ATLS CH 3-4 Flashcards
What are steps one and two in the management of shock?
- Recognize shock
2. identify probable cause of it
What are the types of shock?
- Cardiogenic
- Neurogenic
- Obstructive
- Hypovolemic
- Septic
True or false: for all practical purposes, shock is not the result of an isolated brain injury
True
What is the most common cause of shock in the trauma patient?
Hemorrhage
What percent of blood is in the venous system?
70%
What is the earliest sign of shock?
Tachycardia
Why are vasopressors contraindicated in the management of hemorrhagic shock?
Worsens tissue perfusion
True or false: the presence of shock in an injured patient warrants the immediate involvement of a surgeon
True
What are the two main early indicators of shock?
Tachycardia
Cool extremities
True or false: any injured patient who is cool and tachycardic is in shock until proven otherwise
True
Why is reliance on SBP to determine shock dangerous?
fall late in shock
What is the definition of tachycardia for the following ages:
- Infant
- preschool age
- school to puberty
- adults
- Infant = 160
- preschool age = 140
- school to puberty = 120
- adults = 100
True or false: Hb and HCT correlate well with blood loss until very low levels
False–does not correlate at all with blood loss
What are two major causes of obstructive shock in the trauma patient?
tension PTX
Cardiac tamponade
What are the major causes of cardiogenic shock in the trauma patient?
Myocardial injury
Cardiac tamponade
Air embolus
MI
True or false: most causes of shock respond well to volume resuscitation, at least initially
True
What places in the body can house blood?
Head Chest Abdomen Retroperitoneal space Pelvis Extremities
What sort of injury typically produces cardiac damage? What type of monitoring, in addition to the usual trauma treatment, should the patients receive?
Deceleration injuries
Continuous ECG/monitor
What is the role of CK levels in diagnosing blunt myocardial injury?
Not useful
If a patient has a blunt cardiac injury producing shock, what intervention will be helpful in guiding resuscitation?
CVP monitoring
What is the most common type of injury associated with a cardiac tamponade?
Penetrating injuries
What are the s/sx of cardiac tamponade? (3)
Tachycardia
Muffled heart sounds
dilated, engorged neck veins
How does BP respond to IVFs in cardiac tamponade? Should it be given?
Lower than expected, but still should be given
What is the definitive treatment for a cardiac tamponade?
Thoracotomy–pericardiocentensis is only a temporizing measure
What happens to pulse pressure with hemorrhagic and neurogenic shock respectively?
Hemorrhagic = narrows Neurogenic = no narrowing
What percent of an adult patient’s ideal body weight is blood? Child?
Adult = 7% Child = 8-9%
What are the following for Class I shock:
- Blood loss in mL
- Blood loss %
- Pulse (#)
- SBP (normal, increased or decreased)
- Pulse pressure (normal or decreased)
- Respiratory rate (#)
- Urine output (mL/hr)
- CNS/mental status (how anxious)
- Initial fluid replacement (type)
- Blood loss in mL = up to 750
- Blood loss % = up to 15%
- Pulse = Less than 100
- SBP = Normal
- Pulse pressure = Normal or increased
- Respiratory rate = normal
- Urine output = over 30 mL/hr
- CNS/mental status = Slightly anxious
- Initial fluid replacement = nothing to crystalloids
What are the following for Class II shock:
- Blood loss in mL
- Blood loss %
- Pulse (#)
- SBP (normal, increased or decreased)
- Pulse pressure (normal or decreased)
- Respiratory rate (#)
- Urine output (mL/hr)
- CNS/mental status (how anxious)
- Initial fluid replacement (type)
- Blood loss in mL =750-1000
- Blood loss % = 15-30%
- Pulse = 100-120
- SBP = Normal
- Pulse pressure =decreased
- Respiratory rate = 20-30
- Urine output (mL/hr) = 20-30
- CNS/mental status = Mildly anxious
- Initial fluid replacement = Crystalloid
What are the following for Class III shock:
- Blood loss in mL
- Blood loss %
- Pulse (#)
- SBP (normal, increased or decreased)
- Pulse pressure (normal or decreased)
- Respiratory rate (#)
- Urine output (mL/hr)
- CNS/mental status (how anxious)
- Initial fluid replacement (type)
- Blood loss in mL =1500-2000
- Blood loss % =30-40%
- Pulse =120-140
- SBP =Decreased
- Pulse pressure = Decreased
- Respiratory rate = 30-40
- Urine output (mL/hr) = 5-15
- CNS/mental status =Anxious/confused
- Initial fluid replacement =Crystalloid and blood
What are the following for Class IV shock:
- Blood loss in mL
- Blood loss %
- Pulse (#)
- SBP (normal, increased or decreased)
- Pulse pressure (normal or decreased)
- Respiratory rate (#)
- Urine output (mL/hr)
- CNS/mental status (how anxious)
- Initial fluid replacement (type)
- Blood loss in mL = over 2000
- Blood loss % =over 40%
- Pulse = over 140
- SBP =Decreased
- Pulse pressure =Decreased
- Respiratory rate = over 35
- Urine output (mL/hr) = None
- CNS/mental status =Confused, lethargic
- Initial fluid replacement =Crystalloids and blood
What are the two major contributing factors to volume loss with soft tissue injuries?
Blood loss
Edema from inflammation
How common is gastric dilation in trauma patients, and what are the serious effects this can cause? (3)
- Very common
- Increased vagal tone causes bradycardia, dysrhythmia, or hypotension
- Aspiration
What gauge IVs should be inserted for adult trauma patients?
Two 16 gauge
Are short or long IV lines preferred to get fluids in faster?
Short
In children below what age should IO placement take place before placement of a central line?
6 years
What is the usual bolus dose of IVFs for adults and children respectively? Does this include IVFs given in the prehospital setting?
Adults = 1-2 L Children = 20 mL/kg
Does include prehospital setting
What is the strongest guide to fluid replacement?
Patient response
What happens if blood volume is increased prior to definitive control of bleeding?
Increased bleeding
What happens if only IVFs are used to replace significant volume loss?
Exacerbate acidosis, hypothermia, and coagulopathy
When monitoring fluids replacement, what is an appropriate urinary output in mL/kg/hr for adults and children? Infants?
Adults = 0.5 mL/kg/hr Children = 1 mL/kg/hr Infants = 2 mL/kg/hr
What are the common pH changes that occur early in shock?
Respiratory alkalosis, followed by mild metabolic acidosis
What is the most common cause of metabolic acidosis in trauma patients? Treatment?
Hypovolemia, so give them fluids
True or false: sodium bicarb should not be used to treat metabolic acidosis 2/2 shock
True
Is surgical consultation needed for rapid responders to fluid boluses?
Yes, always
What is the EBL for rapid responders, transient responders, and non-responders to IVF boluses?
Rapid = 10-20 Transient = 20-40% Non = 40%+
If a patient fails to respond to IVFs in the ED, what should be done?
Immediate surgical consultation
What type of blood is indicated for transient vs non responders to fluid boluses?
Transient = crossed Non = O-
When is Ca supplementation needed with blood transfusions?
Massive transfusions for the most part, but watch for s/sx
Does an increase in BP = an increase in cardiac output? Why or why not?
No, because V=IxR, where V = BP, I = CO, and R = SVR
Does pregnant mothers require less or more blood loss to begin to show s/sx of volume loss?
More
What is used to guide fluid resuscitation therapy in patients with pacemakers? Why?
CVP monitoring, since CO is directly related to HR
CVP is equivalent to pressure in what chamber of the heart?
RA
In whom may the CVP be high in, despite significant fluid loss?
COPD pts (cor pulmonale)
What does a minimal rise in CVP with fluid replacement generally mean?
More fluids needed
A decreasing CVP with fluid replacement generally indicates what?
Ongoing fluid loss
An abrupt increase in CVP with fluid replacement generally means what?
Volume replacement is adequate OR cardiac function is compromised
Hyper or hypo adrenalism produces shock?
Hypoadrenalism
How can you detect if injury to the SC joint (posterior displacement) has caused airway obstruction? Treatment?
Listen to upper lung fields, and for stridor
Reduction of the SC joint
What are the warning signs of chest injury causing hypoxia? (3)
Increased RR
Change in breathing pattern
Progressively shallower breaths
What are the 5 major causes of thoracic injuries that impair respiration?
- tension PTX
- Open PTX
- Flail chest
- Pulmonary contusion
- Massive hemothorax
What is the most common cause of tension PTX?
mechanical ventilation with positive pressure
Where is the needle site for darting a tension PTX?
2nd intercostal space in the midclavicular line
Where is the usual location for placement of a chest tube?
5th intercostal space just anterior to the midaxillary line
How often will a 5 cm needle decompress a tension PTX?
50% (may need longer)
What is the best way to assess for a flail chest on physical exam, besides observation of paradoxical chest movement?
Palpation of the area
What is the treatment for a flail chest?
Ensure adequate ventilation
IVFs carefully
narcotics or local anesthetics
Why must you be careful in giving IVFs to a patient with a flail chest without hypotension?
Volume overload will further compromise the patient’s ventilatory status
Both tension pneumothorax and massive hemothorax
are associated with decreased breath sounds on
auscultation. How can you differentiate this on physical exam?
- hemothorax will have dullness to percussion, while tPTX will have hyperresonance
- tracheal deviation often occurs with tPTX
What are the three major insults to circulation that need to be ruled out with chest trauma?
tPTX
Massive hemothorax
Cardiac tamponade
Approximately how much blood is needed to cause a massive hemothorax? (% or in mL)
1500 mL or 1/3 of patient’s blood
What is the stabilizing treatment for a massive hemothorax?
IVFs and blood, with chest tube placement
What is the size of a typical chest tube for a hemothorax?
36-40 french
What amount of blood out of a chest tube indicates the need for an emergent thoracotomy?
1500 mL
What rate of blood loss from a hemothorax (not immediate output) indicates the need for a thoracotomy?
200 mL/hr for 2-4 hours)
What, besides the amount of initial blood loss and rate of blood loss from a hemothorax, indicates the need for a thoracotomy?
Clinical response to resuscitation/blood products
True or false: the color of the blood coming out of a hemothorax indicating either a venous or arterial bleed, is a good indicator for the need for emergent thoracotomy
False–not reliable
Who makes the ultimate call to do a thoracotomy?
Surgeon
What are the boundaries on the chest and back that, if penetrated by a sharp object, indicate the possibility of penetrating the great vessels?
Nipple line on front
Scapula line on back
What are the components of Beck’s triad?
- Venous pressure elevation
- Decline in arterial pressure
- Muffled heart sounds
What is Kussmaul’s sign, and what is it indicative of?
Rise in venous pressure with inspiration indicating cardiac tamponade
Because of the propensity of injured myocardium
to self-seal, aspiration of pericardial blood alone may
temporarily relieve symptoms. Thus if a patient respond well to pericardiocentesis, can they be observed and managed supportively?
No–all patients with acute tamponade and a positive pericardiocentesis will require surgery to examine the heart and repair the injury
When is closed heart massage ineffective for cardiac arrest or PEA?
Hypovolemia
True or false: a surgeon is needed to perform an ED thoracotomy
True
If a patient in the prehospital setting suffers a penetrating chest wound and there is no pulse and no signs of life, should further resuscitation attempts be made?
No
What are the signs of life used to determine if further resuscitation attempts should be made? (3)
Reactive pupils
Organized ECG rhythm
Spontaneous movement
What are the four therapeutic maneuvers that can be accomplished with a thoracotomy?
- Evacuation of pericardial tamponade
- Direct control of exsanguinating hemorrhage
- Open cardiac massage
- Cross clamping of descending aorta
What is the goal of cross clamping the aorta?
Slow blood loss below the diaphragm, and increase perfusion of the heart and brain
Which ribs and other bone that if broken signify significant force has been encountered? What diagnoses should be entertained (3)?
- 1st or 2nd rib or scapula
- Tracheobronchial injury, aortic disruption, and head/neck injuries
What are the monitoring and imaging orders that should be placed for patients with significant chest trauma?
- pulse ox
- CXR
- ECG
- ABG
If a patient sustains a traumatic PTX, what two things should be avoided until a chest tube is placed?
Avoid sedation and positive pressure ventilation
What vessels are usually responsible for a small (less than 1500 mL) hemothorax?
Internal mammary or intercostal vessel
What are the longer term effects of an untreated hemothorax?
- Lung entrapment
- Empyema
True or false: pulmonary contusion can occur without a rib fracture
True, but it usually is
How fast can pulmonary contusions manifest?
Fast or very slowly
What are the signs of a pulmonary contusion?
Decrease in PaO2 or oxygen sat lower than 90%
What is the treatment for a pulmonary contusion?
Supportive to Intubation and PPV
What are the s/sx of tracheobronchial tree disruption? (3)
Hemoptysis
SQ emphysema
tension PTX
What happens when you place a chest tube with a tracheobronchial disruption?
Inadequate reexpansion of the lung
What is the definitive way to diagnose a tracheobronchial disruption?
Bronchoscopy
How do you stabilize a tracheobronchial disruption?
Intubate the intact bronchus
Chest tubes
What are the sequelae of cardiac contusion?
- hypotension
- dysrhythmias
- 2D echo
How long must patients with ECG changes due to cardiac contusion be on the monitor for?
24 hours
What is the common cause of aortic disruption, and where anatomically does this occur?
Sudden deceleration injuries
Ligamentum arteriosum
If you are to survive an aortic disruption, what is usually true?
Disruption contained by a hematoma
There are no specific s/sx of an aortic disruption. What is used to diagnose one?
CXR and a high index of suspicion
What may happen with the trachea on CXR with an aortic disruption? (1)
Deviated to the right
What may happen with the bronchi on CXR with an aortic disruption? (2)
Depression of left mainstem
Elevation of right mainstem
What may happen with the esophagus on CXR with an aortic disruption?
Deviation to the right
What bones, if broken, should prompt evaluation of aortic disruption?
first of second rib or scapula
What imaging test can assess for aortic disruption?
CT
Why do diaphragmatic injuries typically occur on the left side?
Liver protects the right side somewhat
How do you assess for a diaphragmatic injury?
CXR, followed by NG tube placement
What is the definitive means to diagnose a diaphragmatic injury?
Upper GI series with contrast
Peritoneal lavage fluid from a chest tube indicates what pathology?
Diaphragmatic injury
What is the usual type of trauma that causes esophageal rupture?
Penetrating injury
Blunt injury where can produce esophageal rupture? Why?
- Epigastric area
- Forceful expulsion of gastric contents upwards results in tear in esophagus
How is esophageal rupture typically diagnosed?
PTX or hemothorax with pain out of proportion to exam
What should be done if SQ emphysema is present on one side of the chest and you plan on intubating?
Chest tube on that side
Sternal fractures should prompt entertaining what diagnoses?
Cardiac or pulmonary contusion
The older you are, the more brittle bones are. What does this say about rib fractures in young patients compared to older ones?
More force is required
