ATLS Flashcards
How do you asses airway adequacy ?
By talking to the patient, if the patient answers appropriately and with a clear voice. The airway is in the moment patent. ventilation is sufficent and brain perfusion is good.
Definie the term “definitive airway”
A tube placed in the trachea with the cuff inflated below the vocal cords , the tube connected to a form of oxygen-enriched assited ventilation and the airway secured in place with an appropriate stabilizing method.
How do i know the airway is patent?
- Patient is alert and oriented
- Patient is talking normally
- No evidence of head or neck injury
- You have assesed and reassesed for detoriation
Signs of airway compromise? (Look, hear and feel)
Look: Head or neck injury, sore throat, dyspnea, tachypnea, agitation, abnormal breathing pattern, low oxygen saturation and Deviated trachea
Listen: Change in voice, Noisy breathing, Lung fields with absent sounds
Feel: Subcutaneous emfysm in head neck or chest. Head or neck injury
Which patients are at risk for compromised ventilation?
- Unconscious patient with head injuries
- Obtunded patients (Alcohol, drugs)
- Patients with thoracic injuries
- Patients with facial burns
- Patients with potential inhalation injuries.
What is a huge pitfall during ventilation?
Aspiration due to vomiting
1. Ensure functional suction equipment close to hands
2. Rotate the patient laterally while protecting the cervical spine
Maxillofacial trauma, signs of potential airway obstruction?
- Fractures compromising naso or oropharynx
- Oropharyngeal hemorrhage
- Swelling
- Increased secretions
- Dislodged teeth
- Loss of airway structural support
- Altered level of conscioussnes
Neck trauma, penetrating and blunt trauma can result in ?
- Vascular injury with significant hematoma
- Displacement or obstruction of the airway
- Massive hemorrhage into the tracheobrachial tree
- Airway obstruction from disruption of larynx or trachea
Signs and symptoms of laryngeal fracture
1- Hoarsness (Heshet)
2. Subcutaneous emphysema
3. Palpable fracture
If laryngeal fracture is suspected?
A CT can confirm, only after patient stabilization.
Signs of airway obstruction? LOOK, LISTEN, HEAR
LOOK: Agitation? = Hypoxia?, Obtundation=hypercarbia?, Cyanosis, retractions and use of accessory muscles of ventilation, Labored respiration, Altered level of consiussness
Listen: Decreased or lack of breath sounds? = Pneumothorax or hemothorax
Noisy breathing = Obstructed breathing?
Snoring, gurgling or stridor = Partial occluusion of pharynx or larynx
heshet?
For a paitent who is gurgling, initialt assessment for ventialtion should include?
Looking for symmetrical chestrise and listening to breath sounds.
Decreased or absent breath sounds over one or two hemithoracies should alert the examiner to the prescence of ?
- Pneumothorax
- Hemithorax
- Contusion
- Flail chest
Causes of ventilation problems?
1.Direct chest trauma
2. Intracranial injury
3. Cervical spine injury
4. Complete Cervical cord transection
- Painful breathing, rapid and shallow ventilation and hypoxemia
- Abnormal breathing patterns and compromised breathing
- Diaphragmatic breathing and compromised ability to meet increased oxygen demands
- Abnormal breathing and paralysis of the intercostal muscles
Objective signs of Inadequte ventilation ?
LOOK, LISTEN, FEEL?
- Look: Look for assymetry or labored breathing
- Listen: Decreased or absent = thoracic injury and Rapid respiratory rate
- Adjuncts : Pulse oximeter and capnography when intubating
How to minimize failure to recognize inadequte ventilation?
- Monitor patients respiratory rate and work of breathing
- Obtain arterial or venous blood gas measurements
- Perform continous capnography
Symptoms of inadequate ventilation?
Difficulty breathing, shortness of breath and if the patient request to sit up to breath.
Objective signs of inadequte ventilation?
1.Tachypnea,
2.Tachycardia,
3.Arrythmia,
4.Altered mental status(Obtunded,combativeness, agigation and lethargy),
5.Use of accessory muscles,
6.Dimineshed breath sounds
Low oxygen saturation.
When performing airway maneuvers that do not involve neck motion, temporary release of c-spine protection is warrented?
False !!!
Trauma patients with glasgow coma scale of 8 or less require?
Prompt placement of definitive airway!
Airway management Techniques?
- Manual maneuvers( Chin lift, Jaw thrust)
- Basic adjuncts( Näskantarell, Svalgtub, Mask)
- Supraglottic adjuncts
- Intratracheal tube
When to intervene with a patient with a patent airway?
- Impending Airway compromise (Airway problem)
- Need for ventilation (Breathing problem)
- Shock (Circulation problem)
- Inability to self-protect airway (Disability problem)
- Need for suctioning
- Hypoxia
Helmet removal?
- Always 2 persons to protect C-spine
- one provides manual inline motion restrictions from below and one expands the sides and removes it from above.
Factors that indicate diffcult airways?
- C-spine injury
- Severe athritis of the C-spine
- Significant maxillofacial or mandibular trauma
- Obvious airway obstruction
- Limited mouth opening
- Obese patients
- Small chin, overbite, short muscular neck
- Pediatric patients
LEMON ASSesment
- Look externally things that obviuously makes it hard to intubate
- Evaluate 3-3-2
- Mallampati (1-4)
- Obstruction Epiglottitis, peritonsillary abcsess and trauma
- Neck mobility
Airway decision scheme for ?
- Patients in acute respiratory distress
- Patients with apnea
- Patients in need of an immediate airway
- Patients with suspected C-spine injury based on mechanism of injury or physical exam.
Airway maintenance technique?
- Chin-lift or Jaw-thrust
- Nasopharyngeal airway (NPO), often well tolerated in awake and unconscious patients
- Oropharyngeal airway (OPA)
- Laryngeal mask airway(LMA), Intubatin LMA, Laryngeal tube airway (LTA), Intubatin LTA, Multilumen esophageal airway
What are the 3 types of defintive airways?
- Orotracheal tubes
- Nasaltracheal tubes
- Surgical airways (Cricothyrodotomy or tracheostomy)
Indications for defintive airways?
Airway: Inability to maintain a patent airway by other means, with impending or potential airway compromise
Breathing: Inability to maintain adequate oxygenation by facemask or the presence of apnea
Circulation: Obtundation or combativness resulting from cerebral hypoperfusion
Disability: Obtundation indicating the prescene of head injury and required assisted ventilation, GCS score of 8 or less, sustained seizure activity; need to protect lower airway from aspiration
If the orotracheal intubation does not work ?
Use gum elastic bougie
How to check if intubation and ventilation is good?
- LIsten for lungsounds and no borborygimi in epigastrium
- Look: Capnopgraphy looks for presence of CO2 in exhaled air, if not detected its esophageal intubation that happend
- Chest X-ray is best confirming.
- When patient is moved reasses the tube placement
Inability to to intubate, what to do ?
- Use rescure airway devices
- Perform needle cricothyroidotomy followed by surgical airway
- Establish surgical airway
Equipment failure?
- Perform equipment cheeks
- Ensure backup equipment is available
Rapid sequence intubation - Indications?
- Patients who need airway control, but have intact gag reflexes
- Patients who have sustained head injury
What are the 2 surgical airways?
- Needle cricothyroidotomy (prefered for childreen under 12 years)
- Surgical cricothyroidotomy (Not recommended for children younger than 12)
What is the equipment needed for needle cricothyroidotomy?
1 12-14 gauge over the needle catheter
2. 6-12 ml syringe
3. Oxygen tubing connected to a source capable of delivering 50 psi or greater at the nipple
What adjuncts can be used in ventilation?
- Suction
- Manual laryngeal manipulation technique: Backward, upward and rightward pressure (BURP)
- Gum elastic bougie - if orotracheal intubation is unsuccesful on the first attempt or if the chords are diffcult to visualise
- Anesthetics, analgesics or neuromusculuar blocking agents for rapid sequence intubation
Why is continual pulse oximetry monitoring necessary in critically ill patients?
Because change in oxygenation occur rapidly and are impossible to detect clinically.
Ensuring adequate oxygenation by?
- Tight fitting oxygen resorvoir face mask
- Flow rate at least 10L/min
- Nasal catheter, nasal cannula or nonbreather mask can improve inspired oxygen concentration
- Continous pulse oxymetri (95 eller mer tyder för adekvat perifer perfusion)
What indicates the the endotracheal tube is in the proper position?
It is suggested if you hear equal breathing sounds, no borborygmi in epigastrium (talande för intubation av esophagus), Capnography och slutligen Chest X-ray to confirm.
What suggests sufficent ventilation?
- Arterial blood gas
- Continual end-tidal carbon dioxide analysis
Indications for surgical airway ?
- Edema of the glottis
- Fracture of the larynx
- Severe oropharyngeal hemorrhage that obstructs the airway
- Inability to place an orotracheal tube through the vocal cords.
What is the definition of shock?
An abnormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation.
What are diffrent types of shock?
1.Hypovolemic/hemorrhagic
2. Cardiogenic
3. Obstructiv
4. Neurogenic
5. Septic
How to think in shock?
- Identify shock–> Tachykardia and coldness
- Determine which type of shock it is
- Do something !!!
What is important information to obtain about a automobile collision?
- Seat-belt use
- Steering wheel deformation
- Activation of airbags
- Direction of imapct
- Major deformation or intrusion to the passenger compartment
- Patient position in vehicle
What could cause confusion in a trauma patient?
- SHOCK !!! due to hemorrhage
- Brain injury
- Stroke
- Alcohol and/or drugs.
What is the common cause of shock in trauma patients?
Hemorrhage
What does preload mean and what does hemorrhage do to it?
Volume of venous blood return to the left and right sides of the heart.
It decreases it
What does myocardial contractility mean
The volume of venous blood return determines myocardial fiber length after ventricular filling at the end of diastole.
What does afterload mean?
Resistance to the forward flow of blod
What are the physiological responses to blood loss?
- Progressive vasoconstriction to preserve perfusion to kidneys, heart and brain.
- Tachycardia to preserve cardiac output
- Release of catecholamines, which increases peripheral vascular resistance and diastolic pressure
- Shift from aerobic to anaerobic metbolism in cells.
What are the early manifestations of shock?
- Tachycardia
- Cutaneous vasoconstriction (Kall)
Evaluate: Respiratory rate, pulse rate and charachter, skin perfusion och pulse pressure
Very low hematocrit value shortly after injury talar för?
Massive blood loss or preexisting anemia
Base deficit and or lactate can help determine … ?
presence and severity of shock.
What are the blod on the floor and 4 more?
Chest, abdomen, retroperiteneum, pelvis, extremeties.
What are the goal of treating hemorrhagic shock?
Definitive control of bleeding and restoration of adequate cirulation volume.
The 5 ways to manage hemorrhagic shock
- Administer isotonic electrolyte solutions, blood and blood products
- Stop the bleeding
- Provide adequate oxygenation and ventilation
- Involve a surgeon
- Transfer in necessary
What is the percentage of weight in adult is the estimated blood volume
7 % of body weight
What is the percentage of weight in children is the estimated blood volume?
8-9 % of body weight (80-90ml/kg)
What are the classification of hemorrhagic shock?
Class I hemorrhage: Individual that donates one unit of blood
Class II hemorrhage: Uncomplicated hemorrhage requiring crystalloid fluid resuscitation
Class III: Complicated hemorrhage state requiring at least crystalloid infusion and possible blood replacement
Class IV: Preterminal event, if drastic measurement is not take the patient is dead within minutes.
Class II hemorrhage, symptoms, how much is lost and what to do ?
Tachycardia and tachypnea
Urinary output 20-30 ml/h in adults
loss of 15-30 % of blood
Base deficit -2 to -6
Crystalloid
Class III hemorrhage symptoms, how much is lost and what to do ?
- Inadequate perfusion
- Tachycardia and Tachypnea
- Significant decrease in systolic blood pressure
- Base deficit: -6 to -10
Behandling: Crystalloids, blood components and definitive control of bleeding.
31-40 %
Class IV hemorrhage symptoms, how much is lost and what to do?
Tachycardia, Significant low systolic pressure, negligible urinary output
Cold pale skin
Base deficit -10 or higher
Behandling: Rapid transfusion and definitive control of bleeding.
Confunding factors that can alter hemodynamic response in shock?
- Age
- Severity of injury
- Time lapse between injury and initiation of treatment
- Prehospital fluid therapy
- Medication use
- Implanted cardiac devices
What to look for clinically for shock?
Heart rate, blood pressure, skin perfusion and mental status.
Fluid changes secondary to soft tissue injury?
Blood loss at the site of injury
- Edema in injured soft tissues from fluid shifts
Which patients are at risk for extensive blood loss into tissues?
Elderly and obese patients
How to monitor patient response to therapy?
Vitala parametrar, urinary output och mental status
Gastric distention can cause and increase risk for?
What can you do?
Hypotension or dysrythmia. Increase the risk for aspiration in unconscious patient
- Decompress stomach with nasal or oral tube and begin suction.
Urinary catherization is good for?
Hematuria measurement and evaluation of renal perfusion.
Shock does not respond to initial crystalloid fluid bolus?
- Look for source on ongoing blood loss Floor and four more
- Consider nonhemorrhagic source of shock(Obstructiv or cardiogenic)
- Begin blood and blood component replacement
- Surgical consultation
Urinary outputs in adults, peds and infants?
0.5 ml/kg/h for adult
1 ml/kg/h for peds
2 ml/kg/h for infants
What are the 3 types of responses to fluid therapy?
- Rapid
- Transient
- Minimal or no response
Transient responders?
Transfusion of blood and products, consider MTP
- Surgical consultation
Minimal or no response to fluid therapy?
- Immediate definitive intervention
- MTP DIREKT
What adjuncts should be considered to determine cause of shock?
- Chest X-ray: Hemo/pneumothorax
- Pelvic X-ray to exclude pelvic fracutres
- FAST EXAM: Intra abdominal bleeding and
cardiac tamponade
What is the most common cause of transient response to fluid therapy?
An undiagnosed source of bleeding.
What are the physiological consequences in thoracic trauma?
HHA
Hypoxia
Hypercarbia
Acidosis
What kind of injuries can you expect in a front impact car collision?
- Simple pneumothorax
- Tensionpneumothorax
- Massive hemothorax
- Pericardial tamponade
What are the clinical manifestation of tracheobronchial tree injury and what is the treatment?
- Large air leak(alot of bubbles)
- Crepitus on the affected side
- Give the patient a second chest tube and consult a surgeon urgently
Does the vast majority of thoracic injuries (blunt and penetrating trauma) require surgical intervention?
No!
Less than 10 % of blunt chest traumas and 15-30 % of penetrating trauma require surgical intervention(Thoracostopy or thoracotomy)
What are the 8 life-threatening thoracic injuries? A to C please
A: Airway obstruction, Tracheobronchial tree injury
B: Tension pneumothorax, open pneumothorax and Massive hemothorax
C: Massive hemothorax
Pericardial tamponade
Traumatic circulatory collapse.
Detail assesment of life-threatening breathin problems.
Look: Neck veins, breathing(Symmetrical/assymetrical), chest wall
Listen: Breath sounds, changes in breathing pattern
Feel: Tenderness, crepitus, defects
What should you do if the patient has a C-spine restriction collar and you need to asses for traumatic thoracic injuries?
Take of the collar from the anterior side, at the same time maintain C-spine restriction.
What are the causes of airway obstruction?
Swelling, blood and vomitus aspiration.
What are the most common mechanisms of injury in airway obstruction?
- Laryngeal injury(Hoarsness, emphysema, palpable fracture)
- Posterior dislocation of clavicular head
- Penetrating trauma to the neck or chest
What are the common causes of trachebronchial tree injury ?
- Deceleration in blunt trauma
- High prehospital mortality rate
Why is there a high mortality rate in hospital for trachebronchial tree injury?
- Associated injuries
- Inadequate airway
- Tension pneumothorax
- Pneumopericardium
What are the signs of trachebronchial tree injury?
- Hemoptys
- Cervical subcutaneous emphysema
- Tension pneumothorax
- Cyanosis
- Incomplete expansion of the lung
- Continued air leak after chest tube placement
How can you confirm diagnosis of trachebronchial tree injury?
Bronchoscopy
Treatment for trachebronchail tree injury?
- Urgent surgical consultation and intubation (difficult due to anatomical reasons)
What is the mechanism of injury in tension pneumothorax?
- One-way valve air leak
- air forced into the pleural space
- Displaced mediastinum
- Decreased venous return(preload)
- Compression that lead to hypotension
What are the causes of tension pneumothorax?
- Mechanical positive pressure ventilation in patients with visceral pleural injury
- Trauma to the chest wall
What are the signs and symptoms of the patient with pneumothorax?
- Air hunger
- Tachypnea
- Respiratory distress
- Tachycardia
- Hypotension
- Tracheal deviation to the normal lung
- Unilateral abscence of breath sounds
- Hyperresonant note on percussion
- Elevated hemithorax without respiratory movement
- Neck vein distention
- Cyanosis (Late sign)
- Chest pain
How to asses for tension pneumothorax?
- Breathing assesment
- Pulse oximetry
- eFAST
What is the treatment for tension pneumothorax and how does it happen?
Needle or finger decompression
1. Large over the needle catheter
2. Place it in fifth intercostal space slightly anterior to the midaxillary line) Mellan nipple och armpit
3. Hör du luft pysa ut ?
3. Converts tension pneumothorax to simple pneumothorax
4. Chest tube/ Tube thoracostomy
What is open pneumothorax?
Caused by large injuries to the chest wall that remain open; Air passes through the chest wall defect.
What does open pneumthorax do patophysiolgoicaly
Impairs ventilation and leads to hypoxia and hypercarbia.
What are the signs and symptoms of open pneumothorax?
- Pain
- Diffculty breathing
- Tachypnea
- Decreased breath sounds on the affected side
- Noisy movement of air through the chest wall injury
What is the treatment of open pneumothorax?
- Fast closure of the defect with sterile dressing
- Tape only three sides to make a flutter-valve(So when inspiring the sterile dressing occludes and with expiration air comes out)
- Definitive surgical wound closure
What happens if you place a dressing and occlude the open pneumothorax?
- Tension pneumothorax
- Set the chest tube on intact skin remote from the injury.
What is the cause of massive hemithorax?
Accumlation of > 1500 ml blood in one side of the chest
What is the mechanism of massive hemithorax?
- Injury compress the lung –> Preventing adequate ventilation and oxygenation
Usually due to penetrating trauma
What is the treatment of massive hemithorax?
- Placement of chest tube
- Emergent surgical consultation
- Begin apropriate resuscitation
How to asses and monitor for circulatory problems?
LOOK: mottling, cyanosis, pallor, neckvein distention
Listen: Heartbeat regularity, central pulse over the apex of the heart, HR and quality
Feel: Skin temperature and dry or sweaty
Monitor: BP, pulse pressure, cardiac rythm and oxygenation saturation
What are the signs and symptoms of massive hemithorax?
- Flattened neckveins (due to great hypovolemia)
- Distended neckveins (associated tension pneumothorax)
- Shock with absent breathing sounds
- Dullness upon percussion
What is the treatment for massive hemothorax?
- Restore blood and at the same time decompress chest cavity.
- If the blood back is > 1500 ml or continued bleeding urgent thoracotomy
What are the indications for thoracotomy?
- After chest tube placement, if the volume back >1500 ml or continued bleeding
- Persistent need for blood transfusion
- Penetrating anterior chest wounds medial to nipple line and posterior wounds medial to the scapula.
What are the mechanism of pericardial tamponade?
Compression of the heart due to accumlation of fluid in the pericardial sac. Leading to decreased flow to the heart and decreased cardiac output
What are the common type mechanism of injury in pericardial tamponade?
Mostly penetrating trauma, but can also occur in blunt trauma.
Pericardial tamponade can occur ?
Slowely or fast
What are the signs of pericaridal tampoande?
Distended Muffled heart sounds, hypotension and distended neck veins
Kussmaul sign is seen in
Pericaridal tamponade
Pulseless electrical acivitiy is seen amongst in ?
Pericardial tamponade
Which tension pneumothorax side is known to mimic pericardial tamponade?
Left tension pneumothorax
How to diagnose pericardial tamponade?
EFAST, repeated because tamponade can occur slow.
Treatment of pericardial tamponade?
Emergency thoracotomy or sternotomy.
- IV FLUIDS
- Pericardiocentesis if surgeon is not in place
A trauma patient who is unconcious and no pulse?
Traumatic circulatory arrest
Causes of traumatic circulatory arrest?
- Severe hypoxia
- Tension penumothorax
- Cardiac tamponade
- Profound hypovolemia
- Cardiac hernation
- Severe myocardial contusion
- Consider possibility of cardiac event preceding trauma
Treatment of traumatic circulatory arrest?
- CLOSED CPR
- Bilateral thoracostomies
- Continous ecg and pulse oxymetri
- Rapid fluid resuscitation
- Epinephrine
- Decompressive pericardiocentesis
What is involved in the secondary of thoracic injury?
in depth physical exam
- Ongoing ECG and pulse oximetry monitoring
- Up-right chest X-ray
- Arterial blodgas or CT maybe
