Trauma and Burns

A 27-year-old man is brought to the emergency department by ambulance 20 minutes after sustaining a stab wound to the abdomen during an altercation. On arrival, he is lethargic and confused. His temperature is $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), blood pressure is $80/45\text{ mmHg}$, pulse is $135/\text{min}$, and respiratory rate is $22/\text{min}$. Pulse oximetry is $97\%$ on room air. Two large-bore intravenous lines are established, and a bolus of warmed isotonic crystalloid is initiated. The airway is patent, and breath sounds are clear and equal bilaterally. Physical examination reveals a 4-cm transverse laceration in the left lower quadrant of the abdomen. The abdomen is distended, and there is generalized guarding and rebound tenderness across all four quadrants. Which of the following is the most appropriate next step in management?

A 38-year-old male is brought to the emergency department after a high-speed head-on motor vehicle collision. He was an unrestrained driver and was ejected from the vehicle. Upon arrival, his blood pressure is 76/40 mmHg and his heart rate is 135/min. He is unresponsive with a Glasgow Coma Scale score of 3. The airway is secured with an endotracheal tube, and breath sounds are clear and equal bilaterally. The trachea is midline, and jugular veins are flat. Examination of the abdomen reveals mild distension and a transverse band of ecchymosis across the lower abdomen. The pelvis is mechanically stable to anteroposterior and lateral compression. Intravenous access is rapidly established, and a massive transfusion protocol is initiated. Which of the following is the most appropriate next step in management?

Following a severe pedestrian-vehicle collision, a young adult female is delivered to the trauma bay by paramedics. She was struck directly by a commercial truck that lost control on an icy road. On arrival, the patient is agitated, pale, and sweating profusely. The airway is clear, and bilateral breath sounds are symmetric and unlabored. Vital signs show a heart rate of 135/min and a blood pressure of 78/42 mm Hg, which remain unchanged after the rapid intravenous infusion of one liter of crystalloid solution. The abdomen is diffusely tender and mildly distended with a large ecchymosis across the periumbilical region. The pelvis is mechanically stable to anteroposterior and lateral compression. Which of the following is the most appropriate next step in management?

Match the following specific clinical trauma and burn presentations with their most appropriate immediate next step in management.

Paramedics arrive at the trauma bay with a $24$-year-old construction worker who sustained a stab wound to the left lower chest during an altercation at a job site. The injury occurred approximately $30$ minutes ago. On presentation, blood pressure is $82/45 \text{ mm Hg}$ and heart rate is $134 \text{/min}$. Pulse oximetry shows $96\%$ on supplemental oxygen. Primary survey reveals a $3\text{-cm}$ linear laceration in the left $6^{\text{th}}$ intercostal space at the midclavicular line. The airway is patent. Breath sounds are clear and symmetric bilaterally, and heart sounds are normal without muffling. Examination of the abdomen reveals diffuse rigidity, guarding, and severe tenderness to palpation in all four quadrants. Which of the following is the most appropriate next step in the management of this patient?

A 40-year-old female is rescued from an enclosed house fire and brought to the emergency department. She has sustained deep partial-thickness and full-thickness burns over her trunk and extremities. Physical examination reveals soot in her oropharynx, singed nasal hairs, and hoarseness. Her right arm has a circumferential full-thickness burn, and the distal radial pulse is absent on Doppler ultrasound. Arrange the following clinical interventions in the most appropriate chronological sequence according to standard trauma and burn management protocols.

A $27$-year-old male is brought to the emergency department $2$ hours after sustaining thermal injuries in an industrial flash fire. He is awake and alert. His airway is intact with no evidence of inhalational injury. Vital signs show a blood pressure of $115/75$ mm Hg, a heart rate of $108/min$, and a respiratory rate of $18/min$. Physical examination reveals deep partial-thickness burns over his entire anterior chest and abdomen, as well as his entire left upper extremity (circumferential). He weighs $80$ kg. Peripheral intravenous access is established.

Using the traditional Parkland formula ($4$ mL/kg/$\%$ total body surface area), what is the appropriate intravenous fluid administration rate (in mL/hr) for the remainder of the first $8$ hours following the injury?

Following a high-velocity collision during a collegiate rugby match, an athlete is transported to the trauma center complaining of progressive lightheadedness and severe left-sided abdominal pain. On arrival, the patient appears pale and diaphoretic. Vital signs show a heart rate of 128/min and a blood pressure of 82/50 mmHg. Primary survey reveals a patent airway, clear breath sounds bilaterally, and a rigid, distended abdomen with significant guarding. After rapid intravenous infusion of 1 liter of warmed lactated Ringer's solution, the blood pressure transiently improves to 105/65 mmHg but subsequently drops to 85/45 mmHg within 10 minutes. A bedside focused assessment with sonography for trauma (FAST) reveals a large amount of anechoic fluid in the splenorenal recess. Which of the following is the most appropriate next step in the management of this patient?

A 19-year-old man is rushed to the trauma center by emergency medical services after being struck by a fast-moving motor vehicle while crossing the street. On arrival, his blood pressure is 72/44 mmHg, heart rate is 140/min, and respiratory rate is 26/min. Pulse oximetry shows 96% on a non-rebreather mask. The airway is patent, and breath sounds are present and equal bilaterally. Trachea is midline. Peripheral pulses are rapid and thready. He immediately receives 1 L of intravenous Ringer's lactate and 1 unit of uncrossmatched packed red blood cells. Reassessment vital signs show a blood pressure of 78/48 mmHg and a heart rate of 130/min. Physical examination reveals a distended abdomen with diffuse guarding and rebound tenderness. The pelvis is mechanically stable to gentle compression. A focused assessment with sonography for trauma (FAST) exam demonstrates a prominent anechoic stripe in the right upper quadrant between the liver and kidney. Which of the following is the most appropriate next step in management?

A 34-year-old industrial worker is brought to the trauma bay after being involved in an accident with heavy machinery. On arrival, he has a pulsatile, massive hemorrhage from a mangled right leg. He is making gurgling sounds, his respiratory rate is 8/min, and he has a weak radial pulse of 130/min.

Arrange the following acute management steps in the correct chronological sequence according to current Advanced Trauma Life Support (ATLS) principles.

Emergency medical services bring a 32-year-old male warehouse worker to the trauma center 30 minutes after he was pinned between a forklift and a concrete loading dock. He is awake, diaphoretic, and complains of agonizing pain in his hips and lower back.

Vital signs on arrival are temperature 36.8°C (98.2°F), blood pressure 76/40 mmHg, heart rate 138/min, and respiratory rate 24/min. The airway is patent, and breath sounds are equal bilaterally. The trachea is midline. Two large-bore intravenous catheters are placed, and 1 L of warmed lactated Ringer solution is administered rapidly. Following fluid resuscitation, his blood pressure remains 74/42 mmHg.

Physical examination reveals a rapidly expanding scrotal hematoma and a small amount of blood at the urethral meatus. Gentle anteroposterior compression of the iliac crests demonstrates gross mechanical instability, and a pelvic binder is immediately applied.

A bedside focused assessment with sonography for trauma (FAST) demonstrates no free fluid in the pericardial, pleural, or peritoneal cavities. A portable chest radiograph is normal. A portable anteroposterior pelvic radiograph confirms a 4-cm diastasis of the pubic symphysis and disruption of the left sacroiliac joint.

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

A 42-year-old woman is transported to the emergency department after a grease fire erupted at the commercial kitchen where she works. The incident occurred exactly 3 hours before her arrival at the trauma center. She weighs $80 \text{ kg}$. On primary survey, her airway is patent, breathing is spontaneous but tachypneic, and hemodynamics are stable. Physical examination reveals deep partial-thickness and full-thickness burns involving her entire anterior trunk, her entire right arm, and the anterior surface of her right lower extremity. The remainder of her skin is uninjured. Using the traditional Parkland formula ($4 \text{ mL/kg/\%TBSA}$), at what rate (in $\text{mL/hour}$) should the initial intravenous crystalloid infusion be set to deliver the appropriate fluid volume over the remainder of the first 8-hour window?

Paramedics bring a 28-year-old construction worker to the emergency department following a 15-foot (4.5-meter) fall from scaffolding. He is conscious but reports intense pain across his entire abdomen. Vital signs reveal a blood pressure of 82/50 mmHg, a heart rate of 128/min, and a respiratory rate of 24/min. Pulse oximetry is 96% on ambient air. Primary evaluation demonstrates an intact airway with bilateral breath sounds present and equal. No obvious sources of external blood loss are identified. Abdominal examination reveals marked distension, diffuse tenderness, and involuntary guarding. The pelvis is mechanically stable to manual compression. A bedside ultrasound examination (FAST) demonstrates a large anechoic collection in Morison's pouch. Which of the following is the most appropriate next step in management?

Match each clinical presentation of an acutely injured trauma patient with the most appropriate next step in diagnostic or therapeutic management.

An unrestrained driver is ejected from his vehicle during a rollover collision and airlifted to the regional trauma center. Upon arrival, the patient is unresponsive. His airway is rapidly secured via endotracheal intubation. Initial vital signs reveal a heart rate of 138/min and a blood pressure of 72/40 mmHg. Breath sounds are clear and equal bilaterally. The abdomen is grossly distended and rigid to palpation. Anteroposterior compression of the pelvis reveals no mechanical instability. Despite the rapid infusion of 1 L of warmed crystalloid and 1 unit of uncrossmatched packed red blood cells, his blood pressure remains critically low at 76/42 mmHg. A focused assessment with sonography for trauma (FAST) examination demonstrates a significant amount of free fluid in both the splenorenal and hepatorenal spaces. Which of the following is the most appropriate next step in the management of this patient?

A 22-year-old man is brought to the emergency department after a motorcycle collision where he struck a guardrail at highway speeds. Emergency medical services report that he was found unresponsive at the scene. Upon arrival in the trauma bay, the trauma team observes bright red, pulsatile blood spurting from a deep laceration on his right mid-thigh. He is making gurgling respiratory sounds, and there is visible pooling of blood in his oropharynx. Tracheal deviation to the right is noted, and breath sounds are absent over the left hemithorax. His blood pressure is 68/40 mm Hg, and his heart rate is 145/min. Arrange the following acute management steps in the most appropriate sequential order according to the Advanced Trauma Life Support (ATLS) protocol.

An emergency response team brings a 45-year-old male industrial worker to the trauma center after a heavy steel beam collapsed, briefly pinning his lower torso against a concrete floor. On arrival, he is groggy but vigorously localizes to painful stimuli. His temperature is 36.5°C (97.7°F), blood pressure is 82/44 mmHg, heart rate is 134/min, and respiratory rate is 24/min. Pulse oximetry shows 98% on high-flow oxygen. Primary survey reveals a patent airway and bilateral breath sounds without adventitious noises. The trachea is midline, and neck veins are flat. Radial pulses are barely palpable, while femoral pulses are weak but present. A large ecchymosis is visible across the infraumbilical region, and the abdomen appears distended. Pelvic rock testing reveals no mechanical instability. Intravenous access is established with two large-bore peripheral catheters, and rapid crystalloid resuscitation is initiated. Which of the following is the most appropriate next step in the evaluation of this patient?

A 34-year-old woman arrives at the regional burn center via ambulance after being rescued from a residential house fire. She sustained deep partial-thickness and full-thickness thermal burns. Physical examination reveals that her entire right leg and her entire right arm are burned. Her uninjured skin is intact. The patient weighs $75 \text{ kg}$. The incident occurred exactly $2 \text{ hours}$ prior to her arrival at the hospital. Two large-bore intravenous lines are established.

Using the traditional Parkland formula ($4 \text{ mL/kg/}\% \text{TBSA}$), what should be the initial intravenous fluid infusion rate (in $\text{mL/hr}$) to administer the required volume over the remainder of the first 8 hours post-injury?

Following a high-speed collision with a commercial vehicle, a 29-year-old male cyclist is evaluated in the emergency department. He reports severe pain on the left side of his chest and abdomen. Vital signs show a blood pressure of 82/48 mm Hg, a heart rate of 132/min, and a respiratory rate of 24/min. Oxygen saturation is 98% on supplemental oxygen. The airway is secure, and the trachea is midline. Auscultation reveals clear and equal breath sounds bilaterally. There is a prominent transverse contusion across the left upper quadrant of the abdomen, consistent with a handlebar impact. The abdomen is tender to deep palpation in this region, but there is no involuntary guarding or rebound tenderness. The pelvis is mechanically stable to compression. Intravenous access is established, and a bolus of warmed isotonic crystalloid is initiated. Which of the following is the most appropriate next step in the management of this patient?

A 30-year-old woman, gravida 2, para 1, at 33 weeks gestation, is brought to the emergency department via ambulance after her vehicle struck a concrete barrier at highway speeds. Upon arrival, she is lethargic, pale, and diaphoretic. She localizes to painful stimuli and moans incomprehensibly. Her temperature is 36.4°C (97.5°F), blood pressure is 76/40 mmHg, heart rate is 135/min, and respiratory rate is 26/min. Physical examination reveals a seatbelt sign across her lower abdomen. The abdomen is distended and exhibits diffuse rebound tenderness. A focused assessment with sonography for trauma (FAST) demonstrates significant free fluid in the hepatorenal and splenorenal recesses. Continuous fetal monitoring shows a baseline heart rate of 100/min with minimal variability. Which of the following is the most appropriate next step in management?