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ATLS10 2019/2020 POST-TEST ATLS10 EXAM (ANSWERS OUTLINED!!), ATLS EXAM WITH 2022 SOLUTIONS ALL CORRECT ANSWERS ARE HIGHLIGHTED &ATLS EXAM WITH COMPLETE SOLUTIONS GRADED A.
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ATLS10 2019/2020 Post-Test ATLS10 exam questions with answers (answers outlined!!)
ATLS10 2019/2020 Post-Test ATLS10 exam questions with answers (answers outlined!!) 1. A 24-year-old male pedestrian, struck by an automobile, is admitted... [Show More] to the emergency department 1 hour after injury. His blood pressure is 80/60 mmHg, heart rate 140 beats per minute and respiratory rate is 36 per minute. He is lethargic. Oxygen is delivered via face mask, and two largecaliber IVs are initiated. Arterial blood gases are obtained. His PaO2 is 118 mmHg (15.7 kPa), PaCO2 is 30 mmHg (4.0 kPa), and pH is7.21. The treatment of his acid-base disorder is best accomplished by: a. Hyperventilation b. Restoration of normal perfusion c. Initiation of low-dose dopamine d. Administration of sodium bicarbonate e. Initiation of phenylepinephrine infusion 2. The highest priority in managing a patient whose injuries include closed extremity fractures is: a. Assesing limb perfusion b. Preventing necrosis of the skin c. Decompressing compartment syndrome d. Addressing respiratory insufficiency Identifying crush syndrome 3. A 34-year-old female is involved in a motor vehicle crash is brought to the emergency department. She is talking, but her voice is hoarse and on exposure she has diagonal bruising of the chest and anterior neck. What is the next step? a. Direct laryngoscopy to exclude laryngeal trauma b. Oxygen by non-rebreathing mask c. Protecting the spine by making her lie down d. Palpation of the anterior neck e. Attaching a pulse oximeter to her finger 4. A 30-year-old male sustains a gunshot wound to the right lower chest, midway between the nipple and the costal margin. He is brought by ambulance to a hospital that has full surgical capabilities. In the emergency department he is endotracheally intubated, fluid resuscitation is initiated through two large-caliber IV lines, and a closed tube thoracostomy is performed, with the return of 200 ml of blood. A chest xray reveals correct placement of the chest tube and a small residual hemothorax. His blodd pressure is now 70/0 mmHg, and his heart rate is 140 beats per minute. His hypotension is most likely due to: a. Tension pneumothorax b. Massive hemothorax c. Pericardial tamponade d. Intraabdominal bleeding e. Insufficient isotonic crystalloid infusion 5. A 20-year-old athlete is involved in a motorcycle crash after having ridden for hours on a very hot day. When he arrives in the emergency department, he shouts that he cannot move his legs. On physical examination, there are no abnormalities of the chest, abdomen, or pelvis. The patient has no sensation in his legs and cannot move them, but his arms are moving. The patient’s respiratory rate is 22, heart rate is 88, and blood pressure is 80/60 mmHg. He is pale and sweaty. What is the most likely cause of his hypotension? a. Neurogenic shock b. Cardiac tamponade c. Myocardial contusion d. Hyperthermia e. Hemorrhagic shock 6. Comapred with adults, children have: a. A longer, wider, funnel-shaped airway b. A less pliable, calcified skeleton c. Greater mobility of mediastinal structures d. A relatively smaller head and larger jaw e. Anterior displacement of C5 on C6 7. Which one of the findings below requires a definitive airway in trauma patients? a. Facial lacerations b. Repeated vomiting c. Partial thickness facial burns, cough, and hoarseness d. Sternal fracture e. Glascow Coma Scale score of 12 8. In a patient with spinal cord injury, sacral sparing: a. Refers to a fracure of the sacrum b. Is part of the spinal shock syndrome c. Is a good prognostic sign d. Indicates a complete spinal cord injury e. Occurs only with complete transection of the lumbosacral spinal cord 9. A 22-year-old woman falls whil skiing. She is evaluated at a small community hospital that does not have neurological services. Spinal motion is restricted, supplemental oxygen by mask is administered, and two antecubital IVs are placed. Her Glascow Coma Scale score is 12, pupils are equal, blood pressure is 135/76 mmHg, heart rate is 105, and respiratory rate is 19. Chest x-ray is normal. This patient’s management priorities are: a. Repeat primary survey and transfer to a trauma center b. Definitive airway, CT of the head, and intracranial pressure monitor c. IV mannitol, definitive airway, CT of the head, and neurosurgery consult d. CT of the head, EEG, cerebral perfusion pressure monitoring, and hypertonic saline e. IV Dilantin, IV mannitol, mild hyperventilation, and serial arterial blood gases 10. A young male patient is brought to the emergency department following a 5- meter (16-foot) fall from a roof. He responds to pressure by pushing away your hand, opening his eyes, and verbalizing inappropriate words. Pupils are equal. The most important step is management of this patient would be: a. Immidiate intubation to protect his airway b. Administer 25 mg/kg IV bolus mannitol c. Insert two large-bore IVs d. Alcohol and drug screening e. Determine whether amnesia is present and, if so, for what period of time 11. Twenty-seven patients are seriously injured in an airplane crash at a local airport. The principles of triage include: a. Establish a triage site whthin the hot zone of the crash site b. Treat only the most severely injured patients first c. Immidiately transport all patients to the nearest hospital d. Treat the greatest number of patients in the shortest period of time e. Produce the greatest number of survivors based on available resources 12. A 35-year-old female falls down a flight of stairs. She has extensive bruising of her face and head. Her heart rate is 120, blood pressure 90/70 mmHg, and respiratory rate is 26. The patient`s condition is most readily explained by: a. Associated head injury b. Hypovolemia from hemorrhagic shock c. Alcohol intoxication d. Spinal shock from cervical spine injury e. Neurogenic shock from cervical spine injury 13. Which one of the following statements is correct: a. Cerebral contusions may coalesce to form an intracerebral hematoma b. Epidural hematomas are usually seen in the frontal region c. Subdural hematomas are caused by injury to the middle meningeal artery d. Subdural hematomas typically have a lenticular shape on CT scan e. The associated brain damage is more severe in epidural hematomas 14. An 18-year-old is brought to the emergency department after having been shot. He has one bullet wound just below the right clavicle and another just below the costal margin in the right posterior axillary line. His blood pressure is 110/60 mmHg, heart rate is 90 beats per minute, and respiratory rate is 34 breaths per minute. After ensuring a patent airway and inserting two large-caliber IV lines, the next appropriate step is to: a. Obtain a portable chest x-ray b. Administer a bolus of additional IV fluid c. Perform a laparotomy d. Obtain an abdominal CT scan e. Perform diagnostic peritoneal lavage 15. Which one of the following statements is true concerning cranial anatomy related to traumatic injury? CONTINUES... [Show Less]
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ATLS EXAM WITH QUESTIONS AND ANSWERS 2022 SOLUTIONS ALL CORRECT ANSWERS ARE HIGHLIGHTED
ATLS EXAM WITH QUESTIONS AND ANSWERS 2022 SOLUTIONS ALL CORRECT ANSWERS ARE HIGHLIGHTED A 22-year-old man is hypotensive and tachycardic after a shotg... [Show More] un wound to the left shoulder. His blood pressure is initially 80/40 mm Hg. After initial fluid resuscitation his blood pressure increases to 122/84 mm Hg. His heart rate is now 100 beats per minute and his respiratory rate is 28 breaths per minute. A tube thoracostomy is performed for decreased left chest breath sounds with the return of a small amount of blood and no air leak. After chest tube insertion, the most appropriate next step is: ANS: re-examine the chest 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: ANS: complete spine x-ray series What is true regarding the initial resuscitation of a trauma patient? ANS: Evidence of improved perfusion after fluid resuscitation could include improvement in Glasgow Coma Scale score on reevaluation In managing a patient with a severe traumatic brain injury, the most important initial step is to: ANS: secure the airway A previously healthy, 70-kg (154-pound) man suffers an estimated acute blood loss of 2 liters. What applies to this patient? ANS: An ABG would demonstrate a base deficit between -6 and -10 mEq/L. The physiological hypervolemia of pregnancy has clinical significance in the management of the severely injured, gravid woman by: ANS: increasing the volume of blood loss to produce maternal hypotension. The best assessment of fluid resuscitation of the adult burn patient is: ANS: urinary output of 0.5 mL/kg/hr The diagnosis of shock must include: ANS: evidence of inadequate organ perfusion A 7-year-old boy is brought to the emergency department by his parents several minutes after he fell through a window. He is bleeding profusely from a 6-cm wound of his medial right thigh. Immediate management of the wound should consist of: ANS: direct pressure on the wound For the patient with severe traumatic brain injury, profound hypocarbia should be avoided to prevent: ANS: cerebral vasoconstriction with diminished perfusion After being involved in a motor vehicle crash, a 25-year-old man is brought to a hospital that has surgery capabilities available.. Computed tomography of the chest and abdomen shows an aortic injury and splenic laceration with free abdominal fluid. His blood pressure falls to 70 mm Hg after CT. The next step is: ANS: perform an exploratory laparotomy What statements regarding abdominal trauma in the pregnant patient is TRUE? ANS: Leakage of amniotic fluid is an indication for hospital admission. The first maneuver to improve oxygenation after chest injury is: ANS: administer supplemental oxygen A 25-year-old man, injured in a motor vehicular crash, is admitted to the emergency department. His pupils react sluggishly and his eyes open to pressure. He does not follow commands, but he does moan periodically. His right arm is deformed and does not respond to pressure; however, his left hand reaches purposefully toward the stimulus. Both legs are stiffly extended. His GCS score is: ANS: 9 A 20-year-old woman who is at 32 weeks gestation, is stabbed in the upper right chest. In the emergency department, her blood pressure is 80/60 mm Hg. She is gasping for breath, extremely anxious, and yelling for help. Breath sounds are diminished in the right chest. The most appropriate first step is to: ANS: perform needle or finger decompression of the right chest What findings in an adult is most likely to require immediate management during the primary survey? ANS: respiratory rate of 40 breaths per minute The most important, immediate step in the management of an open pneumothorax is: ANS: placement of an occlusive dressing over the wound The following are contraindications for tetanus toxoid administration: ANS: history of neurological reaction or severe hypersensitivity to the product A 56-year-old man is thrown violently against the steering wheel of his truck during a motor vehicle crash. On arrival in the emergency department he is diaphoretic and complaining of chest pain. His blood pressure is 60/40 mm Hg and his respiratory rate is 40 breaths per minute. What best differentiates cardiac tamponade from tension pneumothorax as the cause of his hypotension? ANS: breath sounds Bronchial intubation of the right or left mainstem bronchus can easily occur during infant endotracheal intubation because: ANS: The trachea is relatively short. A 23-year-old man sustains 4 stab wounds to the upper right chest during an altercation and is brought by ambulance to a hospital that has full surgical capabilities. His wounds are all above the nipple. He is endotracheally intubated, closed tube thoracostomy is performed, fluid resuscitation is initiated through 2 large-caliber IVs. FAST exam does not reveal intraabdominal injuries. His blood pressure now is 60/0 mm Hg, heart rate is 160 beats per minute, and respiratory rate is 14 breaths per minute (ventilated with 100% O2). 1500 mL of blood has drained from the right chest. The most appropriate next step in managing this patient is to: ANS: urgently transfer the patient to the operating room A 39-year-old man is admitted to the emergency department after an automobile collision. He is cyanotic, has insufficient respiratory effort, and has a GCS score of 6. His full beard makes it difficult to fit the oxygen facemask to his face. The most appropriate next step is to: ANS: restrict cervical motion and attempt orotracheal intubation using 2 people A patient is brought to the emergency department after a motor vehicle crash. He is conscious and there is no obvious external trauma. He arrives at the hospital completely immobilized on a long spine board. His blood pressure is 60/40 mm Hg and his heart rate is 70 beats per minute. His skin is warm. What do you expect to see with the patient? ANS: Flaccidity of the lower extremities and loss of deep tendon reflexes are expected. What is the most effective method for initially treating frostbite? ANS: Moist heat A 32-year-old man's right leg is trapped beneath his overturned car for nearly 2 hours before he is extricated. On arrival in the emergency department, his right lower extremity is cool, mottled, insensate, and motionless. Despite normal vital signs, pulses cannot be palpated below the right femoral artery and the muscles of the lower extremity are firm and hard. During the management of this patient, what is most likely to improve the chances for limb salvage? ANS: surgical consultation for right lower extremity fasciotomy A patient arrives in the emergency department after being beaten about the head and face with a wooden club. He is comatose and has a palpable depressed skull fracture. His face is swollen and ecchymotic. He has gurgling respirations and vomitus on his face and clothing. The most appropriate step after providing supplemental oxygen and elevating his jaw is to: ANS: suction the oropharynx A 22-year-old man sustains a gunshot wound to the left chest and is transported to a small community hospital no surgical capabilities are available. In the emergency department, a chest tube is inserted and 700 mL of blood is evacuated. The trauma center accepts the patient in transfer. Just before the patient is placed in the ambulance for transfer, his blood pressure decreases to 80/68 mm Hg and his heart rate increases to 136 beats per minute. The next step should be to: ANS: repeat the primary survey and proceed with transfer A 64-year-old man involved in a high-speed car crash, is resuscitated initially in a small hospital without surgical capabilities. He has a closed head injury with a GCS score of 13. He has a widened mediastinum on chest x-ray with fractures of left ribs 2 through 4, but no pneumothorax. After initiating fluid resuscitation, his blood pressure is 110/74 mm Hg, heart rate is 100 beats per minute, and respiratory rate is 18 breaths per minute. He has gross hematuria and a pelvic fracture. You decide to transfer this patient to a facility capable of providing a higher level of care. The facility is 128 km (80 miles) away. Before transfer, you should first: ANS: call the receiving hospital and speak to the surgeon on call Hemorrhage of 20% of the patient's blood volume is associated usually with ANS: tachycardia What statement concerning intraosseous infusion is TRUE? ANS: Aspiration of bone marrow confirms appropriate positioning of the needle. A young woman sustains a severe head injury as the result of a motor vehicle crash. In the emergency department, her GCS is 6. Her blood pressure is 140/90 mm Hg and her heart rate is 80 beats per minute. She is intubated and mechanically ventilated. Her pupils are 3 mm in size and equally reactive to light. There is no other apparent injury. The most important principle to follow in the early management of her head injury is to ANS: avoid hypotension A 33-year-old woman is involved in a head-on motor vehicle crash. It took 30 minutes to extricate her from the car. Upon arrival in the emergency department, her heart rate is 120 beats per minute, BP is 90/70 mm Hg, respiratory rate is 16 breaths per minute, and her GCS score is 15. Examination reveals bilaterally equal breath sounds, anterior chest wall ecchymosis, and distended neck veins. Her abdomen is flat, soft, and not tender. Her pelvis is stable. Palpable distal pulses are found in all 4 extremities. Of the following, the most likely diagnosis is: ANS: cardiac tamponade A hemodynamically normal 10-year-old girl is hospitalized for observation after a Grade III (moderately severe) splenic injury has been confirmed by computed tomography (CT). What mandates prompt celiotomy (laparotomy)? ANS: development of peritonitis on physical exam A 40-year-old woman who was a restrained driver in a motor vehicle crash is evaluated in the emergency department. She is hemodynamically normal and found to be paraplegic at the level of T10. What precaution should be taken during evaluation and management? ANS: Log rolling using 4 people is a safe approach to restrict spinal motion when moving her. A trauma patient presents to your emergency department with inspiratory stridor and a suspected cspine injury. Oxygen saturation is 88% on high-flow oxygen via a nonrebreathing mask. The most appropriate next step is to: ANS: restrict cervical motion and establish a definitive airway When applying the Rule of Nines to infants ANS: The head is proportionally larger in infants than in adults A healthy young male is brought to the emergency department following a motor vehicle crash. His vital signs are a blood pressure of 84/60, pulse 123, GCS 10. The patient moans when his pelvis is palpated. After initiating fluid resuscitation, the next step in management is: ANS: placement of a pelvic binder What situations requires Rh immunoglobulin administration to an injured woman? ANS: positive pregnancy test, Rh negative, and has torso trauma A 22-year-old female athlete is stabbed in her left chest at the third interspace in the anterior axillary line. On admission to the emergency department and 15 minutes after the incident, she is awake and alert. Her heart rate is 100 beats per minute, blood pressure 80/60 mm Hg, and respiratory rate 20 breaths per minute. A chest x-ray reveals a large left hemothorax. A left chest tube is placed with an immediate return of 1600 mL of blood. The next management step for this patient is: ANS: prepare for an exploratory thoracotomy A 6-year-old boy walking across the street is struck by the front bumper of a sports utility vehicle traveling at 32 kph (20 mph). What's true about this patient? ANS: A pulmonary contusion may be present in the absence of rib fractures. Adjuncts used during the primary survey ANS: ECG Pulse ox CO2 monitoringV Ventilatory rate ABGs Foleys (UOP) Gastric catheter FAST or eFAST DPL Urinary output is sensitive for ANS: Patient's volume status and renal perfusion "Golden hour" ANS: The time from injury to definitive care, during which treatment of shock and traumatic injuries should occur because survival potential is best; also called the Golden Period. Leading cause of trauma deaths worldwide ANS: MVCs Trimodal death distribution ANS: 1st: seconds to minutes of injury (apnea) 2nd: minutes to several hours (EDH, SDH, liver lac, pelvic fractures, spleen ruptures) 3rd: several days to weeks after injury (sepsis and multi-organ failure) An 18-year-old male was the unrestrained driver in a MVC involving contact with a tree, He is being transported to the ED by ambulance after a prolonged extrication process. He is receive oxygen by mask and IVF via one large-bore IV, and he is immobilized on a long spine board. How would you prepare for arrival of this patient? ANS: Airway equipment for possible intubation IV equipment to place a second IV and get blood work Lab/Xray available Monitor equipment ready Notify blood bank and have transfusion protocol available Consider appropriate transfer AMPLE hx ANS: Allergies Medications currently used Past illnesses/Pregnancy Last meal Events/Environment related to the injury Blunt trauma MOI ANS: Seatbelt use Steering wheel deofrmation Presence/activation of airbags Direction of impact Damage to vehicle Patient position Ejection from vehicle? Penetrating trauma MOI ANS: Body region Velocity of weapon Caliber Heat loss can occur at moderated temperatures ANS: 59 to 68 F (15-20 C) Prehospital phase should include what interventions and considerations? ANS: Airway maintenance Breathing support Control of bleeding and shock Immobilization Immediate transport to closest appropriate facility Hospital preparation for trauma ANS: Resuscitation area Airway équipement Warmed IV crystalloid solution Monitoring devices Protocol for requesting additional assistance Transfer agreements Primary survey ANS: Airway maintenance with restriction of cervical spine motion Breathing Circulation Disability Exposure/Environmental control Patients with maxillofacial or head trauma should be presumed to have ANS: A cervical pine injury and cervical spine motion must be restricted PITFALL: equipment failure ANS: Test regularly Ensure spare equipment and batteries are readily available PITFALL: unsuccessful intubation ANS: Identify patients with difficult anatomy Identify the most experienced/skilled airway manager on team Ensure appropriate equipment is available Be prepared to prefer a surgical airway PITFALL: progressive airway loss ANS: Recognize the dynamic status of the airway Recognize the injuries that can result in progressive airway loss Frequently reassess the patient for signs of deterioration of the airway In a trauma patient with hypotension, what are the two most important causes to consider in order of importance? ANS: Tension pneumothorax Hemorrhage What is the best way to manage rapid external blood loss? ANS: Direct manual pressure on the wound What are the major areas of internal hemorrhage? ANS: Chest Abdomen Retroperitoneum Pelvis Long bones How should fluids be administered in trauma patients with shock? ANS: Warm IVFs If unresponsive to initial IVF, give blood transfusion immediately What are the uses for ETCO2? ANS: Detect ROSC Confirm ET intubation Help avoid hypoventilation and hyperventilation You'd like to insert a foley catheter for a trauma patient but you notice urethras injury. What test should be performed prior to the insertion of a urinary catheter? ANS: Retrograde urethrogram DDX for blood in gastric aspirate in a trauma patient ANS: Swallowed blood Traumatic gastric tube placement UGI injury What's a C/I to NGT insertion? ANS: Fracture of the cribriform/midface fracture (insert OG instead) What injuries are at high risk of compartment syndrome in trauma patients? ANS: Long bones Crush injuries Circumferential thermal burns Prolonged ischemia to the limb What's normal UOP? ANS: Adult: 0.5 ml/kg/hr Child: 1-2 ml/kg/hr MIST for obtaining info from EMS ANS: Mechanism and time of injury Injuries found and suspected Symptoms and signs Treatment initiated Retroperitoneal organs ANS: Abdominal aorta IVC Duodeum Pancreas Kidneys Ureters Posterior aspects of ascending/descending colon Bladder Rectum Reproductive organs What's the most frequently injured abdominal organ in blunt trauma? Followed by? ANS: Spleen (40- 55%) Liver (35-45%) Small bowel (5-10%) Which patients should you consider transferring, and what tests should be performed prior to transfer? ANS: The patients whose injuries exceed your ability to care for them, either sue to specialize needs, or resource availably. Only perform testing that enables the referring physician to resuscitate, stabilize, and ensure the safer transfer of the patient What's a pulse oximetry measure? ANS: Oxygen saturation by relative absorption of light by oxyhemoglobin and deoxyhemoglobin Gastric catheter placement can induce vomiting ANS: Be prepared to logroll Ensure suction is immediately available Special populations that may have physiological responses that do not follow expected patterns ANS: Children Pregnant females Elderly Obese individuals Athletes Why is info about mechanism of injury so important? ANS: The patient's condition is greatly influenced by MOI. It can enhance the understanding of the patient's condition and anticipated injuries Possible adjuncts to secondary survey ANS: X-rays of spine and extremities CT scans of head, chest, abdomen, spine Contrast urography and angiography TEE Bronchoscopy Esophagoscopy Frontal impact MVC ANS: Cervical spine fracture Flail chest Myocardial contusion Pneumothroax Traumatic aortic disruption Fractured spleen or liver Posterior fracture/dislocation hip/knee Head injury Facial fractures Side impact MVC ANS: Contralateral neck sprain Head injury Cervical spine fracture Flail chest Pneumothorax Traumatic aortic disrution Diaphragmatic rupture Fractured spleen/liver/kidney Fractured pelvis or acetabulum Rear impact MVC ANS: Cervical spine injury Head injury Soft tissue injury to neck MVC vs pedestrian ANS: Head injury Traumatic aortic disruption Abdominal visceral injuries Fractured lower extremities/ pelvis Fall from heigh ANS: Head injury Axial spine injury Abdominal visceral injuries Fractured pelvis or acetabulum Bilateral LE fractures Anterior stab wound ANS: Cardiac tamponade Hemothorax Pneumothorax Hemopneumothorax Left stab wound ANS: Left diaphragm injury Spleen injury Hemopneumothoax Abdomen stab wound ANS: Visceral injury Extremity GSW ANS: Neurovascular injury Fractures Compartment syndrome Thermal burns ANS: Eschar on extremities or chest Electrical burns ANS: Cardiac arrhythmias Myonecrosis Compartment syndrome Inhalation burns ANS: CO poisoning Upper airway swelling Pulmonary edema What is your first step when a patient condition changes? ANS: ABCDEs What's the importance of meticulous record keeping? ANS: Crucial during patient assessment and management because often more than one clinician cares for an individual patient and allows those to evaluate the patient's needs and clinical status What info should be provided to the receiving facility for a transferring patient? ANS: As much info as possible! Event of injury, patient exam, treatments done, responses of treatments, tests and results, and possible injuries What key information should prehospital providers obtain and report to the receiving hospital? ANS: Events associated with injury What patient sign can be quickly observed to assess a patient's hemodynamic status? ANS: Skin perfusion Definitive airway ANS: A tube placed in the trachea with the cuff inflated below the vocal cords, the tube connected to a form of oxygen-enriched assisted ventilation and the airway secured in place with an appropriate stabilizing method What's critical management for trauma patients, especially those with sustained head injuries? ANS: Maintaining oxygenation and printing hypercarbia Triad of largyneal fracture ANS: Hoarseness Subcutaneous emphysema Palpable fracture In a conscious trauma patient, airway adequacy can quickly be assessed by ANS: Talking to the patient-- A positive verbal response with clear voice indicated patent airways, ventilation, and brain perfusion What can conform a suspected laryngeal fracture? ANS: CT scan For a patient who is gurgling, initial assessment for ventilation should include ANS: Looking for symmetrical chest rise and listening for breath sounds Decreased or absent breath sounds over one or both hemithoraxes should alert the examiner to the presence of? ANS: Pneumothorax, hemothoax, contusion, or flail chest Adjuncts of ventilation problems ANS: Pulse ox to measure oxygen saturation and gauge peripheral perfusion Capnography to assess adequacy fo ventilation What are the symptoms of inadequate ventilation? ANS: Difficulty breathing SOB Request to sit up to breath LEMON assessment of difficult intubation ANS: Look externally Evaluate the 3-3-2 rule Mallampati Obstruction Neck mobility Types of definitive airways ANS: Orotracheal tube Nasotracheal tube Surgical airways (cricothyroidotomy and tracheostomy) Laryngeal manipulation for visualization ANS: Backward, upward, and rightward pressure on thyroid cartilage can aid in visualizing vocal cords Which surgical airway is recommended in children under 12? ANS: Needle cricothyroidotomy What're adjuncts that might be used during intubation? ANS: Suction Manual laryngealmanipulation (BURP) Elastic bougie Anesthetics, analgesics, and neuromuscular blocking agents Why is continual pulse ox monitoring necessary in critically injured patients? ANS: Because changes in oxygenation occur rapidly and are impossible to detect clinically What indicates that the endotracheal tube is in the proper position? ANS: Equal breath sounds bilaterally Carbon dioxide monitor (capnograph or colorimetric CO2 device) Confirmed with CXR What suggests sufficient ventilation? ANS: ABG or continual end-tidal carbon dioxide analysis On exam, an unrestrained driver is hoards and has minimal subcutaneous neck emphysema. This patient likely has a/an ANS: Obstructed airway In an agitated trauma patient who refuses to lay down ANS: Assessment of airway adequacy may include suctioning What's an indication for rapid sequence intubation? ANS: Patients who need airway control, have intact gag reflex, especially those who have sustained head injury A surgical airway is indicated in the presence of ANS: Edema of the glottis Fracture of larynx Severe oropharyngeal hemorrhage that obstructs airway Inability to place an endotracheal tube Possible causes of confusion after traumatic event? ANS: Hemorrhage Brain injury Stroke Intoxication What's the most common cause of shock after an injury? ANS: Hemorrhage What're the early clinical manifestations of shock? ANS: Tachycardia and cutaneous vasoconstriction What's the preferred method of vascular access for a patient involved in a MVC? ANS: 2 large bore PIVs in the antecubital veins What's the most appropriate means to restore cardiac output and end organ perfusion in hemorrhagic shock? ANS: Stopping the source of bleeding and ensuring appropriate volume repletion A 24-year-old male arrives in ED already intubated. He has significant crepitus of the right chest wall and diminished breath sounds. You place a chest tube and note a large amount of bubbling in the water seal chamber. His O2 saturation remains at 85% and he has goodCO2 return on capnography. The most likely cause of his low oxygen saturation is ANS: Tracheobronchial tree injury Most injuries to the tracheobronchial tree occur where? ANS: Within 2.5 cm from the carina Do the vast majority of thoracic injuries (blunt and penetrating) require operative intervention? ANS: No, most are treated with technical procedures Airway thoracic injuries ANS: Airway obstruction (laryngeal injury, posterior dislocation of clavicular head, or penetrating trauma) Tracheobronchial tree injury Breathing thoracic injuries ANS: Tension pneumothorax Open pneumothorax Massive hemothorax Circulation thoracic injuries ANS: Massive hemothorax Cardiac tamponade Traumatic circulatory arrest What's the most common cause of a tension pneumothorax? ANS: Mechanical positive-pressure ventilation in patients with a visceral pleural inury Where is the ideal location for needle decompression of a tension pneumothorax? ANS: 5th intercostal space, slightly anterior to midaxillary line What do you need to remember when treating an open pneumothorax? ANS: Place a dressing on the site and only secure is on 3 sides so air can escape, then place a chest tube Massive hemothorax ANS: Accumulation of >1500 ml of blood in one side of chest Causes of PEA? ANS: Hypovolemia Hypoxia Hydrogen acidosis Hypo/hyperkalemia Hypoglycemia Hypothermia Toxins Tamponade Tension pneumo Thrombosis Indications of a thoracotomy ANS: Immediate return of > 1500 ml of blood or significant bleeding Persistent blood transfusions Penetrating anterior chest wounds medial to the nipple line Posterior wounds medial to the scapula A 26-year-old male sustained a posterior stab wound. Blood and bubbling are coming from the wound. ANS: Open pneumothorax A 46-year-old male sustained a gunshot wound to the chest ANS: Massive hemothorax A 65-year-old female who takes warfarin was involved in a MVC. She initially presented complaining of sternal pain. BP deteriorated to 90/60 after arriving to the ED ANS: Cardiac tamponade Eight life-threatening injuries during the secondary survey? ANS: Simple pneumothorax Hemothorax Flail chest Pulmonary contusion Blunt cardiac injury Traumatic aortic disruption Traumatic diaphragmatic injury Blunt esophageal rupture A patient with a simple pneumothorax ANS: May be watched for progression if pneumothorax is small (<15%) and patient is stable and does not require transfer A 38-year-old male presents to the ED after a head-on, high-speed collision. His vitals are HR 130, BP 156/90, RR 20, and O2 sat 92% on 15L of O2. His voice is raspy and he complains of chest pain that radiates to his back. A CXR shows a widened mediastinum, obliteration of the aortic notch, and depression of the left mainstream bronchus. You should ANS: Administer agents to manage his pain and lower his HR and BP (aortic disruption) What's a characteristic that is shared by all traumatic aortic disruption survivors? ANS: Contained hematoma A 36-year-old female was involved in an altercation, sustaining a knife wound to the chest, below the left nipple. She is mildly short of breath with an oxygen sat of 92%. BP is 115/80. ANS: Simple pneumothorax A 56-year-old male archer was riding a horse when it bucked and the saddle struck him in the chest wall. You note paradoxical chest wall movement on the left anterior chest. CXR is negative. ANS: Flail chest due to costochondral disruption What would confirm a diaphragmatic injury in a patient? ANS: Presence of NGT What is a common finding associated with traumatic asphyxia? ANS: Upper torso, facial, and arm plethora with petechiae secondary to acute temporary compression of SVC. Massive swelling and cerebral edema may be present. Why are rib fractures in older adults a more significant concern than in young patients? ANS: The incidence of PNA and mortality is doubled in older patients Pulmonary contusion/flail chest is best treated by? ANS: Supplemental oxygen, pain control, and recognition if the patient is unable to ventilate properly The cause of hypoxia associated with flail chest is ANS: Pulmonary contusion A patient arrives in your hospital after a fall from 20 ft landing on his right side. He has been intubated and two large-bore IVs have been started. His o2 sat is 82%, he has a good capnography waveform, and significant deformity to right chest wall. He has no breath sounds on the right. His BP is 75/30. Your next step should be to ANS: Perform a needle decompression or finger throacostomy on the right side You have completed a secondary survey on a patient who feel from a standing height. You note exquisite tenderness posterolaterally on the left chest wall at 9-11 ribs. This should raise suspicion for what other injury? ANS: Splenic injury A patient's CXR reveals left pneumothorax. Additionally, the left diaphragm is obscured and there is an air fluid level in the left hemithorax. You decide to place a chest tube. The patient is at increased risk for damage to ANS: Abdominal contents that have become displaced into the chest cavity Stab wounds most commonly injury? ANS: Liver (40%) Small bowel (30%) Diaphragm (20%) Colon (15%) Gunshot wounds most commonly injury? ANS: Small bowel (50%) Colon (40%) Liver (30%) Abd vascular structures (25%) When is a retrograde urethrogram mandatory? ANS: Patient is unable to void, requires pelvic binder, or has blood at the meatus, scrotal hematoma, or perineal ecchymosis A 28-year-old male, helmeted motorcyclist was in a high speed MVC, striking head-on into the side of a vehicle. He arrives on a backboard and with a cervical collar in place via pre-hospital BLS transport. Vitals are: BP 100/75, HR 115, RR 20, GCS 15. The patient reports a brief loss of consciousness and is complaining of pain in the chest, abdomen, and pelvis. What're the priorities for management? ANS: Rapidly assess ABCs Auscultate the lungs, provide supplemental oxygen, and apply pulse ox A 28-year-old male, helmeted motorcyclist was in a high speed MVC, striking head-on into the side of a vehicle. He arrives on a backboard and with a cervical collar in place via pre-hospital BLS transport. Vitals are: BP 100/75, HR 115, RR 20, GCS 15. The patient reports a brief loss of consciousness and is complaining of pain in the chest, abdomen, and pelvis. What's the interpretation of the VS and the initial therapy? ANS: VS are consistent with hemorrhagic shock from intraabdominal or pelvic sound Maintain IV/IO access and initiate volume resuscitation, including blood transfusion if indicated Pelvic binder application may be appropriate Will retroperitoneal injuries prevent with obvious signs of peritoneal irritation? ANS: No, retroperitoneal structures are separated from anterior peritoneum by the intraperitoneal viscera, therefore no peritonitis may be present A patient was found 10' from his motorcycle, laying on his right side. He was wearing a helmet. He was going ~45 mph. He had brief LOC. He states he has no allergies, medications that he takes, no current illness. Last meal was 6 hours ago. Based on mechanism, what intra-abdominal and/or pelvic injuries is he likely to have sustained? ANS: Visceral lacerations (liver/spleen) Bowel visceral/vascular injuries Retroperitoneal visceral/vascular injuries (kidneys/adrenal) Pelvic fractures A patient was found 10' from his motorcycle, laying on his right side. He was wearing a helmet. He was going ~45 mph. He had brief LOC. He states he has no allergies, medications that he takes, no current illness. Last meal was 6 hours ago. How would the risk of intra-abdominal injury change if the patient described stroking the handlebar into the epigastrium? ANS: A direct blow to the epigastrium would raise the risk of a pancreas, duodenal, or small bowel injury A 30-year-old male presents with a 2 cm stab wound to the mid-abdomen, 3 cm to the right of the umbilicus. VS are BP 85/60, HR 130, RR 25, GCS 14. Neck veins are flat. Chest exam is CTAB. The abdomen is tender. What's the ONE BEST therapy to treat this patient's injury? ANS: Airway appears intact. Breathing has increased rate. Circulation demonstrated hemorrhagic shock. Penetrating abdominal injury with shock is one of the indications for emergent laparotomy. In a patient with a possible pelvic fracture, how frequently should the pelvis be tested for mechanical stability? ANS: The pelvis should not be tested in a hemodynacilly unstable patient. Mechanical instability of he pelvic ring should be assumed in patients who have suspected pelvic fractures. Avoid manually manipulating the pelvis (dislodge an existing clot) Hypotension + pelvic fracture = ANS: High mortality A 12-year-old male complains of LUQ tenderness and L shoulder pain 8 hours after playing rugby. ABCDE are normal. Circulatory assessment remains normal. Abdominal exam reveals mild LUQ TTP without peritoneal signs. FAST demonstrated fluid in the hepatorenal space and the plenorenal recess. What's the appropriate next step? ANS: Observation A 29-year-old woman is the restrained driver in a head-on collision. Airbags deployed. ABCDE are normal. The patient complains of lower abd and back pain. A lower abd contusion is present and associated with tenderness. There is no evidence of diffuse peritonitis. Your institution has NOT surgical capabilities. What's the most appropriate treatment plan? ANS: The patient should be urgently transferred for surgical intervention A 50-year-old male arrives to the ED following fall of 26'. He hs gurgling respirations and is not responsive to voice. VS are BP 80/5-, RR 30, HR 138, O2 sat is undetectable. Your hospital does not have surgical capabilities. The first step in management is ANS: Application of oxygen and securing an airway A 25-year-old ale arrives at the ED following a motorcycle crash. BP is 80/60, HR 140. Airway and breathing are controlled. There are no open wounds. The abd is not distended. Both legs are externally rotated but soft. The pelvis is tender. The scrotum is swollen and ecchymotic. While vascular access is obtained, what the next most appropriate step? ANS: Application of a pelvic binder A 45-year-old male with a BMI of 48 was working in an industrial plant when 2 pieces of wood flew off a sa and struck him in the abdomen and right chest. CXR demonstrates rib fractures. What's true about this scenario? ANS: Despite multiple imaging studies, detection of intestinal and retroperitoneal injuries may be difficult Your institution does not have surgical capabilities. You have intubated a 25-year-old man who was in a rollover MVC. You have also placed bilateral chest tubes for pneumothoraxes. The patient's SBP is continually < 90 and HR > 140. Potential therapy and evaluation includes ANS: Activation of massive transfusion protocol, application of pelvic binder, and CXR What's the primary goal of treatment for patient's with suspected TBIs? ANS: To prevent secondary brain injury by ensuring adequate oxygenation and maintain BP that's sufficient to perfuse the brain Cerebral perfusion pressure (CPP) ANS: MAP - ICP A 23-year-old male fell from a bike, striking his head on the curb. He was not wearing a helmet. The patient has a 10 cm laceration to the temporal-parietal region of the left scalp. He is initially able to say hi name. VS are HR 115, BP 100/60, oxygen sat 88%, GCS initially 12. 2 hours after transfer to a local hospital, he has sonorous respirations, a HR of 120, BP 100/70, and GCS of 6. What the initial priorities in the management of this patient? ANS: Airway protection with a subglottic device Oxygenation to prevent hypoxia Maintain SBP > 100 mmHg A 23-year-old male fell from a bike, striking his head on the curb. He was not wearing a helmet. The patient has a 10 cm laceration to the temporal-parietal region of the left scalp. He is initially able to say hi name. VS are HR 115, BP 100/60, oxygen sat 88%, GCS initially 12. 2 hours after transfer to a local hospital, he has sonorous respirations, a HR of 120, BP 100/70, and GCS of 6. What are the signs that the patient's injury is progressing? ANS: Decreased GCS indicates worsening intracranial pathology with possible intracranial HTN and impending herniation... [Show Less]
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ATLS EXAM WITH COMPLETE SOLUTIONS QUESTIONS AND ANSWERS GRADED A
ATLS EXAM WITH COMPLETE SOLUTIONS QUESTIONS AND ANSWERS GRADED A True or false? Although the mechanism of injury may be similar to those for the younger... [Show More] population, data shows increased mortality with similar severity of injury in older adults. ANS: True In the elderly population, what is decreased physiological reserve? ANS: aging is characterized by impaired adaptive and homeostatic mechanisms that caused an increased susceptibility to the stress of injury. Insults tolerated by the younger population can lead to devastating results in elderly patients. Pre-existing conditions that affect morbidity and mortality include: ANS: cirrhosis, coagulopathy, COPD, ischemic heart disease, DM What is the most common mechanism of injury in the elderly? ANS: Fall. Nonfatal falls are common in women and fractures are common in women who fall. Falls are the most common cause of TBI. In the elderly population, what are risk factors for falls? ANS: advanced age, physical impairment, history of previous fall, medication use, dementia, unsteady gait, and visual, cognitive impairment Most of elderly traffic fatalities occur in the daytime and on weekends and typically involve other vehicles. Why? ANS: Older people drive on more familiar roads and at lower speeds and tend to drive during the day. Older people have slower reaction time, a larger blind spot, limited cervical mobility, decreased hearing, and cognitive impairment. True or False? Mortality associated with small to moderate sized burns in older adults remains high ANS: True Spilled hot liquids on the leg, which in younger patients may re-epithelialize due to an adequate number of hair follicles, will result in a full thickness burn in older patients. ANS: this is true Airway-patients may have dentures that may loosen or obstruct the airway. If dentures are not obstructing the airway, leave them in place for what? ANS: bag mask ventilation, as it improves mask fitting. When preforming rapid sequence intubation, the dose of benzos, barbiturates, and other sedatives should be reduced to what percentage to minimize the risk of cardiovascular depression? ANS: 20-40% Functional changes in cardiac system include declining function, decreased sensitivity to catechol amines, atherosclerosis of coronary vessels, increased afterload, fixed heart rate (beta blockers) ANS: this results in lack of classic response to hypovolemia, risk for cardiac ischemia, elevated BP at baseline, and increased risk of dysrhythmias. Functional changes in pulmonary system include decreased elastic recoil, reduced residual capacity, decreased gas exchange and decreased cough reflex ANS: thus they are at increased risk for respiratory failure, increased risk for pneumonia, and poor tolerance to rib fractures Functional changes in renal system include loss of renal mass, decreased GFR, and decreased sensitivity to ADH and aldosterone ANS: resulting in drug dosing for renal insufficiency, decreased ability to concentrate urine, increased risk for AKI and urine flow may be normal with hypovolemia Functional changes to MSK include loss of lean body mass, osteoporosis, changes in joints and cartilage, c spine degenerative changes and loss of skin elastin and subcutaneous fat ANS: resulting in increased risk for fractures, decreased mobility, difficulty for oral intubation, risk of skin injury, increased risk for hypothermia, challenges in rehabilitation Functional changes in Endocrine system include decreased production and response to thyroxin and decreased dehydroepiandrosterone (DHEA) ANS: resulting in occult hypothyroidism, relative hyper cortisone states and increased risk of infection True or false: Arthritis can complicate the airway and cervical spine. Patients can have multilevel degenerative changes affecting disk spaces and posterior elements associated with severe central canal stenosis, cord compression, and myelomalacia ANS: true In elderly population, due to their changes in pulmonary system, placing a gauze between gums and cheek to achieve seal when using bag valve mask ventilation is okay. In addition, because aging causes a suppressed heart rate response to hypoxia...... ANS: respiratory failure may present insidiously in older adults. Age related changes in the cardiovascular system place the elderly trauma patient at significant risk for being inaccurately categorized as hemodynamically stable. ANS: Elderly patients have a fixed heart rate and fixed cardiac output, thus, their response to hypovolemia will involve increasing their systemic vascular resistance. Furthermore, since older patients have HTN, an acceptable BP may truly reflect a hypotensive state. A systolic BP of 110 is to be utilized as the threshold for identifying hypotension in patients 65 and older. Do no equate blood pressure with shock in older patients ANS: BP in older patients may look normal due to the medications they are on. Use lactate and base deficit to evaluate for evidence of shock what 2 factors place elderly patients at risk for intracranial hemorrhage? ANS: aging causes dura to become more adherent to the skull increasing risk of injury and older patients are on anticoagulant and antiplatelet medications. Loss of subcutaneous fat, nutritional deficiencies, chronic medical conditions place elderly patients as risk for hypothermia and complications for immobility. ANS: Rapid evaluation and when possible early liberation from spine boards and cervical collars will minimize complications. True or False: Fall prevention is the mainstay of reducing the mortality associated with pelvic fractures. ANS: true poor hygiene, dehydration, oral injury, contusions affecting the inner arms, inner thighs, palms, soles, scalp, ear, nasal bridge and temple injury from being struck while wearing glasses, contact burns and scalds. These are all signs of.......? ANS: Elder maltreatment. The presence of physical findings of maltreatment should prompt a detailed history. if history conflicts with findings, immediately report findings to authorities. True of false: early activation of the trauma team may be required for elderly patients who do not meet traditional criteria for activation ANS: True. A simple injury such as an open tibia fracture in a frail elderly patient may become life threatening. Common mechanisms of injury include falls, MVC, burns, and penetrating injuries ANS: common injuries in the elderly include rib fractures, TBI, pelvic fractures The best initial treatment for the fetus is to provide optimal resuscitation of the mother. True or False? ANS: True. Also if xray examination is indicated during the pregnant patient's treatment, it should not be withheld because of the pregnancy. What happens as the uterus enlarged and the bowel is pushed cephalad. ANS: When the uterus enlarges it pushes the bowel cephalad and the uterus lies in the upper abdomen. As a result, the bowel is somewhat protected from blunt abdominal trauma, whereas the uterus and its contents (fetus and placenta) become more vulnerable. Uterus remains intrapelvic until 12 weeks and then at 20 weeks it is at the umbilicus, and at 34-36 weeks it reaches the costal margin. Amniotic fluid can cause amniotic fluid embolism and disseminated intravascular coagulation following trauma if fluid enters maternal intravascular space. True or False ANS: True By the third trimester, what is the complication of trauma to the pelvis of the mother? ANS: by the third trimester, the uterus is large and thin walled. In vertex presentation, fetal head is usually in the pelvis and the remainder of the fetus is exposed above the pelvic brim. Pelvic fractures in late gestation can result in skull fracture or intracranial injury to the fetus. Also we can have a placental abruption due to its little elasticity and vulnerability to sheer forces. An abrupt decrease in maternal intravascular volume can result in a profound increase in uterine vascular resistance reducing fetal oxygenation despite reasonably normal maternal vital signs. ANS: this is true Physiological anemia of pregnancy ANS: A smaller increase in red blood cell volume can occur resulting in a decreased hematocrit level. Thus, in late pregnancy a hematocrit of 31-33% is normal. Healthy pregnancy patients can lose 1200-1500 mL of blood before exhibiting signs and symptoms of hypovolemia. How can this manifest? ANS: this amount of hemorrhage may be reflected by fetal distress as evidenced by an abnormal fetal heart rate. What are some of the lab changes in pregnancy? ANS: WBC increases to 12000 and during labor can be 25000. Fibrinogen and other clotting factors are mildly elevated and PT and pTT are shortened, but bleeding time and clotting time are unchanged. After the 10th week of pregnancy, cardiac output can increase 1.0-1.5 L/min because of the increase in plasma volume and decrease in vascular resistance of the uterus and placenta. ANS: The placenta receives 20% of the patient's cardiac output during the 3rd trimester. In supine position, vena cava compression can decrease cardiac output by 30% because of decreased venous return from lower extremities. During pregnancy the heart rate increases to a maximum of 10-15 beats per minute over baseline by the third trimester. ANS: this heart rate must be considered when interpreting a tachycardia response to hypovolemia. Blood pressure falls 5-15 mm Hg in systolic and diastolic pressures during second trimester, although it returns to near normal levels at term. ANS: some women experience hypotension when placed in the supine position due to the compression of teh inferior vena cava. hypertension in the pregnant if accompanied by proteinuria may represent what? ANS: pre-eclampsia. EKG findings in pregnant patient ANS: Flatted or inverted T waves in leads III and AVF and the precordial leads may be normal. Ectopic beats are increased during pregnancy. Minute ventilation increases primarily due to an increase in tidal volume. Hypercapnia (30 mm Hg) is common in late pregnancy ANS: Monitor ventilation in late pregnancy with arterial blood gas values. A PaCO2 of 35-40 mm Hg may indicate impending respiratory failure during pregnancy. Pregnant patients should be hypo apneic. Anatomical alterations in the thoracic cavity seem to account for the decreased residual volume associated with diaphragmatic elevation and chest x ray reveals increased lung marking and prominence of the pulmonary vessels. ANS: oxygen consumption increases during pregnancy and its important when resuscitating injured pregnant patients to maintain adequate oxygenation above 95% In patients with advanced pregnancy, those that require a chest tube placement, where should the test tube be placed? ANS: it should be positioned higher to avoid intra-abdominal placement given the elevation of the diaphragm. Urinary system: what happens to the GFR, serum creatinine and urea nitrogen levels? ANS: GFR and renal blood increases during pregnancy, whereas levels of the serum creatinine and urea nitrogen fall to one half of the normal pre pregnancy levels. Glycosuria is common in pregnancy. When interpreting x ray films of the pelvis in a pregnant patient, the symphysis pubis widens 4-8 mm and the sacroiliac joint spaces increase by the 7th month ANS: keep this in mind Eclampsia ANS: Maintain a high index of suspicion for eclampsia when seizures are accompanied by HTN, proteinuria, hyperreflexia, and peripheral edema in pregnant trauma patients. This can mimic head injury. External contusions and abrasions of the abdominal wall are signs of blunt uterine trauma. ANS: true. Fetal injuries can occur when the abdominal wall strikes an object, such as the dashboard or steering wheel, or when a pregnant patient is struck by a blunt instrument. Using a shoulder restraints in conjunction with a lap belt reduces the likelihood of direct and indirect fetal injury, presumably because the shoulder belt dissipates deceleration forces over a great surface area and helps prevent the mother from flexing forward over the gravid uterus. ANS: the deployment of air bags in vehicles does not appear to increase pregnancy specific risks. Using lap belt alone allows for forward flexion and uterine compression with possible uterine rupture or placental abruption. Lap belt worn too high over uterus may produce uterine rupture. Penetrating injury to pregnant women ANS: As uterus grows larger, other viscera are protected from penetrating injury. Dense uterine musculature in early pregnancy can absorb significant amount of energy from penetrating objects decreasing their velocity and lowering risk of injury to other viscera. However, fetal outcome is generally poor with penetrating injury to uterus. carefully observe pregnant patients with even minor injuries since occasionally minor injuries are associated with placental abruption and fetal loss. ANS: True. AND to optimize outcomes for mother and baby, clinicians must assess and resuscitate the mother first and then assess the fetus before conducting second survey of the mother. Failure to displace the uterus to the left side in a hypotensive pregnant patient ANS: logroll all patients appearing clinically pregnant (second and third trimester) to the left 15-30 degrees and elevate the right side 4-6 inches and support with a bolstering device to maintain spinal motion restriction and decompression of the vena cava. Due to increases intravascular volume, pregnant patients can lose a significant amount of blood before tachycardia, hypotension, and other signs of hypovolemia occur. Thus, what do stable vital signs in a pregnant patient indicate about the fetus? ANS: The fetus may be in distress and the placenta deprived of vital perfusion while the mother's condition and vital signs appear stable. Administer crystalloid fluid resuscitation and blood to support the physiological hypervolemia of pregnancy. vasopressers should be an absolute last resort in restoring maternal blood pressure as they further reduce uterine blood flow, resulting in fetal hypoxia. What does a normal fibrinogen level indicate in a pregnant patient? ANS: Fibrinogen level may double in late pregnancy and a normal level may indicate early disseminated intravascular coagulation Most common cause of fetal death? ANS: maternal shock and maternal death. Placental abruption is second. Placental abruption is suggested by vaginal bleeding, uterine tenderness, frequent uterine contractions, uterine tetany, and uterine irritability (uterus contracts when touched). In 30% of cases of abruption, bleeding may not occur. Uterine ultrasound may be helpful in diagnosis, but is NOT definitive. Signs of uterine rupture ANS: abdominal tenderness, guarding, rigidity, or rebound tenderness. Signs of peritonitis are hard to tell due to expansion and attenuation of the abdominal wall musculature. Other findings include abdominal fetal lie (oblique or transverse lie), easy palpation of the fetal parts because of their extrauterine location and inability to readily palpate the uterine fundus when there is fundal rupture. Xray evidence of rupture include extended fetal extremities, abnormal fetal position, and free intraperitoneal air. Perform continuous fetal monitoring with a tocodynamometer beyond 20-24 weeks of gestation. ANS: Patients with no risk factors for fetal loss should have continuous monitoring for 6 hours, whereas, patients with risk factors for fetal loss or placental abruption should be monitored for 24 hours. RISK FACTORS ARE: heart rate > 110, an injury severity score >9, evidence of placental abruption, fetal heart rate >160 or less than 120, ejection during MV, and motorcycle or pedestrian collisions REMEMBER: maternal bicarbonate is low during pregnancy to compensate for respiratory alkalosis. ANS: 17-22 in pregnant patient. (non pregnant patient is 22-28) Fetal heart rate is a sensitive indicator of maternal blood volume status and fetal well being. ANS: normal range for fetus is 120-160. abnormal heart rate, repetitive decelerations, absence of accelerations or beat to beat variability and frequent uterine activity can be signs of impending maternal and or fetal decompensation (hypoxia or acidosis) and should prompt immediate obstetrical consultation. If a DPL is to be placed in a pregnant trauma patient, place the catheter above the umbilicus using the open technique. Be alert to uterine contractions which suggest early labor and tetanic contractions which suggest placental abruption. ANS: evidence of ruptured chorioamniotic membranes include amniotic fluid in vagina evidenced by a pH of 4.5 Bleeding in 3rd trimester may indicate placental abruption and impending death of the fetus, a vaginal exam is vital ANS: however, avoid repeating vaginal examination, CT abdominal imaging can be done and radiation doses less than 50mGy are not associated with fetal anomalies or higher risk of fetal loss. Admission to hospital for pregnant patients: ANS: vaginal bleeding, uterine irritability, abdominal tenderness, pain or cramping, evidence of hypovolemia, changes in or absence of fetal heart tones and or leakage of amniotic fluid With extensive placental separation or amniotic fluid embolization, widespread consumptive coagulopathy can emerge rapidly causing depletion of fibrinogen, other clotting factors, and platelets. ANS: immediately perform uterine evacuation and replace platelets, fibrinogen, and other clotting factors. As little as 0.01mL of RH+ blood will sensitize 70% of Rh- women. ANS: All pregnany RH negative trauma patients should receive RH immunoglobulin therapy unless injury is remote from the uterus (isolated distal extremity injury) Intimate partner violence in pregnant patient: ANS: injuries inconsistent with history, diminished self image, depression or suicide attempts, self abuse, frequent ED visits, symptoms suggestive of substance abuse, isolated injuries to the gravid abdomen, parter insists on being present for the interview and exam and monopolizes discussion What is the difference between burns and other injuries? ANS: The biggest difference is that the consequences of burn injury are directly linked to the extent of the inflammatory response to the injury. The larger and deeper the burn, the worse the inflammation. Flame injury is more evident than most chemical injuries. ANS: Monitor IV lines closely to ensure they do not become dislodged as the patient becomes more edematous. Regularly check ties securing ET or NG to ensure they are not too tight. Factors that increase the risk of upper airway obstruction are: ANS: increasing burn size and depth, burns to the head and face, inhalation injury, associated trauma, and burns inside the mouth. Airway can become obstructed form direct injury such as inhalation injury, but also from massive edema resulting from burn injury. How do you decontaminate burn areas? ANS: Completely remove the patient's clothing to stop burning process, but do not peel off adherent clothing. Synthetic fabrics can ignite, burn rapidly at high temps and melt into hot residue that continues to burn the patient. brush any dry chemical powder from wound. rinse with copious amounts of warm saline irrigation or rinsing in a warm shower. once the burning process has been stopped, cover the patient with warm, clean, dry linens to prevent hypothermia. hoarseness, stridor, accessory respiratory muscle use, sternal retraction are signs of what? ANS: airway obstruction. Clinical manifestations of inhalation injury may be subtle and may not show up within the first 24 hours. do not wait for the xray to show evidence of pulmonary injury or changes in blood gas because airway edema can preclude intubation and a surgical airway will be required. A carboxyhemoglobin level greater than what percentage indicates a patient was involved in a fire and has inhalation injury? ANS: 10% Indications for early intubation in burn patients: ANS: full thickness circumferential neck burns, signs of airway obstruction, extent of the burn > 40%, burns inside the mouth, difficulty clearing secretions or swallowing, decreased level of consciousness, Patient with inhalation injury are at risk for bronchial obstruction from secretions and debris and they may require bronchoscopy. ANS: Make sure to place an adequately sized airway tube Direct thermal injury to the lower airway is very rare and essentially occurs only after exposure to superheated steam or ignition of inhaled inflammable gases. Breathing concerns arise from what 3 general causes: ANS: hypoxia, carbon monoxide poisoning, and smoke inhalation injury. Always assume CO exposure in patients who were burned in enclosed areas. Patients with CO levels less than 20% may not show any symptoms ANS: HA and nausea (20-30%), confusion (30-40%), coma (40-60%) and death (>60%). Cherry red skin color in patients may only be seen in moribund patients. Measurements of arterial PaO2 do not reliably predict CO poisoning b/c a partial pressure of only 1 mm Hg results in an HbCO level of 40% or greater. Pulse ox cannot be relied on to rule out carbon monoxide poisoning b/c we cant distinguish oxyhemoglobin from carboxyhemoglobin. A discrepancy between pulse ox and arterial blood gas may be explained by presence of carboxyhemoglobin. Cyanide inhalation poisoning can occur in confined spaces and sign of potential toxicity is persistent profound unexplained metabolic acidosis. ANS: THERE IS NO ROLE for hyperbaric oxygen therapy in the primary resuscitation of a patient with critical burn injury. American Burn Association states 2 requirements for diagnosis of smoke inhalation injury: ANS: 1. exposure to combustible agent 2. signs of exposure to smoke in the lower airway, below the vocal cords, seen on bronchoscopy. A chest Xray and arterial blood gases should be ordered to evaluate the pulmonary status of a patient with smoke inhalation injury, but normal values on admission DO NOT exclude an inhalation injury. The treatment of smoke inhalation injury is supportive. ANS: Any patient with smoke inhalation injury and significant burns greater than 20% TBSA should be intubated. IF the patient's hemodynamic condition permits and spinal injury has been excluded, elevate the patient's head and chest 30 degrees to help reduce neck and chest wall edema. True or false: Clinicians should provide burn resuscitation fluids for deep partial and full thickness burns larger than 20% TBSA ANS: True. urine output monitoring is 0.5mL/kg/hr in adults and should be maintained at 30-50cc/hr to minimize over resuscitation in a burn patient, cardiac dysrhythmias may be the first sign of hypoxia and electrolyte or acid base abnormalities. ANS: therefore an ECG should be performed for cardiac rhythm disturbances. Persistent academia in patients with burn injuries may be due to under resuscitation or infusion of large volumes of saline. Tachycardia is a poor indication for resuscitation in the burn patient. ANS: Adjust the fluid rate up or down based on the urine output and recognize that factors such as inhalation injury, age of patient, renal failure, diuretics, and alcohol can affect the volume of resuscitation and urine output. True of false: Burn patients should get tetanus. ANS: true Partial thickness burns ANS: are characterized as either superficial partial thickness (moist, painfully hypersensitive, , potentially blistered, homogenously pink, and blanch to touch) or deep partial thickness ( drier, less painful, potentially blistered, red or mottled in appearance, and do not blanch to touch) Full thickness burns ANS: appear leathery and skin may be white or translucent or waxy white. surface area is painless to light touch or pinprick and generally dry Compartment syndrome in burn patients: ANS: Compartment syndrome can result from an increase in pressure inside the compartment that interferes with perfusion to the structures within that compartment. In burns, this condition results from a combination of decreased skin elasticity and increased edema in the soft tissue. A pressure > 30 mm Hg within the compartment can lead to muscle necrosis and once the pulse is gone it may be TOO LATE to save the muscle. so recognize the signs early: pain greater than expected and out of proportion to the injury pain on passive stretch of the affected muscle tense swelling of the affected compartment paresthesias or altered sensation distal to the affected compartment compartment syndrome may be present with circumferential chest and abdominal burns ANS: chest and abdominal escharotomies performed along the anterior axillary lines with cross incision at the clavicular line and the junction of the thorax and abdomen usually relieve this problem. relieve circulatory compromise in a circumferentially burned limb by eschartomy and these escharotimies are not needed within the first 6 hours. Partial thickness burns are painful when air currents pass over the burned surface. ANS: gently cover the burn with clean sheets will decrease the pain and deflect air currents. Do not break blisters or apply an antiseptic and application of cold compress can cause hypothermia. DO not apply cold water to a burn patient. electrical burns are more serious than they appear on the body surface and extremities, particularly the digits. ANS: current can travel inside blood vessels and nerves and can cause local thrombosis and nerve injury. So a severe electrical injury usually results in contracture of the affected extremity. A clenched hand with a small electrical entrance wound should alert the clinician that a deep soft tissue injury is likely much more extensive than is visable to the naked eye ANS: true. patients with severe electrical injuries require fasciotomies. Electricity can cause forced contraction of muscles, doctors need to examine patient for skeletal and muscular damage, especially for fractures of the spine and rhabdomyolysis How do you dissolve a tar burn? ANS: Use mineral oil Abuse and burns ANS: circular burns and burns with clear edges and unique patterns may reflect cigarette burns or iron. Burns on the sole of the feet usually suggest child was placed in hot water. A burn on the posterior aspect of the LE and buttocks Patient with electrical burn can develop for acute renal failure ANS: remember these burns can cause serious muscle damage without showing signs outright. Test urine for hem chromogen and administer proper volume. Assess for compartment syndrome and attach EKG leads as electrical injury can cause arrhythmias. Frostbite is due to freezing of tissue with intracellular ice crystal formation, microvascular occlusion, and subsequent tissue anoxia. ANS: first degree: hyperemia and edema are present w/o skin necrosis second degree: large clear vesicles accompany the hyperemia and edema with partial thickness skin necrosis. third degree frostbite: full thickness skin necrosis including muscle and bone with later necrosis treatment is circulating water at constant 40 degrees C or 104F until pink color and perfusion return in 20-30 minutes. CONTINUES... [Show Less]
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