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Trauma > ATLS principles > Flashcards

ATLS principles Flashcards

0
Q

Airway (assessment)

A 
Talking
Foreign bodies
Maxilla facial trauma
Neck trauma
GCS
Listen for air entry at the nose, mouth and lung fields
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1
Q

ATLS Procedure

A 
Preparation
Triage
Primary survey
Resuscitation
Adjuncts to primary survey, and resuscitation
Consider need for transferral
Secondary survey
Adjuncts to secondary survey
Continued post resuscitative monitoring and evaluation 
Definitive care
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2
Q

Breathing (assessment)

A

Inspection, including chest rise
Percussion
Palpation
Auscultation

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3
Q

Circulation (assessment)

A 
Blood volume/CO
- GCS
- skin
- pulse
- pulse pressure
External hemorrhage
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4
Q

Disability (assessment)

A

Consciousness/ GCS
Pupils
Lateralising signs
Spinal cord injury

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5
Q

Adjuncts to the primary survey

A 
Urinary and gastric catheters 
ABG
Ventilatory rate
Sats 
Blood pressure
ECG
Chest and pelvis X-ray
Fast scan
DPL
Urinalysis
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6
Q

Breathing (resuscitation)

A

Needle decompression
Ventilation
Oxygenation (and sats monitoring)

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7
Q

Airway (resuscitation)

A

Chin lift and jaw thrust
Intermediate airways
Intubation
Surgical airway

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8
Q

Circulation (resuscitation)

A 
2 large bore IV lines (min 16 gauge)
Fluid resuscitation (Ringer's lactate)
Control hemorrhage
Transfusion
Blood tests (Hb, crossmatch, pregnancy)
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9
Q

Fluid resuscitation

A

Ringer’s lactate or normal saline

Loading dose: 1-2L (adults); 20ml/kg (kinders) - observe 3 to 1 rule

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10
Q

Blood transfusion - options

A

Depends on response to fluid resuscitation:
Rapid - order fully cross matched blood if necessary (1 hour)
Transient - typed blood (10 minutes)
Poor - O negative, although typed blood preferred if possible (immediate)

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11
Q

Secondary survey

A 
History: AMPLE  (BEST) and MIST
Head and eyes
Neck
Thorax
Abdomen
Perineum, vagina and rectum
Musculoskeletal
Neurological
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12
Q

Post resuscitative monitoring

A 
Vital signs
Urinary output (0.5ml/kg/hour in adults, 1ml/kg/hour in paeds)
ABG
Cardiac monitoring devices
Pulse oximetry
End tidal volume carbon dioxide
Analgesia and anxiolysis
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13
Q

Adjuncts to secondary survey

A 
X-ray
CT
Urography
Angiography
Specialized ultrasound 
Bloods (Hb, U&E, b-hCG, BAC, amylase, INR, compat, troponin)
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14
Q

Circulation (monitoring)

A

BP, pulse pressure, and pulse rate suggest perfusion is returning
Urine output and CVP are better indicators
- 0.5ml/kg/hour (adults)
- 1ml/kg/hour (kinders)
- 2ml/kg/hour (infants)
Lactate and base excess give an indication of severity of shock
Hematocrit, Hb
CNS function and skin colour may also be applied as markers of recovery

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15
Q

Airway and breathing (monitoring)

A

Pulse oximetry
Respiratory rate
ABG

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16
Q

Thoracic trauma - primary survey

A

Airway obstruction - control airway with c-spine protection
Tension pneumothorax - immediate decompression
Open pneumothorax (wound >2/3 diameter of trachea - 1.5c,) - flutter valve dressing
Flail chest and pulmonary contusion - judicious use of fluids, analgesia, intubation and ventilation
Massive hemothorax - initial drainage, consultation with surgeon for thoracotomy
Cardiac tamponade - thoracotomy, with pericardiocentesis as a temporizing manouevre

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17
Q

Thoracic trauma - secondary survey

A

Simple pneumothorax - tube thoracostomy
Hemothorax - tube thoracostomy
Pulmonary contusion - judicious fluid resuscitation and selective intubation
Tracheobronchial tree injury - operative repair
Blunt cardiac injury
Traumatic aortic disruption - surgical consult
Traumatic diaphragmatic disruption - laparotomy
Blunt esophageal rupture - surgical consult
Fracture of first three ribs, sternum, or thoracic vertebrae
Blunt cardiac injury

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18
Q

Manifestations of severe thoracic trauma

A

Subcutaneous emphysema - airway or lung injury
Crush injuries (petechia and plethora of the head, neck and upper torso) - brain injury and cerebral edema
Injuries to upper 3 ribs, scapulae and sternum - underlying head, spine and cardiothoracic injury

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19
Q

Indications for thoracotomy

A 
Cardiac tamponade
Hemothorax
Tracheobronchial injury
Aortic rupture
Esophageal rupture
SBP < 70 despite adequate resuscitation
Diminished peripheral pulses with thoracic inlet injury
20
Q

Indications for ER thoracotomy

A

Cardiac arrest in penetrating injury

SBP < 70 despite active resuscitation in any injury

21
Q

Indications for operative management of hemothorax

A

> 1000-1500ml blood immediately drained
240ml/hour for 4 hours
100ml/hour for 10 hours
If blood transfusion is required

22
Q

Diagnostic peritoneal lavage - method

A

If gross blood (>10ml) or gastrointestinal content not aspirated, perform lavage:
- 1000ml warmed saline (10ml/kg in kinders)
- ensure adequate mixing
- withdraw, inspect for obvious blood or gastric content
- laboratory tests if microscopic matter suspected:
>100000 RBCs/ mm^3
>500 WBCs/mm^3
Bacteria on Gram staining
Raised amylase

23
Q

Indications for chest tube drain in the trauma patient

A 
Pneumothorax
Hemothorax
Patient transfer, especially by air
General anesthesia
Positive pressure ventilation
24
Q

Life saving measures in burns

A

Identify and manage inhalation injury
Stop the burning (remove clothing and jewellery, cold water, wash chemicals)
IV lines

25
Q

Indications for laparotomy

A

Hemodynamic abnormality in abdominal trauma
Clinical evidence of intraperitoneal bleeding
Positive FAST scan
Positive DPL
Gunshot wound (high velocity, trams abdominal, close range shotgun, peppering)
Peritoneal irritation (indicating rupture of hollow viscus)
Signs of fascial penetration
Positive finding on wound exploration
Evisceration
Gastrointestinal or genitourinary bleeding
Free air, retroperitoneal air, rupture of hemidiaphragm
Positive finding on CT

26
Q

Assessment of burns

A

History
Body surface area affected
Depth of burns

27
Q

Body surface area in burns

A

Adults

  • rule of 9: head, each upper limb, anterior lower limb, posterior limb
  • 18%: anterior torso, posterior torso
  • 1%: perineum

Kinders

  • rule of 9: anterior head, posterior head, each upper limb
  • 18%: anterior torso, posterior torso (each butt cheek 2.5%)
  • 7%: anterior lower limb, posterior lower limb

Inhalation injury - 10-20%

28
Q

Burn depth

A

1st degree: erythema, pain, no vesicles
2nd degree: erythema or mottled, swelling and vesicles, wet and exudative, painfully sensitive
3rd degree: dark, leathery, dry, waxy white, mottled, translucent, painless

29
Q

Primary and secondary survey conditions in burns

A

Primary survey:

  • inhalation injury
  • chemical injury to lungs
  • CO poisoning
  • fluids: 2-4ml/kg/%BSA, half in first 8hrs after injury, half in next 16hrs

Secondary survey:

  • physical examination
  • documentation
  • baseline investigations (CXR, FBC, U&E, glucose, HbCO, compat, ABG, BhCG)
  • wound care
  • antibiotics as indicated
  • analgesia
  • tetanus prophylaxis
  • nasogastric tube
  • peripheral circulation (remove constricting clothing and jewelry, assess peripheral perfusion, escharotomy and fasciotomy as indicated)
30
Q

Special considerations in the primary survey of a child

A

Airway: position, alternative insertion of oropharyngeal airway contraindicated, atropine prior intubation, needle cricothyroidotomy
Breathing: increased risk of barotrauma (tidal volume 6-8ml/kg); smaller chest tube and needle for decompression
Circulation: occult intracranial or intraabdominal hemorrhage, subtle signs of shock, increased compensatory ability, 20ml/kg fluid boluses, 10ml/kg RBCs, intraosseous infusion, urine output
Disability: increased compliance of bones means fewer fractures
Thermoregulation: increased surface area

31
Q

Acute deterioration of the intubated child

A

Dislodgement of endotracheal tube
Obstruction of endotracheal tube
Tension pneumothorax
Equipment failure

32
Q

Pediatric verbal score

A 
5 - appropriate words, social smile, fixes and follows
4 - cries, but consolable
3 - persistently irritable
2 - restless, agitated
1 - none
33
Q

Resuscitation, monitoring, and re-evaluation

A

Oxygen saturation monitor applied
2 wide bore lines, Ringers lactate IVI at maximum speed
Arterial blood gas collected
ECG monitor connected
Logroll, rectal and perineal examination. While logrolling, a rapid secondary survey of the back can be performed
Remove all clothing and then cover
Urinary catheter if perineum intact
Nasogastric (or orogastric) tube if required
Analgesia and sedation
X-ray chest (all cases) and pelvis(in blunt trauma)
Repeat the Primary Survey to re-evaluate the response to resuscitation

34
Q

Clinically clearing C-spine

A

Patient fully awake and orientated (co-operative)
No abnormal neurology related to spinal trauma
No discomfort/pain related to spinal column
No distracting injury in the vicinity, e.g. above clavicle, paraspinal area
No tenderness, step-deformities, bruising or induration over spine
Collar and other immobilizing devices removed, and patient capable of gently moving each element without any discomfort or new neurology

If it: CT or X-ray (lateral, AP, and open mouth)

35
Q

Injuries in blunt abdominal trauma

A 
Liver, spleen, kidney
Small bowel rupture
Diaphragm rupture
Duodenum and pancreas
Bladder rupture
Retroperitoneal hematoma
36
Q

Injuries in stab abdomen

A

Liver
Small bowel
Colon
Diaphragm

37
Q

Indications for intubation

A

SBP < 70mmHg
GCS < 8
Burns inhalation injury
Clinically compromised airway

38
Q

Indication for thoracotomy in hemothorax

A

Chest drains >1.5L initially
Chest drains >200ml/h for 4 hours
Chest drains >100ml/h for 10 hours
Repeat CXR reveals persistent hemothorax

39
Q

Special considerations in burns

A

Circumferential burns - neurovascular compromise (escharotomy)
CO inhalation - monitor CO level, 100% oxygen, intubate and ventilate
Chemical burns - brush dry chemicals off, rinse wet chemicals
Electrical burns - rhabdomyolysis, demyelinisation, fractures, and arrhythmia

40
Q

Triage sieve

A 
Injured
Walking
Breathing
Resp rate
Circulation (pulse, capillary refill)

Green - walking
Red - only breathing with airway manoeuvre, RR > 30 or 120, capillary refill >2 seconds
Yellow - not walking, but not red

41
Q

Triage sort

A

GCS
Resp rate
SBP

Green

  • SBP >90
  • RR 10-30
  • GCS 13-15

Yellow - ONE of

  • SBP 75-90
  • RR > 30
  • GCS 9-12

Red - not green or yellow

42
Q

Management goals in head injury

A 
MAP > 90
Normovolemia
PO2 80-100
SATS > 95
PCO2 30-35
Mannitol
Temp 35-37
Phenytoin 
No steroids
Early enteral feeding
Sucralfate
DVT prophylaxis (NB brain bleeds)
Pressure sore prevention
Drain mass lesions
\+/- ICP monitoring
43
Q

Musculoskeletal injuries

A

Life threatening

  • unstable pelvic fracture
  • major arterial hemorrhage
  • crush syndrome

Limb threatening

  • open fractures
  • joint injuries
  • vascular injuries
  • compartment syndrome
  • neurological injury

Other

  • contusion and laceration
  • fracture
  • joint injury
44
Q

Secondary survey of extremity injuries

A

Look, feel and move - assess skin, bone, muscle, neurovascular, and joints

Adjuncts:
Pelvic X-rays 
X rays of injured limbs
U/S for large hematomas
Assess perfusion
Full neurological examination
Differential Doppler pressures
Compartment pressures
Angiography and arteriography
45
Q

Chest drain cocktail

A

400ml saline

1000iu heparin

46
Q

Chest drain removal - indications

A

No bubbling for 24 hours

Draining les than 150ml per day

47
Q

Indications for chest drain in simple pneumothorax

A 
>2 cm lung collapse
Respiratory distress
General anesthetic
Positive pressure ventilation
Transfer

Trauma (5 decks)

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