ATLS Flashcards
There are more than ___________ MVC deaths worldwide per year.
1 million
Describe the trimodal distribution of death from trauma.
The first peak is the first seconds to minutes after the injury. This is from severe traumas and patients likely cannot be saved.
The second peak is the minutes to hours after the injury. These are from delayed consequences of the trauma, such as bleeding, hematomas, and swelling.
The third peak is days to weeks after the trauma. This is from the secondary effects of trauma, like wound infection.
ATLS is supervised by ____________.
the American College of Surgeons
What are the primary and secondary surveys?
Primary: ABCDEs
Secondary: full HPI and PE, labs, images (x-rays, CTs, and USs)
What are the duties of prehospital providers in a trauma?
- Airway and breathing
- Control of hemorrhage
- Immobilization
What information should you obtain from EMS in a trauma?
- Mechanism of injury
- Blood on scene
- Vitals and GCS
- Interventions done by EMS
- Access
- Immobility
- ETA
Review ABCDE.
Airway: maintain a patent airway, intubate if otherwise
Breathing: maintain adequate respiration, support if otherwise
Circulation and hemorrhage: control bleeding, identify cardiac causes of death, and identify dehydration
Disability: assess for neurologic damage that may require immediate immobilization and NSGY management
Exposure: look for missed things (on the body) and control temperature with warm blankets
How should you begin the ABCDE?
Introduce yourself, ask the patient’s name, and ask them to tell you what happened. If they answer correctly and without stridor or other airway sounds then you know they are breathing and their airway is patent. You can simultaneously get them hooked up to monitors and begin your assessment of their BC portion.
What do you need to do for the “D” part of the primary survey?
- GCS
- Pupillary exam
- UE motor function
- LE motor function
The only x-rays obtained in the primary survey are _______________.
chest and pelvis
There are two main kinds of trauma: _____________.
blunt and penetrating trauma
Thermal and toxic injuries are other types but are less common.
What types of injuries do you need to worry about in an electrical trauma?
- Arrhythmia
- Rhabdomyolysis
- Compartment syndrome
What kinds of non-burn injuries do you need to worry about in a burn patient?
Occult blunt trauma
The person may have sustained blunt trauma while escaping a fire or with a blunt trauma that involved a burn.
In the secondary survey, you need to auscultate for _________ bruits.
carotid
Neck trauma can cause dissection.
In each exam of the secondary survey, you need to do what?
- Inspect
- Palpate (crepitus, tenderness, drop offs)
- Auscultate (breath sounds, heart sounds)
Note: if you see any superficial lacerations or hematomas, check for puncture/penetration.
Place a ____________ when you’re concerned for pelvic fracture.
pelvic binder
Worse injuries typically occur in what type of MVC?
(Side impact or front impact)
Side impact
Define definitive airway.
An endotracheal intubation that is secured (cuff inflated, confirmed by CXR, and secured in place)
How do you know if a patient is at risk of airway compromise?
Talk to them and examine their head and neck.
If they can talk to you without worrisome sounds (stertor, stridor, or hoarseness) and they are not showing AMS, then you can rule out AMS and some mechanical causes of airway compromise. You then examine their head, next, and oropharynx for signs of injury (like hematoma, deformity, or bleeding) that might indicate other causes of airway compromise.
Why do you need to look and feel for maxillofacial fractures in assessing the airway?
Loss of bony support structures can cause loss of airway, particularly with bag-masking
Go through the look, listen, feel for airway assessment.
Look for the following:
- Symmetrical chest rise
- Presence/absence of retractions
- Hematomas or puncture wounds to the head and neck
- Maxillofacial deformity
- Midline trachea
- Tachypnea
Listen for the following:
- Gurgling, stertor, stridor, hoarseness
- Bilateral lung fields equal and clear
Feel for the following:
- Crepitus of the chest and neck
- Maxillofacial fractures
- Deep masses that might suggest developing hematomas
What are three things you do to confirm proper airway placement?
- Look for positive capnography
- Listen for symmetric breath sounds
- CXR
It is important to identify which type of shock trauma patients have because _______________.
while hemorrhagic shock is most common, they can also have obstructive (from PTX, tamponade, or PE that could have caused or been caused by the trauma), neurogenic (from a spinal cord injury), or even septic/anaphylactic/cardiogenic (if this preceded the trauma)
Hemorrhage induces shock by ____________.
reducing preload
What do you need to remember about hemoglobin and hematocrit shortly after a trauma?
The H/H will usually be normal in the first hour or so after significant blood loss because both plasma and RBCs are lost with bleeding, so a massive bleed can have a normal H/H. In fact, a low hemoglobin shortly after a trauma is very worrisome because of this.
Normal blood volume is approximately ________ of body weight.
7% of ideal body weight in adults and 8-9% in children
A 70 kg adult has about 5 L of blood.
In a preemie who only weighs 1 kg, they have only 80 mL of blood. Hence the caution against obtaining repeat labs in the NICU.
Review the four classes of hemorrhage.
I: hemorrhage <15% of blood volume (like a person who donated one unit of blood); may have minimal tachycardia but no other vital sign abnormalities
II: uncomplicated hemorrhage 15% to 30% only requiring fluids; likely tachycardia and tachypnea; base deficit is -2 to -6
III: complicated hemorrhage 31% to 40%; requiring fluids and blood; marked tachycardia and tachypnea; decreased SBP; AMS
IV: hemorrhage >40%; will lead to death if not transfused; narrow pulser pressure with decreased SBP; lethargic; skin perfusion changes
Why is it important to decompress the stomach in trauma?
Gastric distension (most commonly from bag-mask ventilation) can cause hypotension and arrhythmia
Early consideration of blood products to patients with class _____ hemorrhage needs to be considered.
III and IV
Anytime you see sustained tachycardia, tachypnea, hypotension, and AMS in a trauma patient then prepare blood and consider giving.
What is balanced resuscitation?
Accepting slight hypotension to avoid increasing bleeding from HTN
What is the “floor and four more” rule?
Think of where blood might be:
- On scene (“floor”)
- Thorax, abdomen/pelvis, retroperitoneum, and extremities (“four more” cavities)
Go through the three categories of response to initial IV fluids in trauma patients.
- Vitals normalize with initial boluses: no further interventions needed but keep matched blood ready in case of surgical intervention
- Vitals normalize temporarily after boluses but then deteriorate: likely indicates ongoing bleeding; consider giving blood and expedite bleeding control (e.g., surgical correction or angio-embolization)
- Vitals fail to normalize with boluses: likely indicates severe bleeding; strongly consider starting massive transfusion protocol with emergency release blood
In addition to advanced age, young age, pregnant women, and medication use, you also need to consider what special population that might respond to trauma differently?
Athletic people
Young athletes likely have increased ability to compensate for hemorrhage, so they may have normal vitals even with significant injury.
Why do you need to know if someone has a pacemaker in a trauma?
They may have settings that make their HR stay constant, which will mask tachycardia.
A patient suffers thoracic trauma and is in respiratory distress. After placement of a chest tube for PTX, there is significant bubbling in the water chamber. What could be happening?
Tracheobronchial tree injury or leak around chest tube
Tracheobronchial tree injury results from deceleration injuries or blast injuries.
Review the look, listen, feel for the thoracic exam.
Look:
- Is there obvious deformity to the chest or neck such as flail chest, hematoma, or bleeding?
- Is the airway midline?
- Is the patient tachypneic or using accessory muscles?
Listen:
- Are breath sounds equal and not diminished?
- Is there stridor or stertor?
Feel:
- Is there crepitus?
- Is there instability of the ribs?
What are the presenting signs of tracheobronchial tree injury?
- Tension PTX
- Subcutaneous emphysema
- Hemoptysis
- Respiratory distress
- Hypoxia
- Bubbling in the water chamber of a chest tube
The most common cause of a tension PTX is ______________.
mechanical ventilation in someone with an injury to the visceral pleura
Review the signs and symptoms of tension PTX.
- Respiratory distress (e.g., tachypnea, hypoxia, accessory muscle usage)
- Tracheal deviation away from the affected side
- Hypotension (from decreased preload)
- JVD on the affected side
- Hyperresonance on affected side
- Absent breath sounds on the affected side
Needle thoracostomy converts a tension pneumothorax to a ________________.
simple pneumothorax
What is an open pneumothorax?
This occurs when there is an open injury to the thorax that is > 2/3 the diameter of the trachea. When this occurs, air preferentially enters the thorax instead of the trachea when the diaphragm contracts. It thus needs to be treated with occlusive dressings. The occlusive dressings need to be three-sided to make a flutter valve.
A sucking chest wound is also called ______________.
open pneumothorax
A patient has severely decreased breath sounds on one side in addition to hypotension. What things can differentiate hemothorax from tension pneumothorax?
- Percussion: PTX is hyper resonant while hemothorax is dull
- Tracheal deviation: tension PTX will cause deviation while hemothorax will not
- Neck veins: hemothorax causes flattened veins while tension PTX causes JVD
Immediate return of greater than _______ mL of blood after chest tube placement indicates the need of emergent thoracotomy.
1500
Muffled heart sounds, hypotension, and JVD indicate _____________.
tamponade
What is different about the traumatic cardiac arrest algorithm (compared to ACLS)?
Bilateral thoracostomy tubes can be placed to treat suspected PTX
What type of x-ray is best for assessing pneumothorax?
Upright expiratory chest x-ray
Where are chest tubes placed for pneumothorax?
In the fifth intercostal space (about nipple line) in the mid-axillary line
Other than immediate return of 1500 mL, what other criterion indicates surgery for hemothorax?
Greater than 200 mL/hr for 2-4 hours after chest tube insertion
Pulmonary _________ is typically a later development after a traumatic injury.
contusion
Traumatic aortic ____________ is a common cause of sudden death from trauma.
disruption
How is traumatic aortic disruption treated?
Control tachycardia and hypertension while awaiting surgical consultation
Esophageal disruption most commonly occurs from what type of traumatic injury?
Penetrating trauma
A patient appears to have flail chest but the chest x-ray is negative. What could be happening?
Costochondral disruption (ribs disconnecting from the sternal cartilage) can also cause flail chest
Older adults with rib fractures are at significantly increased risk of __________ when compared with younger patients.
pneumonia
Traumatic asphyxia is ________________.
a crush injury to the upper torso that results in plethora of the upper torso; it can cause cerebral edema
Fractures of the lower ribs should raise concern for ______________.
hepatosplenic injury
What causes hypoxia in flail chest?
Pulmonary contusion
Suspect intraperitoneal trauma with penetrating wounds from the ___________ to the perineum.
nipple line
What causes damage in a deceleration injury?
Differences in how mobile viscera are can cause tearing. For instance, the liver and spleen each have parts that are mobile and parts that are fixed. When deceleration occurs, the mobile parts will move and the fixed parts will be restricted. This causes shearing.
The shockwave that surrounds a bullet going through the body is called _______________.
cavitation effect
Why can you not reliably predict the path of a bullet through the body?
If a bullet hits something hard (like bone) it can then change direction. Bullets can also tumble which changes direction.
What are the signs of occult pelvic fracture?
Blood at the urethral meatus
Hematuria
Scrotal hematoma
Leg rotation without obvious leg deformity
Why should you not test for pelvic instability?
Because pelvic fractures often lead to pelvic bleeding and manipulating the pelvis is thought to lead to increased bleeding from dislodged clots
What information do you need to assess in an MVC?
Speed of crash
Mechanism of crash (i.e., single vs multiple car, rollover, objects struck)
Intrusion into vehicle
Ejection from vehicle
Seat belt use
Air bag deployment
Patient position
Status of other passengers
You must inspect the _____________ durign the visual assessment of the abdomen.
scrotum, perineum, and rectum
What is the utility of a pelvic binder?
If someone has an intrapelvic bleed with a fracture, the instability of the fracture can open up the pelvis and create more room for blood to accumulate. Pelvic binders narrow the pelvis to limit the space that blood could go and tamponade the vessels.
In a trauma patient, there are two purposes of the rectal exam: ________________.
assess for tone (lack of which indicates spinal cord injury) and assess for frank blood (presence of which indicates luminal injury of the GI tract)
True or false: always obtain a pelvic x-ray in a trauma, even if the person is awake, normotensive, and denying pelvis tenderness.
False
Certainly, if someone has a high mechanism of injury you can do an x-ray, but it is not mandated by any ATLS protocol.
Obtain a chest x-ray if there is penetrating abdominal trauma above the level of the ______________.
umbilicus
Diagnostic peritoneal lavage is indicated only in settings without _____________.
CT or FAST
The primary goal of treating head injuries is to ______________.
prevent secondary injuries from developing
The ____________ doctrine states that if a new mass appears in the brain (like blood or tumor) then the rest of the brain will accommodate it because it is a closed space. The order of accommodation goes fluid (blood and CSF) to brain.
Monroe-Kellie
Spinal injury is most common in which region of the spine?
Cervical – this accounts for 55% of spinal injury
The rest of the regions are each about 15%.
This is because the thoracic, lumbar, and sacral spine have other supports like the ribs, visceral organs, and pelvis.
It’s important to assess that the patient is __________ to a backboard and cervical collar.
properly adhered to and fitted for
If they aren’t then movement is possible.
Neurogenic shock typically occurs from injuries to ________ and higher.
level T6
Thoracic spine fracture/dislocations almost always cause _____________.
complete spinal cord injuries
The motor level is given by _______________.
the most caudal level at which a grade 3 or higher is examined
The main consideration in severe MSK injuries is ____________.
don’t get distracted by the ABCs: someone’s severely disfigured limb will not cause them death
The best way to prevent further internal hemorrhage in a severely injured limb is ____________.
immobilization
Review the order in which to escalate hemorrhage control.
First: apply direct pressure to the wound
Second: apply a pressure bandage (wrapped ace around the wound)
Third: apply direct pressure to the artery proximal to the wound
Fourth: apply a tourniquet
If time to operative intervention is suspected to be over an hour, consider ____________ the tourniquet in a stable patient.
a trial of deflating/loosening
For disfigured limbs, the goal for the emergency medical provider is to ______________.
reduce the fracture to a grossly normal position and splint it to avoid further damage to the fractured site; if reduction is not possible then splint it in place
Always assess the neurovascular status before and after.
Review the physical exam for MSK injury.
Assess each limb at a time.
Look for gross deformity, wounds, and hematomas.
Palpate all joints for tenderness and crepitus
Palpate relevant pulses.
Ask conscious patients to assess for sensation and gross motor function.
How should you remove caustic powder from a patient’s body?
Attempt to brush it off before using water to rinse it off. Making the powder into a solvent can lead to worse injury.
What physical exam finding in a burn patient indicates deep injury?
Contractures of the extremities
Iatrogenic hypothermia has been shown to increase ______________ in trauma patients.
mortality
The three ways that frost bite causes cell death are ___________________.
direct injury to cells from ice crystals, tissue ischemia from absent blood flow due to frozen vessels, and reperfusion injury with rewarding
Review the treatment of frostbite.
- Remove damp or frozen clothing
- Apply warm blankets
- Give the person warm fluids by mouth or by IV
- Place the affected extremity in a warm water bath (~104º)
- Treat pain (reperfusion of frostbitten areas is extremely painful)
- Minimize local irritation to the skin
- Avoid vasoconstrictive agents
Why should you intubate a burn patient with a larger ETT?
They may require bronchoscopy because of airway sloughing, so a tube larger than 7.5 mm may be helpful.
What is the biggest difference in evaluating the seriousness of a traumatic injury in a child compared to an adult?
Children often will not have hemodynamic instability with severe trauma.
Review the BP rule of children.
Systolic BP is usually 90 + 2(age in years).
Hypotension is given by BP less than 70 + 2(age in years)
Diastolic BP is usually 2/3 systolic BP.
Why are pediatric patients at higher risk of multisystem injuries?
Because kids are smaller, the same area of force (say, a car’s bumper) will be spread over multiple organs.
Suspect internal organ injury in a child with what two fracture types?
Skull and rib
It takes significant trauma to break these bones, so underlying organs are likely to be damaged.
In kids, a blood loss of up to _____% may not cause changes in BP.
30
True or false: hemorrhagic shock causes a widened pulse pressure.
False
It causes a narrow pulse pressure.
Because hypotension happens so late in the decompensation of children, it’s important to look at ______________, which happen earlier.
tachycardia, delayed capillary refill, and AMS
Unlike adults, children can have _____________ even without rib fractures.
pulmonary contusions
What does the word viscus mean?
It is the singular of viscera. You’ll hear the term “hollow viscus injury” and it means luminal organs like the small intestines.
What is SCIWORA?
Spinal cord injury without radiographic abnormality
This is a diagnosis of clinical spinal injury (e.g., paralysis and a sensory level) without evidence of injury on CT or MRI. It’s more common in children because of their hypermobile joints and bones. Treat them as if they have a spinal cord injury.
What factors make geriatric trauma more serious?
- Preexisting comorbidities
- Frailty
- Increased mortality with similar trauma
When evaluating for shock in the elderly, consider _____________.
the possibility that pre-existing hypertension may mean that their “normal BP” may actually be hypotensive
If you are sending a patient to a higher level of care, what are your responsibilities?
- Stabilize the patient for transport
- Communicate a handoff to the receiving hospital
- Maintain familiarity with transportation options and select the appropriate mode of transport
- Select an appropriate receiving venue for the patient (with the help of the receiving physician)
What are some hard indications that you need to transfer a patient to a dedicated trauma center?
- Evidence of injury that requires or may require operative intervention (e.g., spleen or liver lac, broken bone)
- Shock
- Deterioration in status from presentation
- Death of co-passengers in accident
How is traumatic arrest different than non-traumatic arrest?
Chest compressions are of limited use in traumatic arrest. Some people even think that chest compressions may get in the way of more helpful procedures in traumatic cardiac arrest, such as access, blood transfusion, intubation, thoracotomy, and chest tube insertion.
Note: only delay CPR if the arrest was in hospital, though, because if they have been down for a while the benefits of CPR outweigh the risks of delaying other procedures.
In traumatic cardiac arrest, what procedures are indicated?
Bilateral chest tubes
A cooler (one round) of massive transfusion protocol includes what?
6 pRBCs, 6 FFP, and 1 platelets
In MTP, when and how much calcium should you give?
All trauma patients are hypocalcemic. Give 1 g of Ca for every L of product (three units).
Review the SALT system for mass causality incidents
- Sort which patients to assess first. Still or unresponsive patients need to be assessed first. Patients who are non-ambulatory but have purposeful movements need to be assessed second. Walking patients are assessed last.
- Assess and perform Lifesaving interventions: perform hemorrhage control, chest decompression, and open airway.
- Triage: If the person is not breathing after your interventions or they have injuries that they are not likely to survive then they are black (do not treat). If they are alive but have a life-threatening injury that they can survive, then they are red (treat immediately). If they do not have an apparent life-threatening injury but they may later have one, they are yellow (treat after reds). If they have only minor injury then they are green (no further treatment needed).
What are the six areas you can hemorrhage from in a trauma?
Externally
Thorax
Abdomen
Retroperitoneum
Pelvis
Upper legs
What TWELVE things should you check the neck of a trauma patient for?
There’s only six but the mnemonic is fun because if you check them twice…
Tracheal deviation
Wounds
External marks
Laryngeal disruption (i.e., stridor, hoarseness)
Venous distention
Emphysema
High pressure injuries can cause what type of injury?
Retained foreign bodies that produce widespread necrosis and infection if not debrided
This is important to know because the exam can be innocuous at first, with minimal superficial abnormalities, normal ROM, and normal neurovascular status. You should consider obtaining XRs or even CTs and surgical consult for high pressure injuries.
What is the indications for resuscitative thoracotomy after a trauma?
Cardiac arrest at any point after having vitals by initial EMS presentation
The survival rate of resuscitative thoracotomy from penetrating trauma is ___%.
15
Blunt trauma is much less.
Where do you make the pericardial incision in a resuscitative thoracotomy?
At the apex of the heart near the diaphragm, anterior and parallel to the phrenic nerve
What is the ratio of RBCs:FFP:Platelets in MTP?
1:1:1
What is the dose of defibrillation for internal paddles?
30 J
What are the four stages of blast injury?
Primary: injury from the blast shockwave (e.g., lung barotrauma)
Secondary: injury from shrapnel
Tertiary: injury from body being propelled into objects
Quaternary: injury from chemicals in the bomb
What is Waddell’s triad?
In MVC vs pedestrian, there are three impacts:
- 1st: pelvis and femur injury from bumpers
- 2nd: thoracic injury as body strikes hood
- 3rd: head injuries as body strikes floor
What test do you need to do to an overall well appearing blast victim with normal vitals?
TM evaluation
The TMs suffer blast pressure changes at levels lower than any other organ. If these are normal in a well appearing person with no localizing complaints, the odds of occult blast injury are sufficiently low that they can be discharged.
Chest tube output > 200 ml/hr for how many hours indicates emergent thoracotomy?
3 hours
How is thoracic trauma different in children?
They have cartilaginous ribs that break much less often. On the other hand, they are more likely to get pulmonary contusion.
What is the most commonly fatal blast injury?
Blast lung – a combination of contusion, hemothorax, and pneumothorax that presents with respiratory distress, hypotension, and/or apnea
