Chapter 22 Flashcards
What is the most critical concept of ATLS?
Treat the greatest threat to life first
What is the ABCDE mnemonic?
Airway establishment or maintenance with cervical spine protection
Breathing/ensuring adequate ventilation
Circulation/hemorrhage control and maintenance of adequate perfusion pressure
Disability/neurologic status
Exposure/environmental control/injury identification
When should C-spine injury be presumed?
In who sustains injury from a blunt trauma mechanism, any trauma pt who displays an altered LOC, or suffers multiple system trauma
What is a simple way to assess an intact airway?
Asking a simple question
If the pt can speak in sentences with a clear voice, airway is patent
When does a patent airway need to be established and maintained?
Hoarse Stridorous Cannot speak Has garbled speech Does not follow commands
What are considered fractures of the upper airway?
Facial bones
Mandible
Larynx
Trachea
What should occur airway-wise in the obtunded trauma pt?
Jaw-thrust, chin-lift maneuvers, or naso/oropharyngeal airways alleviate obstruction from pharyngeal tissues or the tongue
How is supplemental oxygen applied in an obtunded pt?
Up to 6 L via NC or up to 12 L via NRB
When should a definitive airway be obtained?
If there is any doubt about the pt’s ability to maintain a patent airway and/or ventilate
Or if their GCS is 8 or less
When should an airway device be exchanged for an endotracheal tube?
Trauma pts who present with emergently placed rescue airway devices, such as a laryngeal mask airway (LMA) or an esophageal tracheal combitube
When should an early cricothyroidotomy be performed?
If the airway is not obtainable via other ways, such as in trauma pts with severe obesity, severe maxillofacial bleeding, or facial features
What should occur after the airway is secured?
The function of the chest wall, diaphragm and lungs must be investigated
How is ventilation determined clinically?
Gas exchange at the nose and mouth Chest excursion Palpation Percussion Auscultated breath sounds Capnometry ABG GCS
When can false-positive readings occur in end-tidal CO2?
If the pt recently ingested a CO2-containing beverage like soda or recently received positive pressure ventilation via a BVM
Why should a CXR be obtained after endotracheal intubation?
To confirm appropriate endotracheal tube position within the thoracic inlet, at least 2 cm above the carina, and also to identify chest pathology
Presentation of a tension pneumo
May be present in an unstable pt with unilateral breath sounds, contralateral tracheal deviation, and a significant drop in end-tidal CO2
DDx of PEA
Tension pneumo Tamponade, cardiac Toxins (drug overdose) Thrombosis, coronary Thrombosis, pulmonary embolism Hypothermia Hypoxia Hyper/hypokalemia Hydrogen ion acidosis Hypo/hyperglycemia
What is the most common cause of preventable postinjury death?
When can it be suspected?
Hemorrhage Shock-like sx, including: Altered LOC Skin pallor Rapid, thready pulse
Control of external hemorrhage
Use direct manual pressure
Compression of the proximal palpable pulse either digitally or with a tourniquet
When should one suspect the presence of occult hemorrhage?
In the chest and abdominal cavities, in the soft tissues surrounding a long bone fracture, or in the retroperitoneum of the hypotensive trauma pt
Tx of hemorrhage
A minimum of two large-bore IV catheters should be established, and warm lactated Ringer’s should be administered rapidly
In PEA, who is a poor candidate for a thoracotomy?
Blunt trauma pts
How should pulses be evaluated?
Centrally (carotid or femoral)
Peripherally (radial and dorsalis pedis)
Bilaterally
For quality, rate, and regularity
Pulse-wise, when are pts usually normovolemic?
Pts with full, slow regular pulses, unless they are medicated with beta-adrenergic blockade
What are the corresponding systolic blood pressures for different palpable pulses?
Radial- 80
Femoral-70
Carotid- 60
What should be established for circulation?
continuous intermittent noninvasive blood pressure monitoring and continuous EKG monitoring
Definition of shock
The state of inadequate perfusion of oxygen to end organs and tissues
What should one do if shock persists despite initial volume replacement with 2L of crystalloid fluid?
Blood product administration should be started to augment the resuscitation effort
What is the ratio of blood products recommended?
1:1:1 volume ratio of packed RBCs, FFP, and platelets
What is the most important measure in resuscitation?
Early and repeated assessment of the pt’s response to fluid administration
What should be considered upon completion of the primary survey?
Why?
Placement of a urinary catheter
Urinary output is a sensitive indicator of renal perfusion or GU injury
What should be done prior to transurethral catheterization?
Examination of the rectum and genitalia
When to suspect urethral injury
Blood at the urethral meatus Perineal ecchymosis Blood in the scrotum A high-riding or nonpalpable prostate A pelvic fx
What should one do if a urethral injury is suspected?
A retrograde urethrogram should be performed prior to catheterization
Alternatively, a suprapubic bladder catheterization may be performed
Criteria for declaring pts dead on arrival
Blunt trauma: prehospital CPR >5 mins, age >12 yo, no pulse on arrival
Penetrating trauma: Abdomen, head neck, groin: prehospital CPR >5 min, age >12 yr, no pulse on arrival
Penetrating trauma: chest: prehospital CPR >15 mins, age >12 yo, no pulse on arrival
Child with any of the above who has inhospital CPR >15 mins (open or closed) without pulse
Class I hemorrhagic shock
Less than or equal to 750 mL blood loss Less than or equal to 15% blood volume loss HR <100 Nl BP Nl pulse pressure RR 14-20 Urine output >30 mL/h Slightly anxious Crystalloid fluid replaceDecment
Class II hemorrhagic shock
750-1500 mL blood loss 15-30% blood volume loss HR >100 Nl BP Decreased pulse pressure RR 20-30 Urine output 20-30 mL/h Mildly anxious Crystalloid replacement fluid
Class III hemorrhagic shock
1500-2000 mL blood loss 30-40% blood volume loss HR >120 Decreased BP Decreased pulse pressure RR 30-40 Urine output 5-15 mL/h Anxious, confused Crystalloid and blood replacement fluid
Class IV hemorrhagic shock
>2000 mL blood loss >40% blood volume loss HR >140 Decreased BP Decreased pulse pressure RR >35 Negligible urine output Confused, lethargic Crystalloid and blood replacement fluid
What should be established in the neurologic evaluation?
Pt’s LOC
Pupillary size/reaction
Lateralizing signs
Spinal cord injury level
What can an altered LOC alert the provider to?
Deficiency in oxygenation, ventilation, and/or cerebral perfusion
What should AMS be attributed to if hypoxia and hypotnesion are excluded?
CNS injury until proven otherwise
What is a GCS assessment not designed for?
Not designed to assess for spinal cord injury
How should a spinal cord injury be assessed?
Pt should be asked to move all of their extremities
What may be the source of neurologic impairment and should be excluded?
Hypoglycemia
Alcohol
Narcotics
Other drugs
What should be performed prior to emergent intubation whenever possible?
An adequate assessment of both cognitive and motor/sensory neurologic function
GCS- eye opening
4- spontaneous
3- to speech
2-to pain
1-none
GCS- verbal response
5- oriented 4-confused 3-inappropriate 2- incomprehensible 1-none
GCS- motor score
6- obeys commands 5-localizes to pain 4-withdraws to pain 3-flexion to pain 2-extension to pain 1-none
How is the primary survey completed?
By undressing the trauma pt, cutting away his or her clothing, examining the back by means of log roll by keeping axial spine alignment, and providing warm blankets or a warming convection device to prevent hypothermia
Why is exposure necessary?
To accomplish the full head-to-toe physical examination comprising the secondary survey
When should the secondary survey start?
Once the primary survey is completed, resuscitation is underway, and the trauma pt demonstrates a normalization of vital signs
What are the components of the secondary survey?
A complete medical hx and a head-to-toe PE, including a reassessment of the mnemonic ABCDE are performed
What should occur if a life- or limb-threatening injury is found at the time of the secondary survey?
Temporizing measures (i.e., splinting displaced fxs, suturing a bleeding scalp laceration) should be performed prior to continuing on with the survey
What mnemonic should be used in the secondary survey?
Allergies Medications Past illnesses and surgeries Last meal Events related to the injury
Procedure for the secondary survey PE
Each anatomic area is examined by inspection, palpation, and if necessary, auscultation and percussion
The exam should systematically proceed from the scalp to toes in a routine pattern so as not to skip even areas of low suspicion for injury
Secondary survey of the head and eyes
Examined for direct trauma and foreign bodies
Basilar skull fx is suggested by ecchymosis behind the ears (Battle’s sign) or around the eyes (raccoon eyes), hemotypanum, and drainage of CSF from the nose or ears
Assess visual acuity when possible as well as pupillary size and reactions
Secondary survey of the neck
Examined after removal of the anterior segment of the cervical collar, with in-line stabilization maintained
When can the cervical spine be cleared clinically?
Only in those pts without tenderness through a full range of motion who are awake, alert, and without evidence of intoxication or distracting injuries
What should be done with a pt whose C-spine can’t be cleared?
A CT scan of the entire C-spine is the diagnostic imaging modality of choice to r/o bony c-spine injury
MRI of the c-spine is often needed in addition in order to r/o ligamentous injury prior to C-spine clearance and collar removal
What should be done for penetrating injuries to the neck?
CT has been shown to accurately portray trajectory, and CTA is emerging as an appropriate single modality for injury screening
