Answer: A. Left pupillary dilatation, right-sided weakness

Subdural hematomas (SDHs) are typically the result of tearing of tiny bridging veins that link the brain surface to the dura. Cerebral lacerations and dural sinus tears are less common SDH etiologies. Bleeding is usually venous. As blood accumulates within the closed cranial vault, increasing pressure forces the brain downward, to the only natural opening, the foremen magnum. The patient with a LEFT subdural hematoma will experience LEFT (ipsilateral) pupil dilation, because the cranial nerves are PERIPHERAL nerves, and peripheral nerves do not cross. However, the patient will demonstrate RIGHT-SIDED (contralateral) weakness (paresis) and sensory dysfunction (paresthesia) because neural fibers to and from the motor and sensory strips in the brain DO cross.

Answer: C. Fiberoptic bronchoscopy

A "bubble wrap" or "Rice Krispies" sensation on palpation indicates air in the subcutaneous tissues. In the thoracic trauma patient, the source of subcutaneous air is usually a tracheal or bronchial tear. In contrast to pneumothorax (air in the pleural space), air from tracheobronchial tears travels into the soft tissues along the fascial planes. Because air rises, it usually accumulates in the upper chest, neck, and face. However, air may also travel downward. Chest radiography and computed tomography readily identify air in the soft tissues, but do not localize the site of the tear. Laryngoscopy could identify an injury ABOVE the glottis, but fiberoptic bronchoscopy facilitates visualization below the cords, and most blunt tears occur within 1 inch of the carina. Large tracheobronchial defects require urgent surgical repair. Small injuries are managed conservatively.

Answer: D. fluid mobilization from edematous tissue.

Increasing serosanguinous drainage from a wound, which occurs as patient activity intensifies, is an expected event. This is a particularly common finding 2-3 days after injury in the patient who is progressing well. As the body recovers and reestablishes homeostasis, excess resuscitation and intraoperative fluid is mobilized from the intracellular and interstitial spaces. This phenomenon is also manifest as increased urine output. Open fractures always place patients at risk for infection. Judicious use of perioperative antibiotics can reduce this risk, but not eliminate it. However, infected wounds typically produce pus, rather than serous fluid. Monitor the patient for signs of infection such as leukocytosis, fever, foul-smelling or discolored wound drainage, increasing pain, and erythematous wound margins.

Answer: C. acute stress disorder.

Stress disorders are a common sequela of the emotional trauma many injured patients have faced. Technically, the condition is "acute stress disorder" for the first 30 days and becomes posttraumatic stress disorder on day 31. However, the symptoms are the same. Stress disorders are associated with a wide variety of findings. Bedside nurses--and the patient's close friends and family members–are in the optimal position to detect symptoms of traumatic stress. How is the patient coping? Is he sleeping and eating appropriately? Is he having nightmares? How does he interact with family members? etc. Stress disorders are real diagnoses that require our best efforts at prevention and treatment. Patients with a stress disorder do not "just get over it." EARLY intervention is crucial to better long term outcomes.

Answer: A. document the time, name, and title of the receiving provider.

Clear documentation of the provider accepting responsibility for the patient and the exact time of transfer of care leaves no room for confusion regarding who was responsible for the patient at any given moment during the transport process. The admitting physician is often not immediately available. Fortunately, a physician's signature is not required. It is not the transport team's responsibility to deliver insurance documents or other paperwork to various departments. It is the sending facility's responsibility to complete and forward any EMTALA-mandated paperwork. These documents can be transmitted electronically.