Trauma and Burns

A $28$-year-old male is brought to the trauma bay after a high-speed motorcycle collision. Emergency medical services report a prolonged scene time. On arrival, the patient is unresponsive. There is active, pulsatile bleeding from a traumatic partial amputation of the left lower leg. He has severe maxillofacial smash injuries with pooling of blood and vomitus in the oropharynx. Breath sounds are absent on the right side, and the trachea is deviated to the left. His blood pressure is $70/40$ mm Hg, and his heart rate is $145$/min. Arrange the following initial management steps in the correct chronological sequence according to the current Advanced Trauma Life Support (ATLS) primary survey protocol.

A 29-year-old woman, primigravida at 34 weeks gestation, is brought to the emergency department after a high-speed motor vehicle collision. She was the unrestrained driver. Upon arrival, her blood pressure is 78/42 mm Hg, pulse is 138/min, and respirations are 26/min. The airway is patent, and the trachea is midline. Breath sounds are vesicular and equal bilaterally. The patient is lethargic and pale. Abdominal examination reveals a gravid uterus, diffuse abdominal rigidity, and severe rebound tenderness. A Focused Assessment with Sonography for Trauma (FAST) exam reveals a large anechoic stripe in the hepatorenal space. After the rapid administration of 2 liters of intravenous crystalloid, her blood pressure is 82/46 mm Hg. Fetal heart rate monitoring shows a baseline of 105/min with recurrent late decelerations. The patient's husband, who was a restrained passenger and sustained no significant injuries, frantically demands that the surgical team perform an emergency Cesarean delivery immediately to save the baby. Which of the following is the most appropriate next step in management?

A $45$-year-old man is brought to the emergency department by ambulance following an industrial boiler explosion. The injury occurred exactly $2$ hours prior to his arrival. He sustained deep partial-thickness and full-thickness thermal burns to his entire anterior trunk and his entire left lower extremity. His airway is intact without signs of inhalation injury, and there is no evidence of electrical injury. The patient weighs $80\text{ kg}$ ($176\text{ lbs}$). No intravenous fluids were administered in the prehospital setting. According to current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns, the medical team initiates resuscitation with lactated Ringer solution. What is the appropriate initial rate of intravenous fluid administration in $\text{mL/hr}$ for this patient?

Match each clinical trauma scenario with the most appropriate definitive diagnostic or therapeutic next step.

A 54-year-old female pedestrian is transported to the trauma bay after being struck by a public transit bus. Upon arrival, she is lethargic and pale. Her blood pressure is 75/40 mmHg, heart rate is 138/min, and respiratory rate is 26/min. The airway is patent, and breath sounds are equal bilaterally. Physical examination reveals extensive ecchymoses over the lower abdomen and flanks. There is a palpable diastasis of the pubic symphysis, and the pelvis is mechanically unstable to anteroposterior compression. An initial point-of-care ultrasound of the chest and abdomen shows no evidence of pericardial, pleural, or intraperitoneal fluid. An anteroposterior pelvic radiograph confirms a severely displaced open-book pelvic fracture. A circumferential non-invasive pelvic binder is promptly placed over the greater trochanters. Following the administration of two units of uncrossmatched type O-negative packed red blood cells, her blood pressure remains 78/42 mmHg and heart rate is 135/min. Which of the following is the most appropriate next step in the management of this patient?

A 37-year-old male is brought to the emergency department by ambulance after falling approximately 20 feet (6 meters) from scaffolding. He is immobilized on a backboard with a cervical collar. Upon arrival, his temperature is $36.1^{\circ}\text{C}$ ($97.0^{\circ}\text{F}$), blood pressure is $78/45\text{ mmHg}$, heart rate is $138\text{ /min}$, and respiratory rate is $26\text{ /min}$. Oxygen saturation is $97\%$ on room air. Two large-bore intravenous lines are established, and aggressive crystalloid fluid resuscitation is initiated. The airway is patent, and breath sounds are present and equal bilaterally. The abdomen is distended and diffusely tender. The pelvis is stable to anteroposterior compression. Focused assessment with sonography for trauma (FAST) reveals a significant anechoic fluid collection in the splenorenal recess. His blood pressure remains $80/48\text{ mmHg}$ after $1\text{ L}$ of crystalloid infusion. Which of the following is the most appropriate next step in management?

Match the following clinical presentations of trauma patients to the most appropriate next step in management. Assume airway and breathing have been assessed and secured in all patients.

Identify the most appropriate next step in management for each of the following burn-related clinical scenarios.

A 31-year-old man is brought to the emergency department by ambulance after sustaining a stab wound to the abdomen during a physical altercation. On arrival, he is lethargic and pale. Vital signs are temperature $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure $78/42\text{ mmHg}$, pulse $142/\text{min}$, and respirations $24/\text{min}$. Pulse oximetry is $97\%$ on high-flow oxygen. Primary survey reveals a patent airway and equal bilateral breath sounds. There is a single $4\text{ cm}$ laceration in the left upper quadrant, just below the costal margin. The patient's abdomen is markedly distended, rigid, and exhibits diffuse rebound tenderness. Peripheral pulses are 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 the management of this patient?

A 38-year-old man is brought to the trauma bay following a high-speed motorcycle collision. He is confused and agitated. His blood pressure is 75/40 mm Hg, and his heart rate is 142/min. His airway is patent, and breath sounds are clear and equal bilaterally. The pelvis is clinically stable on examination, and there are no obvious sources of external hemorrhage. Arrange the following steps in the most appropriate chronological sequence for the evaluation and management of this patient's condition.

A 42-year-old woman is brought to the emergency department by ambulance following an all-terrain vehicle (ATV) rollover. She was thrown from the vehicle and struck her abdomen against a large rock. She reports severe diffuse abdominal pain. On presentation, her temperature is 36.6°C (97.9°F), blood pressure is 82/50 mmHg, pulse is 132/min, and respirations are 24/min. Intravenous fluid resuscitation with lactated Ringer's is initiated. Primary survey demonstrates an intact airway and clear, equal breath sounds bilaterally. The abdomen is visibly distended with diffuse involuntary guarding and rebound tenderness. Compression of the iliac crests reveals a stable pelvis. A bedside focused assessment with sonography for trauma (FAST) is performed and demonstrates an anechoic fluid collection in the hepatorenal recess (Morison pouch). Which of the following is the most appropriate next step in management?

Emergency medical services bring a 24-year-old male to the trauma center following a high-velocity motorcycle collision. He was found approximately 30 meters from his vehicle without a helmet. Due to a severely depressed level of consciousness (Glasgow Coma Scale score of 5), he was intubated at the scene. Upon arrival, he is receiving mechanical ventilation. Vital signs show a blood pressure of $76/40 \text{ mmHg}$ and a heart rate of $142 \text{ /min}$. Physical examination reveals a right pupil that is $7 \text{ mm}$ and unresponsive to light, while the left pupil is $3 \text{ mm}$ and reactive. Breath sounds are clear and symmetric bilaterally. A portable chest radiograph shows clear lung fields without pneumothorax. A portable pelvic radiograph demonstrates intact pelvic ring structures. Bedside ultrasonography of the abdomen demonstrates a significant anechoic fluid collection between the liver and the right kidney. Two large-bore intravenous lines are present, and the massive transfusion protocol is actively running. What is the most appropriate next step in the management of this patient?

A 19-year-old male collegiate rugby player collapses on the field after being tackled forcefully around the midsection by an opposing player. He is rushed to the emergency department. En route, emergency medical services administer 2 L of intravenous crystalloid solution. On arrival, he is restless and complaining of severe abdominal pain. His temperature is 36.1°C (97.0°F), pulse is 142/min, blood pressure is 76/40 mm Hg, and respiratory rate is 26/min. Oxygen saturation is 98% on high-flow oxygen. Physical examination reveals an exquisitely tender, board-like abdomen with severe rebound tenderness across all four quadrants. There is early ecchymosis developing over the periumbilical area. The pelvis is mechanically stable to anteroposterior and lateral compression. Cardiopulmonary auscultation reveals clear breath sounds bilaterally. Which of the following interventions should be prioritized next for this patient?

A 28-year-old man is brought to the emergency department via ambulance after being rescued from a house fire. The incident occurred exactly 2 hours prior to arrival. He weighs $80$ kg. Primary survey reveals a patent airway, clear breath sounds bilaterally, and a heart rate of $115$/min. Physical examination shows deep partial-thickness and full-thickness burns covering his entire anterior torso, entire right arm, and the anterior surface of his right leg. Peripheral intravenous access is established. Based on current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burn resuscitation (using $2 \text{ mL/kg/\%TBSA}$), what should be the initial intravenous crystalloid fluid infusion rate programmed for the remainder of the first 8 hours post-injury?

A 35-year-old male construction worker is brought to the emergency department after falling 20 feet (6 meters) from a scaffold. He is secured to a backboard with a rigid cervical collar in place. He is obtunded, opens his eyes only to painful stimuli, and makes incomprehensible sounds. Vital signs are temperature 36.5°C (97.7°F), blood pressure 75/45 mm Hg, pulse 135/min, and respirations 28/min. Pulse oximetry shows 88% on high-flow oxygen. Physical examination reveals copious blood in the oropharynx with audible gurgling. There are absent breath sounds and dullness to percussion over the right hemithorax. The abdomen is grossly distended and rigid. Arrange the following management steps in the most appropriate sequential order according to the Advanced Trauma Life Support (ATLS) protocol.

Emergency medical services via helicopter transport a 22-year-old male to the trauma center following a high-speed motorcycle crash. Upon arrival, he has a traumatic partial amputation of the left lower leg. Bright red blood is spurting profusely through the prehospital bandages despite direct pressure. The patient is unresponsive, with a Glasgow Coma Scale score of 6, and is making gurgling respiratory sounds. His abdomen is markedly distended and rigid to palpation. Vital signs are temperature $35.2^\circ\text{C}$ ($95.4^\circ\text{F}$), heart rate $148/\text{min}$, blood pressure $70/40 \text{ mm Hg}$, and respiratory rate $8/\text{min}$. Large-bore intravenous access is currently being established. Arrange the following management steps in the most appropriate chronological order according to current Advanced Trauma Life Support (ATLS) and damage control surgery principles.

A 30-year-old G1P0 woman at 35 weeks gestation is brought to the trauma center after being involved in a high-speed motor vehicle collision as the unrestrained driver. On arrival, she is lethargic but conversant and protecting her airway. She is placed on a backboard with left lateral tilt and receives 2 liters of warmed intravenous crystalloids. Reassessment reveals a blood pressure of 78/42 mm Hg and a heart rate of 135/min. Breath sounds are clear and equal bilaterally. Her abdomen is gravid, rigid, and diffusely tender with rebound and guarding. Bedside focused assessment with sonography for trauma (FAST) demonstrates a large volume of free fluid in the hepatorenal recess. Fetal monitoring shows a baseline heart rate of 115/min with recurrent late decelerations. Arterial blood gas analysis reveals a pH of 7.21, $pCO_2$ of 25 mm Hg, and $HCO_3^-$ of 10 mEq/L. Which of the following is the most appropriate next step in management?

A 68-year-old man is evaluated in the surgical intensive care unit for sudden-onset hypotension and altered mental status. He was admitted 3 days ago after a severe motor vehicle collision. His initial injuries included multiple left-sided rib fractures, bilateral pulmonary contusions, and a grade III liver laceration that was managed nonoperatively. His past medical history includes heart failure with preserved ejection fraction and chronic obstructive pulmonary disease (COPD).

Currently, his blood pressure is 76/45 mm Hg and his heart rate is 135/min. Oxygen saturation is 89% on 4 L/min via nasal cannula. His temperature is 38.3°C (100.9°F). Physical examination reveals a rigid, distended abdomen with involuntary guarding and rebound tenderness. Auscultation of the lungs reveals decreased breath sounds at the bases with scattered wheezes.

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

Review the following trauma patient presentations and pair each one with its definitive diagnostic modality or most appropriate immediate intervention.

A 25-year-old man is brought to the emergency department after being involved in a chemical plant fire. The incident occurred exactly 3 hours prior to his arrival. His weight is $70 \text{ kg}$. Primary survey reveals a patent airway, but due to facial burns, he is electively intubated. Physical examination reveals deep partial-thickness and full-thickness burns involving his entire head and neck, his entire anterior trunk, and circumferential burns to both arms. There are no other burn injuries identified. Two large-bore intravenous catheters are placed. According to the traditional Parkland formula ($4 \text{ mL/kg/\% TBSA}$), what should be the initial rate of intravenous crystalloid infusion for the remainder of the first 8-hour post-burn period?