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Responding to

TRAUMA Your priorities


in the first hour
In a few minutes, a patient who’s sustained serious
traumatic injuries will arrive at your hospital. Are
you ready to care for him?
Here you’ll learn a quick, evidence-based
system to guide your initial assessments
and interventions.

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

MICHAEL PETRI, a 54-year-old They also place a 16-gauge intra- injury. But learning details about
roofer, just fell 20 feet from a venous (I.V.) catheter in his left the mechanism of injury can help
building under construction. Ini- forearm and begin an infusion of them predict the types and com-
tially he struck the ground with 0.9% sodium chloride solution. binations of injuries that he may
his feet, then fell onto his left side. If Michael were on his way to have sustained—information that
Conscious and alert at the scene, your hospital’s emergency depart- will help you and the other team
he complains of severe back and ment (ED) for treatment, would members plan effective care.
lower leg pain. His vital signs are: you be prepared to provide imme- Mechanism of injury describes
BP, 140/88; heart rate, 112; respira- diate and appropriate nursing the circumstances and energy
tory rate, 28; SpO2, 96%; and tem- care? In this article, I’ll explain forces that produced the trauma,
perature, 98° F (36.7° C). His the primary and secondary assess- usually blunt or penetrating.
Glasgow Coma Scale (GCS) score ment surveys you need to com- Examples of blunt force trauma
is 15. Michael’s odds of survival plete as soon as he arrives and include injuries from motor-
are good: Of trauma patients who discuss how your findings guide vehicle crashes, falls, assault,
enter the trauma care system with nursing and medical interven- industrial incidents, blast force,
vital signs intact, more than 95% tions. But first, let’s review how to and sports-related injuries. Pene-
survive. prepare for a trauma patient’s trating trauma injuries include
Paramedics administer oxygen arrival in the ED. stab and gunshot wounds,
at a flow rate of 15 liters/minute impaled objects, and damage
via non-rebreather mask and apply Getting ready for your patient from projectiles.
a cervical collar and a backboard to Trauma team members must be As the trauma team awaits
immobilize his neck and spine. prepared to deal with any type of Michael’s arrival at the hospital,

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


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they review the information the arrive, don a fluid-impervious life-threatening injuries are dis-
paramedics provided by radio and gown, gloves, and face and eye pro- covered, the team intervenes to
discuss their concerns about his tection, such as a face shield or optimize oxygenation, ventilation,
possible injuries based on his goggles and mask, in case blood and perfusion. Interventions
mechanism of injury. Knowing that splashes. Ensure ready access to include clearing the airway, pro-
Michael has had a blunt injury personal protective equipment to viding supplemental oxygen, ven-
mechanism and that he landed on prevent delays in patient care. tilating the patient, controlling
his feet in the fall, team members Trauma care always begins with hemorrhage, inserting I.V. devices
suspect they’ll find lumbar spine the primary survey, a rapid assess- and chest tubes, and replacing flu-
compression fractures and lower ment of the patient’s ABCs— ids and blood.
extremity trauma—particularly cal- airway, breathing, and circula- Diagnostic studies follow the
caneus fractures. Knowing that he tion—with the addition of D (dis- primary and secondary surveys,
suffered an impact to his left side, ability) and E (exposure). although blood is usually drawn
they’ll also be ready to assess for The primary survey focuses on when I.V. lines are placed during
traumatic injuries to the chest and what can kill the patient now. It’s the primary survey. Test results fur-
abdomen. followed by the secondary survey, ther define the nature and severity
Your first priority as a member of a complete head-to-toe assess- of the injuries and help guide the
the trauma team is to protect your- ment to identify other serious treatment plan.
self from exposure to blood and injuries that could kill or disable Now let’s take a closer look at
body fluids. Prepare to use standard the patient later. how assessment and interventions
precautions, which are mandatory. Resuscitation occurs simultane- mesh during the crucial first hour
While you wait for the patient to ously with the primary survey. As after an injury.

www.nursing2006.com Nursing2006, September 53


Primary survey: Managing When Michael is brought into In the meantime, a syringe or
immediate threats the trauma room, he can speak commercial Heimlich valve (or
By taking a standardized approach clearly and provide an account of similar device) is attached to the
to assessment and treatment, the the accident. Because he can con- catheter hub so that air can escape
trauma team can address the most verse, his airway assessment is without being drawn back into the
significant risks to life first. As straightforward: He has a patent chest. If available, have a chest
always, start with the ABCs. airway. However, he’s still consid- tube drainage system that can col-
Airway. The first part of the pri- ered to be at risk for cervical spine lect blood for autotransfusion on
mary survey is always assessing the injury. Spinal precautions continue hand during chest tube insertion,
airway. This includes checking for until cervical injury is ruled out. in case a hemothorax is present.
potential injury to the cervical Breathing. Assess your patient’s Michael’s ventilatory efforts are
spine. Until cervical spine injury breathing next. Note respiratory adequate. His breath sounds are
has been ruled out, open the rate and depth, chest expansion, clear and equal bilaterally, but he
patient’s airway using a jaw-thrust and accessory muscle use and aus- complains of pain in his left side
maneuver with manual, in-line sta- cultate breath sounds bilaterally. on palpation. The supplemental
bilization of the neck. If you find Also palpate for crepitus or subcu- oxygen he’s receiving via the non-
food, blood, vomitus, or other taneous air in the neck and chest, rebreather mask (which was
debris, suction the airway quickly which can indicate a pneumotho- applied by the paramedics) is kept
to prevent aspiration. To better rax or airway injury. Find out if he at a flow rate of 15 liters/minute.
remove secretions, has pain with breathing or on pal- His SpO2 is now 100%.
you may need to pation. Injuries that can impair Circulation. Once you’ve
carefully logroll the ventilation include rib fractures assessed and supported your
Your first priority patient to his side. (especially a flail chest), a pneu- patient’s breathing, attend to his
as a member of Manually stabilize mothorax, a hemothorax, and circulatory status. Assess for the
his neck and spine spinal cord or head trauma. presence and quality of peripheral
the trauma team is as you do so. Supplemental oxygen is always pulses to quickly estimate BP, as
to protect yourself If the patient can’t indicated at this stage. For a spon- follows.
from exposure to maintain a patent taneously breathing patient like • If he has a radial pulse, his sys-
airway because of Michael, a non-rebreather mask tolic BP is at least 80 mm Hg.
blood and body copious secretions, with the flow rate set at 12 to 15 • If he’s lost his radial pulse but
fluids. an impaired level of liters/minute is appropriate. How- still has a femoral pulse, he has a
consciousness, or ever, if the patient isn’t breathing systolic BP of at least 70 mm Hg.
other critical well enough to sustain optimal • If he lacks all pulses except a
injuries, he’ll need oxygenation, begin manual bag- carotid pulse, he has a systolic BP
endotracheal intubation. Insert a valve–mask ventilation to support of at least 60 mm Hg.
large-diameter (#18 French his ventilatory efforts until he can Note the patient’s skin color and
catheter) gastric tube as soon as be intubated and mechanically level of consciousness (LOC).
possible after intubation to decom- ventilated. Pallor and cold, clammy skin indi-
press his stomach and remove gas- If the patient is having severe res- cate shock.
tric contents. Remember, even after piratory distress and hypotension His LOC is an important indica-
the airway has been secured, he as well as unilateral decreased or tor of cerebral perfusion. Agitation
could still vomit and aspirate. absent breath sounds, suspect a is common in the early stages of
If the patient has any head or tension pneumothorax, a potential- shock. (Think of the “fight or
midface trauma, pass the gastric ly fatal complication requiring flight” response.) As shock pro-
tube orally. Nasogastric tube inser- rapid treatment. To perform an gresses, his LOC will decline until
tion would be risky because a dis- emergency chest decompression, he’s unconscious.
ruption of the cribriform plate (the the trauma team physician will per- Obtain a complete set of vital
bone between the sinuses and the form a needle thoracostomy, insert- signs, including temperature, as
brain) could allow the tube to be ing a 14-gauge I.V. catheter into the soon as possible. Use this set of
inadvertently inserted into the cra- patient’s chest at the second inter- vital signs as a baseline for compar-
nium. costal space, midclavicular line on ison with subsequent measure-
If massive facial injuries prevent the affected side. A rush of air from ments. You may need to take vital
oral endotracheal intubation, the the catheter confirms the presence signs every 5 to 15 minutes until
patient will need surgical airway of a tension pneumothorax. The the patient’s condition improves.
placement (typically a cricothyrot- catheter is left in place until a chest A key part of your circulatory
omy). tube can be inserted. assessment is to identify and con-

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


trol hemorrhage. External hemor- in shock. If ABG results show a transfusion reaction. Signs and
rhage is usually, but not always, base deficit that’s greater than 2 symptoms of a transfusion reaction
obvious. Logroll the patient to mEq/liter, suspect ongoing hemor- vary according to what type of
inspect his back and buttocks for rhage, internal injuries, or insuffi- reaction it is. For instance, intra-
bleeding. cient resuscitation. vascular hemolysis may cause
To control bleeding, apply direct As ordered, administer an ap- fever, lower back pain, pain at the
pressure over the site of hemor- propriate crystalloid solution for I.V. site, hypotension, and renal
rhage. If this isn’t effective by itself, I.V. volume replacement, such as failure. If you suspect a transfusion
apply pressure over the major arte- 0.9% sodium chloride or lactated reaction, discontinue the infusion
rial pulse point proximal to the Ringer’s solution. Warm the solu- immediately and follow your hos-
bleeding site. tion in a commercial fluid warmer pital’s protocol for managing trans-
Use a tourniquet only if you or use a high-volume infuser/ fusion reactions.
must stanch severe hemorrhage in warming device. Don’t administer During the primary assessment,
an extremity to save the patient’s D5W for volume replacement Michael’s vital signs change signif-
life. Using a tourniquet puts the because the dextrose will be icantly from those obtained by the
limb’s viability at risk. metabolized and
Next, ask yourself if the mecha- leave free water, a
nism of injury makes internal hem- hypotonic solution Using the Glasgow Coma Scale
orrhage likely. If the patient has that won’t stay in the
Eye opening Spontaneous 4
signs and symptoms of shock with- vascular space. To voice 3
out visible bleeding, he may have Provide 3 mL of To pain 2
an occult internal hemorrhage that crystalloid solution None 1
requires surgery. to replace each 1 mL Best verbal response Oriented 5
Besides assessing and document- of blood lost. If you Confused 4
ing his circulatory status, you may infuse 2 liters of Inappropriate 3
need to intervene to sustain circu- crystalloid solution Incomprehensible 2
lation. For a patient who’s in and the patient’s BP None 1
shock, consider both noninvasive hasn’t returned to Best motor response Obeys commands 6
Localizes pain 5
and invasive strategies to support the normal range, be
Withdraws (pain) 4
his BP. Keep him supine and ele- prepared to adminis-
Flexion 3
vate his legs 6 to 8 inches (15 to 20 ter blood products. Extension 2
cm) to promote venous return and Typing and cross- None 1
improve cardiac output. Don’t put matching typically Total score 3-15
him in the Trendelenburg position take 30 to 40 min-
Here’s how to interpret the score:
because this can cause his stomach utes, which may be • 13-14 is mild brain injury.
to compress his diaphragm, im- too long for a trauma • 9-12 is moderate brain injury.
pairing ventilation. patient to wait. • 3-8 is severe brain injury.
Make sure he has venous access When immediate
with two large-bore I.V. catheters blood transfusion is
(ideally 14- to 16-gauge) to facili- needed, the only option is to give paramedics: His BP drops to
tate rapid fluid and blood product uncrossmatched universal donor 96/58, his SpO2 falls to 95%, his
administration if needed. Draw blood, as ordered. Give group O, heart rate increases to 120, his res-
blood for lab analysis. Send speci- Rh-negative packed red blood cells piratory rate remains at 28, and
mens for typing and crossmatch- (RBCs) to female patients of child- his temperature is now 97.4° F
ing, complete blood cell count, bearing age or younger. Male (36.3° C). He has no external
serum glucose, electrolytes, and a patients and women who can’t hemorrhage, so the physician sus-
coagulation profile. Depending on become pregnant can receive group pects a spleen injury because he
the patient’s condition and suspect- O, Rh-positive blood. Remember knows the left chest and abdomen
ed injuries, you may also need that 0.9% sodium chloride is the were injured in the fall and the
specimens for other studies, such only solution you can infuse in the lower left rib cage is tender. You
as creatine kinase, amylase, and same I.V. line as blood. hang a liter of 0.9% sodium chlo-
serum lactate. Expect each unit of packed ride using a high-volume fluid
An arterial blood gas (ABG) RBCs to raise the patient’s hemo- infuser/warmer and begin the
analysis can help clinicians assess globin by 1 gram/dL unless he’s infusion via the second I.V. access
the patient’s oxygenation status continuing to hemorrhage. During line previously established with a
and determine whether or not he’s the infusion, remain vigilant for a 14-gauge catheter.

www.nursing2006.com Nursing2006, September 55


Disability. To evaluate disability, numbness, tingling, or other had been raised to 78° F (25.6° C)
you’ll evaluate the patient’s LOC, abnormal sensations in his body before his arrival, and he’s been
pupil response, and gross sensori- after the traumatic event and if he receiving warmed I.V. fluids.
motor function. To document his can move his limbs. Injuries to the
baseline LOC, quickly assess and extremities, spinal cord, head, Secondary survey: Uncovering
record an initial GCS score. If pos- blood vessels, or nerves can cause other serious threats
sible, determine his GCS before he sensorimotor deficits. Once you’ve completed the pri-
receives any drugs that could alter Michael’s GCS score stays at 15. mary survey and managed any
his LOC to better enable you to He didn’t lose consciousness dur- immediate threats to the patient’s
predict his outcome. For example, ing or after the fall and he can life, begin a secondary survey for
if a patient’s GCS score on arrival at recall the event vividly. His pupils injuries that could kill or disable
the hospital is 4, his prognosis for are equal (4 mm/4 mm) and him later. Start at his head and
recovery is much worse than a round, react to light, and accom- assess him methodically, moving
patient whose modate normally. Despite the pain down his body systematically as
initial score is in his back and leg, Michael’s gross you search for injuries. Inspect
12. sensorimotor function is intact. for contusions, abrasions, lacera-
Keep in mind Exposure. The final component tions, deformities, discoloration,
that accurate of the primary survey is exposure. edema, foreign bodies, and other
Agitation is scoring can be Remove the patient’s clothing abnormalities.
common in the impaired by completely so you can inspect his Auscultate breath sounds and
traumatic, entire body for injuries. Use good heart sounds. Assess all body
early stages toxic, and meta- judgment when removing cloth- areas to locate areas of pain or
of shock. bolic causes. ing; trying to remove a shirt by tenderness, crepitus, deformity,
Even if the pulling or manipulating it may loss of function, and the location
patient shows worsen the injury or pain. Cutting and quality of pulses. If you sus-
evidence of clothing away with trauma shears pect he has a fracture of an arm
alcohol or drug is usually best. or leg, assess the neurovascular
use, never Once you’ve removed clothing, status of the limb, then splint it
assume that his altered mental sta- protect the patient from hypo- to prevent movement and
tus is due purely to intoxicants thermia, which is particularly decrease pain. Assess neurovas-
until injury and other medical dangerous to any trauma patient cular status again after splinting.
causes are ruled out. (See Using the because it impairs blood coagula- Administer I.V. opioid pain med-
Glasgow Coma Scale.) tion, interferes with resuscitation ication as ordered and make sure
Note whether the patient can efforts, and increases the risk of that pain is managed optimally.
recall the events surrounding the acidosis and death. At this point, the trauma
traumatic event. Amnesia about Take these measures to prevent physician will consider ordering
the event suggests that he lost con- heat loss and rewarm the patient. an indwelling urinary catheter to
sciousness. • Remove wet clothing and accurately measure urinary out-
Next, assess his pupils for size, sheets. Cover the patient with put, an indication of renal perfu-
equality, shape, and response to warm blankets. sion, and to check for blood in
light. If he can follow commands, • Increase the room temperature the urine. First, though, he’ll
check for accommodation—the to 75° F to 80° F (23.9° C to perform a rectal examination to
pupillary size changes that occur 26.7° C). check for blood or evidence of
when focusing on near objects • Infuse only warm crystalloid urethral injury, such as a high-
(constriction) and far objects (dila- solutions. riding prostate gland in a male
tion). Unequal or abnormal pupil • Consider using commercial patient. (If the urethra is
response can indicate direct ocular patient-warming devices, such as injured, the patient may need to
trauma or head injury and elevated heat lights or temperature- have a suprapubic catheter
intracranial pressure or the effects regulating blankets. inserted instead.)
of drugs, such as atropine (pupil When Michael is exposed, you Before inserting a urinary
dilation) or opioids (pupil con- note that he has abrasions over catheter, look for blood at the
striction). his lower left ribs and deformities urethral meatus. If you see
The final component of the dis- in both feet. You quickly cover blood, notify the physician and
ability evaluation is an assessment him with heavy blankets that don’t insert the catheter. The
of gross sensorimotor function. Try have been kept in a blanket patient will need further diag-
to determine if the patient has any warmer. The room temperature nostic testing (for instance, a

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


retrograde urethrogram or cys- diaphragmatic injury and to ly injured patients because it takes
togram) before a catheter can be assess for a pneumothorax or too long and safely placing an
safely inserted. hemothorax. He’ll also need a cer- injured patient into the MRI tube
Reassess the patient’s vital vical spine X-ray series to check is difficult. In addition, the patient
signs and GCS score as frequent- for cervical spine injury. The X- might have ferrous metal in his
ly as needed, depending on his ray will also confirm the correct body (for example, braces,
condition. Also try to obtain a position of chest and endotra- implants, or metal fragments left
more complete history from the cheal tubes and central venous in his eyes from industrial work).
patient or significant others. Use catheters. Depending on the Any ferrous metal is dangerous in
the mnemonic “AMPLE” to help results of the primary and sec- an MRI room and is a contraindi-
you remember the key informa- ondary surveys, he may have cation for MRI.
tion to gather. (See Get AMPLE additional X-rays of the pelvis, However, the patient may need
information.) spine, extremities, or other areas. an MRI if he shows any evidence
Assess carefully for medica- He may have bedside ultra- of an acute spinal cord injury. Be
tions the patient has taken that sonography with the focused sure to carefully assess him for
could affect his condition and abdominal sonography for trauma ferrous metal objects. If they can
treatment. For example, taking (FAST) technique, which is used be removed, do so before taking
an anticoagulant, such as war- to rapidly examine all four him to the MRI. The technologist
farin, or a platelet inhibitor, abdominal quadrants and the will ask him if he has any im-
such as daily aspirin therapy, pericardium to identify the pres- plants or fragments in his eyes
will make him much more prone ence of free fluid, usually blood. from metal work. If he does, an
to bleeding from his injuries. If If he’s lost consciousness or MRI is contraindicated.
he’s using any of these drugs, tell shows evidence of a head injury, Michael’s diagnostic workup
the health care provider immedi- he’ll need a computed tomography includes a bedside FAST ultra-
ately so that he can order appro- (CT) scan of his head. Other CT sound; chest, pelvis, and lower
priate reversal agents or take scans of the spine, chest, abdomen, extremity X-rays; a full series of
measures to counteract anticoag- or pelvis may be indicated to help spinal X-rays; and CT scans of his
ulation effects. the health care provider plan treat- chest, abdomen, and lumbar spine.
Assess the patient for steroid ment. The tests identify these injuries:
use. If he’s taking a steroid med- Your patient may need
ication, he many need an I.V. a vascular ultrasound or
steroid bolus so that he can an arteriogram if he has
Get AMPLE information
physiologically respond in a vascular injuries, This mnemonic will remind you of the critical
stress or shock state. If you don’t decreased or absent puls- history to gather from your trauma patient or
know the date of his last tetanus es, evidence of limb his significant other:
immunization or if it was more ischemia, or a widened A llergies
than 5 years ago, administer mediastinum, indicating a M edication use
tetanus prophylaxis. possible aortic injury. P ast medical history
Michael’s secondary survey is Magnetic resonance L ast meal
remarkable for pain on palpation imaging (MRI) is rarely E vents or environment related to the injury.
in his lumbar spine, tenderness used for diagnosing acute-
and abrasions over his left lower
rib cage anteriorly, and heel pain
and swelling in both feet. You Adequate resuscitation? Watch for these indicators
insert a urinary catheter and
• Hemodynamic and renal parameters within normal limits
perform a dipstick urine test,
• Core body temperature normal
which is positive for a small • Serum lactate less than 2 mmol/liter
amount of blood. • No base deficit
• Arterial pH of 7.35 to 7.45
Next up: An eye on diagnostics • Hemoglobin greater than 9 grams/dL (based on individual needs)
• Ionized calcium within normal limits. (Blood transfusion can lower serum cal-
After the primary and secondary
cium because of the calcium-binding effects of the citrate preservative in
surveys are complete, prepare banked blood products.)
your patient for a series of X-rays • Serum potassium of 3.5 to 5.3 mEq/liter
and scans. He’ll have a stat • Coagulation profile within normal limits
portable chest X-ray to identify • Pain under control
rib fractures or mediastinal or

www.nursing2006.com Nursing2006, September 57


fractures of the 9th and 10th ribs monitoring and pain management. interventions for Michael accord-
on the left side, an L3 compression She elects to manage his spleen ing to recognized standards of trau-
fracture, bilateral calcaneus frac- injury nonoperatively because his ma care, you’ve given him the best
tures, a renal contusion, and a vital signs normalized after he chance for survival and a full
grade III spleen injury. received 2 liters of resuscitation recovery.‹›
fluids. His rib fractures and renal SELECTED REFERENCES
Providing definitive care contusion require only observation Clontz AS, Tasota FJ. FAST results: Using fo-
cused assessment with sonography for trauma.
The definitive care phase begins at this time. Orthopedic and spine Nursing2004. 34(2):21, February 2004.
after the patient’s injuries have surgeons are consulted to treat his Laskowski-Jones L. Trauma and shock. In Kee JL,
been identified and initial lifesav- calcaneus fractures and L3 com- et al. (eds), Fluids and Electrolytes with Clinical
Applications: A Programmed Approach, 7th edition.
ing interventions have been per- pression fracture. Clifton Park, N.Y., Thomson-Delmar Learning,
formed. If your hospital doesn’t 2004.

have the resources to provide the Meeting the standard of care Laskowski-Jones L, Toulson K. Emergency and
mass casualty nursing. In Ignatavicius D, Work-
care he needs, he may need to be Key outcome measures will help man ML (eds), Medical-Surgical Nursing: Critical
transferred to a trauma center. you to determine how well the Thinking for Collaborative Care, 5th edition.
Philadelphia, Pa., Elsevier Saunders, 2006.
In a facility that can provide patient has responded to resusci- Peitzman AB, et al. The Trauma Manual, 2nd edi-
trauma management, the patient tation and help you anticipate his tion. Philadelphia, Pa., Lippincott Williams &
Wilkins, 2002.
may go to the operating room, in- needs. (See Adequate resuscita-
Rapid Response to Everyday Emergencies: A Nurse’s
tensive care unit (ICU), or a surgi- tion? Watch for these indicators.) Guide. Philadelphia, Pa., Lippincott Williams &
cal unit after his trauma workup. An organized team approach in Wilkins, 2006.
Most patients go home after dis- the first hour after a traumatic Linda Laskowski-Jones is vice-president of emer-
charge, but some require inpatient injury provides fast, efficient gency, trauma, and aeromedical services at
Christiana Care Health System in Wilmington, Del.
rehabilitation first. patient care and saves lives.
In Michael’s case, the surgeon Because you and other team mem- The author has disclosed that she has no significant
relationship with or financial interest in any commer-
admits him to the ICU for close bers prioritized assessment and cial companies that pertain to this educational activity.

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Responding to trauma: Your priorities in the first hour


GENERAL PURPOSE To familiarize nurses with priorities of initial assessment and intervention for patients with a traumatic injury. LEARNING
OBJECTIVES 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.

1. Which of the following is an example 7. If your patient has a radial pulse, his 13. If typed, crossmatched blood isn’t
of blunt force trauma? systolic BP is at least available, which blood type should a
a. stab wound c. impalement a. 50 mm Hg. c. 70 mm Hg. 24-year-old woman receive?
b. fall injury d. gunshot wound b. 60 mm Hg. d. 80 mm Hg. a. group O, Rh-negative
b. group O, Rh-positive
2. What’s always the first intervention 8. Which of the following is an early sign c. group AB, Rh-negative
for a trauma victim? of hypovolemic shock? d. group AB, Rh-positive
a. Maintain a patent airway. a. cool, damp skin c. unresponsiveness
b. Check vital signs. b. agitation d. bradycardia 14. After a patient with a hemoglobin
c. Perform a head-to-toe assessment. level of 7 grams/dL receives two units of
d. Control hemorrhage. 9. What’s the first intervention for packed RBCs, his hemoglobin level
copious bleeding from a hand wound? should increase to
3. Until cervical spine injury is ruled out, a. Apply direct pressure to the wound. a. 8 grams/dL. c. 10 grams/dL.
open the airway by using a b. Apply pressure over the radial artery. b. 9 grams/dL. d. 11 grams/dL.
a. jaw lift. c. Apply pressure over the radial and ulnar arteries.
b. jaw-thrust maneuver. d. Apply a tourniquet to the wrist. 15. Which statement about the GCS is
c. head-tilt—chin-lift maneuver. true?
d. head-tilt—neck-lift maneuver. 10. What’s the best position for a a. It should be deferred until after pain medication
responsive patient with symptomatic is given.
4. For a trauma patient, when’s the best hypotension? b. A score of 15 demonstrates severe brain injury.
time to insert a gastric tube? a. his head 6 inches lower than his body c. It helps to predict outcomes and disability.
a. before intubation b. his legs elevated 8 inches higher than his heart d. It shouldn’t be used if the patient appears
b. simultaneously with intubation c. reverse Trendelenburg intoxicated.
c. very soon after intubation d. recovery position
d. An intubated patient doesn’t need a gastric tube. 16. Tetanus prophylaxis is indicated if the
11. The smallest bore I.V. catheter insert- patient hasn’t been immunized in the last
5. Crepitus on palpation of the neck and ed in a trauma patient should be a. 2 years. c. 4 years.
chest is a sign of a. 14-gauge. c. 18-gauge. b. 3 years. d. 5 years.
a. cervical spine injury. c. pneumothorax. b. 16-gauge. d. 20-gauge.
b. flail chest. d. hemorrhage. 17. MRI is best indicated for
12. For a clinically unstable trauma a. a mottled leg.
6. The first intervention needed for a patient patient, give packed RBCs after b. an eye injury incurred in a machine shop.
with heart rate of 150 beats/minute, systolic a. infusing D5W for 30 minutes. c. an acute spinal cord injury.
BP of 70 mm Hg, respiratory rate of 40, b. typing and crossmatching. d. a sudden loss of consciousness.
and unilateral diminished breath sounds c. providing 2 mL of 0.9% sodium chloride for
is most likely emergency each 1 mL of blood lost.
a. chest decompression. c. ABG monitoring. d. administering 2,000 mL of lactated Ringer’s.
b. chest radiograph. d. intubation.
✄ ENROLLMENT FORM Nursing2006, September, Responding to trauma: Your priorities in the first hour

A. Registration Information: ❑ LPN ❑ RN ❑ CNS ❑ NP ❑ CRNA ❑ CNM ❑ other ___________________
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❑ Please fax my certificate to me.
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B. Test Answers: Darken one circle for your answer to each question.
a b c d a b c d a b c d a b c d
1. ❍ ❍ ❍ ❍ 6. ❍ ❍ ❍ ❍ 11. ❍ ❍ ❍ ❍ 16. ❍ ❍ ❍ ❍
2. ❍ ❍ ❍ ❍ 7. ❍ ❍ ❍ ❍ 12. ❍ ❍ ❍ ❍ 17. ❍ ❍ ❍ ❍
3. ❍ ❍ ❍ ❍ 8. ❍ ❍ ❍ ❍ 13. ❍ ❍ ❍ ❍
4. ❍ ❍ ❍ ❍ 9. ❍ ❍ ❍ ❍ 14. ❍ ❍ ❍ ❍
5. ❍ ❍ ❍ ❍ 10. ❍ ❍ ❍ ❍ 15. ❍ ❍ ❍ ❍
C. Course Evaluation* D. Two Easy Ways to Pay:
1. Did this CE activity's learning objectives relate to its general purpose? ❑ Yes ❑ No ❑ Check or money order enclosed (Payable to Lippincott Williams & Wilkins)
2. Was the journal home study format an effective way to present the material? ❑ Yes ❑ No ❑ Charge my ❑ Mastercard ❑ Visa ❑ American Express
3. Was the content relevant to your nursing practice? ❑ Yes ❑ No
Card # _____________________________________________ Exp. date __________________
4. How long did it take you to complete this CE activity?___ hours___minutes
5. Suggestion for future topics __________________________________________________________ Signature _______________________________________________________________________

*In accordance with the Iowa Board of Nursing administrative rules governing grievances, a copy of your evaluation of the CE offering may be submitted directly to the Iowa Board of Nursing.
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