JRNL-Responding to Trauma Your Priorities in the First Hour

52 Nursing2006, Volume 36, Number 9 www.nursing2006.com

MICHAEL PETRI, a 54-year-oldroofer, just fell 20 feet from abuilding under construction. Ini-tially he struck the ground withhis feet, then fell onto his left side.Conscious and alert at the scene,he complains of severe back andlower leg pain. His vital signs are:BP, 140/88; heart rate, 112; respira-tory rate, 28; SpO2, 96%; and tem-perature, 98° F (36.7° C). HisGlasgow Coma Scale (GCS) scoreis 15. Michael’s odds of survivalare good: Of trauma patients whoenter the trauma care system withvital signs intact, more than 95%survive.

Paramedics administer oxygenat a flow rate of 15 liters/minutevia non-rebreather mask and applya cervical collar and a backboard toimmobilize his neck and spine.

They also place a 16-gauge intra-venous (I.V.) catheter in his leftforearm and begin an infusion of0.9% sodium chloride solution.

If Michael were on his way toyour hospital’s emergency depart-ment (ED) for treatment, wouldyou be prepared to provide imme-diate and appropriate nursingcare? In this article, I’ll explainthe primary and secondary assess-ment surveys you need to com-plete as soon as he arrives anddiscuss how your findings guidenursing and medical interven-tions. But first, let’s review how toprepare for a trauma patient’sarrival in the ED.

Getting ready for your patientTrauma team members must beprepared to deal with any type of

injury. But learning details aboutthe mechanism of injury can helpthem predict the types and com-binations of injuries that he mayhave sustained—information thatwill help you and the other teammembers plan effective care.

Mechanism of injury describesthe circumstances and energyforces that produced the trauma,usually blunt or penetrating.Examples of blunt force traumainclude injuries from motor-vehicle crashes, falls, assault,industrial incidents, blast force,and sports-related injuries. Pene-trating trauma injuries includestab and gunshot wounds,impaled objects, and damagefrom projectiles.

As the trauma team awaitsMichael’s arrival at the hospital,

TRAUMAYour priorities in the first hourIn a few minutes, a patient who’s sustained serioustraumatic injuries will arrive at your hospital. Areyou ready to care for him?

Here you’ll learn a quick, evidence-based system to guide your initial assessments and interventions.

Responding to

BY LINDA LASKOWSKI-JONES, RN, APRN,BC, CCRN, CEN, MS

they review the information theparamedics provided by radio anddiscuss their concerns about hispossible injuries based on hismechanism of injury. Knowing thatMichael has had a blunt injurymechanism and that he landed onhis feet in the fall, team memberssuspect they’ll find lumbar spinecompression fractures and lowerextremity trauma—particularly cal-caneus fractures. Knowing that hesuffered an impact to his left side,they’ll also be ready to assess fortraumatic injuries to the chest andabdomen.

Your first priority as a member ofthe trauma team is to protect your-self from exposure to blood andbody fluids. Prepare to use standardprecautions, which are mandatory.While you wait for the patient to

arrive, don a fluid-imperviousgown, gloves, and face and eye pro-tection, such as a face shield orgoggles and mask, in case bloodsplashes. Ensure ready access topersonal protective equipment toprevent delays in patient care.

Trauma care always begins withthe primary survey, a rapid assess-ment of the patient’s ABCs—airway, breathing, and circula-tion—with the addition of D (dis-ability) and E (exposure).

The primary survey focuses onwhat can kill the patient now. It’sfollowed by the secondary survey,a complete head-to-toe assess-ment to identify other seriousinjuries that could kill or disablethe patient later.

Resuscitation occurs simultane-ously with the primary survey. As

life-threatening injuries are dis-covered, the team intervenes tooptimize oxygenation, ventilation,and perfusion. Interventionsinclude clearing the airway, pro-viding supplemental oxygen, ven-tilating the patient, controllinghemorrhage, inserting I.V. devicesand chest tubes, and replacing flu-ids and blood.

Diagnostic studies follow theprimary and secondary surveys,although blood is usually drawnwhen I.V. lines are placed duringthe primary survey. Test results fur-ther define the nature and severityof the injuries and help guide thetreatment plan.

Now let’s take a closer look athow assessment and interventionsmesh during the crucial first hourafter an injury.

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Primary survey: Managingimmediate threatsBy taking a standardized approachto assessment and treatment, thetrauma team can address the mostsignificant risks to life first. Asalways, start with the ABCs.

Airway. The first part of the pri-mary survey is always assessing theairway. This includes checking forpotential injury to the cervicalspine. Until cervical spine injuryhas been ruled out, open thepatient’s airway using a jaw-thrustmaneuver with manual, in-line sta-bilization of the neck. If you findfood, blood, vomitus, or otherdebris, suction the airway quicklyto prevent aspiration. To better

remove secretions,you may need tocarefully logroll thepatient to his side.Manually stabilizehis neck and spineas you do so.

If the patient can’tmaintain a patentairway because ofcopious secretions,an impaired level ofconsciousness, orother criticalinjuries, he’ll need

endotracheal intubation. Insert alarge-diameter (#18 Frenchcatheter) gastric tube as soon aspossible after intubation to decom-press his stomach and remove gas-tric contents. Remember, even afterthe airway has been secured, hecould still vomit and aspirate.

If the patient has any head ormidface trauma, pass the gastrictube orally. Nasogastric tube inser-tion would be risky because a dis-ruption of the cribriform plate (thebone between the sinuses and thebrain) could allow the tube to beinadvertently inserted into the cra-nium.

If massive facial injuries preventoral endotracheal intubation, thepatient will need surgical airwayplacement (typically a cricothyrot-omy).

When Michael is brought intothe trauma room, he can speakclearly and provide an account ofthe accident. Because he can con-verse, his airway assessment isstraightforward: He has a patentairway. However, he’s still consid-ered to be at risk for cervical spineinjury. Spinal precautions continueuntil cervical injury is ruled out.

Breathing. Assess your patient’sbreathing next. Note respiratoryrate and depth, chest expansion,and accessory muscle use and aus-cultate breath sounds bilaterally.Also palpate for crepitus or subcu-taneous air in the neck and chest,which can indicate a pneumotho-rax or airway injury. Find out if hehas pain with breathing or on pal-pation. Injuries that can impairventilation include rib fractures(especially a flail chest), a pneu-mothorax, a hemothorax, andspinal cord or head trauma.

Supplemental oxygen is alwaysindicated at this stage. For a spon-taneously breathing patient likeMichael, a non-rebreather maskwith the flow rate set at 12 to 15liters/minute is appropriate. How-ever, if the patient isn’t breathingwell enough to sustain optimaloxygenation, begin manual bag-valve–mask ventilation to supporthis ventilatory efforts until he canbe intubated and mechanicallyventilated.

If the patient is having severe res-piratory distress and hypotensionas well as unilateral decreased orabsent breath sounds, suspect atension pneumothorax, a potential-ly fatal complication requiringrapid treatment. To perform anemergency chest decompression,the trauma team physician will per-form a needle thoracostomy, insert-ing a 14-gauge I.V. catheter into thepatient’s chest at the second inter-costal space, midclavicular line onthe affected side. A rush of air fromthe catheter confirms the presenceof a tension pneumothorax. Thecatheter is left in place until a chesttube can be inserted.

In the meantime, a syringe orcommercial Heimlich valve (orsimilar device) is attached to thecatheter hub so that air can escapewithout being drawn back into thechest. If available, have a chesttube drainage system that can col-lect blood for autotransfusion onhand during chest tube insertion,in case a hemothorax is present.

Michael’s ventilatory efforts areadequate. His breath sounds areclear and equal bilaterally, but hecomplains of pain in his left sideon palpation. The supplementaloxygen he’s receiving via the non-rebreather mask (which wasapplied by the paramedics) is keptat a flow rate of 15 liters/minute.His SpO2 is now 100%.

Circulation. Once you’veassessed and supported yourpatient’s breathing, attend to hiscirculatory status. Assess for thepresence and quality of peripheralpulses to quickly estimate BP, asfollows.• If he has a radial pulse, his sys-tolic BP is at least 80 mm Hg.• If he’s lost his radial pulse butstill has a femoral pulse, he has asystolic BP of at least 70 mm Hg.• If he lacks all pulses except acarotid pulse, he has a systolic BPof at least 60 mm Hg.

Note the patient’s skin color andlevel of consciousness (LOC).Pallor and cold, clammy skin indi-cate shock.

His LOC is an important indica-tor of cerebral perfusion. Agitationis common in the early stages ofshock. (Think of the “fight orflight” response.) As shock pro-gresses, his LOC will decline untilhe’s unconscious.

Obtain a complete set of vitalsigns, including temperature, assoon as possible. Use this set ofvital signs as a baseline for compar-ison with subsequent measure-ments. You may need to take vitalsigns every 5 to 15 minutes untilthe patient’s condition improves.

A key part of your circulatoryassessment is to identify and con-


Your first priority as a member of the trauma team is to protect yourself from exposure toblood and bodyfluids.

trol hemorrhage. External hemor-rhage is usually, but not always,obvious. Logroll the patient toinspect his back and buttocks forbleeding.

To control bleeding, apply directpressure over the site of hemor-rhage. If this isn’t effective by itself,apply pressure over the major arte-rial pulse point proximal to thebleeding site.

Use a tourniquet only if youmust stanch severe hemorrhage inan extremity to save the patient’slife. Using a tourniquet puts thelimb’s viability at risk.

Next, ask yourself if the mecha-nism of injury makes internal hem-orrhage likely. If the patient hassigns and symptoms of shock with-out visible bleeding, he may havean occult internal hemorrhage thatrequires surgery.

Besides assessing and document-ing his circulatory status, you mayneed to intervene to sustain circu-lation. For a patient who’s inshock, consider both noninvasiveand invasive strategies to supporthis BP. Keep him supine and ele-vate his legs 6 to 8 inches (15 to 20cm) to promote venous return andimprove cardiac output. Don’t puthim in the Trendelenburg positionbecause this can cause his stomachto compress his diaphragm, im-pairing ventilation.

Make sure he has venous accesswith two large-bore I.V. catheters(ideally 14- to 16-gauge) to facili-tate rapid fluid and blood productadministration if needed. Drawblood for lab analysis. Send speci-mens for typing and crossmatch-ing, complete blood cell count,serum glucose, electrolytes, and acoagulation profile. Depending onthe patient’s condition and suspect-ed injuries, you may also needspecimens for other studies, suchas creatine kinase, amylase, andserum lactate.

An arterial blood gas (ABG)analysis can help clinicians assessthe patient’s oxygenation statusand determine whether or not he’s

in shock. If ABG results show abase deficit that’s greater than 2mEq/liter, suspect ongoing hemor-rhage, internal injuries, or insuffi-cient resuscitation.

As ordered, administer an ap-propriate crystalloid solution forI.V. volume replacement, such as0.9% sodium chloride or lactatedRinger’s solution. Warm the solu-tion in a commercial fluid warmeror use a high-volume infuser/warming device. Don’t administerD5W for volume replacementbecause the dextrose will bemetabolized andleave free water, ahypotonic solutionthat won’t stay in thevascular space.

Provide 3 mL ofcrystalloid solutionto replace each 1 mLof blood lost. If youinfuse 2 liters ofcrystalloid solutionand the patient’s BPhasn’t returned tothe normal range, beprepared to adminis-ter blood products.

Typing and cross-matching typicallytake 30 to 40 min-utes, which may betoo long for a traumapatient to wait.When immediateblood transfusion isneeded, the only option is to giveuncrossmatched universal donorblood, as ordered. Give group O,Rh-negative packed red blood cells(RBCs) to female patients of child-bearing age or younger. Malepatients and women who can’tbecome pregnant can receive groupO, Rh-positive blood. Rememberthat 0.9% sodium chloride is theonly solution you can infuse in thesame I.V. line as blood.

Expect each unit of packedRBCs to raise the patient’s hemo-globin by 1 gram/dL unless he’scontinuing to hemorrhage. Duringthe infusion, remain vigilant for a

transfusion reaction. Signs andsymptoms of a transfusion reactionvary according to what type ofreaction it is. For instance, intra-vascular hemolysis may causefever, lower back pain, pain at theI.V. site, hypotension, and renalfailure. If you suspect a transfusionreaction, discontinue the infusionimmediately and follow your hos-pital’s protocol for managing trans-fusion reactions.

During the primary assessment,Michael’s vital signs change signif-icantly from those obtained by the

paramedics: His BP drops to96/58, his SpO2 falls to 95%, hisheart rate increases to 120, his res-piratory rate remains at 28, andhis temperature is now 97.4° F(36.3° C). He has no externalhemorrhage, so the physician sus-pects a spleen injury because heknows the left chest and abdomenwere injured in the fall and thelower left rib cage is tender. Youhang a liter of 0.9% sodium chlo-ride using a high-volume fluidinfuser/warmer and begin theinfusion via the second I.V. accessline previously established with a14-gauge catheter.


Using the Glasgow Coma Scale

Eye opening

Best verbal response

Best motor response

Total score

SpontaneousTo voiceTo painNoneOrientedConfusedInappropriateIncomprehensibleNoneObeys commandsLocalizes painWithdraws (pain)FlexionExtensionNone

4321543216543213-15

Here’s how to interpret the score:• 13-14 is mild brain injury.• 9-12 is moderate brain injury.• 3-8 is severe brain injury.

Disability. To evaluate disability,you’ll evaluate the patient’s LOC,pupil response, and gross sensori-motor function. To document hisbaseline LOC, quickly assess andrecord an initial GCS score. If pos-sible, determine his GCS before hereceives any drugs that could alterhis LOC to better enable you topredict his outcome. For example,if a patient’s GCS score on arrival atthe hospital is 4, his prognosis forrecovery is much worse than a

patient whoseinitial score is12. Keep in mind

that accuratescoring can beimpaired bytraumatic,toxic, and meta-bolic causes.Even if thepatient showsevidence ofalcohol or druguse, never

assume that his altered mental sta-tus is due purely to intoxicantsuntil injury and other medicalcauses are ruled out. (See Using theGlasgow Coma Scale.)

Note whether the patient canrecall the events surrounding thetraumatic event. Amnesia aboutthe event suggests that he lost con-sciousness.

Next, assess his pupils for size,equality, shape, and response tolight. If he can follow commands,check for accommodation—thepupillary size changes that occurwhen focusing on near objects(constriction) and far objects (dila-tion). Unequal or abnormal pupilresponse can indicate direct oculartrauma or head injury and elevatedintracranial pressure or the effectsof drugs, such as atropine (pupildilation) or opioids (pupil con-striction).

The final component of the dis-ability evaluation is an assessmentof gross sensorimotor function. Tryto determine if the patient has any

numbness, tingling, or otherabnormal sensations in his bodyafter the traumatic event and if hecan move his limbs. Injuries to theextremities, spinal cord, head,blood vessels, or nerves can causesensorimotor deficits.

Michael’s GCS score stays at 15.He didn’t lose consciousness dur-ing or after the fall and he canrecall the event vividly. His pupilsare equal (4 mm/4 mm) andround, react to light, and accom-modate normally. Despite the painin his back and leg, Michael’s grosssensorimotor function is intact.

Exposure. The final componentof the primary survey is exposure.Remove the patient’s clothingcompletely so you can inspect hisentire body for injuries. Use goodjudgment when removing cloth-ing; trying to remove a shirt bypulling or manipulating it mayworsen the injury or pain. Cuttingclothing away with trauma shearsis usually best.

Once you’ve removed clothing,protect the patient from hypo-thermia, which is particularlydangerous to any trauma patientbecause it impairs blood coagula-tion, interferes with resuscitationefforts, and increases the risk ofacidosis and death.

Take these measures to preventheat loss and rewarm the patient.• Remove wet clothing andsheets. Cover the patient withwarm blankets.• Increase the room temperatureto 75° F to 80° F (23.9° C to 26.7° C).• Infuse only warm crystalloidsolutions. • Consider using commercialpatient-warming devices, such asheat lights or temperature-regulating blankets.

When Michael is exposed, younote that he has abrasions overhis lower left ribs and deformitiesin both feet. You quickly coverhim with heavy blankets thathave been kept in a blanketwarmer. The room temperature

had been raised to 78° F (25.6° C)before his arrival, and he’s beenreceiving warmed I.V. fluids.

Secondary survey: Uncoveringother serious threats Once you’ve completed the pri-mary survey and managed anyimmediate threats to the patient’slife, begin a secondary survey forinjuries that could kill or disablehim later. Start at his head andassess him methodically, movingdown his body systematically asyou search for injuries. Inspectfor contusions, abrasions, lacera-tions, deformities, discoloration,edema, foreign bodies, and otherabnormalities.

Auscultate breath sounds andheart sounds. Assess all bodyareas to locate areas of pain ortenderness, crepitus, deformity,loss of function, and the locationand quality of pulses. If you sus-pect he has a fracture of an armor leg, assess the neurovascularstatus of the limb, then splint itto prevent movement anddecrease pain. Assess neurovas-cular status again after splinting.Administer I.V. opioid pain med-ication as ordered and make surethat pain is managed optimally.

At this point, the traumaphysician will consider orderingan indwelling urinary catheter toaccurately measure urinary out-put, an indication of renal perfu-sion, and to check for blood inthe urine. First, though, he’llperform a rectal examination tocheck for blood or evidence ofurethral injury, such as a high-riding prostate gland in a malepatient. (If the urethra isinjured, the patient may need tohave a suprapubic catheterinserted instead.)

Before inserting a urinarycatheter, look for blood at theurethral meatus. If you seeblood, notify the physician anddon’t insert the catheter. Thepatient will need further diag-nostic testing (for instance, a


Agitation is common in the early stages of shock.

retrograde urethrogram or cys-togram) before a catheter can besafely inserted.

Reassess the patient’s vitalsigns and GCS score as frequent-ly as needed, depending on hiscondition. Also try to obtain amore complete history from thepatient or significant others. Usethe mnemonic “AMPLE” to helpyou remember the key informa-tion to gather. (See Get AMPLEinformation.)

Assess carefully for medica-tions the patient has taken thatcould affect his condition andtreatment. For example, takingan anticoagulant, such as war-farin, or a platelet inhibitor,such as daily aspirin therapy,will make him much more proneto bleeding from his injuries. Ifhe’s using any of these drugs, tellthe health care provider immedi-ately so that he can order appro-priate reversal agents or takemeasures to counteract anticoag-ulation effects.

Assess the patient for steroiduse. If he’s taking a steroid med-ication, he many need an I.V.steroid bolus so that he canphysiologically respond in astress or shock state. If you don’tknow the date of his last tetanusimmunization or if it was morethan 5 years ago, administertetanus prophylaxis.

Michael’s secondary survey isremarkable for pain on palpationin his lumbar spine, tendernessand abrasions over his left lowerrib cage anteriorly, and heel painand swelling in both feet. Youinsert a urinary catheter andperform a dipstick urine test,which is positive for a smallamount of blood.

Next up: An eye on diagnosticsAfter the primary and secondarysurveys are complete, prepareyour patient for a series of X-raysand scans. He’ll have a statportable chest X-ray to identifyrib fractures or mediastinal or

diaphragmatic injury and toassess for a pneumothorax orhemothorax. He’ll also need a cer-vical spine X-ray series to checkfor cervical spine injury. The X-ray will also confirm the correctposition of chest and endotra-cheal tubes and central venouscatheters. Depending on theresults of the primary and sec-ondary surveys, he may haveadditional X-rays of the pelvis,spine, extremities, or other areas.

He may have bedside ultra-sonography with the focusedabdominal sonography for trauma(FAST) technique, which is usedto rapidly examine all fourabdominal quadrants and thepericardium to identify the pres-ence of free fluid, usually blood.

If he’s lost consciousness orshows evidence of a head injury,he’ll need a computed tomography(CT) scan of his head. Other CTscans of the spine, chest, abdomen,or pelvis may be indicated to helpthe health care provider plan treat-ment.

Your patient may needa vascular ultrasound oran arteriogram if he hasvascular injuries,decreased or absent puls-es, evidence of limbischemia, or a widenedmediastinum, indicating apossible aortic injury.

Magnetic resonanceimaging (MRI) is rarelyused for diagnosing acute-

ly injured patients because it takestoo long and safely placing aninjured patient into the MRI tubeis difficult. In addition, the patientmight have ferrous metal in hisbody (for example, braces,implants, or metal fragments leftin his eyes from industrial work).Any ferrous metal is dangerous inan MRI room and is a contraindi-cation for MRI.

However, the patient may needan MRI if he shows any evidenceof an acute spinal cord injury. Besure to carefully assess him forferrous metal objects. If they canbe removed, do so before takinghim to the MRI. The technologistwill ask him if he has any im-plants or fragments in his eyesfrom metal work. If he does, anMRI is contraindicated.

Michael’s diagnostic workupincludes a bedside FAST ultra-sound; chest, pelvis, and lowerextremity X-rays; a full series ofspinal X-rays; and CT scans of hischest, abdomen, and lumbar spine.The tests identify these injuries:


Get AMPLE informationThis mnemonic will remind you of the criticalhistory to gather from your trauma patient orhis significant other:

llergies edication use ast medical history ast mealvents or environment related to the injury.

AMPLE

Adequate resuscitation? Watch for these indicators• Hemodynamic and renal parameters within normal limits• Core body temperature normal• Serum lactate less than 2 mmol/liter• No base deficit• Arterial pH of 7.35 to 7.45• Hemoglobin greater than 9 grams/dL (based on individual needs)• Ionized calcium within normal limits. (Blood transfusion can lower serum cal-

cium because of the calcium-binding effects of the citrate preservative inbanked blood products.)

• Serum potassium of 3.5 to 5.3 mEq/liter • Coagulation profile within normal limits• Pain under control

fractures of the 9th and 10th ribson the left side, an L3 compressionfracture, bilateral calcaneus frac-tures, a renal contusion, and agrade III spleen injury.

Providing definitive care The definitive care phase beginsafter the patient’s injuries havebeen identified and initial lifesav-ing interventions have been per-formed. If your hospital doesn’thave the resources to provide thecare he needs, he may need to betransferred to a trauma center.

In a facility that can providetrauma management, the patientmay go to the operating room, in-tensive care unit (ICU), or a surgi-cal unit after his trauma workup.Most patients go home after dis-charge, but some require inpatientrehabilitation first.

In Michael’s case, the surgeonadmits him to the ICU for close

monitoring and pain management.She elects to manage his spleeninjury nonoperatively because hisvital signs normalized after hereceived 2 liters of resuscitationfluids. His rib fractures and renalcontusion require only observationat this time. Orthopedic and spinesurgeons are consulted to treat hiscalcaneus fractures and L3 com-pression fracture.

Meeting the standard of careKey outcome measures will helpyou to determine how well thepatient has responded to resusci-tation and help you anticipate hisneeds. (See Adequate resuscita-tion? Watch for these indicators.)

An organized team approach inthe first hour after a traumaticinjury provides fast, efficientpatient care and saves lives.Because you and other team mem-bers prioritized assessment and

interventions for Michael accord-ing to recognized standards of trau-ma care, you’ve given him the bestchance for survival and a fullrecovery.‹›SELECTED REFERENCESClontz AS, Tasota FJ. FAST results: Using fo-cused assessment with sonography for trauma.Nursing2004. 34(2):21, February 2004.

Laskowski-Jones L. Trauma and shock. In Kee JL,et al. (eds), Fluids and Electrolytes with ClinicalApplications: A Programmed Approach, 7th edition.Clifton Park, N.Y., Thomson-Delmar Learning,2004.

Laskowski-Jones L, Toulson K. Emergency andmass casualty nursing. In Ignatavicius D, Work-man ML (eds), Medical-Surgical Nursing: CriticalThinking for Collaborative Care, 5th edition.Philadelphia, Pa., Elsevier Saunders, 2006.

Peitzman AB, et al. The Trauma Manual, 2nd edi-tion. Philadelphia, Pa., Lippincott Williams &Wilkins, 2002.

Rapid Response to Everyday Emergencies: A Nurse’sGuide. Philadelphia, Pa., Lippincott Williams &Wilkins, 2006.

Linda Laskowski-Jones is vice-president of emer-gency, trauma, and aeromedical services atChristiana Care Health System in Wilmington, Del.

The author has disclosed that she has no significantrelationship with or financial interest in any commer-cial companies that pertain to this educational activity.


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Responding to trauma: Your priorities in the first hourGENERAL PURPOSE To familiarize nurses with priorities of initial assessment and intervention for patients with a traumatic injury. LEARNINGOBJECTIVES After reading the preceding article and taking this test, you should be able to: 1. Identify components of the primary trauma survey. 2. Identify components of the secondary trauma survey. 3. Describe the indications for various diagnostic studies in the trauma patient.

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1. Which of the following is an example of blunt force trauma? a. stab wound c. impalementb. fall injury d. gunshot wound

2. What’s always the first intervention for a trauma victim?a. Maintain a patent airway. b. Check vital signs.c. Perform a head-to-toe assessment.d. Control hemorrhage.

3. Until cervical spine injury is ruled out,open the airway by using aa. jaw lift.b. jaw-thrust maneuver.c. head-tilt—chin-lift maneuver. d. head-tilt—neck-lift maneuver.

4. For a trauma patient, when’s the besttime to insert a gastric tube?a. before intubationb. simultaneously with intubationc. very soon after intubationd. An intubated patient doesn’t need a gastric tube.

5. Crepitus on palpation of the neck andchest is a sign of a. cervical spine injury. c. pneumothorax.b. flail chest. d. hemorrhage.

6. The first intervention needed for a patientwith heart rate of 150 beats/minute, systolicBP of 70 mm Hg, respiratory rate of 40,and unilateral diminished breath soundsis most likely emergency a. chest decompression. c. ABG monitoring.b. chest radiograph. d. intubation.

7. If your patient has a radial pulse, hissystolic BP is at least a. 50 mm Hg. c. 70 mm Hg.b. 60 mm Hg. d. 80 mm Hg.

8. Which of the following is an early signof hypovolemic shock?a. cool, damp skin c. unresponsivenessb. agitation d. bradycardia

9. What’s the first intervention for copious bleeding from a hand wound?a. Apply direct pressure to the wound.b. Apply pressure over the radial artery.c. Apply pressure over the radial and ulnar arteries.d. Apply a tourniquet to the wrist.

10. What’s the best position for a responsive patient with symptomatichypotension?a. his head 6 inches lower than his body b. his legs elevated 8 inches higher than his heart c. reverse Trendelenburgd. recovery position

11. The smallest bore I.V. catheter insert-ed in a trauma patient should be a. 14-gauge. c. 18-gauge.b. 16-gauge. d. 20-gauge.

12. For a clinically unstable traumapatient, give packed RBCs aftera. infusing D5W for 30 minutes.b. typing and crossmatching.c. providing 2 mL of 0.9% sodium chloride for

each 1 mL of blood lost.d. administering 2,000 mL of lactated Ringer’s.

13. If typed, crossmatched blood isn’tavailable, which blood type should a 24-year-old woman receive?a. group O, Rh-negativeb. group O, Rh-positivec. group AB, Rh-negatived. group AB, Rh-positive

14. After a patient with a hemoglobinlevel of 7 grams/dL receives two units ofpacked RBCs, his hemoglobin levelshould increase toa. 8 grams/dL. c. 10 grams/dL.b. 9 grams/dL. d. 11 grams/dL.

15. Which statement about the GCS istrue?a. It should be deferred until after pain medication

is given.b. A score of 15 demonstrates severe brain injury.c. It helps to predict outcomes and disability.d. It shouldn’t be used if the patient appears

intoxicated.

16. Tetanus prophylaxis is indicated if thepatient hasn’t been immunized in the lasta. 2 years. c. 4 years.b. 3 years. d. 5 years.

17. MRI is best indicated for a. a mottled leg.b. an eye injury incurred in a machine shop.c. an acute spinal cord injury.d. a sudden loss of consciousness.

JRNL-Responding to Trauma Your Priorities in the First Hour

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