ATLS Chapters 4-6
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| How should you position the patient before placing a subclavian or IJ line? | SUPINE, head down 15 degrees to distend neck veins and prevent embolism, only turn head away if C-SPINE HAS BEEN CLEARED FIRST.
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| 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.
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| 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.
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| 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.
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| 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.
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| 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
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| 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
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| 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.
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| 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.
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| 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).
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| 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.
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| 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.
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| 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.
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| 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.
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| 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.
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| 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.
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| 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.
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| 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.
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| 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.
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| 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.
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| Fractures for the lower ribs (10-12) should increase suspicion for _____ injury. | hepatosplenic
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| Why are upper torso, facial, and arm plethora with petechiae associated with crush injuries to the chest? | Temporary compression of the superior vena cava.
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| How does ATLS suggest you should review a chest radiograph? | Trachea & bronchi, pleural spaces and parenchyma, mediastinum, diaphragm, bones, soft tissues, tubes & lines.
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| 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.
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| 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.
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| 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.
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| For patients with facial fractures or basillar skull fractures, gastric tubes should be inserted ____ before doing a DPL. | through the mouth
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| 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.
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| DPL is considered to be __% sensitive for detecting intraperitoneal bleeding. | 98
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| What are the four places you should look first when doing a FAST scan? | Mediastinum, hepatorenal fossa, splenorenal fossa, pouch of Douglas.
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| 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...).
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| What is the only ABSOLUTE contraindication to DPL? | An existing indication for laparotomy.
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| What are some RELATIVE contraindications to DPL? | Morbid obesity, advanced cirrhosis, preexisting coagulopathy, and previous abdominal operations (adhesions).
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| When should you use an open SUPRAUMBILICAL approach for a DPL? | PELVIC FRACTURES (don't want to enter pelvic hematoma) and ADVANCED PREGNANCY (don't want to damage enlarged uterus).
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| When doing a DPL, what INITIAL findings (not from lab) would mandate a laparotomy? | Free blood (>10 mL) or GI contents (vegetable fiber, bile).
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| If you don't get gross blood upon initial DPL aspiration, what do you do next for an adult? For a child? | Adult - 1,000 mL warm isotonic crystalloid. Kid - 10 mL/kg
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| 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).
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| 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!
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| What are some indications for laparotomy in patients with penetrating abdominal wounds? | Unstable, GSW, peritoneal irritation, fascial penetration
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| What percentage of stab wounds to the anterior abdomen do NOT penetrate the peritoneum? | 25-33%
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| Does an early normal serum amylase level exclude major pancreatic trauma? | NO
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| 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).
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| 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.
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| Anterior/posterior forces causes _____ book pelvic fractures, and lateral forces cause _____ book fractures. | AP = Open Book, LATERAL = Closed Book
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| Which are more common, open or closed book pelvic fracturs? | CLOSED BOOK - 60-70% (Open book 15-20%, vertical shear 5-15%)
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| 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
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| What do you need to do BEFORE you do a DPL? (Other than getting stuff together and surgically prepping, etc...) | DECOMPRESS BLADDER, DECOMPRESS STOMACH
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| What is "adequate" fluid return when getting DPL fluid back? | 30%
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| 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).
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| What is a "normal" ICP in the resting state? | 10mm Hg (Pressures >20, particularly if sustained, are associated with poor outcomes).
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| 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).
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| 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
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| 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)
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| What signs might you see if a patient has a basillar skull fracture? | PERIORBITAL ECCHYMOSIS (raccoon eyes), RETROAURICULAR ECCHYMOSIS (Battle sign), and otorrhea/rhinorrhea.
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| What do you need to know about the GCS? | EVERYTHING - Know it COLD!
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| 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.
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| 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).
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| 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)
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| High levels of CO2 will cause cerebral vasculature to _____. | Dilate (to increase blood flow) - so you might want to HYPERventilate people with brain injuries.
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| Ideally, you want to wait to perform a GCS on a person with SEVERE brain injury until what? | BP is normalized
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| 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.
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| A midline shift of greater than ___ often indicates the need for neurosurgical evacuation of the mass/blood. | 5mm
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| 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
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| 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.
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