ATLS EXAM WITH DETAILED VERIFIED ANSWERS (100% CORRECT ANSWERS) ALREADY GRADED A+

ATLS EXAM WITH DETAILED VERIFIED ANSWERS (100% CORRECT ANSWERS) ALREADY GRADED A+ "In the elderly population, what is decreased physiological reserve? - CORRECT ANSWER aging is characterized by impaired adaptive and homeostatic mechanisms that caused an increased susceptibility to the stress of injury. Insults tolerated by the younger population can lead to devastating results in elderly patients." "In the elderly population, what are risk factors for falls? - CORRECT ANSWER advanced age, physical impairment, history of previous fall, medication use, dementia, unsteady gait, and visual, cognitive impairment" "True or False? Mortality associated with small to moderate sized burns in older adults remains high - CORRECT ANSWER True" "Spilled hot liquids on the leg, which in younger patients may re-epithelialize due to an adequate number of hair follicles, will result in a full thickness burn in older patients. - CORRECT ANSWER this is true" "Airway-patients may have dentures that may loosen or obstruct the airway. If dentures are not obstructing the airway, leave them in place for what? - CORRECT ANSWER bag mask ventilation, as it improves mask fitting." "Functional changes in pulmonary system include decreased elastic recoil, reduced residual capacity, decreased gas exchange and decreased cough reflex - CORRECT ANSWER thus they are at increased risk for respiratory failure, increased risk for pneumonia, and poor tolerance to rib fractures" "Functional changes in renal system include loss of renal mass, decreased GFR, and decreased sensitivity to ADH and aldosterone - CORRECT ANSWER resulting in drug dosing for renal insufficiency, decreased ability to concentrate urine, increased risk for AKI and urine flow may be normal with hypovolemia" "True or false: Arthritis can complicate the airway and cervical spine. Patients can have multilevel degenerative changes affecting disk spaces and posterior elements associated with severe central canal stenosis, cord compression, and myelomalacia - CORRECT ANSWER true" "In elderly population, due to their changes in pulmonary system, placing a gauze between gums and cheek to achieve seal when using bag valve mask ventilation is okay. In addition, because aging causes a suppressed heart rate response to hypoxia...... - CORRECT ANSWER respiratory failure may present insidiously in older adults." "what 2 factors place elderly patients at risk for intracranial hemorrhage? - CORRECT ANSWER aging causes dura to become more adherent to the skull increasing risk of injury and older patients are on anticoagulant and antiplatelet medications." "Loss of subcutaneous fat, nutritional deficiencies, chronic medical conditions place elderly patients as risk for hypothermia and complications for immobility. - CORRECT ANSWER Rapid evaluation and when possible early liberation from spine boards and cervical collars will minimize complications." "True or False: Fall prevention is the mainstay of reducing the mortality associated with pelvic fractures. - CORRECT ANSWER true" "Common mechanisms of injury include falls, MVC, burns, and penetrating injuries - CORRECT ANSWER common injuries in the elderly include rib fractures, TBI, pelvic fractures" "The best initial treatment for the fetus is to provide optimal resuscitation of the mother. True or False? - CORRECT ANSWER True. Also if xray examination is indicated during the pregnant patient's treatment, it should not be withheld because of the pregnancy." "An abrupt decrease in maternal intravascular volume can result in a profound increase in uterine vascular resistance reducing fetal oxygenation despite reasonably normal maternal vital signs. - CORRECT ANSWER this is true" "Physiological anemia of pregnancy - CORRECT ANSWER A smaller increase in red blood cell volume can occur resulting in a decreased hematocrit level. Thus, in late pregnancy a hematocrit of 31-33% is normal." "Healthy pregnancy patients can lose mL of blood before exhibiting signs and symptoms of hypovolemia. How can this manifest? - CORRECT ANSWER this amount of hemorrhage may be reflected by fetal distress as evidenced by an abnormal fetal heart rate." "What are some of the lab changes in pregnancy? - CORRECT ANSWER WBC increases to 12000 and during labor can be 25000. Fibrinogen and other clotting factors are mildly elevated and PT and pTT are shortened, but bleeding time and clotting time are unchanged." "After the 10th week of pregnancy, cardiac output can increase 1.0-1.5 L/min because of the increase in plasma volume and decrease in vascular resistance of the uterus and placenta. - CORRECT ANSWER The placenta receives 20% of the patient's cardiac output during the 3rd trimester. In supine position, vena cava compression can decrease cardiac output by 30% because of decreased venous return from lower extremities." "EKG findings in pregnant patient - CORRECT ANSWER Flatted or inverted T waves in leads III and AVF and the precordial leads may be normal. Ectopic beats are increased during pregnancy." "Urinary system: what happens to the GFR, serum creatinine and urea nitrogen levels? - CORRECT ANSWER GFR and renal blood increases during pregnancy, whereas levels of the serum creatinine and urea nitrogen fall to one half of the normal pre pregnancy levels. Glycosuria is common in pregnancy." "When interpreting x ray films of the pelvis in a pregnant patient, the symphysis pubis widens 4-8 mm and the sacroiliac joint spaces increase by the 7th month - CORRECT ANSWER keep this in mind" "Eclampsia - CORRECT ANSWER Maintain a high index of suspicion for eclampsia when seizures are accompanied by HTN, proteinuria, hyperreflexia, and peripheral edema in pregnant trauma patients. This can mimic head injury." "External contusions and abrasions of the abdominal wall are signs of blunt uterine trauma. - CORRECT ANSWER true. Fetal injuries can occur when the abdominal wall strikes an object, such as the dashboard or steering wheel, or when a pregnant patient is struck by a blunt instrument." "Using a shoulder restraints in conjunction with a lap belt reduces the likelihood of direct and indirect fetal injury, presumably because the shoulder belt dissipates deceleration forces over a great surface area and helps prevent the mother from flexing forward over the gravid uterus. - CORRECT ANSWER the deployment of air bags in vehicles does not appear to increase pregnancy specific risks. Using lap belt alone allows for forward flexion and uterine compression with possible uterine rupture or placental abruption. Lap belt worn too high over uterus may produce uterine rupture." "Failure to displace the uterus to the left side in a hypotensive pregnant patient - CORRECT ANSWER logroll all patients appearing clinically pregnant (second and third trimester) to the left 15-30 degrees and elevate the right side 4-6 inches and support with a bolstering device to maintain spinal motion restriction and decompression of the vena cava." "Due to increases intravascular volume, pregnant patients can lose a significant amount of blood before tachycardia, hypotension, and other signs of hypovolemia occur. Thus, what do stable vital signs in a pregnant patient indicate about the fetus? - CORRECT ANSWER The fetus may be in distress and the placenta deprived of vital perfusion while the mother's condition and vital signs appear stable. Administer crystalloid fluid resuscitation and blood to support the physiological hypervolemia of pregnancy. vasopressers should be an absolute last resort in restoring maternal blood pressure as they further reduce uterine blood flow, resulting in fetal hypoxia." "Perform continuous fetal monitoring with a tocodynamometer beyond 20-24 weeks of gestation. - CORRECT ANSWER Patients with no risk factors for fetal loss should have continuous monitoring for 6 hours, whereas, patients with risk factors for fetal loss or placental abruption should be monitored for 24 hours. RISK FACTORS ARE: heart rate > 110, an injury severity score >9, evidence of placental abruption, fetal heart rate >160 or less than 120, ejection during MV, and motorcycle or pedestrian collisions" "REMEMBER: maternal bicarbonate is low during pregnancy to compensate for respiratory alkalosis. - CORRECT ANSWER 17-22 in pregnant patient. (non pregnant patient is 22-28)" "Fetal heart rate is a sensitive indicator of maternal blood volume status and fetal well being. - CORRECT ANSWER normal range for fetus is 120-160. abnormal heart rate, repetitive decelerations, absence of accelerations or beat to beat variability and frequent uterine activity can be signs of impending maternal and or fetal decompensation (hypoxia or acidosis) and should prompt immediate obstetrical consultation." "If a DPL is to be placed in a pregnant trauma patient, place the catheter above the umbilicus using the open technique. Be alert to uterine contractions which suggest early labor and tetanic contractions which suggest placental abruption. - CORRECT ANSWER evidence of ruptured chorioamniotic membranes include amniotic fluid in vagina evidenced by a pH of 4.5" "Bleeding in 3rd trimester may indicate placental abruption and impending death of the fetus, a vaginal exam is vital - CORRECT ANSWER however, avoid repeating vaginal examination, CT abdominal imaging can be done and radiation doses less than 50mGy are not associated with fetal anomalies or higher risk of fetal loss." "Admission to hospital for pregnant patients: - CORRECT ANSWER vaginal bleeding, uterine irritability, abdominal tenderness, pain or cramping, evidence of hypovolemia, changes in or absence of fetal heart tones and or leakage of amniotic fluid" "With extensive placental separation or amniotic fluid embolization, widespread consumptive coagulopathy can emerge rapidly causing depletion of fibrinogen, other clotting factors, and platelets. - CORRECT ANSWER immediately perform uterine evacuation and replace platelets, fibrinogen, and other clotting factors." "As little as 0.01mL of RH+ blood will sensitize 70% of Rh- women. - CORRECT ANSWER All pregnany RH negative trauma patients should receive RH immunoglobulin therapy unless injury is remote from the uterus (isolated distal extremity injury)" "Factors that increase the risk of upper airway obstruction are: - CORRECT ANSWER increasing burn size and depth, burns to the head and face, inhalation injury, associated trauma, and burns inside the mouth. Airway can become obstructed form direct injury such as inhalation injury, but also from massive edema resulting from burn injury." "Indications for early intubation in burn patients: - CORRECT ANSWER full thickness circumferential neck burns, signs of airway obstruction, extent of the burn > 40%, burns inside the mouth, difficulty clearing secretions or swallowing, decreased level of consciousness," "Patient with inhalation injury are at risk for bronchial obstruction from secretions and debris and they may require bronchoscopy. - CORRECT ANSWER Make sure to place an adequately sized airway tube" "Direct thermal injury to the lower airway is very rare and essentially occurs only after exposure to superheated steam or ignition of inhaled inflammable gases. Breathing concerns arise from what 3 general causes: - CORRECT ANSWER hypoxia, carbon monoxide poisoning, and smoke inhalation injury." "Always assume CO exposure in patients who were burned in enclosed areas. Patients with CO levels less than 20% may not show any symptoms - CORRECT ANSWER HA and nausea (20-30%), confusion (30-40%), coma (40-60%) and death (>60%). Cherry red skin color in patients may only be seen in moribund patients. Measurements of arterial PaO2 do not reliably predict CO poisoning b/c a partial pressure of only 1 mm Hg results in an HbCO level of 40% or greater. Pulse ox cannot be relied on to rule out carbon monoxide poisoning b/c we cant distinguish oxyhemoglobin from carboxyhemoglobin. A discrepancy between pulse ox and arterial blood gas may be explained by presence of carboxyhemoglobin." "Cyanide inhalation poisoning can occur in confined spaces and sign of potential toxicity is persistent profound unexplained metabolic acidosis. - CORRECT ANSWER THERE IS NO ROLE for hyperbaric oxygen therapy in the primary resuscitation of a patient with critical burn injury." "Tachycardia is a poor indication for resuscitation in the burn patient. - CORRECT ANSWER Adjust the fluid rate up or down based on the urine output and recognize that factors such as inhalation injury, age of patient, renal failure, diuretics, and alcohol can affect the volume of resuscitation and urine output." "True of false: Burn patients should get tetanus. - CORRECT ANSWER true" "Partial thickness burns - CORRECT ANSWER are characterized as either superficial partial thickness (moist, painfully hypersensitive, , potentially blistered, homogenously pink, and blanch to touch) or deep partial thickness ( drier, less painful, potentially blistered, red or mottled in appearance, and do not blanch to touch)" "Full thickness burns - CORRECT ANSWER appear leathery and skin may be white or translucent or waxy white. surface area is painless to light touch or pinprick and generally dry" "compartment syndrome may be present with circumferential chest and abdominal burns - CORRECT ANSWER chest and abdominal escharotomies performed along the anterior axillary lines with cross incision at the clavicular line and the junction of the thorax and abdomen usually relieve this problem. relieve circulatory compromise in a circumferentially burned limb by eschartomy and these escharotimies are not needed within the first 6 hours." "Partial thickness burns are painful when air currents pass over the burned surface. - CORRECT ANSWER gently cover the burn with clean sheets will decrease the pain and deflect air currents. Do not break blisters or apply an antiseptic and application of cold compress can cause hypothermia. DO not apply cold water to a burn patient." "electrical burns are more serious than they appear on the body surface and extremities, particularly the digits. - CORRECT ANSWER current can travel inside blood vessels and nerves and can cause local thrombosis and nerve injury. So a severe electrical injury usually results in contracture of the affected extremity." "A clenched hand with a small electrical entrance wound should alert the clinician that a deep soft tissue injury is likely much more extensive than is visable to the naked eye - CORRECT ANSWER true. patients with severe electrical injuries require fasciotomies. Electricity can cause forced contraction of muscles, doctors need to examine patient for skeletal and muscular damage, especially for fractures of the spine and rhabdomyolysis" "How do you dissolve a tar burn? - CORRECT ANSWER Use mineral oil" "Abuse and burns - CORRECT ANSWER circular burns and burns with clear edges and unique patterns may reflect cigarette burns or iron. Burns on the sole of the feet usually suggest child was placed in hot water. A burn on the posterior aspect of the LE and buttocks" "Patient with electrical burn can develop for acute renal failure - CORRECT ANSWER remember these burns can cause serious muscle damage without showing signs outright. Test urine for hemochromogen and administer proper volume. Assess for compartment syndrome and attach EKG leads as electrical injury can cause arrhythmias." "Frostbite is due to freezing of tissue with intracellular ice crystal formation, microvascular occlusion, and subsequent tissue anoxia. - CORRECT ANSWER first degree: hyperemia and edema are present w/o skin necrosis second degree: large clear vesicles accompany the hyperemia and edema with partial thickness skin necrosis. third degree frostbite: full thickness skin necrosis including muscle and bone with later necrosis treatment is circulating water at constant 40 degrees C or 104F until pink color and perfusion return in 20-30 minutes." "In frostbite injury, warming large areas can result in reperfusion syndrome, with acidosis, hyperK and local swelling. - CORRECT ANSWER therefore monitor the patient's cardiac status and peripheral perfusion during rewarming." "Sympathetic blockade agents and vasodilating agents have shown to be effective in altering the progression of acute cold injury - CORRECT ANSWER false" "hypothermia is a core temp below 36C or 96.8F - CORRECT ANSWER hypothermia can worsen coagulopathy and affect organ function." "Rhabdomyolysis can lead to metabolic acidosis, hyperK, hypoC, and DIC. - CORRECT ANSWER Myoglobin induced renal failure can be prevented with intravascular fluid expansion, alkalinization of the urine by IV administration of Bicarbonate and osmotic diuresis." "For MSK trauma, loss of sensation in a stocking or glove distribution is an early sign of.... - CORRECT ANSWER early sign of vascular impairment" "Knee dislocations can reduce spontaneously and may not present with any gross external or radiographic anomalies until a physical exam of is joint is perfromed. - CORRECT ANSWER an ankle brachial index of less than 0.9 indicates abnormal arterial flow secondary to injury or peripheral vascular disease" "Blanched skin associated with fractures and dislocations can lead to soft tissue necrosis. The purpose of promptly reducing this injury is to prevent pressure necrosis of the lateral left ankle soft tissue - CORRECT ANSWER the only reason to forgo an xray exam before treating a dislocation or fracture is the presence of vascular compromise or impending skin breakdown, often seen with fracture dislocations of the ankle" "Treat all patients with open fractures as soon as possible with iv antibiotics - CORRECT ANSWER cephalosporins are necessary for all open fractures" "operative revascularization to an avascular extremity is important to treat emergently. - CORRECT ANSWER muscle necrosis begins where there is a lack of blood flow for 6 hours. is there is an associated fracture deformity, correct it by gently pulling the limb out to length, realigning the fracture and splinting the injured extremity. This maneuver can restore the blood flow" "High risk activities that can cause compartment syndrome include: - CORRECT ANSWER excessive exercise burns severe crush injury to muscle localized prolonged external pressure to an extremity increased capillary permeability secondary to reperfusion of ischemic muscle." "Compartment syndrome is a clinical diagnosis and pressure measurements are only an adjunct to aid in its diagnosis. a pressure greater than 30 can cause anoxia. - CORRECT ANSWER the absence of a palpable distal pulse is an uncommon or late finding and is not necessary to diagnose compartment syndrome. Capillary refill times are also unreliable weakness or paralysis of the involved muscle is a late sign and indicates nerve or muscle damage the lower the systemic pressure, the lower the compartment pressure that causes compartment syndrome" "risk of tetanus: - CORRECT ANSWER wounds that are more than 6 hours old contused or abraded more than 1cm in depth from high velocity missiles due to burns or cold significantly contaminated ischemic tissue or denervated wounds" "True or false? on page 162. To exclude occult dislocation and concomitant injury, x ray films must include the joints above and below the suspected fracture site - CORRECT ANSWER true. unless life threatening, splinting of extremity injuries should be done during the secondary survey." "do not apply traction to patients with an ipsilateral tibia shaft fracture. - CORRECT ANSWER true" "Laryngeal Trauma presents as hoarseness, subcutaneous emphysema, and palpable fracture - CORRECT ANSWER true. sounds of airway obstruction and include snoring, gurgling, stridor, hoarseness, cyanosis, agitation" "LEMON assessment for difficult airway - CORRECT ANSWER Look, evaluate 3-3-2 rule, mallampati, obstruction, neck mobility" "Do not give a nasopharyngeal airway to someone suspected of having a cribriform plate fracture. - CORRECT ANSWER also do not give nasotracheal intubation to patients with basillar skull fracture" "A tube placed in the trachea with the cuff inflated below the vocal cords and the tube connected to oxygen enriched assisted ventilation and airway secured in place. - CORRECT ANSWER definitive airway" "patients use the gum elastic bougie when vocal cords cannot be visualized on direct laryngoscopy. - CORRECT ANSWER using the GEB has allowed for rapid intubation of nearly 80% of prehospital patients in whom laryngoscopy was difficult. A GEB inserted into the esophagus will pass its full length without resistance" "Reliable ways to detect proper intubation - CORRECT ANSWER proper placement of the tube is suggested but not confirmed: 1. hearing equal breath sounds bilaterally 2. detecting no borborygmi (rumbling or gurgling noises) in the epigastrium. the presence of this with inspiration suggestion esophageal intubation and warrants removal of tube 3. A CO2 detector ideally capnograph or colorimetric CO2 monitoring device. If CO2 is not detected in exhaled air, then esophageal intubation has occurred. 4. Proper position of the tube is best confirmed via chest xray" "definitive control of hemorrhage and restoration of adequate circulating volume are the goals of treating hemorrhagic shock. - CORRECT ANSWER never give vasopressors as the first line treatment as they worsen tissue perfusion. most injured patients who are in hemorrhagic shock require early surgical intervention or angioembolization to reverse the shock state. The presence of shock in a trauma patient warrants the immediate involvement of a surgeon." "An injured patient who is cool to the touch and is tachycardic should be considered to be in shock until proven otherwise. Massive blood loss may only produce a slight decrease in HCT/Hgb. - CORRECT ANSWER relying solely on BP as an indicator of shock can delay recognition of the condition b/c compensatory mechanisms can prevent measurable fall in systolic pressure until up to 30% of the patient's blood volume is loss. A narrowed pulse pressure suggests significant blood loss and involvement in compensatory mechanisms. tachycardia is diagnosed as > 100 in adults > 160 in infants >140 in preschool aged children >120 in children from school age to puberty." "Tachycardia, muffled heart sounds, dilated engorged neck veins, hypotension and insufficient response to fluid therapy is what? - CORRECT ANSWER cardiac tamponade, which is commonly caused by penetrating thoracic trauma, but can result from blunt injury to the thorax. Definitive treatment is operative intervention as pericardiocentesis is temporary measure. Tension pneumothorax differs because it presents with distended neck veins and hypotension as well as absent breath sounds and hyperresonant percussion" "Acute respiratory distress, subcutaneous emphysema, absent unilateral breath sounds, hyperresonance to percussion, and tracheal shift supports the diagnosis of???? - CORRECT ANSWER tension pneumothorax. needle or finger decompression temporarily relieves this life threatening condition and follow this with a chest tube" "isolated intracranial injuries do not cause shock, unless the brainstem is injured. A narrowed pulse pressure is not seen in neurogenic shock. - CORRECT ANSWER The classic presentation of neurogenic shock is hypotension (due to loss of sympathetic tone) without tachycardia. A narrowed pulse pressure is not seen in neurogenic shock. The failure of fluid resuscitation to restore organ perfusion and tissue oxygenation suggest either continuing hemorrhage or neurogenic shock" "Less than 15% blood loss. no change in HR, BP, pulse pressure, RR, urine output. - CORRECT ANSWER this is class 1 hemorrhage and requires monitoring with base deficit of 0- -2" "15-30% blood loss. increase in heart rate. decrease in pulse pressure. BP, RR, urine output do not change - CORRECT ANSWER class II hemorrhagic shock. possible need for blood products, but mostly crystalloid fluid and base deficit of -2 to -6. anxiety, fear" "31-40% blood loss. heart rate increase, respiratory rate increase, blood pressure decrease, pulse pressure decrease, urine output and GCS decrease - CORRECT ANSWER class III and this is the least amount of blood loss that consistently causes a drop in systolic blood pressure. blood products needed and base deficit is -6 to -10" "> 40% blood loss. heart rate increase, RR increase, BP decrease, pulse pressure decrease, urine output and GCS decrease - CORRECT ANSWER MTP and base deficit is -10 or less" "A chest xray must be obtained after attempts at inserting a subclavian or IJ to document position of line and evaluate for pneumo or hemothorax. - CORRECT ANSWER do not use sodium bicarb to treat metabolic acidosis from hypovolemic shock" "Hypothermia can be prevented and reversed by storing crystalloids in a warmer or infusing them through intravenous fluid warmers. - CORRECT ANSWER blood products cannot be store in a warmer, but they can be heated by passage through intravenous fluid warmers. Fluids should be warmed to 39C or 102.2F before infusing them." "Massive fluid resuscitation with the resultant dilution of platelets and clotting factors (severe hemorrhage and injury results in consumption of coagulation factors and early coagulopathy) contributes to coagulopathy in injured patients. - CORRECT ANSWER The response of elderly patients, athletes, pregnant patients, patients on medications, hypothermic patients, and patients with pacemakers or implantable devices may have different set of vitals in response to shock." "Older patients are unable to increase their HR when stressed by blood volume loss. A systolic BP of 100 may represent shock in an elderly patient. Due to medications, HR may not increase in the elderly population when in shock. - CORRECT ANSWER Blood volumes may increase 15-20% in athletes, cardiac output can increase 6 fold and the rest HR can be 50. Trained athletes have a remarkable ability to compensate for blood loss and they may not manifest the usual way to hypovolemia, even with significant blood loss." "Patients suffering from hypothermia and hemorrhagic shock do not respond as expected to the administration of blood products and fluid resuscitation. IN hypothermia, coagulopathy may develop and worsen. - CORRECT ANSWER When a patient fails to respond to fluid therapy one or more of these causes may be: tension pneumothorax, cardiac tamponade, undiagnosed bleeding, unrecognized fluid loss, acute gastric distention, MI, diabetic acidosis, neurogenic shock" "Tracheobronchial injury will present with hemoptysis, cervical subcutaenous emphysema, tension pneumothorax, and/or cyanosis. - CORRECT ANSWER A bronchoscopy can confirm the diagnosis, but these patients require immediate surgical consultation. intubation of these patients may be difficult, so they may need fiber optic assisted ET" "what are these signs and symptoms describing? chest pain, air hunger, tachypnea, respiratory distress, tachycardia, hypotension, tracheal deviation away from side of injury, unilateral absence of breath sounds, neck vein distention, cyanosis (late manifestation), hyperresonance on percussion - CORRECT ANSWER tension pneumothorax. initially, you can do a needle decompression or finger thoracostomy. place tube in afterwards" "pain, difficulty breathing, tachypnea, decreased breath sounds on affected side, and noisy movement of air through chest wall injury - CORRECT ANSWER these are signs and symptoms of an open pneumothorax. sterile occlusive dressing large enough to overlap the wound's edges and tap it securely on 3 sides" "Causes of Pulseless Electrical Activity - CORRECT ANSWER hypovolemia, hypokalemia, hyperkalemia, hypoglycemia, hypothermia, toxins, cardiac tamponade, tension pneumothorax, thrombosis" "Massive hemothorax is suggested when a patient is in shock and has decreased breath sounds or dullness to percussion on one side of the chest with collapsed neck veins - CORRECT ANSWER chest tube at the fifth intercostal space at the midaxillary line and you get a return of 1500mL or 1/3 or more of the patient's blood in the chest, that indicated the need for urgent thoracotomy. persistent need for blood is an indication for a thoracotomy. color of the blood is a poor indicator of the necessity for thoracotomy." "muffled heart sounds, hypotension, and distended necks veins may not always be present in cardiac tamponade. Kussmaul's sign (rise in venous pressure with inspiration when breathing spontaneously) is a true paradoxical venous pressure abnormality that is associated with tamponade - CORRECT ANSWER The presence of hyperresonance on percussion indicated tension pneumothorax whereas presence of bilateral breath sounds is cardiac tamponade. FAST can identify cardiac tamponade. if FAST is unavailable, use echo or pericardial window. definitive treatment is surgery so thoracotomy or sternotomy." "potentially life threatening injuries that should be identified on secondary survey - CORRECT ANSWER simple pneumothorax, hemothorax, flail chest, pulmonary contusion, blunt cardiac injury, traumatic aortic disruption, traumatic diaphragmatic injury, esophageal rupture" "pulmonary contusion can occur with rib fractures and flail chest (two or more adjacent ribs fractured in two or more places). - CORRECT ANSWER initial treatment includes humidified oxygen, adequate ventilation, and cautious fluid resuscitation. definitive treatment includes pain control, adequate oxygenation" "Blunt cardiac injury can present with hypotension, dysrhythmias, EKG changes, premature ventricular contractions, unexplained sinus tachycardia, AFib, bundle branch block, elevated central venous pressure without any obvious cause may indicate right ventricular dysfunction secondary to contusion. - CORRECT ANSWER cardiac troponins can be diagnostic in an MI but have little role in diagnosing blunt cardiac injury. patients with a blunt injury to the heart diagnosed by conduction abnormalities are at increased risk for sudden dysrhythmias and need to be monitored for 24 hours." "Traumatic aortic disruption- most survive if they have an incomplete laceration near the ligmentum arteriosum. commonly caused by vehicle collision or fall from a great height. have a high index of suspicion if history has decelerating force. - CORRECT ANSWER Look for widened mediastinum on chest xray, obliteration of the aortic knob, deviation of the trachea to the right, depression of the L mainstem bronchus, elevation of R mainstem bronchus, deviation of the esophagus to the right, left hemothorax, presence of the pleural or apical cap, fractures of the first or second rib or scapula, widened paraspinal interface, widened paratracheal stripe." "In a traumatic aortic rupture, heart rate and blood pressure control can decrease the likelihood of rupture. - CORRECT ANSWER definitive treatment is surgery." "Diaphragmatic injury-displaced bowel, stomach, and nasogastric tube on left side. - CORRECT ANSWER The appearance of peritoneal lavage fluid in the chest tube also confirms diagnosis" "esophageal injury- clinical picture is a patient with a left pneumothorax or hemothorax without a rib fracture who has received a severe blow to the lower sternum or epigastrum and is in pain or shock out of proportion to the apparent injury - CORRECT ANSWER presence of mediastinal air also suggests diagnosis and definitive treatment is direct repair of the injury." "injuries to the retroperitoneal structures are difficult to recognize because they occur deep within the abdomen and may not initially present with signs or symptoms of peritonitis. - CORRECT ANSWER the retroperitoneal space is NOT sampled by DPL or FAST" "physical exam findings suggestive of a pelvic fracture include: - CORRECT ANSWER ruptured urethra, scrotal hematoma or blood at the urethral meatus, discrepancy in limb length and rotational deformity of a leg w/o obvious fracture. use pelvic binder that is centered at the greater trochanters rather than over the iliac crests." "signs of urethral injury include: - CORRECT ANSWER blood at the uretheral meatus, ecchymosis or hematoma of the scrotum and perineum. Palpation of the prostate gland is NOT a reliable sign of urethral injury. a retrograde urethorgram is mandatory when the patient is unable to void, requires a pelvic binder, or has blood at the meatus, scrotal hematoma, or perineal ecchymosis. confirm an intact urethra before inserting a urinary catheter." "DPL: Aspiration of gastrointestinal contents, vegetable fibers, or bile through the lavage mandate laparotomy. Aspiration of 10cc or more of blood in hemodynamically abnormal patients requires laporotomy. - CORRECT ANSWER performed rapidly, invasive procedure sensitive for detecting intraperitoneal hemorrhage low specificity requires gastric and urinary decompression not repeatable a positive DPL is an indication for laparotomy contraindications include previous abdominal operations, morbid obesity, advanced cirrhosis, pre-existing coagulopathy." "FAST - CORRECT ANSWER noninvas and can be done rapidly repeatable does not assess retroperitoneal structures. obesity can degrade images obtained by FAST" "indications for a laparotomy: - CORRECT ANSWER Blunt abdominal trauma with hypotension, positive FAST hypotension with an abdominal wound that penetrates anterior fascia gunshot wounds that traverse the peritoneal cavity evisceration bleeding from stomach, rectum, or GU tract peritonitis free air of hemidiaphragm contrast CT showing rupture GI tract, bladder injury Aspiration of gastrointestinal contents, vegetable fibers, or bile through the lavage mandate laparotomy. Aspiration of 10cc or more of blood in hemodynamically abnormal patients requires laparotomy." "Diaphragm injuries - CORRECT ANSWER elevation or blurring of the hemidiaphragm, hemothorax, an abnormal gas shadow that obscures the hemidiaphragm, or a gastric tube in the chest" "Duodenal injuries- a bloody gastric aspirate or retroperitoneal air on abdominal CT or radiograph should raise suspicion - CORRECT ANSWER classically seen in unrestrained drives involved in frontal-impact MVC and patients who sustain direct blows to the abdomen from bicycle handlebars." "Any early normal serum amylase level or an elevated amylase level does not conclude pancreas injury - CORRECT ANSWER " "uncal herination - CORRECT ANSWER ipsilateral pupillary dilation associated w/contralateral hemiparesis and loss of pupillary response to light" "ICP - CORRECT ANSWER normal is 10. > 22 has poor outcomes. increased ICP decreases cerebral perfusion pressure. monroe kellie doctrine states that total volume of intracranial contents must remain constant because cranium is a rigid container incapable of expanding." "CPP= MAP -ICP - CORRECT ANSWER a MAP of 50-150 is autoregulated to maintain a constant cerebral blood flow. GCS of 8 or less= severe brain injury GCS of 9-12= moderate GCS of 13-15= mild" "Indications for CT scanning - CORRECT ANSWER GCS < 15 at 2 hours after injury suspected open or depressed skull fracture any sign of basilar skull fracture emesis more than 2 episodes age > 65 anticoagulant use LOC > 5 minutes amnesia before impact" "Goals of treatment of brain injury - CORRECT ANSWER systolic BP > 100 temp 36-38 Glucose 80-180 Hgb > 7 PaCO2 35-45 ICP 5-15 pulse ox > 95 NA 135-145" "TBI treatment - CORRECT ANSWER IV fluids & hypertonic saline (do not give hypotonic fluids or glucose containing fluids because this can harm the injured brain) Avoid hyponatremia reversal of anticoagulants Hyperventilation to keep PaCO2 at 35-temporizing measure Mannitol-do not give to patients with hypotension" "reversal agents: - CORRECT ANSWER aspirin/plavix: platelets warfarin: FFP, vitamin K, Prothrombin Complex Heparin or LMWH: Protamine Sulfate Direct thrombin inhibitors: Idarucizumab Rivaroxaban: N/A" "Neurogenic shock - CORRECT ANSWER loss of vasomotor tone and sympathetic innervation to the heart. Injury T6 and above can cause impairment of the sympathetic pathways. We get hypotension and bradycardia. Neurogenic shock is not reversed with fluid resuscitation alone. Vasopressors may be required. spinal shock refers to the loss of muscle tone (flaccid) and reflexes immediately after injury" "Central cord syndrome - CORRECT ANSWER loss of function in upper extremities > lower extremities occurring after a hyperextension injury, forward fall resulting in facial impact." "Anterior Cord Syndrome - CORRECT ANSWER injury to the motor and sensory pathways in the anterior part of cord. paraplegia and bilateral loss of pain and temp. However, position, vibration, and deep pressure sense are preserved (sensations from dorsal columns). commonly due to cord ischemia" "Brown-Sequard Syndrome - CORRECT ANSWER results from hemisection of the spinal cord. Ipsilateral motor loss and loss of position sense and contralateral loss of pain and temp" "Atlanto Occipital Dislocation - CORRECT ANSWER this is commonly seen in shaken baby syndrome due to severe traumatic flexion and distraction. Most patients with this injury die of brainstem destruction and apnea or have profound neurological impairments." "Jefferson Fracture - CORRECT ANSWER Burst fracture of C1 due to axial loading, which occurs when a large load falls vertically on the head in a relatively neutral position. Disruption of anterior and posterior rings of C1 Fracture best seen on an open mouth view of the C1-C2 region on CT" "Hangman Fracture - CORRECT ANSWER this involves the posterior elements of C2, the pars interarticularis and this type of fracture is caused by an extension type injury" "Chance Fracture - CORRECT ANSWER transverse fractures through the vertebral body seen after MVC where patient was restrained by only an improperly placed lap belt. Chance fractures can be associated with retroperitoneal and abdominal visceral injuries. these are unstable and require internal fixation" "NEXUS - CORRECT ANSWER Neurological deficit ethanol intoxication distracting injury unable to provide history spinal tenderness midline" "Signs of blood loss in a child - CORRECT ANSWER progressive weakening of peripheral pulses, narrowing pulse pressure less than 20, skin mottling (clammy skin), cool extremities compared with torso skin, decrease in level of consciousness with dulled response to pain. often times tachycardia may be the only sign of shock in a kid" "hypotension in child - CORRECT ANSWER systolic BP for kid is 90 + twice the child's age in years. hypotension represents a state of decompensated shock and can indicated blood loss of > 45%." “True or false? Although the mechanism of injury may be similar to those for the younger population, data shows increased mortality with similar severity of injury in older adults. - CORRECT ANSWER True" "Pre-existing conditions that affect morbidity and mortality include: - CORRECT ANSWER cirrhosis, coagulopathy, COPD, ischemic heart disease, DM" "What is the most common mechanism of injury in the elderly? - CORRECT ANSWER Fall. Nonfatal falls are common in women and fractures are common in women who fall. Falls are the most common cause of TBI." "Most of elderly traffic fatalities occur in the daytime and on weekends and typically involve other vehicles. Why? - CORRECT ANSWER Older people drive on more familiar roads and at lower speeds and tend to drive during the day. Older people have slower reaction time, a larger blind spot, limited cervical mobility, decreased hearing, and cognitive impairment." "When preforming rapid sequence intubation, the dose of benzos, barbiturates, and other sedatives should be reduced to what percentage to minimize the risk of cardiovascular depression? - CORRECT ANSWER 20-40%" "Functional changes in cardiac system include declining function, decreased sensitivity to catecholamines, atherosclerosis of coronary vessels, increased afterload, fixed heart rate (beta blockers) - CORRECT ANSWER this results in lack of classic response to hypovolemia, risk for cardiac ischemia, elevated BP at baseline, and increased risk of dysrythmias." "Functional changes to MSK include loss of lean body mass, osteoporosis, changes in joints and cartilage, c spine degenerative changes and loss of skin elastin and subcutaneous fat - CORRECT ANSWER resulting in increased risk for fractures, decreased mobility, difficulty for oral intubation, risk of skin injury, increased risk for hypothermia, challenges in rehabiliation" "Functional changes in Endocrine system include decreased production and response to thyroxin and decreased dehydroepiandrosterone (DHEA) - CORRECT ANSWER resulting in occult hypothyroidism, relative hypercortisone states and increased risk of infection" "Age related changes in the cardiovascular system place the elderly trauma patient at significant risk for being inaccurately categorized as hemodynamically stable. - CORRECT ANSWER Elderly patients have a fixed heart rate and fixed cardiac output, thus, their response to hypovolemia will involve increasing their systemic vascular resistance. Furthermore, since older patients have HTN, an acceptable BP may truly reflect a hypotensive state. A systolic BP of 110 is to be utilized as the threshold for identifying hypotension in patients 65 and older." "Do no equate blood pressure with shock in older patients - CORRECT ANSWER BP in older patients may look normal due to the medications they are on. Use lactate and base deficit to evaluate for evidence of shock" "poor hygiene, dehydration, oral injury, contusions affecting the inner arms, inner thighs, palms, soles, scalp, ear, nasal bridge and temple injury from being struck while wearing glasses, contact burns and scalds. These are all signs of.......? - CORRECT ANSWER Elder maltreatment. The presence of physical findings of maltreatment should prompt a detailed history. if history conflicts with findings, immediately report findings to authorities." "True of false: early activation of the trauma team may be required for elderly patients who do not meet traditional criteria for activation - CORRECT ANSWER True. A simple injury such as an open tibia fracture in a frail elderly patient may become life threatening." "What happens as the uterus enlarged and the bowel is pushed cephalad. - CORRECT ANSWER When the uterus enlarges it pushes the bowel cephalad and the uterus lies in the upper abdomen. As a result, the bowel is somewhat protected from blunt abdominal trauma, whereas the uterus and its contents (fetus and placenta) become more vulnerable. Uterus remains intrapelvic until 12 weeks and then at 20 weeks it is at the umbilicus, and at 34-36 weeks it reaches the costal margin." "Amniotic fluid can cause amniotic fluid embolism and disseminated intravascular coagulation following trauma if fluid enters maternal intravascular space. True or False - CORRECT ANSWER True" "By the third trimester, what is the complication of trauma to the pelvis of the mother? - CORRECT ANSWER by the third trimester, the uterus is large and thin walled. In vertex presentation, fetal head is usually in the pelvis and the remainder of the fetus is exposed above the pelvic brim. Pelvic fractures in late gestation can result in skull fracture or intracranial injury to the fetus. Also we can have a placental abruption due to its little elasticity and vulnerability to sheer forces." "During pregnancy the heart rate increases to a maximum of 10-15 beats per minute over baseline by the third trimester. - CORRECT ANSWER this heart rate must be considered when interpreting a tachycardic response to hypovolemia." "Blood pressure falls 5-15 mm Hg in systolic and diastolic pressures during second trimester, although it returns to near normal levels at term. - CORRECT ANSWER some women experience hypotension when placed in the supine position due to the compression of teh inferior vena cava." "hypertension in the pregnant if accompanied by proteinuria may represent what? - CORRECT ANSWER pre-eclampsia." "Minute ventilation increases primarily due to an increase in tidal volume. Hypocapnia (30 mm Hg) is common in late pregnancy - CORRECT ANSWER Monitor ventilation in late pregnancy with arterial blood gas values. A PaCO2 of 35-40 mm Hg may indicate impending respiratory failure during pregnancy. Pregnant patients should be hypocapneic." "Anatomical alterations in the thoracic cavity seem to account for the decreased residual volume associated with diphragmatic elevation and chest x ray reveals increased lung marking and prominence of the pulmonary vessels. - CORRECT ANSWER oxygen consumption increases during pregnancy and its important when resuscitating injured pregnant patients to maintain adequate oxygenation above 95%" "In patients with advanced pregnancy, those that require a chest tube placement, where should the test tube be placed? - CORRECT ANSWER it should be positioned higher to avoid intra-abdominal placement given the elevation of the diaphragm." "Penetrating injury to pregnant women - CORRECT ANSWER As uterus grows larger, other viscera are protected from penetrating injury. Dense uterine musculature in early pregnancy can absorb significant amount of energy from penetrating objects decreasing their velocity and lowering risk of injury to other viscera. However, fetal outcome is generally poor with penetrating injury to uterus." "carefully observe pregnant patients with even minor injuries since occasionally minor injuries are associated with placental abruption and fetal loss. - CORRECT ANSWER True. AND to optimize outcomes for mother and baby, clinicians must assess and resuscitate the mother first and then assess the fetus before conducting second survey of the mother." "What does a normal fibrinogen level indicate in a pregnant patient? - CORRECT ANSWER Fibrinogen level may double in late pregnancy and a normal level may indicate early disseminated intravascular coagulation" "Most common cause of fetal death? - CORRECT ANSWER maternal shock and maternal death. Placental abruption is second. Placental abruption is suggested by vaginal bleeding, uterine tenderness, frequent uterine contractions, uterine tetany, and uterine irritability (uterus contracts when touched). In 30% of cases of abruption, bleeding may not occur. Uterine ultrasound may be helpful in diagnosis, but is NOT definitive." "Signs of uterine rupture - CORRECT ANSWER abdominal tenderness, guarding, rigidity, or rebound tenderness. Signs of peritonitis are hard to tell due to expansion and attenuation of the abdominal wall musculature. Other findings include abdominal fetal lie (oblique or transverse lie), easy palpation of the fetal parts because of their extrauterine location and inability to readily palpate the uterine fundus when there is fundal rupture. Xray evidence of rupture include extended fetal extremities, abnormal fetal position, and free intraperitoneal air." "Intimate partner violence in pregnant patient: - CORRECT ANSWER injuries inconsistent with history, diminished self image, depression or suicide attempts, self abuse, frequent ED visits, symptoms suggestive of substance abuse, isolated injuries to the gravid abdomen, parter insists on being present for the interview and exam and monopolizes discussion" "What is the difference between burns and other injuries? - CORRECT ANSWER The biggest difference is that the consequences of burn injury are directly linked to the extent of the inflammatory response to the injury. The larger and deeper the burn, the worse the inflammation." "Flame injury is more evident than most chemical injuries. - CORRECT ANSWER Monitor IV lines closely to ensure they do not become dislodged as the patient becomes more edematous. Regularly check ties securing ET or NG to ensure they are not too tight." "How do you decontaminate burn areas? - CORRECT ANSWER Completely remove the patient's clothing to stop burning process, but do not peel off adherent clothing. Synthetic fabrics can ignite, burn rapidly at high temps and melt into hot residue that continues to burn the patient. brush any dry chemical powder from wound. rinse with copious amounts of warm saline irrigation or rinsing in a warm shower. once the burning process has been stopped, cover the patient with warm, clean, dry linens to prevent hypothermia." "hoarseness, stridor, accessory respiratory muscle use, sternal retraction are signs of what? - CORRECT ANSWER airway obstruction. Clinical manifestations of inhalation injury may be subtle and may not show up within the first 24 hours. do not wait for the xray to show evidence of pulmonary injury or changes in blood gas because airway edema can preclude intubation and a surgical airway will be required." "A carboxyhemoglobin level greater than what percentage indicates a patient was involved in a fire and has inhalation injury? - CORRECT ANSWER 10%" "American Burn Association states 2 requirements for diagnosis of smoke inhalation injury: - CORRECT ANSWER 1. exposure to combustible agent 2. signs of exposure to smoke in the lower airway, below the vocal cords, seen on bronchoscopy. A chest Xray and arterial blood gases should be ordered to evaluate the pulmonary status of a patient with smoke inhalation injury, but normal values on admission DO NOT exclude an inhalation injury." "The treatment of smoke inhalation injury is supportive. - CORRECT ANSWER Any patient with smoke inhalation injury and significant burns greater than 20% TBSA should be intubated. IF the patient's hemodynamic condition permits and spinal injury has been excluded, elevate the patient's head and chest 30 degrees to help reduce neck and chest wall edema." "True or false: Clinicians should provide burn resuscitation fluids for deep partial and full thickness burns larger than 20% TBSA - CORRECT ANSWER True. urine output monitoring is 0.5mL/kg/hr in adults and should be maintained at 30-50cc/hr to minimize over resuscitation" "in a burn patient, cardiac dysrhytmias may be the first sign of hypoxia and electrolyte or acid base abnormalities. - CORRECT ANSWER therefore an ECG should be performed for cardiac rhythm disturbances. Persistent acidemia in patients with burn injuries may be due to under resuscitation or infusion of large volumes of saline." "Compartment syndrome in burn patients: - CORRECT ANSWER Compartment syndrome can result from an increase in pressure inside the compartment that interferes with perfusion to the structures within that compartment. In burns, this condition results from a combination of decreased skin elasticity and increased edema in the soft tissue. A pressure > 30 mm Hg within the compartment can lead to muscle necrosis and once the pulse is gone it may be TOO LATE to save the muscle. so recognize the signs early: pain greater than expected and out of proportion to the injury pain on passive stretch of the affected muscle tense swelling of the affected compartment paresthesias or altered sensation distal to the affected compartment"