ATLS 1 Flashcards
Base excess and lactate in shock?
Low BE (Base deficit), high lactate
Hemorrhage classes, 1-4, what can you say about them in regards of blood loss and intervention?
- Loss of 1 unit of blood. 0-15%. Monitoring, perhaps crystalloids.
- 15-30%. Thin pulses. Base deficit -2 to -6. Tachycardia, tachypnea, tube nervous signs (fear). Requires crystalloids.
- 31-40%. Possibly required blood transfusion. Inadequate perfusion. Severe tachycardia and tachypnea. Significant changes mental status. Decreased systolic BP. Base deficit -6 to -10.
- > 40%. Preterminal event, dies in minutes. Super low BT. Pale. No urine. Base deficit < -10.
Blood volume = how many percent of ideal weight in adults? Higher or lower in children?
7%. 70kg male => 5l. Slightly higher in children.
Look for blood on floor and four more. Which four?
Pelvis, thorax, extremities, retropeitoneum/abdomen
Normal urinary output in adults, children and infants
0.5ml/kg/h adults
1ml/kg/h children
2ml/kg/h infants
Patient responds to bolus crystalloids then deteriorates, what to do?
Blood transfusion, plan for surgical hemorrhage control
Indications for thoracotomy
- > 1500ml from chest tube.
- Continuation of bleeding.
- Penetrating anterior chest wounds medial to mamilla or penetrating wounds medial to scapula.
- Persistent need for transfusion.
What is Kussmaul sign on cardiac tamponade?
Paradoxical filling of jugular veins on inspirations.
Differentiate cardiac tamponade and tension pneumothorax
Breath sounds.
Needle decompression tension pneumothorax, where?
5th intercostal room slightly anterior to mid axillary line
Pulseless electrical activity can be present in?
Cardiac tamponade, tension pneumothorax, extreme hypovolemia
Treatment cardiac tamponade?
Thoracotomy/sternotomy.
Cardiocentesis if surgery unavailable, not definitive treatment. Fluid resucitation in preparation for surgery.
Algorithm for traumatic cardiac arrest
CPR => No rosc => Bilateral chest decompression => No rosc => Thoracotomy (release tamponade if present), clamp bleeding vessels.. Give epinephrine 1mg somewhere along the line early.
Placement of more than one chest tube?
Incomplete expansion of lung and continued air leakage suggest tracheobronchial injury and may require additional chest tubes to overcome leak.
List a bunch of indications for operation - abdominal injury
- Hemodynamically unstable + suspected abdominal injury
- Free air
- Diaphragm injury
- Intraperitoneal bladder rupture
- Peritonitis
- Blood per gastric/rectal/urethral
Glasgow coma scale
Eye opening response
- Spontaneously
- To speech
- To pain
- No response
Verbal response
- Oriented x3
- Confused
- Inappropriate words
- Incomprehensible sounds
- No response
Motor response
- Obeys command
- Moves to localized pain
- Flex to withdraw from pain
- Abnormal flexion
- Abnormal extension
- No response
What is Monro-Kellie doctrine?
ICP and cerebral hemodynamics. A “mass” will displace venous volume and CSF => pressure will remain stable until compensatory mechanisms cannot withstand.
Severity of head injury according to GCS
Severe - GCS 8 or less
Moderate - GCS 9-12
Mild - GCS 13-15
CT scan findings that may require surgical intervention
Midline shift, loss of definition of basil cisterns, severe fractures with intrusion to brain matter
Who not hyperventilate brain injuries?
Hyperventilation => Hypocarbia => Vasoconstriction => Ischemia
At what levels shall Co2 be kept in head injuries and what’s the issue with hypo and hypercarbia?
Remain at Co2 4.7 kPa
Hypocarbia => vasoconstriction => ischemia.
Hypercarbia => dilation of blood vessels => High ICP
What does mannitol do and when shall it not be used? How much over what period of time?
Lowers ICP. Do not give to hypovolemic pat (diuretic). Give 1g/kg 20% solution over 20min.
Epidural/subdural hematoma results in widening of ipsilateral or contralateral pupil?
Ipsilateral pupil widening
Dermatomes for sensory response on 2ndary survey, suspected spinal injury
C5 - Deltoid T4 - Nipple line T10 - Umbilicus L4 - Medial aspect of calf L5 - Medial aspect of feet S1 - Lateral aspect of feet S4/S5 - Rectal
Myotome exams on 2ndary survey, suspected spinal injury
C5 - Deltoid C6 - Elbow flexion C7 - Triceps C8 - Wrist T1 - Spread fingers L2 - Hip flexure L3/L4 - Loft lower legs off bed L5 - Knee flexion + push down on the gas S1 - Toes to nose
Central cord syndrome?
Greater loss of strength in upper limbs than lower
Anterior cord syndrome?
Paraplegia and loss of pain and temp
Brown-Séquard syndrome?
Ipsilateral muscle loss, contralateral sensation loss
Before applying splints for skeletal injury, check what?
Neurology and vascular status.. Check after applying as well.
Extremities.. On primary or 2ndary survey?
Life threatening on primary, otherwise secondary.
Systematic review musculoskeletal status
Palpate through all extremities, torso and pelvis, ask to move, check temp, sensation and pulses.
Use traction on combined femur + tibia/fibula fracture?
Nah, can cause neural damage
Presence of vascular compromise or sin breakdown in fractured limb, x-ray or treat injury?
Treat injury
All burns trapped in environment, what should be assumed? Treatment?
CO-poisoning. Provide O2 100% mask. Monitor carboxyhemoglobin levels.
Burn. Simple measure to prevent edema (neck, chest)
Elevate 30 degrees
Pitfall IV lines in burn patients
May dislodge due to edema, use long catheters, re evaluate.
Initial fluid resuscitation in burns according to Parkland formula. Any difference in electrical burns?
2ml lactated ringer * body weight * % of area burned.
First half over 8h, 2nd half over 16h. Adjust according to urinary output.
4ml for electrical burns.
Rule of 9 in estimation of burn area
Head/neck - 9% Arm - 9% each Thorax and upper back - 9% each Abdomen and lower back - 9% each Legs - 9% front + 9% back each Genital area - 1%
Types of burns
Superficial - erythema
Superficial partial thickness - Moist erythema, possible blisters, blanches to touch
Deep partial thickness - Dry. Not painful, possible blister, does not blanch to touch.
Full thickness - Dry, leather, painless, waxy
Why cover burns?
Prevents infection, less pain
Management of frostbite
Stop tissue freezing. Moist heat. Warm fluids per os and IV. Warm objects in groin. 40C circulating water. Analgetics. Monitor heart.
Do not use dry heat.
Reperfusion syndrome? What to monitor etc
Acidosis. Hyperkalemia. Local swelling. Monitor heart.
Normal systolic blood pressure in children (formula)
90 + 2*age upper limit.
70 + 2*age lower limit.
Weight estimation children
Age*2 + 10
Step by step airway management in children
Reverse sniffing position Jaw thrust Clear secretions Preoxygenation Oral airway (do not use unless unconscious) Use tongue repressor
Deterioration in intubated patients nemonic
DOPE D Dislodgement of tube O Obstruction (suction or replace tube) P Pneumothorax E Equipment failure
Rely not on blood pressure to determine shock in children, but rather?
BP may be normal until 30% blood loss. Rely on tachycardia and reduced skin perfusion.
Urine output goals in children
Infants 1-2ml/kg/h
Children 1ml/kg/h
Teens 0.5ml/kg/h
Is hypotension in a trauma child bad?
Yes.. May indicate blood loss of 40%. If penetrating or blunt abdominal trauma => op.
Early reversal of anticoagulation.. ASA, plavix Warfarin Heparin DOAK
Antiplatelets (ASA, plavix) - Platelets
Warfarin - Plasma + vitamin K
Heparin - Protamine sulfate
DOAK - Ocpex (prothrombin complex concentrate)
How to interpret a normal PCo2 in pregnant lady?
May indicated respiratory difficulties, should be lower.
Is there reason to worry about the fetus in normotensive pregnant lady?
Yes. Hypotension may occur later. Fetal distress can occur earlier.
Heartrate in fetus, what is normal?
120-160bpm. Absence of accelerations is a sign of hypoxia. You want increased HR for about 15 beats - ie accelerations
Blood samples in pregnancy, how are the following affected?
Hematocrit, WBC, pH, Bicarbonate, PCo2, Fibrinogen, PO2
Hematocrit - Lower WBC - Lower pH - Higher Bicarbonate - Lower PCo2 - Lower Fibrinogen - Higher PO2 - Higher
Fibrinogens role in pregnancy trauma?
Should be higher, if normal value - can indicate intravascular coagulation
Eclampsia can mimic head injury, consider eclampsia when:
Seizures, hypertension, peripheral edema, proteinuria, hyperreflexia.
Signs abruptio placentae
Vaginal bleeding, pain, uterine tenderness, contractions, uterine irritability
Signs uterine rupture
Guard, abnormal fetal lie, Easy palpation fetal parts, inability palpate fundus.
Give Rh immunoglobulin to mother when?
Determine RH status ASAP. Give immunoglobulin if mother is RH NEGATIVE.
When screen for intimate partner violence and malpractice?
Always, interview patient alone.
Gastric tube in all intubated patients?
Yes
When initiate transfer? Before, under or after resuscitation?
Under resuscitation
How to report patient to receiving caregiver?
ABC SBAR
