Notes in Chapter_15:_Trauma

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Published	07/07/2024	In penetrating chest trauma, a thoracotomy is indicated if the patient is {{c1::hemodynamically unstable}} and has had {{c2::CPR}} for less than …
Published	07/07/2024	Contraindications to emergency thoracotomy in penetrating trauma include:  - {{c1::Pulselessness >15 minutes}} - {{c1::Lifeless - pa…
Published	07/07/2024	The 1st peak for trauma deaths occurs from {{c1::0}} to {{c1::30 minutes}}(timeframe)
Published	07/07/2024	The 2nd peak for trauma deaths occurs from {{c1::30 minutes}} to {{c1::4 hours}}(timeframe)
Published	07/07/2024	The 3rd peak for trauma deaths occurs from {{c1::days}} to {{c1::weeks}}(timeframe)
Published	07/07/2024	The 2nd peak of trauma deaths are usually due to {{c1::head injury}} (#1) or {{c1::hemorrhage}} (#2)
Published	07/07/2024	The 3rd peak of trauma deaths is usually due to {{c1::multisystem organ failure}} and {{c1::sepsis}}
Published	07/07/2024	Blunt injury constitutes {{c2::80}}% of all trauma with the {{c1::liver/spleen}} being the most commonly injured organ
Published	07/07/2024	The equation for calculating kinetic energy is {{c1::½mv2}}
Published	07/07/2024	The LD50 for falls is {{c1::4}} stories
Published	07/07/2024	The most commonly injured organ from penetrating injury is the {{c1::small bowel}}
Published	07/07/2024	The most common cause of trauma death in the first 1 hour is {{c1::hemorrhage}}
Published	07/07/2024	Blood pressure during hemorrhage usually does not decrease significantly until {{c1::30}}% of total blood volume is lost
Published	07/07/2024	Resuscitation with blood should be begun after initial resuscitation with {{c1::2 liters::volume}} of Lactated Ringers
Published	07/07/2024	The most common cause of trauma death after reaching the ER alive is {{c1::head injury}}
Published	07/07/2024	The most common cause of trauma death in the long term is {{c1::infection}}
Published	07/07/2024	The most common cause of trauma upper airway obstruction is {{c1::the tongue}}
Published	07/07/2024	Seat belts in trauma can cause {{c1::small bowel perforations}}, lumbar spine fractures, and sternal fractures
Published	07/07/2024	The best site for cutdown for venous access is the {{c1::saphenous vein}}
Published	07/07/2024	Coagulopathy occurs in severely injured trauma patients {{c1::before}} arrival at the hospital(before or after)
Published	07/07/2024	Hemostatic resuscitation is indicated for patients receiving > {{c1::4}} units of packed RBCs in the first hour
Published	07/07/2024	Hemostatic resuscitation is indicated for patients receiving > {{c1::10}} units of packed RBCs within 24 hours
Published	07/07/2024	Giving RBCs, fresh frozen plasma, and platelets in a ratio of 1:1:1 is known as {{c1::hemostatic}} resuscitation
Published	07/07/2024	Crystalloid solutions should be limited to avoid {{c1::hemodilution}} for severely injured trauma patients
Published	07/07/2024	Permissive hypotension of systolic BP greater than {{c1::70}} is allowed in severely injured trauma patients until hemorrhage is controlled
Published	07/07/2024	Severely injured trauma patients need early correction of hypo-{{c3::thermia}}, {{c1::acidosis}}, and hypo-{{c2::calcemia}}
Published	07/07/2024	Diagnostic peritoneal lavage (DPL) is used in hypotensive patients with {{c1::blunt}} trauma
Published	07/07/2024	Diagnostic peritoneal lavage (DPL) is considered positive if: 1) greater than {{c2::10}} mL blood2) greater than {{c3::100,000}} RBCs/mL3) {…
Published	07/07/2024	A positive diagnostic peritoneal lavage (DPL) warrants {{c1::exploratory laparotomy}}
Published	07/07/2024	A diagnostic peritoneal lavage (DPL) needs to be performed {{c1::supraumbilically}} if a pelvic fracture is present
Published	07/07/2024	Diagnostic peritoneal lavages (DPLs) are unable to detect {{c2::retroperitoneal}} bleeds and contained {{c1::hematomas}}
Published	07/07/2024	FAST exams check for blood in:1) {{c4::Perihepatic fossa}}2) {{c3::Perisplenic fossa}}3) {{c2::Pelvis}}4) {{c1::Pericardium}}
Published	07/07/2024	A positive FAST exam warrants {{c1::exploratory laparotomy}}
Published	07/07/2024	FAST exams are unable to detect {{c1::retroperitoneal}} bleeding and {{c1::hollow viscus}} injury
Published	07/07/2024	Hypotensive trauma patients with a negative FAST or DPL exam may have bleeding from a(n) {{c1::pelvic fracture}}, a(n) {{c1::extremity}}, or {{c1…
Published	07/07/2024	CT scans in trauma patients tend to miss {{c2::hollow viscus}} injury and {{c1::diaphragm}} injury
Published	07/07/2024	Free card{{c1:::)}}Didn't know how to make cards over these flowcharts, but should probably look over them to be familiar. Use this card as a reminder…
Published	07/07/2024	Penetrating abdominal injury generally warrants {{c1::exploratory laparotomy}}
Published	07/07/2024	Possible penetrating abdominal injuries generally warrant local exploration and observation if the {{c1::fascia}} is not violated
Published	07/07/2024	Hypotension, abdominal distention, low urine output, and increased airway pressures in a trauma patient are concerning for {{c1::abodminal compar…
Published	07/07/2024	Bladder pressure greater than 25-30 mm Hg suggests {{c1::abdominal compartment syndrome}}
Published	07/07/2024	Decreased cardiac output in abdominal compartment syndrome is due to {{c1::IVC compression}}
Published	07/07/2024	Decreased urine output in abdominal compartment syndrome is due to renal {{c1::hypoperfusion}}
Published	07/07/2024	Ventilation is affected in abdominal compartment syndrome due to {{c1::upward displacement of the diaphragm}}
Published	07/07/2024	Treatment for abdominal compartment syndrome is {{c1::decompressive laparotomy}}
Published	07/07/2024	An inflatable garment used to combat shock in trauma patients without thoracic injury is a(n) {{c1::pneumatic antishock garment (PASG)}}
Published	07/07/2024	An ED thoracotomy is only used in {{c1::blunt}} trauma if pressure/pulse is lost in the ED
Published	07/07/2024	An ED thoracotomy is only used in {{c1::penetrating}} trauma if pressure/pulse is lost on the way to or in the ED
Published	07/07/2024	The pericardium is opened in an ED thoracotomy longitudinally and anterior to the {{c1::phrenic}} nerve
Published	07/07/2024	ED thoracotomies are typically performed through the {{c1::4th}} and {{c1::5th}} intercostal spaces
Published	07/07/2024	A patient who undergoes ED thoracotomy for abdominal injury only proceeds to laparotomy if clamping of the aorta raised the blood pressure a…
Published	07/07/2024	Catecholamines peak {{c1::24}}-{{c1::48}} hour(s) after injury
Published	07/07/2024	ADH, ACTH, and glucagon levels all {{c1::increase}} after trauma(increase or decrease)
Published	07/07/2024	Thyroid hormone levels {{c1::do not change :)}} after trauma(increase or decrease)
Published	07/07/2024	Females who are prepubescent or of childbearing age should not receive Rh-{{c1::positive}} blood during trauma resuscitation
Published	07/07/2024	Trauma patients with solid organ injuries (spleen/liver hematoma grade 1-2) who develop a PE or DVT are treated with {{c1::heparin}}
Published	07/07/2024	In the Glasgow Coma Scale (GCS), motor responsiveness is rated from a scale of 1 to {{c1::6}}
Published	07/07/2024	In the Glasgow Coma Scale (GCS), verbal responsiveness is rated from a scale of 1 to {{c1::5}}
Published	07/07/2024	In the Glasgow Coma Scale (GCS), eye responsiveness is rated from a scale of 1 to {{c1::4}}
Published	07/07/2024	A Glasgow Coma Score (GCS) of < {{c1::14}} warrants a head CT
Published	07/07/2024	A Glasgow Coma Score (GCS) of < {{c1::10}} warrants intubation
Published	07/07/2024	A Glasgow Coma Score (GCS) of < {{c1::8}} warrants ICP monitoring
Published	07/07/2024	The most important prognostic indicator in the Glasgow Coma Scale (GCS) is the {{c1::motor}} score
Published	07/07/2024	Intubated patients are given a Glasgow Coma Scale (GCS) verbal score of {{c1::1T}}
Published	07/07/2024	A penetrating injury has the {{c1::worst}} survival of all head injuries
Published	07/07/2024	Indications for a head CT (free card){{c1:::)}}Figured cards over all this would be annoying to do, so here's a reminder to look over this info
Published	07/07/2024	Intracerebral hematomas are typically located at the temporal or {{c1::frontal}} region of the brain
Published	07/07/2024	A cerebral contusion where a moving head strikes a stationary object is known as {{c1::contrecoup}}
Published	07/07/2024	A cerebral contusion where a moving object strikes a stationary head is known as {{c1::coup}}
Published	07/07/2024	A traumatic intraventricular hemorrhage that causes hydrocephalus needs {{c1::ventriculostomy}}
Published	07/07/2024	The best imaging study for diffuse axonal injury is {{c1::MRI}}
Published	07/07/2024	The treatment for diffuse axonal injury with an increased intracranial pressure is {{c1::craniectomy}}
Published	07/07/2024	Cerebral perfusion pressure (CPP) is calculated by {{c2::mean arterial pressure (MAP)}} minus {{c1::intracranial pressure (ICP)}}
Published	07/07/2024	A patient with increased ICP may have a(n) {{c1::decrease}} in ventricular size(increase or decrease)
Published	07/07/2024	An intracranial pressure (ICP) of greater than {{c1::20}} mmHg requires treatment
Published	07/07/2024	The goal cerebral perfusion pressure (CPP) in patients with trauma is greater than {{c1::60}} mmHg
Published	07/07/2024	Elevated ICP can be treated with relative hyperventilation with goal CO2 levels around {{c1::30}}-{{c1::35}}
Published	07/07/2024	Goal sodium level for a patient with elevated ICP is {{c1::140}}-{{c1::150}} mEq/L
Published	07/07/2024	In a patient with elevated ICP, the loading dose for mannitol is {{c1::1}} g/kg with a {{c2::0.25}} g/kg maintenance dose every {{c2::4}} hour(s)
Published	07/07/2024	A patient with elevated ICP that is not responding to medical management can be induced into a coma via {{c1::barbiturates}}
Published	07/07/2024	Seizure prophylaxis in patients with elevated ICP is performed with {{c1::fosphenytoin}} and {{c1::levetiracetam}}
Published	07/07/2024	Peak ICP (max brain swelling) occurs {{c1::48}}-{{c1::72}} hours after injury
Published	07/07/2024	A stable patient with a blown pupil gets {{c1::head CT}}
Published	07/07/2024	An unstable patient with a blown pupil gets {{c1::surgery}}
Published	07/07/2024	Raccoon eyes (peri-orbital ecchymosis) is a sign of a(n) {{c1::anterior}} fossa fracture
Published	07/07/2024	Battle's sign (mastoid ecchymosis) is a sign of a(n) {{c1::middle}} fossa fracture
Published	07/07/2024	A middle fossa fracture (Battle's sign) can injure the {{c1::facial}} nerve
Published	07/07/2024	A middle fossa fracture with {{c1::acute}} facial nerve injury needs surgical exploration and repair(acute or delayed)
Published	07/07/2024	Temporal skull fractures can injure cranial nerves {{c1::7}} and {{c1::8}}
Published	07/07/2024	The most common site of facial nerve injury in temporal skull fractures is the {{c1::geniculate ganglion}}
Published	07/07/2024	Skull fractures only require surgical treatment if there is significant depression (> 1 cm), contamination, or persistent {{c1::CSF leak}}
Published	07/07/2024	CSF leaks after skull fractures can be treated with {{c1::lumbar CSF drainage}} if it is persistent
Published	07/07/2024	Coagulopathy with traumatic brain injury is due to release of {{c1::tissue thromboplastin}}
Published	07/07/2024	A patient with head trauma who is taking warfarin gets a repeat head CT in {{c1::8}} hour(s)
Published	07/07/2024	The {{c1::Cattell-Braasch}} maneuver involves mobilizing the right colon, {{c3::duodenum}}, and {{c2::head of pancreas}}
Published	07/07/2024	The {{c1::Mattox}} maneuver involves mobilizing the left colon, {{c2::spleen}}, and {{c3::pancreas}}
Published	07/07/2024	There is greater morbidity and mortality for {{c1::higher}} spine injuries(higher or lower)
Published	07/07/2024	A C1 burst spine fracture is known as a(n) {{c2::Jefferson fracture}} and is treated with {{c1::rigid collar}}
Published	07/07/2024	A C2 hangman's spine fracture is treated with {{c1::traction and halo}}
Published	07/07/2024	A C2 odontoid fracture that is above the base and stable is type {{c1::1}}
Published	07/07/2024	A C2 odontoid fracture that is at the base and unstable is type {{c1::2}}
Published	07/07/2024	A C2 odontoid fracture that extends into the vertebral body is type {{c1::3}}
Published	07/07/2024	The dens of the C2 spine is also known as the {{c1::odontoid process}}
Published	07/07/2024	The thoracolumbar spine has a total of {{c1::3}} column(s)
Published	07/07/2024	The anterior longitudinal ligament and anterior 1/2 of the vertebral body compose the {{c1::anterior}} column of the thoracolumbar spine
Published	07/07/2024	The posterior 1/2 of the vertebral body and posterior longitudinal ligament compose the {{c1::middle}} column of the thoracol…
Published	07/07/2024	The facet joints, lamina, spinous process, and interspinous ligament compose the {{c1::posterior}} column of the thoracolumbar spi…
Published	07/07/2024	The thoracolumbar spine is considered unstable if there is disruption of greater than {{c1::1}} column(s)
Published	07/07/2024	Compression (wedge) fractures usually involve the {{c1::anterior}} column of the thoracolumbar spine
Published	07/07/2024	Burst fractures of the thoracolumbar spine are considered {{c1::unstable}}(stable or unstable)
Published	07/07/2024	An MRI is necessary for neurologic deficits without injury to bone to check for {{c1::ligamentous}} injury
Published	07/07/2024	The most common cause of facial nerve injury in trauma is a fracture of the {{c1::temporal}} bone
Published	07/07/2024	Maxillofacial fractures are described with the {{c1::Le Fort}} classification
Published	07/07/2024	A maxillary facial fracture that runs straight across is Le Fort type {{c1::1}}
Published	07/07/2024	A facial fracture that runs lateral to the nasal bone, but underneath the eyes toward the maxilla is Le Fort type {{c1::…
Published	07/07/2024	A facial fracture that involves the lateral orbital walls is Le Fort type {{c1::3}}
Published	07/07/2024	The treatment for Le Fort facial fracture types {{c1::1}} and {{c1::2}} is the same
Published	07/07/2024	70% of nasoethmoidal orbital fractures have a(n) {{c1::CSF leak}}
Published	07/07/2024	A nasoethmoidal orbital fracture with CSF leak is initially treated with conservative therapy for up to {{c1::2 weeks::timeframe}}
Published	07/07/2024	Anterior nosebleeds are treated with {{c1::packing}}
Published	07/07/2024	Posterior nosebleeds are treated initially with {{c1::balloon tamponade}}
Published	07/07/2024	Posterior nosebleeds may require angioembolization to the {{c1::ethmoidal}} artery or {{c2::internal maxillary}} artery
Published	07/07/2024	Patients with orbital blowout fractures that have impaired upward gaze or diplopia require {{c1::restoration of the orbital floor}}
Published	07/07/2024	The primary indicator for mandibular injury is {{c1::malocclusion}}
Published	07/07/2024	A tripod fracture of the zygomatic bone is treated with {{c1::ORIF}}
Published	07/07/2024	Patients with maxillofacial fractures must be assessed for {{c1::cervical spine}} injury
Published	07/07/2024	Do scalp laceration repairs typically require hair removal?{{c1::No}}
Published	07/07/2024	The next step for a patient with asymptomatic blunt neck trauma is {{c1::CT scan}}
Published	07/07/2024	Zone 1 of the neck is from the {{c1::clavicle}} to the {{c1::cricoid cartilage}}
Published	07/07/2024	Zone 2 of the neck is from the {{c1::cricoid cartilage}} to the {{c1::angle of the mandible}}
Published	07/07/2024	Zone 3 of the neck is from the {{c1::angle of the mandible}} to the {{c1::base of the skull}}
Published	07/07/2024	Neck surgical exploration is always indicated for asymptomatic injury in neck zone {{c1::2}}
Published	07/07/2024	Symptomatic blunt or penetrating neck trauma both require {{c1::surgical exploration}}
Published	07/07/2024	"Hard signs" in penetrating neck injury can be remembered with the mnemonic BEN SHAPiroB{{c1::leeding}}E{{c2::mphysema (subcutaneous air, air bubbling…
Published	07/07/2024	The best modality to find esophageal injuries in trauma is combined {{c1::esophagoscopy}} and {{c1::esophagogram}}
Published	07/07/2024	Esophageal injuries can be observed if the injury is {{c1::contained}}
Published	07/07/2024	An noncontained esophageal injury can be repaired with {{c1::primary closure}} if the injury is small and has minimal contamination
Published	07/07/2024	An esophagus with extensive injury or contamination in the {{c1::neck}} is treated with drains
Published	07/07/2024	An esophagus with extensive injury or contamination in the {{c1::chest}} is treated with chest tubes with even…
Published	07/07/2024	Esophageal and hypopharyngeal repairs always require {{c1::drains}}
Published	07/07/2024	Laryngeal fractures and tracheal injuries are surgical emergencies that typically require {{c1::cricothyroidotomy}}
Published	07/07/2024	The definitive treatment for laryngeal fractures or tracheal injuries is {{c2::primary closure}} and {{c1::tracheostomy}}
Published	07/07/2024	Thyroid gland injuries in trauma are treated with {{c1::bleeding control}} and {{c1::drains}}
Published	07/07/2024	Recurrent laryngeal nerve injury in trauma can be attempted to repair or reimplant in the {{c1::cricoarytenoid muscle}}
Published	07/07/2024	Shotgun injuries to the neck require angiogram and {{c1::neck CT}}
Published	07/07/2024	Vertebral artery bleeds in trauma can be treated with {{c1::embolization}}
Published	07/07/2024	Ligation of common carotid artery bleeds in trauma will cause stroke in {{c1::20}}% of patients
Published	07/07/2024	A chest trauma with significant chest tube drainage is an indication for thoracotomy on the {{c1::anterolateral}} side of the injury
Published	07/07/2024	A chest trauma that drains greater than {{c1::1000}}-{{c1::1500}} mL after initial chest tube insertion gets thoracotomy
Published	07/07/2024	A chest trauma that drains greater than {{c1::250}} mL/hour for 3 hours gets thoracotomy
Published	07/07/2024	A chest trauma that drains greater than {{c1::2500}} mL/24 hours gets thoracotomy
Published	07/07/2024	An unresolved hemothorax after 2 well-placed chest tubes is an indication for {{c1::thoracoscopic drainage}}
Published	07/07/2024	The most important risk factor for empyema in chest trauma is {{c1::retained hemothorax}}
Published	07/07/2024	A persistent pneumothorax despite 2 well-placed chest tubes is an indication for {{c1::bronchoscopy}}
Published	07/07/2024	Multiple painful rib fractures in chest trauma are treated with {{c1::paravertebral}} block or {{c1::thoracic}} epidural
Published	07/07/2024	A sucking chest wound needs to be at least {{c1::2/3rds}} the diameter of the trachea to be significant
Published	07/07/2024	A sucking chest wound is covered with a dressing that has tape on {{c1::3}} side(s)
Published	07/07/2024	A patient with chest trauma who has worse oxygenation after chest tube may have {{c1::tracheobronchial}} injury
Published	07/07/2024	Bronchus injuries in chest trauma are more common on the {{c1::right}} side
Published	07/07/2024	Tracheobronchial injury in chest trauma may require {{c1::mainstem}} intubation
Published	07/07/2024	90% of tracheobronchial injuries are within 1 cm of the {{c1::carina}}
Published	07/07/2024	Tracheobronchial injuries are diagnosed with {{c1::bronchoscopy}}
Published	07/07/2024	Right mainstem tracheobronchial injuries are repaired via {{c1::right}} thoracotomy
Published	07/07/2024	Trachea tracheobronchial injuries are repaired via {{c1::right}} thoracotomy
Published	07/07/2024	Proximal left mainstem tracheobronchial injuries are repaired via {{c1::right}} thoracotomy
Published	07/07/2024	Distal left mainstem tracheobronchial injuries are repaired via {{c1::left}} thoracotomy
Published	07/07/2024	Diaphragm injuries from chest trauma are more common on the {{c1::left}} side
Published	07/07/2024	Diaphragm injuries from chest trauma are repaired via a {{c1::transabdominal}} approach if less than 1 week
Published	07/07/2024	Diaphragm injuries from chest trauma are repaired via a {{c1::chest}} approach if greater than 1 week
Published	07/07/2024	The tear in an aortic transection typically occurs at the {{c1::ligamentum arteriosum}}
Published	07/07/2024	Aortic transection is diagnosed with {{c1::CT angiogram}}
Published	07/07/2024	Distal aortic transections can be repaired with a(n) {{c1::covered stent endograft}}
Published	07/07/2024	Aortic transections are treated {{c1::after}} other life-threatening injuries(before or after)
Published	07/07/2024	Traumatic injuries to the distal left subclavian artery are repaired via {{c1::left thoracotomy}} incision
Published	07/07/2024	Traumatic injuries to the proximal left subclavian artery are repaired via {{c1::median sternotomy}} incision
Published	07/07/2024	Traumatic injuries to the ascending aorta are repaired via {{c1::median sternotomy}} incision
Published	07/07/2024	Traumatic injuries to the descending aorta are repaired via {{c1::left thoracotomy}} incision
Published	07/07/2024	Traumatic injuries to the proximal right subclavian artery are repaired via {{c1::median sternotomy}} incision
Published	07/07/2024	Traumatic injuries to the distal right subclavian artery are repaired via {{c1::midclavicular}} incision
Published	07/07/2024	The most common arrhythmia in patients with myocardial contusion is {{c1::supra-ventricular tachycardia}}
Published	07/07/2024	The most common cause of death in patients with myocardial contusion is {{c1::cardiac arrhythmia}}
Published	07/07/2024	A flail chest results when at least {{c1::2}} consecutive ribs are broken in at least {{c1::2}} sites
Published	07/07/2024	The biggest pulmonary impairment in a patient with flail chest injury is {{c1::pulmonary contusion}}
Published	07/07/2024	The first step in management in a stable patient with a penetrating chest injury is {{c1::CXR}}
Published	07/07/2024	The borders of the cardiac "box" in penetrating chest injuries are {{c1::clavicles}}, {{c1::xiphoid process}}, and {{c1::nipples}}
Published	07/07/2024	Penetrating chest wounds outside the cardiac "box" need chest tube if the patient requires {{c1::intubation}}
Published	07/07/2024	Finding blood during creation of a pericardial window is an indication for {{c1::median sternotomy}}
Published	07/07/2024	Penetrating injuries anteromedial to midaxillary line and below the nipples require {{c1::laparotomy}}
Published	07/07/2024	A tension pneumothorax can cause a(n) {{c1::cardiogenic}} shock
Published	07/07/2024	A bulging diaphragm during laparotomy can be an indicator of {{c1::tension pneumothorax}}
Published	07/07/2024	Patients with sternal fractures are at a high risk for {{c1::cardiac contusion}}
Published	07/07/2024	There is a high risk for aortic transection with fractures of the {{c1::1st}} and {{c1::2nd}} ribs
Published	07/07/2024	Dividing pulmonary parenchyma between adjacent staple lines along the tract of a penetrating injury is known as a pulmonary {{c1::tractotomy}}
Published	07/07/2024	A hemodynamically unstable patient with pelvic fracture with no known reason for shock should undergo {{c1::angioembolization}}
Published	07/07/2024	Type(s) {{c1::3}} pelvic fractures are considered {{c2::stable}}(stable or unstable)
Published	07/07/2024	Type(s) {{c1::1 and 2}} pelvic fractures are considered {{c2::unstable}}(stable or unstable)
Published	07/07/2024	{{c2::Anterior}} pelvic fractures are more likely to have {{c1::venous}} bleeding
Published	07/07/2024	{{c2::Posterior}} pelvic fractures are more likely to have {{c1::arterial}} bleeding
Published	07/07/2024	Intra-op {{c1::penetrating}} injury pelvic hematomas can be treated open(penetrating or blunt)
Published	07/07/2024	Intra-op {{c1::blunt}} injury pelvic hematomas are left alone(penetrating or blunt)
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