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ATLS - Ch 1
Assessment & Management
|Give three signs for transport to trauma center
|1-GCS < 14 2-RR < 10 or > 29 3-SBP < 90
|Give twelve MVA criteria for transport to trauma center
|1-Ejection 2-Death 3-Run over or thrown 4-Unrestrained > 40 mph 5-Deformity > 20 in 6-Intrusion > 12 in 7-Extrication > 20 min 8-Fall > 20 ft 9-Rollover 10-Hit > 5 mph 11-Motorcycle > 20 mph 12-Separation
|Give nine situations prompting transport to trauma center
|1-Flail 2-Fx 2+ proximal long bones 3-Amputation > wrist or ankle, crushed, mangled, degloved 4-Penetration to head, neck, chest, extremities prox to knee or elbow 5-Open or depressed skull 6-Paralysis 7-Pelvic fx 8-Trauma & burns 9-Isolated major burns
|After evaluating airway,
|Protect the cervcial spine
|When is definitive airway management indicated? (3)
|1-Tracheal/laryngeal fractures 2-GCS < 8 3-Nonpurposeful motor responses
|How do you confirm ETT placement? (5)
|1-Auscultation bilateral breath sounds 2-Watching chest rise & fall 3-End-tidal CO2 detector 4-Visualizing ETT through cords 5-CXR
|What is No. 1 cause of preventable post-traumatic death?
|Give three examples of occult hemorrhage
|1-Thoracic/abdominal cavity 2-Surrounding femur fracture 3-Pelvic fx c retroperitoneal hemorrhage
|What is an unlikely cause of occult hemorrhage?
|Neurogenic shock secondary to spinal cord injury
|___ patients may not demonstrate ____ as an early sign of significant blood loss.
|Elderly, pediatric, athletic....tachycardia
|How should rapid external hemorrhage be controlled during the primary survey?
|direct manual compression
|GCS measures ____ ____ and ____.
|Eye opening, BEST Motor Response, and Verbal Response
|Give four contributions to low GCS
|1-Hemorrhage 2-Hypoglycemia 3-Meds & Drugs 4-C-spine injury
|Which type of hematoma leads to rapid ____ sometimes after a ____ interval?
|alteration in mental status lucid epidural, not subdural
|What factors determine maximum rate of fluid administration?
|1-Internal diameter of IV catheter and 2-inversely, the length of IV catheter, not the size of the vein
|Which IV fluid is preferred and how is it prepared?
|Ringers lactate warmed
|What can IV NS cause?
|hyperchloremic acidosis, especially with impaired renal function
|Give blood priority:
|MTSp UTSp ONeg
|Give three considerations in PEA
|1-Cardiac tamponade 2-Tension Pneumothorax 3-Massive hemorrhage c hypovolemia
|When should urethral injury be suspected? (6)
|1-Blood at penile urethral meatus 2-Perineal ecchymosis 3-Nonpalpable prostate (high-riding) 4-Ecchymotic scrotum 5-Blood in scrotum 6-Pelvic fracutre
|When should a Foley not be inserted?
|When urethral injury suspected
|Best way to diagnose urethral injury
|Give four complications of NG tube insertion
|1-Insertion into brain via fx cribriform plate 2-Pulmonary aspiration of oropharyngeal or gastric contents 3-Bradycardia 4-Vomiting
|What does pulse oximetry measure?
|Percent of hemoglobin saturated with oxygen
|Give four ways to evaluate cervical vasculature
|1-U/S 2-Contrast CT 3-MRI/MRA 4-Angiography
|Give four criteria for surgical exploration of penetrating trauma to neck
|1-Expanding hematoma 2-Airway compromise 3-Arterial bleeding 4-New bruit
|Give two examples of delayed abdominal trauma
|1-Small bowel injury 2-Pancreatic injury
|Which findings are consistent with tension pneumothorax? (5)
|1-Distended neck veins 2-Hyperresonance to percussion 3-Decreased breath sounds 4-Tracheal deviation 5-Hypotension
|Which findings are consistent with cardiac tamponade? (3)
|1-Hypotension 2-Distended neck veins 3-distant heart sounds
|Which findings are consistent with aortic rupture? (7)
|1-Widened mediastinum 2-Blurring/obliteration of aortic knob 3-Rightward deviation of trachea and esophagus 4-Depression of left mainstem bronchus 5-Obliteration of space between PA and Aorta 6-Widened paratracheal stripe 7-Widened paraspinal interface
|Three indications for DPL
|1-Unexplained hypotension 2-Abdominal pain and tenderness 3-Inability to perform reliable exam d/t neuro injury or altered mental status
|Urethral injury is more common in ____.
|Immobilization if neuro injury suspected
|1-Semi-rigid cervical collar 2-long spine board
|Adult maintenance urine output
|Child maintenance urine output
|Under 1 year of age maintenance urine output
|Route of pain meds for trauma patient
|IV, not oral or IM
|Best method for opening airway in trauma patient
|Chin lift or Jaw thrust
|What should you do with an open pneumothorax?
|Seal it on three sides, not four
|Ten steps in initial assessment process 1-8
|1-Preparation 2-Triage 3-Primary Survey 4-Resuscitation 5-Adjuncts to Primary Survey and Resuscitation 6-Consider need for Patient Transport 7-Secondary Survey (Head to Toe Evaluation and Patient History 8-Adjuncts to Secondary Survey
|Ten steps in initial assessment process 9-10
|9-Continued Postresuscitation Monitoring and Reevaluation 10-Definitive Care
|1-Airway maintenance 2-Control of external bleeding and shock 3-Immobilization of patient 4-Transport to closest appropriate facility 5-Minimization of scene time 6-Obtaining/reporting information, mechanism of injury
|Give six more reasons to transfer to trauma center
|10-Crush, degloved, or mangled extremity 11-Pregnancy > 20 wks 12-Time-sensitive extremity injury 13-End-stage renal disease requiring dialysis 14-Burns w/o trauma: Triage to burn facility 15-Burns w trauma: Triage to trauma center
|Considerations for Hospital Phase of trauma care (6)
|1-Proper airway equipment 2-Warmed IV crystalloid solutions 3-Appropriate monitoring capabilities 4-Method to summon additional help 5-Transfer agreements 6-Universal precautions
|Appropriate patients should arrive at
|Two types of triage situations
|1-Multiple casualities 2-Mass casualities
|Characteristics and goal of Multiple Casualities
|1-Number and severity do not exceed ability 2-Life-threateningand multiple-system injuries treated first
|Characteristics and goal of Mass Casualities
|1-Number and severity DO exceed capability 2-Greatest chance of survival and least expenditure treated first
|Ten-second assessment (3)
|1-injuries 2-vital signs 3-injury mechanism
|Trauma is a common cause of death in the
|Two things to promote survival in elderly trauma patients
|1-prompt, aggressive resuscitation 2-early recognition of preexisting conditions and medication use
|What suggests airway is not in immediate jeopardy?
|Patient able to communicate verbally.
|Does neurologic exam alone exclude C-spine injury?
|Assume a C-spine injury in patients with (3)
|1-multi-system trauma 2-altered level of consciousness 3-blunt injury above the clavicle
|Airway patency alone does not ensure
|Ventilation requires adequate function of the (3)
|lungs, chest wall, and diaphragm
|Impaired ventilation during primary survey (4)
|1-tension pneumothorax 2-flail chest w pulmonary contusion 3-massive hemothorax 4-open pneumothorax
|Impaired ventilation during secondary survey (4)
|1-simple pneumothorax 2-simple hemothorax 3-fractured ribs 4-pulmonary contusions
|Intubation and vigorous bag-valve ventilation can make patient worse with
|pneumothorax or tension pneumothorax
|Until proven otherwise, injury related hypotension is considered
|hypovolemic in origin.
|Three elements of hypovolemia
|1-level of consciousness 2-skin color 3-pulse
|A conscious patient may have lost
|a significant amount of blood.
|Skin in hypovolemic patient may show
|1-ashen, gray facial skin 2-white extremities
|Easily accessible central pulses
|carotid and femoral
|Pulses in hypovolemia
|thready, rapid, irregular, absent
|What kind of hemorrhage is identified and controlled during what survey?
|Two things not to use during primary control of hemorrhage
|tourniquets and hemostats
|When is a rapid neuro exam done?
|at the end of the primary survey
|Four things assessed during rapid neuro exam
|1-level of consciousness 2-pupillary size and reaction 3-lateralizing signs 4-spinal cord injury level
|What correlation with CO does BP have in elderly?
|What can increase blood loss in elderly?
|Regarding room temperature, consider ____ rather than ____.
|patient's body temp health-care providers
|Immediate ____ should be started if tension pneumothorax is suspected.
|How many, and what kind of IV catheters?
|Prioritize volume resuscitation vs definitive control of hemorrhage
|definitive control of hemorrhage
|Shock w injury most often ____ in origin.
|What can and cannot be warmed in a microwave oven?
|crystalloid fluids blood products
|Name nine adjuncts used during primary survey
|1-electrocardiographic monitoring 2-urinary catheters 3-gastric catheters 4-ventilatory rate 5-ABG levels 6-pulse oximetry 7-blood pressure 8-x-rays 9-diagnostic studies
|Dysrhythmias can indicate
|blunt cardiac injury
|Hypoxia, hypoperfusion and/or hypothermia can cause what dysrhythmias? (3)
|1-bradycardia 2-aberrant conduction 3-premature beats
|Rectal exam and genital exam should be done before
|inserting a urinary catheter
|Gastric tube used to
|1-reduce stomach distension 2-decrease risk of aspiration
|Blood in gastric aspirate may indicate (3)
|1-oropharyngeal (swallowed) blood 2-traumatic insertion 3-actual injury to upper digestive trace
|Capnography does not confirm
|proper placement of tube in trachea.
|Pulse oximetry does not measure
|the partial pressure of oxygen, nor the partial pressure of carbon dioxide
|Blood pressure may be a poor measure of
|actual tissue perfusion
|On which arm should pulse oximetry not be placed?
|the one with the blood pressure cuff on
|Essential x-rays should be obtained EVEN
|in pregnant patients
|F A S T
|Focused Assessment Sonography in Trauma
|D P L
|Diagnostic Peritoneal Lavage
|Two limiting factors in FAST
|obesity and intraluminal bowel gas
|Three limiting factors in DPL
|1-obesity 2-previous abdominal operations 3-pregnancy
|Potential in unresponsive or unstable patient (2)
|1-missing an injry 2-failing to appreciate significance of injury
|Medical assessment always includes
|history of mechanism of injury
|A in AMPLE
|M in AMPLE
|Medications currently used
|P in AMPLE
|Past illness and Pregnancy
|L in AMPLE
|E in AMPLE
|Events/Environment related to injury
|Four categories of injury
|1-Blunt trauma 2-Penetrating trauma 3-Thermal injuries 4-Hazardous environment
|Considerations in blunt trauma from MVC (5)
|1-seat-belt use 2-steering wheel deformation 3-direction of impact 4-damage (deformation or intrusion) 5-ejection
|Considerations in penetrating trauma (2)
|1-organs in the path 2-velocity of the missile
|Clues to extent of injury in gunshot victims (4)
|1-velocity 2-caliber 3-presumed path of bullet 4-distance from weapon to wound
|Burns can occur ____ or with ____
|alone blunt and penetrating trauma
|Two considerations in a fire
|1-inhalation injury 2-carbon monoxide poisoning
|Two considerations about exposure to hazardous environment
|1-pulmonary, cardiac, internal organ dysfunction in patient 2-hazard to healthcare providers
|Eyes should be evaluated for (7)
|1-visual acuity 2-pupillary size 3-hemorrhage of conjunctiva and/or fundi 4-penetrating injury 5-contact lenses (remove before edema) 6-dislocation of lens 7-ocular entrapment
|Mechanism of Injury (5)
|1-Frontal impact 2-Side impact 3-Rear impact 4-Ejection 5-Pedestrian struck by motor vehicle
|Mechanism of Injury
|Suspected Injury Pattern
|SIP in Frontal Impact MVC (7)
|1-Cervical spine fracture 2-Anterior flail chest 3-Myocardial contusion 4-Pneumothorax 5-Traumatic aortic disruption 6-Fractured spleen or liver 7-Posterior fracture/dislocation of hip and/or knee
|SIP in Side Impact MVC (8)
|1-Contralateral neck sprain 2-Cervical spine fracture 3-lateral flail chest 4-Pneumothorax 5-Traumatic aortic disruption 6-Diaphragmatic rupture 7-Fracture spleen/liver and/or kidneys, depending on side of impact 8-Fractured pelvis or acetabulum
|SIP in Rear Impact MVC (2)
|1-Cervical spine injury 2-Soft tissue injury to neck
|SIP in Ejection from vehicle
|Meaningful pattern precluded
|SIP in Pedestrian Struck by Vehicle (4)
|1-Head injury 2-Traumatic aortic disruption 3-Abdominal visceral injuries 4-Fractured lower extremities/pelvis
|Patient with mid-face fracture can have
|fracture of cribriform plate
|Presumption with maxillofacial or head trauma
|unstable cervical spine injury
|Does not exclued injury to cervical spine
|absence of neurological deficit
|Exam of neck includes (3)
|1-Inspection 2-Palpation 3-Auscultation
|Unexplained or isolated paralysis of upper extremity
|suspect cervical nerve root injury and document
|Palpation of chest cage includes (3)
|1-clavicles 2-ribs 3-sternum
|Auscultation of breath sounds for hemothorax
|Auscultation of breath sounds for pneumothorax
|high on anterior chest
|Children often sustain significant injury to the ____ without evidence of ____.
|1-intrathoracic structures 2-thoracic skeletal trauma
|What are you looking for in vaginal exam?
|1-blood in vaginal vault 2-vaginal lacerations
|Pelvic fractures should be suspected when you identify ecchymosis over the (4)
|1-iliac wings 2-pubis 3-labia 4-scrotum
|Manipulation of the pelvis should be done
|Complete musculoskeletal exam includes
|Prioritize treatment vs consent
|consent, then treatment, usually, but when not possible, treat, then obtain consent