- Beck's triad
- Hypotension + jugular venous distension + muffled heart sounds = cardiac tamponade.
- Lowest possible GCS score
- 3 (no eye, verbal, or motor response) — there is no score of 0.
- Highest GCS score
- 15 (eye 4 + verbal 5 + motor 6) — a fully alert, oriented patient.
- GCS three components
- Eye opening (1–4), verbal response (1–5), best motor response (1–6).
- Severe TBI GCS
- 8 or below — usually requires definitive airway protection (intubation).
- Moderate TBI GCS
- 9–12.
- Mild TBI GCS
- 13–15 (includes concussion).
- Cushing's triad
- Hypertension with widening pulse pressure + bradycardia + irregular respirations — a LATE sign of raised ICP.
- Normal intracranial pressure (ICP)
- 5–15 mmHg.
- Cerebral perfusion pressure (CPP) formula
- CPP = MAP − ICP; keep it adequate (about 60–70 mmHg) to prevent secondary ischemia.
- Epidural hematoma — vessel & CT
- Arterial (middle meningeal artery); biconvex/lens-shaped on CT; does NOT cross suture lines.
- Epidural hematoma — classic presentation
- Brief lucid interval after impact, then rapid deterioration ('talk and die').
- Subdural hematoma — vessel & CT
- Venous (bridging veins); crescent-shaped on CT; crosses suture lines.
- Subdural hematoma — typical patient
- Older or anticoagulated adults; slower onset than epidural.
- Subarachnoid hemorrhage — presentation
- Blood in the sulci/cisterns; 'worst headache of life' with nuchal rigidity.
- Primary vs secondary brain injury
- Primary = mechanical damage at impact (irreversible); secondary = hypoxia/hypotension/edema cascade the nurse can PREVENT.
- Rising ICP — nursing measures
- Head of bed 30°, head midline, normocapnia, normothermia, hypertonic saline/mannitol; avoid hypoxia and hypotension.
- Single biggest worseners of TBI outcome
- Hypoxia and hypotension — preventing both IS the brain-saving intervention.
- Basilar skull fracture signs
- Raccoon eyes, Battle's sign, CSF rhinorrhea/otorrhea — do NOT place nasal/NG tubes.
- Neurogenic shock
- Distributive shock after a high SCI: hypotension WITH bradycardia and warm, dry skin from lost sympathetic tone.
- Spinal shock
- Temporary loss of ALL reflexes, motor, and sensation below the injury; gradually resolves.
- Neurogenic vs hypovolemic shock clue
- Neurogenic = hypotension with BRADYcardia and warm skin; hypovolemic = hypotension with TACHYcardia and cool, clammy skin.
- Neurogenic shock treatment
- Fluids, vasopressors, and atropine for symptomatic bradycardia — but rule out hemorrhage first.
- Autonomic dysreflexia — level
- Injuries at or above T6.
- Autonomic dysreflexia — presentation & first action
- Severe hypertension, pounding headache, flushing (often from a full bladder) → SIT the patient up and remove the trigger.
- First trauma assumption for hypotension
- Hemorrhage until proven otherwise.
- Maxillofacial trauma — top priority
- The airway (blood, edema, broken teeth, Le Fort fractures can obstruct rapidly).
- Ruptured globe management
- Shield the eye (do NOT apply pressure), keep the patient upright, and avoid further manipulation.
- Chemical eye burn — first action
- Immediate, copious irrigation.
- Penetrating neck trauma — don't do this
- Never probe or explore the wound; watch for expanding hematoma, bruit, and subcutaneous emphysema.
- Concussion danger
- Missing a deteriorating bleed — trend the GCS; a falling score is the alarm.
- Decorticate vs decerebrate posturing
- Decorticate (flexion toward the core) is less severe than decerebrate (extension); both signal serious brain injury.
- Le Fort fractures
- Midface fractures (I, II, III) that can cause airway compromise and CSF leak.
- Hyphema
- Blood in the anterior chamber of the eye after blunt trauma; elevate head, shield, limit activity.
- GCS motor 'localizes' vs 'withdraws'
- Localizes (5) = purposeful movement toward a stimulus; withdraws (4) = pulls away — localizing is the better response.
- Tension pneumothorax signs
- Absent breath sounds + hyperresonance on one side, hypotension, JVD, and LATE tracheal deviation away from the injury.
- Tension pneumothorax treatment
- Immediate needle decompression, then a chest tube — a clinical diagnosis (do not wait for a film).
- Open pneumothorax treatment
- Three-sided occlusive (flutter-valve) dressing, then a chest tube.
- Massive hemothorax definition
- >1,500 mL initial chest-tube output, or ongoing >200 mL/hr — needs a chest tube and surgery.
- Cardiac tamponade — cause in trauma
- Usually penetrating chest injury; blood compresses the heart and impairs filling (obstructive shock).
- Pulsus paradoxus
- A fall in systolic BP of more than 10 mmHg on inspiration; a sign of cardiac tamponade.
- Cardiac tamponade treatment
- Pericardiocentesis or, in trauma, emergency thoracotomy.
- Flail chest definition
- Three or more adjacent ribs each fractured in two or more places → paradoxical chest movement.
- Flail chest — real danger
- The underlying pulmonary contusion, which can worsen over 24–48 hours.
- Tension pneumothorax vs tamponade
- Both: hypotension + JVD. Tension PTX = ABSENT breath sounds + hyperresonance; tamponade = MUFFLED heart sounds, breath sounds intact.
- Pulmonary contusion
- Bruised lung tissue causing hypoxia that can worsen over 24–48 hours; support oxygenation, careful fluids.
- Blunt aortic injury — mechanism & sign
- High-speed deceleration; widened mediastinum on imaging; most often at the aortic isthmus.
- Blunt aortic injury management
- Strict heart-rate and blood-pressure control to limit shear while awaiting repair.
- FAST exam — what & where
- Bedside ultrasound for free fluid in four windows: perihepatic (RUQ), perisplenic (LUQ), pelvic, and pericardial.
- eFAST adds
- Evaluation of the chest for pneumothorax and hemothorax.
- Positive FAST in an UNSTABLE patient
- Means the operating room — not the CT scanner.
- Most commonly injured solid organ (blunt)
- The spleen, followed by the liver.
- Kehr's sign
- Referred left shoulder pain from diaphragmatic irritation — a clue to splenic injury/bleeding.
- Seat-belt sign significance
- A red flag for underlying bowel, mesenteric, and lumbar-spine injury even if the patient looks well early.
- Nonoperative solid-organ management — nursing role
- Serial abdominal exams, serial hematocrits, bed rest, and vigilance for a failing nonoperative course.
- AAST organ injury scale
- Grades solid-organ injury severity from I (least) to V (most severe).
- Unstable pelvic fracture risk
- Exsanguination into the retroperitoneum.
- Pelvic binder placement
- At the level of the greater trochanters, to reduce pelvic volume and tamponade venous bleeding.
- Pelvic exam — what NOT to do
- Do not repeatedly rock or 'spring' the pelvis; it can worsen bleeding.
- Urethral injury signs
- Blood at the meatus, a high-riding prostate, scrotal/perineal bruising → NO urinary catheter until excluded.
- Diaphragmatic rupture
- Usually left-sided after blunt trauma; bowel sounds in the chest, respiratory distress; needs surgical repair.
- Chest tube — continuous bubbling
- Indicates an air leak in the system.
- Chest tube — never do this
- Never clamp a functioning chest tube without an order (risk of tension pneumothorax).
- Retroperitoneal hemorrhage
- Bleeding behind the peritoneum (kidneys, pelvis, great vessels) that can be occult; suspect with flank/back pain and unexplained shock.
- Hemodynamically unstable + positive FAST → fluids fail
- Anticipate massive transfusion and emergent operative source control.
- Vertebral column injury precautions
- Spinal motion restriction, log-roll for movement and skin checks, image per validated criteria.
- NEXUS / Canadian C-spine rule
- Validated criteria used to decide which patients need cervical-spine imaging.
- Compartment syndrome — 6 P's
- Pain, Paresthesia, Pallor, Pulselessness, Paralysis, Poikilothermia.
- Compartment syndrome — earliest sign
- Pain out of proportion to the injury and pain on passive stretch.
- Compartment syndrome — late signs
- Pulselessness and paralysis (ominous).
- Compartment syndrome treatment
- Emergent fasciotomy.
- Compartment syndrome — what NOT to do
- Do NOT elevate the limb above the heart or apply ice; remove constricting casts/dressings.
- Fat embolism syndrome — timing & triad
- 24–72 hours after a long-bone/pelvic fracture: hypoxia, neurologic change, and a petechial rash.
- Rhabdomyolysis — cause & signs
- Crush injury releasing myoglobin; elevated CK and dark, tea-colored urine; risks AKI.
- Rhabdomyolysis treatment
- Aggressive IV fluids; monitor potassium and renal function.
- Open fracture care
- Early antibiotics, tetanus prophylaxis, sterile dressing, and neurovascular checks.
- Neurovascular check timing
- Before AND after splinting/reduction.
- Rule of Nines (adult)
- Head 9%, each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, perineum 1%.
- Parkland formula
- 4mL×kg×%TBSA of lactated Ringer's over 24 h; give half in the first 8 h from the burn, the rest over 16 h.
- Parkland — fluid titration target
- Urine output about 0.5 mL/kg/hr in adults (1 mL/kg/hr in children).
- Major-burn first priority
- The airway — intubate EARLY for inhalation injury before edema closes it.
- Inhalation injury signs
- Facial burns, singed nasal hairs, soot in the mouth, hoarseness, stridor.
- Carbon monoxide poisoning + SpO2
- SpO₂ can be falsely NORMAL; treat with high-flow 100% oxygen.
- Circumferential burn risk
- Constriction; may require escharotomy to restore perfusion/ventilation.
- Burn TBSA — what to count
- Only partial-thickness and full-thickness burns (not superficial/first-degree).
- Lund-Browder chart
- A more accurate burn TBSA estimate, especially in children (larger head proportion).
- Impaled object rule
- Stabilize it in place; do NOT remove it (it may be tamponading a vessel).
- Life-threatening extremity hemorrhage
- Direct pressure, then a tourniquet (note the time applied).
- Tetanus prophylaxis
- Update based on wound type and immunization history.
- Necrotizing soft-tissue infection
- Pain out of proportion, crepitus, systemic toxicity — a surgical emergency.
- Traumatic amputation — part care
- Wrap the part in saline-moistened gauze, seal in a bag, and place on ice (not directly on ice).
- Dislocation priority
- Assess neurovascular status; reduce promptly to relieve pressure on vessels and nerves.
- Splinting principle
- Immobilize the joint above and below the injury.
- 5 P's neurovascular assessment
- Pain, Pallor, Pulses, Paresthesia, Paralysis (a fracture/limb perfusion check).
- Pediatric earliest shock sign
- Tachycardia — children maintain BP until late, so hypotension is a very late, ominous sign.
- Pediatric head/body ratio
- Larger head-to-body ratio increases head-injury risk.
- Pediatric chest wall
- Compliant ribs transmit force to organs → significant injury with few external marks.
- Broselow tape
- A length-based tape for weight-based pediatric drug doses and equipment sizing.
- Pediatric abuse red flag
- Injuries inconsistent with the history or developmental stage — mandatory to report.
- Geriatric trauma danger
- Minor mechanisms (a ground-level fall) cause serious injury from reduced reserve and anticoagulation.
- Beta-blockers in geriatric shock
- They can mask the tachycardia of shock, hiding deterioration.
- Geriatric 'normal' blood pressure
- May be relative hypotension in a chronically hypertensive patient — undertriage is dangerous.
- Anticoagulated head trauma
- Greatly raised risk of intracranial bleeding even after minor head injury → low CT threshold.
- Leading cause of injury death in older adults
- Falls.
- Pregnancy positioning after 20 weeks
- Left lateral tilt or manual uterine displacement to relieve aortocaval compression.
- Best treatment for the fetus
- Aggressive resuscitation of the mother.
- Pregnant blood-loss reserve
- A pregnant patient can lose 30–35% of blood volume before showing shock signs — the fetus is compromised first.
- Placental abruption signs
- Abdominal pain, vaginal bleeding, uterine tenderness/contractions after abdominal trauma.
- Perimortem cesarean timing
- Considered within about 4 minutes of maternal cardiac arrest after roughly 20–24 weeks.
- Bariatric trauma challenges
- Airway, ventilation, imaging, dosing, access, and pressure-injury risk — plan equipment early.
- Intoxicated trauma patient + low GCS
- Assume brain injury and image — do not attribute a depressed GCS to alcohol alone.
- Substance use disorder in trauma
- Confounds the exam, masks pain; anticipate withdrawal during the stay; screen and intervene.
- Victims of violence — nurse duties
- Recognize/report abuse (IPV, child, elder, trafficking), preserve evidence, maintain chain of custody.
- Electrical burn hidden danger
- Deep tissue and cardiac/muscle damage beneath minimal skin findings; monitor ECG and for rhabdomyolysis.
- Chemical burn first step
- Brush off dry chemical, then irrigate copiously with water; remove contaminated clothing.
- Pediatric Parkland titration
- Titrate burn fluids to a urine output of about 1 mL/kg/hr in children.
- Elder abuse signs
- Unexplained injuries, malnutrition, poor hygiene, or inconsistent caregiver accounts — mandatory to report.
- Comorbidities in trauma
- Pre-existing disease (e.g., on anticoagulation, COPD, diabetes) changes injury response and recovery.
- Primary survey order (XABCDE)
- eXsanguinating hemorrhage, Airway with C-spine, Breathing, Circulation with hemorrhage control, Disability, Exposure.
- Why X before A
- Uncontrolled bleeding kills fastest — control exsanguinating hemorrhage first.
- Secondary survey
- Head-to-toe exam plus an AMPLE history, AFTER the primary survey and life threats are addressed.
- AMPLE history
- Allergies, Medications, Past medical history, Last meal, Events/Environment of the injury.
- Blunt vs penetrating mechanism
- Blunt transfers energy over a wide area (internal/deceleration injuries); penetrating injures along the object's path.
- High-energy mechanism flags
- Ejection, death of another occupant, a fall over ~20 feet, high-speed deceleration.
- Hemorrhagic shock Class I
- Up to 15% loss; HR <100, normal BP, normal mentation.
- Hemorrhagic shock Class II
- 15–30% loss; HR 100–120, narrowing pulse pressure, mild anxiety.
- Hemorrhagic shock Class III
- 30–40% loss; HR 120–140, frank hypotension, confusion — BP reliably drops here.
- Hemorrhagic shock Class IV
- Over 40% loss; HR >140, severe hypotension, lethargy, negligible urine — life-threatening.
- Earliest signs of hemorrhagic shock
- Tachycardia and a narrowing pulse pressure.
- Latest sign of hemorrhagic shock
- A falling systolic blood pressure (young patients compensate until they crash).
- Four shock states in trauma
- Hypovolemic, obstructive, distributive (neurogenic/septic), and cardiogenic.
- Obstructive shock causes in trauma
- Tension pneumothorax, cardiac tamponade, and massive pulmonary embolism.
- Hemorrhage control stepwise
- Direct pressure → tourniquet/hemostatic dressing (limbs) → pelvic binder → operative/angiographic control.
- Trauma resuscitation fluid of choice
- Blood products — NOT large-volume crystalloid (which dilutes clotting factors and cools the patient).
- Massive transfusion ratio
- Balanced 1:1:1 — packed red cells : plasma : platelets.
- TXA (tranexamic acid) timing
- Give early — ideally within 3 hours of injury — to reduce death from bleeding.
- Trauma triad of death
- Hypothermia + acidosis + coagulopathy — a self-reinforcing cycle that worsens bleeding.
- Trauma diamond of death
- The triad (hypothermia, acidosis, coagulopathy) PLUS hypocalcemia — the BCEN outline's updated term.
- Citrate in massive transfusion
- Binds calcium → hypocalcemia; replace calcium during massive transfusion.
- Permissive hypotension
- A lower BP target until surgical control, in selected patients WITHOUT TBI (TBI needs adequate cerebral perfusion).
- TACO vs TRALI
- TACO = transfusion-associated circulatory overload (volume); TRALI = transfusion-related acute lung injury (non-cardiogenic pulmonary edema).
- Damage-control resuscitation
- Hemorrhage control + balanced blood products + permissive hypotension + warming, bridging to damage-control surgery.
- Tertiary survey
- A repeat head-to-toe exam (often 24 h later) to catch injuries missed during initial resuscitation.
- Trauma continuum sequence
- Injury → field care → resuscitation → definitive care → rehabilitation → reintegration (or end-of-life).
- Safe trauma transport prep
- Secure the airway and lines before moving; anticipate deterioration and altitude effects in flight.
- Early rehabilitation goal
- Prevent immobility complications (VTE, pressure injury, pneumonia) and restore function.
- Trauma end-of-life nursing
- Compassionate care, family presence, support for organ/tissue donation per protocol, and psychosocial/spiritual needs.
- Brain death
- Irreversible loss of all brain and brainstem function; a clinical/confirmatory determination that may precede organ donation.
- Reassessment rule
- Reassess the primary survey from the top after every intervention and whenever the patient deteriorates.
- ARDS after trauma
- Refractory hypoxemia with bilateral infiltrates not from cardiac failure; managed with lung-protective ventilation.
- Pre-intubation optimization
- Apneic oxygenation and appropriate induction/paralytic medications to avoid hypoxia/hypotension on intubation.
- Level I trauma center
- Provides the most comprehensive trauma care (full specialty coverage, research, and education).
- Trauma center verification
- Centers are designated/verified by level (I = most comprehensive, fewer resources at II–V).
- Trauma registry
- A database of trauma cases used for performance improvement, benchmarking, and research.
- PIPS program
- Performance Improvement and Patient Safety — audit filters, peer review, and M&M reviews to close care gaps.
- Just culture
- A non-punitive environment that encourages error and near-miss reporting to improve safety.
- START triage
- Simple Triage And Rapid Treatment — sorts MCI patients by Respirations, Perfusion, and Mental status.
- START tag colors
- Red = immediate, Yellow = delayed, Green = minor/walking wounded, Black = expectant/deceased.
- START red criteria
- Respirations over 30, capillary refill over 2 sec (or no radial pulse), or unable to follow commands.
- START black tag
- A patient not breathing after the airway is repositioned (expectant).
- MCI triage goal
- Do the most good for the most people — the opposite of everyday one-patient care.
- JumpSTART
- The pediatric version of START triage.
- Injury prevention levels
- Primary (prevent the event), secondary (reduce severity), tertiary (optimize recovery).
- Primary prevention examples
- Seat belts, helmets, fall-proofing.
- Secondary prevention examples
- Airbags and restraint systems (reduce injury severity once the event occurs).
- SBAR
- Situation, Background, Assessment, Recommendation — a structured handoff/escalation tool.
- EMTALA
- The duty to screen, stabilize, and appropriately transfer any patient regardless of ability to pay.
- HIPAA
- Federal law protecting patient health-information privacy.
- Forensic evidence preservation
- Document wounds objectively, handle clothing/bullets carefully, and maintain chain of custody.
- Chain of custody
- A documented, unbroken record of who handled evidence and when — required for it to be admissible.
- Implied consent
- In a life-threatening emergency, consent is presumed for a patient who cannot consent.
- Over-triage vs under-triage
- Under-triage (missing serious injury) is the dangerous one; systems accept some over-triage to keep it low.
- Decontamination
- Removing hazardous agents from a patient (often before ED entry) to protect the patient and staff.
- Mandatory reporting
- Suspected abuse, neglect, and certain injuries (e.g., gunshot wounds) must be reported by law.
- Debriefing/team support
- Structured post-event support that addresses staff stress and improves future performance.
- Evidence-based practice
- Integrating best research evidence, clinical expertise, and patient values into trauma care decisions.
- Workplace violence
- A recognized hazard in trauma/emergency care addressed by prevention programs and reporting.
- Glasgow Coma Scale purpose
- A standardized 3–15 score of level of consciousness used to classify and trend TBI severity.
- Coup vs contrecoup injury
- Coup = brain injury at the impact site; contrecoup = injury on the opposite side from rebound.
- Diffuse axonal injury
- Widespread shearing of axons from rotational/deceleration forces; severe TBI often with a poor CT-to-coma mismatch.
- Cerebral herniation sign
- A blown (fixed, dilated) pupil with rapid neuro decline — a neurosurgical emergency.
- CSF leak test
- A 'halo'/ring sign on gauze or glucose-positive fluid suggests CSF rhinorrhea/otorrhea.
- Anterior cord syndrome
- Loss of motor and pain/temperature below the lesion with preserved proprioception; poor prognosis.
- Central cord syndrome
- Greater motor loss in the UPPER than lower extremities; often hyperextension injury in older adults.
- Pericardiocentesis
- Needle aspiration of pericardial fluid to relieve cardiac tamponade.
- Sucking chest wound
- An open pneumothorax that draws air through the wound; seal on three sides.
- Pneumothorax breath/percussion
- Decreased/absent breath sounds with hyperresonance on the affected side.
- Hemothorax breath/percussion
- Decreased breath sounds with DULLNESS to percussion (blood, not air).
- Bladder injury + catheter
- Suspected urethral injury (blood at meatus) contraindicates catheter placement until a retrograde urethrogram.
- Cardiac contusion
- Blunt cardiac injury causing dysrhythmias and elevated troponin; monitor ECG.
- Mesenteric injury clue
- A seat-belt/handlebar mark with delayed peritonitis — easy to miss early.
- Delta pressure (compartment)
- Diastolic BP minus compartment pressure; a value of ≤30 mmHg supports fasciotomy.
- Superficial (1st-degree) burn
- Epidermis only (e.g., sunburn); red, painful, no blisters; NOT counted in TBSA.
- Partial-thickness (2nd-degree) burn
- Epidermis + dermis; blisters, very painful, moist red base; counted in TBSA.
- Full-thickness (3rd-degree) burn
- Through the dermis; dry, leathery, white/charred, often painless; counted in TBSA.
- Escharotomy
- An incision through burn eschar to relieve constriction and restore perfusion/ventilation.
- Tourniquet documentation
- Always record the TIME applied; prolonged use risks ischemia.
- JumpSTART use
- Pediatric mass-casualty triage adapted for children's physiology.
- Pregnancy + Rh-negative trauma
- Consider Rho(D) immune globulin (RhoGAM) after abdominal trauma to prevent isoimmunization.
- Pediatric vascular access
- If IV access fails quickly, use intraosseous (IO) access for resuscitation.
- Intimate partner violence screening
- Screen privately, document objectively, ensure safety, and report per law/policy.
- Capillary refill normal
- Less than 2 seconds; a delay suggests poor perfusion/shock.
- Hypothermia in trauma
- Worsens coagulopathy and acidosis; prevent it with warming during resuscitation (part of the triad/diamond of death).
- Distributive shock types
- Neurogenic, septic, and anaphylactic — vasodilation lowers systemic vascular resistance.
- Field/prehospital trauma triage
- Matches injured patients to the appropriate level of trauma center based on physiology, anatomy, and mechanism.
- Interfacility vs intrafacility transfer
- Interfacility = between facilities (EMTALA applies); intrafacility = within a facility (e.g., ED to OR).
- Trauma-informed care
- Care that recognizes the impact of trauma and avoids re-traumatization, addressing psychosocial needs.
- Discharge planning elements
- Patient/family education, addressing barriers, and home-readiness/safety for a safe transition of care.
- Coagulopathy of trauma
- Early clotting dysfunction from tissue injury, shock, and dilution; treated with balanced products and TXA.
- Morbidity & mortality (M&M) review
- A structured case review of complications and deaths to improve care.
- Audit filters
- Predefined trauma indicators that flag cases for performance-improvement review.
- Community outreach (trauma)
- Injury-prevention education and programs that are part of trauma-center designation.
- Event reporting
- Documenting safety events/near-misses to drive system improvement in a just culture.
