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MED SURG III
EXAM 1 - CRUSH INJURIES, CHEST INJURIES, HEMORRAGE, WOUNDS
| Question | Answer |
|---|---|
| Symptoms of Shock | Cool, moist skin, decreased BP, increased HR, delayed capillary refill, and decreased urine volume. |
| Goal of Emergency Management of Hemorrhage | Control the bleeding, maintain adequate circulating blood volume for tissue oxygenation, and prevent shock. |
| Fluid Replacement in Hemorrhage | Two large-gauge IV catheters are inserted, blood samples are obtained for analysis, typing, and cross-matching. Replacement fluids are given which may include isotonic electrolyte solutions (LR, NS), colloids, and blood components. |
| Massive Blood Loss Replacement | Packed Red Blood Cells, which may also necessitate transfusion of other blood components, including platelets & clotting factors. |
| Blood Water | Should be used when possible, if several units of blood is being administered, that has been refrigerated, as cold can lead to cardiac arrest and coagulopathy. |
| Controlling External Hemorrhage | Rapid physical assessment, cut clothing away. Direct firm pressure is applied over the bleeding area or the involved artery at a site that is proximal to the wound. Firm pressure dressing is applied. If the injured part is an extremity, it should be immobilized to control blood loss. A tourniquet is applied when hemorrhage cannot be controlled by other means, until surgery is performed. |
| Controlling Internal Hemorrhage | Suspected if the signs of hemorrhage are present, but there are no obvious signs of bleeding. Typically packed RBCs, plasma, and platelets are given at a rapid rate, and the patient is prepared for surgery or pharmacologic therapy. ABGs are obtained to monitor pulmonary function & tissue perfusion and to establish baseline hemodynamic parameters. Patient is maintained in the supine position and monitored closely until hemodynamic or circulatory parameters improve, or until surgery is performed |
| Crystalloids | Electrolyte solutions that move freely between intravascular compartments and interstitial spaces (0.9% NS, LR). Widely Available and help buffer metabolic acidosis |
| Colloids | Large-molecule IV solutions that are too large to pass through capillary membranes (Albumin 5%, 25%). Rapidly expands plasma volume. |
| Blood Components | Packed RBCs, fresh-frozen plasma, and platelets. Rapidly replaces volume lost due to hemorrhage |
| ISOTONIC FLUIDS | 0.9% NS, LR, 5% Dextrose in Water (D5W) |
| 0.9% Normal Saline | Expands extracellular fluid volume. Used in hypovolemia, resuscitative efforts in shock, DKA, metabolic alkalosis, hypercalcemia, and mild hyponatremia. Can cause fluid volume excess if given in large quantities. ONLY one to be used with blood products. |
| Lactated Ringers (LR) | Contains multiple electrolytes. Used in hypovolemia, burns, fluid lost as bile or diarrhea, and for acute blood loss replacement. Not to be given with a pH >7.5 because can cause alkalosis |
| 5% Dextrose in water (D5W) | Frees water to aid in renal excretion of solutions. Contains no electrolytes. Used in hypernatremia, fluid loss, and dehydration. Should not be used in large volumes in acute postop. Should not be used solely in the treatment of fluid volume deficit because it dilutes plasma electrolyte concentrations. Contraindicated in head injuries as it may cause ICP. Do not use in fluid replacement as it can cause hyperglycemia |
| HYPOTONIC FLUIDS | 0.45% NaCl |
| 0.45% Sodium Chloride | Free water is desirable in the kidneys in elimination of solutes. Lacks electrolytes other than Na & Cl. Used to treat hypertonic dehydration, Na & Cl depletion, and gastric fluid loss. Not indicated for third-space fluid shifts or ICP. Administer cautiously, because it can cause fluid shifts from vascular system into cells, resulting in CV collapse and ICP |
| HYPERTONIC FLUIDS | 3% NaCl & 5% NaCl |
| 3% Sodium Chloride & 5% Sodium Chloride | Used to increase ECF volume, and decrease cellular swelling. Supplies no calories. Used only in critical care situations to treat hyponatremia. Also used to assist in intracellular fluid excess. Administer slowly, as it can cause intravascular volume overload and pulmonary edema |
| COLLOID FLUIDS | Dextran in NS or D5W |
| Dextran | Used as volume/plasma expander for intravascular part of ECF. Affecting clotting by coating platelets and decreasing the ability to clot. Remains in circulatory system for 24 hours. Used in hypovolemia in early shock to increase pulse pressure, cardiac output, and arterial blood pressure. Improves microcirculation by decreasing RBC aggregation. Contraindicated in hemorrhage, thrombocytopenia, renal disease, and severe dehydration. Not a substitute for blood products |
| Simple Pneumothorax | Occurs when air enters the pleural space through a breach of either the parietal or visceral pleura. Can happen in a healthy person, or with diffuse interstitial lung disease and severe emphysema |
| Traumatic Pneumothorax | Occurs when air escapes from a laceration in the lung itself and enters the pleural space or from a wound in the chest wall. Often results from blunt trauma (rib fractures), penetrating abdominal trauma (stab or gunshot wounds), or diaphragmatic tears. Often accompanied by a hemothorax |
| Hemothorax | Collection of blood in the pleural space, resulting from torn intercostal vessels, lacerations of the great vessels, or lacerations of the lungs |
| Hemopneumothorax | Both blood and air in the chest cavity |
| Tension Pneumothorax | Occurs when air is drawn into the pleural space from a lacerated lung or through a small opening or wound in the chest wall. Can be a complication of other types of pneumothorax. Air that enters the chest cavity with each inspiration is trapped and cannot be expelled during expiration. Causes lungs to collapse and heart, great vessels and trachea to shift to the unaffected side of the chest (mediastinal shift) |
| Pneumothorax Assessment | Percussion - Hyper resonant or tympanic over the pleural air. Trachea - Shifted toward the unaffected side if tension pneumothorax. Breath Sounds - Decreased to absent over the pleural air. Adventitious Sounds - None except a possible pleural rub. Tactile Fremitus - Decreased to absent over the pleural air |
| Pneumothorax Care | Small chest tube is inserted into the second intercostal space. |
| What is the most common solid organ injured in intra-abdominal injuries? | The liver, due to its size and anterior placement in the right upper quadrant of the abdomen. |
| In an intra-abdominal injury, pain in the left shoulder is common in.. | Patients bleeding from a ruptured spleen |
| In an intra-abdominal injury, pain in the right should is common in… | A laceration of the liver. |
| FLAIL CHEST | Complication of blunt chest trauma, which may occur from a steering wheel, motor vehicle crash, or a significant fall onto the chest, or an assault with a blunt weapon. Occurs when 3 or more adjacent ribs are fractured at two or more sites, resulting in free-floating rib segments. |
| CRUSH INJURIES | Compression of extremities or other parts of the body that causes muscle swelling and/or neurological disturbances. |
| Monitoring of Patients with Crush Injuries | Hypovolemic shock resulting from extravasation of blood and plasma into injured tissues after compression has been released. Spinal cord injuries, erythema and blistering of skin, fractures, Acute Kidney Injuries, and Acute Tubular Necrosis. |
| Rhabdomyolysis | results when muscle mass is compressed, causing direct injury to muscle fibers. As the tissue is compressed, it is deprived of blood flow and becomes ischemic, eventually leading to cellular death |
| Injured Extremity Management | Elevation to relieve swelling and pressure. A fasciotomy may be performed if compartment syndrome develops. Hyperbaric Oxygen Chamber for crushed tissue |
| Fasciotomy | Surgical incision to the level of the fascia to restore neurovascular function in compartment syndrome |
| Hyperbaric Oxygen Chamber in Crushing Injuries | Used to hyper oxygenate crushed tissue |
| Abrasion | Denuded Skin when the skin rubs or scrapes against a rough or hard surface (road rash) |
| Avulsion | Tearing away of tissue from supporting structures |
| Cut | Incision of the skin with well-defined edges, usually longer than deep |
| Ecchymosis/Contusion | Blood trapped under the surface of the skin |
| Hematoma | Tumorlike mass of blood trapped under the skin |
| Laceration | Skin tear with irregular edges and vein bridging (Knives, tools, machinery) |
| Patterned | Wound representing the outline of the object (steering wheel) causing the wound |
| Stab | Incision of the skin with well-defined edges, usually caused by a sharp instrument. Typically deeper than longer |
| Puncture | Small hole, caused by a long, pointy object, such as a nail or needle. |
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