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A1 > ATLS CH 3-4 > Flashcards

ATLS CH 3-4 Flashcards

1
Q

What are steps one and two in the management of shock?

A
  1. Recognize shock

2. identify probable cause of it

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2
Q

What are the types of shock?

A
  • Cardiogenic
  • Neurogenic
  • Obstructive
  • Hypovolemic
  • Septic
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3
Q

True or false: for all practical purposes, shock is not the result of an isolated brain injury

A

True

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4
Q

What is the most common cause of shock in the trauma patient?

A

Hemorrhage

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5
Q

What percent of blood is in the venous system?

A

70%

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6
Q

What is the earliest sign of shock?

A

Tachycardia

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7
Q

Why are vasopressors contraindicated in the management of hemorrhagic shock?

A

Worsens tissue perfusion

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8
Q

True or false: the presence of shock in an injured patient warrants the immediate involvement of a surgeon

A

True

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9
Q

What are the two main early indicators of shock?

A

Tachycardia

Cool extremities

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10
Q

True or false: any injured patient who is cool and tachycardic is in shock until proven otherwise

A

True

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11
Q

Why is reliance on SBP to determine shock dangerous?

A

fall late in shock

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12
Q

What is the definition of tachycardia for the following ages:

  • Infant
  • preschool age
  • school to puberty
  • adults
A
  • Infant = 160
  • preschool age = 140
  • school to puberty = 120
  • adults = 100
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13
Q

True or false: Hb and HCT correlate well with blood loss until very low levels

A

False–does not correlate at all with blood loss

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14
Q

What are two major causes of obstructive shock in the trauma patient?

A

tension PTX

Cardiac tamponade

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15
Q

What are the major causes of cardiogenic shock in the trauma patient?

A

Myocardial injury
Cardiac tamponade
Air embolus
MI

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16
Q

True or false: most causes of shock respond well to volume resuscitation, at least initially

A

True

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17
Q

What places in the body can house blood?

A 
Head
Chest
Abdomen
Retroperitoneal space
Pelvis
Extremities
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18
Q

What sort of injury typically produces cardiac damage? What type of monitoring, in addition to the usual trauma treatment, should the patients receive?

A

Deceleration injuries

Continuous ECG/monitor

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19
Q

What is the role of CK levels in diagnosing blunt myocardial injury?

A

Not useful

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20
Q

If a patient has a blunt cardiac injury producing shock, what intervention will be helpful in guiding resuscitation?

A

CVP monitoring

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21
Q

What is the most common type of injury associated with a cardiac tamponade?

A

Penetrating injuries

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22
Q

What are the s/sx of cardiac tamponade? (3)

A

Tachycardia
Muffled heart sounds
dilated, engorged neck veins

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23
Q

How does BP respond to IVFs in cardiac tamponade? Should it be given?

A

Lower than expected, but still should be given

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24
Q

What is the definitive treatment for a cardiac tamponade?

A

Thoracotomy–pericardiocentensis is only a temporizing measure

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25
Q

What happens to pulse pressure with hemorrhagic and neurogenic shock respectively?

A 
Hemorrhagic = narrows
Neurogenic = no narrowing
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26
Q

What percent of an adult patient’s ideal body weight is blood? Child?

A 
Adult = 7%
Child = 8-9%
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27
Q

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)
A
  • 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
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28
Q

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)
A
  • 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
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29
Q

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)
A
  • 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
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30
Q

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)
A
  • 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
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31
Q

What are the two major contributing factors to volume loss with soft tissue injuries?

A

Blood loss

Edema from inflammation

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32
Q

How common is gastric dilation in trauma patients, and what are the serious effects this can cause? (3)

A
  • Very common
  • Increased vagal tone causes bradycardia, dysrhythmia, or hypotension
  • Aspiration
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33
Q

What gauge IVs should be inserted for adult trauma patients?

A

Two 16 gauge

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34
Q

Are short or long IV lines preferred to get fluids in faster?

A

Short

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35
Q

In children below what age should IO placement take place before placement of a central line?

A

6 years

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36
Q

What is the usual bolus dose of IVFs for adults and children respectively? Does this include IVFs given in the prehospital setting?

A 
Adults = 1-2 L
Children = 20 mL/kg

Does include prehospital setting

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37
Q

What is the strongest guide to fluid replacement?

A

Patient response

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38
Q

What happens if blood volume is increased prior to definitive control of bleeding?

A

Increased bleeding

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39
Q

What happens if only IVFs are used to replace significant volume loss?

A

Exacerbate acidosis, hypothermia, and coagulopathy

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40
Q

When monitoring fluids replacement, what is an appropriate urinary output in mL/kg/hr for adults and children? Infants?

A 
Adults = 0.5 mL/kg/hr
Children = 1 mL/kg/hr
Infants = 2 mL/kg/hr
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41
Q

What are the common pH changes that occur early in shock?

A

Respiratory alkalosis, followed by mild metabolic acidosis

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42
Q

What is the most common cause of metabolic acidosis in trauma patients? Treatment?

A

Hypovolemia, so give them fluids

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43
Q

True or false: sodium bicarb should not be used to treat metabolic acidosis 2/2 shock

A

True

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44
Q

Is surgical consultation needed for rapid responders to fluid boluses?

A

Yes, always

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45
Q

What is the EBL for rapid responders, transient responders, and non-responders to IVF boluses?

A 
Rapid = 10-20
Transient = 20-40%
Non = 40%+
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46
Q

If a patient fails to respond to IVFs in the ED, what should be done?

A

Immediate surgical consultation

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47
Q

What type of blood is indicated for transient vs non responders to fluid boluses?

A 
Transient = crossed
Non = O-
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48
Q

When is Ca supplementation needed with blood transfusions?

A

Massive transfusions for the most part, but watch for s/sx

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49
Q

Does an increase in BP = an increase in cardiac output? Why or why not?

A

No, because V=IxR, where V = BP, I = CO, and R = SVR

50
Q

Does pregnant mothers require less or more blood loss to begin to show s/sx of volume loss?

A

More

51
Q

What is used to guide fluid resuscitation therapy in patients with pacemakers? Why?

A

CVP monitoring, since CO is directly related to HR

52
Q

CVP is equivalent to pressure in what chamber of the heart?

A

RA

53
Q

In whom may the CVP be high in, despite significant fluid loss?

A

COPD pts (cor pulmonale)

54
Q

What does a minimal rise in CVP with fluid replacement generally mean?

A

More fluids needed

55
Q

A decreasing CVP with fluid replacement generally indicates what?

A

Ongoing fluid loss

56
Q

An abrupt increase in CVP with fluid replacement generally means what?

A

Volume replacement is adequate OR cardiac function is compromised

57
Q

Hyper or hypo adrenalism produces shock?

A

Hypoadrenalism

58
Q

How can you detect if injury to the SC joint (posterior displacement) has caused airway obstruction? Treatment?

A

Listen to upper lung fields, and for stridor

Reduction of the SC joint

59
Q

What are the warning signs of chest injury causing hypoxia? (3)

A

Increased RR
Change in breathing pattern
Progressively shallower breaths

60
Q

What are the 5 major causes of thoracic injuries that impair respiration?

A
  • tension PTX
  • Open PTX
  • Flail chest
  • Pulmonary contusion
  • Massive hemothorax
61
Q

What is the most common cause of tension PTX?

A

mechanical ventilation with positive pressure

62
Q

Where is the needle site for darting a tension PTX?

A

2nd intercostal space in the midclavicular line

63
Q

Where is the usual location for placement of a chest tube?

A

5th intercostal space just anterior to the midaxillary line

64
Q

How often will a 5 cm needle decompress a tension PTX?

A

50% (may need longer)

65
Q

What is the best way to assess for a flail chest on physical exam, besides observation of paradoxical chest movement?

A

Palpation of the area

66
Q

What is the treatment for a flail chest?

A

Ensure adequate ventilation
IVFs carefully
narcotics or local anesthetics

67
Q

Why must you be careful in giving IVFs to a patient with a flail chest without hypotension?

A

Volume overload will further compromise the patient’s ventilatory status

68
Q

Both tension pneumothorax and massive hemothorax
are associated with decreased breath sounds on
auscultation. How can you differentiate this on physical exam?

A
  • hemothorax will have dullness to percussion, while tPTX will have hyperresonance
  • tracheal deviation often occurs with tPTX
69
Q

What are the three major insults to circulation that need to be ruled out with chest trauma?

A

tPTX
Massive hemothorax
Cardiac tamponade

70
Q

Approximately how much blood is needed to cause a massive hemothorax? (% or in mL)

A

1500 mL or 1/3 of patient’s blood

71
Q

What is the stabilizing treatment for a massive hemothorax?

A

IVFs and blood, with chest tube placement

72
Q

What is the size of a typical chest tube for a hemothorax?

A

36-40 french

73
Q

What amount of blood out of a chest tube indicates the need for an emergent thoracotomy?

A

1500 mL

74
Q

What rate of blood loss from a hemothorax (not immediate output) indicates the need for a thoracotomy?

A

200 mL/hr for 2-4 hours)

75
Q

What, besides the amount of initial blood loss and rate of blood loss from a hemothorax, indicates the need for a thoracotomy?

A

Clinical response to resuscitation/blood products

76
Q

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

A

False–not reliable

77
Q

Who makes the ultimate call to do a thoracotomy?

A

Surgeon

78
Q

What are the boundaries on the chest and back that, if penetrated by a sharp object, indicate the possibility of penetrating the great vessels?

A

Nipple line on front

Scapula line on back

79
Q

What are the components of Beck’s triad?

A
  • Venous pressure elevation
  • Decline in arterial pressure
  • Muffled heart sounds
80
Q

What is Kussmaul’s sign, and what is it indicative of?

A

Rise in venous pressure with inspiration indicating cardiac tamponade

81
Q

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?

A

No–all patients with acute tamponade and a positive pericardiocentesis will require surgery to examine the heart and repair the injury

82
Q

When is closed heart massage ineffective for cardiac arrest or PEA?

A

Hypovolemia

83
Q

True or false: a surgeon is needed to perform an ED thoracotomy

A

True

84
Q

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?

A

No

85
Q

What are the signs of life used to determine if further resuscitation attempts should be made? (3)

A

Reactive pupils
Organized ECG rhythm
Spontaneous movement

86
Q

What are the four therapeutic maneuvers that can be accomplished with a thoracotomy?

A
  • Evacuation of pericardial tamponade
  • Direct control of exsanguinating hemorrhage
  • Open cardiac massage
  • Cross clamping of descending aorta
87
Q

What is the goal of cross clamping the aorta?

A

Slow blood loss below the diaphragm, and increase perfusion of the heart and brain

88
Q

Which ribs and other bone that if broken signify significant force has been encountered? What diagnoses should be entertained (3)?

A
  • 1st or 2nd rib or scapula

- Tracheobronchial injury, aortic disruption, and head/neck injuries

89
Q

What are the monitoring and imaging orders that should be placed for patients with significant chest trauma?

A
  • pulse ox
  • CXR
  • ECG
  • ABG
90
Q

If a patient sustains a traumatic PTX, what two things should be avoided until a chest tube is placed?

A

Avoid sedation and positive pressure ventilation

91
Q

What vessels are usually responsible for a small (less than 1500 mL) hemothorax?

A

Internal mammary or intercostal vessel

92
Q

What are the longer term effects of an untreated hemothorax?

A
  • Lung entrapment

- Empyema

93
Q

True or false: pulmonary contusion can occur without a rib fracture

A

True, but it usually is

94
Q

How fast can pulmonary contusions manifest?

A

Fast or very slowly

95
Q

What are the signs of a pulmonary contusion?

A

Decrease in PaO2 or oxygen sat lower than 90%

96
Q

What is the treatment for a pulmonary contusion?

A

Supportive to Intubation and PPV

97
Q

What are the s/sx of tracheobronchial tree disruption? (3)

A

Hemoptysis
SQ emphysema
tension PTX

98
Q

What happens when you place a chest tube with a tracheobronchial disruption?

A

Inadequate reexpansion of the lung

99
Q

What is the definitive way to diagnose a tracheobronchial disruption?

A

Bronchoscopy

100
Q

How do you stabilize a tracheobronchial disruption?

A

Intubate the intact bronchus

Chest tubes

101
Q

What are the sequelae of cardiac contusion?

A
  • hypotension
  • dysrhythmias
  • 2D echo
102
Q

How long must patients with ECG changes due to cardiac contusion be on the monitor for?

A

24 hours

103
Q

What is the common cause of aortic disruption, and where anatomically does this occur?

A

Sudden deceleration injuries

Ligamentum arteriosum

104
Q

If you are to survive an aortic disruption, what is usually true?

A

Disruption contained by a hematoma

105
Q

There are no specific s/sx of an aortic disruption. What is used to diagnose one?

A

CXR and a high index of suspicion

106
Q

What may happen with the trachea on CXR with an aortic disruption? (1)

A

Deviated to the right

107
Q

What may happen with the bronchi on CXR with an aortic disruption? (2)

A

Depression of left mainstem

Elevation of right mainstem

108
Q

What may happen with the esophagus on CXR with an aortic disruption?

A

Deviation to the right

109
Q

What bones, if broken, should prompt evaluation of aortic disruption?

A

first of second rib or scapula

110
Q

What imaging test can assess for aortic disruption?

A

CT

111
Q

Why do diaphragmatic injuries typically occur on the left side?

A

Liver protects the right side somewhat

112
Q

How do you assess for a diaphragmatic injury?

A

CXR, followed by NG tube placement

113
Q

What is the definitive means to diagnose a diaphragmatic injury?

A

Upper GI series with contrast

114
Q

Peritoneal lavage fluid from a chest tube indicates what pathology?

A

Diaphragmatic injury

115
Q

What is the usual type of trauma that causes esophageal rupture?

A

Penetrating injury

116
Q

Blunt injury where can produce esophageal rupture? Why?

A
  • Epigastric area

- Forceful expulsion of gastric contents upwards results in tear in esophagus

117
Q

How is esophageal rupture typically diagnosed?

A

PTX or hemothorax with pain out of proportion to exam

118
Q

What should be done if SQ emphysema is present on one side of the chest and you plan on intubating?

A

Chest tube on that side

119
Q

Sternal fractures should prompt entertaining what diagnoses?

A

Cardiac or pulmonary contusion

120
Q

The older you are, the more brittle bones are. What does this say about rib fractures in young patients compared to older ones?

A

More force is required

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