Trauma and Burns

Paramedics bring a 34-year-old woman to the emergency department after she struck a tree at high speed while downhill mountain biking. She was found unresponsive at the scene and underwent field endotracheal intubation. Upon arrival, she is receiving mechanical ventilation. Breath sounds are present and equal bilaterally. Blood pressure is 70/40 mm Hg and heart rate is 135/min. Neurologic examination reveals a right pupil that is 8 mm and nonreactive to light, and a left pupil that is 3 mm and briskly reactive. She does not move her extremities to deep painful stimuli. An extended focused assessment with sonography for trauma (eFAST) reveals a large volume of anechoic fluid in the hepatorenal and splenorenal recesses. There is no evidence of pneumothorax. Pelvic radiography reveals no fractures. Which of the following is the most appropriate next step in the management of this patient?

A 26-year-old male is brought to the emergency department after being struck by a motor vehicle while riding an electric scooter. On arrival, his airway is patent and he is breathing spontaneously. Vital signs are temperature 36.5°C (97.7°F), blood pressure 80/50 mm Hg, pulse 130/min, and respirations 20/min. Physical examination reveals a pale, diaphoretic man who is drowsy but arousable. Breath sounds are clear and equal bilaterally. His abdomen is soft and non-distended, without guarding or rebound tenderness. Gentle anteroposterior compression of the iliac crests reveals abnormal mobility and elicits a groan of pain from the patient. There is a hematoma over the perineum, and blood is visible at the urethral meatus. A focused assessment with sonography for trauma (FAST) examination shows no fluid in the hepatorenal, splenorenal, or rectovesical spaces, and no pericardial effusion. Two large-bore intravenous lines are placed, and fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

Following a high-velocity motor vehicle collision, a 28-year-old male is admitted to the trauma resuscitation unit. He was extricated from the driver's seat after a prolonged entrapment. The patient is intubated and mechanically ventilated upon arrival. Initial vital signs demonstrate a blood pressure of 72/38 mm Hg and a heart rate of 144/min. Physical examination of the head reveals a right-sided pupil that measures 8 mm and does not react to light, whereas the left pupil is 3 mm and briskly reactive. The thorax exhibits equal breath sounds bilaterally. The abdomen is markedly distended and firm. Bedside ultrasonography reveals large anechoic spaces in the hepatorenal recess and the splenorenal recess. Which of the following is the most appropriate next step in management?

A 42-year-old male is brought to the trauma bay after a high-speed motor vehicle collision. On arrival, he is unresponsive. He has audible gurgling respirations with pooling of blood in his oropharynx. His blood pressure is 75/40 mmHg, heart rate is 142/min, and respiratory rate is 32/min. Physical examination reveals tracheal deviation to the left and absent breath sounds over the right hemithorax. His pelvis is mechanically unstable on anterior-posterior compression. Arrange the following management steps in the correct chronological order according to standard trauma resuscitation protocols.

A 42-year-old man weighing 90 kg is brought to the emergency department via ambulance after being involved in an industrial boiler explosion and fire. The incident occurred exactly 3 hours prior to arrival. He has a patent airway and his respirations are unlabored. Physical examination reveals erythema, blistering, and severe pain over the entire anterior torso and the entire posterior torso. The entire right lower extremity demonstrates leathery, charred, and insensate skin. Both upper extremities exhibit painful, blanching erythema with no blistering. During transport, emergency medical services established peripheral intravenous access and administered exactly 1260 mL of lactated Ringer solution.

Based on current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns, what should the infusion rate (in mL/hour) of lactated Ringer solution be set to for the remainder of the first 8 hours post-injury?

Match each of the following clinical presentations of trauma patients with the most appropriate definitive next step in diagnosis or management.

A 38-year-old male is brought to the emergency department via ambulance after his compact car was struck on the driver's side by a commercial truck. On arrival, he is pale and lethargic but follows simple commands. Vitals show a temperature of $36.5^{\circ}$ C ($97.7^{\circ}$ F), blood pressure of $82/46$ mm Hg, pulse of $130$/min, and respiratory rate of $28$/min.

Primary survey reveals a patent airway. Breathing assessment demonstrates markedly diminished breath sounds over the left lower hemithorax, and the trachea appears slightly deviated to the right. The abdomen is diffusely tender with involuntary guarding. A focused assessment with sonography for trauma (FAST) reveals an anechoic collection in the splenorenal recess.

An orogastric tube is placed to decompress the stomach. A portable anteroposterior chest radiograph is immediately obtained in the resuscitation bay, which demonstrates the radiopaque tip of the orogastric tube coiled within the left lower thorax and a shift of the mediastinal structures toward the right.

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

A 62-year-old man is brought to the emergency department after a motor vehicle collision in which he was an unrestrained driver. Paramedics report significant front-end vehicle damage. The patient's wife arrives and states he has a history of alcoholic cirrhosis and was hospitalized two months ago for abdominal distension requiring paracentesis. On presentation, his temperature is 36.8°C (98.2°F), blood pressure is 80/50 mm Hg, heart rate is 132/min, and respiratory rate is 24/min. He is confused but localizes to pain. His airway is patent and breath sounds are equal bilaterally. Physical examination reveals scleral icterus, spider angiomas on the chest, and a markedly distended abdomen with shifting dullness and a positive fluid wave. There is no overt abdominal guarding or rebound tenderness. The pelvis is stable to anterior-posterior and lateral compression. A bedside focused assessment with sonography for trauma (FAST) demonstrates a large volume of anechoic fluid in the hepatorenal recess (Morison pouch) and the splenorenal recess. Which of the following is the most appropriate next step in the management of this patient?

During a home renovation project, a 55-year-old contractor falls approximately 4 meters (13 feet) from a scaffold, landing forcefully on his left side. He is rapidly transported to the local trauma center. On primary survey, his airway is patent and breath sounds are clear and equal bilaterally. Cervical spine precautions are maintained. Vital signs show a heart rate of 132/min, blood pressure of 78/48 mmHg, and respiratory rate of 22/min. Peripheral pulses are weak and thready. Physical examination reveals significant ecchymosis over the left lower rib cage. The abdomen is distended, diffusely tender to palpation, and exhibits involuntary guarding. The pelvis is clinically stable to anterior-posterior and lateral compression. Bedside ultrasonography of the left upper quadrant demonstrates a distinct anechoic fluid collection between the spleen and the left kidney. Which of the following is the most appropriate next step in management?

A 24-year-old woman arrives at the trauma center via helicopter after losing control while down-hill skiing and forcefully striking a stationary snow-making machine. She complains of severe left flank and abdominal pain. Her temperature is 36.2 °C (97.2 °F), pulse is 135/min, blood pressure is 78/48 mmHg, and respirations are 24/min. On physical examination, her airway is patent, and breath sounds are clear and equal bilaterally. The abdomen exhibits marked tenderness in the left upper quadrant with localized guarding. The pelvis is stable to anteroposterior and lateral compression. A bedside focused assessment with sonography for trauma (FAST) exam reveals an anechoic stripe between the spleen and the left kidney. She is rapidly administered 1 L of warmed lactated Ringer solution and 1 unit of uncrossmatched O-negative packed red blood cells. Reassessment vital signs show a pulse of 128/min and a blood pressure of 82/50 mmHg. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation of acute thoracic trauma with the most appropriate immediate diagnostic or therapeutic next step.

A 28-year-old man is brought to the emergency department via ambulance after being struck by a sport utility vehicle while crossing the street. He complains of severe lower abdominal and groin pain. His airway is patent, and breath sounds are equal bilaterally. Temperature is 36.5°C (97.7°F), heart rate is 135/min, blood pressure is 78/40 mm Hg, and respiratory rate is 24/min. Physical examination reveals a soft, non-distended abdomen with no rebound tenderness or guarding. There is prominent ecchymosis over the suprapubic and scrotal regions, and a small amount of blood is present at the urethral meatus. Gentle anteroposterior compression of the iliac crests reveals mechanical instability. A focused assessment with sonography for trauma (FAST) examination shows no free fluid in the pericardial, right upper quadrant, left upper quadrant, or suprapubic spaces. A pelvic binder is immediately applied, and the patient receives 2 units of uncrossmatched packed red blood cells. Fifteen minutes later, his heart rate is 128/min and blood pressure is 82/45 mm Hg. Which of the following is the most appropriate next step in management?

Emergency medical services arrive at the trauma center with a 32-year-old male victim of a high-speed motorcycle crash. He was found unresponsive at the scene after a prolonged extrication time. Upon presentation, the patient exhibits loud, gurgling respirations and central cyanosis. Hemodynamic monitoring reveals a blood pressure of 65/40 mmHg and a heart rate of 145/min. The physical examination is notable for active, pulsatile arterial bleeding from a severely mangled left lower extremity. Arrange the following acute management steps in the correct chronological sequence according to the Advanced Trauma Life Support (ATLS) protocol.

During an amateur equestrian event, a 35-year-old woman was thrown from her horse and subsequently kicked in the left flank. She arrives at the emergency department immobilized on a backboard. She is alert but restless and complains of severe abdominal pain. Her temperature is $36.6^\circ\text{C}$ ($97.9^\circ\text{F}$), blood pressure is $82/54\text{ mmHg}$, pulse is $128/\text{min}$, and respirations are $22/\text{min}$. Oxygen saturation is $97\%$ on room air. The airway is patent, and breath sounds are vesicular and symmetric bilaterally. The pelvis is mechanically stable to anteroposterior and lateral compression. The abdomen is distended, with significant ecchymosis over the left flank, and diffuse tenderness with guarding is noted. A focused assessment with sonography for trauma (FAST) demonstrates a substantial anechoic fluid collection in the hepatorenal recess (Morison's pouch) and the splenorenal recess. Intravenous access is established, and rapid infusion of 1 L of warmed crystalloid is initiated. Which of the following is the most appropriate next step in management?

Emergency medical services bring a 32-year-old man to the trauma bay 30 minutes after he sustained a gunshot wound to the left gluteal region during an altercation. On arrival, he appears pale, diaphoretic, and confused. Blood pressure is 74/40 mm Hg, heart rate is 135/min, and respiratory rate is 24/min. Oxygen saturation is 96% on room air. The primary survey reveals a patent airway and equal breath sounds bilaterally. Physical examination shows a single entry wound in the left upper outer quadrant of the buttock with no visible exit wound. The abdomen is tense, distended, and diffusely tender with involuntary guarding. A focused assessment with sonography for trauma (FAST) is technically limited due to overlying bowel gas. Bilateral large-bore intravenous lines are established, and he receives a rapid infusion of 1 L of warmed crystalloid and 1 unit of uncrossmatched group O blood. Five minutes later, his blood pressure is 78/42 mm Hg and heart rate is 130/min. Which of the following is the most appropriate next step in management?

A 30-year-old male electrician is brought to the emergency department after sustaining a high-voltage electrical injury at a construction site. The accident occurred exactly 2 hours prior to his arrival. On physical examination, the patient is awake and alert. Vital signs show a heart rate of 115/min and blood pressure of 105/65 mm Hg. He has deep partial-thickness and full-thickness burns involving his entire right arm and his entire anterior trunk (chest and abdomen). No other areas of the body are burned. His body weight is 75 kg. Two large-bore peripheral intravenous lines are established, and a Foley catheter is placed.

Based on current Advanced Trauma Life Support (ATLS) guidelines for high-voltage electrical burns, what should be the continuous intravenous fluid infusion rate (in mL/hr) of lactated Ringer solution for this patient over the next 6 hours?

A 19-year-old female collegiate rugby player arrives at the trauma center via ambulance shortly after sustaining an injury during a match. Witnesses report she was forcefully tackled and struck in the left abdomen by an opponent's knee. Upon arrival, her temperature is $36.2^\circ\text{C}$ ($97.2^\circ\text{F}$), heart rate is $138/\text{min}$, blood pressure is $76/42\text{ mmHg}$, and respiratory rate is $26/\text{min}$. Oxygen saturation is $95\%$ on room air. The patient is lethargic but localizes to painful stimuli. The airway is patent, and breath sounds are vesicular and equal bilaterally. The abdomen is grossly distended with severe diffuse tenderness to palpation, guarding, and rebound tenderness. A large ecchymosis is present over the left upper quadrant. The pelvis is stable to anterior-posterior and lateral compression. Bedside ultrasound of the abdomen demonstrates a significant anechoic collection in the splenorenal recess and the rectouterine pouch. Which of the following is the most appropriate next step in the management of this patient?

A 26-year-old man is evaluated in the emergency department after a mountain biking accident. He lost control on a steep downhill trail and was thrown over the handlebars, striking his left flank against a large tree stump. He complains of severe left-sided abdominal pain that radiates to his left shoulder.

His temperature is 37.1°C (98.8°F), blood pressure is 132/84 mmHg, heart rate is 86/min, and respiratory rate is 16/min. On physical examination, the patient is alert and oriented. There is an abrasion and extensive ecchymosis over the left lower rib cage. Abdominal examination reveals tenderness to palpation in the left upper quadrant, but no guarding, rigidity, or rebound tenderness is present. The pelvis is stable to anteroposterior and lateral compression.

A bedside focused assessment with sonography for trauma (FAST) demonstrates a small accumulation of anechoic fluid in the splenorenal recess.

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

Correlate each of the following thoracic trauma patient scenarios with its corresponding definitive next step in management or acute diagnostic evaluation.

A 31-year-old woman, gravida 2, para 1, at 34 weeks gestation is brought to the emergency department via ambulance after being involved in a high-speed motor vehicle collision. She was the restrained driver of a vehicle that struck a concrete barrier. On arrival, the patient is lethargic and complains of severe, diffuse abdominal pain.

Vital signs are:
Temperature: 36.5°C (97.7°F)
Heart rate: 138/min
Blood pressure: 78/42 mmHg
Respiratory rate: 26/min
Oxygen saturation: 96% on face mask

Physical examination reveals bruising across the lower abdomen in a seatbelt distribution. The abdomen is diffusely tender with guarding. A focused assessment with sonography for trauma (FAST) demonstrates a large amount of anechoic free fluid in the hepatorenal and splenorenal recesses.

Continuous fetal heart rate monitoring reveals a baseline of 165/min with minimal variability and recurrent late decelerations.

Intravenous access is established, and the patient receives 2 L of warmed lactated Ringer solution and 2 units of uncrossmatched type O-negative blood. Repeat vital signs show a heart rate of 132/min and a blood pressure of 80/45 mmHg.

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