Advanced Trauma Life Support (ATLS) Exam 2024 New Latest Version with All Questions, Exams of Nursing

Download Advanced Trauma Life Support (ATLS) Exam 2024 New Latest Version with All Questions and more Exams Nursing in PDF only on Docsity! Advanced Trauma Life Support (ATLS) Exam 2024 New Latest Version with All Questions from Actual Past Exam and 100% Correct Answers 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: Select one: a: 2 b: 4 c: 6 d: 9 e: 12 --------- Correct Answer ---------- d: 9 How do you manage post-cardiac arrest seizures? --------- Correct Answer ---------- Levetiracetam or sodium valproate What can you use to control myoclonus and electrographic seizures? --------- Correct Answer ---------- Propofol or benzodiazepines What is common in the first 2-3 days following cardiac arrest, particularly in the comatose patient? --------- Correct Answer ---------- Pyrexia Which one of the following findings in an adult is most likely to require immediate management during the primary survey? Select one: a. distended abdomen b. Glasgow Coma Scale score of 11 c. temperature of 36.5°C (97.8°F) d. deformity of the right thigh e. respiratory rate of 40 breaths per minute --------- Correct Answer ---------- e. respiratory rate of 40 breaths per minute If you add up BSA head, chest, back, arms, and legs you get 99% of BSA. What is the remaining 1%? -------- Correct Answer ---------- Perineum Partial/2nd degree burns extend into the _____ whereas full thickness/3rd degree burns -------- Correct Answer ---------- Partial - go into dermis, FULL go all the way through dermis and into/beyond SQ tissue For patients with CO poisoning, the ½ life is ___ when breathing room air and ___ breathing 100% oxygen -------- Correct Answer ---------- 4 hours on RA, 40 min on 100% O2 How do you calculate the Parkland formula? (BURNS) -------- Correct Answer ---------- 4 * weight (kg) * percent BSA burned = volume in 24 hours (1st half in 8 hrs, 2nd half over 16 hrs).4*70kg*25 percent = 7 liters in 24 hours. ***Use 25, NOT 0.25)*** Partial or full thickness burns of ___% in patients less than 10 or older than 50 warrants transfer to a burn center. -------- Correct Answer ---------- 10% What percent partial/full thickness burns would qualify a 25 year old for a burn center transfer? -------- Correct Answer ---------- 20% What anatomical positions with partial/full thickness burns warrant burn center transfer? -------- Correct Answer ---------- Face, eyes, ears, hands, genitalia, perineum, feet, skin overlying joints. Does an inhalation injury warrant transfer to a burn center? -------- Correct Answer ------- --- Yes Should you treat frostbite by soaking body part in water or not? -------- Correct Answer -- -------- YES, 40 degree (104F) for 20-30 min should suffice. Don't warm if there is risk of REFREEZING. Insofar as hypothermia is concerned, patients are not pronounced dead until they are _____ and dead. -------- Correct Answer ---------- warm What are you thinking if a child has broken ribs? -------- Correct Answer ---------- MASSIVE force and highly likely organ damage (since their ribs are very pliable, a huge amount of force is required to break them, there is often underlying organ damage WITHOUT broken ribs). Which one of the following statements concerning intraosseous infusion is TRUE? Select one: a. Only crystalloid solutions may be safely infused through the needle. b. Aspiration of bone marrow confirms appropriate positioning of the needle. c. Intraosseous infusion is the preferred route for volume resuscitation in small children. d. Select one: a. The trachea is relatively short. b. The distance from the lips to the larynx is relatively short. c. The use of cuffed endotracheal tubes eliminates this issue. d. The mainstem bronchi are less angulated in their relation to the trachea. e. So little friction exists between the endotracheal tube and the wall of the trachea. --------- Correct Answer ---------- a. 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 Select one: a. perform diagnostic peritoneal lavage b. obtain a CT of the chest c. perform an angiography d. urgently transfer the patient to the operating room e. immediately transfer the patient to a trauma center --------- Correct Answer ---------- d. 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 Select one: a. perform a surgical cricothyroidotomy b. attempt nasotracheal intubation c. ventilate him with a bag-mask device until c-spine injury can be excluded d. restrict cervical motion and attempt orotracheal intubation using 2 people e. ventilate the patient with a bag-mask device until his beard can be shaved for better mask fit a. perform a surgical cricothyroidotomy b. attempt nasotracheal intubation c. ventilate him with a bag-mask device until c-spine injury can be excluded d. restrict cervical motion and attempt orotracheal intubation using 2 people e. ventilate the patient with a bag-mask device until his beard can be shaved for --------- Correct Answer ---------- d. 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. His blood pressure is 60/40 mm Hg and his heart rate is 70 beats per minute. His skin is warm. Which one of the following statements is TRUE? Select one: a. Vasoactive medications have no role in this patient's management. b. The hypotension should be managed with volume resuscitation alone. c. Flexion and extension views of the c-spine should be performed early. d. Abdominal visceral injuries can be excluded as a cause of hypotension. e. Flaccidity of the lower extremities and loss of deep tendon reflexes are expected. -------- - Correct Answer ---------- e. Flaccidity of the lower extremities and loss of deep tendon reflexes are expected Which one of the following is the most effective method for initially treating frostbite? Select one: a. moist heat b. early amputation c. padding and elevation d. vasodilators and heparin e. topical application of silver sulfadiazine --------- Correct Answer ---------- a. 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 to the emergency department, his right lower extremity is cool, mottled, insensate, and motionless. Despite normal vital signs, a pulse 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, which of the following is most likely to improve the chances for limb salvage? Select one: a. applying skeletal traction b. administering anticoagulant drugs c. administering thrombolytic therapy d. surgical consultation for right lower extremity fasciotomy e. transferring the patient to the trauma center 120 km away --------- Correct Answer -------- -- d. 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: Select one: a. request a CT scan b. insert a gastric tube c. suction the oropharynx d. obtain a lateral cervical spine x-ray e. ventilate the patient with a bag-mask --------- Correct Answer ---------- c. 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 A patient that presents with a torso gunshot wound and is hypotensive should receive crystalloid fluid resuscitation until the blood pressure is normal b. Evidence of improved perfusion after fluid resuscitation could include improvement in Glasgow coma scale score on reevaluation c. Massive transfusion is defined as transfusion of more than >10 of packed red blood cells and plasma in 24 hours d. When tranexamic acid is administered by pre-hospital providers a second dose is required within 24 hours e. Fluid resuscitation is far more important than bleeding control in trauma patients --------- Correct Answer ---------- b. 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: Select one: a. Secure the airway b. obtain a c-spine film c. support the circulation d. control scalp hemorrhage e. determine the GCS score Feedback Your answer is corr --------- Correct Answer ---------- a. Secure the airway A previously healthy, 70-kg (154-pound) man suffers an estimated acute blood loss of 2 liters. Which one of the following statements applies to this patient? Select one: a. His pulse pressure will be widened. b. His urinary output will be at the lower limits of normal. c. He will have tachycardia, but no change in his systolic blood pressure. d. An ABG would demonstrate a base deficit between -6 and -10 mEq/L e. His systolic blood pressure will be maintained with an elevated diastolic pressure. -------- - Correct Answer ---------- d. An ABG would demonstrate a base deficit between -6 and -10 mEq/L The physiologic hypervolemia of pregnancy has clinical significance in the management of the severely injured, gravid woman by: Select one: a. reducing the need for blood transfusion b. resulting in an elevated hematocrit c. complicating the management of closed head injury d. reducing the volume of crystalloid required for resuscitation e. increasing the volume of blood loss to produce maternal hypotension --------- Correct Answer ---------- e. increasing the volume of blood loss to produce maternal hypotension The best assessment of fluid resuscitation of the adult burn patient is: Select one: a. Urine output of 0.5 mL/kg/hr b. normalization of blood pressure c. normalization of the heart rate d. measuring a normal central venous pressure e. providing 4 mL/kg/percent body burn/24 hours of crystalloid fluid --------- Correct Answer ---------- a. Urine output of 0.5 mL/kg/hr The diagnosis of shock must include: Select one: a. hypoxemia b. acidosis c. hypotension d. increased vascular resistance e. evidence of inadequate organ perfusion --------- Correct Answer ---------- e. 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: Select one: a. application of a tourniquet b. direct pressure on the wound c. packing the wound with gauze d. direct pressure on the femoral artery at the groin e. debridement of devitalized tissue --------- Correct Answer ---------- b. direct pressure on the wound For the patient with severe traumatic brain injury, profound hypocarbia should be avoided to prevent: Select one: a. respiratory acidosis b. metabolic acidosis c. cerebral vasoconstriction with diminished perfusion d. neurogenic pulmonary edema e. shift of the oxyhemoglobin dissociation curve --------- Correct Answer ---------- c. 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: Select one: a. obtain contrast angiography b. transfer to a higher level trauma center c. perform an exploratory laparotomy A trauma patient presents to your emergency department with inspiratory stridor and a suspected c- spine injury. Oxygen saturation is 88% on high-flow oxygen via a nonrebreathing mask. The most appropriate next step is to: Select one: a. apply cervical traction b. perform immediate tracheostomy c. insert bilateral thoracostomy tubes d. maintain 100% oxygen and obtain immediate c-spine x-rays e. restrict cervical motion and establish a definitive airway --------- Correct Answer ---------- e. restrict cervical motion and establish a definitive airway When applying the Rule of Nines to infants: Select one: a. It is not reliable. b. The body is proportionally larger in infants than in adults. c. The head is proportionally larger in infants than in adults. d. The legs are proportionally larger in infants than in adults. e. The arms are proportionally larger in infants than in adults. --------- Correct Answer ------- --- c. 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: Select one: a. placement of a pelvic binder b. transfer to a trauma center c. pelvic x-ray d. insert urinary catheter e. repeat examination of pelvis --------- Correct Answer ---------- a. placement of a pelvic binder Which situation requires Rh immunoglobulin administration to an injured female? Select one: a. negative pregnancy test, Rh negative, and has torso trauma b. positive pregnancy test, Rh positive, and has torso trauma c. positive pregnancy test, Rh negative, and has torso trauma d. positive pregnancy test, Rh positive, and has an isolated wrist fracture e. positive pregnancy test, Rh negative, and has an isolated wrist fracture --------- Correct Answer ---------- c. 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 ED and 15 minutes after the incident, she is awake and alert. Her heart rate is 100 beats per minute, blood pressure is 80/60 mm Hg, and respiratory rate is 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 to: Select one: a. perform a thoracoscopy b. perform an arch aortogram c. insert a second left chest tube d. prepare for an exploratory thoracotomy e. perform a chest CT --------- Correct Answer ---------- d. 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). Which one of the following statements is TRUE about this patient? Select one: a. A flail chest is probable. b. A symptomatic blunt cardiac injury is expected. c. A pulmonary contusion may be present in the absence of rib fractures. d. Transection of the thoracic aorta is more likely than in an adult patient. e. Rib fractures are commonly found in children with this mechanism of injury. --------- Correct Answer ---------- c. A pulmonary contusion may be present in the absence of rib fractures Patients with GSC of less than _____ usually require intubation -------- Correct Answer - --------- 8 The "A" in ABCD stands for ______. -------- Correct Answer ---------- Airway maintenance with Cervical SPINE protection You should assume that any patient in a multisystem trauma with an altered level of consciousness or blunt injury above the clavice has what type of injury -------- Correct Answer ---------- Cervical Spine Injury Flail chest is invariably accompanied by _______ which can interfere with blood oxygenation -------- Correct Answer ---------- pulmonary contusion - do NOT over fluid resuscitate these patients. Hypotension is caused by ______ until proven otherwise. -------- Correct Answer --------- - hypovolemia When you dont have a BP what are three things to look for when evaluating perfusion? - ------- Correct Answer ---------- 1. level of consciousness (brain perfusion 2. Skin color (ashen face/grey extremities) 3. Pulse (bilateral femoral - thready/tachy) Elderly patients have a limited ability to ___________ to compensate for blood loss ------ -- Correct Answer ---------- increase heart rate Resuscitation fluids should be warmed to 39 Celsius -------- Correct Answer ---------- Only for Cyrstalloids, NOT for blood Urinary catheters are good for assessing renal perfusion and volume status. List 5 signs of urethral injury that might precent you from inserting one -------- Correct Answer -------- -- Blood at urethral meatus, perineal ecchymosis, blood in scrotum, high-riding/non- palpable prostate, pelvic fracture Which arm should you NOT put a pulse-ox on? -------- Correct Answer ---------- The arm with the BP cuff What should you do with the balloon on an ET tube/LMA/foley before you insert it? ------ -- Correct Answer ---------- Inflate it to make sure it doesnt leak- then deflate and insert What size LMA do you use for Kid, woman/small man, large woman/man -------- Correct Answer ---------- Kid: 3 Woman/Small Man: 4 Large woman/Man 5 C3,4,5 keep them all alive The proper size ET tube for an infant is -------- Correct Answer ---------- The same size as the infants nostril or little finger (3 for neonates, 3.5 for infants What size cuffed endotracheal tube do you use for an emergency cricothyroidotomy? --- ----- Correct Answer ---------- 5 or 6 Use a size 3 ET tube for neonates 3.5 for infants for 0-6 months 4 fo infants 6-12 months How do you calculate what size ET tube to use or toddlers and kids? -------- Correct Answer ---------- Age/4 +4mm = internal diameter Shock is defined as an abnormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation. what are the 4 different types -------- Correct Answer ---------- Neurogenic, cardiogenic, hypovolemic, septic The most common cause of shock in the injured trauma patient is _________. -------- Correct Answer ---------- hemorrhage Approximately ___% of the body's total blood volume is located in the venous circuit/ ---- ---- Correct Answer ---------- 70 Why does shock actually reduce the total volume of circulating blood? -------- Correct Answer ---------- Anaerobic metabolism --> cant make more ATP --> endoplasmic then mitochondrial damage --> lysosomes rupture --> sodium and water enter the cell, which SWELLS and dies Which vasopressors should you use to treat hemorrhagic shock? What are the drug doses -------- Correct Answer ---------- Never use pressors hypovolemic shock - use VOLUME replacement. Pressors will worsen tissue perfusion in hemorrhagic shock Compensatory mechanisms may preclude a measurable fall in systolic blood pressure until up to ____% of the patient's blood volume is lost. -------- Correct Answer ---------- 30 Any patient who is cool and is tachycardic is considered to be _______until proven otherwise. -------- Correct Answer ---------- in shock The definition of tachycardia depends on patients age. What heart rate is considered tachycardic for infants, toddlers/PS, schoolage/prepubescent, and adults -------- Correct Answer ---------- Infants >160 toddlers/PS > 140 schoolage/prepubescent >120 Adults > 100 Elderly patients may not exhibit tachycardia in response to hypovolemia because of limited cardiac response to catecholamines. Why else might they not get tachy? -------- Correct Answer ---------- On a Beta-Blocker or have a pacemaker A FAST scan in an excellent way to diagnose cardiac tamponade. What signs sugget tamponade -------- Correct Answer ---------- Beck's Triad: JVD, muffled heard sounds and hypotension (will be resistant to fluid therapy). Will also likely be tachycardic Patients with a tension pneumo and patient with cardiac tamponade may present with many of the same signs. What findings will you see with a tension will you NOT see with tamponade? -------- Correct Answer ---------- Absent breath sounds and hyperresonance to percussion over the affected hemithorax. Immediate thoracic decompresion is warrented for anyone with absent breath sounds, hyperressonance to percussion, tracheal deviation, _________ and _________ -------- Correct Answer ---------- Acute respiratory distress & subcutaneous emphysema Can isolated intracranial injuries cause neurogenic shock? -------- Correct Answer -------- -- NO How do you calculate total blood volume in an adult? -------- Correct Answer ---------- 70 mL per kg. A 70 kg person has about 5 L of circulating blood. (70*70) = 4900 mL How do you calculate TBV in child -------- Correct Answer ---------- BW (kg) X 80-90 mL The blood volume of an obese person is calculated based upon their _________ weight -------- Correct Answer ---------- ideal Fluid replacement should be guided by __________, not simply by the initial classification (Class I-IV) -------- Correct Answer ---------- The patient's response to initial replacement How much blood volume is lost with Class I hemorrhage? -------- Correct Answer --------- - Up to 15% Donating 1 pint, or ~500 mL of blood is about 10% volume lose and would classify as Class I Hemorrhage. Transcapillary refill and other compensatory mechanisms restore blood volume within 24 hours How much blood volume is lost with Class II hemorrhage> -------- Correct Answer -------- -- 15-30% (750-1500 mL in a 70 kg adult) How do you treat a Class II hemorrhage -------- Correct Answer ---------- Usually just crystalloid resuscitation Subtle CNS changes such as anxiety, fright, and hostility would be expected in patient with a Class ____ hemorrhage -------- Correct Answer ---------- II How much blood volume is lost with Class III hemorrhage? -------- Correct Answer ------- --- 30-40% (2000 mL in a 70 kg adult) A patient with inadequate perfusion, marked tachycardia and tachypnea, significant mental status change, and a measurable fall in systolic blood pressure likely has a Class _____ Hemorrhage -------- Correct Answer ---------- III or IV - these patients requre a blood transfusion, which depends on their response to initial fluid resuscitation. The first priority is stopping the hemorrhage. Loss of more than 50% of blood volume results in loss of consciousness. -------- Correct Answer ---------- 50 How much blood volume is lost with Class IV hemorrhage? -------- Correct Answer ------- --- More than 40%. Unless very aggressive measures are taken the patients will die within minutes A Class _____ Hemorrhage represents the smallest volume of blood lost that is consistently associated with a drop in systolic blood pressure -------- Correct Answer ---- ------ III Up to __________ mL of blood loss is commonly associated with femur fractures -------- Correct Answer ---------- 1500 Unexplained hypotension or cardiac dsyrhythmias (usually bradycardia from excessive vagal stimulation) are often caused by ______ especially in children -------- Correct Answer ---------- gastric distention How much crystalloid should you give an adult for an initial fluid resuscitation bolus? for kids -------- Correct Answer ---------- Adults: 2 L Kids: 20 mL/kg (may repeat and give as much as 60 mL/Kg but wit high reserve in kids, if they're in shock they should get blood sooner rather than later Each mL of blood loss would be replaced with ____ mL of crystalloid, thus allowing for replacement of plasma volume lot into interstitial and intracellular saces -------- Correct Answer ---------- 3 Answer ---------- Chest tube - positive pressure ventilation can turn a sumple pneumo into a tension pneumo, so put in a chest tube first. Should you evacuate a simple hemothorax if it is not causing any respiratory problems? -------- Correct Answer ---------- YES - A simple hemothorax, if not fully evacuated, may result in a retained, clotted hemothroax with lung entrapment or, if infected, develop into an empyema. A pneumothorax associated with a persistent large air leak after tube thoracostomy suggests a _______ injury. -------- Correct Answer ---------- tracheobronchial - Use bronchoscopy to confirm, you may need more than one chest tube before definitive operative management. What radiographic findings are suggestive of traumatic aortic disruption? -------- Correct Answer ---------- Widened mediastinum, obliteration of aortic knob, deviation of trachea to the right, depression of left mainstem bronchus, deviation of esophagus (NG tube) to right, widened paratracheal stripe, fx'd 1st/2nd ribs or scapula. A deceleration injury victim with a left pnuemothorax or hemothorax without rib fractures, is in pain or shock out of proportion to the apparent injury, and has particulate matter in their chest tube may have _________. -------- Correct Answer ---------- an ESOPHAGEAL RUPTURE - a forceful blow causes expulsion of gastric contents into the esophagus, producing a linear tear in the lower esophagus allowing leakage into the mediastinum. Fractures for the lower ribs (10-12) should increase suspicion for _____ injury. -------- Correct Answer ---------- hepatosplenic Why are upper torso, facial, and arm plethora with petechiae associated with crush injuries to the chest? -------- Correct Answer ---------- Temporary compression of the superior vena cava. How does ATLS suggest you should review a chest radiograph? -------- Correct Answer ---------- Trachea & bronchi, pleural spaces and parenchyma, mediastinum, diaphragm, bones, soft tissues, tubes & lines. You should use a size 16 or 18 gauge 6" needle for pericardiocentesis. How do you insert it? -------- Correct Answer ---------- Puncture the skin 1-2 cm inferior to the left xiphohondral junction at a 45 degree angle to the skin towards the heart, aiming toward the top of the left scapula. What's a good way to know if you've advanced your needle too far during pericardiocentesis and have entered ventricular muscle? -------- Correct Answer ---------- ECG Changes - extreme ST-changes, widened QRS, PVCs, etc... Withdrawl needle until ECG returns to baseline. What should you do with your needle after you successfully evacuate blood during pericardiocentesis? -------- Correct Answer ---------- Lock the stopcock and leave the catheter in place in case it needs to be reevacuated. If possible, use the Seldinger technique to pass a 14 gauge flexible catheter over the guidewire. This is NOT a definitive treatment. For patients with facial fractures or basillar skull fractures, gastric tubes should be inserted ____ before doing a DPL. -------- Correct Answer ---------- through the mouth You need to do retrograde urethrography PRIOR to foley placement if _____. -------- Correct Answer ---------- inability to void, unstable pelvic fracture, blood at urethral meatus, scrotal hematoma, perineal ecchymoses, or high-riding prostate. DPL is considered to be __% sensitive for detecting intraperitoneal bleeding. -------- Correct Answer ---------- 98 What are the four places you should look first when doing a FAST scan? -------- Correct Answer ---------- Mediastinum, hepatorenal fossa, splenorenal fossa, pouch of Douglas. DPL is indicated when a patient with multiple blunt injuries is hemodynamically unstable, especially when they have _____. -------- Correct Answer ---------- Change in sensorium (brain injury/EtOH or drug intoxication), change in sensation (spinal cord injury), injury to adjacent structures (pelvis, lumbar spine), lap-belt sign (from seatbelt), or if patient is going for long studies (CT, ortho surgery...). What is the only ABSOLUTE contraindication to DPL? -------- Correct Answer ---------- An existing indication for laparotomy. What are some RELATIVE contraindications to DPL? -------- Correct Answer ---------- Morbid obesity, advanced cirrhosis, preexisting coagulopathy, and previous abdominal operations (adhesions). When should you use an open SUPRAUMBILICAL approach for a DPL? -------- Correct Answer ---------- PELVIC FRACTURES (don't want to enter pelvic hematoma) and ADVANCED PREGNANCY (don't want to damage enlarged uterus). When doing a DPL, what INITIAL findings (not from lab) would mandate a laparotomy? - ------- Correct Answer ---------- Free blood (>10 mL) or GI contents (vegetable fiber, bile). If you don't get gross blood upon initial DPL aspiration, what do you do next for an adult? For a child? -------- Correct Answer ---------- Adult - 1,000 mL warm isotonic crystalloid. Kid - 10 mL/kg 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? -------- Correct Answer ---------- >100,000 red cells/mm^3, 500 white cells/mm^3, or BACTERIA (on gram stain). Your trauma patient needs an urgent laparotomy, can you take them to the CT scanner first to evaluate injuries? -------- Correct Answer ---------- No, if they need an emergent laparotomy they are unstable - unstable patients should NOT go to the CT scanner! What are some indications for laparotomy in patients with penetrating abdominal wounds? -------- Correct Answer ---------- Unstable, GSW, peritoneal irritation, fascial penetration What percentage of stab wounds to the anterior abdomen do NOT penetrate the peritoneum? -------- Correct Answer ---------- 25-33% Does an early normal serum amylase level exclude major pancreatic trauma? -------- Correct Answer ---------- NO Do you need to operate on anyone with an isolated solid organ injury? -------- Correct Answer ---------- No - not if they remain hemodynamically stable (Of all patients who are initially thought to havea ISOLATED solid organ injury, <5% will have hollow viscus injury as well). Which is LESS likely to have a life-threating hemorrhage - an open book or closed book pelvic fracture? -------- Correct Answer ---------- Closed book - the pelvic volume is compressed, so not as much room for blood. Anterior/posterior forces causes _____ book pelvic fractures, and lateral forces cause _____ book fractures. -------- Correct Answer ---------- AP = Open Book, LATERAL = Closed Book Which are more common, open or closed book pelvic fracturs? -------- Correct Answer -- -------- CLOSED BOOK - 60-70% (Open book 15-20%, vertical shear 5-15%) If a patient with a pelvic fracture is positive for intraperitoneal gross blood, a ex-lap is warranted. What is your next move if that same patient is NEGATIVE for gross intraperitoneal blood? -------- Correct Answer ---------- Angiography What do you need to do BEFORE you do a DPL? (Other than getting stuff together and surgically prepping, etc...) -------- Correct Answer ---------- DECOMPRESS BLADDER, DECOMPRESS STOMACH What is "adequate" fluid return when getting DPL fluid back? -------- Correct Answer ----- ----- 30% Attempts to align the spine for the purpose of immobilization on the backboard are not recommended if they _______. -------- Correct Answer ---------- cause pain Can you clear a c-spine without films? -------- Correct Answer ---------- Yes, if they are awake, alert, sober, neurological normal, have NO pain, and can flex, extend, and move their head to both sides without pain - you don't need films. Should a quadriplegic or paraplegic patient be put on a hard board? -------- Correct Answer ---------- Not for more than 2 hours - get them off ASAP. What's a big difference in a physical finding between hypovolemic and neurogenic shock? -------- Correct Answer ---------- Hypovolemic = usually TACHY, Neurogenic = usually BRADY Partial or total loss of respiratory function may be seen in a patient with a cervical spine injury above ___. -------- Correct Answer ---------- C6 Why might someone not be able to breathe if they have a long bone fracture -------- Correct Answer ---------- Fat embolism - uncommon though Abnormal arterial blood flow is indicated by an ABI of ____. -------- Correct Answer ------- --- <0.9 By LOOKING at the patient, what findings might suggest pelvic injury? -------- Correct Answer ---------- Leg-length discrepancy, rotation (usually external) Crush injuries may result in rhabdomyolysis - casts block flow, also iron is released which forms ROS which then damage cells and impair ability to regulate K+ etc... What can you do to prevent this? -------- Correct Answer ---------- Volume expansion, and alkalization of urine with bicarb will reduce intratubular precipitation of myoglobin. UOP should be 100 mL/hr until myoglobinuria is cleared. Muscle does not tolerate lack of arterial flow (tourniquet) for more than ___ hours before necrosis begins. -------- Correct Answer ---------- 6 What things increase the risk for tetanus? -------- Correct Answer ---------- Wounds >6 hours old, wounds contused or abraded, >1 cm deep, from high velocity missiles, due to burns or cold, and significantly contaminated wounds. Should legs be completely straight when splinting? -------- Correct Answer ---------- No, flexion of 10 degrees recommended to take pressure off neurovascular structures. Any patient with burns covering more than ___% of BSA require fluid resuscitation. ------ -- Correct Answer ---------- 20 The palmer surface of a patient's hand represents approximately ___% of their BSA. ---- ---- Correct Answer ---------- 1% A high index of suspicion for inhalation injury must be maintained, because patients may not display clinical evidence for up to ___ hours, by this time edema may prevent non-surgical intubation. -------- Correct Answer ---------- 24 Carbon monoxide has ____ times the affinity for oxygen as hemoglobin. -------- Correct Answer ---------- 240 Patients with CO levels less than ___% usually don't have any physical symptoms ------- - Correct Answer ---------- 20% Adult head BSA = ___%. -------- Correct Answer ---------- 9 (ENTIRE head front and back = 9) Baby head BSA = __% -------- Correct Answer ---------- 18 (9 front, 9 back) What is the main difference between adult and baby BSA determination for burns? ------ -- Correct Answer ---------- Entire head on baby is 18, whereas it's 9 for adults. This difference of 9 is made up by the fact that each side (front/back) on adult = 9, but only 7 for kids. (36 vs 28). Chest BSA = ___%. -------- Correct Answer ---------- 18 Back BSA = ____% -------- Correct Answer ---------- 18 Arm BSA = ___%. -------- Correct Answer ---------- 9 TOTAL (front AND back). Leg BSA for adult = ___%. -------- Correct Answer ---------- 18 TOTAL (9 front, 9 back). Baby front or back of leg BSA =___%. -------- Correct Answer ---------- 7 (TOTAL leg = 14%) How should you insert a Guedel in a kid? -------- Correct Answer ---------- Use tongue blade depressor and insert gently without turning - otherwise there is great risk for trauma and resultant hemorrhage. NOT the 180 degree spin trick. The normal systolic BP in kids can be estimated by what? -------- Correct Answer --------- - 90 mm Hg + (age x 2) How do you estimate a child's total circulating volume? -------- Correct Answer ---------- 80 mL/kg When shock in a child is suspected, how much fluid do you give them? -------- Correct Answer ---------- 20 mL/kg warm crystalloid May need to repeat up to 3 times (60 mL/kg) then consider blood products. Optimal UOP for infants is ___ mL/kg/hr. -------- Correct Answer ---------- 2 (1.5 for younger kids, and 1.0 for older kids) How much warmed crystalloid should be used for a DPL in kids? -------- Correct Answer ---------- 10 mL/kg (up to 1000 mL) What would you see in an infant that would make you suspect very severe brain injury despite normal LOC? -------- Correct Answer ---------- Bulging fontanelles - these allow tolerance for expanding masses/swelling... What is a possible mistake about a blood pressure of 120/80 in a 87 year old man? ------ -- Correct Answer ---------- Assuming that normal blood pressure = normovolemia. Many geriatric patients have uncontrolled hypertension, and if their normal systolic is 180, then 120/80 is relative HYPOtension for them. How well do geriatric patients do with non-operative management of abdominal injuries compared to younger people? -------- Correct Answer ---------- Not as well - the risks of non-operative management are often worse than the risks of surgery. Why would geriatric patients be MORE susceptible to head bleeds when there is increased space around a shrinking brain to protect them from contusion? -------- Correct Answer ---------- Atrophic brains = stretching of the parasagittal bridging veins, making them more prone to rupture upon impact. Plasma volume increases during pregnancy, what happens to hematocrit? -------- Correct Answer ---------- Decreases - dilution by plasma (31-35% is normal in pregnancy) What would you think of a WBC of 15,000 in a pregnant woman? -------- Correct Answer ---------- Normal, it can go up to 25,000 during labor! What should you always assume about a pregnant patient's stomach? -------- Correct Answer ---------- That it is always full. (Gastric emptying time increases during pregnancy). Early NG tube placement recommended. A PaCO2 of 35 to 40 in a pregnant patient may indicate what? -------- Correct Answer --- ------- Impending respiratory failure. It is usually around 30 due to hyperventilation due to increased levels of progesterone. True or False: All Rh negative pregnant trauma patients should get Rhogam? -------- Correct Answer ---------- True, unless the injury is remote from the uterus (distal extremity injury only). This therapy should be initiated within 72 hours of injury. What are some of the decisions that can be made at an arrest? --------- Correct Answer - --------- Choice of shock, appropriate treatment, how long to continue resuscitation, appropriate post-resus care What makes a good resuscitation team member? --------- Correct Answer ---------- Competence, communication, commitment, supportive, accountable, creative, prepare to admit when help is needed What is the TEAM tool? --------- Correct Answer ---------- Team Emergency Assessment Measure - teaching instrument and discussion point for both instructors and candidates What is SBARD? --------- Correct Answer ---------- Situation, background, assessment, recommendation, decision What is RSVP? --------- Correct Answer ---------- Reason, story, vitals, plan What is the normal body temperature? --------- Correct Answer ---------- 36.1-38C What is the frequency of monitoring for someone with a NEWS between 5-6? --------- Correct Answer ---------- Minimum 1 hourly What is the frequency of monitoring for someone with a NEWS of 7 or more? --------- Correct Answer ---------- Continuous What is the frequency of monitoring for someone with a NEWS of 3 in a single parameter? --------- Correct Answer ---------- Minimum 1 hourly What is the frequency of monitoring for someone with a NEWS between 1-4? --------- Correct Answer ---------- Minimum 4-6 hourly What are some causes of airway obstruction? --------- Correct Answer ---------- Vomit, foreign body, reduced GCS, direct trauma, epiglottitis, pharyngeal swelling, bronchospasm, bronchial secretions, block tracheostomy What can be utilised to manage airway obstruction relating to secretions? --------- Correct Answer ---------- Suctioning, turn patient on their side, give oxygen What are the accessory muscles of respiration? --------- Correct Answer ---------- Intercostal muscles, sternocleidomastoid, abdominal muscles, trapezius, scalene muscles, etc On an ABG, what is a late sign of severe respiratory problems? --------- Correct Answer ---------- Decreasing pH and rising pCO2 What is the first-line oxygen therapy in an acutely unwell patient? --------- Correct Answer ---------- 15L/ minute high-concentration reservoir (non-rebreathe) mask What are some of the causes of ventricular fibrillation? --------- Correct Answer ---------- ACS, hypertensive heart disease, valve disease, drugs (e.g. anti-arrythmics), inherited cardiac disease (e.g. long QT), acidosis, electrolyte abnormalities (K/Na/Mg), hypothermia, electrocution What is the commonest cause of sudden cardiac death? --------- Correct Answer ---------- Age >35 = Arrhythmia caused by either ischaemia or myocardial infarction Age < 35 = Inherited cardiac conditions (e.g. WPW) What are indicators of an arrhythmic syncope? --------- Correct Answer ---------- Syncope while supine, after exercise, no prodrome, repeated episodes, history of SCD or inherited cardiac conditions What is involved in the assessment and interventions for AIRWAY? --------- Correct Answer ---------- Check for noisy breathing or absence of breathing, paradoxical chest/ abdominal movements, reduced GCS / GCS <8. Consider airway manoeuvres and adjuncts, suctioning, intubation and oxygen. What is involved in the assessment and interventions for BREATHING? --------- Correct Answer ---------- Chest exam (e.g. cyanosis, deformity, accessory muscle use, tracheal deviation, AE, added sounds), pulse oximetry, RR, calves. Consider sitting the patient up, oxygen, CXR, NIV, treating obvious causes. What is involved in the assessment and interventions for CIRCULATION? --------- Correct Answer ---------- Chest exam (e.g. warmth, heart sounds, JVP), CRT, BP, HR, pulse, signs of haemorrhage, fluid assessment (e.g. catheter/ drain OP, peripheral oedema), ECG, bloods + VBG, Consider IV access, IV fluid bolus 500mL warmed Plasmalyte 15 minutes, transfusion, inotropes/ vasopressors. What is involved in the assessment and interventions for DISABILITY? --------- Correct Answer ---------- RE-REVIEW ABC. GCS, BMs, pupils +/- neuro exam, check drug chart. Consider correction of glucose, analgesia, toxin reversal. What is involved in the assessment and interventions for EXPOSURE? --------- Correct Answer ---------- Full body exposure (whilst maintaining dignity and temperature), rashes, haemorrhage, temperature, focused examinations if appropriate. What is the initial oxygen therapy recommended for an acutely deteriorating patient with known COPD? --------- Correct Answer ---------- Venturi mask 24%-28% (2-4L), aiming SpO2 88-92% If a patient is still hypotensive despite fluid resuscitation, what type of BP support do they require? --------- Correct Answer ---------- Vasopressors (e.g. vasopressin, terlipressin, adrenaline/ noradrenaline) If a patient is persistently hypotensive and overloaded, what type of BP support do they require? --------- Correct Answer ---------- Inotropes (e.g. dopamine, dobutamine, adrenaline/ noradrenaline) What is the difference between vasopressors and inotropes? --------- Correct Answer ---- ------ Vasopressors cause vasoconstriction, increasing MAP. Inotropes increase cardiac contractility. What is the criteria for unstable angina? --------- Correct Answer ---------- Angina on exertion (or unpredictably), occurring with increasing frequency, provoked by progressively less exertion, can be settled by GTN. ECG may be normal, have ST depression or T wave inversion. Troponin negative. What is the criteria for STEMI? --------- Correct Answer ---------- Cardiac chest pain on exertion or unprovoked, lasting >20 minutes, not resolved with GTN. ECG shows ST elevation (>2ss in 2 or more chest lead/ >1ss in 2 or more limb leads) OR new LBBB. Troponin positive. What is the criteria for NSTEMI? --------- Correct Answer ---------- Cardiac chest pain on exertion or unprovoked, lasting > 20 minutes, not resolved with GTN. ECG may be normal, or show ST depression or T wave inversion. Troponin positive. Which cardiac territory is ECG leads II, III and aVF? --------- Correct Answer ---------- Inferior (RCA or LCx) Which cardiac territory is ECG leads I, aVL, V5 and V6? --------- Correct Answer ---------- Lateral (LCx or diagonal branch of LAD) Which cardiac territory is ECG leads V1 and V2? --------- Correct Answer ---------- Septal (LAD) Which cardiac territory is ECG leads V3 and V4? --------- Correct Answer ---------- Anterior (LAD) What is the treatment for STEMI? --------- Correct Answer ---------- MONAC = Morphine, oxygen, nitrates (if BP not low), aspirin 300mg, clopidogrel 600mg OR ticagrelor 180mg. Immediate contact w/ Cardiology and PCI within 12 hours. What are the appropriate initial interventions if the patient has a pulse but is not breathing (respiratory arrest)? --------- Correct Answer ---------- Ventilate lungs Check pulse every minute Precordial thump --------- Correct Answer ---------- A blow to the centre of the sternum used as an initial response to a witnessed VF/ pVT cardiac arrest when no defibrillator is available Use ulnar edge of tightly clenched fist, deliver a sharp impact to lower half of sternum from a height of about 20cm, then retract the fist immediately to create an impulse-like stimulus Where should you position the defibrillation pads? --------- Correct Answer ---------- One below clavicle, other in the V6 position in the mid axillary line What energy setting should be chose for debrillation? --------- Correct Answer ---------- 120-150J for the first shock, the same or higher for subsequent shocks Whilst the defibrillator charges, who should be touching the patient? --------- Correct Answer ---------- Only the person performing chest compressions If organised electrical rhythm is noted at a rhythm check, what should be done? --------- Correct Answer ---------- Seek evidence of ROSC => check signs of life, check central pulse, check end-tidal CO2 If amiodarone is not available, what other drug can be given? --------- Correct Answer --- ------- Lidocaine, 1mg/ kg IV What should you consider in refractory VF/ pVT? --------- Correct Answer ---------- Consider changing defib pad position (e.g. anterior-posterior) Consider amiodarone 150mg IV after the fifth shock For cardiac arrest in PEA/ asystole, when should you give adrenaline? --------- Correct Answer ---------- Give adrenaline 1mg IV as soon as intravascular access achieved How often should you change the individual performing chest compressions? --------- Correct Answer ---------- Every 2 minutes if possible What is the normal range of pCO2 in arterial blood? --------- Correct Answer ---------- 5.3kPa (range 4.7-6.0kPa) At what point of breathing is CO2 concentration/ partial pressure at its highest? --------- Correct Answer ---------- End of expiration (end-tidal) What does end-tidal CO2 reflect? --------- Correct Answer ---------- Cardiac output, pulmonary blood flow and ventilation minute volume During CPR, what is the expected end-tidal CO2 during ongoing arrest, and during ROSC? --------- Correct Answer ---------- <1.33kPa during cardiac arrest 4.8kPa (4.3-5.5kPa) during ROSC How do you measure waveform capnography during CPR? --------- Correct Answer ------ ---- Capnographers - a connector (T piece) is placed in the breathing system, usually on the end of a tracheal tube or SGA. This has a small port on the side to which is attached a fine bore sampling tube and a continuous gas sample is aspirated and analysed using absorption of infrared light. Explain the capnography waveform --------- Correct Answer ---------- A-B = End of inspiration. CO2 measured from air. B-C = Start of expiration. Initial minimal CO2 coming from anatomical dead space followed by rapid rise in CO2. C-D= Alveolar plateau reached. Represents gas from alveoli taking part in gas exchange. D = End of expiration. Maximal CO2 concentration/ end-tidal CO2. Typically 4.8kPa. D-E = Start of inspiration. Air containing no CO2 is mixed with small amount of residual expired gas in breathing circuit. If there are signs of waking, purposeful movement, arterial blood pressure waveform or sharp rise in end-tidal CO2, what should be done? --------- Correct Answer ---------- Consider stopping chest compressions for a rhythm check and pulse check When administering resuscitation drugs, what should be done following this administration? --------- Correct Answer ---------- Flush with at least 20mL sterile saline Elevation of extremity for 10-20 seconds What are the 3 main insertion sites for IO access? --------- Correct Answer ---------- Proximal humerus, proximal tibia and distal tibia What are contraindications to IO access? --------- Correct Answer ---------- Trauma, infection or prosthesis at target site, recent IO access (last 48 hours), failure to identify anatomical landmarks What should you always suspect in a drowning incident? --------- Correct Answer --------- - Hypothermia What are some of the causes of PEA? --------- Correct Answer ---------- Hypovolaemia due to severe haemorrhage or tension pneumothorax In cases of massive pulmonary embolism in which fibrinolytic therapy has been given, how long should CPR be continued for prior to decision of termination? --------- Correct Answer ---------- Consider CPR for at least 60-90 minutes How do you manage tension pneumothorax? --------- Correct Answer ---------- Rapid decompression by open/ clamshell thoracostomy OR needle thoracocentesis (inserting large-bore 14/16G needle into the 2nd intercostal space in the midclavicular line) Chest drain insertion How do you diagnose cardiac tamponade during CPR? How is this managed? --------- Correct Answer ---------- Focused cardiac ultrasound Resuscitative thoracotomy In which situations are automated mechanical chest compression devices appropriate? --------- Correct Answer ---------- CPR in a moving ambulance Prolonged CPR (e.g. hypothermic arrest) CPR during procedures (e.g. coronary angiography or preparation for ECPR) At what point should the resuscitation team leader consider stopping CPR? --------- Correct Answer ---------- Based on individual/ patient circumstances Asystole >20 minutes in absence of reversible causes If CPR is unsuccessful in achieving ROSC and a decision is made to discontinue CPR, how long should you wait following this to diagnose death? --------- Correct Answer ------ ---- 5 minutes minimum If there is return of cardiac or respiratory activity during the 5 minute observation following discontinuation of CPR, what should be done? --------- Correct Answer ---------- Observe for a further 5 minutes from the next cardiorespiratory arrest What can cause laryngeal obstruction? --------- Correct Answer ---------- Oedema from burns, inflammation or anaphylaxis In partial airway obstruction, what are the common noises heard and what do they each correlate to? --------- Correct Answer ---------- Inspiratory stridor - Obstruction at laryngeal level or above Expiratory wheeze - Obstruction at lower airways Gurgling - Presence of liquid or semisolid foreign material in upper airways Snoring - Pharynx is partially occluded by tongue or palate In what situation may you observe paradoxical chest and abdominal movements? -------- - Correct Answer ---------- Complete airway obstruction What should you attempt if a patient with a tracheostomy develops airway obstruction? - -------- Correct Answer ---------- Remove the inner tube of the tracheostomy Pass a suction catheter + perform tracheal suctioning What is the pathway for a choking patient (severe obstruction)? --------- Correct Answer ---------- 5 back blows 5 abdominal thrusts If electrical cardioversion is used to convert atrial or ventricular tachyarrhythmias, when must the shock be synchronised to? Why? --------- Correct Answer ---------- The R-wave of the ECG To reduce risk of inducing VF What energy level should you not exceed with internal defibrillation? --------- Correct Answer ---------- 50J What is the intrinsic rate of each component of the electrical conduction system of the heart? --------- Correct Answer ---------- SA node = 60-70bpm AV junctional region = 40-50bpm, narrow QRS Distal His-Purkinje fibres = 0-30bpm, broad QRS What duration of ventricular pauses makes the need for pacing urgent? --------- Correct Answer ---------- >3s What are the methods of pacing? --------- Correct Answer ---------- Invasive = temporary transvenous pacing OR permanent pacing Non-Invasive = percussion pacing OR transcutaneous pacing How do you perform percussion pacing? --------- Correct Answer ---------- Side of closed fist, deliver repeated firm thumps to the precordium, from 20cm above the chest to lateral of the lower left sternal edge What is an appropriate pacing rate for transcutaneous pacing? --------- Correct Answer - --------- 60-90bpm What is an appropriate current for transcutaneous pacing? --------- Correct Answer ------- --- 50-100mA What are the three ways transvenous pacing can fail? --------- Correct Answer ---------- Connection failure High threshold Lead displacement How can you temporarily disable the defibrillator function of implantable devices? Does this affect their pacing function? --------- Correct Answer ---------- Holding/ taping a ring magnet over the implantable device No, this does not affect pacing When a patient passes away with an implantable device in situ, what do you need to do? --------- Correct Answer ---------- Arrange ICD deactivation as soon as possible Arrange removal of ICD/ pacemakers if cremation What are the life-threatening features of arrhythmias? --------- Correct Answer ---------- Shock (e.g. hypotension <90mmHg/ pallor/ sweating/ cold extremities/ confusion/ impaired consciousness) Syncope Heart failure (e.g. pulmonary oedema/ raised JVP) Myocardial ischaemia (e.g. ischaemic chest pain or ischaemia on ECG) Extremes of heart rate (e.g. HR >150bm OR <40bpm) If a patient with a tachyarrhythmia has life threatening features, how are they best managed? --------- Correct Answer ---------- Synchronised DC shock up to 3 attempts If unsuccessful, give amiodarone 300mg IV over 10-20 minutes and repeat synchronised DC shock How would you administer amiodarone in the context of unstable tachyarrhythmia? ------ --- Correct Answer ---------- Amiodarone 300mg IV over 10-25 minutes (loading dose) Amiodarone 900mg IV infusion over 24 hours through large vein or central venous catheter How would you manage a patient who is stable with polymorphic VT (pulse present)? --- ------ Correct Answer ---------- A-E assessment Give magnesium 2g IV over 10 minutes Amiodarone 300mg IV over 10-60 minutes How would you manage a patient who is stable with supraventricular tachycardia? ------- -- Correct Answer ---------- A-E assessment Vagal maneouvres Adenosine 6mg IV rapid bolus (continuous ECG monitoring) If unsuccessful, give adenosine 12mg IV If unsuccessful, give adenosine 18mg IV If unsuccessful, give verapamil 2.5-5mg IV over 2 minutes or beta blocker (e.g. metoprolol 2.5-15mg IV in 2.5mg boluses) If ineffective, give synchronised DC shocks up to 3 attempts How would you manage a patient who is stable with atrial fibrillation with a rate >100bpm? --------- Correct Answer ---------- A-E assessment Control rate with beta blocker Consider digoxin or amiodarone if HF Anticoagulation if >48 hours How would you manage a patient who is stable with monomorphic ventricular tachycardia (pulse present)? --------- Correct Answer ---------- A-E assessment Give amiodarone 300mg IV over 10-60 minutes If ineffective, give synchronised DC shocks up to 3 attempts How would you manage a patient who is stable with broad QRS, regular rhythm (previous certain SVT with bundle branch block/ aberrant conduction)? --------- Correct Answer ---------- A-E assessment Adenosine 6mg IV rapid bolus (continuous ECG monitoring) If unsuccessful, give adenosine 12mg IV If unsuccessful, give adenosine 18mg IV If unsuccessful, give verapamil or beta blocker If ineffective, give synchronised DC shocks up to 3 attempts What is the appropriate energy for synchronised cardioversion for broad complex tachycardia, atrial fibrillation and atrial flutter/ narrow complex tachycardia? --------- Correct Answer ---------- Broad complex tachycardia = 120-150J Atrial fibrillation = Maximum defibrillator output Atrial flutter/ narrow complex tachycardia = 70-120J What is the typical rate of atrial flutter? And with a 2:1 conduction? --------- Correct Answer ---------- 300bpm 150bpm A narrow complex tachycardia with a rate of 170-250bpm is most likely to be what? ------ --- Correct Answer ---------- SVT What is the management for a patient with no pulse, however notable regular narrow complex tachycardia >250bpm on rhythm check? --------- Correct Answer ---------- Immediate synchronised DC cardioversion EXCEPTION to non-shockable branch of ALS algorithm Which drugs should you avoid in patients with pre-excited AF or atrial flutter? Why? ----- ---- Correct Answer ---------- Adenosine, diltiazem, verapamil or digoxin They block AV node If a patient with a bradyarrhythmia has life threatening features, how are they best managed? --------- Correct Answer ---------- Atropine 500mcg IV bolus If unsuccessful, repeat every 3-5 minutes to maximum of 3mg If unsuccessful, transcutaneous pacing if available If no available, give isoprenaline infusion 5mcg/ minute IV If unsuccessful, give adrenaline 2-10mcg/ minute IV Aim for transvenous pacing How would you manage a patient who is stable with bradycardia, with a risk of asystole (e.g. recent asystole/ Mobitz type II/ complete HB with broad QRS/ ventricular pause >3s)? --------- Correct Answer ---------- Atropine 500mcg IV bolus If unsuccessful, repeat every 3-5 minutes to maximum of 3mg If unsuccessful, transcutaneous pacing if available If unsuccessful, give isoprenaline infusion 5mcg/ minute IV If unsuccessful, give adrenaline 2-10mcg/ minute IV What is the management of life-threatening asthma? --------- Correct Answer ---------- O = High flow oxygen 100% 15L NRM S = Salbutamol nebuliser 5-10mg every 15-30 minutes H = Hydrocortisone 100mg IV 6-hourly or prednisolone 40-50mg oral if suitable I = Nebulised ipratropium bromide 500mcg 4-6 hourly T = Theophylline: aminophylline infusion - SENIOR instruction M = Magnesium sulphate 2g IV over 20 minutes E = Escalate (intubation and ventilation if worsening acidosis/ progressive exhaustion) What is something that needs to be considered in CPR in a patient with severe asthma? --------- Correct Answer ---------- Dynamic hyperinflation - consider period of apnoea to relieve gas trapping What is the management of anaphylaxis? --------- Correct Answer ---------- Lie patient flat + remove trigger ADRENALINE 0.5mg IM (0.5mL of 1:1000 solution) in anterolateral thigh, repeated after 5 minutes up to 2 doses Secure airway Attach 100% 15L oxygen NRB Salbutamol nebuliser 5mg if wheeze IV fluid bolus - 500mL 0.9% saline ECG monitoring Mast cell tryptase within 2 hours of symptoms (ideally 3 timed samples => as soon as possible, at 1-2h, at 24hrs) When should you follow the refractory anaphylaxis pathway? What does this involve? --- ------ Correct Answer ---------- In patients with anaphylaxis, no improvement in breathing or circulation despite 2 doses of IM adrenaline Adrenaline infusion 1mg (1mL of 1:1000) in 100mL of 0.9% sodium chloride => start at 0.5-1mL/ kg/ hr and TITRATE to response Consider second vasopressor in addition to adrenaline What are the most common causes of cardiac arrest in pregnancy? --------- Correct Answer ---------- Cardiac disease, PE, epilepsy, stroke, sepsis, bleeding, hypertensive disorders of pregnancy What are the differences in management of a pregnant patient in cardiac arrest, compared to a non-pregnant patient? --------- Correct Answer ---------- Place patient in left lateral position (15-30 degree tilt) OR manually displace uterus to left Early tracheal intubation to prevent aspiration Establish IV/ IO access above the diaphragm Early involvement of obstetrics, anaesthetists and neonatologists Abdominal ultrasound What things should you consider in management of haemorrhage in the pregnant patient? --------- Correct Answer ---------- Tranexamic acid, Oxytocin/ ergometrine/ prostaglandins Uterine massage Uterine compression sutures and intrauterine balloon devices IR involvement Hysterectomy What is the treatment for eclampsia? --------- Correct Answer ---------- A-E assessment IV magnesium sulfate 4g in 100 ml 0.9% sodium chloride for seizures (same as prophylactic dose) IV labetalol or hydralazine for BP management Prompt delivery of baby and placenta Commotio Cardis --------- Correct Answer ---------- Actual or near cardiac arrest (VF/ pVT) caused by blunt impact to chest wall over the heart. Commonly occurs at impacts of 35-40mph What is the appropriate dose of tranexamic acid in traumatic haemorrhage patients? ---- ----- Correct Answer ---------- Loading dose = 1g IV over 10 minutes Infusion = 1g IV over 8 hours In traumatic cardiac arrest, when there is no response to ALS, all reversible causes have been excluded and there is no detectable cardiac activity on ultrasound, when should resuscitation efforts be stopped? --------- Correct Answer ---------- 20 minutes What is resuscitative thoracostomy? When is this indicated? --------- Correct Answer ----- ----- Surgical opening of chest to facilitate management of intrathoracic complications from chest trauma Patients with penetrating chest trauma in whom <15 minutes have elapsed since loss of vital signs How do you exclude cardiac tamponade as a cause of cardiac arrest? --------- Correct Answer ---------- Transthoracic echocardiography What is the difference between immersion and submerson? --------- Correct Answer ----- ----- Immersion = when a person's head remains above water Submersion = when a person's face is underwater/ covered in water What is the pathophysiology of drowning? --------- Correct Answer ---------- Following submersion, person breath holds by reflex As this continues, hypoxia and hypercapnia develop Reflex laryngospasm may temporarily prevent entrance of water into the lungs Eventually these reflexes abate and person aspirates water Bradycardia occurs as a consequence of hypoxia followed by cardiac arrest What is the first step in resuscitation with a patient retrieved from water? --------- Correct Answer ---------- 5 initial ventilations, supplemented with oxygen if available What are some modifications to ALS in patients after drowning? --------- Correct Answer ---------- Give high flow oxygen (10-15L/ min) NRB Reduced pulmonary compliance requiring high inflation pressures may limit the use of a supraglottic airway Set positive end expiratory pressure (PEEP) to at least 5-10cm Pulse check not reliable - check ECG and end-tidal CO2 Dry the persons chest before applying defib pads Rapid IV fluid bolus for expected hypovolaemia When should you consider discontinuing resuscitation efforts in a drowning patient? ----- ---- Correct Answer ---------- Continue resuscitation unless clear evidence that such attempts are futile (e.g. major traumatic injuries, rigor mortis, putrefaction) or timely evacuation to medical facility is not possible What are people of drowing at risk from? --------- Correct Answer ---------- ARDS and pneumonia What are the Swiss classifications/ staging of hypothermia? --------- Correct Answer ----- ----- Stage I/ mild = 32-35C Stage II/ moderate = 28-32C Stage III/ severe = 24-28C Stage IV/ cardiac arrest or low flow state = <24C Stafe V/ death = <11.8C What type of thermometers are used to diagnose hypothermia? --------- Correct Answer ---------- Low-reading thermometers Can measure lower 1/3rd of oesophagus OR tympanic measurement (sealed) NOT bladder and rectal thermometers as these temperatures lag behind What is intermittent CPR and when is it used? --------- Correct Answer ---------- Periods of chest compressions followed by no chest compressions Used in hypothermic patients where continuous CPR not possible Consider 5 minutes on/ <5 minutes off in patients <28C Consider 5 minutes on/ 10 minutes off in patients <20C What is an important thing to consider in resuscitation in the hypothermic patient? -------- - Correct Answer ---------- Rewarming during CPR prior to consideration of withdrawing efforts What are the modifications in resuscitation of a hypothermic patient? --------- Correct Answer ---------- Check for signs of life for up to 1 minute Palpate a central artery and assess cardiac rhythm Once CPR underway, confirm hypothermia with low-reading thermometer Withold adrenaline and other drugs until patient warmed to 30C or more Once reached 30C, intervals between drug doses doubled