Trauma and Burns

Emergency medical personnel deliver a 19-year-old male to the emergency department following a gunshot wound to the abdomen. The patient is confused and visibly pale. Initial vital signs include a blood pressure of 72/42 mm Hg, a heart rate of 145/min, and respirations of 26/min. Examination shows a single bullet entry hole in the periumbilical region with no corresponding exit wound. The abdominal wall is rigid, and generalized guarding is present. Bilateral breath sounds are clear. Large-bore intravenous access is obtained, and a massive transfusion protocol is initiated. Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old woman is brought to the emergency department via ambulance after being rescued from a house fire. Paramedics report the injury occurred exactly 2 hours prior to her arrival. On physical examination, she is in significant pain but has a patent airway with no signs of inhalation injury. She has deep partial-thickness and full-thickness burns involving her entire anterior torso, her entire left arm, and the anterior surface of her left leg. The remainder of her skin is uninjured. Her weight is $75\text{ kg}$. Large-bore intravenous access is established. Based on the most current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns, what should be the initial rate of intravenous lactated Ringer solution administration for this patient in $\text{mL/hr}$?

Emergency medical services bring a 26-year-old male construction worker to the trauma center after he was crushed under a collapsed retaining wall. The patient's primary survey reveals a patent airway, clear breath sounds bilaterally, and stable hemodynamics with a blood pressure of 118/76 mm Hg and a heart rate of 92/min. Secondary survey is notable for severe pelvic instability, marked perineal ecchymosis, and fresh blood visible at the urethral meatus. Digital rectal examination demonstrates a high-riding prostate. Assuming sequential workup eventually reveals a complete posterior urethral transection accompanied by an intraperitoneal bladder rupture, arrange the following management steps in the correct chronological sequence.

Following an industrial accident where he was struck in the torso by a swinging steel pipe, a 48-year-old construction worker is transported to the trauma bay. Upon arrival, his blood pressure is 82/48 mm Hg, heart rate is 126/min, and respiratory rate is 22/min. Oxygen saturation is 97% on room air. The patient is lethargic but appropriately protects his airway. The trachea is midline, and breath sounds are clear and equal bilaterally. Heart sounds are normal. The abdomen is distended and exhibits diffuse tenderness to palpation, with involuntary guarding. Anteroposterior and lateral compression of the pelvis does not elicit pain or instability. Peripheral pulses are weak and thready. Two large-bore intravenous lines are established, and isotonic fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

Paramedics transport a 55-year-old male pedestrian to the trauma center after he was struck by a moving delivery van. He complains of excruciating pain in his lower abdomen and hips. On primary assessment, his airway is patent, and breath sounds are equal bilaterally. His blood pressure is 78/42 mm Hg, and his pulse is 135/min. Physical examination demonstrates marked bruising over the suprapubic region. Gentle lateral compression of the iliac crests reveals a mechanically unstable pelvic ring. A pelvic binder is immediately applied, and 1 liter of intravenous Lactated Ringer's solution is infused rapidly. A bedside ultrasound (FAST) examination reveals an anechoic stripe in the hepatorenal recess. Repeat vital signs show a blood pressure of 82/46 mm Hg and a pulse of 128/min. Which of the following is the most appropriate next step in management?

Match each trauma patient presentation with the most appropriate immediate diagnostic test or therapeutic intervention.

A $45$-year-old male construction worker is brought to the emergency department after a high-voltage electrical injury. He accidentally touched a live power line and was thrown to the ground. The incident occurred exactly $3\text{ hours}$ prior to his arrival at the trauma center. No intravenous fluids were administered during transport. The patient weighs $90\text{ kg}$. On physical examination, there are deep, full-thickness burns covering his entire anterior torso and his entire right upper extremity. The remainder of his skin is unaffected. A Foley catheter is placed, yielding dark red urine. According to the Advanced Trauma Life Support (ATLS) guidelines, at what rate (in $\text{mL/hr}$) should intravenous lactated Ringer solution be administered over the remainder of the first 8-hour post-injury window?

A 24-year-old man is brought to the emergency department after a high-speed collision while snowboarding, during which he struck a tree. On arrival, he is confused and complains of severe abdominal pain. His temperature is 36.5°C (97.7°F), blood pressure is 82/45 mmHg, pulse is 134/min, and respirations are 24/min. Pulse oximetry is 96% on room air. Primary survey reveals a patent airway and clear breath sounds bilaterally. Cardiac auscultation shows a rapid, regular rhythm with no murmurs. The abdomen is distended with diffuse tenderness, guarding, and rebound tenderness. Examination of the pelvis reveals stability to anteroposterior and lateral compression. Intravenous access is established, and the patient receives 1 L of warmed lactated Ringer solution, after which his blood pressure is 86/48 mmHg and pulse is 128/min. A bedside focused assessment with sonography for trauma (FAST) demonstrates a significant amount of anechoic fluid in the splenorenal and hepatorenal recesses. Which of the following is the most appropriate next step in management?

A $34$-year-old woman is brought to the emergency department via helicopter after being thrown from a horse and subsequently trampled. She complains of severe right flank and abdominal pain. Her medical history is unremarkable. On arrival, her temperature is $36.6^\circ\text{C}$, blood pressure is $85/50\text{ mmHg}$, heart rate is $126\text{/min}$, and respiratory rate is $24\text{/min}$. She is pale and diaphoretic. Primary survey reveals a patent airway and clear, equal breath sounds bilaterally. There is significant ecchymosis and guarding over the right upper quadrant and right flank. A Foley catheter is placed and returns frankly bloody urine. Intravenous access is established, and the patient is resuscitated with $1\text{ L}$ of warmed lactated Ringer solution and $1$ unit of uncrossmatched packed red blood cells. Following the initial resuscitation, her blood pressure improves to $105/65\text{ mmHg}$ but rapidly drops back to $78/45\text{ mmHg}$ within ten minutes. A bedside focused assessment with sonography for trauma (FAST) reveals free fluid in the hepatorenal recess (Morison pouch). Which of the following is the most appropriate next step in management?

A 24-year-old man is brought to the emergency department after a severe hyperextension injury to his right knee sustained during a rugby match. He is in severe pain. Physical examination reveals gross deformity of the right knee with a prominent medial femoral condyle. The right foot is slightly cool, and the right dorsalis pedis and posterior tibial pulses are palpable but noticeably weaker than those on the left. Capillary refill is 3 seconds in the right toes. Motor and sensory functions in the right foot are intact. Arrange the following steps in the most appropriate chronological sequence for evaluating and managing this patient's limb.

Evaluate the following clinical scenarios of trauma patients and pair each presentation with the single most appropriate next step in management.

A 42-year-old male roofing contractor arrives at the trauma center via ambulance after plunging approximately 6 meters (20 feet) off a residential roof. On arrival, he is pale and diaphoretic. His heart rate is 135/min, blood pressure is 76/40 mmHg, respiratory rate is 22/min, and oxygen saturation is 97% on room air. The trachea is midline, and breath sounds are clear and symmetric bilaterally. The pelvis is mechanically stable to anteroposterior and lateral compression. The abdomen is tense and exhibits involuntary guarding. Large-bore intravenous access is secured, and a bolus of warmed isotonic fluids is administered without a significant change in his hemodynamic parameters. Bedside ultrasonography demonstrates an anechoic fluid collection separating the liver and the right kidney. Which of the following is the most appropriate next step in the management of this patient?

A 50-year-old man is brought to the emergency department via ambulance exactly 2 hours after being caught in a large brush fire. His estimated weight is $75 \text{ kg}$. On physical examination, the patient is awake and speaking in full sentences without hoarseness. Airway is patent. He has deep partial-thickness and full-thickness burns involving his entire anterior trunk, his entire right arm, and the anterior surface of his left leg. The remainder of his body surface is unaffected. A large-bore peripheral intravenous line is established. Based on the most current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns, what is the target intravenous fluid administration rate for the remainder of the first 8 hours post-injury?

A 27-year-old male pedestrian is brought to the emergency department after being struck by a motor vehicle. He complains of severe pelvic and lower abdominal pain. On arrival, his temperature is $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure is 80/50 mmHg, heart rate is 132/min, and respiratory rate is 22/min. Oxygen saturation is 98% on room air. The patient's airway is patent, and breath sounds are equal bilaterally. A focused assessment with sonography for trauma (FAST) exam is negative for intraperitoneal fluid. Chest radiography reveals no abnormalities. Pelvic radiography demonstrates widening of the pubic symphysis and sacroiliac joints. An external pelvic binder is applied, and an institutional massive transfusion protocol is initiated. Reassessment 15 minutes later shows a blood pressure of 82/52 mmHg and a heart rate of 128/min. Which of the following is the most appropriate next step in management?

Evaluate the following unique presentations of thermal and chemical injuries. Match each distinct clinical presentation with the most appropriate immediate next step in management.

For each of the described victims of thoracic injury, select the most critical diagnostic or therapeutic intervention to optimize their survival or establish a definitive diagnosis.

Emergency medical services bring a $32$-year-old gravid patient (estimated $32$ weeks gestation) to the trauma bay following a high-speed motor vehicle collision. Paramedics report she was a restrained passenger wearing a lap belt without a shoulder strap. Upon arrival, the patient is immobilized on a backboard with a left lateral tilt. She is pale, diaphoretic, and confused. Vital signs are temperature $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), pulse $138/\text{min}$, respirations $28/\text{min}$, and blood pressure $78/42\text{ mm Hg}$. Physical examination reveals a protuberant abdomen that is rigid, with diffuse rebound tenderness and a transverse ecchymosis across the lower abdomen. Fetal heart rate monitoring demonstrates a baseline of $105/\text{min}$ with absent variability and recurrent late decelerations. Despite the rapid intravenous infusion of $2\text{ L}$ of warmed crystalloids and $2\text{ units}$ of uncrossmatched type O-negative blood, her blood pressure remains $82/45\text{ mm Hg}$. A bedside focused assessment with sonography for trauma (FAST) shows a large volume of anechoic fluid in the hepatorenal and splenorenal recesses. Which of the following is the most appropriate next step in management?

A 21-year-old man is brought to the emergency department after sustaining a direct blow to the left side of his abdomen during a rugby match. On presentation, he complains of severe left upper quadrant pain that radiates to his left shoulder. Initial vital signs show a blood pressure of 118/76 mmHg, heart rate of 92/min, and respiratory rate of 18/min. Bedside focused assessment with sonography for trauma (FAST) reveals a moderate amount of free fluid in the splenorenal recess. Two large-bore peripheral intravenous lines are established, and blood is drawn for laboratory studies. Ten minutes later, the patient becomes agitated, pale, and diaphoretic. Repeat vital signs show a blood pressure of 72/38 mmHg and a heart rate of 144/min. Which of the following is the most appropriate next step in management?

A 41-year-old female warehouse employee is brought to the emergency department after being struck by a reversing forklift and pinned against a concrete wall. She complains of diffuse abdominal pain and dizziness.

Vital signs upon arrival are temperature $36.4^\circ\text{C}$ ($97.5^\circ\text{F}$), blood pressure $78/45\text{ mmHg}$, heart rate $132/\text{min}$, and respiratory rate $22/\text{min}$.

Primary survey reveals a patent airway, and breath sounds are equal bilaterally. Her neck veins are flat. The pelvis demonstrates no mechanical instability to gentle compression. A focused assessment with sonography for trauma (FAST) demonstrates a substantial anechoic stripe in Morison's pouch.

She immediately receives a transfusion of uncrossmatched type O-negative packed red blood cells. Following this initial resuscitation, her blood pressure rises to $92/55\text{ mmHg}$ and her heart rate slows to $115/\text{min}$. The physician notes that her peripheral pulses remain weak and her capillary refill time is delayed.

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

A $33$-year-old construction worker is brought to the emergency department after a $20$-foot fall from a scaffold. On arrival, he is lethargic and diaphoretic. His temperature is $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), blood pressure is $78/45\text{ mm Hg}$, and pulse is $132\text{/min}$. Oxygen saturation is $96\%$ on room air. Primary survey reveals a patent airway and bilaterally equal breath sounds. The abdomen is soft, non-distended, and without guarding. Inspection of the pelvis shows a scrotal hematoma and blood at the urethral meatus. Gentle lateral compression of the iliac crests elicits crepitus and abnormal mobility. A bedside focused assessment with sonography for trauma (FAST) shows no free fluid in the peritoneal cavity or pericardial sac. An anteroposterior pelvic radiograph reveals a $4.5\text{-cm}$ pubic symphysis diastasis and widening of the left sacroiliac joint. Intravenous access is established, and aggressive crystalloid resuscitation is initiated. Which of the following is the most appropriate next step in management?