SUMMARY ATLS EXAMINATION ATLS Chapters 1-3 ( LATEST

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