Trauma and Burns

A 31-year-old woman is brought to the trauma center by emergency medical services after a high-speed head-on motor vehicle collision. At the scene, she was unresponsive and intubated for airway protection. Upon arrival, her temperature is 36.1°C (97.0°F), blood pressure is 76/40 mmHg, and heart rate is 142/min. She is receiving mechanical ventilation. Glasgow Coma Scale score is 3T. Pupillary examination reveals a 7-mm nonreactive right pupil and a 3-mm reactive left pupil. Breath sounds are equal bilaterally. The pelvis is mechanically stable on anteroposterior compression. There are no obvious external sources of bleeding. A focused assessment with sonography for trauma (FAST) examination reveals a large anechoic stripe in the hepatorenal recess. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old pregnant woman at 34 weeks gestation is evaluated in the trauma center following a high-velocity motor vehicle collision. First responders noted substantial vehicular damage. On arrival, she is alert but anxious. Her airway is patent and breathing is unlabored. Vital signs show a temperature of $36.7^\circ\text{C}$ ($98.1^\circ\text{F}$), blood pressure of $78/48\text{ mm Hg}$, pulse of $134/\text{min}$, and respiratory rate of $24/\text{min}$. The trachea is midline, and breath sounds are symmetric. Her abdomen is distended, gravid, and diffusely tender with rebound. Manual compression of the iliac crests reveals a stable pelvis. Two large-bore peripheral intravenous catheters are placed, and warmed crystalloid infusion is started. A bedside ultrasonographic assessment demonstrates an anechoic fluid collection in the hepatorenal space. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old construction worker is brought to the emergency department after a heavy concrete beam fell on his pelvis. His blood pressure is 118/76 mmHg and heart rate is 92/min. Primary survey reveals a patent airway and clear lungs. A pelvic binder is applied. Physical examination reveals a scrotal hematoma and blood at the urethral meatus. Arrange the following diagnostic and therapeutic steps in the correct chronological sequence to appropriately evaluate and manage this patient, assuming findings lead to the diagnosis and treatment of an intraperitoneal bladder rupture.

A 54-year-old man arrives at the trauma center via ambulance after falling approximately 20 feet from a roof. En route, emergency medical services placed a cervical collar and secured him to a backboard. Upon arrival, the patient is agitated, pale, and diaphoretic. His temperature is $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure is $78/48\text{ mmHg}$, pulse is $132\text{/min}$, and respiratory rate is $22\text{/min}$. Oxygen saturation is $98\%$ on a non-rebreather mask. The airway is patent, and breath sounds are clear and equal bilaterally. The abdomen is notably distended and diffusely tender to palpation, with significant involuntary guarding. The pelvis is mechanically stable to manual compression. Two large-bore intravenous lines are established, and rapid resuscitation with warmed isotonic crystalloids is initiated. 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 trauma bay after being struck by a car while crossing the street. He is moaning in pain and has visible bruising 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 28-year-old military contractor is brought to the trauma bay immediately after an improvised explosive device (IED) blast. On arrival, bright red blood is vigorously spurting from a right mid-thigh amputation. The patient has agonal respirations, severe maxillofacial crush injuries, and a hoarse, gurgling voice. Physical examination reveals absent breath sounds on the left hemithorax with distended neck veins. His blood pressure is undetectable, and his heart rate is 145/min. Arrange the following critical management steps in the correct chronological order according to the Advanced Trauma Life Support (ATLS) primary survey protocol.

Paramedics rush a 41-year-old female to the emergency department after she was thrown from a horse. The patient is confused and diaphoretic. Vital signs show a heart rate of 135/min, respiratory rate of 24/min, and blood pressure of 78/50 mm Hg. Large-bore intravenous access is established, and a 1-liter bolus of crystalloid is rapidly infused, but her blood pressure only improves to 82/55 mm Hg. Physical examination reveals extensive ecchymosis and guarding over the left upper quadrant of the abdomen. A bedside focused assessment with sonography for trauma (FAST) demonstrates a large anechoic stripe in the splenorenal recess. Which of the following is the most appropriate next step in management?

A 34-year-old man is brought to the emergency department after sustaining a single stab wound to the left lateral chest during an altercation. On arrival, he is in severe respiratory distress. His blood pressure is 82/50 mmHg, heart rate is 128/min, and oxygen saturation is 88% on room air. Physical examination reveals a 3-cm linear laceration in the left 5th intercostal space at the mid-axillary line. Breath sounds are markedly diminished on the left side, and the trachea is deviated to the right. A needle thoracostomy is immediately performed, followed by placement of a left-sided tube thoracostomy. The chest tube yields a rush of air and 400 mL of dark blood. Following the procedure, the patient's oxygen saturation improves to 96% on supplemental oxygen, but his blood pressure remains 84/52 mmHg and heart rate is 125/min. A focused assessment with sonography for trauma (FAST) exam reveals no pericardial effusion but demonstrates a large amount of anechoic fluid in the splenorenal recess. Which of the following is the most appropriate next step in management?

Emergency medical responders transport a 42-year-old bicyclist to the trauma center following a high-speed collision with a delivery van. Upon arrival, the patient is agitated, diaphoretic, and confused. Vital signs show a temperature of 36.4°C (97.5°F), blood pressure of 76/40 mm Hg, heart rate of 138/min, and respiratory rate of 28/min. Physical examination reveals extensive ecchymoses over the left lower thorax and a rigid, distended abdomen with diffuse rebound tenderness. The pelvis is stable to anteroposterior compression. A Focused Assessment with Sonography for Trauma (FAST) reveals a large anechoic stripe in the splenorenal and hepatorenal recesses. The patient's personal belongings include a legally executed advance directive designating his sister as his healthcare proxy. His father arrives at the trauma bay simultaneously and demands to make all treatment decisions. What is the most appropriate next step in management?

A 24-year-old man is brought to the emergency department after a high-speed motorcycle collision. He complains of severe pain in his left leg. Physical examination reveals a deformed left knee with an obvious posterior dislocation. The dislocation is promptly reduced in the emergency department. Afterward, palpation of the left pedal pulses reveals they are diminished compared to the right side. The patient remains hemodynamically stable. To evaluate for potential popliteal artery injury, the physician measures systolic blood pressures using a continuous-wave Doppler ultrasound and a sphygmomanometer. The following systolic pressures are recorded:

What is the Ankle-Brachial Index (ABI) of the injured extremity?

A 45-year-old industrial worker is brought to the emergency department after a chemical vat exploded. He sustained deep partial-thickness burns. Physical examination reveals burns covering his entire anterior trunk (chest and abdomen), his entire right upper extremity (both anterior and posterior surfaces), and his entire right lower extremity (both anterior and posterior surfaces). No other areas of the body are affected.

Based on the Rule of Nines, what is the estimated total body surface area (TBSA) percentage affected by burns in this patient?

Match each clinical trauma presentation with the most appropriate next step in definitive management or diagnosis.

Helicopter emergency medical services arrive at a regional burn center with a 50-year-old male who was extricated from a residential fire. The injury occurred exactly 3 hours prior to arrival. Upon presentation, he is intubated and mechanically ventilated. His estimated body weight is 80 kg. Vital signs show a blood pressure of 115/75 mm Hg and a heart rate of 112/min. Physical examination of the skin reveals blistering, weeping, and exquisitely tender lesions over the entire anterior trunk. The entire right lower extremity is covered in white, leathery, and insensate eschar. The entire left upper extremity exhibits diffuse erythema with intact epidermis, blanching on pressure, and no blistering. A large-bore peripheral intravenous catheter is successfully placed. Based on the most current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns, what should the initial intravenous crystalloid infusion rate be set to in mL/hr?

Following a collision with a tree while skiing, a 21-year-old man is transported to the trauma center by medical helicopter. Upon arrival, his blood pressure is 82/45 mm Hg and his heart rate is 128/min. His respiratory rate is 22/min, and oxygen saturation is 98% on high-flow oxygen. He appears pale and is confused, but localizes to painful stimuli. The airway is patent, and breath sounds are equal bilaterally. Examination reveals significant ecchymosis over the left lower chest wall and left upper quadrant of the abdomen. The abdomen is tender to palpation with involuntary guarding. The pelvis is mechanically stable to lateral and anteroposterior compression. Which of the following is the most appropriate next step in the management of this patient?

A 29-year-old male is brought to the emergency department after being crushed between a concrete loading dock and a reversing forklift. On arrival, his airway is patent, and breath sounds are equal bilaterally. Vital signs show a blood pressure of 76/40 mm Hg and a heart rate of 142/min. Physical examination reveals a mechanically unstable pelvis in response to anteroposterior compression. Genitourinary examination demonstrates a scrotal hematoma and a prominent drop of blood at the urethral meatus. A commercial pelvic binder is immediately applied, and a massive transfusion protocol is initiated. Ten minutes later, after the rapid infusion of uncrossmatched packed red blood cells and fresh frozen plasma, his blood pressure remains 78/42 mm Hg. A Focused Assessment with Sonography for Trauma (FAST) examination demonstrates a large stripe of anechoic fluid in the hepatorenal and splenorenal recesses. Which of the following is the most appropriate next step in management?

Following a kick to the left flank by a horse, a 45-year-old man arrives at the trauma center. He complains of severe left-sided abdominal pain that radiates to his left shoulder. Upon arrival, he appears in significant distress. Vital signs are temperature 36.8°C (98.2°F), blood pressure 105/65 mm Hg, pulse 112/min, and respirations 18/min. Oxygen saturation is 98% on room air. Two large-bore intravenous lines are established, and he is rapidly infused with 1 L of lactated Ringer solution. Following the fluid resuscitation, his blood pressure improves to 128/76 mm Hg and his pulse decreases to 88/min. Physical examination reveals ecchymosis over the left lower ribs and significant tenderness in the left upper quadrant with voluntary guarding. Breath sounds are clear and equal bilaterally. A bedside focused assessment with sonography for trauma (FAST) reveals a moderate amount of anechoic fluid in the splenorenal recess. Which of the following is the most appropriate next step in management?

A 52-year-old man is transported to the trauma center by helicopter after a high-speed head-on motor vehicle collision. On arrival, he is confused and diaphoretic. His blood pressure is 82/54 mm Hg, heart rate is 128/min, and respiratory rate is 22/min. Oxygen saturation is 97% on a nonrebreather mask. The airway is secure, and breath sounds are present and equal bilaterally. The abdomen is grossly distended and rigid to palpation. Pelvic compression does not elicit instability. Intravenous access is established, and rapid fluid resuscitation with warmed crystalloid is initiated. A focused assessment with sonography for trauma (FAST) examination reveals an anechoic stripe in the hepatorenal recess. Which of the following is the most appropriate next step in management?

Correlate the following classic clinical findings in blunt trauma patients with their most likely associated underlying injury.

Match each clinical trauma presentation with the most appropriate next step in definitive diagnosis or management.

A 25-year-old male is brought to the emergency department after falling 20 feet from a roof. He is unconscious, hypotensive, and has obvious facial trauma. Arrange the following steps of his initial assessment and management in the correct chronological order according to Advanced Trauma Life Support (ATLS) protocols.