SUMMARY ATLS EXAMINATION ATLS Chapters 1-3 2023 QUESTIONS & ANSWERS LATEST UPDATE

SUMMARY ATLS EXAMINATION ATLS Chapters 1-3 Question Patients with a GSC of less than usually require intubation. 8 Answer The "A" in ABCD stands for . You should assume that any patient in a multisystem trauma with an altered level of consciousness or blunt injury above the clavicle has what type of injury? Flail chest is invariably accompanied by which can interfere with blood oxygenation. Hypotension is caused by until proven otherwise. When you don't have/can't get a blood pressure, what are three things to look for when evaluating perfusion. Elderly patients have a limited ability to to compensate for blood loss. Resuscitation fluids should be warmed 39 degrees Celsius (102.2 F). Can you use a microwave to do this? Urinary catheters are good for assessing renal perfusion and volume status. List 5 signs of urethral injury that might prevent you from inserting one. Which arm should you NOT put a pulse-ox on? Name two anatomical things that can interfere with doing a FAST scan. When should radiographs be obtained? How do you get an ample patient history? Why might you want a Bair Hugger for a patient who smells of alcohol? What things are you looking for when you do a DRE in a trauma? What should you do for every female patient? Adult patients should maintain UOP of at least Airway maintenance with CERVICAL SPINE PROTECTION Cervical spine injury pulmonary contusion - do NOT over fluid resuscitate these patients! hypovolemia 1. Level of consciousness (brain perfusion), 2. Skin color (ashen face/grey extremities) 3. Pulse (bilateral femoral - thready/tachy) increase heart rate YES - for CRYSTALLOID ONLY (but NOT for blood products). Blood at urethral meatus, perineal ecchymosis, blood in scrotum, highriding/non-palpable prostate, pelvic fracture The arm with a blood pressure cuff on it Obesity & intraluminal bowel gas During the SECONDARY survey. A=Allergies, M=Medications, P=PMH/Pregnancy, L=Last meal, E=Events/Environment of injury Vasodilation can lead to hypothermia Blood, high-riding prostate (in males), and sphincter tone Pregnancy test (females of childbearing age) Adults 0.5 mL/kg/hr, Kids 1.0 ml/kg/hr Downloaded by: CHRISJAY | Distribution of this document is illegal Want to earn $103 per month? mL/kg/hr. Kids should have at least mL/kg/hr. Preventing hypercarbia is critical in patients who have sustained a injury. head What two places would you LOOK at a patient if Lips and fingernail beds you suspect hypoxemia? Patients may be abusive and belligerent because of , so don't just assume it's due to drugs, alcohol, or the fact that they are just inherently a jerk. hypoxia Yes, if the phrenic nerves (C3-C5) are Can a patient breathe on their own after complete spared. This will result in "abdominal" cervical cord transection? Can you use an OPA (Guedel) in a conscious patient? Bougies are typically inserted blindly, how do you know you are in the trachea and not the esophagus? breathing. The intercostal muscles will be paralyzed though. No, it could make them vomit. An NPA (trumpet) would be okay. You can feel the "clicks" as the distal tip rubs against the cartilaginous tracheal rings, or it will deviate right or left when entering either bronchus (usually at 50 cm). What do you NOT want to hear if you ascultate a Borborygmi - rumbling or gurgling noises patient after placement of an ET tube? What is the RSI dose for etomidate? What is the RSI dose for sux? How does etomidate affect blood pressure? A RSI dose of sux usually lasts about minutes. What hypnotic/sedative/induction agent do you NOT want to use for a severely burned patient? Oxygen should flow at 15L for needle cricothyroidotomy, and have a Y-connector for insufflation if possible. What size needle do you use for adults? Kids? Cricoid cartilage is the only circumferential support for the upper trachea in kids, therefore surgical cricothyroidotomy is not recommended in kids under the age of . In a "normal" patient without significant chest wall injury or lung disease, needle cricothyroidotomy can provide adequate oxygenation for approximately minutes. For a patient with difficulty breathing, what things might you try before you provide a suggesting esophageal insertion. 0.3 mg/kg (usually 20 mg) 1-2 mg/kg (usually 100 mg) It doesn't - at least it SHOULDN'T have any significant effect on BP. Ketamine will increase BP, and propofol and thiopental will both drop BP. 5 SUX - patients with severe burns, crush injuries, hyperkalemia, or chronic paralytic/neuromuscular diseases should NOT get sux because of hyperkalemia risk. Adults 12-14 gauge, kids 16-18 gauge 12 30-45 Chin-lift, jaw-thrust (NOT head-tilt while maintaining c-spine precautions), OPA Downloaded by: CHRISJAY | Distribution of this document is illegal Want to earn $103 per month? surgical airway? (guedel), NPA (trumpet), LMA, Combitube, ET tube +/- bougie How do you know if an OPA/Guedel is the correct size for the patient? What should do with the balloon on an ET tube/LMA/foley before you insert it? A correctly sized OPA will extend from the corner of the patient's mouth to the external auditory canal. Inflate it to make sure it doesn't leak - then deflate and insert. What size LMA do you use for kid, woman/small Kid: 3, Woman/small man: 4, Large man, large woman/man? The proper size ET tube for an infant is . What size cuffed endotracheal tube do you use for an emergency cricothyroidotomy? Use size 3 ET tubes for neonates, 3.5 for infants 0-6 months, and size 4 for infants 6-12 months. How do you calculate what size ET tube to use for toddlers and kids? Shock is defined as an abnormality of the circulatory system that results in inadequate woman/man: 5 (C3,4,5 keep the diaphragm alive) The same size as the infant's nostril or little finger. (Usually size 3 for neonates, 3.5 for infants) 5 or 6 Age/4 + 4 mm = internal diameter Neurogenic, cardiogenic, hypovolemic, organ perfusion and tissue oxygenation. What are septic the 4 different types? The most common cause of shock in the injured trauma patient is . Approximately % of the body's total blood volume is located in the venous circuit. hemorrhage 70 Anaerobic metabolism --> can't make more Why does shock actually reduce the total volume ATP --> Endoplasmic then mitochondrial of circulating blood? Which vasopressors should you use to treat hemorrhagic shock? What are the drug doses? Compensatory mechanisms may preclude a damage --> lysosomes rupture --> sodium and WATER enter the cell, which SWELLS and dies. NEVER use pressors for hypovolemic shock - use VOLUME replacement. Pressors will worsen tissue perfusion in hemorrhagic shock. measurable fall in systolic blood pressure until up 30 to % of the patient's blood volume is lost. Any patient who is cool and is tachycardic is considered to be until proven otherwise. The definition of tachycardia depends on the patient's age. What heart rate is considered tachycardic for infants, toddlers/preschoolers, school age/prebuscent, and adults? Elderly patients may not exhibit tachycardia in response to hypovolemia because of limited cardiac response to catecholamines. Why else in shock Infants >160, toddlers/preschoolers >140, school age/prebuscent >120, adults >100 They might be on a beta-blocker or have a pacemaker. Downloaded by: CHRISJAY | Distribution of this document is illegal Want to earn $103 per month? might not they get tachy? A FAST scan is an excellent way to diagnose cardiac tamponade. What signs suggest tamponade? Patients with a tension pneumo and patients with Becks's Triad: JVD, muffled heart sounds, and hypotension (will be resistant to fluid therapy). Will also likely be tachycardic. cardiac tamponade may present with many of the Absent breath sounds and hyperresonance same signs. What findings will you see with a tension pneumo that you will NOT see with tamponade? Immediate thoracic decompression is warranted for anyone with absent breath sounds, to percussion over the affected hemithorax. Acute respiratory distress & subcutaneous hyperresonance to percussion, tracheal deviation, emphysema , and . Can isolated intracranial injuries cause neurogenic shock? How do you calculate total blood volume in an adult? How do you calculate total blood volume in an child? The blood volume of an obese person is calculated based upon their weight. Fluid replacement should be guided by , not simply by the initial classification (Class I-IV). How much blood volume is lost with Class I Hemorrhage? How do you treat a Class I Hemorrhage? How much blood volume is lost with Class II Hemorrhage? How do you treat a Class II Hemorrhage? Subtle CNS changes such as anxiety, fright, and hostility would be expected in a patient with a Class Hemorrhage. How much blood volume is lost with Class III Hemorrhage? A patient with inadequate perfusion, marked tachycardia and tachypnea, significant mental status change, and a measurable fall in systolic blood pressure likely has a Class Hemorrhage. Loss of more than % of blood volume results in loss of consciousness. How much blood volume is lost with Class IV NO 70 mL per kg body weight. A 70 kg person has about 5 liters of circulating blood. (70*70=4900) Body weight in kg x 80-90 mL ideal The patient's response to initial replacment Up to 15% Donating 1 pint, or ~500 mL of blood is about a 10% volume loss and would qualify as Class I Hemorrhage! You don't (usually). Transcapillary refill and other compensatory mechanisms usually restore blood volume within 24 hours. 15-30% (750-1500 mL in a 70 kg adult) Usually just crystalloid resuscitation II 30-40% (2000 mL in a 70 kg adult) III or IV - These patients almost always require a blood transfusion, which depends on their response to initial fluid resuscitation. The first priority is stopping the hemorrhage. 50 More than 40%. Unless very aggressive Downloaded by: CHRISJAY | Distribution of this document is illegal Want to earn $103 per month? Hemorrhage? measures are taken the patient will die within minutes. A Class Hemorrhage represents the smallest volume of blood loss that is consistently associated wiht a drop in systolic blood pressure. Up to mL of blood loss is commonly associated with femur fractures. Unexplained hypotension or cardiac dysrhythmias (usually bradycardia from excessive vagal stimulation) are often caused by , especially in children. How much crystalloid should you give an adult for an initial fluid resuscitation bolus? For kids? Each mL of blood loss whould be replaced with mL of crystalloid, thus allowing for replacement of plasma volume lost into interstitial and intracellular spaces. III 1500 gastric distention Adults: 2 liters, Kids: 20 mL/kg (may repeat and give as much as 60 mL/kg but with high reserve in kids, if they're in shock they should get blood sooner rather than later. 3 Blood on the floor x four more is a mnemonic for Chest, pelvis, retroperitoneum, and thigh occult blood loss where? For children UNDER 1 year of age, UOP should be mL/kg/hr. 2 Alkalotic - respiratory alkalosis from Would patients in EARLY hypovolemic shock be tachypnea....followed later by mild acidodic or alkalotic? "Rapid responders" whose vital signs return to normal (and stay there) after fluid resuscitation likely have/had a Class Hemorrhage. "Transient responders" are associated with Class Hemorrhage. What differential diagnoses should you always consider for "non-responders" following fluid resuscitation? Most patients receiving blood transfusions need calcium replacement. metabolic acidosis in the early phase of shock. I or II II or III NON-HEMORRHAGIC causes, e.g. tension pneumothorax, tamponade, blunt cardiac injury, MI, acute gastric distention, neurogenic shock... don't ATLS Chapters 4-6 Question How should you position the patient before Answer SUPINE, head down 15 degrees to distend neck Downloaded by: CHRISJAY | Distribution of this document is illegal Want to earn $103 per month? placing a subclavian or IJ line? How long can you keep an IO line in? Where do you want to make an incision for a saphenous vein cutdown and how long should your incision be? veins and prevent embolism, only turn head away if C-SPINE HAS BEEN CLEARED FIRST. Intraosseous infusion should be limited to emergency resuscitation and shoudl be discontinued as soon as other venous access is obtained. The saphenous vein can be accessed approximately 1 cm anterior and 1 cm superior to the medial malleolus. Make a 2.5 cm transverse incision through the skin and SQ tissue, careful not to injure the vessel. A patient arrives to the trauma bay intubated This may NOT be a pneumothorax, for intubated and there are absent breath sounds over the left hemithorax, where should you place your decompression needle? Where would you insert a large caliber needle to decompress a tension pnuemothorax? For an open pneumothorax, (sucking chest wound) air passes preferentially through the chest wall defect (least resistance) if the diameter of the defect is at least the diameter of the trachea. Flail chest results from multiple rib fractures - by definition this would be or more ribs, fractured in or more places. Both tension pneumothorax and massive hemothorax are associated with decreased breath sounds on auscultation, so you can tell which it is by . If a patient doesn't have JVD, does this mean they don't have a tension pneumo or tamponade? By definition, how much blood is in the chest cavity to call it a "massive hemothorax"? What size chest tube might you use to evacuate a massive hemothorax? What is Kussmaul's sign? How well do CPR compressions work on someone with a penetrating chest injury and hypovolemia? patients always suspect a right main-stem before attempting needle decompression. Into the 2nd intercostal space in the midclavicular line of the affected hemithorax. 2/3 2 or more ribs fractured in 2 or more places Percussion - hyperresonant with pnuemo, dull with hemothorax. No, they might have a massive internal hemorrhage and be hypovolemic. 1500 mL or 1/3 or more of the patient's total blood volume. (Some also define it as continued blood loss of 200 mL/hr for 2-4 hours- but ATLS does NOT use this rate for any mandatory treatment decisions). #38 French - inserted at the 4th or 5th intercostal space, just anterior to the midaxillary line. A rise in venous pressure with inspiration while breathing spontaneously, and is a true paradoxical venous pressure abnormality associated with cardiac tamponade. "Closed heart massage for cardiac arrest or PEA is INEFFECTIVE in patients with hypovolemia." Patients with PENETRATING thoracic injuries who arrive pulseless, but with Downloaded by: CHRISJAY | Distribution of this document is illegal Want to earn $103 per month? Are patients with PEA who have sustained blunt thoracic injuries candidates for an ED thoracotomy? An ED thoracotomy can allow you to do what? For a patient with a traumatic simple pneumothorax, what should you do BEFORE you start positive pressure ventilation or take them to surgery for a GA? myocardial electrial activity, may be candidates for an ED thoacotomy. NO - Only PEA with PENETRATING thoracic injuries should get an ED thoracotomy. Evacuate pericardial blood, direcly control hemorrhage, cardiac massage, cross-clamp the descending aorta to slow blood loss below the diaphragm and increase perfusion to the heart and brain. CHEST TUBE - positive pressure ventilation can turn a simple pneumo into a tension pneumo, so put in a chest tube first. YES - A simple hemothorax, if not fully Should you evacuate a simple hemothorax if evacuated, may result in a retained, clotted it is not causing any respiratory problems? hemothroax with lung entrapment or, if infected, develop into an empyema. A pneumothorax associated with a persistent tracheobronchial - Use bronchoscopy to confirm, large air leak after tube thoracostomy suggests a injury. What radiographic findings are suggestive of traumatic aortic disruption? A deceleration injury victim with a left pnuemothorax or hemothorax without rib fractures, is in pain or shock out of proportion to the apparent injury, and has particulate matter in their chest tube may have . Fractures for the lower ribs (10-12) should increase suspicion for injury. Why are upper torso, facial, and arm plethora with petechiae associated with crush injuries to the chest? How does ATLS suggest you should review a chest radiograph? You should use a size 16 or 18 gauge 6" needle for pericardiocentesis. How do you insert it? What's a good way to know if you've advanced your needle too far during pericardiocentesis and have entered ventricular muscle? you may need more than one chest tube before definitive operative management. Widened mediastinum, obliteration of aortic knob, deviation of trachea to the right, depression of left mainstem bronchus, deviation of esophagus (NG tube) to right, widened paratracheal stripe, fx'd 1st/2nd ribs or scapula. an ESOPHAGEAL RUPTURE - a forceful blow causes expulsion of gastric contents into the esophagus, producing a linear tear in the lower esophagus allowing leakage into the mediastinum. hepatosplenic Temporary compression of the superior vena cava. Trachea & bronchi, pleural spaces and parenchyma, mediastinum, diaphragm, bones, soft tissues, tubes & lines. Puncture the skin 1-2 cm inferior to the left xiphohondral junction at a 45 degree angle to the skin towards the heart, aiming toward the top of the left scapula. ECG Changes - extreme ST-changes, widened QRS, PVCs, etc... Withdrawl needle until ECG returns to baseline. Downloaded by: CHRISJAY | Distribution of this document is illegal Want to earn $103 per month? What should you do with your needle after you successfully evacuate blood during pericardiocentesis? For patients with facial fractures or basillar skull fractures, gastric tubes should be inserted before doing a DPL. You need to do retrograde urethrography PRIOR to foley placement if . DPL is considered to be % sensitive for detecting intraperitoneal bleeding. What are the four places you should look first when doing a FAST scan? DPL is indicated when a patient with multiple blunt injuries is hemodynamically unstable, especially when they have . What is the only ABSOLUTE contraindication to DPL? What are some RELATIVE contraindications to DPL? When should you use an open SUPRAUMBILICAL approach for a DPL? When doing a DPL, what INITIAL findings Lock the stopcock and leave the catheter in place in case it needs to be reevacuated. If possible, use the Seldinger technique to pass a 14 gauge flexible catheter over the guidewire. This is NOT a definitive treatment. through the mouth inability to void, unstable pelvic fracture, blood at urethral meatus, scrotal hematoma, perineal ecchymoses, or high-riding prostate. 98 Mediastinum, hepatorenal fossa, splenorenal fossa, pouch of Douglas. Change in sensorium (brain injury/EtOH or drug intoxication), change in sensation (spinal cord injury), injury to adjacent structures (pelvis, lumbar spine), lap-belt sign (from seatbelt), or if patient is going for long studies (CT, ortho surgery...). An existing indication for laparotomy. Morbid obesity, advanced cirrhosis, preexisting coagulopathy, and previous abdominal operations (adhesions). PELVIC FRACTURES (don't want to enter pelvic hematoma) and ADVANCED PREGNANCY (don't want to damage enlarged uterus). Free blood (>10 mL) or GI contents (vegetable (not from lab) would mandate a laparotomy? fiber, bile). If you don't get gross blood upon initial DPL Adult - 1,000 mL warm isotonic crystalloid. Kid aspiration, what do you do next for an adult? - 10 mL/kg For a child? You've just put a bunch of fluid in the belly and aspirated more fluid for your DPL. No gross GI contents or anything alarming are present, what QUANTATIVE things would make the DPL positive? Your trauma patient needs an urgent laparotomy, can you take them to the CT scanner first to evaluate injuries? >100,000 red cells/mm^3, 500 white cells/mm^3, or BACTERIA (on gram stain). No, if they need an emergent laparotomy they are unstable - unstable patients should NOT go to the CT scanner! What are some indications for laparotomy in Unstable, GSW, peritoneal irritation, fascial patients with penetrating abdominal wounds? What percentage of stab wounds to the anterior abdomen do NOT penetrate the penetration 25-33% Downloaded by: CHRISJAY | Distribution of this document is illegal Want to earn $103 per month? peritoneum? Does an early normal serum amylase level exclude major pancreatic trauma? Do you need to operate on anyone with an isolated soild organ injury? Which is LESS likely to have a lifethreating hemorrhage - an open book or closed book pelvic fracture? Anterior/posterior forces causes book pelvic fractures, and lateral forces cause book fractures. Which are more common, open or closed book pelvic fracturs? If a patient with a pelvic fracture is positive for intraperitoneal gross blood, a ex-lap is warranted. What is your next move if that same patient is NEGATIVE for gross intraperitoneal blood? What do you need to do BEFORE you do a DPL? (Other than getting stuff together and surgically prepping, etc...) NO No - not if they remain hemodynamically stable (Of all patients who are initially thought to havea ISOLATED solid organ injury, <5% will have hollow viscus injury as well). Closed book - the pelvic volume is compressed, so not as much room for blood. AP = Open Book, LATERAL = Closed Book CLOSED BOOK - 60-70% (Open book 15-20%, vertical shear 5-15%) Angiography DECOMPRESS BLADDER, DECOMPRESS STOMACH What is "adequate" fluid return when getting 30% DPL fluid back? A blown pupil in a patient with a traumatic injury is caused by compression of which nerve? What is a "normal" ICP in the resting state? The Monro-Kellie Doctrine describes compensatory mechanisms inside the Superficial parasympathetic fibers of the CN III (occulomotor). 10mm Hg (Pressures >20, particularly if sustained, are associated with poor outcomes). Venous Blood & CSF (decreased in equal volumes, when this is exhausted, herniation can calvarium to stabilize pressure - what are the occur and brain perfusion will likely be 2 main/first ones? Patients with a GCS of 3-8 meet the accepted definition of "coma" or "severe brain injury." What are the GCS scores for "minor" and "moderate" brain injury? inadequate). Minor = 13-15, Moderate = 8-12 When calculating GCS and there is right/left The "BEST" response. (Better predictor than assymetry in the motor response - which one worst response) do you use? What signs might you see if a patient has a basillar skull fracture? What do you need to know about the GCS? What things might require a person with MINOR brain injury get admitted? PERIORBITAL ECCHYMOSIS (raccoon eyes), RETROAURICULAR ECCHYMOSIS (Battle sign), and otorrhea/rhinorrhea. EVERYTHING - Know it COLD! Abnormal CT (or no scan available), penetrating head injury, prolonged LOC, worsening LOC, moderate to severe HA, significant drug/alcohol Downloaded by: CHRISJAY | Distribution of this document is illegal Want to earn $103 per month? What would you want to do if a patient with a minor brain injury fails to reach a GCS of 15 within 2 hour post injury, had LOC >5 min, are older than 65, emesis x 2, or had retrograde amnesia >30 minutes? What 2 things do you need to do first for everyone with a MODERATE brain injury (according to ATLS algorithm)? High levels of CO2 will cause cerebral vasculature to . Ideally, you want to wait to perform a GCS on a person with SEVERE brain injury until what? A FAST scan, DPL, or ex-lap should take priority over a CT scan if you can't get the brain injured patient's BP up to mm Hg. A midline shift of greater than often indicates the need for neurosurgical evacuation of the mass/blood. Your patient has a dilated pupil and you want to give mannitol on the way to the CT scanner or OR. What is the correct dose? intoxication, skull fx, oto/rhinorrhea, nobody at home to watch, GCS stays <15, focal neuro deficits. CT scan - Everything but the 30 min amnesia makes them HIGH risk for neurosurgical intervention (as would a basillar skull fx). CT scan, admit to faciolity capable of definitive neurosurgical care (Moderate = GCS 9-12) Dilate (to increase blood flow) - so you might want to HYPERventilate people with brain injuries. BP is normalized 100 If a patient has a systolic over 100 with evidence of intracranial mass (blown pupil, unequal motor exam) THEN a CT would take first priority. 5mm 0.25-1.0 g/kg via rapid bolus A cast cutter should be removed to remove a the patient experiences pain or paresthesias trauma victim's helmet if there is evidence of a c-spine injury or if . during an initial attempt to remove the helmet. ATLS Chapters 7-13 Question What are the signs of neurogenic shock? How do you treat neurogenic shock? What is the most common type of C1 Answer Vasodilation of lower extremity blood vessels – resulting in pooling of blood and hypotension. This loss of sympathetic tone may cause bradycardia or inhibit the tachycardic response to hypovolemia. Judicious use of pressors and MODERATE fluid resuscitation. Too much fluid may result in overload and pulmonary edema. Burst fractures (Jefferson fracture) Downloaded by: CHRISJAY | Distribution of this document is illegal Want to earn $103 per month? fracture? What’s the difference between types I, II, and I=tip of odontoid, II=fx at base, III=base of III odontoid process fractures? What are the indications for c-spine odontoid and extends obliquely into body of axis. (Odontoid process = dens). Midline neck pain, tenderness on palpation, radiographs in a trauma patient? Which x-ray neurological deficits related to c-spine injuries, views should be obtained? With the proper views of the c-spine, and a qualified radiologist – what is the sensitivity for finding unstable cervical spine injuries? Ten percent of all patients with a c-spine fracture have what? Attempts to align the spine for the purpose of immobilization on the backboard are not recommended if they . Can you clear a c-spine without films? Should a quadriplegic or paraplegic patient be put on a hard board? What’s a big difference in a physical finding altered LOC or intoxication. 1) Lateral, 2) AP, 3) Open mouth odontoid view >97% (CT with 3mm slices >99%). A second, noncontiguous vertebral column fracture. (So scan the rest of their spine). cause pain Yes, if they are awake, alert, sober, neurological normal, have NO pain, and can flex, extend, and move their head to both sides without pain – you don’t need films. Not for more than 2 hours – get them off ASAP. Hypovolemic = usually TACHY, Neurogenic = between hypovolemic and neurogenic shock? usually BRADY Partial or total loss of respiratory function may be seen in a patient with a cervical spine injury above . Why might someone not be able to breathe if they have a long bone fracture? Abnormal arterial blood flow is indicated by an ABI of . By LOOKING at the patient, what findings might suggest pelvic injury? Crush injuries may result in rhabdomyolysis C6 Fat embolism – uncommon though <0.9 Leg-length discrepancy, rotation (usually external) Volume expansion, and alkalization of urine – casts block flow, also iron is released which with bicarb will reduce intratubular forms ROS which then damage cells and impair ability to regulate K+ etc… What can you do to prevent this? Muscle does not tolerate lack of arterial flow (tourniquet) for more than hours before necrosis begins. What things increase the risk for tetanus? Should legs be completely straight when splinting? Any patient with burns covering more than precipitation of myoglobin. UOP should be 100 mL/hr until myoglobinuria is cleared. 6 Wounds >6 hours old, wounds contused or abraded, >1 cm deep, from high velocity missiles, due to burns or cold, and significantly contaminated wounds. No, flexion of 10 degrees recommended to take pressure off neurovascular structures. 20 Downloaded by: CHRISJAY | Distribution of this document is illegal Want to earn $103 per month? % of BSA require fluid resuscitation. The palmer surface of a patient’s hand represents approximately % of their BSA. A high index of suspicion for inhalation injury must be maintained, because patients may not display clinical evidence for up to hours, by this time edema may prevent non-surgical intubation. Carbon monoxide has times the affinity for oxygen as hemoglobin. Patients with CO levels less than % usually don’t have any physical symptoms. 1% 24 240 20% Adult head BSA = %. Baby head BSA = % What is the main difference between adult and baby BSA determination for burns? Chest BSA = %. Back BSA = %. Arm BSA = %. Leg BSA for adult = %. Baby front or back of leg BSA = %. If you add up BSA head, chest, back, arms, and legs you get 99% of BSA. What is the remaining 1%? Partial/2nd degree burns extend into the whereas full thickness/3rd degree burns . 9 (ENTIRE head front and back = 9) 18 (9 front, 9 back) Entire head on baby is 18, whereas it’s 9 for adults. This difference of 9 is made up by the fact that each side (front/back) on adult = 9, but only 7 for kids. (36 vs 28). 18 18 9 TOTAL (front AND back). 18 TOTAL (9 front, 9 back). 7 (TOTAL leg = 14%) Perineum Partial – go into dermis, FULL go all the way through dermis and into/beyond SQ tissue. For patients with CO poisoning, the ½ life is when breathing room air and breathing 100% oxygen How do you calculate the Parkland formula? Partial or full thickness burns of % in 4 hours on RA, 40 min on 100% O2 4 * weight (kg) * percent BSA burned = volume in 24 hours (1st half in 8 hrs, 2nd half over 16 hrs).4*70kg*25 percent = 7 liters in 24 hours. ***Use 25, NOT 0.25)*** patients less than 10 or older than 50 warrants 10% transfer to a burn center. What percent partial/full thickness burns would qualify a 25 year old for a burn center transfer? What anatomical positions with partial/full thickness burns warrant burn center transfer? Does an inhalation injury warrant transfer to a burn center? Should you treat frostbite by soaking body part in water or not? 20% Face, eyes, ears, hands, genitalia, perineum, feet, skin overlying joints. YES!!!!! YES, 40 degree (104F) for 20-30 min should suffice. Don’t warm if there is risk of Downloaded by: CHRISJAY | Distribution of this document is illegal Want to earn $103 per month? REFREEZING. Insofar as hypothermia is concerned, patients are not pronounced dead until they are warm and dead. What are you thinking if a child has broken ribs? How should you insert a Guedel in a kid? The normal systolic BP in kids can be estimated by what? How do you estimate a child’s total circulating volume? When shock in a child is suspected, how much fluid do you give them? Optimal UOP for infants is mL/kg/hr. How much warmed crystalloid should be used for a DPL in kids? What would you see in an infant that would make you suspect very severe brain injury despite normal LOC? What is a possible mistake about a blood pressure of 120/80 in a 87 year old man? How well do geriatric patients do with nonoperative management of abdominal injuries compared to younger people? Why would geriatric patients be MORE susceptible to head bleeds when there is increased space around a shrinking brain to protect them from contusion? Plasma volume increases during pregnancy, what happens to hematocrit? MASSIVE force and highly likely organ damage (since their ribs are very pliable, a huge amount of force is required to break them, there is often underlying organ damage WITHOUT broken ribs). Use tongue blade depressor and insert gently without turning – otherwise there is great risk for trauma and resultant hemorrhage. NOT the 180 degree spin trick. 90 mm Hg + (age x 2) 80 mL/kg 20 mL/kg warm crystalloid May need to repeat up to 3 times (60 mL/kg) then consider blood products. 2 (1.5 for younger kids, and 1.0 for older kids). 10 mL/kg (up to 1000 mL) Bulging fontanelles – these allow tolerance for expanding masses/swelling… Assuming that normal blood pressure = normovolemia. Many geriatric patients have uncontrolled hypertension, and if their normal systolic is 180, then 120/80 is relative HYPOtension for them. Not as well – the risks of non-operative management are often worse than the risks of surgery. Atrophic brains = stretching of the parasagittal bridging veins, making them more prone to rupture upon impact. Decreases – dilution by plasma (31-35% is normal in pregnancy) What would you think of a WBC of 15,000 in Normal, it can go up to 25,000 during labor! a pregnant woman? What should you always assume about a pregnant patient’s stomach? A PaCO2 of 35 to 40 in a pregnant patient may indicate what? That it is always full. (Gastric emptying time increases during pregnancy). Early NG tube placement recommended. Impending respiratory failure. It is usually around 30 due to hyperventilation due to increased levels of progesterone. Downloaded by: CHRISJAY | Distribution of this document is illegal Want to earn $103 per month? True or False: All Rh negative pregnant trauma patients should get Rhogam? When worn correctly, seatbelts reduce fatalities by %. True, unless the injury is remote from the uterus (distal extremity injury only). This therapy should be initiated within 72 hours of injury. 65-70%, with a 10-fold reduction in serious injury