Trauma and Burns

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A 45-year-old man is brought to the emergency department via ambulance following a high-speed motor vehicle collision. On arrival, he is unresponsive with a Glasgow Coma Scale score of 6. His respiratory rate is 8/min and shallow. His blood pressure is 85/50 mm Hg and heart rate is 135/min. Examination reveals an open, severely deformed right lower extremity with pulsatile arterial bleeding. According to current Advanced Trauma Life Support (ATLS) protocols, arrange the following management steps in the correct chronological sequence from first to last.

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Cevap

The correct chronological sequence is: 1. Apply a tourniquet to the right lower extremity, 2. Secure the airway with endotracheal intubation, 3. Establish large-bore intravenous access, 4. Perform a Focused Assessment with Sonography for Trauma (FAST) exam, 5. Transfer the patient for computed tomography (CT) imaging.

The correct sequence follows the standard ATLS <C>ABCDE protocol: Catastrophic hemorrhage control, Airway, Breathing, Circulation, Disability, Exposure, followed by primary survey adjuncts, and finally the secondary survey/definitive imaging.

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Identify the immediate life-threatening injury that supersedes airway management.

The patient has pulsatile arterial bleeding from a deformed right lower extremity.

According to the updated ATLS 10th edition, catastrophic hemorrhage (<C>) must be controlled before Airway (A) management because exsanguination occurs more rapidly than death from hypoxia.

Determine the next priority in the primary survey (<C>ABCDE).

The patient has a GCS of 6 and a shallow respiratory rate of 8/min.

Airway (A) is the next priority. A GCS less than 8 necessitates definitive airway management with endotracheal intubation, along with cervical spine protection.

Identify the subsequent step in the primary survey.

The patient is hypotensive (BP 85/50 mm Hg) and tachycardic (HR 135/min).

Circulation (C) follows Airway and Breathing. Large-bore intravenous access must be established to initiate fluid and blood product resuscitation for hypovolemic shock.

Determine the role of diagnostic adjuncts in the initial evaluation.

The FAST exam is performed at the bedside.

FAST is an adjunct to the primary survey. It is used to rapidly identify the source of internal bleeding (e.g., intra-abdominal) without removing the unstable patient from the resuscitation area.

Determine the appropriate timing for definitive imaging.

The CT scan of the head and cervical spine is ordered.

CT imaging is part of the secondary survey. It requires leaving the trauma bay and should only be performed once the primary survey is complete and the patient's airway and hemodynamics are stabilized.

Anahtar Kavram

Advanced Trauma Life Support (ATLS) Primary Survey Sequence (<C>ABCDE)

Soru 282Soru →

A 41-year-old male warehouse worker is brought to the trauma center after being pinned between a forklift and a loading dock. He complains of severe abdominal pain. On arrival, he is awake and anxious.

Vital signs show a temperature of $36.8^\circ\text{C}$ ( $98.2^\circ\text{F}$ ), a blood pressure of $78/48\text{ mmHg}$ , a heart rate of $136\text{ /min}$ , and a respiratory rate of $26\text{ /min}$ . Oxygen saturation is $96\%$ on room air.

Primary survey reveals a patent airway and equal breath sounds bilaterally. There are extensive abrasions and ecchymoses across the anterior abdominal wall. Palpation of the abdomen elicits diffuse tenderness with involuntary guarding. The pelvis is mechanically stable to anteroposterior and lateral compression.

Two large-bore intravenous lines are established, and $1\text{ L}$ of warmed lactated Ringer solution is rapidly infused. Following the fluid bolus, his blood pressure is $82/50\text{ mmHg}$ and heart rate is $130\text{ /min}$ . A bedside focused assessment with sonography for trauma (FAST) demonstrates a significant anechoic collection in the hepatorenal recess (Morison pouch).

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

Immediate exploratory laparotomy

Computed tomography scan of the abdomen and pelvis with intravenous contrast

Application of a pelvic circumferential compression device

Admission to the surgical intensive care unit for serial abdominal examinations

Administration of broad-spectrum intravenous antibiotics

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Cevap: Immediate exploratory laparotomy

Cevap

Immediate exploratory laparotomy

The correct next step is an immediate exploratory laparotomy. This patient has sustained blunt abdominal trauma and presents with hemorrhagic shock. Despite initial fluid resuscitation with

1\text{ L}

of crystalloids, he remains hemodynamically unstable (blood pressure

82/50\text{ mmHg}

, heart rate

130\text{ /min}

). The positive FAST exam demonstrates intraperitoneal free fluid, which in this context represents active bleeding. The standard of care for a hemodynamically unstable patient with a positive FAST exam is immediate transport to the operating room for an exploratory laparotomy to achieve source control of the hemorrhage.

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Assess hemodynamic status and response to initial fluid resuscitation.

The patient remains hemodynamically unstable (hypotensive and tachycardic) after a

1\text{ L}

crystalloid bolus.

Determining hemodynamic stability is the critical branch point in the blunt abdominal trauma algorithm.

Identify the potential source of hemorrhage.

The FAST exam reveals free fluid in Morison's pouch, confirming intraperitoneal bleeding.

In unstable trauma patients, a FAST exam rapidly identifies whether the abdomen, thorax, or pericardium is the source of shock.

Determine the definitive management based on the findings.

The combination of hemodynamic instability and a positive FAST exam mandates immediate surgical source control.

An unstable patient with active intra-abdominal hemorrhage cannot tolerate the delay of further diagnostic imaging and requires emergent laparotomy.

Anahtar Kavram

Hemodynamically unstable patients with blunt abdominal trauma and a positive FAST exam require immediate exploratory laparotomy.

Tahmini Süre:1m 0s

Soru 283Soru →

A 42-year-old man is brought to the emergency department after being rescued from a house fire. On primary survey, his airway is patent, breathing is spontaneous, and breath sounds are equal bilaterally. Vital signs are temperature $37.1^\circ\text{C}$ ( $98.8^\circ\text{F}$ ), pulse $115/\text{min}$ , respirations $22/\text{min}$ , and blood pressure $110/70\text{ mmHg}$ . Physical examination reveals deep, blistered, weeping skin as well as charred, leathery eschar over his entire head and neck, his entire anterior trunk, his entire left arm, and the anterior surface of his left leg. The skin of his entire right arm is erythematous, dry, and painful to touch but lacks blisters. Based on the Rule of Nines, what is the calculated total body surface area (TBSA) percentage that should be used to guide his initial fluid resuscitation?

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Cevap: 45

Cevap

The correct TBSA is 45% because the calculation must only include deep partial-thickness and full-thickness burns. These correspond to the head and neck (9%), the anterior trunk (18%), the entire left arm (9%), and the anterior left leg (9%). The superficial burns on the right arm are excluded from resuscitation calculations.

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Determine burn depth for each affected region.

The head, anterior trunk, left arm, and anterior left leg have second- or third-degree burns. The right arm has first-degree burns.

Only partial-thickness (second-degree) and full-thickness (third-degree) burns are included in TBSA calculations for fluid resuscitation.

Apply the Rule of Nines to the qualifying body regions.

Head/neck = 9%, anterior trunk = 18%, entire left arm = 9%, anterior left leg = 9%.

Standard adult TBSA estimation divides the body into specific anatomical sections of 9% or multiples thereof.

Calculate the total percentage.

9 + 18 + 9 + 9 = 45%.

Summing the qualifying regions provides the correct TBSA required for determining fluid resuscitation needs.

Anahtar Kavram

Total Body Surface Area (TBSA) calculation using the adult Rule of Nines

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