Trauma and Burns

A 34-year-old woman is brought to the emergency department after falling approximately 15 feet from a roof. Upon arrival, she is lethargic but responsive to painful stimuli. Her blood pressure is 78/45 mmHg, and her heart rate is 132/min. Oxygen saturation is 96% on room air. Her airway is clear, and breath sounds are present and equal bilaterally. The abdomen appears distended and is tense on palpation. A bedside focused assessment with sonography in trauma (FAST) reveals a significant amount of anechoic fluid surrounding the spleen and liver. Which of the following is the most appropriate next step in management?

Match the following complex trauma patient presentations with the most appropriate definitive next step in their diagnostic or therapeutic management. Assume all patients have established, secure airways and are receiving appropriate initial fluid resuscitation.

A 41-year-old factory worker is evaluated in the resuscitation bay following an industrial explosion inside an enclosed warehouse. Physical examination reveals singed facial hair, hoarseness, carbonaceous sputum, and extensive blistering over the anterior chest and both upper extremities.

Arrange the following acute management steps in the correct chronological sequence according to standard trauma life support protocols.

A 31-year-old woman is evaluated in the emergency department after a paragliding collision with a mountain ridge. Upon arrival, she is lethargic and diaphoretic. Her temperature is 36.4°C (97.5°F), blood pressure is 78/42 mm Hg, pulse is 134/min, and respiratory rate is 24/min. Oxygen saturation is 96% on 15 L/min via non-rebreather mask. The airway is unobstructed, and breath sounds are clear and symmetric bilaterally. There is no active external bleeding. Physical examination reveals a large ecchymosis over the left flank. The abdomen is markedly distended, rigid, and diffusely tender with guarding. A focused assessment with sonography for trauma (FAST) demonstrates a large volume of anechoic fluid in the hepatorenal space (Morison pouch) and splenorenal recess. Intravenous access is rapidly secured and fluid resuscitation is initiated. Which of the following is the most appropriate next step in the management of this patient?

A 38-year-old male is brought to the emergency department after a high-speed collision in which his snowmobile struck a tree. Upon arrival, he is in severe respiratory distress. Vital signs are blood pressure 80/50 mm Hg, heart rate 138/min, and respiratory rate 32/min. Oxygen saturation is 86% on a non-rebreather mask. Physical examination reveals absent breath sounds over the left hemithorax and dullness to percussion. The trachea is deviated to the right. The abdomen is noticeably scaphoid and diffusely tender to palpation. A needle thoracostomy is immediately performed in the left second intercostal space, yielding a small rush of air but no significant clinical improvement. A subsequent tube thoracostomy in the left fifth intercostal space returns 200 mL of dark blood mixed with particulate matter resembling partially digested food. Which of the following is the most appropriate next step in management?

Emergency medical services bring a $28$-year-old male to the trauma bay following a high-speed motorcycle collision. He was found unresponsive at the scene. Currently, the patient is obtunded but his airway remains patent with equal bilateral breath sounds. Initial vital signs include a blood pressure of $70/40\text{ mmHg}$ and a heart rate of $142\text{ beats/min}$. Abdominal examination shows severe distension and a rigid contour with prominent ecchymosis over the lower quadrants. A bedside focused assessment with sonography for trauma (FAST) reveals a large volume of anechoic fluid in the hepatorenal recess and pelvis. Peripheral intravenous access is secured and crystalloid fluid administration is started. Which of the following is the most appropriate next step in management?

A 56-year-old man is brought to the emergency department after a high-speed motor vehicle collision. He was the restrained driver in a head-on impact with a concrete pillar. His airway is secure, and breath sounds are equal bilaterally. Vital signs show a heart rate of 118/min and a blood pressure of 165/92 mmHg. He is alert but complains of severe interscapular back pain. Secondary survey reveals a seatbelt sign across the chest. A portable anteroposterior chest radiograph obtained in the trauma bay demonstrates a widened mediastinum and loss of the aortic knob contour. The patient remains hemodynamically stable. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for the optimal management of this patient.

A 35-year-old man is brought to the emergency department after a structural fire. He weighs $80 \text{ kg}$. The burn injury occurred exactly 2 hours prior to his arrival at the emergency department. Physical examination reveals deep partial-thickness and full-thickness burns involving the entire anterior surface of his torso, his entire right arm, and the entire anterior surface of his right leg. No other burn injuries are identified. Using the traditional Parkland formula ($4 \text{ mL/kg}$ per percentage of total body surface area), what should be the target intravenous fluid administration rate (in $\text{mL/hr}$) for this patient for the remainder of the first 8-hour post-injury period?

A 34-year-old plumber weighing 80 kg is brought to the emergency department 30 minutes after a commercial water heater exploded at a job site. He is awake and in significant pain. Vital signs show a heart rate of 110/min, blood pressure of 130/85 mm Hg, and respiratory rate of 20/min. Physical examination reveals second- and third-degree thermal burns involving his entire anterior trunk, his entire right arm, and the anterior surface of his right leg. There is no facial involvement or singed nasal hairs. The remainder of his skin is unaffected. Using the Rule of Nines for adults, what is the estimated total body surface area (TBSA) percentage affected by these burns?

A 28-year-old unrestrained driver is extricated from a crushed vehicle after a prolonged entrapment. On arrival at the trauma center, his systolic blood pressure is 65 mm Hg, heart rate is 142/min, and core temperature is 34.0°C (93.2°F). Focused assessment with sonography in trauma (FAST) demonstrates massive intraperitoneal free fluid. Initial arterial blood gas analysis reveals a pH of 7.12, and coagulation studies show an international normalized ratio (INR) of 1.9. Arrange the following management steps in the most appropriate chronological sequence according to established damage control principles for this patient.

A 29-year-old male utility worker is brought to the emergency department after sustaining a high-voltage electrical injury while working on a power line. The injury occurred exactly 3 hours ago. On presentation, he has full-thickness burns involving his entire anterior trunk, entire right arm, entire left arm, and the anterior surface of his right leg. The remainder of his skin is uninjured. He weighs 90 kg. During transport, emergency medical services established intravenous access and administered 1,100 mL of lactated Ringer solution. According to the Advanced Trauma Life Support (ATLS) guidelines for electrical burns, what should be the intravenous fluid infusion rate (in mL/hr) for the remainder of the first 8-hour resuscitation period?

A 42-year-old male construction worker is evaluated in the trauma center after a 15-foot fall from scaffolding. On arrival, his blood pressure is $75/40 \text{ mmHg}$ and heart rate is $132 \text{ /min}$. His airway is patent, and breath sounds are present and equal bilaterally. A chest radiograph shows no abnormalities. The abdomen is soft and non-distended without guarding or rigidity. A focused assessment with sonography for trauma (FAST) reveals no free intraperitoneal or pericardial fluid. Gentle compression of the iliac crests reveals mechanical instability and crepitus. Which of the following is the most appropriate next step in management?

A 22-year-old woman is brought to the emergency department by paramedics after falling from a horse. The horse reportedly stepped directly on her mid-abdomen. She is groaning in pain and appears confused. Her temperature is 36.5°C (97.7°F), heart rate is 134/min, blood pressure is 82/50 mm Hg, and respiratory rate is 24/min. Pulse oximetry is 97% on room air. The patient is lethargic but is actively protecting her airway. Breath sounds are clear and equal bilaterally. The abdomen is visibly distended, tense, and diffusely tender to palpation with guarding. The pelvis is stable to gentle compression. Two large-bore intravenous lines are established, and a 1-liter bolus of warm crystalloid is rapidly administered. Reassessment reveals a heart rate of 128/min and a blood pressure of 84/52 mm Hg. Which of the following is the most appropriate next step in management?

A $45$-year-old man is brought to the emergency department after a high-speed motorcycle collision. On arrival, he is confused and diaphoretic.

Temperature is $35.8^\circ\text{C}$ ($96.4^\circ\text{F}$), blood pressure is $78/40\text{ mmHg}$, heart rate is $135/\text{min}$, and respiratory rate is $28/\text{min}$. Primary survey reveals a patent airway and equal breath sounds bilaterally. The abdomen is distended with diffuse tenderness to palpation. Pelvic compression produces gross mechanical instability. Bilateral lower extremities are cool with weak dorsalis pedis pulses.

A pelvic binder is immediately applied, and massive transfusion protocol is initiated. Following the rapid administration of $2\text{ units}$ of uncrossmatched packed red blood cells and $2\text{ units}$ of fresh frozen plasma, his blood pressure is $82/45\text{ mmHg}$.

A focused assessment with sonography for trauma (FAST) exam demonstrates a moderate amount of anechoic fluid in the hepatorenal recess (Morison pouch). An anteroposterior pelvic radiograph shows a $4\text{ cm}$ diastasis of the pubic symphysis and widening of the right sacroiliac joint.

Arterial blood gas analysis reveals a $\text{pH}$ of $7.22$, $\text{pCO}_2$ of $29\text{ mmHg}$, and $\text{HCO}_3^-$ of $12\text{ mEq/L}$.

The patient's estranged brother arrives and demands that all life-saving procedures be halted, stating the patient 'would never want to be kept alive like this.' There is no formal advance directive on file, and the patient's wife is currently unreachable.

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

A 34-year-old woman is evaluated in the trauma bay after being struck by a fast-moving electric bicycle while crossing the street. She was thrown several feet and struck her abdomen against the edge of a sidewalk. On arrival, she is lethargic but responds to voice. Her temperature is $36.8^\circ C$ ($98.2^\circ F$), blood pressure is $82/50$ mm Hg, pulse is $128$/min, and respirations are $22$/min. Primary survey reveals a patent airway and clear, equal breath sounds bilaterally. The abdomen is visibly distended, firm, and diffusely tender to palpation with guarding. A focused assessment with sonography for trauma (FAST) shows a large amount of anechoic fluid in the hepatorenal recess (Morison's pouch) and the splenorenal recess. Two large-bore intravenous lines are placed, and fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

A 31-year-old man is brought to the trauma center by helicopter after falling approximately 10 meters (33 feet) from a construction scaffold. His airway was secured by paramedics at the scene with an endotracheal tube. Large-bore intravenous access is established, and a massive transfusion protocol is initiated. Current vital signs are temperature 35.6°C (96.1°F), blood pressure 72/40 mm Hg, and heart rate 148/min. Breath sounds are equal bilaterally. The patient does not open his eyes or move his extremities to painful stimuli. His right pupil is 7 mm and nonreactive to light, while his left pupil is 3 mm and reactive. The abdomen is visibly distended and tense. Bedside sonography for trauma demonstrates a large volume of anechoic fluid in the hepatorenal and perisplenic spaces. Which of the following is the most appropriate next step in the management of this patient?

A 32-year-old man is brought to the emergency department via ambulance after being rescued from a house fire. He weighs 100 kg. The fire started at 13:00, and he was extricated shortly after. He arrives at the emergency department at 16:00. Physical examination reveals deep partial-thickness and full-thickness thermal burns involving his entire back, entire right arm, entire left arm, and the anterior surface of his right leg. During transport, emergency medical services administered 900 mL of intravenous Lactated Ringer's solution. Vital signs are blood pressure 110/70 mmHg, heart rate 115/min, and respiratory rate 22/min. Assuming adherence to the most current Advanced Trauma Life Support (ATLS) recommendations for adult thermal burn fluid resuscitation ($2 \text{ mL} \times \text{weight in kg} \times \%\text{TBSA}$), what should be the intravenous fluid infusion rate (in mL/hr) programmed on the pump for the remainder of the first 8-hour resuscitation window?

A $32$-year-old man is brought to the trauma bay via ambulance after being ejected from a vehicle during a high-speed rollover collision. On arrival, he is unresponsive. Vital signs show a blood pressure of $75/40$ mm Hg, a heart rate of $142$/min, and a respiratory rate of $6$/min with shallow, gurgling respirations. Paramedics report a large, deep laceration on his left mid-thigh that is actively spurting bright red blood. According to standard trauma resuscitation protocols, arrange the following initial management steps in the correct chronological order.

Match each trauma patient presentation with the most appropriate next step in acute management according to Advanced Trauma Life Support (ATLS) principles.

During the second day of hospitalization, a patient who suffered deep partial-thickness and full-thickness burns over $55\%$ of the total body surface area experiences sudden clinical deterioration. The thermal injuries predominantly involve the posterior torso and bilateral lower extremities. The patient is intubated, deeply sedated, and paralyzed with continuous neuromuscular blockade in the intensive care unit. An orogastric tube is in place and set to low continuous suction. Fluid resuscitation with isotonic crystalloids has been ongoing per standard burn protocols. Over the last three hours, urine output has decreased to $5\text{ mL/hr}$. Vital signs now show a blood pressure of $78/45\text{ mm Hg}$ and a heart rate of $138/\text{min}$. The abdomen is severely distended and tense to palpation. Mechanical ventilation parameters reveal a new increase in peak inspiratory pressures to $46\text{ cm H}_2\text{O}$. A transurethral bladder pressure measurement reveals a value of $32\text{ mm Hg}$. Which of the following is the most appropriate next step in the management of this patient?