ATLS FACS with correct answers

ATLS FACS What's ABCDE to trauma assessment? - correct answer Airway w/ C-spine protection Breathing and ventilation Circulation Disability- neurological status Exposure (undress) and Environment (temperature control) Ortho-related injuries from frontal impact automobile collision? - correct answer - C-spine fracture - Posterior fracture/dislocation of hip/knee Ortho-related injuries from side-impact automobile collision? - correct answer - C-spine fracture - Fractured pelvis/acetabulum Ortho-related injuries from motor impact w/ pedestrian? - correct answer Fractured pelvis/lower extremities Ortho-related injuries from fall from height? - correct answer - Fractured pelvis/acetabulum - Bilateral lower extremity fractures (including Calc fractures) What are some physical exam findings that might suggest pelvic fracture? - correct answer - Ruptured urethra (scrotal hematoma or blood at meatus) - Limb length discrepancy - Rotational deformity of a leg w/out obvious fracture * In patients w/ these signs, do NOT manually manipulate pelvis * What are some pertinent historical points to collect about MVC trauma? - correct answer Vehicle speed, Collision type, Ejection, Restraint type, Air bags, Patient position, Status of other passengers When should you place pelvic binder in trauma situation? - correct answer If pelvic fractures, hypotension, and no other source of blood loss Most common type of pelvic fracture (mechanism)? - correct answer - Lateral compression (70%) - AP (15-20%) - Highly unstable vertical shear Total blood loss in an active pelvic hemorrhage is up to ____ liters - correct answer 2 What's the purpose of a pelvic binder in trauma setting? - correct answer Pelvis is a potential space. By binding the pelvis, there is less volume and therefore less ability for blood loss in the pelvic potential space * Specifically recommended for AP/Open book pelvic fractures 4 regions assessed in FAST exam? - correct answer Pericardial sac, hepatorenal fossa, splenorenal fossa, pelvis What's a Chance fracture? - correct answer Lumbar distraction fracture Reversal agent for antiplatelet agents like Aspirin and Plavix? - correct answer Platelets Reversal agents for coumadin/warfarin? What lab do you want to normalize? - correct answer FFP, Vitamin K INR Reversal agents for heparin? Lab that you want to normalize? - correct answer Protamine Sulfate PTT Reversal agent of LMWHeparin (Lovenox)? - correct answer Protamine sulfate (monitor PTT) Reversal agent of direct thrombin inhibitors (like Pradaxa)? - correct answer Praxbind (idarucizumab) Reversal agent for Xarelto (Rivaroxaban)? - correct answer N/a... Possibly improved by prothrombin complex concentrate (Kcentra) True or False. Many patients w/ C-spine fractures have a second, noncontiguous vertebral column fracture. - correct answer True (10%) Neurogenic shock is associated with spinal cord injuries above ____. Why? - correct answer T6 Due to descending sympathetic fibers from upper thoracic spinal cord that help maintain tone of vasculature and heart rate Why are injuries to C-spine below C3 more likely to cause injury to spinal cord? What about injuries above C3? - correct answer Smaller canal diameter Usually death from apnea What classifies a COMPLETE spinal cord injury? - correct answer No demonstrable sensory or motor function below a certain level What classifies an INCOMPLETE spinal cord injury? - correct answer Patient has some degree of motor or sensory function, prognosis for recovery is SIGNIFICANTLY better What is a SENSORY LEVEL in spine? - correct answer The lowest dermatome w/ normal sensory function (Can differ on the two sides of the body) Which sensory levels are around the anus? - correct answer S3-S5 Dermatome of the inner lower leg? Outer/lateral lower leg? - correct answer L4 L5 What's the 0-5 muscle strength grading system? - correct answer 0 - Total paralysis 1 - Palpable for visible contraction 2 - Full ROM w/ gravity eliminated 3 - Full ROM against gravity 4 - Full ROM, less than normal strength 5 - Normal strength Finger abductor myotome? - correct answer T1 Hip flexor myotome? - correct answer L2 Knee extensor myotome? - correct answer L3-L4 Ankle plantar flexor myotome? - correct answer S1 Knee flexor myotome? - correct answer L5 What's spinal shock? What's neurogenic shock? - correct answer Loss of muscle tone and reflexes immediately after spinal cord injury Loss of vasomotor tone and sympathetic innervation to heart, causing hypotension How do you define a "motor level" in spine talk? - correct answer The lowest key muscle that has a muscle-strength grade of at least 3 (ROM against gravity only) Paraplegia occurs when there is an injury to (C/T)-spine - correct answer Thoracic Quadriplegia/tetraplegia occurs when there is an injury to (C/T)-spine - correct answer Cervical Most common level of C-spine fracture? - correct answer C5 Most common level of C-spine subluxation? - correct answer C5 on C6 Difference between an anterior wedge compression fracture and a chance fracture? - correct answer Anterior wedge compression injury occurs due to axial loading w/ flexion. Chance fractures involve flexion about an axis anterior to vertebral column (commonly from impropery placed lap belts) Mechanism of burst spinal injury? - correct answer Vertical-axial compression Common cause of fracture/dislocation of spine? - correct answer Extreme flexion or blunt injury Patients with C-fractures above C___ are at risk of impaired diaphragm function, which can progress to respiratory failure during transport - correct answer C6 (C3-C5 keeps diaphragm alive) Common X-rays you want for assessment of C-spine pathology? If patient has neck pain but these XR's are normal--what should you get? - correct answer From occiput to T1 - lateral, AP, open-mouth odontoid MRI, Flexion-extension X-rays A femur fracture can result in blood loss up to ___ liters and tibial shaft fracture can cause up to ___ liters of blood loss What's the best way to control hemorrhage from these? - correct answer 2 1.5 FRACTURE IMMOBILIZATION What are the major potentially life-threatening extremity injuries due to hemorrhage? - correct answer Femur fractures (b/l), Crush syndrome, Pelvic disruption Lab assessment for Crush syndrome (Traumatic rhabdo)? Treatment? - correct answer Myoglobin assay (may not be available), Serum CK Early, aggressive fluid therapy, Intravascular fluid expansion Appearance of anteriorly dislocated shoulder? - correct answer Squared off Appearance of posteriorly dislocated shoulder? - correct answer Locked in IR Most common direction of ankle dislocation? Appearance? - correct answer Lateral ER, Prominent medial mal 2 most common areas of fractures at risk for compartment syndrome? - correct answer Tibia and forearm Suspected closed, isolated tibial shaft fracture, what XRs do you want to obtain? - correct answer Right-angle films (AP and lateral) at fracture site as well as Knee and ankle XR's * Always get right angle films of fracture + Joints above and below When splinting/immobilizing fractures, what's the principle/how high do you go? What should you always do before and after splinting/casting? - correct answer Immobilize w/ splint the joint above and below the fracture Neurovascular status check (pulses, cap refill, sensation, motor) Antibiotics given for all open fractures no matter what? - correct answer - Ancef (Cefazolin) IV -- usually 2-3 grams - AND either Cipro or Gentamicin IV for gram-negative coverage AND Tetanus should be given if tetanus is not up to date or status is unknown How should you splint/immobilize femoral fractures? What's one situation when you shouldn't do this though? What should you do in this case instead? - correct answer Traction splints Ipsilateral tibial shaft fractures Long-leg posterior splint with additional sugar-tong splint for the lower leg How should you splint/immobilize knee injuries? How much flexion/extension should there be? - correct answer Knee immobilizer or posterior long-leg splint 10 degrees of flexion How should you splint/immobilize tibial fractures? - correct answer Plaster splint to immobilize the lower thigh, knee, and ankle (posterior long leg) All patients with radiographic evidence of injury and all those with neurological deficits should be considered to have a(n) (stable/unstable) spinal injury What's this mean for immediate management? - correct answer Unstable Spinal motion of these patients should be RESTRICTED -- must be moved via logrolling until experts (ortho or neurosurgeon) sign off What constitutes stable vs. unstable vertebral fracture? - correct answer Generally, a fracture is considered stable if only the anterior column is involved, as in the case of most wedge fractures. When the anterior and middle columns are involved, the fracture may be considered more unstable What's clinical significance of the Denis' three column concept for vertebral fractures (terminology)? - correct answer Ist column only -- always stable 2nd column involvement -- possibly unstable 3rd column involvement -- always unstable What's a Jefferson fracture? Mechanism? Best seen on what imaging? - correct answer C1 burst fracture; Most common fracture of C1' Involve Anterior and posterior ring disruption of C1 with lateral displacement of lateral masses Axial loading Open mouth view of C1 to C2, Axial CT 2 of the common types of C2 (axis) fractures? - correct answer - Odontoid fracture (Type 2 - base of dens) - Hangman's fracture (posterior element; pars interarticularis--so it's a traumatic spondylolysthesis of the axis) What's a Chance fracture? - correct answer Transverse fracture through the vertebral body 4 main types of thoracic spine fractures? How are each managed? - correct answer Anterior wedge Burst Chance Fracture-dislocation Most anterior wedge/simple compression fractures are stable and managed w/ rigid brace Most burst fractures, Chance fractures, and Fracture-dislocations (disruption of posterior elements) are UNSTABLE and ALWAYS require internal fixation Why is probability of complete neurological deficit much less likely in lumbar vertebral fractures compared to thoracic and thoracolumbar? - correct answer Because at lumbar region all that's there is cauda equine, whereas thoracic and thoracolumbar contain the entire cord w/ conus medlaris at L1 How do you know you have a good lateral C-spine view (ie-what must be included?)? - correct answer Must view the base of skull, all 7 cervical vertebrae, first thoracic vertebra (above and below) What should a good open-mouth odontoid view include? - correct answer Entire odontoid process, right and left C1 and C2 articulations When can you remove the C-collar for patients? - correct answer A doctor qualified to interpret these films must review the complete series of cervical spine radiographs before the spine is considered normal. Do not remove the cervical collar until a neurologic assessment and evaluation of the c-spine, including palpation of the spine with voluntary movement in all planes, have been performed and found to be unconcerning or without injury When patient w/ neck pain but normal initial C-spine radiographs (Lateral, AP, Odontoid), what imaging could/should you do to assess for instability? - correct answer - Flexion-Extension XR of C-spine - MRI Ideal INITIAL imaging of suspected Cervical, Thoracic, and Lumbar spine fractures? What if this isn't available? - correct answer Multidetector CT (Superior sensitivity, I'll always have access to this) AP and lateral plain XR An ABI less than ____ indicates abnormal arterial flow secondary to injury of PVD - correct answer 0.9 How to calculate ABI? - correct answer Systolic BP of ankle/un-injured arm... < 0.9 = pathology Only reason to forgo XR exam before treating a dislocation or fracture? - correct answer The only reason to forgo x-ray examination before treating a dislocation or a fracture is the presence of vascular compromise or impending skin breakdown. This condition is commonly seen with fracture-dislocations of the ankle Tissue pressures greater than ____ mm Hg suggest decreased capillary blood flow, which can result in muscle and nerve damage from anoxia - correct answer 30 Approximate intra-compartmental pressure that suggests compartment syndrome? - correct answer 30 mm Hg ** But compartment syndrome is only a clinical diagnosis, pressure measurements are only and adjunct Key signs and symptoms of compartment syndrome? - correct answer Pain out of proportion, Pain on passive stretch, Tense swelling of affected compartment, Paresthesias or altered sensation distal to affected compartment