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
