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TCRN EXAM REVIEWED QUESTIONS
AND ANSWERS
Shock - CORRECT ANSWER-Lack of oxygen to the cells Hypovolemic Shock - CORRECT ANSWER-Lack of volume ex: hemorrhage, burns Distributive Shock - CORRECT ANSWER-Maldistribution of blood (pooled in extremities) Decreased preload ex: neurogenic shock Cardiogenic Shock - CORRECT ANSWER-Inadequate cardiac output ex: blunt cardiac trauma Obstructive Shock - CORRECT ANSWER-Inability of blood to enter or exit heart properly ex: tamponade, tension pneumothorax Systemic Inflammatory Response Syndrome (SIRS) - CORRECT ANSWER-Severe tissue trauma activates an inflammatory response leading to vasodilation, capillary permeability, and coagulation Early (Compensated) Shock - CORRECT ANSWER-Normal BP Weak, thready pulse Deep and rapid RR Normal lactic levels Anxious
Late (Decompensated) Shock - CORRECT ANSWER- Decreased BP Tachycardia Shallow and rapid RR Increased Lactic Decreased LOC Decreased urinary output BUN to Creatinine Ratio - CORRECT ANSWER-Normal - 10: Indicated effective renal function Trauma Triad of Death - CORRECT ANSWER-Hypothermia Acidosis Coagulopathies Effects of Acidosis - CORRECT ANSWER-Increased ICP Exacerbates coagulopathies Depressed myocardial contractility DIC - CORRECT ANSWER-Excessive clotting > all clotting factors used > no more clotting > excessive bleeding Effects of coagulopathies - CORRECT ANSWER-Decreased platelet count Decreased fibrinogen Decreased HnH Increased PT, PTT Increased Ddimer Multi-Organ Dysfunction Syndrome (MODS) - CORRECT ANSWER-Irreversible Shock resulting from Triad of Death Symptoms start within the first week after trauma Steps to control hemorrhage - CORRECT ANSWER- Tourniquet TXA REBOA
MTP Protocol - CORRECT ANSWER-1 : 1 : 1 RBC : Plasma : Platelet Blood Loss Grades - CORRECT ANSWER-I - Loss of 15% with normal BP II - Loss of 15-30% with normal BP III - Loss: of 31-40% with lowered BP IV - Loss > 40% with hemodynamic instability Permissive Hypotension - CORRECT ANSWER-Maintaining BP as low as 70/40 so allow for clotting. Contra-indicated in head injuries, peds, and elderly SCIWORA - CORRECT ANSWER-Spinal Cord Injury WithOut Radiological Abnormality Common in Age < 2 yrs Significance of Bariatric Patients - CORRECT ANSWER- Increased HR and RR at baseline Increased abdominal pressures Increased risk of coagulopathies SBIRT - CORRECT ANSWER-Comprehensive intervention to deliver treatment for substance use disorders Screening Brief Intervention Referral to Treatment Triad of Abusive Brain Injury - CORRECT ANSWER-Subdural Hemorrhage Retinal Hemorrhage Decreased LOC Types of Stress Disorders - CORRECT ANSWER-State of Crisis - Immediately after event Acute Stress Disorder - Lasting at least three days
Post Traumatic Stress Disorder - Lasting one month or longer Three things to identify state of crisis - CORRECT ANSWER-1. Perception of the event
- Support System
- Coping mechanisms Steps of Research - CORRECT ANSWER-1. Research question
- Literature Review
- Research Methodologies
- Institutional Review Board (IRB) Quantitative Research Methods - CORRECT ANSWER- Descriptive - Describe current status of variable Correlational Retrospective - Chart review association of variables Quasi-experimental - Comparison of independent and dependent variable, but no control group Experimental - Comparison of variable and control group Qualitative Research Methods - CORRECT ANSWER- Phenomenology - Describe experiences of the subjects in the study Grounded Theory - Collecting a hypothesis by discussing the viewpoints from the subjects Ethnography - Observations of behavioral patterns Tool Reliability vs Validity - CORRECT ANSWER-Reliability - Consistency of the tool to measure what it is supposed to Validity - Extent to which tool measures what it is supposed to measure Role of the IRB - CORRECT ANSWER-Ensure informed consent is obtained Subjects can make independent decisions
Compassion Fatigue - CORRECT ANSWER-Loss of nurse's ability to empathize and provide compassionate care to patients Secondary Traumatic Stress leading to Burnout Autonomy - CORRECT ANSWER-Ability of individual to determine his/her own course of action ex: not receiving blood due to religious reasons Beneficence - CORRECT ANSWER-Duty of health care providers to be a benefit to the patients ex: prevent or remove harm from the patient Non-maleficence - CORRECT ANSWER-Do no harm ex: honor DNR status of patient Veracity - CORRECT ANSWER-Honesty, providing all information needed to make balanced decision ex: review all risks and benefits of surgery prior to consent Justice - CORRECT ANSWER-Fair distribution of goods in society ex: medicare/medicaid Protected Health Information may be shared to: - CORRECT ANSWER-Past, present or future providers Law enforcement Medical reviews Intracranial Pressure Measurements - CORRECT ANSWER- 0 - 15 Normal 20 - 40 Elevated Above 40 Severely Elevated Deficits in Elevated ICP (20-40) - CORRECT ANSWER- Ipsilateral - deficits above the neck on same side of bleed Contralateral - deficits below the neck on opposite side of blood Vomiting
Disorientation Restlessness Deficits in Severely Elevated ICP (Above 40) - CORRECT ANSWER-LOC Posturing Cushing's Triad Decorticate vs Decerebrate - CORRECT ANSWER- DeCORticate - Hands are pulled towards the CORE (Early) DEcErEbratE - Extension of the arms and legs (Late) Extraventricular Device (EVD) - CORRECT ANSWER-Allows drainage of CSF fluid Keep HOB 30 degrees Keep transducer level with the Foramen of Monro (Ear canal) Excessive drainage could lead to subdural hematoma Basilar Skull Fractures - CORRECT ANSWER-Anterior Fossa fracture - Around eyes and forehead (Could affect eyes and nose) Middle Fossa - Around ears (Could affect hearing) Posterior Fossa - Posterior portion of the head (Could lose gag reflex, or movement of the neck or tongue) Cerebral Contusion - CORRECT ANSWER-Bruising on the surface of the brain Three Meninges - CORRECT ANSWER-Pia Arachnoid Dura Meninges PAD the brain Epidural Bleed - CORRECT ANSWER-Between the skull and dura mater Arterial
Tests for CSF leakage - CORRECT ANSWER-"Halo" test Reagent strip - test for glucose Cerebral Perfusion Pressure (CPP) - CORRECT ANSWER- CPP = MAP - ICP Indirect measurement of cerebral oxygen delivery CPP Measurements - CORRECT ANSWER- 80 - 100: Healthy Above is 60: Required for consciousness Less than 50: Critical reduction in brain tissue oxygenation Less than 30: Irreversible brain ischemia MAP - CORRECT ANSWER-Mean Arterial Pressure MAP = (2D + S) / 3 Treatment of Elevated ICP - CORRECT ANSWER-Reducing volume of the brain (mannitol, hypertonic saline) Reducing the volume of the blood (elevated HOB, reduce cerebral activity, Anti-seizure medication) Reducing the volume of CSF (EVD) Maximize oxygenation (Reduction in CO2 in critical situations) Normalize blood glucose level Normalize temperature Spinal Cord Inuries - CORRECT ANSWER-C1-C4 - breathe no more C5-T1 - upper extremities T4 - Nipple line T7 and above - lose the ability to cough T10 - Hip line L2-L5 - lower extremities S3 - That's the end Anterior Cord Injury - CORRECT ANSWER-Descending (Brain to Body) Loss of motor function
Posterior Cord Injury - CORRECT ANSWER-Ascending (Body to Brain) Loss of proprioception, vibration, fine touch Lateral Cord - CORRECT ANSWER-Ascending (Body to Brain) Controls pain, temperature, crude touch Central Cord Injury - CORRECT ANSWER-Greater loss of motor function in upper vs lower extremities More likely to affect lateral cord Brown-Sequard Injury - CORRECT ANSWER-Loss of motor function on same side of injury Loss of pain and temp on opposite side of injury Cauda-Equina Syndrome - CORRECT ANSWER-Damage to lower spinal cord, resulting in problems with bowel and bladder control Spinal Shock - CORRECT ANSWER-Temporary neurological deficits immediately after spinal injury Islands of Sparing - CORRECT ANSWER-Areas without deficits due to a partial cord injury Sensory Assessment in SCI - CORRECT ANSWER-Start from areas of decreased sensation and move towards areas of increased sensation Neurogenic Shock - CORRECT ANSWER-Activation of parasympathetic nervous system causing vasodilation, hypotension and bradycardia Treat with fluids, and vasopressors Autonomic Dysreflexia symptoms - CORRECT ANSWER- Hypertension Bradycardia
Ocular Foreign Object - CORRECT ANSWER-Secure protruding object and cover unaffected eye Retrobulbar Hemorrhage - CORRECT ANSWER-Blood clot behind globe pushing it forward Use paper cup on affected eye Globe Luxation - CORRECT ANSWER-Extrusion of eye ball from the socket Ocular entrapment - CORRECT ANSWER-Orbital of the eye is stuck due to fracture Eye is angled downward toward the feet Rib Fractures - CORRECT ANSWER-1st and 2nd - Tracheal trauma, great vessel injury 3rd through 9th - Lung trauma 9th through 12th on the left - Splenic injury, left kidney 9th through 12th on the right - Liver injury, right kidney Sternum Fractures - CORRECT ANSWER-Blunt cardiac injury, esophageal trauma Laryngeal trauma Symptoms - CORRECT ANSWER-Hoarse voice Subcutaneous emphysema Flail Chest Segment - CORRECT ANSWER-Three or more rib fractures in two or more locations causing a free-floating segment of the rib cage Paradoxical chest wall movement - CORRECT ANSWER- Sinking of the flail segment during inspiration, and bulging of the flail chest segment during exhalation (opposite of normal) Treatment for Rib Fractures - CORRECT ANSWER-Pain management
Oxygenation Euvolemia Chest Physiotherapy Suctioning Aortic Trauma Symptoms - CORRECT ANSWER-Higher systolic in the right upper extremity compared to the left upper. Difference of 20. Precordial Systolic Murmur Treatment for Aortic Injuries - CORRECT ANSWER-Permissive Hypotension Beta-blockers Surgery Ankle Brachial Index - CORRECT ANSWER-Ratio to determine severity of peripheral vascular disease ABI = Ankle SBP / Brachial SBP ABI Measurements - CORRECT ANSWER-Greater than 0.9 : Normal 0.6 - 0.9 : Mild 0.3 - 0.6 : Moderate Less than 0.3 : Critical Ischemia Pericardial Tamponade - CORRECT ANSWER-Collection of fluid in the pericardial sac Symptoms: Beck's Triad, Pulsus Alternans, Paradoxical pulse, Narrowed pulse pressure, PEA Treatment: Pericardiocentesis, Open thoracotomy Beck's Triad - CORRECT ANSWER-Muffled heart tones Systemic Hypotension Distended neck veins Paradoxical Pulse - CORRECT ANSWER-Decrease of more than 10 in arterial pressure during inspiration
P:F ratio - CORRECT ANSWER-Indirect measurement of the degree of oxygenation across the alveolar membrane P:F ratio = Oxygen in the blood (PaO2) / Oxygen delivered (FiO2) Healthy Adult = 400 Mild ARDS = 200- 300 Moderate ARDS = 100- 200 Severe ARDS = Less then 100 Treatment of ARDS - CORRECT ANSWER-Euvolemia Lower Tidal Volume Elevated PEEP Prone Positioning ECMO Extracorporeal Membrane Oxygenation (ECMO) - CORRECT ANSWER-System that circulates the blood through an oxygenation system, to allow for the heart and lungs to recover Ruptured Diaphragm - CORRECT ANSWER-Symptoms: Heart sounds shift to the right side Pain to LEFT shoulder Signs of obstructive shock Dysphagia Dyspnea Confirmed by laparotomy Treatment: Surgery Seatbelt Sign - CORRECT ANSWER-Bruising along the lower abdomen Concern for small bowl injury and fractures of the lumbar spine Steps for Abdominal Assessment - CORRECT ANSWER- Visualization Auscultation Percussion
Palpation Tympany vs Dullness - CORRECT ANSWER-Tympany - Hyperresonance, Air, Hollow organs Dullness - Hyporesonance, Fluid, Solid organs Narrowed vs Widened Pulse Pressure - CORRECT ANSWER- Narrowed - Concerned for bleeding Widened - Concerned for head injuries Rebound Tenderness - CORRECT ANSWER-Pain that increases when pressure is removed due to irritation caused by presence of blood, enzymes, and bacterial contaminants Hollow Organs - CORRECT ANSWER-Esophagus, Stomach, Small intestine, Large intestine Complications of Hollow Organ Injuries - CORRECT ANSWER- Hematomas can cause obstructions hours or days after trauma Expected elevated WBC count, amylase, and lactic acid levels Escaping air can cause tympany and abdominal distention Rebound Tenderness Solid Organs - CORRECT ANSWER-Spleen, Liver, Pancreas, Kidneys Injury to the Spleen - CORRECT ANSWER-LUQ pain, Left shoulder pain Concerned for major blood loss Vulnerable to infections Treatment: Splenorrhaphy (surgical repair) or Splenectomy Long-term complications from a Splenectomy - CORRECT ANSWER-Vulnerable to infections caused by encapsulated bacteria: Flu, PNA, Meningococcus, E.coli, Staph, and Strep
Retroperitoneal Bleeding - CORRECT ANSWER-Cullen's Sign Bruising to the flanks Anterior vs Posterior Urethral Trauma - CORRECT ANSWER- Anterior - At end of urethra. More common in males. Usually due to straddle injuries or external forces. Posterior - Close to bladder. Almost always associated with pelvic fractures Types of Bladder Rupture - CORRECT ANSWER- Intraperitoneal - Top of bladder is ruptured into abdomen, can cause rebound tenderness and abdominal distention Extraperitoneal - Bottom of bladder is ruptured, can cause suprapubic swelling and tenderness Coopernail's Sign - CORRECT ANSWER-Bruising to the scrotum or labia Urinoma - CORRECT ANSWER-Collection of urine located outside the kidney or bladder Treatment: Percutaneous drain Complications of Renal Injury - CORRECT ANSWER- Hemorrhage Infection AKI Long term complication - Hypertension Acute Kidney Injury (AKI) - CORRECT ANSWER-Rapid loss of renal function due to damage to the kidneys Pre-Renal Failure - CORRECT ANSWER-Poor blood flow to the kidneys Treatment: Fluids, vasopressors, inotropes Intra-Renal Failure - CORRECT ANSWER-Damage to the kidneys due to nephrotoxins or ischemic sources
Treatment: Withdraw nephrotoxins, diuretics Post-Renal Failure - CORRECT ANSWER-Injury to the urinary collection system Treatment: Relieve obstruction, urinary catheterization Expected Lab Values in Renal Failure - CORRECT ANSWER- Elevated Creatinine Elevated BUN Elevated Potassium Decreased HnH Hemodialysis vs CRRT - CORRECT ANSWER-Hemodialysis - Shorter treatments, but rapid shifts in electrolytes CRRT - Slower corrections, but requires more anticoagulation Respiratory Changes in Pregnant Patients - CORRECT ANSWER-Elevated diaphragm Increased respiratory rate Decreased CO2 and Bicarb Circulation Changes in Pregnant Patients - CORRECT ANSWER-Increased blood volume Increased heart rate Increased clotting factors Displace uterus to either side to prevent vena cava from becoming compressed GI / GU Changes in Pregnant Patients - CORRECT ANSWER- More susceptible to splenic, liver, and bladder trauma Urinary Frequency Orthopedic Changes in Pregnant Patients - CORRECT ANSWER-Relaxation of ligaments Apply pelvic binder in normal position, below the level of the uterus
