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MRCS: ATLS > Basics > Flashcards

Basics Flashcards

1
Q

What is the distribution of mortality from trauma?

A

Trimodal

1) Immediate (50% of all deaths)
- Massive brain injuries
- Great vessel injuries
- Airway occlusion
- Cord transection
- Exanguination

2) Early (30% of all deaths) - minutes to hours “golden hour”
- Uncontrolled blood loss
- 2ndry CNS damage

3) Late Phase (20%) - days to weeks
- Sepsis
- MODS

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2
Q

In deceleration injuries, which structures are at risk of being avulsed from the site at which they are anchored?

A

1) C - spine
2) Brain
3) Main Bronchus
4) Thoracic Aorta
5) Renal vessels
6) Transverse Mesocolon

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3
Q

What is a crush injury?

A

Injury + sustained compression of tissues

causing ischaemia & muscle necrosis

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4
Q

What are the complications of crush injuries?

A

1) Fluid loss
2) Rhabdomyolysis - myoglobin release from muscles
3) DIC
4) Release of toxins from muscles
5) Acute tubular necrosis
6) Renal failure

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5
Q

In trauma, which type of shock is the cause of the hypotension (until proven otherwise)?

A

Hypovolaemia

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6
Q

Cellular destruction in hypovolaemic shock, what changes does the acidosis cause?

A

1) Disruption of Na+/K+ pump

Na+ accumulates => cell swells => intercellular spaces enlarge => fluid 3rd spacing => disruption of organ integrity

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7
Q

How do you calculate cardiac output?

A

CO = SV x HR (normal is 6L/min)

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8
Q

How do you calculate SBP?

A

SBP = DBP + PP

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9
Q

In Hypovolaemic shock, what is seen in the following parameters?

1) HR
2) CVP/PAOP
3) CO
4) SV
5) SVR

A

1) HR - Increased
2) CVP/PAOP - Decreased
3) CO - Decreased
4) SV - Decreased
5) SVR - Increased

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10
Q

In Cardiogenic shock, what is seen in the following parameters?

1) HR
2) CVP/PAOP
3) CO
4) SV
5) SVR

A

1) HR - Increased
2) CVP/PAOP - Increased
3) CO - Decreased
4) SV - Decreased
5) SVR - Increased

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11
Q

In Septic shock, what is seen in the following parameters?

1) HR
2) CVP/PAOP
3) CO
4) SV
5) SVR

A

1) HR - Increased
2) CVP/PAOP - Decreased
3) CO - Increased
4) SV - Decreased
5) SVR - Decreased

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12
Q

In cardiac tamponade shock, what is seen in the following parameters?

1) HR
2) CVP/PAOP
3) CO
4) SV
5) SVR

A

1) HR - Increased
2) CVP/PAOP - VERY Increased
3) CO - Decreased
4) SV - Decreased
5) SVR - Increased

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13
Q

In neurogenic shock, what is seen in the following parameters?

1) HR
2) CVP/PAOP
3) CO
4) SV
5) SVR

A

1) HR - Decreased
2) CVP/PAOP - -
3) CO - Decreased
4) SV - -
5) SVR - Decreased

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14
Q

What are the main features of class 1 shock?

A

Volume loss 0-750mls
15% loss
Restless
BE 0 - -2

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15
Q

What are the main features of class 2 shock?

A 
Volume loss 750-1500mls
15-30% loss
HR> 100
Pulse Pressure Decreased
Urine 20-30mls/h
RR 20-30
Anxious
BE -2 - -6
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16
Q

What are the main features of class 3 shock?

A 
Volume loss 1500-2000mls
30-40% loss
HR> 120
BP Decreased
Pulse pressure Decreased
Urine 5 - 15ml/h
RR 30-40
Anxious/Confused
BE -6 - -10
Must give BLOOD
17
Q

What are the main features of class 4 shock?

A 
Volume loss >2000mls
>40% loss
HR> 140
BP Decreased
Pulse Pressure Decreased
Urine Anuric
RR >40
Confused/Lethargic
BE > -10
Must give BLOOD
18
Q

What is the immediate management of hypovolaemic shock?

A

Control bleeding

1) Direct Pressure
2) Elevation of injured limb
3) Head down tilt

Establish IV access - 2 16-gauge cannulas

1) Forearm antecubital veins
2) Cut down to Great Sapehnous vein
3) IO Access for <6yrs kids
* CENTRAL ACCESS ONLY WHEN STABLE*

Fluid replacement & identify cause for hypovolaemia

19
Q

Which situations may CVP be falsely raised?

A

1) Tension penumothorax
2) Pericardial Effusion
3) Air embolus
4) MI

20
Q

Which situations can physiological responses be distorted?

A 
B Blockers
Opiates
IHD
Pacemakers
Pre-hospital fluid resus
Pneumatic anti-shock garments
Spinal Injury
Head injury
21
Q

What are transient responders?

A

Given fluid bolus and immediately improves => then deteriotates
THINK ONGOING BLOOD LOSS

22
Q

Which of the following parameters can you measure patient response to successful fluid resusitation?

A

1) Pulse
2) BP
3) Skin colour
4) CNS state

23
Q

What metabolic changes are seen initially in hypovolaemic shock?

A

Respiratory alkalosis - due to high RR

24
Q

What metabolic changes are seen later on in hypovolaemic shock?

A

Metabolic acidosis - uncompensated tissue hypoperfusion/insufficient fluid replacement => anaerobic metabolism

On VBG:

  • lower pH
  • progressive base deficit
  • low bicarbonate
25
Q

What spaces can major blood loss be found?

A

1) Chest
2) Abdo
3) Pelvis - use pelvic binder
4) Long bones - use splint
5) On the floor

26
Q

What causes neurogenic shock?

A

Injury to descending sympathetic pathways
(T2-T6 for heart)
Loss of vasomotor tone with pooling in veins
Inability to go into tachycardia

Treat this with selective ionotropes & atropine

27
Q

What is the endocrine response to trauma?

A

Stimulates Ascending reticular formation & limbic system =>

stimulates Hypothylamus =>

Anterior Pituitary => ACTH, GH, Prolactin
Posterior Pituitary => ADH

ACTH => Cortisol & Aldosterone

28
Q

What is the immunological response to trauma?

A

1) Raised Temp
2) Raised WCC
3) Raised IgG

29
Q

Why is there a lucid interval in younger people in extradural bleeds?

A

Expanding haematoma is being accomodated in extradural bleeds

30
Q

Why is there a rapid decompensation in young people after lucid interval?

A

ICP rises as the inner edge of temporal lobe descends into tentorial opening

31
Q

Extradural haematomas are limited by what structure in the skull?

A

Suture lines

32
Q

What is normal ICP?

A

10mmHg

33
Q

What is abnormal ICP?

A

> 20mmHg

34
Q

In the situation of raised ICP, why does muscle weakness manifest?

A

corticospinal tract decompression

35
Q

What is Cushings Triad?

A

1) Decreased RR
2) Decreased HR
3) Widened Pulse Pressure - high systolic & low diastolic

36
Q

How do you measure cerebral perfusion pressure?

A

CCP = MAP - ICP

37
Q

Increased cerebral blood flow is caused by?

A

1) Raised CO2
2) Raised extracellular K+
3) Decreased pO2

38
Q

How do you calculate MAP?

A

(systolic + 2(diastolic))/3

39
Q

How to manage raised ICP (non-surgical management)?

A

1) Maintain normal PCO2 (3.5-4.0)
2) Monitor with ICP bolt & transducer
3) Aim to maintain CPP at 60-70mmHg (fluids/ionotropes)
4) Maintain ICP of 10mmHg with
a) Mannitol
b) Hyperventilation to PCO2 4.5kPa
c) Thiopental infusion
d) Hypothermia
5) Emergency burr holes / craniotomy

MRCS: ATLS (6 decks)

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