ADVANCED TRAUMA LIFE SUPPORT (ATLS)-with 100% verified solutions 2024-2025, Exams of Nursing

Download ADVANCED TRAUMA LIFE SUPPORT (ATLS)-with 100% verified solutions 2024-2025 and more Exams Nursing in PDF only on Docsity! ADVANCED TRAUMA LIFE SUPPORT (ATLS)-with 100% verified solutions 2024-2025 A patient with inadequate perfusion, marked tachycardia and tachypnea, significant mental status change, and a measurable fall in systolic blood pressure likely has a Class _____ Hemorrhage III or IV - these patients 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. 50 How much blood volume is lost with Class IV hemorrhage? 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 III Up to __________ mL of blood loss is commonly associated with femur fractures 1500 Unexplained hypotension or cardiac dsyrhythmias (usually bradycardia from excessive vagal stimulation) are often caused by ______ especially in children gastric distention How much crystalloid should you give an adult for an initial fluid resuscitation bolus? for kids Adults: 2 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 3 Blood on the floor x four more is mneumonic for occult blood loss where? Chest, pelvis, retroperitoneum, and thigh For children UNDER 1 year of age, UOP should be ______ mL/Kg/Hr 2 Would patients in EARLY hypovolemic shock be acidodic or alkalotic? Alkalotic - respiratory alkalosis from tachypnea .... followed later by mild metabolic acidosis in the early phase of shock "Rapid Responders" whose vital signs return to normal (and stay there) after fluid I or II "Transient responders" are associated with Class ______ hemorrhage II or III What differential diagnosis shoudl you always consider for "non- responders" following fluid resuscitation? #38 French - inserted at the 4th or 5th intercostal space, just anterior to the midaxillary line. What is Kussmaul's sign? A rise in venous pressure with inspiration while breathing spontaneously, and is a true paradoxical venous pressure abnormality associated with cardiac tamponade. How well do CPR compressions work on someone with a penetrating chest injury and hypovolemia? "Closed heart massage for cardiac arrest or PEA is INEFFECTIVE in patients with hypovolemia." Patients with PENETRATING thoracic injuries who arrive pulseless, but with myocardial electrial activity, may be candidates for an ED thoacotomy. Are patients with PEA who have sustained blunt thoracic injuries candidates for an ED thoracotomy? NO - Only PEA with PENETRATING thoracic injuries should get an ED thoracotomy. An ED thoracotomy can allow you to do what? Evacuate pericardial blood, directly control hemorrhage, cardiac massage, cross-clamp the descending aorta to slow blood loss below the diaphragm and increase perfusion to the heart and brain. For a patient with a traumatic simple pneumothorax, what should you do BEFORE you start positive pressure ventilation or take them to surgery for a GA? Chest tube - positive pressure ventilation can turn a 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? YES - A simple hemothorax, if not fully evacuated, may result in a retained, clotted hemothroax with lung entrapment or, if infected, develop into an empyema. A pneumothorax associated with a persistent large air leak after tube thoracostomy suggests a _______ injury. tracheobronchial - Use bronchoscopy to confirm, you may need more than one chest tube before definitive operative management. What radiographic findings are suggestive of traumatic aortic disruption? Widened mediastinum, obliteration of aortic knob, deviation of trachea to the right, depression of left mainstem bronchus, deviation of esophagus (NG tube) to right, widened paratracheal stripe, fx'd 1st/2nd ribs or scapula. A deceleration injury victim with a left pnuemothorax or hemothorax without rib fractures, is in pain or shock out of proportion to the apparent injury, and has particulate matter in their chest tube may have _________. an ESOPHAGEAL RUPTURE - a forceful blow causes expulsion of gastric contents into the esophagus, producing a linear tear in the lower esophagus allowing leakage into the mediastinum. Fractures for the lower ribs (10-12) should increase suspicion for _____ injury. hepatosplenic Why are upper torso, facial, and arm plethora with petechiae associated with crush injuries to the chest? Temporary compression of the superior vena cava. How does ATLS suggest you should review a chest radiograph? 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? Puncture the skin 1-2 cm inferior to the left xiphohondral junction at a 45 degree angle to the skin towards the heart, aiming toward the top of the left scapula. What's a good way to know if you've advanced your needle too far during pericardiocentesis and have entered ventricular muscle? ECG Changes - extreme ST-changes, widened QRS, PVCs, etc... Withdrawl needle until ECG returns to baseline. What should you do with your needle after you successfully evacuate blood during pericardiocentesis? Lock the stopcock and leave the catheter in place in case it needs to be reevacuated. If possible, use the Seldinger technique to pass a 14 gauge flexible catheter over the guidewire. This is NOT a definitive treatment. What are some indications for laparotomy in patients with penetrating abdominal wounds? Unstable, GSW, peritoneal irritation, fascial penetration What percentage of stab wounds to the anterior abdomen do NOT penetrate the peritoneum? 25-33% Does an early normal serum amylase level exclude major pancreatic trauma? NO Do you need to operate on anyone with an isolated solid organ injury? No - not if they remain hemodynamically stable (Of all patients who are initially thought to havea ISOLATED solid organ injury, <5% will have hollow viscus injury as well). Which is LESS likely to have a life-threating hemorrhage - an open book or closed book pelvic fracture? Closed book - the pelvic volume is compressed, so not as much room for blood. Anterior/posterior forces causes _____ book pelvic fractures, and lateral forces cause _____ book fractures. AP = Open Book, LATERAL = Closed Book Which are more common, open or closed book pelvic fracturs? CLOSED BOOK - 60-70% (Open book 15-20%, vertical shear 5-15%) If a patient with a pelvic fracture is positive for intraperitoneal gross blood, a ex-lap is warranted. What is your next move if that same patient is NEGATIVE for gross intraperitoneal blood? Angiography What do you need to do BEFORE you do a DPL? (Other than getting stuff together and surgically prepping, etc...) DECOMPRESS BLADDER, DECOMPRESS STOMACH What is "adequate" fluid return when getting DPL fluid back? 30% A blown pupil in a patient with a traumatic injury is caused by compression of which nerve? Superficial parasympathetic fibers of the CN III (occulomotor). What is a "normal" ICP in the resting state? 10mm Hg (Pressures >20, particularly if sustained, are associated with poor outcomes). The Monro-Kellie Doctrine describes compensatory mechanisms inside the calvarium to stabilize pressure - what are the 2 main/first ones? Venous Blood & CSF (decreased in equal volumes, when this is exhausted, herniation can occur and brain perfusion will likely be inadequate). Patients with a GCS of 3-8 meet the accepted definition of "coma" or "severe brain injury." What are the GCS scores for "minor" and "moderate" brain injury? Minor = 13-15, Moderate = 8-12 When calculating GCS and there is right/left assymetry in the motor response - which one do you use? The "BEST" response. (Better predictor than worst response) What signs might you see if a patient has a basillar skull fracture? PERIORBITAL ECCHYMOSIS (raccoon eyes), RETROAURICULAR ECCHYMOSIS (Battle sign), and otorrhea/rhinorrhea. What do you need to know about the GCS What things might require a person with MINOR brain injury get admitted? Abnormal CT (or no scan available), penetrating head injury, prolonged LOC, worsening LOC, moderate to severe HA, significant drug/alcohol What are the indications for c-spine radiographs in a trauma patient? Which x-ray views should be obtained? Midline neck pain, tenderness on palpation, neurological deficits related to c-spine injuries, altered LOC or intoxication. 1) Lateral, 2) AP, 3) Open mouth odontoid view With the proper views of the c-spine, and a qualified radiologist - what is the sensitivity for finding unstable cervical spine injuries? >97% (CT with 3mm slices >99%). Ten percent of all patients with a c-spine fracture have what? A second, noncontiguous vertebral column fracture. (So scan the rest of their spine). Attempts to align the spine for the purpose of immobilization on the backboard are not recommended if they _______. cause pain Can you clear a c-spine without films? Yes, if they are awake, alert, sober, neurological normal, have NO pain, and can flex, extend, and move their head to both sides without pain - you don't need films. Should a quadriplegic or paraplegic patient be put on a hard board? Not for more than 2 hours - get them off ASAP. What's a big difference in a physical finding between hypovolemic and neurogenic shock? Hypovolemic = usually TACHY, Neurogenic = usually BRADY Partial or total loss of respiratory function may be seen in a patient with a cervical spine injury above ___. C6 Why might someone not be able to breathe if they have a long bone fracture Fat embolism - uncommon though Abnormal arterial blood flow is indicated by an ABI of ____. <0.9 By LOOKING at the patient, what findings might suggest pelvic injury? 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? Volume expansion, and alkalization of urine with bicarb will reduce intratubular precipitation of myoglobin. UOP should be 100 mL/hr until myoglobinuria is cleared. Muscle does not tolerate lack of arterial flow (tourniquet) for more than ___ hours before necrosis begins. 6 What things increase the risk for tetanus? Wounds >6 hours old, wounds contused or abraded, >1 cm deep, from high velocity missiles, due to burns or cold, and significantly contaminated wounds. Should legs be completely straight when splinting? No, flexion of 10 degrees recommended to take pressure off neurovascular structures. Any patient with burns covering more than ___% of BSA require fluid resuscitation. 20 The palmer surface of a patient's hand represents approximately ___% of their BSA. 1% A high index of suspicion for inhalation injury must be maintained, because patients may not display clinical evidence for up to ___ hours, by this time edema may prevent non-surgical intubation. 4 hours on RA, 40 min on 100% O2 How do you calculate the Parkland formula? (BURNS) 4 * weight (kg) * percent BSA burned = volume in 24 hours (1st half in 8 hrs, 2nd half over 16 hrs).4*70kg*25 percent = 7 liters in 24 hours. ***Use 25, NOT 0.25)*** Partial or full thickness burns of ___% in patients less than 10 or older than 50 warrants transfer to a burn center. 10% What percent partial/full thickness burns would qualify a 25 year old for a burn center transfer? 20% What anatomical positions with partial/full thickness burns warrant burn center transfer? Face, eyes, ears, hands, genitalia, perineum, feet, skin overlying joints. Does an inhalation injury warrant transfer to a burn center? Yes Should you treat frostbite by soaking body part in water or not? YES, 40 degree (104F) for 20-30 min should suffice. Don't warm if there is risk of REFREEZING. Insofar as hypothermia is concerned, patients are not pronounced dead until they are _____ and dead. warm What are you thinking if a child has broken ribs? MASSIVE force and highly likely organ damage (since their ribs are very pliable, a huge amount of force is required to break them, there is often underlying organ damage WITHOUT broken ribs). How should you insert a Guedel in a kid? Use tongue blade depressor and insert gently without turning - otherwise there is great risk for trauma and resultant hemorrhage. NOT the 180 degree spin trick. The normal systolic BP in kids can be estimated by what? 90 mm Hg + (age x 2) How do you estimate a child's total circulating volume? 80 mL/kg When shock in a child is suspected, how much fluid do you give them? 20 mL/kg warm crystalloid May need to repeat up to 3 times (60 mL/kg) then consider blood products. Optimal UOP for infants is ___ mL/kg/hr. 2 (1.5 for younger kids, and 1.0 for older kids) How much warmed crystalloid should be used for a DPL in kids? 10 mL/kg (up to 1000 mL) What would you see in an infant that would make you suspect very severe brain injury despite normal LOC? Bulging fontanelles - these allow tolerance for expanding masses/swelling... What is a possible mistake about a blood pressure of 120/80 in a 87 year old man? Assuming that normal blood pressure = normovolemia. Many geriatric patients have uncontrolled hypertension, and if their normal systolic is 180, then 120/80 is relative HYPOtension for them. How well do geriatric patients do with non-operative management of abdominal injuries compared to younger people? Not as well - the risks of non-operative management are often worse than the risks of surgery. hypovolemia When you dont have a BP what are three things to look for when evaluating perfusion? 1. level of consciousness (brain perfusion 2. Skin color (ashen face/grey extremities) 3. Pulse (bilateral femoral - thready/tachy) Elderly patients have a limited ability to ___________ to compensate for blood loss increase heart rate Resuscitation fluids should be warmed to 39 Celsius 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 Blood at urethral meatus, perineal ecchymosis, blood in scrotum, high- riding/non-palpable prostate, pelvic fracture Which arm should you NOT put a pulse-ox on? The arm with the BP cuff 2 anatomical things that can interfere Obesity and intraluminal bowel gas When should radiographs be obtained? During the Secondary survey! How do get an ample patient history? Allergies Medications PMH/Pregnancy Last meal Events/Environment Why might you want a Bair Hugger for a patient who smells of Alcohol? Vasodilation can lead to hypothermia What things are you looking for when you do a DRE in trauma Blood, high riding prostate, sphincter tone, What should be done for every female patient Pregnancy test Adult patients should maintain UOP of at least _____mL/kg/hr. Kids should have at least ______ mL/kg/hr Adults 0.5 mL/kg.hr Kids 1.0 mL/kg/hr Preventing hypercarbia (hypercapnia) is critical in patients who have sustained a _______ injury head What two places would you LOOK at a patient if you suspect hypoxemia? Lips and fingernail beds Patients may be abusive and belligerent because of ______-, so don't just assume its due to drugs, alcohol, or the fact they they are just inherently a jerk hypoxia Can a patient breath on their own after complete cervical cord transection Yes if the phrenic nerves (C3-C5 are spared. This will result in 'abdominal' breathing. The intercostal muscles will be paralyzed though Can you use an OPA (Guedel) in a conscious patient No, it could make them vomit. An NPA (trumpet) would be okay. Bougies are typically inserted blindly, how do you know you are in the trachea and not the esophagus? A correctly sized OPA will extend from the corner of the patients mouth to the external auditory canal. What should you do with the balloon on an ET tube/LMA/foley before you insert it? 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 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 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? 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? 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 Neurogenic, cardiogenic, hypovolemic, septic The most common cause of shock in the injured trauma patient is _________. hemorrhage Approximately ___% of the body's total blood volume is located in the venous circuit/ 70 Why does shock actually reduce the total volume of circulating blood? Anaerobic metabolism --> 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 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. 30 Any patient who is cool and is tachycardic is considered to be _______until proven otherwise. in shock The definition of tachycardia depends on patients age. What heart rate is considered tachycardic for infants, toddlers/PS, schoolage/prepubescent, and adults 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? On a Beta-Blocker or have a pacemaker A FAST scan in an excellent way to diagnose cardiac tamponade. What signs sugget tamponade Beck's Triad: JVD, muffled heard sounds and hypotension (will be resistant to fluid therapy). Will also likely be tachycardic