A HIGH YIELD ATLS & TRAUMA QUESTIONS AND ANSWERS 2023

A HIGH YIELD ATLS & TRAUMA QUESTIONS AND ANSWERS 2023 Approach Overview 1. Preparation → Known & Potential Problems, People, Plan, & Props • Equipment Airway trays, BVM, C-spine equipment Breathing → chest tube tray x2, decompression needles Circulation → warmed IVF, O+/- PRBCs, tourniquet, splints, thoracotomy tray Drugs → code cart, RSI drugs, pain meds Extras → foleys, blankets, NG tube 2. Triage → Check for surgeon/TT/Trauma transfer cirteria → activate TT ± surgeon 3. Primary Survey (ABCDE) & Resus 4. Adjuncts to Primary & Resus → ECG, FAST, CXR, C-spine XR, AP pelvis XR, ABG, coags, CBC, C7, Foley, NG • Adjuncts should not interrupt resus 5. Decide to transfer or not 6. Secondary Survey & AMPLE Hx 7. Continuous Post-Resus Monitoring & Re-evaluation 8. Transfer to Definitive Care Criteria for any • Trauma Activation • Transfer to Trauma Centre • Presence of surgeon in trauma (Only the first 4 criteria) • Shock (SBP<90) • Required ETT • GCS<8 • Pentrating trauma to head, neck or torso • Limb amputation prox to wrist/ankle • 2 long bone # • Evidence of spinal cord injury • Major peds or preg >20w trauma Chest trauma + unstable VS + suspected HTX or PTX 1) Immediate needle/finger thoracostomies → chest tube 2) If >1500ml or >200ml/h → urgent thoracic consult Classification of Hemorrhagic SHOCK Class 1 → Normal VS (<750ml) Class 2 → Tachy, ↓PP (750-1500ml) Class 3 → HypoTN (1.5-2L) Class 4 →↓LOC/lethargic (>2L) Airway in trauma • Always maintain C-spine In trauma intubations, always ues • Manual n-line stabilization • A bougie • RSI unless predicted difficult intubation or mid-face trauma or CI (→ awake ± cric) • VL if possible (↓ c-spine movement) Trauma Primary Survey Airway & C-Spine precautions • Decide to ETT or not • If ETT → do neuro exam before ETT Breathing & Ventilation • Check: BS B/L, distress, asym, lacs/contusion/deformity/crepitus • R/O & treat ATOM-FC • O2 for all trauma patients Circulation & Hemorrhage Control • Check: Pulses, body-wide check for obvious bleeding (incl logroll+DRE , pelvis & FAST • R/O non-hemorrhagic shock → ATOM-FC + neurogenic shock → If suspect c-spine injury then expect neurogenic shock to follow (fluids won't work, need pressors!) • Circulation: If shock → warm NS/LR 2L bolus (20ml/kg PEDS) → O±blood & surgeon if refractory • Hemorrhage Control: quickly inspect the abdomen, pelvis & limbs for obvious massive bleeds → External: direct pressure & splint → Internal: Pelvic binder & OR Disability • Check: GCS/AVPU, pupils, 4 limbs for lateralizing signs, suspicious head/neck/spinal trauma • R/O Intracranial (herniation) or spine injury that require urgent interventions • Spinal precautions PRN Exposure • COMPLETELY UNDRESS, LOGROLL & DRE • Look for penetrating trauma, deformity, and contusions • Commonly missed areas → Axilla, Perineum, Skin folds • Blankets & warm IVFs Order Adjuncts Massive HTX criteria ADULTS • >1500ml initial output • >200 ml/h over next 2-4h PEDS • >15ml/kg initial output • 2 ml/kg over the first 4h Primary Survey Breathing/THORAX & Interventions ATOM FC → Critical intervention Airway obstruction → ETT/nasoTT/cric TPTX → decompression OPTX → 3 sided dressing Massive HTX → chest tube & surgical consult Flail chest → ETT Cardiac Tamponade → pericardiocentesis Trauma Secondary Survey Ensure primary survey is complete General GCS, LOC, specific complaints HEAD • Pupils, contusions, lacs, signs of skull# → skull #, ICH, herniation, spinal injury FACE • Midface instability, malocclusion → leforge #, mandibular # EYE • ↓EOM/vision/diplopia → blowout # or retrobulbar hematoma NECK → Maintain C-spine • Lacs, contusions, trach dev, JVD, crepitus, focal masses, c-spine TTP, voice → Penetrating neck injury → Blunt neck injury → C-spine # THORAX → ATOM FC • Lacs, contusions, resp effort/asym, TTP/crepitus, HS & BS Aortic injury Thorax injuries → non-massive HTX, simple PTX Oesphageal perforation Muscular diaphragmatic injury Fistula (bronchopleural) and other tracheobronchial injury Contusion to the heart or lungs ABDO/FLANK • Lacs, contusions, TTP, peritoneal signs → Diaphragmatic injury → Solid organ injury → Hollow organ injury → Retroperitoneal injury or bleeding GU & PELVIS • Lacs, contusions, sympheal TTP, DRE, blood/hematoma of meatus, penis, scrotum, PV → Pelvic # → Bladder & urethral injuries → External genital injury (scrotal & penile) NEURO • MS, parasthesias, motor or sensory deficits, mid-line spine TTP or deformity, rectal tone, peri-A sensation → Neuro/spinal injuries EXTREMITIES • Lacs, contusions, deformity, pulses, cap-refill, compartments → # or dislocations → Soft tissue injuries → Peripheral vascular injuries → Potential compartment syndromes Scalp Lac • Must close galeal defects • R/O the following in any scalp laceration → Underlying skull # → FBs → ICI Skull # Basilar # = temporal bone # • Clinical dx → NeuroSx consult & Abx AND CT to R/O other associated injuries • Signs → raccoon, battle, hemo-TM, CSF leak (rign sign), CN7 palsy, vertigo/hearing change Open # • Clinical dx → NeuroSx consult & Abx Traumatic Intracranial Injury • 4 types (excluding H-CVA) → age, mech, pathophys, S&S • Bare bones of management • Treatment goals • What if suspect ↑ICP? • Additional action if CT abnl, GCS<10? PART OF PRIMARY SURVEY SDH, EDH, traumatic SAH, Parenchymal injury 1. SDH → old, EtOH, btw dura & arachnoid, bridging veins, crescent shape, does not cross suture lines, AMS, more common than EDH, worse prog & higher mortality, presents late 2. EDH → rare in elderly & <2y, btw dura & skull, middle meningeal artery, lenticular shape, crosses suture lines, often temporal skull #, more immediate symptoms, lucid ↓LOC, ipsi dilated pupil, less common than SDH, better prognosis 3. Traumatic SAH → any age with blunt trauma, under the arachnoid, subarachnoid vessels bleed into basilar cisternsm, sulci & fissures, most common >mild TBI, H/A, photophobia, meningeal signs 4. Cerebral contusion → any age blunt trauma, ant temp or post frontal lobe, bleeds often delayed, common cause is shaken baby, severe blunt trauma, symptoms vary from none to LOC, commonly associated SAH Bare Bones Treatment • Reverse anticoagulation & call NSx • Manage BP • Avoid Hs (↓O2, ↓BG, ↑/↓CO2, ↑/↓T) • PRN → Manage ±ICP & ±Sz Treatment GOALs • Avoid HypoTN → MAP >80 to maintain CPP • Avoid Hyoxemia → PaO2 >60 or O2sat >90% • Avoid Hypoglycemia → BG 5-10 • Avoid Hypo/Hyper-carbia → PCO2 35-45 (neutral) • Avoid Hypo/Hyper-thermia → 36-38C • Suspect ↑ICP → Hob 30 (±mannitol if NO hypoTN & NO ICH) • Prophylactic phenytoin if abnl CT and GCS <10 or if already had a sz