Responding to

TRAUMA
Your priorities
in the first hour

In a few minutes, a patient whos sustained serious

traumatic injuries will arrive at your hospital. Are
you ready to care for him?
Here youll 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

roofer, just fell 20 feet from a
building under construction. Initially he struck the ground with
his feet, then fell onto his left side.
Conscious and alert at the scene,
he complains of severe back and
lower leg pain. His vital signs are:
BP, 140/88; heart rate, 112; respiratory rate, 28; SpO2, 96%; and temperature, 98 F (36.7 C). His
Glasgow Coma Scale (GCS) score
is 15. Michaels odds of survival
are good: Of trauma patients who
enter the trauma care system with
vital signs intact, more than 95%
survive.
Paramedics administer oxygen
at a flow rate of 15 liters/minute
via non-rebreather mask and apply
a cervical collar and a backboard to
immobilize his neck and spine.
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Nursing2006, Volume 36, Number 9

They also place a 16-gauge intravenous (I.V.) catheter in his left

forearm and begin an infusion of
0.9% sodium chloride solution.
If Michael were on his way to
your hospitals emergency department (ED) for treatment, would
you be prepared to provide immediate and appropriate nursing
care? In this article, Ill explain
the primary and secondary assessment surveys you need to complete as soon as he arrives and
discuss how your findings guide
nursing and medical interventions. But first, lets review how to
prepare for a trauma patients
arrival in the ED.
Getting ready for your patient

Trauma team members must be

prepared to deal with any type of

injury. But learning details about

the mechanism of injury can help
them predict the types and combinations of injuries that he may
have sustainedinformation that
will help you and the other team
members plan effective care.
Mechanism of injury describes
the circumstances and energy
forces that produced the trauma,
usually blunt or penetrating.
Examples of blunt force trauma
include injuries from motorvehicle crashes, falls, assault,
industrial incidents, blast force,
and sports-related injuries. Penetrating trauma injuries include
stab and gunshot wounds,
impaled objects, and damage
from projectiles.
As the trauma team awaits
Michaels arrival at the hospital,
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they review the information the

paramedics provided by radio and
discuss their concerns about his
possible injuries based on his
mechanism of injury. Knowing that
Michael has had a blunt injury
mechanism and that he landed on
his feet in the fall, team members
suspect theyll find lumbar spine
compression fractures and lower
extremity traumaparticularly calcaneus fractures. Knowing that he
suffered an impact to his left side,
theyll also be ready to assess for
traumatic injuries to the chest and
abdomen.
Your first priority as a member of
the trauma team is to protect yourself from exposure to blood and
body fluids. Prepare to use standard
precautions, which are mandatory.
While you wait for the patient to
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arrive, don a fluid-impervious

gown, gloves, and face and eye protection, such as a face shield or
goggles and mask, in case blood
splashes. Ensure ready access to
personal protective equipment to
prevent delays in patient care.
Trauma care always begins with
the primary survey, a rapid assessment of the patients ABCs
airway, breathing, and circulationwith the addition of D (disability) and E (exposure).
The primary survey focuses on
what can kill the patient now. Its
followed by the secondary survey,
a complete head-to-toe assessment to identify other serious
injuries that could kill or disable
the patient later.
Resuscitation occurs simultaneously with the primary survey. As

life-threatening injuries are discovered, the team intervenes to

optimize oxygenation, ventilation,
and perfusion. Interventions
include clearing the airway, providing supplemental oxygen, ventilating the patient, controlling
hemorrhage, inserting I.V. devices
and chest tubes, and replacing fluids and blood.
Diagnostic studies follow the
primary and secondary surveys,
although blood is usually drawn
when I.V. lines are placed during
the primary survey. Test results further define the nature and severity
of the injuries and help guide the
treatment plan.
Now lets take a closer look at
how assessment and interventions
mesh during the crucial first hour
after an injury.
Nursing2006, September

53

Primary survey: Managing

immediate threats

By taking a standardized approach

to assessment and treatment, the
trauma team can address the most
significant risks to life first. As
always, start with the ABCs.
Airway. The first part of the primary survey is always assessing the
airway. This includes checking for
potential injury to the cervical
spine. Until cervical spine injury
has been ruled out, open the
patients airway using a jaw-thrust
maneuver with manual, in-line stabilization of the neck. If you find
food, blood, vomitus, or other
debris, suction the airway quickly
to prevent aspiration. To better
remove secretions,
you may need to
carefully logroll the
patient to his side.
Your first priority
Manually stabilize
as a member of
his neck and spine
the trauma team is as you do so.
If the patient cant
to protect yourself
maintain
a patent
from exposure to
airway because of
blood and body
copious secretions,
an impaired level of
fluids.
consciousness, or
other critical
injuries, hell need
endotracheal intubation. Insert a
large-diameter (#18 French
catheter) gastric tube as soon as
possible after intubation to decompress his stomach and remove gastric contents. Remember, even after
the airway has been secured, he
could still vomit and aspirate.
If the patient has any head or
midface trauma, pass the gastric
tube orally. Nasogastric tube insertion would be risky because a disruption of the cribriform plate (the
bone between the sinuses and the
brain) could allow the tube to be
inadvertently inserted into the cranium.
If massive facial injuries prevent
oral endotracheal intubation, the
patient will need surgical airway
placement (typically a cricothyrotomy).
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Nursing2006, Volume 36, Number 9

When Michael is brought into

the trauma room, he can speak
clearly and provide an account of
the accident. Because he can converse, his airway assessment is
straightforward: He has a patent
airway. However, hes still considered to be at risk for cervical spine
injury. Spinal precautions continue
until cervical injury is ruled out.
Breathing. Assess your patients
breathing next. Note respiratory
rate and depth, chest expansion,
and accessory muscle use and auscultate breath sounds bilaterally.
Also palpate for crepitus or subcutaneous air in the neck and chest,
which can indicate a pneumothorax or airway injury. Find out if he
has pain with breathing or on palpation. Injuries that can impair
ventilation include rib fractures
(especially a flail chest), a pneumothorax, a hemothorax, and
spinal cord or head trauma.
Supplemental oxygen is always
indicated at this stage. For a spontaneously breathing patient like
Michael, a non-rebreather mask
with the flow rate set at 12 to 15
liters/minute is appropriate. However, if the patient isnt breathing
well enough to sustain optimal
oxygenation, begin manual bagvalvemask ventilation to support
his ventilatory efforts until he can
be intubated and mechanically
ventilated.
If the patient is having severe respiratory distress and hypotension
as well as unilateral decreased or
absent breath sounds, suspect a
tension pneumothorax, a potentially fatal complication requiring
rapid treatment. To perform an
emergency chest decompression,
the trauma team physician will perform a needle thoracostomy, inserting a 14-gauge I.V. catheter into the
patients chest at the second intercostal space, midclavicular line on
the affected side. A rush of air from
the catheter confirms the presence
of a tension pneumothorax. The
catheter is left in place until a chest
tube can be inserted.

In the meantime, a syringe or

commercial Heimlich valve (or
similar device) is attached to the
catheter hub so that air can escape
without being drawn back into the
chest. If available, have a chest
tube drainage system that can collect blood for autotransfusion on
hand during chest tube insertion,
in case a hemothorax is present.
Michaels ventilatory efforts are
adequate. His breath sounds are
clear and equal bilaterally, but he
complains of pain in his left side
on palpation. The supplemental
oxygen hes receiving via the nonrebreather mask (which was
applied by the paramedics) is kept
at a flow rate of 15 liters/minute.
His SpO2 is now 100%.
Circulation. Once youve
assessed and supported your
patients breathing, attend to his
circulatory status. Assess for the
presence and quality of peripheral
pulses to quickly estimate BP, as
follows.
If he has a radial pulse, his systolic BP is at least 80 mm Hg.
If hes lost his radial pulse but
still has a femoral pulse, he has a
systolic BP of at least 70 mm Hg.
If he lacks all pulses except a
carotid pulse, he has a systolic BP
of at least 60 mm Hg.
Note the patients skin color and
level of consciousness (LOC).
Pallor and cold, clammy skin indicate shock.
His LOC is an important indicator of cerebral perfusion. Agitation
is common in the early stages of
shock. (Think of the fight or
flight response.) As shock progresses, his LOC will decline until
hes unconscious.
Obtain a complete set of vital
signs, including temperature, as
soon as possible. Use this set of
vital signs as a baseline for comparison with subsequent measurements. You may need to take vital
signs every 5 to 15 minutes until
the patients condition improves.
A key part of your circulatory
assessment is to identify and conwww.nursing2006.com

trol hemorrhage. External hemorrhage is usually, but not always,

obvious. Logroll the patient to
inspect his back and buttocks for
bleeding.
To control bleeding, apply direct
pressure over the site of hemorrhage. If this isnt effective by itself,
apply pressure over the major arterial pulse point proximal to the
bleeding site.
Use a tourniquet only if you
must stanch severe hemorrhage in
an extremity to save the patients
life. Using a tourniquet puts the
limbs viability at risk.
Next, ask yourself if the mechanism of injury makes internal hemorrhage likely. If the patient has
signs and symptoms of shock without visible bleeding, he may have
an occult internal hemorrhage that
requires surgery.
Besides assessing and documenting his circulatory status, you may
need to intervene to sustain circulation. For a patient whos in
shock, consider both noninvasive
and invasive strategies to support
his BP. Keep him supine and elevate his legs 6 to 8 inches (15 to 20
cm) to promote venous return and
improve cardiac output. Dont put
him in the Trendelenburg position
because this can cause his stomach
to compress his diaphragm, impairing ventilation.
Make sure he has venous access
with two large-bore I.V. catheters
(ideally 14- to 16-gauge) to facilitate rapid fluid and blood product
administration if needed. Draw
blood for lab analysis. Send specimens for typing and crossmatching, complete blood cell count,
serum glucose, electrolytes, and a
coagulation profile. Depending on
the patients condition and suspected injuries, you may also need
specimens for other studies, such
as creatine kinase, amylase, and
serum lactate.
An arterial blood gas (ABG)
analysis can help clinicians assess
the patients oxygenation status
and determine whether or not hes
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in shock. If ABG results show a

transfusion reaction. Signs and
base deficit thats greater than 2
symptoms of a transfusion reaction
mEq/liter, suspect ongoing hemor- vary according to what type of
rhage, internal injuries, or insuffireaction it is. For instance, intracient resuscitation.
vascular hemolysis may cause
As ordered, administer an apfever, lower back pain, pain at the
propriate crystalloid solution for
I.V. site, hypotension, and renal
I.V. volume replacement, such as
failure. If you suspect a transfusion
0.9% sodium chloride or lactated
reaction, discontinue the infusion
Ringers solution. Warm the soluimmediately and follow your hostion in a commercial fluid warmer
pitals protocol for managing transor use a high-volume infuser/
fusion reactions.
warming device. Dont administer
During the primary assessment,
D5W for volume replacement
Michaels vital signs change signifbecause the dextrose will be
icantly from those obtained by the
metabolized and
leave free water, a
Using the Glasgow Coma Scale
hypotonic solution
that wont stay in the
Eye opening
Spontaneous
4
vascular space.
To voice
3
Provide 3 mL of
To pain
2
crystalloid solution
None
1
to replace each 1 mL Best verbal response
Oriented
5
of blood lost. If you
Confused
4
Inappropriate
infuse 2 liters of
3
Incomprehensible
2
crystalloid solution
None
1
and the patients BP
Best
motor
response
Obeys
commands
6
hasnt returned to
Localizes pain
5
the normal range, be
Withdraws (pain)
4
prepared to adminisFlexion
3
ter blood products.
Extension
2
Typing and crossNone
1
matching typically
Total score
3-15
take 30 to 40 minHeres how to interpret the score:
utes, which may be
13-14 is mild brain injury.
too long for a trauma 9-12 is moderate brain injury.
patient to wait.
3-8 is severe brain injury.
When immediate
blood transfusion is
needed, the only option is to give
paramedics: His BP drops to
uncrossmatched universal donor
96/58, his SpO2 falls to 95%, his
heart rate increases to 120, his resblood, as ordered. Give group O,
Rh-negative packed red blood cells piratory rate remains at 28, and
his temperature is now 97.4 F
(RBCs) to female patients of child(36.3 C). He has no external
bearing age or younger. Male
hemorrhage, so the physician suspatients and women who cant
become pregnant can receive group pects a spleen injury because he
knows the left chest and abdomen
O, Rh-positive blood. Remember
were injured in the fall and the
that 0.9% sodium chloride is the
only solution you can infuse in the lower left rib cage is tender. You
hang a liter of 0.9% sodium chlosame I.V. line as blood.
ride using a high-volume fluid
Expect each unit of packed
infuser/warmer and begin the
RBCs to raise the patients hemoinfusion via the second I.V. access
globin by 1 gram/dL unless hes
line previously established with a
continuing to hemorrhage. During
14-gauge catheter.
the infusion, remain vigilant for a
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55

Disability. To evaluate disability,

youll evaluate the patients LOC,
pupil response, and gross sensorimotor function. To document his
baseline LOC, quickly assess and
record an initial GCS score. If possible, determine his GCS before he
receives any drugs that could alter
his LOC to better enable you to
predict his outcome. For example,
if a patients GCS score on arrival at
the hospital is 4, his prognosis for
recovery is much worse than a
patient whose
initial score is
12.
Keep in mind
that accurate
scoring can be
Agitation is
impaired by
common in the
traumatic,
early stages
toxic, and metabolic causes.
of shock.
Even if the
patient shows
evidence of
alcohol or drug
use, never
assume that his altered mental status is due purely to intoxicants
until injury and other medical
causes are ruled out. (See Using the
Glasgow Coma Scale.)
Note whether the patient can
recall the events surrounding the
traumatic event. Amnesia about
the event suggests that he lost consciousness.
Next, assess his pupils for size,
equality, shape, and response to
light. If he can follow commands,
check for accommodationthe
pupillary size changes that occur
when focusing on near objects
(constriction) and far objects (dilation). Unequal or abnormal pupil
response can indicate direct ocular
trauma or head injury and elevated
intracranial pressure or the effects
of drugs, such as atropine (pupil
dilation) or opioids (pupil constriction).
The final component of the disability evaluation is an assessment
of gross sensorimotor function. Try
to determine if the patient has any
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Nursing2006, Volume 36, Number 9

numbness, tingling, or other

abnormal sensations in his body
after the traumatic event and if he
can move his limbs. Injuries to the
extremities, spinal cord, head,
blood vessels, or nerves can cause
sensorimotor deficits.
Michaels GCS score stays at 15.
He didnt lose consciousness during or after the fall and he can
recall the event vividly. His pupils
are equal (4 mm/4 mm) and
round, react to light, and accommodate normally. Despite the pain
in his back and leg, Michaels gross
sensorimotor function is intact.
Exposure. The final component
of the primary survey is exposure.
Remove the patients clothing
completely so you can inspect his
entire body for injuries. Use good
judgment when removing clothing; trying to remove a shirt by
pulling or manipulating it may
worsen the injury or pain. Cutting
clothing away with trauma shears
is usually best.
Once youve removed clothing,
protect the patient from hypothermia, which is particularly
dangerous to any trauma patient
because it impairs blood coagulation, interferes with resuscitation
efforts, and increases the risk of
acidosis and death.
Take these measures to prevent
heat loss and rewarm the patient.
Remove wet clothing and
sheets. Cover the patient with
warm blankets.
Increase the room temperature
to 75 F to 80 F (23.9 C to
26.7 C).
Infuse only warm crystalloid
solutions.
Consider using commercial
patient-warming devices, such as
heat lights or temperatureregulating blankets.
When Michael is exposed, you
note that he has abrasions over
his lower left ribs and deformities
in both feet. You quickly cover
him with heavy blankets that
have been kept in a blanket
warmer. The room temperature

had been raised to 78 F (25.6 C)

before his arrival, and hes been
receiving warmed I.V. fluids.
Secondary survey: Uncovering
other serious threats

Once youve completed the primary survey and managed any

immediate threats to the patients
life, begin a secondary survey for
injuries that could kill or disable
him later. Start at his head and
assess him methodically, moving
down his body systematically as
you search for injuries. Inspect
for contusions, abrasions, lacerations, deformities, discoloration,
edema, foreign bodies, and other
abnormalities.
Auscultate breath sounds and
heart sounds. Assess all body
areas to locate areas of pain or
tenderness, crepitus, deformity,
loss of function, and the location
and quality of pulses. If you suspect he has a fracture of an arm
or leg, assess the neurovascular
status of the limb, then splint it
to prevent movement and
decrease pain. Assess neurovascular status again after splinting.
Administer I.V. opioid pain medication as ordered and make sure
that pain is managed optimally.
At this point, the trauma
physician will consider ordering
an indwelling urinary catheter to
accurately measure urinary output, an indication of renal perfusion, and to check for blood in
the urine. First, though, hell
perform a rectal examination to
check for blood or evidence of
urethral injury, such as a highriding prostate gland in a male
patient. (If the urethra is
injured, the patient may need to
have a suprapubic catheter
inserted instead.)
Before inserting a urinary
catheter, look for blood at the
urethral meatus. If you see
blood, notify the physician and
dont insert the catheter. The
patient will need further diagnostic testing (for instance, a
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retrograde urethrogram or cystogram) before a catheter can be

safely inserted.
Reassess the patients vital
signs and GCS score as frequently as needed, depending on his
condition. Also try to obtain a
more complete history from the
patient or significant others. Use
the mnemonic AMPLE to help
you remember the key information to gather. (See Get AMPLE
information.)
Assess carefully for medications the patient has taken that
could affect his condition and
treatment. For example, taking
an anticoagulant, such as warfarin, or a platelet inhibitor,
such as daily aspirin therapy,
will make him much more prone
to bleeding from his injuries. If
hes using any of these drugs, tell
the health care provider immediately so that he can order appropriate reversal agents or take
measures to counteract anticoagulation effects.
Assess the patient for steroid
use. If hes taking a steroid medication, he many need an I.V.
steroid bolus so that he can
physiologically respond in a
stress or shock state. If you dont
know the date of his last tetanus
immunization or if it was more
than 5 years ago, administer
tetanus prophylaxis.
Michaels secondary survey is
remarkable for pain on palpation
in his lumbar spine, tenderness
and abrasions over his left lower
rib cage anteriorly, and heel pain
and swelling in both feet. You
insert a urinary catheter and
perform a dipstick urine test,
which is positive for a small
amount of blood.
Next up: An eye on diagnostics

After the primary and secondary

surveys are complete, prepare
your patient for a series of X-rays
and scans. Hell have a stat
portable chest X-ray to identify
rib fractures or mediastinal or
www.nursing2006.com

diaphragmatic injury and to

ly injured patients because it takes
assess for a pneumothorax or
too long and safely placing an
hemothorax. Hell also need a cer- injured patient into the MRI tube
vical spine X-ray series to check
is difficult. In addition, the patient
for cervical spine injury. The Xmight have ferrous metal in his
ray will also confirm the correct
body (for example, braces,
position of chest and endotraimplants, or metal fragments left
cheal tubes and central venous
in his eyes from industrial work).
catheters. Depending on the
Any ferrous metal is dangerous in
results of the primary and secan MRI room and is a contraindiondary surveys, he may have
cation for MRI.
additional X-rays of the pelvis,
However, the patient may need
spine, extremities, or other areas.
an MRI if he shows any evidence
He may have bedside ultraof an acute spinal cord injury. Be
sonography with the focused
sure to carefully assess him for
abdominal sonography for trauma ferrous metal objects. If they can
(FAST) technique, which is used
be removed, do so before taking
to rapidly examine all four
him to the MRI. The technologist
abdominal quadrants and the
will ask him if he has any impericardium to identify the presplants or fragments in his eyes
ence of free fluid, usually blood.
from metal work. If he does, an
If hes lost consciousness or
MRI is contraindicated.
shows evidence of a head injury,
Michaels diagnostic workup
hell need a computed tomography includes a bedside FAST ultra(CT) scan of his head. Other CT
sound; chest, pelvis, and lower
scans of the spine, chest, abdomen, extremity X-rays; a full series of
or pelvis may be indicated to help
spinal X-rays; and CT scans of his
the health care provider plan treatchest, abdomen, and lumbar spine.
ment.
The tests identify these injuries:
Your patient may need
a vascular ultrasound or
Get AMPLE information
an arteriogram if he has
This mnemonic will remind you of the critical
vascular injuries,
history to gather from your trauma patient or
decreased or absent pulshis significant other:
es, evidence of limb
ischemia, or a widened
A llergies
mediastinum, indicating a M edication use
possible aortic injury.
P ast medical history
Magnetic resonance
L ast meal
E vents or environment related to the injury.
imaging (MRI) is rarely
used for diagnosing acute-

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 calcium because of the calcium-binding effects of the citrate preservative in
banked blood products.)
Serum potassium of 3.5 to 5.3 mEq/liter
Coagulation profile within normal limits
Pain under control

Nursing2006, September

57

fractures of the 9th and 10th ribs

on the left side, an L3 compression
fracture, bilateral calcaneus fractures, a renal contusion, and a
grade III spleen injury.
Providing definitive care

The definitive care phase begins

after the patients injuries have
been identified and initial lifesaving interventions have been performed. If your hospital doesnt
have the resources to provide the
care he needs, he may need to be
transferred to a trauma center.
In a facility that can provide
trauma management, the patient
may go to the operating room, intensive care unit (ICU), or a surgical unit after his trauma workup.
Most patients go home after discharge, but some require inpatient
rehabilitation first.
In Michaels case, the surgeon
admits him to the ICU for close

monitoring and pain management.

She elects to manage his spleen
injury nonoperatively because his
vital signs normalized after he
received 2 liters of resuscitation
fluids. His rib fractures and renal
contusion require only observation
at this time. Orthopedic and spine
surgeons are consulted to treat his
calcaneus fractures and L3 compression fracture.

interventions for Michael according to recognized standards of trauma care, youve given him the best
chance for survival and a full
recovery.

Meeting the standard of care

Laskowski-Jones L, Toulson K. Emergency and

mass casualty nursing. In Ignatavicius D, Workman ML (eds), Medical-Surgical Nursing: Critical
Thinking for Collaborative Care, 5th edition.
Philadelphia, Pa., Elsevier Saunders, 2006.

Key outcome measures will help

you to determine how well the
patient has responded to resuscitation and help you anticipate his
needs. (See Adequate resuscitation? Watch for these indicators.)
An organized team approach in
the first hour after a traumatic
injury provides fast, efficient
patient care and saves lives.
Because you and other team members prioritized assessment and

SELECTED REFERENCES
Clontz AS, Tasota FJ. FAST results: Using focused 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 Clinical
Applications: A Programmed Approach, 7th edition.
Clifton Park, N.Y., Thomson-Delmar Learning,
2004.

Peitzman AB, et al. The Trauma Manual, 2nd edition. Philadelphia, Pa., Lippincott Williams &
Wilkins, 2002.
Rapid Response to Everyday Emergencies: A Nurses
Guide. Philadelphia, Pa., Lippincott Williams &
Wilkins, 2006.
Linda Laskowski-Jones is vice-president of emergency, trauma, and aeromedical services at
Christiana Care Health System in Wilmington, Del.
The author has disclosed that she has no significant
relationship with or financial interest in any commercial 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
of blunt force trauma?
a. stab wound
c. impalement
b. fall injury
d. gunshot wound

7. If your patient has a radial pulse, his

systolic BP is at least
a. 50 mm Hg.
c. 70 mm Hg.
b. 60 mm Hg.
d. 80 mm Hg.

2. Whats 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.

8. Which of the following is an early sign

of hypovolemic shock?
a. cool, damp skin
c. unresponsiveness
b. agitation
d. bradycardia

13. If typed, crossmatched blood isnt

available, which blood type should a
24-year-old woman receive?
a. group O, Rh-negative
b. group O, Rh-positive
c. group AB, Rh-negative
d. group AB, Rh-positive
14. After a patient with a hemoglobin
level of 7 grams/dL receives two units of
packed RBCs, his hemoglobin level
should increase to
a. 8 grams/dL.
c. 10 grams/dL.
b. 9 grams/dL.
d. 11 grams/dL.

9. Whats 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.

3. Until cervical spine injury is ruled out,

open the airway by using a
a. jaw lift.
b. jaw-thrust maneuver.
c. head-tiltchin-lift maneuver.
d. head-tiltneck-lift maneuver.

15. Which statement about the GCS is

true?
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 shouldnt be used if the patient appears
intoxicated.

10. Whats the best position for a

responsive patient with symptomatic
hypotension?
a. his head 6 inches lower than his body
b. his legs elevated 8 inches higher than his heart
c. reverse Trendelenburg
d. recovery position

4. For a trauma patient, whens the best

time to insert a gastric tube?
a. before intubation
b. simultaneously with intubation
c. very soon after intubation
d. An intubated patient doesnt need a gastric tube.

16. Tetanus prophylaxis is indicated if the

patient hasnt been immunized in the last
a. 2 years.
c. 4 years.
b. 3 years.
d. 5 years.

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

5. Crepitus on palpation of the neck and

chest is a sign of
a. cervical spine injury.
c. pneumothorax.
b. flail chest.
d. hemorrhage.
6. The first intervention needed for a patient
with heart rate of 150 beats/minute, systolic
BP of 70 mm Hg, respiratory rate of 40,
and unilateral diminished breath sounds
is most likely emergency
a. chest decompression.
c. ABG monitoring.
b. chest radiograph.
d. intubation.

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.

12. For a clinically unstable trauma

patient, give packed RBCs after
a. 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 Ringers.

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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Address _______________________________________________________________________________
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Registration Deadline: September 30, 2008
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B. Test Answers: Darken one circle for your answer to each question.

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C. Course Evaluation*
1. Did this CE activity's learning objectives relate to its general purpose? Yes No
2. Was the journal home study format an effective way to present the material? Yes No
3. Was the content relevant to your nursing practice? Yes No
4. How long did it take you to complete this CE activity?___ hours___minutes
5. Suggestion for future topics __________________________________________________________

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*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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