SUMMARY ATLS EXAMINATION ATLS Chapters 1-3 Question Answer Patients with a GSC of less than ___ usually require intubation. 8 The "A" in ABCD stands for _______. Airway maintenance with CERVICAL SPINE PROTECTION 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? Cervical spine injury Flail chest is invariably accompanied by ______ which can interfere with blood oxygenation. pulmonary contusion - do NOT over fluid resuscitate these patients! Hypotension is caused by _____ until proven otherwise. hypovolemia When you don't have/can't get a blood pressure, what are three things to look for when evaluating perfusion. 1. Level of consciousness (brain perfusion), 2. Skin color (ashen face/grey extremities) 3. Pulse (bilateral femoral - thready/tachy) Elderly patients have a limited ability to ______ to compensate for blood loss. increase heart rate Resuscitation fluids should be warmed 39 degrees Celsius (102.2 F). Can you use a microwave to do this? YES - for CRYSTALLOID ONLY (but NOT for blood products). Urinary catheters are good for assessing renal perfusion and volume status. List 5 signs of urethral injury that might prevent you from inserting one. Blood at urethral meatus, perineal ecchymosis, blood in scrotum, high-riding/non- palpable prostate, pelvic fracture Which arm should you NOT put a The arm with a blood pressure
Transcript
SUMMARY ATLS EXAMINATIONATLS Chapters 1-3
Question AnswerPatients with a GSC of less than ___ usually require intubation.
8
The "A" in ABCD stands for _______.Airway maintenance with CERVICAL SPINE PROTECTION
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?
Cervical spine injury
Flail chest is invariably accompanied by ______ which can interfere with blood oxygenation.
pulmonary contusion - do NOT over fluid resuscitate these patients!
Hypotension is caused by _____ until proven otherwise.
hypovolemia
When you don't have/can't get a blood pressure, what are three things to look for when evaluating perfusion.
1. Level of consciousness (brain perfusion), 2. Skin color (ashen face/grey extremities) 3. Pulse (bilateral femoral - thready/tachy)
Elderly patients have a limited ability to ______ to compensate for blood loss.
increase heart rate
Resuscitation fluids should be warmed 39 degrees Celsius (102.2 F). Can you use a microwave to do this?
YES - for CRYSTALLOID ONLY (but NOT for blood products).
Urinary catheters are good for assessing renal perfusion and volume status. List 5 signs of urethral injury that might prevent you from inserting one.
Blood at urethral meatus, perineal ecchymosis, blood in scrotum, high-riding/non-palpable prostate, pelvic fracture
Which arm should you NOT put a pulse-ox on? The arm with a blood pressure cuff on itName two anatomical things that can interfere with doing a FAST scan.
Obesity & intraluminal bowel gas
When should radiographs be obtained? During the SECONDARY survey.
How do you get an ample patient history?A=Allergies, M=Medications, P=PMH/Pregnancy, L=Last meal, E=Events/Environment of injury
Why might you want a Bair Hugger for a patient who smells of alcohol?
Vasodilation can lead to hypothermia
What things are you looking for when you do a DRE in a trauma?
Blood, high-riding prostate (in males), and sphincter tone
What should you do for every female patient?
Pregnancy test (females of childbearing age)
Adult patients should maintain UOP of at least ___ mL/kg/hr. Kids should have at least ___ mL/kg/hr.
Adults 0.5 mL/kg/hr, Kids 1.0 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 you suspect hypoxemia?
Lips and fingernail beds
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
Can a patient breathe on their own after complete cervical cord transection?
Yes, if the phrenic nerves (C3-C5) are spared. This will result in "abdominal" breathing. The intercostal muscles will be paralyzed though.
Can you use an OPA (Guedel) in a conscious patient?
No, it could make them vomit. An NPA (trumpet) would be okay.
Bougies are typically inserted blindly, how do you know you are in the trachea and not the esophagus?
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 patient after placement of an ET tube?
Borborygmi - rumbling or gurgling noises suggesting esophageal insertion.
What is the RSI dose for etomidate? 0.3 mg/kg (usually 20 mg)What is the RSI dose for sux? 1-2 mg/kg (usually 100 mg)
How does etomidate affect blood pressure?
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.
A RSI dose of sux usually lasts about ___ minutes.
5
What hypnotic/sedative/induction agent do you NOT want to use for a severely burned patient?
SUX - patients with severe burns, crush injuries, hyperkalemia, or chronic paralytic/neuromuscular diseases should NOT get sux because of hyperkalemia risk.
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?
Adults 12-14 gauge, kids 16-18 gauge
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 ___.
12
In a "normal" patient without significant chest wall injury or lung disease, needle cricothyroidotomy can provide adequate oxygenation for approximately ____ minutes.
30-45
For a patient with difficulty breathing, what Chin-lift, jaw-thrust (NOT head-tilt while
things might you try before you provide a surgical airway?
How do you know if an OPA/Guedel is the correct size for the patient?
A correctly sized OPA will extend from the corner of the patient's mouth to the external auditory canal.
What should do with the balloon on an ET tube/LMA/foley before you insert it?
Inflate it to make sure it doesn't leak - then deflate and insert.
What size LMA do you use for kid, woman/small man, large woman/man?
Kid: 3, Woman/small man: 4, Large woman/man: 5 (C3,4,5 keep the diaphragm alive)
The proper size ET tube for an infant is ______.The same size as the infant's nostril or little finger. (Usually size 3 for neonates, 3.5 for infants)
What size cuffed endotracheal tube do you use for an emergency cricothyroidotomy?
5 or 6
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?
Age/4 + 4 mm = internal diameter
Shock is defined as an abnormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation. What are the 4 different types?
Neurogenic, cardiogenic, hypovolemic, septic
The most common cause of shock in the injured trauma patient is _____.
hemorrhage
Approximately ___% of the body's total blood volume is located in the venous circuit.
70
Why does shock actually reduce the total volume of circulating blood?
Anaerobic metabolism --> can't make more ATP --> Endoplasmic then mitochondrial damage --> lysosomes rupture --> sodium and WATER enter the cell, which SWELLS and dies.
Which vasopressors should you use to treat hemorrhagic shock? What are the drug doses?
NEVER use pressors for hypovolemic shock - use VOLUME replacement. Pressors will worsen tissue perfusion in hemorrhagic shock.
Compensatory mechanisms may preclude a measurable fall in systolic blood pressure until up to __% of the patient's blood volume is lost.
30
Any patient who is cool and is tachycardic is considered to be ______ until proven otherwise.
in shock
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?
Infants >160, toddlers/preschoolers >140, school age/prebuscent >120, adults >100
Elderly patients may not exhibit tachycardia in response to hypovolemia because of limited
They might be on a beta-blocker or have a pacemaker.
cardiac response to catecholamines. Why else might not they get tachy?A FAST scan is an excellent way to diagnose cardiac tamponade. What signs suggest tamponade?
Becks's Triad: JVD, muffled heart sounds, and hypotension (will be resistant to fluid therapy). Will also likely be tachycardic.
Patients with a tension pneumo and patients with cardiac tamponade may present with many of the same signs. What findings will you see with a tension pneumo that you will NOT see with tamponade?
Absent breath sounds and hyperresonance to percussion over the affected hemithorax.
Immediate thoracic decompression is warranted for anyone with absent breath sounds, hyperresonance to percussion, tracheal deviation, ____, and ____.
Can isolated intracranial injuries cause neurogenic shock?
NO
How do you calculate total blood volume in an adult?
70 mL per kg body weight. A 70 kg person has about 5 liters of circulating blood. (70*70=4900)
How do you calculate total blood volume in an child?
Body weight in kg x 80-90 mL
The blood volume of an obese person is calculated based upon their ______ weight.
ideal
Fluid replacement should be guided by ________, not simply by the initial classification (Class I-IV).
The patient's response to initial replacment
How much blood volume is lost with Class I Hemorrhage?
Up to 15% Donating 1 pint, or ~500 mL of blood is about a 10% volume loss and would qualify as Class I Hemorrhage!
How do you treat a Class I Hemorrhage?
You don't (usually). Transcapillary refill and other compensatory mechanisms usually restore blood volume within 24 hours.
How much blood volume is lost with Class II Hemorrhage?
15-30% (750-1500 mL in a 70 kg adult)
How do you treat a Class II Hemorrhage? Usually just crystalloid resuscitationSubtle CNS changes such as anxiety, fright, and hostility would be expected in a patient with a Class __ Hemorrhage.
II
How much blood volume is lost with Class III Hemorrhage?
30-40% (2000 mL in a 70 kg adult)
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.
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.
Loss of more than ___% of blood volume results in loss of consciousness.
50
How much blood volume is lost with Class IV Hemorrhage?
More than 40%. Unless very aggressive 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.
III
Up to ______ mL of blood loss is commonly associated with femur fractures.
1500
Unexplained hypotension or cardiac dysrhythmias (usually bradycardia from excessive vagal stimulation) are often caused by ______, especially in children.
gastric distention
How much crystalloid should you give an adult for an initial fluid resuscitation bolus? For kids?
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.
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.
3
Blood on the floor x four more is a mnemonic for occult blood loss where?
Chest, pelvis, retroperitoneum, and thigh
For children UNDER 1 year of age, UOP should be ___ mL/kg/hr.
2
Would patients in EARLY hypovolemic shock be acidodic or alkalotic?
Alkalotic - respiratory alkalosis from tachypnea....followed later by mild metabolic acidosis in the early phase of shock.
"Rapid responders" whose vital signs return to normal (and stay there) after fluid resuscitation likely have/had a Class ___ Hemorrhage.
I or II
"Transient responders" are associated with Class ___ Hemorrhage.
II or III
What differential diagnoses should you always consider for "non-responders" following fluid resuscitation?
Most patients receiving blood transfusions ____ need calcium replacement.
don't
ATLS Chapters 4-6
Question AnswerHow should you position the patient before SUPINE, head down 15 degrees to distend neck
placing a subclavian or IJ line?veins and prevent embolism, only turn head away if C-SPINE HAS BEEN CLEARED FIRST.
How long can you keep an IO line in?
Intraosseous infusion should be limited to emergency resuscitation and shoudl be discontinued as soon as other venous access is obtained.
Where do you want to make an incision for a saphenous vein cutdown and how long should your incision be?
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 and there are absent breath sounds over the left hemithorax, where should you place your decompression needle?
This may NOT be a pneumothorax, for intubated patients always suspect a right main-stem before attempting needle decompression.
Where would you insert a large caliber needle to decompress a tension pnuemothorax?
Into the 2nd intercostal space in the midclavicular line of the affected hemithorax.
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.
2/3
Flail chest results from multiple rib fractures - by definition this would be ___ or more ribs, fractured in ___ or more places.
2 or more ribs fractured in 2 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 _______.
Percussion - hyperresonant with pnuemo, dull with hemothorax.
If a patient doesn't have JVD, does this mean they don't have a tension pneumo or tamponade?
No, they might have a massive internal hemorrhage and be hypovolemic.
By definition, how much blood is in the chest cavity to call it a "massive hemothorax"?
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).
What size chest tube might you use to evacuate a massive hemothorax?
#38 French - inserted at the 4th or 5th intercostal space, just anterior to the midaxillary line.
What is Kussmaul's sign?
A rise in venous pressure with inspiration while breathing spontaneously, and is a true paradoxical venous pressure abnormality associated with cardiac tamponade.
How well do CPR compressions work on someone with a penetrating chest injury and hypovolemia?
"Closed heart massage for cardiac arrest or PEA is INEFFECTIVE in patients with hypovolemia." Patients with PENETRATING thoracic injuries who arrive pulseless, but with
myocardial electrial activity, may be candidates for an ED thoacotomy.
Are patients with PEA who have sustained blunt thoracic injuries candidates for an ED thoracotomy?
NO - Only PEA with PENETRATING thoracic injuries should get an ED thoracotomy.
An ED thoracotomy can allow you to do what?
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.
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?
CHEST TUBE - positive pressure ventilation can turn a simple pneumo into a tension pneumo, so put in a chest tube first.
Should you evacuate a simple hemothorax if it is not causing any respiratory problems?
YES - A simple hemothorax, if not fully evacuated, may result in a retained, clotted hemothroax with lung entrapment or, if infected, develop into an empyema.
A pneumothorax associated with a persistent large air leak after tube thoracostomy suggests a _______ injury.
tracheobronchial - Use bronchoscopy to confirm, you may need more than one chest tube before definitive operative management.
What radiographic findings are suggestive of traumatic aortic disruption?
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.
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 _________.
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.
Fractures for the lower ribs (10-12) should increase suspicion for _____ injury.
hepatosplenic
Why are upper torso, facial, and arm plethora with petechiae associated with crush injuries to the chest?
Temporary compression of the superior vena cava.
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?
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.
What's a good way to know if you've advanced your needle too far during pericardiocentesis and have entered ventricular muscle?
ECG Changes - extreme ST-changes, widened QRS, PVCs, etc... Withdrawl needle until ECG returns to baseline.
What should you do with your needle after you successfully evacuate blood during pericardiocentesis?
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.
For patients with facial fractures or basillar skull fractures, gastric tubes should be inserted ____ before doing a DPL.
through the mouth
You need to do retrograde urethrography PRIOR to foley placement if _____.
inability to void, unstable pelvic fracture, blood at urethral meatus, scrotal hematoma, perineal ecchymoses, or high-riding prostate.
DPL is considered to be __% sensitive for detecting intraperitoneal bleeding.
98
What are the four places you should look first when doing a FAST scan?
Mediastinum, hepatorenal fossa, splenorenal fossa, pouch of Douglas.
DPL is indicated when a patient with multiple blunt injuries is hemodynamically unstable, especially when they have _____.
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...).
What is the only ABSOLUTE contraindication to DPL?
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?
>100,000 red cells/mm^3, 500 white cells/mm^3, or BACTERIA (on gram stain).
Your trauma patient needs an urgent laparotomy, can you take them to the CT scanner first to evaluate injuries?
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 patients with penetrating abdominal wounds?
What percentage of stab wounds to the anterior abdomen do NOT penetrate the
25-33%
peritoneum?Does an early normal serum amylase level exclude major pancreatic trauma?
NO
Do you need to operate on anyone with an isolated soild organ injury?
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).
Which is LESS likely to have a life-threating hemorrhage - an open book or closed book pelvic fracture?
Closed book - the pelvic volume is compressed, so not as much room for blood.
Anterior/posterior forces causes _____ book pelvic fractures, and lateral forces cause _____ book fractures.
AP = Open Book, LATERAL = Closed Book
Which are more common, open or closed book pelvic fracturs?
CLOSED BOOK - 60-70% (Open book 15-20%, vertical shear 5-15%)
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?
Angiography
What do you need to do BEFORE you do a DPL? (Other than getting stuff together and surgically prepping, etc...)
DECOMPRESS BLADDER, DECOMPRESS STOMACH
What is "adequate" fluid return when getting DPL fluid back?
30%
A blown pupil in a patient with a traumatic injury is caused by compression of which nerve?
Superficial parasympathetic fibers of the CN III (occulomotor).
What is a "normal" ICP in the resting state?10mm Hg (Pressures >20, particularly if sustained, are associated with poor outcomes).
The Monro-Kellie Doctrine describes compensatory mechanisms inside the calvarium to stabilize pressure - what are the 2 main/first ones?
Venous Blood & CSF (decreased in equal volumes, when this is exhausted, herniation can occur and brain perfusion will likely be inadequate).
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?
Minor = 13-15, Moderate = 8-12
When calculating GCS and there is right/left assymetry in the motor response - which one do you use?
The "BEST" response. (Better predictor than worst response)
What signs might you see if a patient has a basillar skull fracture?
PERIORBITAL ECCHYMOSIS (raccoon eyes), RETROAURICULAR ECCHYMOSIS (Battle sign), and otorrhea/rhinorrhea.
What do you need to know about the GCS? EVERYTHING - Know it COLD!What things might require a person with MINOR brain injury get admitted?
Abnormal CT (or no scan available), penetrating head injury, prolonged LOC, worsening LOC, moderate to severe HA, significant drug/alcohol
intoxication, skull fx, oto/rhinorrhea, nobody at home to watch, GCS stays <15, focal neuro deficits.
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?
CT scan - Everything but the 30 min amnesia makes them HIGH risk for neurosurgical intervention (as would a basillar skull fx).
What 2 things do you need to do first for everyone with a MODERATE brain injury (according to ATLS algorithm)?
CT scan, admit to faciolity capable of definitive neurosurgical care (Moderate = GCS 9-12)
High levels of CO2 will cause cerebral vasculature to _____.
Dilate (to increase blood flow) - so you might want to HYPERventilate people with brain injuries.
Ideally, you want to wait to perform a GCS on a person with SEVERE brain injury until what?
BP is normalized
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.
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.
A midline shift of greater than ___ often indicates the need for neurosurgical evacuation of the mass/blood.
5mm
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?
0.25-1.0 g/kg via rapid bolus
A cast cutter should be removed to remove a trauma victim's helmet if there is evidence of a c-spine injury or if _____.
the patient experiences pain or paresthesias during an initial attempt to remove the helmet.
ATLS Chapters 7-13
Question Answer
What are the signs of neurogenic shock?
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.
How do you treat neurogenic shock?Judicious use of pressors and MODERATE fluid resuscitation. Too much fluid may result in overload and pulmonary edema.
What is the most common type of C1 fracture?
Burst fractures (Jefferson fracture)
What’s the difference between types I, II, and III odontoid process fractures?
I=tip of odontoid, II=fx at base, III=base of odontoid and extends obliquely into body of axis. (Odontoid process = dens).
What are the indications for c-spine radiographs in a trauma patient? Which x-ray views should be obtained?
Midline neck pain, tenderness on palpation, neurological deficits related to c-spine injuries, altered LOC or intoxication. 1) Lateral, 2) AP, 3) Open mouth odontoid view
With the proper views of the c-spine, and a qualified radiologist – what is the sensitivity for finding unstable cervical spine injuries?
>97% (CT with 3mm slices >99%).
Ten percent of all patients with a c-spine fracture have what?
A second, noncontiguous vertebral column fracture. (So scan the rest of their spine).
Attempts to align the spine for the purpose of immobilization on the backboard are not recommended if they _______.
cause pain
Can you clear a c-spine without films?
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.
Should a quadriplegic or paraplegic patient be put on a hard board?
Not for more than 2 hours – get them off ASAP.
What’s a big difference in a physical finding between hypovolemic and neurogenic shock?
Hypovolemic = usually TACHY, Neurogenic = usually BRADY
Partial or total loss of respiratory function may be seen in a patient with a cervical spine injury above ___.
C6
Why might someone not be able to breathe if they have a long bone fracture?
Fat embolism – uncommon though
Abnormal arterial blood flow is indicated by an ABI of ____.
<0.9
By LOOKING at the patient, what findings might suggest pelvic injury?
Crush injuries may result in rhabdomyolysis – casts block flow, also iron is released which forms ROS which then damage cells and impair ability to regulate K+ etc… What can you do to prevent this?
Volume expansion, and alkalization of urine with bicarb will reduce intratubular precipitation of myoglobin. UOP should be 100 mL/hr until myoglobinuria is cleared.
Muscle does not tolerate lack of arterial flow (tourniquet) for more than ___ hours before necrosis begins.
6
What things increase the risk for tetanus?
Wounds >6 hours old, wounds contused or abraded, >1 cm deep, from high velocity missiles, due to burns or cold, and significantly contaminated wounds.
Should legs be completely straight when splinting?
No, flexion of 10 degrees recommended to take pressure off neurovascular structures.
Any patient with burns covering more than ___% of BSA require fluid resuscitation.
20
The palmer surface of a patient’s hand represents approximately ___% of their BSA.
1%
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.
24
Carbon monoxide has ____ times the affinity for oxygen as hemoglobin.
240
Patients with CO levels less than ___% usually don’t have any physical symptoms.
20%
Adult head BSA = ___%. 9 (ENTIRE head front and back = 9)Baby head BSA = __% 18 (9 front, 9 back)
What is the main difference between adult and baby BSA determination for burns?
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).
Chest BSA = ___%. 18Back BSA = ___%. 18Arm BSA = ___%. 9 TOTAL (front AND back).Leg BSA for adult = ___%. 18 TOTAL (9 front, 9 back).Baby front or back of leg BSA =___%. 7 (TOTAL leg = 14%)If you add up BSA head, chest, back, arms, and legs you get 99% of BSA. What is the remaining 1%?
Perineum
Partial/2nd degree burns extend into the _____ whereas full thickness/3rd degree burns ______.
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
4 hours on RA, 40 min on 100% O2
How do you calculate the Parkland formula?
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)***
Partial or full thickness burns of ___% in patients less than 10 or older than 50 warrants transfer to a burn center.
10%
What percent partial/full thickness burns would qualify a 25 year old for a burn center transfer?
20%
What anatomical positions with partial/full thickness burns warrant burn center transfer?
Does an inhalation injury warrant transfer to a burn center?
YES!!!!!
Should you treat frostbite by soaking body part in water or not?
YES, 40 degree (104F) for 20-30 min should suffice. Don’t warm if there is risk of REFREEZING.
Insofar as hypothermia is concerned, patients are not pronounced dead until they are _____ and dead.
warm
What are you thinking if a child has broken ribs?
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).
How should you insert a Guedel in a kid?
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.
The normal systolic BP in kids can be estimated by what?
90 mm Hg + (age x 2)
How do you estimate a child’s total circulating volume?
80 mL/kg
When shock in a child is suspected, how much fluid do you give them?
20 mL/kg warm crystalloid May need to repeat up to 3 times (60 mL/kg) then consider blood products.
Optimal UOP for infants is ___ mL/kg/hr. 2 (1.5 for younger kids, and 1.0 for older kids).How much warmed crystalloid should be used for a DPL in kids?
10 mL/kg (up to 1000 mL)
What would you see in an infant that would make you suspect very severe brain injury despite normal LOC?
Bulging fontanelles – these allow tolerance for expanding masses/swelling…
What is a possible mistake about a blood pressure of 120/80 in a 87 year old man?
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.
How well do geriatric patients do with non-operative management of abdominal injuries compared to younger people?
Not as well – the risks of non-operative management are often worse than the risks of surgery.
Why would geriatric patients be MORE susceptible to head bleeds when there is increased space around a shrinking brain to protect them from contusion?
Atrophic brains = stretching of the parasagittal bridging veins, making them more prone to rupture upon impact.
Plasma volume increases during pregnancy, what happens to hematocrit?
Decreases – dilution by plasma (31-35% is normal in pregnancy)
What would you think of a WBC of 15,000 in a pregnant woman?
Normal, it can go up to 25,000 during labor!
What should you always assume about a pregnant patient’s stomach?
That it is always full. (Gastric emptying time increases during pregnancy). Early NG tube placement recommended.
A PaCO2 of 35 to 40 in a pregnant patient may indicate what?
Impending respiratory failure. It is usually around 30 due to hyperventilation due to increased levels of progesterone.
True or False: All Rh negative pregnant True, unless the injury is remote from the
trauma patients should get Rhogam?uterus (distal extremity injury only). This therapy should be initiated within 72 hours of injury.
When worn correctly, seatbelts reduce fatalities by ___%.
65-70%, with a 10-fold reduction in serious injury.
