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Atls Flashcard
Atls Flashcard
ATLS MCQ #1
A 22 year old man is hypotensive and
tachycardic after a shotgun wound to
the left shoulder. His blood pressure is
initially 80/40 mmHg. After 2 liters of
crystalloid solution his blood pressure
increases to 122/84 mmHg His heart
rate is now 100 beats per minute and
his respiratory rate is 28 breaths per
minute. His breath sounds are
decreased in the left hemithorax, and
after initial IV fluid resuscitation, a
closed tube thoracostomy is performed
for decreased left breath sounds with
the return of a small amount of blood
and no air leak. After chest tube
insertion, the most approriate next step
is
a) reexamine the chest
b) perform an aortogram
c) obtain a CT scan of the chest
d) Obtain arterial blood gas analyses
e) perform tranesohageal
echocardiography
the answer is d ; but a website said a
(and a makes more sense to me. so i'll
go with a)
the website:
http://translate.google.com/translate?
hl=en&sl=nl&u=http://www.atls.nl/alsg
/atls.nsf/uploads/52D1762B14313442C1
25737500476755/%24FILE/Uitleg
%2520schriftelijk
%2520examen.doc&ei=VoIXTLOdCZ
LQM_zFmasL&sa=X&oi=translate&ct
=result&resnum=1&ved=0CBYQ7gEw
AA&prev=/search%3Fq%3D
%2522after%2Bchest%2Btube
%2Binsertion%2Bthe%2Bmost
%2Bappropriate%2522%2Bnext
%2Bstep%2Bis%26hl%3Den
Term
Definition
[Musculoskeletal trauma][Extremity
ATLS MCQ #2
A construction worker falls two stories
from a building and sustains bilateral
calcaneal fractures. In the emergency
department, he is alert, vital signs are
normal, and he is complaining of severe
pain in both heels and his lower back.
Lower extremity pulses are strong and
there is no other deformity. The
suspected diagnosis is most likely to be
confirmed by
a) angiography
b) compartment pressures
c) retrograde urethrogram
d) Doppler-ultrasound studies
e) complete spine x-ray series
the answer is e.
info: can't find the info
-------notes:
- angiography is found as CT
angiography, p.146, which focuses on
Definition
Definition
c) support circulation
c) control scalp hemorrhage
e) determine the GCS score
the answer is a.
info: p.154
Term
Definition
Definition
the answer is e.
Term
Definition
background:
The adequacy of therapy is confirmed
by simple determination of adequate
urine output and of the haemoglobin
and haematocrit levels. The most
important guide is the patients clinical
response
source:
http://www.medbc.com/annals/review/v
ol_16/num_4/text/vol16n4p173.asp
Term
Definition
a) hypoxemia
b) acidosis
c) hypotension
d) increased vascular resistance
e) evidence of inadequate organ
perfusion
the answer is e.
Definition
[MusculoskeletalATLS
trauma][Extremity
MCQ #9
a) application of a tourniquet
b) direct pressure on the wound
c) packing the wound with gauze
d) direct pressure on the femoral artery
at the groin
e) debridement of devitalized tissue
background
- tourniquet can be found on p.194, 195.
they imply that you use a tourniquet if
you are choosing life over limb, and if
direct pressure isn't working. (p.195)
Term
Definition
a) respiratory alkalosis
b) metabolic acidosis
c) cerebral vasoconstriction with
diminished perfusion
d) neurogenic pulmonary edema
e) shift of the oxyhemoglobin
dissociation curve
-------background info
Carbon dioxide is perhaps the most
potent available modulator of
cerebrovascular tone and thus cerebral
blood flow (CBF)
http://www.liebertonline.com/doi/abs/10
.1089/089771501750055776?
journalCode=neu
-----------
Definition
a) contrast angiography
b) transfer to higher level trauma
center
c) exploratory laparotomy
d) transfuse packed red blood cells
e) transesophageal echocardiography
Definition
Definition
background:
Term
Definition
a) 2
b) 4
c) 6
d) 9
e) 12
info: p.138
background info:
i used my card on gcs for this.
Term
Definition
background is:
Term
Definition
a) distended abdomen
b) glasgow coma scale score of 11
c) temperature of 36.5C (97.8F)
d) heart rate of 120 beats per minute
e) respiratory rate of 40 breaths per
minute
background is:
Term
Definition
a) endotracheal intubation
b) operation to close the wound
c) placing a chest tube through the
chest wound
d) placement of an occlusive dressing
over the wound
e) initiation of 2, large-caliber IVs with
crystalloid solution
background is:
Term
Definition
background info:
It is a contraindication to use this or
any other related vaccine after a serious
adverse event temporally associated
with a previous dose including an
anaphylactic reaction.
A history of systemic allergic or
neurologic reactions following a
previous dose of Tetanus Toxoid is an
absolute contraindication for further
use.2,5
found a source
http://www.rxlist.com/tetanus-drug.htm
Term
Definition
a. tachycardia
b. pulse volume
c. breath sounds
d. pulse pressure
e. jugular venous pressure
background info:
Term
Definition
[Pediatric trauma][Trauma
extremes
ATLS MCQin#20
background info:
Term
Definition
a) perform FAST
b) obtain a CT of the chest
c) perform an angiography
d) urgently transfer the patient to the
operating room
e) immediately transfer the patient to a
trauma center
background info:
Term
Definition
a) perform a surgical
cricothyroidotomy
b) attempt nasotracheal intubation
c) ventilate him with a bag-mask device
until c-spine injury can be excluded
d) attempt orotracheal intubation using
2 people and inline stabilization of the
cervical spine.
e) ventilate the patient with a bag-mask
device until his beard can be shaved for
better mask fit.
Definition
background:
Term
Definition
a) moist heat
b) early amputation
c) padding and elevation
d) vasodilators and heparin
e) topical application of silver
sulfadiazine
background is:
"4. Use moist heat (warm water) to
warm the casualty, rather than dry heat
(radiator or fire). Dry heat can cause
more damage."
source http://ezinearticles.com/?10Tips-For-TreatingFrostbite&id=1666183
Term
Definition
[Musculoskeletal
trauma][Extremity
ATLS
MCQ #25
background is:
Term
Definition
a) requires a CT scan
b) insert a gastric tube
c) suction the oropharynx
d) obtain a lateral cervical spine x-ray
e) ventilate the patient with a bag-mask
background is:
Term
Definition
background:
Term
Definition
background:
Term
Definition
a) oliguria
b) confusion
c) hypotension
d) tachycardia
e) blood transfusion requirement
background:
Term
Definition
background:
source:
http://en.wikipedia.org/wiki/Intraosseo
us_infusion
SOURCE OF DIRETIONS
http://docs.google.com/viewer?
a=v&q=cache:Rxmq0CyxS64J:www.fc
hn.org/docs/northstar/EZ-IO
%2520directions.pdf+intraosseous+infu
sion+system+directions&hl=en&gl=us
&pid=bl&srcid=ADGEESj6FX7bjUc0
C5D7KWUFeTb5TaPt3EGkLCJOC9v
BJGAdO4EXJTBlmph03TlX98ISaFN
WzadJs_GpwYvP0plN2qaIUn1G7arMl
9863x6bVhEqWxirhWJBhP-QQ47Hjltels61jbo&sig=AHIEtbTUtqah8qhN
5wrnat9mK5aa3zozoQ
Term
Definition
a) avoid hypotension
b) administer an osmotic diuretic
c) aggressively treat systemic
hypertension
d) reduce metabolic requirements of the
brain
Definition
a) hemorrhagic shock
b) cardiac tamponade
c) massive hemothorax
d) tension pneumothorax
e) diaphragmatic rupture
background is:
Term
Definition
background:
Term
Definition
background:
Term
Definition
background:
some info on flashcards for
tracheostomy indications (i.e. you don't
do it in emergency cases)
Term
Definition
a) It is not reliable
b) the body is proportionally larger in
infants than in adults
c) the head is proportionally larger in
infants than in adults
d) the legs are proportionally larger in
infants than in adults
e) the arms are proportionally larger in
infants than in adults
background info:
Term
Definition
a) perform a colonoscopy
b) perform a barium enema
c) perform an intravenous pyelogram
d) perform serial physical examination
e) suture repair the wound and
outpatient follow up
Term
Definition
background is:
Term
Definition
a) perform a thoracoscopy
b) perform an arch aortogram
c) insert a second left chest tube
d) prepare for an exploratory
thoracotomy
e) perform an chest CT
background:
Term
Definition
statements is true?
background:
Term
Definition
http://forums.studentdoctor.net/showth
read.php?t=736635
Term
Definition
Term
Definition
__________________
http://forums.studentdoctor.net/showth
read.php?t=736635
Term
Definition
Introduction
Bill Elder
A,B,C,D,E
Initial asessment
Injury -- primary survey -resuscitation -- reevaluation -- detailed
secondary survey -- reevaluation -optimize patient status -- transfer
Breathing
- RR, chest movement, air entry, oxygen
saturation
- Pitfall: Iatrogenic pneumothorax -20cm at the teeth is normal
Circulation
- other: base deficit, lactate - low
perfusion
- assess organ perfusion
- level of consciousness
- skin color and temperature
- pulse rate and character
- pulse rate and character
- control bleeding
- restore volume --> how do find goo
dmedicine
- reassess patient
- Pitfalls - elderly - atherosclerosis, keep
on bleeding; children -- bleed, but don't
drop BP; they bleed, squeeze their
vessels more
Disability
- GCS
- pupils
- observe for neurologic deterioration
Exposure/Enfironment
- avoid hypothermia
- eg. electric injury through heart? get
EKG, etc
- eg. electric injury through extremity?
Resuscitation
- protect and secure airway
- ventilate and oxygenate -- etCO2,
ABG
- stop the bleeding
- vigorous shock treatment
- protect from hypothermia
SECONDARY SURVEY
- Start after primary survey
- restart with ABCDEs are reassessed
- Make sure vital functions are
returning to normal
Parts
- history
- PE
- Neuro
- Diagnostic tests
- Reassess
History
A
M
P
L
E
Head
- unconscious? brain vs intoxicated?
- always check every orifice, and/or
look inside
- seat belt sign: cardiac contusion,
mesenteric bowel injury,
- retroperitoneal injury they can bleed
but nt show signs
- rectum: gross blood, pelvic fracture
going into rectum, rectal tone
- pelvis
- Extremities - x-ray involved area joint
above and joint below
- places where you can have blood loss
but wont 'be able to see
- chest, abd, thigh, retroperitoneal,
scalp laceration, (very vascular, can lose
"3L of blood"
Brain injjry
- early neurosurgical consult
Spine
- feel whole spine, any step off
- steroid for spinal cord injury; if > 8hr,
no steroid; based on physician
preference
Pain management
Transfer
- make sure you have secure airway,
adequate IVs
- take care of also what might happen
on transport
- if hemorrhaging, abdominal
distension, operate at facilty, then send
them
Video
- get info from EMS
- assign roles
- ABCDE
- x-rays chest, pelvis
- secondary survey, ABCDE
NOTES
- Be respectful to EMTs
- get mechanism from EMTs
- don't be prideful
- what is your leadership life
- pay attention to the vital sign
- you may be asked to do
cricothyrodotomy
- answer back is very important
- reviewing what they've already done
- ask the team, have we missed
something?
- when you get tertiary center, have an
Airway
- ask them if they are short of breath
- If they can answer, airway OK
- burn/inhalation injury, look ok, then
decompensates 5 minutes later
- airway compromise
- if intubating, chin lift, jaw thrust
- nasoairway -- helps if you're having
problems bagging them
- possible difficult airway; mouth
opening, anatomy (beard, short, thick
neck, receding jaw, protruding upper
teeth
- Oral intubation
- cricoid pressure, suction, c-spine
Airway management
- preoxygenate
- cricoid pressure - just enough to push
cartilage, light pressure
- sedate (medazolam); try to get a look,
see if you can ge tan airway, then
paralytic (succinylcholine); speaker
uses etomodate b/c less CV effects,
EtCO2 monitoring; turns yellow
SHOCK
Shock
- What is shock? How to recognize
shock
- shallow rapid breathing
- cold, diaphoretic
- anxiety
- get the history, AMPLE
- hypovolemic
- cardiogenic -- EKG, etc. arrhythmia,
pump failure
- Neurogenic - below T4, above T4 hypotension
- Other: adrenal insufficiency, DKA
Treatment
- direct pressure/tourniquet
- pelvic binders
- angioembolization -- by IR guys who
can do that
- reduce and spling fractures -- "all
fractures bleed"
Management
- monitor response
- prevent hypothermia
Rapid responders
Transient responders
- make sure you're prepared for them
to get worse
Non-responders
Class I hemorrhage
Class II - can be obnoxious, fluids, ?
blood
Class III
Class IV - have lots of blood ready!
Pitfalls
- athletes: bradycardia, hypotension -their baseline. so they can look like nonresponders
- pregnancy: so don't put them on their
back
- Medications: B-blockers, Ca channel
blockers
- Pacemaker:
- Hypothermia:
- Early coagulopathy:
- blood pressure does not equate to
cardiac output
- misleading Hct/Hgb
THORACIC TRAUMA
Birsche - ED
- Most life threatening injuries are
identified during the primary survey.
- Injuries: tracheal injury, etc
- Airway obstruction
- signs: stridor, accessory muscle use on
inspiration, hoarsness, subcutaneous
emphysema from laryngeal tracheal
tear
- Tension pneumothorax
- don't wait for the neck vein to
distend!
- don't wait 'till cyanosis!
- Open pneumothorax
- Flail chest
- will need to intubate
- intubate
- if you have flail chest, likely will get
pulmonary contusion
- give analgesia so they can take full
breath
- but not so much analgesia that they
are unable to take full breaths
- - you have to be judicious with fluids
- pulmonary contusions get worse the
first 4 hours or so
- you might see them grunting + nasal
flaring -- suggests pulmoanry contusion
Massive hemothorax
- >100mL blood loss
- flat vs distended neck veins
- to OR
- sometimes will need to put in 2 chest
tubes
- get blood ready
- If put in chest tube, can get
destabilized b/c the might had been
tamponaded off, and now you've
disrupted that tamponade.
Cardiac tamponade
- low BP
- distended neck veins
- FAST exam
Resuscitative thoracotomy
- penetrating trauma, pulse in field, lose
it in ED
- blung trauma, loses pulse in ED
- do not do a blunt trauma with PEA.
Other
- blung esophageal rupture - endoscopy
- contrast swallow
- traumatic diaphragmatic injury
- traumatic aortic disruption
- blunt cardiac injury - cardiac
contusion, ectopy, PVCs, etc. abnl EKG
- tracheobronchial tree injury - CXR
doesn't chang eafter chest tube
- pulmonary consuion, intubate sooner
rather than later
- traumatic asphyxia (petechia,
swelling, cerebral edema)
- subcutaneous emphysema
Fractures
- ribs
- old people: if rib fracture, incrased
mortality with each increasing rib
fracture
- kids - worry about associated injuries
RANDOM
- If patient has cerebral edema, don't
use succinylcholine.
ABDOMINAL INJURY
- MVA, seat belt sign
- Blunt trauma
- ? mechanism to determine suspected
abdominal injury
- spleen, liver, small bowel
- put in NG tube to decompress
stomach
- urinary catheter
- Blunt Trauma
- indication for laparotomy in blunt
trauma
- physiology of pelvic binders
- pelvic fractures - wrap/binder
Definition
HEAD TRAUMA
- scan them
- 58 y/o, fall, GCS 12, after admission,
deteriorates to 6
- ddx. head bleed, vs hemorrhage
somewhere
- i.e. could have both or none, or even
be intoxicated
- primary survey: "make sure that
when he comes in, you have a plan."
ATLS helps you manage the stress
- recognize injury, minimize secondary
injuries
- you need to have a plan. It could be
wrong, but you need to have a plan and
go with you. You can't teach someone to
have a plan. But you can correct an
incorrect plan.
- The head. It's a box. Keep it very
simple, and you can't get confused.
- Dural sinus filled with blood, so will
bleed a lot. It's just under the skull.
- Skull is very vascular. You can bleed
to death from a scalp injury.
- Cerebral blood flow -- can't measure
it directly; need to maximize it; what
you can tell is is it adequate vs
inadequate cerebral blood flow. based
Intracranial pressure
- keep it below 20
- can MAP - ICP = CPP (check
equation)
- Keep BP around 100 for patients
- Keep their BP up
- Hypotension is the worst thing that
can happen for the head
- Basilar
- with/without CSF leak
- if you can tell they have CSF, you
are the best doctor. It is hard to see
- with/without cranial nerve deficits
(double check)
Brain injuries
- Focal(ish)
- epidural
- subdural
- intraparenchymal
Diffuse(ish)
- concussion
- multiple contusions
- hypoxic/ischemic injury
Need to assess
- cervial spine fracture, carotid injury,
vertebral injury --> ischemia
- think abou the neck too for these
(above)
EPIDURAL HEMATOMA
- hit head
- look at side of the head
- the vessel is injured where it is secured
-- commonly, generally (think aortic
tear, meningeal artery, etc)
- can be rapidly fatal
- take to OR
- blood has iron, it's bright on CT
HERNIATION
- herniation is a clinical syndrome. If
you see a film, doesn't matter as much.
all about clinical syndrome.
SUBDURAL HEMATOMA
- if small, bone whiteness will hide it
- they don't die from the hematoma per
say
- they have underlying brain injury
(unlike the epidural hematoma)
because you have blood INSIDE the
brain
- if patient doing OK clinically, might
sit on it
- keywords: hyperdnesity, midline shift
- treatment: hemicraniectomy
- get a good neuro exam before you
intubate them
INTRACEREBRAL
HEMATOMA/CONTUSION
- these are proressive injury -- it evolves
over time
GCS
- if giving GCS, can give the
components when presenting your
patient (patient had eye opening, etc)
- tell them what the patient is doing (not
the words decorticate, or decerebrate)
- need to memorize it
GCS 13-15
- neuro exam most important
- most people get head CT
- if head CT normal, no alcoholol/drug,
maybe send home
GCS 9-12
- CT scan all
- neuro exam
GCS 3-8
- neuro
- reevaluate
MANAGEMENT
- ABCDE
- get GCS score
- pupils
- lateralization signs
- controlled ventilation
- goal: PaCO2 at 35mHg
- etCO2
- IV - euvolemia, NS or LR
- consult neuro
- mannitol
- use with signs of tentorial herniation
- can cause profound hypotension
- be careful before using this
Meds
- anticonvulsants, sedation, paralytics
(note that you do not use paralytics to
treat seizures!) duh
- use short acting paralytics
- sedation with propofol
Scalp wounds
- can staple it closed
- direct pressure
- can be badness in kids
Term
Definition
SPINE INJURY
Neurogenic shock
- high spine injury
- can develop airway problems too
- cervical or high thoracic
- give fluids first
- might need to give atropine b/c of
bradycardia
Spinal shock
- no hemodynamic issues
Consequences
- inadequate ventilation
- abdominal evaluation can be
compromised (no abd pain)
- occult compartment syndrome (see it
in M&M a lot)
Management
- keep BP>50
- maintain perfusion of spinal cord
(keep MAP>85 or normotensive); if
they are normally hypertensive, need to
keep their BP higher
- manage hypotension
- transfer for unstable fracture, any
neuro deficit (if outside hospital)
- preparation for transfer
- no studies have shown benefits of
steroids
- if you do use them, loading dose, run
for 24-48 hours
- some people do it, others don't
"when you are a resident, you just do
Definition
Musculoskeletal trauma
- splinting
- prevents further blood loss
- restore and maintain perfusion
- relieves pain
- stabilization
- rational for splinting
- secondary survey
- mechanism of injury
- time of injury - clean open fractures
within 6 hours
- concerns
- look for vascular compromise
- open fracture
- assess and manage vascular
compromize
- managing open fractures
- x-ray studies: a joint above and below
- Injuries causing compartment
syndrome
- crus injuries
- tibia, forearm
- vscular injury (bony injury likely
involved)
- cast, tight dressing
- burns
Pitfalls
- MSK exam
- have them move their extremities
- traction splint
- get to right length
- straps, adjust straps using good leg
- use it
- put ankle stirrup
- 2 straps above, 2 straps below knee
- while doing this, someone is pulling
traction
- you want to reduce the fracture
- when you release it, keep traction
while you pull the pin
- pain control
- pulse, sensation before and after
Vacuum splint
Compartment syndrome
- can miss this
- often seen in m&M
- if you have lactate trending up, think
about this
- sedate patient before you do a
fasciotomy!!!
Pelvic fracture
- legs, limb discrepancy
- look at the ring, follow the ring
Definition
C-spine
- adequate, see 7 cervical vertibrae
- look at alignment (A and C are most
important ones)
- look at bone for fracture or
dislocations
- cartilage
- dens
- odontoid view
- normal odontoid view
- c2 fracture
- hangmans fracture
- c4 fracture
- thoracolumbar fracture
- burst fraction
- in lower spine, do MRI most of the
time
- chance fracture
Definition
Thermal Injuries
Iowa
Burn patient
- intubate before you have to
- if you wait --> increased swelling -intubation more difficult
- breathing -- difficult in chest wall
expansion
- house fire -- can get arsenic poisoning
('cause arsenic is in a lot of stuff!) so
keep that in mind, watch for symptoms
Chemical burns
- wash them off
Electrical burns
- risk of myoglobinuria
Frostnip
- no ice crystal formation
- get patient naked
- passive warming
- fluids, pain meds, tetanus, etc
Treatment
- warmed environment, blankets, and
IV fluids
- surgical rewarming techniques,
lavage, etc
- take care of ABCs
Definition
Pediatric trauma
- most common cause of death in kids is
injury
- when kids do badly, it's because of
respiratory problem most of the time
- kids have a big head -- so put padding
under the shoulder blades when they
are on the board (body on backboard,
head off of it)
- <4y/o, trachea is a cone, reaches a
point at the cricoid membrane; more
A - obstructs easily;
- uncuffed ET tube; only need to put
the ET tube in like 1cm in or so; usually
no cuff before 6 y/o; not a fast rule
though
Intraosseus IV
- ideal spot is anterior tibia, but you can
put it in other places
Child abuse
- delay in care
- injury doesn't match with story
- story changes
- etc