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ATLS Flashcards

1
Q

Most common cause of shock in trauma patient

A

Hemorrhage

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2
Q

What to evaluate to assess shock

A

RR
Pulse rate and character
Skin perfusion
Pulse pressure

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3
Q

Other causes of shock apart from hemorrhage

A

Cardiogenic
Obstructive
Septic
Neurogenic

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4
Q

FAST views

A

Cardiac
LUQ: Liver/kidney/Right hepatorenal (Morrison’s pouch) - 10th-11th rib space/mid axillary
RUQ: Left diaphragm spleen kidney interface - 8th-9th rib space
Suprapubic

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5
Q

Normal adult blood volume

A

Approx 7% body weight

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6
Q

Normal child blood volume

A

Approx 8-9% body weight

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7
Q

Class I hemorrhage: % blood loss, HR, BP, PP, RR, UO, GCS, Base deficit, need for blood pdts

A 
<15% blood volume loss
Minimal tachy
Normal BP, pulse pressure, RR, UO
Base deficit 0 to -2mEq/L
Monitor need for blood pdts
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8
Q

Class II hemorrhage: % blood loss, HR, BP, PP, RR, UO, GCS, Base deficit, need for blood pdts

A 
15-30% blood volume loss
HR same or mildly increased 
BP, RR, UOm GCS same
Decreased pulse pressure 
Base deficit -2 to -6 mEq/L
Possible need for blood pdts 
Give crystalloid
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9
Q

Class III hemorrhage: % blood loss, HR, BP, PP, RR, UO, GCS, Base deficit, need for blood pdts

A 
31-40% blood volume loss
HR elevated
BP same or decreased, PP/UO/GCS decreased
RR same or increased 
Base deficit -6 to -10mEq/L 
Yes blood pdts, crystalloids
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10
Q

Class IV hemorrhage: % blood loss, HR, BP, PP, RR, UO, GCS, Base deficit, need for blood pdts

A 
>40% blood volume loss
Elevated HR, RR 
Decreased BP, PP, UO, GCS 
Base deficit -10mEq/L or less 
Massive transfusion protocol
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11
Q

Preferred vascular access in trauma setting

A

2 short large calibre periphery IVs (min 18-gauge for adults)

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12
Q

UO goals

A

0.5ml/kg/h adults
1ml/kg/h children 1-teens
2ml/kg/h infants

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13
Q

Massive transfusion protocol

A

> 10U of pRBCs in 24h

>4U in 1h

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14
Q

Most common cause of transient response to fluid therapy

A

Undiagnosed source of bleeding

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15
Q

Majority of tracheobronchial tree injuries occur within___ of the carina

A

1inch/2.5cm

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16
Q

Confirm tracheobronchial tree injury via

A

Bronchoscopy

Requires immediate surgical consult

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17
Q

Most common cause of tension pneumothorax

A

Mechanical positive pressure ventilation in pts with visceral pleural injury

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18
Q

Treatment of tension pneumothorax

A

Large (16-18 gauge) over the needle catheter insertion or finger thoracotomy at 5th interspace (level of nipple) slightly anterior to the midaxillary line
Tube thoracotomy is MANDATORY after needle or finger decompression of chest
Chest tube inserted in anterior axillary line

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19
Q

Open pneumothorax mgmt

A

Prompt closure of defect with sterile dressing, taped on three sides only
Chest tube remote from wound
Definite surgical closure often required

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20
Q

Massive hemothorax

A

Accumulation of >1500ml of blood in one side of chest or >/= 1/3 of patient’s blood volume

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21
Q

Massive hemothorax mgmt

A

Restore blood volume and decompress chest cavity with single chest tube 28-32 French inserted at 5th intercostal space just anterior to midaxillary line
Return of 1500cc or more of blood generally indicates need for urgent thoracotomy

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22
Q

Classic clinical triad of cardiac tamponade

A

Muffled heart sounds
Distended neck veins
Hypotension

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23
Q

Kussmauls sign

A

Kussmaul’s sign is a paradoxical rise in jugular venous pressure (JVP) on inspiration, or a failure in the appropriate fall of the JVP with inspiration.
Seen with cardiac tamponade

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24
Q

Flail chest and pulmonary contusion mgmt

A

Initial: oxygen, fluid resuscitations, intubation and mechanical ventilation if necessary
Definitive: Oxygen, fluid resuscitation, analgesia, continuous monitoring and re-eval

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25
Q

Management of traumatic aortic disruption

A

HR and BP control with short-acting BB (ie. esmolol) or CCB (ie. nicardipine)
If that fails, nitroglycerin or nitroprusside can be added
C/I in hypotensive pt

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26
Q

Crushing injury to chest or traumatic asphyxia signs

A

Upper torso/facial/arm plethora with petechia secondary to acute temporary compression of SVC
Massive swelling and cerebral edema may be present

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27
Q

Radiographic signs of blunt aortic injury

A 
Widened mediastinum
Obliteration of aortic knob
Devation of trachea to right 
Depression of left mainstem bronchus
Elevation of right mainstem bronchus 
Obliteration of space btwn pulmonary artery and aorta 
Devation of esophagus to right 
Widened paratracheal stripe 
Widened paraspinal interfaces
Presence of a pleural or apical cap
Left hemothorax 
Fractures of 1st/2nd rib or scapula
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28
Q

Signs of pelvic #

A 
Ruptured urethra (scrotal hematoma or blood at urethral meatus)
Limb length discrepancy 
Rotational deformity of leg without obvious #
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29
Q

Pelvic # initial mgmt

A
  1. Hemorrhage control - stabilize with sheet/binder, internal rotation of lower extremities, ultimate angiographic embolization or OR
  2. Fluid resuscitation
  3. Early transfer
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30
Q

DPL indication

A

Hemodynamically abnormal patient with blunt abdominal trauma and patients with penetrating trauma with multiple cavitary or tangential trajectories
Note: All hemodynamically abnormal patients (esp those with peritonitis or evisceration with penetrating abdominal trauma should have lap)

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31
Q

Indications for laparotomy in adult victims of blunt trauma

A

Hemodynamically abnormal with +ve FAST/DPL or suspected abdominal injury
+ve CT and hemodynamic status not improving
Free/extra-luminal air on imaging
Evidence of diaphragm rupture
Evidence of intraperitoneal bladder rupture
Peritonitis

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32
Q

SBP goals in head injury

A

> /= 100 for 50-69yo, >/=110mmHg for pts 15-49 or older than 70, may decrease mortality and improve outcomes

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33
Q

Ct head shift of ___ or. greater indicates need for surgery to evacuate blood clot or contusion causing shift

A

5mm

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34
Q

Hyperventilation and CO2

A

REDUCES CO2

If PaCO2 <30mmHg –> high risk of cerebral vasoconstriction

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35
Q

Hypoventilation and CO2

A

Increases Co2

If PaCO2 >45mmHg –> high risk of promoting vasodilation and increasing ICP

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36
Q

Normal PaCo2

A

35-45mmHg

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37
Q

Hyperventilation for brain jury

A

Use In moderation and for as limited time as possible
Try to keep at 35, but brief periods of 25-35 may be needed
Avoid PCO2 <28mmHg

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38
Q

Mannitol dose

A

Typically 20% solution (20g per 100mL)

1g/kg bolus over 5min

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39
Q

When to use mannitol

A

Acute Neuro deterioration in a EUVOLEMIC patient –> give mannitol and transfer to CT scanner or directly to OR if lesion is already identified
Does not work in hypovolemic pt b/c it is an osmotic diuretic

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40
Q

Epidural hematoma

A

Skull # lacerate meningeal arteries –> hemorrhage in epidural space
Most common = middle meningeal artery over temporal fossa
Lenticulate or biconvex on CT
Causes same side pupil dilation and opposite side weakness

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41
Q

Classic sign of uncal herniation

A

Ipsilateral pupillary dilation with contralateral hemiparesis

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42
Q

Normal ICP

A

10mmHg

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43
Q

Moderate brain injury

A

GCS 9-12

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44
Q

Severe brain injury

A

GCS 3-8

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45
Q

Subdural hematoma

A

Shearing of blood vessels on cerebral cortex

Appears to cover cerebral surface on CT

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46
Q

Systolic BP guidelines for TBI management

A

SBP >/= 100 aged 50-69

>/=110 aged 15-45 or >70yo

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47
Q

Antiplatelet reversal

A

Tx: platelets

Consider desmopressin acetate

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48
Q

Warfarin reversal

A

Vitamin K, FFP

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49
Q

Heparin reversal

A

Protamine sulfate

Monitor PTT

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50
Q

LMWH reversal

A

Protamine sulfate

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51
Q

NOAC reversal

A

N/A

May benefit from prothrombin completely concentrate

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52
Q

Hypertonic saline for ICP

A

Reduces elevated ICP
May be preferred in patients with systemic hypotension
Does not lower ICP in hypovolemic patients

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53
Q

Posttraumatic epilepsy tx

A

Phenytoin and fosphenytoin in acute phase
Add valium or Ativan if necessary
Prophylactic use of anticonvulsant is NOT recommended

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54
Q

Brain death definition

A

GCS 3
Nonreactive pupils
Absent brainstem reflexes (dolls eyes, no gag, oculocephalic, corneal)
No spontaneous ventilatory effort on formal apnea testing
Absence of confounding factors (ie. EtOH or drug intoxication or hypothermia)

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55
Q

Essentials in maintaining CPP

A

Sedation
Mannitol
IV hydration

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56
Q

Neurogenic shock

A

Bradycardia, low BP, Neuro deficit on exam and warm extremities
Associated w/ injuries above T6 due to descending sympathetic fibres from upper thoracic spinal cord that help maintain tone of vasculature and HR

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57
Q

Corticospinal tract

A

Anterior and lateral cord
Controls motor power on same side of body
Test via voluntary muscle contractions or involuntary response to painful stimuli

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58
Q

Spinothalamic tract

A

Anteriorlateral cord
Transmits pain and temperature sensation from opposite side of body
Test via pinprick

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59
Q

Dorsal columns

A

Posteromedial cord
Carries proprioception, vibration and some light-touch sensation from same side of body
Test via position sense in toes and fingers or vibration sense using tuning fork

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60
Q

Brown Sequard Syndrome

A

Hemisection of cord usually due to penetrating trauma
Ipsilateral motor loss and loss of position sense, contralateral loss of pain and temperature sensation 1-2 levels below level of injury

61
Q

Chance fracture

A

Transverse fractures through vertebral body
Caused by forward flexion, often by MVA when passenger using a lap belt only
Can be a/w retroperitoneal and abdominal visceral injuries

62
Q

Central cord syndrome

A

Disproportionately greater loss of motor strength in upper extremities than lower, with varying degrees of sensory

63
Q

Anterior cord syndrome

A

Injury to motor and sensory pathways in anterior parts of cord, characterized by paraplegia and bilateral loss of pain and temperature sensation

64
Q

Area of greatest flexion and extension of c-spine

A

C5-6

Most common level of subluxation

65
Q

Most common level of c-spine #

66
Q

Neurogenic shock mgmt

A

Moderate IVF resuscitation
Vasopressors
Atropine may be needed

67
Q

Spinal shock

A

Flaccidity and loss of reflexes immediately after SCI

68
Q

C5 innervation

69
Q

C6 innervation

70
Q

C7 innervation

A

Middle finger

71
Q

C8 innervation

A

Little finger

72
Q

T4 innervation

73
Q

T8 innervation

A

Xiphisternum

74
Q

T10 innervation

75
Q

T12 innervation

A

Symphisis pubis

76
Q

L4 innervation

A

Medial calf

77
Q

L5 innervation

A

1st web space

78
Q

S1 innervation

A

Lateral foot

79
Q

S3 innervation

A

Ischial tuberosity area

80
Q

S4 and S5 innervation

A

Perianal region

81
Q

C5 myotome

82
Q

C6 myotome

A

Wrist extensor

83
Q

C7 myotome

84
Q

C8 myotome

A

Finger flexor

85
Q

T1 myotome

A

Finger abductors

86
Q

L2 myotome

A

Hip flexors

87
Q

L3 myotome

A

Knee flexors

88
Q

L4 myotome

A

Ankle dorsiflexion

89
Q

L5 myotome

A

Long toe extensors

90
Q

S1 myotome

A

Ankle plantars

91
Q

Canadian C-spine rule

A

High risk factors:

  • > 65yo
  • Dangerous mechanism (Fall from >/=1m/5 stairs), axial loading to head, MVC (at high speed (>100km/h), rollover, ejection), motorized recreational vehicle collision, bicycle collision
  • Paresthesias in extremities

IF YES –> RADIOGRAPHY
If NO –> any low risk factors? (simple rear-end, sitting position in ED, ambulatory at any time, delayed onset of neck pain, no midline cervical tenderness) –> YES –> able to rotate neck 45 deg left and right? –> YES –> no radiography, if NO –> radiography

92
Q

NEXUS criteria for c-spine criteria

A

Meets ALL low risk criteria

  • No posterior midline cervical spine tenderness
  • No evidence of intoxication
  • Normal level of alertness
  • No focal neuro deficit
  • No painful distracting injuries
NEXUS: 
Neuro deficit (lack of) 
EtOH
eXtreme distracting injuries 
Unable to provide hx (altered LOC)
Spinal tenderness
93
Q

ABI indicative of abnormal arterial flow secondary to injury or PVD

94
Q

Stepwise approach to controlling arterial bleeding

A

Manual pressure
Pressure dressing
Manual pressure to artery proximal to injury
Manual tourniquet or pneumatic tourniquet directly to skin

95
Q

Typical ancef order for open #

A

2g ancef q8h

96
Q

If pt is allergic to penicillins and require IV abx for open #

A

600mg clinda q8h

97
Q

Signs and symptoms of compartment syndrom

A

Pain greater then expected to injury
Pain on passive stretch of affected muscle
Tense swelling of affected compartment
Paresthesias or altered sensation distal to affected compartment

98
Q

Primary survey of patients with burns

A

Stop the burning process
Ensure airway and ventilatory adequacy
Manage circulation

99
Q

Steps to stop burning process

A

Remove patient’s clothing
Prevent overexposure and hypothermia
Recognize possibility of wound contamination
Brush any dry chemical powders from the wound and rinse

100
Q

Factors that increase risk of upper airway obstruction

A 
Increasing burn size and depth
Burns to head and face
Inhalation injury 
Burns inside mouth
Age - children are higher risk
101
Q

Preferable diameter for endotracheal tube in burn patients

A

8mm (minimum 7.5mm for adults)

Larger to allow clearing of secretions

102
Q

CO exposure in burn pts

A

Assume in pts burned in enclosed areas
Provide 100% O2 via non-rebreather
Obtain baseline carboxyhemoglobin levels

103
Q

Inhalation injury dx

A

Exposure to combustible agent and signs of exposure to smoke in lower airway, below vocal cords, seen on broncoscopy

104
Q

When to provide burn resuscitation fluids

A

Deep partial and full-thickness burns > 20% total BSA

105
Q

Fluid type for resuscitation in burn patients

A

Warmed isotonic crystalloid

106
Q

Initial fluids rate for adults with 2nd deg and 3rd deg burns

A 
2 mL lactated ringer's x pt's body weight in kg x % TBSA
1/2 in first 8h
1/2 over next 16h 
Adjust fluids based on UO 
Titrate to desired UO rate 
Avoid fluid bolus
107
Q

Initial fluid rate for Peds pts with 2nd and 3rd deg burns

A

3mL lactated ringer’s x patient’s body weight in kg x %TBSA
1/2 in first 8h
1/2 over next 16h
Children <30kg: Add maintenance fluids of 5% dextrose in water
Titrate to desired UO rate
Avoid fluid bolus

108
Q

Rule of 9s - Head (Peds)

A

9% scalp/head, 9% face

109
Q

Rule of 9s - Arms (Peds)

A

4.5% front, 4.5% back each arm

110
Q

Rule of 9s - Back (Peds)

111
Q

Rule of 9s - Anterior torso (peds)

112
Q

Rule of 9s - Bum (Peds)

A

2.5% each butt cheek

113
Q

Rule of 9s - legs (peds)

A

7% front, 7% back each leg

114
Q

Rule of 9s - Head (Adults)

A

4.5% face, 4.5% scalp

115
Q

Rule of 9s - Back (Adults)

116
Q

Rule of 9s - Anterior torso (Adults)

117
Q

Rule of 9s - Arms (Adults)

A

4.5% front, 4.5% back, each arm

118
Q

Rule of 9s - Groin (adults)

119
Q

Rule of 9s - Legs (Adults)

A

9% front, 9% back, each leg

120
Q

Rule of 9s - Palmar surface (Adults)

121
Q

Superficial burn

A

Erythema, pain, no blisters, no fluid replacement needed

122
Q

Superficial partial thickness burn

A

Moist, painfully hypersensitive, possible blisters, pink, blanches to touch

123
Q

Deep partial thickness burn

A

Dry, not painful, possible blisters, red/mottled, does not blanch

124
Q

Full thickness burn

A

Leathery appearance, translucent/waxy skin, painless, dry

125
Q

Gastric tube insertion indications for burn patients

A

Pts with N/V or abdominal distention
Pts with burns involving >20% total BSA
Insert and attach to suction prior to transfer

126
Q

Antibiotics and burns

A

Do not administer prophylactic abx in early post-burn period unless required

127
Q

Rhabdomyolysis tx

A

Increase fluids to target UO of 100cc/h –> washes out myoglobin before it settles in
Mannitol (osmotic diuretic) –> increases UO and “washes out” myoglobin

128
Q

Electrical burn tx

A

Airway, breathing, monitor ECG, place bladder catheter

Start tx for suspected myoglobinuria

129
Q

Resuscitation guidelines for electrical burn

A

Adults: 4cc/kg/%TBSA to ensure UO of 100cc/h

Children <30kg: 1-1.5mL/kg/h

130
Q

Tar burn tx

A

Rapid cooling of tar and care to avoid further trauma while removing it
Mineral oil to dissolve tar

131
Q

Frostbite management

A

Stop freezing
Warm blankets
Hot fluids PO
Place injured part in circulating water at constant 40C
Avoid excessive dry heat, do not rub or massage area
Use analgesics and monitor pt’s cardiac status and peripheral perfusion during rewarming

132
Q

Hypothermia definition

A

Core temp <36C

133
Q

Severe hypothermia

A

Core temp <32C

134
Q

How should toes be thawed

A

Moist rewarming

135
Q

Burn shock is secondary to

A

Interstitial loss due to inflammation

136
Q

Formula for estimating weight

A

(2 x age in yrs) + 10

137
Q

Endotracheal tube estimate

A

Size of pt’s external nare or tip of small finger

138
Q

Systolic BP estimate in peds

A

High range systolic = 90 + (age x 2)

Low range systolic = 70 + (age x 2)

139
Q

Diastolic BP estimate in peds

A

2/3 systolic BP

140
Q

Most common cause of cardiac arrest in peds trauma cases

A

Inability to establish patent airway with associated lack of oxygenation and ventilation

141
Q

Drug assisted intubation for peds: Pre-oxygenate

A

Atropine sulfate for <1yo 0.1-0.5mg

142
Q

Drug assisted intubation for peds: Sedation

A

Hypovolemic - etomidate 0.1mg/kg or midazolam HCl0.1mg/kg

Normovolemic - etomidate 0.3mg/kg or midazolam 0.1mg/kg

143
Q

Drug assisted intubation for peds: Paralysis

A

Succinylcholine <10kg: 2mg/kg

Succinylcholine >10kg: 1mg/kg

144
Q

Common causes of deterioration in intubated patients

A 
DOPE 
Dislodgement
Obstruction
Pneumothorax
Equipment failure
145
Q

Needle decompression landmarks in peds

A

2nd intercostal space midclavicular line

146
Q

Bolus rate in peds

147
Q

pRBC transfusion rate peds

148
Q

Primary complication of rib # in elderly

149
Q

Pregnancy and CO2 levels

A

Should be hypocapneic

PaCO2 of 35-40 may indicate impending resp failure

ATLS (1 decks)

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