ATLS Flashcards
(149 cards)
1
Q
Most common cause of shock in trauma patient
A
Hemorrhage
2
Q
What to evaluate to assess shock
A
RR
Pulse rate and character
Skin perfusion
Pulse pressure
3
Q
Other causes of shock apart from hemorrhage
A
Cardiogenic
Obstructive
Septic
Neurogenic
4
Q
FAST views
A
Cardiac
LUQ: Liver/kidney/Right hepatorenal (Morrison’s pouch) - 10th-11th rib space/mid axillary
RUQ: Left diaphragm spleen kidney interface - 8th-9th rib space
Suprapubic
5
Q
Normal adult blood volume
A
Approx 7% body weight
6
Q
Normal child blood volume
A
Approx 8-9% body weight
7
Q
Class I hemorrhage: % blood loss, HR, BP, PP, RR, UO, GCS, Base deficit, need for blood pdts
A
<15% blood volume loss Minimal tachy Normal BP, pulse pressure, RR, UO Base deficit 0 to -2mEq/L Monitor need for blood pdts
8
Q
Class II hemorrhage: % blood loss, HR, BP, PP, RR, UO, GCS, Base deficit, need for blood pdts
A
15-30% blood volume loss HR same or mildly increased BP, RR, UOm GCS same Decreased pulse pressure Base deficit -2 to -6 mEq/L Possible need for blood pdts Give crystalloid
9
Q
Class III hemorrhage: % blood loss, HR, BP, PP, RR, UO, GCS, Base deficit, need for blood pdts
A
31-40% blood volume loss HR elevated BP same or decreased, PP/UO/GCS decreased RR same or increased Base deficit -6 to -10mEq/L Yes blood pdts, crystalloids
10
Q
Class IV hemorrhage: % blood loss, HR, BP, PP, RR, UO, GCS, Base deficit, need for blood pdts
A
>40% blood volume loss Elevated HR, RR Decreased BP, PP, UO, GCS Base deficit -10mEq/L or less Massive transfusion protocol
11
Q
Preferred vascular access in trauma setting
A
2 short large calibre periphery IVs (min 18-gauge for adults)
12
Q
UO goals
A
0.5ml/kg/h adults
1ml/kg/h children 1-teens
2ml/kg/h infants
13
Q
Massive transfusion protocol
A
> 10U of pRBCs in 24h
>4U in 1h
14
Q
Most common cause of transient response to fluid therapy
A
Undiagnosed source of bleeding
15
Q
Majority of tracheobronchial tree injuries occur within___ of the carina
A
1inch/2.5cm
16
Q
Confirm tracheobronchial tree injury via
A
Bronchoscopy
Requires immediate surgical consult
17
Q
Most common cause of tension pneumothorax
A
Mechanical positive pressure ventilation in pts with visceral pleural injury
18
Q
Treatment of tension pneumothorax
A
Large (16-18 gauge) over the needle catheter insertion or finger thoracotomy at 5th interspace (level of nipple) slightly anterior to the midaxillary line
Tube thoracotomy is MANDATORY after needle or finger decompression of chest
Chest tube inserted in anterior axillary line
19
Q
Open pneumothorax mgmt
A
Prompt closure of defect with sterile dressing, taped on three sides only
Chest tube remote from wound
Definite surgical closure often required
20
Q
Massive hemothorax
A
Accumulation of >1500ml of blood in one side of chest or >/= 1/3 of patient’s blood volume
21
Q
Massive hemothorax mgmt
A
Restore blood volume and decompress chest cavity with single chest tube 28-32 French inserted at 5th intercostal space just anterior to midaxillary line
Return of 1500cc or more of blood generally indicates need for urgent thoracotomy
22
Q
Classic clinical triad of cardiac tamponade
A
Muffled heart sounds
Distended neck veins
Hypotension
23
Q
Kussmauls sign
A
Kussmaul’s sign is a paradoxical rise in jugular venous pressure (JVP) on inspiration, or a failure in the appropriate fall of the JVP with inspiration.
Seen with cardiac tamponade
24
Q
Flail chest and pulmonary contusion mgmt
A
Initial: oxygen, fluid resuscitations, intubation and mechanical ventilation if necessary
Definitive: Oxygen, fluid resuscitation, analgesia, continuous monitoring and re-eval
25
Management of traumatic aortic disruption
HR and BP control with short-acting BB (ie. esmolol) or CCB (ie. nicardipine)
If that fails, nitroglycerin or nitroprusside can be added
C/I in hypotensive pt
26
Crushing injury to chest or traumatic asphyxia signs
Upper torso/facial/arm plethora with petechia secondary to acute temporary compression of SVC
Massive swelling and cerebral edema may be present
27
Radiographic signs of blunt aortic injury
```
Widened mediastinum
Obliteration of aortic knob
Devation of trachea to right
Depression of left mainstem bronchus
Elevation of right mainstem bronchus
Obliteration of space btwn pulmonary artery and aorta
Devation of esophagus to right
Widened paratracheal stripe
Widened paraspinal interfaces
Presence of a pleural or apical cap
Left hemothorax
Fractures of 1st/2nd rib or scapula
```
28
Signs of pelvic #
```
Ruptured urethra (scrotal hematoma or blood at urethral meatus)
Limb length discrepancy
Rotational deformity of leg without obvious #
```
29
Pelvic # initial mgmt
1. Hemorrhage control - stabilize with sheet/binder, internal rotation of lower extremities, ultimate angiographic embolization or OR
2. Fluid resuscitation
3. Early transfer
30
DPL indication
Hemodynamically abnormal patient with blunt abdominal trauma and patients with penetrating trauma with multiple cavitary or tangential trajectories
Note: All hemodynamically abnormal patients (esp those with peritonitis or evisceration with penetrating abdominal trauma should have lap)
31
Indications for laparotomy in adult victims of blunt trauma
Hemodynamically abnormal with +ve FAST/DPL or suspected abdominal injury
+ve CT and hemodynamic status not improving
Free/extra-luminal air on imaging
Evidence of diaphragm rupture
Evidence of intraperitoneal bladder rupture
Peritonitis
32
SBP goals in head injury
>/= 100 for 50-69yo, >/=110mmHg for pts 15-49 or older than 70, may decrease mortality and improve outcomes
33
Ct head shift of ___ or. greater indicates need for surgery to evacuate blood clot or contusion causing shift
5mm
34
Hyperventilation and CO2
REDUCES CO2
| If PaCO2 <30mmHg --> high risk of cerebral vasoconstriction
35
Hypoventilation and CO2
Increases Co2
| If PaCO2 >45mmHg --> high risk of promoting vasodilation and increasing ICP
36
Normal PaCo2
35-45mmHg
37
Hyperventilation for brain jury
Use In moderation and for as limited time as possible
Try to keep at 35, but brief periods of 25-35 may be needed
Avoid PCO2 <28mmHg
38
Mannitol dose
Typically 20% solution (20g per 100mL)
| 1g/kg bolus over 5min
39
When to use mannitol
Acute Neuro deterioration in a EUVOLEMIC patient --> give mannitol and transfer to CT scanner or directly to OR if lesion is already identified
Does not work in hypovolemic pt b/c it is an osmotic diuretic
40
Epidural hematoma
Skull # lacerate meningeal arteries --> hemorrhage in epidural space
Most common = middle meningeal artery over temporal fossa
Lenticulate or biconvex on CT
Causes same side pupil dilation and opposite side weakness
41
Classic sign of uncal herniation
Ipsilateral pupillary dilation with contralateral hemiparesis
42
Normal ICP
10mmHg
43
Moderate brain injury
GCS 9-12
44
Severe brain injury
GCS 3-8
45
Subdural hematoma
Shearing of blood vessels on cerebral cortex
| Appears to cover cerebral surface on CT
46
Systolic BP guidelines for TBI management
SBP >/= 100 aged 50-69
| >/=110 aged 15-45 or >70yo
47
Antiplatelet reversal
Tx: platelets
| Consider desmopressin acetate
48
Warfarin reversal
Vitamin K, FFP
49
Heparin reversal
Protamine sulfate
| Monitor PTT
50
LMWH reversal
Protamine sulfate
51
NOAC reversal
N/A
| May benefit from prothrombin completely concentrate
52
Hypertonic saline for ICP
Reduces elevated ICP
May be preferred in patients with systemic hypotension
Does not lower ICP in hypovolemic patients
53
Posttraumatic epilepsy tx
Phenytoin and fosphenytoin in acute phase
Add valium or Ativan if necessary
Prophylactic use of anticonvulsant is NOT recommended
54
Brain death definition
GCS 3
Nonreactive pupils
Absent brainstem reflexes (dolls eyes, no gag, oculocephalic, corneal)
No spontaneous ventilatory effort on formal apnea testing
Absence of confounding factors (ie. EtOH or drug intoxication or hypothermia)
55
Essentials in maintaining CPP
Sedation
Mannitol
IV hydration
56
Neurogenic shock
Bradycardia, low BP, Neuro deficit on exam and warm extremities
Associated w/ injuries above T6 due to descending sympathetic fibres from upper thoracic spinal cord that help maintain tone of vasculature and HR
57
Corticospinal tract
Anterior and lateral cord
Controls motor power on same side of body
Test via voluntary muscle contractions or involuntary response to painful stimuli
58
Spinothalamic tract
Anteriorlateral cord
Transmits pain and temperature sensation from opposite side of body
Test via pinprick
59
Dorsal columns
Posteromedial cord
Carries proprioception, vibration and some light-touch sensation from same side of body
Test via position sense in toes and fingers or vibration sense using tuning fork
60
Brown Sequard Syndrome
Hemisection of cord usually due to penetrating trauma
Ipsilateral motor loss and loss of position sense, contralateral loss of pain and temperature sensation 1-2 levels below level of injury
61
Chance fracture
Transverse fractures through vertebral body
Caused by forward flexion, often by MVA when passenger using a lap belt only
Can be a/w retroperitoneal and abdominal visceral injuries
62
Central cord syndrome
Disproportionately greater loss of motor strength in upper extremities than lower, with varying degrees of sensory
63
Anterior cord syndrome
Injury to motor and sensory pathways in anterior parts of cord, characterized by paraplegia and bilateral loss of pain and temperature sensation
64
Area of greatest flexion and extension of c-spine
C5-6
| Most common level of subluxation
65
Most common level of c-spine #
C5
66
Neurogenic shock mgmt
Moderate IVF resuscitation
Vasopressors
Atropine may be needed
67
Spinal shock
Flaccidity and loss of reflexes immediately after SCI
68
C5 innervation
Deltoid
69
C6 innervation
Thumb
70
C7 innervation
Middle finger
71
C8 innervation
Little finger
72
T4 innervation
Nipple
73
T8 innervation
Xiphisternum
74
T10 innervation
Umbilicus
75
T12 innervation
Symphisis pubis
76
L4 innervation
Medial calf
77
L5 innervation
1st web space
78
S1 innervation
Lateral foot
79
S3 innervation
Ischial tuberosity area
80
S4 and S5 innervation
Perianal region
81
C5 myotome
Bicep
82
C6 myotome
Wrist extensor
83
C7 myotome
Tricep
84
C8 myotome
Finger flexor
85
T1 myotome
Finger abductors
86
L2 myotome
Hip flexors
87
L3 myotome
Knee flexors
88
L4 myotome
Ankle dorsiflexion
89
L5 myotome
Long toe extensors
90
S1 myotome
Ankle plantars
91
Canadian C-spine rule
High risk factors:
- >65yo
- Dangerous mechanism (Fall from >/=1m/5 stairs), axial loading to head, MVC (at high speed (>100km/h), rollover, ejection), motorized recreational vehicle collision, bicycle collision
- Paresthesias in extremities
IF YES --> RADIOGRAPHY
If NO --> any low risk factors? (simple rear-end, sitting position in ED, ambulatory at any time, delayed onset of neck pain, no midline cervical tenderness) --> YES --> able to rotate neck 45 deg left and right? --> YES --> no radiography, if NO --> radiography
92
NEXUS criteria for c-spine criteria
Meets ALL low risk criteria
- No posterior midline cervical spine tenderness
- No evidence of intoxication
- Normal level of alertness
- No focal neuro deficit
- No painful distracting injuries
```
NEXUS:
Neuro deficit (lack of)
EtOH
eXtreme distracting injuries
Unable to provide hx (altered LOC)
Spinal tenderness
```
93
ABI indicative of abnormal arterial flow secondary to injury or PVD
<0.9
94
Stepwise approach to controlling arterial bleeding
Manual pressure
Pressure dressing
Manual pressure to artery proximal to injury
Manual tourniquet or pneumatic tourniquet directly to skin
95
Typical ancef order for open #
2g ancef q8h
96
If pt is allergic to penicillins and require IV abx for open #
600mg clinda q8h
97
Signs and symptoms of compartment syndrom
Pain greater then expected to injury
Pain on passive stretch of affected muscle
Tense swelling of affected compartment
Paresthesias or altered sensation distal to affected compartment
98
Primary survey of patients with burns
Stop the burning process
Ensure airway and ventilatory adequacy
Manage circulation
99
Steps to stop burning process
Remove patient's clothing
Prevent overexposure and hypothermia
Recognize possibility of wound contamination
Brush any dry chemical powders from the wound and rinse
100
Factors that increase risk of upper airway obstruction
```
Increasing burn size and depth
Burns to head and face
Inhalation injury
Burns inside mouth
Age - children are higher risk
```
101
Preferable diameter for endotracheal tube in burn patients
8mm (minimum 7.5mm for adults)
| Larger to allow clearing of secretions
102
CO exposure in burn pts
Assume in pts burned in enclosed areas
Provide 100% O2 via non-rebreather
Obtain baseline carboxyhemoglobin levels
103
Inhalation injury dx
Exposure to combustible agent and signs of exposure to smoke in lower airway, below vocal cords, seen on broncoscopy
104
When to provide burn resuscitation fluids
Deep partial and full-thickness burns > 20% total BSA
105
Fluid type for resuscitation in burn patients
Warmed isotonic crystalloid
106
Initial fluids rate for adults with 2nd deg and 3rd deg burns
```
2 mL lactated ringer's x pt's body weight in kg x % TBSA
1/2 in first 8h
1/2 over next 16h
Adjust fluids based on UO
Titrate to desired UO rate
Avoid fluid bolus
```
107
Initial fluid rate for Peds pts with 2nd and 3rd deg burns
3mL lactated ringer's x patient's body weight in kg x %TBSA
1/2 in first 8h
1/2 over next 16h
Children <30kg: Add maintenance fluids of 5% dextrose in water
Titrate to desired UO rate
Avoid fluid bolus
108
Rule of 9s - Head (Peds)
9% scalp/head, 9% face
109
Rule of 9s - Arms (Peds)
4.5% front, 4.5% back each arm
110
Rule of 9s - Back (Peds)
13%
111
Rule of 9s - Anterior torso (peds)
18%
112
Rule of 9s - Bum (Peds)
2.5% each butt cheek
113
Rule of 9s - legs (peds)
7% front, 7% back each leg
114
Rule of 9s - Head (Adults)
4.5% face, 4.5% scalp
115
Rule of 9s - Back (Adults)
18%
116
Rule of 9s - Anterior torso (Adults)
18%
117
Rule of 9s - Arms (Adults)
4.5% front, 4.5% back, each arm
118
Rule of 9s - Groin (adults)
1%
119
Rule of 9s - Legs (Adults)
9% front, 9% back, each leg
120
Rule of 9s - Palmar surface (Adults)
1%
121
Superficial burn
Erythema, pain, no blisters, no fluid replacement needed
122
Superficial partial thickness burn
Moist, painfully hypersensitive, possible blisters, pink, blanches to touch
123
Deep partial thickness burn
Dry, not painful, possible blisters, red/mottled, does not blanch
124
Full thickness burn
Leathery appearance, translucent/waxy skin, painless, dry
125
Gastric tube insertion indications for burn patients
Pts with N/V or abdominal distention
Pts with burns involving >20% total BSA
Insert and attach to suction prior to transfer
126
Antibiotics and burns
Do not administer prophylactic abx in early post-burn period unless required
127
Rhabdomyolysis tx
Increase fluids to target UO of 100cc/h --> washes out myoglobin before it settles in
Mannitol (osmotic diuretic) --> increases UO and "washes out" myoglobin
128
Electrical burn tx
Airway, breathing, monitor ECG, place bladder catheter
| Start tx for suspected myoglobinuria
129
Resuscitation guidelines for electrical burn
Adults: 4cc/kg/%TBSA to ensure UO of 100cc/h
| Children <30kg: 1-1.5mL/kg/h
130
Tar burn tx
Rapid cooling of tar and care to avoid further trauma while removing it
Mineral oil to dissolve tar
131
Frostbite management
Stop freezing
Warm blankets
Hot fluids PO
Place injured part in circulating water at constant 40C
Avoid excessive dry heat, do not rub or massage area
Use analgesics and monitor pt's cardiac status and peripheral perfusion during rewarming
132
Hypothermia definition
Core temp <36C
133
Severe hypothermia
Core temp <32C
134
How should toes be thawed
Moist rewarming
135
Burn shock is secondary to
Interstitial loss due to inflammation
136
Formula for estimating weight
(2 x age in yrs) + 10
137
Endotracheal tube estimate
Size of pt's external nare or tip of small finger
138
Systolic BP estimate in peds
High range systolic = 90 + (age x 2)
| Low range systolic = 70 + (age x 2)
139
Diastolic BP estimate in peds
2/3 systolic BP
140
Most common cause of cardiac arrest in peds trauma cases
Inability to establish patent airway with associated lack of oxygenation and ventilation
141
Drug assisted intubation for peds: Pre-oxygenate
Atropine sulfate for <1yo 0.1-0.5mg
142
Drug assisted intubation for peds: Sedation
Hypovolemic - etomidate 0.1mg/kg or midazolam HCl0.1mg/kg
| Normovolemic - etomidate 0.3mg/kg or midazolam 0.1mg/kg
143
Drug assisted intubation for peds: Paralysis
Succinylcholine <10kg: 2mg/kg
| Succinylcholine >10kg: 1mg/kg
144
Common causes of deterioration in intubated patients
```
DOPE
Dislodgement
Obstruction
Pneumothorax
Equipment failure
```
145
Needle decompression landmarks in peds
2nd intercostal space midclavicular line
146
Bolus rate in peds
20cc/kg
147
pRBC transfusion rate peds
10cc/kg
148
Primary complication of rib # in elderly
PNA
149
Pregnancy and CO2 levels
Should be hypocapneic
| PaCO2 of 35-40 may indicate impending resp failure
