ultrasound of the abdomen and pericardium shows no abnormal fluid collections. A portable chest radiograph is normal. Anteroposterior pelvic radiograph reveals an open-book pubic symphysis diastasis and a right sacroiliac joint disruption. Despite the rapid infusion of 2 units of uncrossmatched packed red blood cells, his blood pressure remains 75/42 mm Hg. Which of the following is the most appropriate next step in management?

A 42-year-old woman is brought to the emergency department 30 minutes after a high-speed motor vehicle collision in which she was the unrestrained driver. Upon arrival, her temperature is 36.5°C (97.7°F), blood pressure is 78/52 mmHg, pulse is 135/min, and respirations are 22/min. Her airway is patent and breath sounds are clear and equal bilaterally. Oxygen saturation is 97% on room air. The abdomen is severely distended with diffuse tenderness, guarding, and rebound tenderness. Two large-bore intravenous lines are established, and fluid resuscitation is initiated. A bedside focused assessment with sonography for trauma (FAST) reveals a significant amount of anechoic free fluid in the splenorenal and hepatorenal recesses. Which of the following is the most appropriate next step in management?

A 45-year-old woman is brought to the emergency department 30 minutes after being rescued from a residential fire. Her airway is patent, and she is hemodynamically stable. Physical examination reveals deep partial-thickness and full-thickness burns involving her entire anterior trunk, her entire right arm, and her entire right leg. Her estimated weight is $80 \text{ kg}$. Using the Parkland resuscitation formula ($4 \text{ mL/kg/} \% \text{TBSA}$), what should be the target rate of intravenous lactated Ringer solution administration, in $\text{mL/hour}$, for the first 8 hours following her injury?

A 41-year-old construction worker is brought to the emergency department after falling approximately 25 feet from a scaffold. On arrival, he is moaning and only withdraws his extremities in response to painful stimuli. His temperature is 36.1°C (97.0°F), blood pressure is 74/40 mm Hg, pulse is 142/min, and respiratory rate is 26/min. Pulse oximetry is 94% on high-flow oxygen. The airway is patent, and breath sounds are present and equal bilaterally. A chest radiograph demonstrates no pneumothorax or hemothorax. The pelvis is mechanically stable to anterior-posterior and lateral compression. Abdominal examination reveals diffuse rigidity and involuntary guarding. Bilateral thigh deformities are noted. Intravenous access is established, and a massive transfusion protocol is initiated. A bedside focused assessment with sonography for trauma (FAST) is attempted but is technically inadequate due to massive subcutaneous emphysema and overlying bowel gas. Which of the following is the most appropriate next step in management?

A 28-year-old male warehouse worker is brought to the emergency department after being crushed laterally against a wall by a moving forklift. Upon arrival, he is confused and diaphoretic. Vital signs are temperature 36.2°C, heart rate 132/min, blood pressure 78/50 mmHg, and respiratory rate 22/min. Oxygen saturation is 96% on room air. Primary survey reveals a patent airway and equal breath sounds bilaterally. The abdomen is soft and non-distended with no peritoneal signs. Palpation of the pelvis reveals gross mechanical instability. Genitourinary examination shows marked scrotal ecchymosis, and digital rectal examination reveals a high-riding prostate. An anteroposterior pelvic radiograph confirms a severely displaced open-book pelvic ring fracture. A pelvic binder is immediately applied, and the patient is resuscitated with 2 units of uncrossmatched packed red blood cells. Following this intervention, his blood pressure remains 80/52 mmHg. A focused assessment with sonography for trauma (FAST) scan is performed and shows no free intraperitoneal or pericardial fluid. Which of the following is the most appropriate next step in management?

A 22-year-old male is evaluated in the surgical intensive care unit for sudden-onset, severe abdominal pain. Three days ago, he was involved in a high-speed motorcycle collision, during which he was thrown forward and struck his upper abdomen against the handlebars. His initial trauma evaluation in the emergency department demonstrated stable hemodynamics, and a computed tomography scan of the abdomen and pelvis showed a non-expanding Grade II splenic laceration without active contrast extravasation. He was admitted for nonoperative management and had been clinically stable until this morning.

Current vital signs include a temperature of 38.6°C (101.5°F), a heart rate of 135/min, a respiratory rate of 24/min, and a blood pressure of 82/48 mm Hg. Physical examination reveals a distended abdomen with diffuse rigidity, involuntary guarding, and severe rebound tenderness in all four quadrants. Bowel sounds are absent. Following the rapid infusion of 2 L of isotonic crystalloid, his blood pressure remains 86/50 mm Hg.

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

A $29$-year-old woman, G2P1, at $32$ weeks gestation is brought to the emergency department via ambulance following a motor vehicle collision. She was the restrained driver of a sedan that was struck on the driver's side by a commercial truck. On arrival, she is immobilized on a backboard with a cervical collar. She appears confused and is diaphoretic. Temperature is $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), blood pressure is $78/45\text{ mmHg}$, heart rate is $132\text{/min}$, and respiratory rate is $24\text{/min}$. Pulse oximetry is $96\%$ on $15\text{ L/min}$ oxygen via a nonrebreather mask. The airway is patent, and breath sounds are equal bilaterally. The uterus is palpated above the umbilicus. The abdomen is diffusely tender to palpation with involuntary guarding. There is no external vaginal bleeding. A focused assessment with sonography for trauma (FAST) reveals a large amount of free fluid in the hepatorenal space (Morison's pouch). Fetal heart tones are $140\text{/min}$. Two large-bore intravenous lines are established, and administration of warmed crystalloid fluids is initiated. Which of the following is the best next step in management?

A 19-year-old male is brought to the emergency department after colliding with a tree while snowboarding. On arrival, he complains of severe left upper quadrant abdominal pain and left shoulder pain. Initial vital signs include a blood pressure of 115/70 mm Hg, heart rate of 105/min, and respiratory rate of 18/min. A Focused Assessment with Sonography for Trauma (FAST) exam shows a moderate amount of free fluid in the splenorenal recess. Because the patient is hemodynamically stable, a computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast is performed, which reveals a deep splenic laceration with active contrast extravasation. Shortly after returning to the trauma bay, the patient becomes confused and diaphoretic. Repeat vital signs show a blood pressure of 82/45 mm Hg and a heart rate of 138/min. The patient is rapidly transfused with 1 unit of uncrossmatched packed red blood cells, but his blood pressure remains 84/48 mm Hg. Which of the following is the most appropriate next step in management?

A 38-year-old female is evaluated in the emergency department after a low-speed collision in which her bicycle was struck by a turning vehicle. She was wearing a helmet and reports no loss of consciousness. She complains primarily of left-sided abdominal pain and left shoulder pain. Upon arrival, her blood pressure is 122/78 mm Hg, heart rate is 88/min, and respiratory rate is 16/min. Oxygen saturation is 99% on room air. The primary survey is unremarkable. Physical examination reveals bruising over the left lower ribs. Abdominal examination demonstrates mild left upper quadrant tenderness but no rebound or guarding. A bedside focused assessment with sonography for trauma (FAST) demonstrates a distinct rim of anechoic fluid surrounding the spleen. Which of the following is the most appropriate next step in management?

As a trauma and burn unit leader, you are tasked with managing multiple complex clinical scenarios simultaneously. Match each specific patient presentation to the most appropriate immediate diagnostic or therapeutic intervention.

Match each classic trauma or burn presentation to its most appropriate definitive intervention or next step in management.

During a trauma surgery conference, a team reviews the intraoperative management algorithms for retroperitoneal hematomas discovered during emergency exploratory laparotomies. The attending surgeon emphasizes that the decision to open and explore a hematoma depends critically on its anatomical zone and the mechanism of injury. Match each specific clinical scenario involving a retroperitoneal hematoma with the most appropriate intraoperative management strategy.

Match each patient's clinical presentation following trauma with the most appropriate next step in diagnosis or management.

A 29-year-old man is brought to the emergency department after a high-speed motorcycle collision. On presentation, he is lethargic and only opens his eyes to painful stimuli. Vital signs are temperature 36.2°C (97.2°F), blood pressure 78/45 mm Hg, heart rate 138/min, and respiratory rate 24/min. Oxygen saturation is 95% on a non-rebreather mask. The patient undergoes rapid sequence intubation for airway protection. Following intubation, a portable chest radiograph shows clear lung fields without pneumothorax or hemothorax. A pelvic radiograph reveals no fractures. Focused assessment with sonography for trauma (FAST) demonstrates a large amount of anechoic fluid in the hepatorenal and splenorenal recesses. The patient receives warmed intravenous crystalloid fluids and uncrossmatched type O-negative blood, but his blood pressure remains 80/48 mm Hg. Which of the following is the most appropriate next step in management?

A 38-year-old forestry worker is brought to the trauma center after a severe chainsaw accident followed by a fall down a steep ravine. On arrival, he is unresponsive with a Glasgow Coma Scale score of 5. He has a massive, spurting arterial laceration to his right thigh. He exhibits sonorous, gurgling respirations. Auscultation reveals absent breath sounds on the left hemithorax with jugular venous distention. His heart rate is 142/min and blood pressure is 65/30 mm Hg. Arrange the following critical interventions in the most appropriate sequential order based on current Advanced Trauma Life Support (ATLS) priorities.

A 35-year-old man is brought to the emergency department after sustaining injuries in a kitchen grease fire. On examination, he is alert and oriented. His blood pressure is 125/80 mm Hg, heart rate is 98/min, and respiratory rate is 16/min. Physical examination reveals deep partial-thickness burns involving the entire anterior surface of his chest and abdomen, as well as the entire anterior surface of both arms. His airway is patent with no signs of inhalational injury. Using the Rule of Nines, what is the estimated total body surface area (TBSA) percentage affected by these burns?