ATLS Flashcards
Massive haemothorax
> 1500ml
Or
1/3 pt blood volume
Indications for thoracotomy
> 1500ml initially
Or
200ml/he for 2-4h
Tx aortic aneurysm
HR<80, MAP 60-70
Labetalol infusion
Cardiothoracic surgeon
Seatbelt sign likely injuries
Chance #
Intestinal injury
Types pelvic #
AP compression
- open book
Lateral
Vertical shear
- consider vertical traction
Combined
Language centre location
Left hemisphere
- all right handed
- 85% left handed
Dysphasia usually seen with x weakness
Right side weakness
Cause of blown pupil - Raised IOP
Parasympathetic fibres compressed
On oculomotor nerve
Tentorial herniation
Signs uncal herniation
Ipsilateral pupil blown
Contra lateral weakness
CPP=
CPP=MAP-ICP
Cerebral Autoregulation range
50-150mmHg
Moderate brain injury definition
GCS 9-12
BP aim for brain injury
sBP >110
Or
sBP> 100
— If 50-70yo
Mannitol dose
1g/kg
Mannitol contraindication
Hypotension
5% NaCl dose
50-100ml
(?max 5ml/kg)
Test; Spinal tracts
Back to front
Dorsal column
- position
Corticospinal
- power
Spinothalamic
- contralateral pinprick
Diaphragm innervation
C3,4,5
Keeps diaphragm alive
Dermatomes
C6 thumb
C8 little finger
T4 nipple
T10 umbilicus
L5 web space 1st/2nd toe
S1 lateral foot
S4/5 perianal
Central cord syndrome Sx
Weakness
Upper > lower
Anterior cord synd Sx
Paraplegia
Bilateral loss pain and temp
Intact; pressure/vibration/proprioception
Brown sequard syndrome Sx
Ipsilateral motor loss
Contralateral pain and temp
COHb >x suggest inhalation injury
> 10%
Significant burn
Adult v child/elderly
Adult > 20%
>10% child or elderly
Fluids for significant burn
2ml x kg x %TBSA
- 3ml paed
- 4ml electrical burn
1/2 over 8h
Then adjust to U/O
Partial thickness burn
Superficial v deep
Superficial
- wet and painful
Deep
- dry, no pain, no blanch
Chest eschatotomy
Anterior axillary line
Cross at
- clavicle line
- abdo/thorax
Hypothermia define and severe
<36C
Severe <32C
DOPE
Dislodgement
Obstruction
PNX
Equipment
Lethal triad
Hypothermia
Acidosis
Coagulopathy
Paed pseudosubluxation
C2 on C3
Normal variant
Important pre-existing conditions
Cirrhosis
Coagulopathy
COPD
IHD
DM
Hypotension >65 yo
sBP<110
RSI in elderly
Reduce dose 20-40%
Trauma: Middle age or older consider
Medical event triggering trauma
Rhesus negative pregnant trauma
Rh Ig within 72h
?>12w
Fetal heart tone
how, Normal, bad
Doppler by 10w gestation
Normal 120-160bpm
Bad: absent accelerations
Tocodynamometer from
20/40
Test amniotic fluid in vagina
pH>4.5
Define definitive airway
Tube in trachea
Cuff up
Below vocal cords
O2 supply
Laryngeal # Sx
Hoarseness
Surgical emphysema
Palpable #
LEMON
Look
Evaluate 3-3-2
Malampati
Obstruction
Neck mobility
See saw breathing consider
below C3
Normal diaphragm
Loss of abdominal and intercostal
3-3-2 rule
3cm incisors
3cm chin hyoid
2cm floor to thyroid
Mallampati
2: partial uvula/fauces
3: base uvula
4: hard palate only
Suxamethonium contraindication
High K, crush injuries
Sats > 95% =~x pO2
9
Neurogenic v spinal shock
Neurogenic
- injury >T6
- disrupt sympathetic outflow
Spinal (concussion)
- temporary LMN signs
Effects on stroke volume
Preload
Contractility
After load
Cardiac output =
CO= HR x stroke volume
High Peripheral vascular resistance causes
Raised dBP and reduced pulse pressure
Tachycardia in age groups
Infant > 160
Pre school > 140
Children > 120
Adults > 100
Multiple vs mass casualty
Multiple
- does not exceed capabilities
Mass
- exceeds capabilities
Major haemorrhage locations
On the floor and 4 more
Chest, AP, retroP, femurs
Urine output per age
Adult = 0.5ml/hr
Paed = 1ml/hr
Infant = 2ml/hr
Secondary survey
Head to toe
Look, feel; bone, joints, pulses
- Eyes (VA, remove contacts)
- Ears (haemotymp)
CN, PN
Active/passive movements
Stable joints; ligaments
Jefferson #
Most common C1 #
Axial load
Burst #
Displaced lateral masses
Chance #
Transverse # through vertebral body
Hangman’s #
Posterior c2 #
Hyper extension
C1 rotatory subluxation
Presents with torticollis
Can be minimal trauma
Canadian c spine
Vs
Nexus
Canadian
- scan if; age>65, dangerous mechanism, paraesthesia, unable to rotate
Nexus
- scan if central pain
Resp dysfunction from spinal injury
Above C6
Diaphragm C3,4,5
Ankle/brachial index
sBP ankle/ sBP arm
>0.9 is normal
Expected Tourniquet time over 1 h
Single attempt at releasing
Rhabdomyolysis complications
High K
Low pH
Low Ca
DIC
Renal failure
Pulse pressure=
sBP-dBP
(Force per contraction)
Consider angio embolisation
In pelvic or abdo bleeds
Paed IVF bolus volume
10-20ml/kg
Class 2 vs class 3 shock
2: 15-30% blood loss
- decrease pulse pressure
- base excess -2 to -6
3: 30-40% blood loss
- increase HR
- decrease urine and GCS
- base excess -6 to - 10
Female ?
?pregnant
Define massive transfusion
> 10unit RBC w/I 24h
Or
4 unit in 1h
Ohms law
BP= CO x after load
Reduce posterior clavicle disloc.
Extend shoulders
Or
Grasp with clamp
R/O in Breathing primary survey
Tension
Open PNX
Massive haemothorax
When open PNX start sucking
Over 2/3 diameter trachea
Consider Tracheobronchial injury
High air leak after placing chest drain
My require multiple chest drains
Initial A to E report
C - immobilise
A - patent, tube, depth, CO2
B - Sats on %, RR
- look, feel, listen
C - BP, HR,
- look, feel: skin, pulse
- abdo, pelvis, femur
D - GCS, pupils, BG, lateralise
E - temp, expose, log roll
A to E treatments
C - block
A - suction, O2, BVM, RSI, tube
B - Thoracostomy; needle, drain
- NG tube, sedation
C - tourniquet, p binder
- IV/IO, TXA
- level 1, blood/FFP
- splint, catheter
D - head up, NaCl, mannitol
- RSI, CO2
E - bait hugger, warm Fluid
Surgical airway procedure
Scalpel (10), bougie, tube (6)
Left of patient
Gloves, clean
Laryngeal handshake - 3 finger
Transverse incision, twist 90
Bougie 90 then twist
Tube, twist
Cuff up
CO2
RSI, ETT
Hx: AMPQT
Anaesthetic Hx
Exam: LEMON
Checklist: SPEEDBOMB
1:1:1, 1:1, 1
Cricoid, BURP
Cuff up
Cricoid off
CO2
Sedation and vent
Needle decompression
CEPAC
18-12G
Paed 2nd IC space mid clav
Adult 4/5th IC space mid axillary
Clean
+|- syringe of water
Place canula
Finger/tube thoracostomy
Kit: 28-33Fr, prepare underwater seal
4/5th IC space mid axillary
Gloves and gown
Clean; chlorhex
LA; 1%, 15ml, Ketamine
3cm incision
Finger and Spencer wells
Over rib, pop, widen, sweep
Clamp tube x2
Connect ? Swinging
Suture I-0 silk, dressing
CXR
Needle cricothyrotomy
3ml syringe, 7.5mm ETT, BVM
12-18G canula
Left of pt
Gloves and clean
Laryngeal handshake: 3 finger
Syringe water
Aspirate and advance 45deg
Place canula
1 s inflation, 4 s expiration
C spine XR report
AABCDE
Adequacy; C7, T1
Alignment
- ant vertebral, ant spinal, post spinal, spinous process
Bone
Cartilage
Dens
Extra axial soft tissue
- 7mm @ C3
- 3cm @ C7
Hot debrief
Summarise
Things that went well
Opportunities
- equipment
Points to action
- family, cold debrief
Feedback points
Situational awareness
Team work
Leadership
Decision making
Task management
- delegate, prioritise
BVM ventilation. Steps
Select proper mask size
Connect oxygen
Ensure patent airway (+/- OP airway)
C or V grip (1 or 2 handed)
Ventilate
Observe chest rise/misting
Ventilate every 5 sec
Dialogue feedback; form
What specific challenges did you encounter
Explore; How did you
- anyone else had similar situation?
Close; Q,S,T
Phases learning
Remember
Apply
Evaluate
Teaching phases ESDC
Environment;
- equipment, lighting, lay out
Set;
- introduce, roles, learning objectives, prior experience
Dialogue
- teaching part
Closure
- questions, summarise, terminate
Asking questions for phases of learning
Remember: ask fact
Apply: ask for application
Evaluating:
- ask why, opinion, experiences, preferences
Synthesis: ask to solve problem
Reasons for intubation
Airway patency; occlusion/ injury
Airway protection; blood, vomit
Respiratory failure
