Airway Maintenance and Cervical Spine Protection in Trauma, Exams of Advanced Education

Download Airway Maintenance and Cervical Spine Protection in Trauma and more Exams Advanced Education in PDF only on Docsity! Atls Exam With 100%Correct Verified Answers 2024 Patients with a 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 clavicle 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 don't have/can't get a blood pressure, 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 39 degrees Celsius (102.2 F). Can you use a microwave to do this? -Correct Answer-YES - for CRYSTALLOID ONLY (but NOT for blood products). Urinary catheters are good for assessing renal perfusion and volume status. List 5 signs of urethral injury that might prevent 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 a blood pressure cuff on it Name two anatomical things that can interfere with doing a FAST scan. -Correct Answer-Obesity & intraluminal bowel gas When should radiographs be obtained? -Correct Answer-During the SECONDARY survey. How do you get an ample patient history? -Correct Answer-A=Allergies, M=Medications, P=PMH/Pregnancy, L=Last meal, E=Events/Environment of injury Why might you want a Bair Hugger for a patient who smells of alcohol? -Correct Answer-Vasodilation can lead to hypothermia What things are you looking for when you do a DRE in a trauma? -Correct Answer- Blood, high-riding prostate (in males), and sphincter tone What should you do for every female patient? -Correct Answer-Pregnancy test (females of childbearing age) Adult patients should maintain UOP of at least ___ mL/kg/hr. Kids should have at least ___ mL/kg/hr. -Correct Answer-Adults 0.5 mL/kg/hr, Kids 1.0 ml/kg/hr Preventing hypercarbia is critical in patients who have sustained a _____ injury. - Correct Answer-head What two places would you LOOK at a patient if you suspect hypoxemia? -Correct Answer-Lips and fingernail beds Patients may be abusive and belligerent because of _____, so don't just assume it's due to drugs, alcohol, or the fact that they are just inherently a jerk. -Correct Answer- hypoxia Can a patient breathe on their own after complete cervical cord transection? -Correct Answer-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? -Correct Answer-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? -Correct Answer-You can feel the "clicks" as the distal tip rubs against the cartilaginous tracheal rings, or it will deviate right or left when entering either bronchus (usually at 50 cm). What do you NOT want to hear if you ascultate a patient after placement of an ET tube? -Correct Answer-Borborygmi - rumbling or gurgling noises suggesting esophageal insertion. What is the RSI dose for etomidate? -Correct Answer-0.3 mg/kg (usually 20 mg) What is the RSI dose for sux? -Correct Answer-1-2 mg/kg (usually 100 mg) Immediate thoracic decompression is warranted for anyone with absent breath sounds, hyperresonance 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 body weight. A 70 kg person has about 5 liters of circulating blood. (70*70=4900) How do you calculate total blood volume in an child? -Correct Answer-Body weight in 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 replacment 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 a 10% volume loss and would qualify as Class I Hemorrhage! How do you treat a Class I Hemorrhage? -Correct Answer-You don't (usually). Transcapillary refill and other compensatory mechanisms usually 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 a 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 almost always require a blood transfusion, which depends on their response to initial fluid resuscitation. The first priority is stopping the hemorrhage. Loss of more than ___% 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 patient will die within minutes. A Class ___ Hemorrhage represents the smallest volume of blood loss that is consistently associated wiht 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 dysrhythmias (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 liters, Kids: 20 mL/kg (may repeat and give as much as 60 mL/kg but with high reserve in kids, if they're in shock they should get blood sooner rather than later. Each mL of blood loss whould be replaced with ___ mL of crystalloid, thus allowing for replacement of plasma volume lost into interstitial and intracellular spaces. -Correct Answer-3 Blood on the floor x four more is a mnemonic for occult blood loss where? -Correct Answer-Chest, pelvis, retroperitoneum, and thigh For children UNDER 1 year of age, UOP should be ___ mL/kg/hr. -Correct Answer-2 Would patients in EARLY hypovolemic shock be acidodic or alkalotic? -Correct Answer- 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 resuscitation likely have/had a Class ___ Hemorrhage. -Correct Answer-I or II "Transient responders" are associated with Class ___ Hemorrhage. -Correct Answer-II or III What differential diagnoses should you always consider for "non-responders" following fluid resuscitation? -Correct Answer-NON-HEMORRHAGIC causes, e.g. tension pneumothorax, tamponade, blunt cardiac injury, MI, acute gastric distention, neurogenic shock... Most patients receiving blood transfusions ____ need calcium replacement. -Correct Answer-don't How should you position the patient before placing a subclavian or IJ line? -Correct Answer-SUPINE, head down 15 degrees to distend neck veins and prevent embolism, only turn head away if C-SPINE HAS BEEN CLEARED FIRST. How long can you keep an IO line in? -Correct Answer-Intraosseous infusion should be limited to emergency resuscitation and shoudl be discontinued as soon as other venous access is obtained. Where do you want to make an incision for a saphenous vein cutdown and how long should your incision be? -Correct Answer-The saphenous vein can be accessed approximately 1 cm anterior and 1 cm superior to the medial malleolus. Make a 2.5 cm transverse incision through the skin and SQ tissue, careful not to injure the vessel. A patient arrives to the trauma bay intubated and there are absent breath sounds over the left hemithorax, where should you place your decompression needle? -Correct Answer-This may NOT be a pneumothorax, for intubated patients always suspect a right main-stem before attempting needle decompression. Where would you insert a large caliber needle to decompress a tension pnuemothorax? -Correct Answer-Into the 2nd intercostal space in the midclavicular line of the affected hemithorax. For an open pneumothorax, (sucking chest wound) air passes preferentially through the chest wall defect (least resistance) if the diameter of the defect is at least ___ the diameter of the trachea. -Correct Answer-2/3 Flail chest results from multiple rib fractures - by definition this would be ___ or more ribs, fractured in ___ or more places. -Correct Answer-2 or more ribs fractured in 2 or more places Both tension pneumothorax and massive hemothorax are associated with decreased breath sounds on auscultation, so you can tell which it is by _______. -Correct Answer- Percussion - hyperresonant with pnuemo, dull with hemothorax. If a patient doesn't have JVD, does this mean they don't have a tension pneumo or tamponade? -Correct Answer-No, they might have a massive internal hemorrhage and be hypovolemic. By definition, how much blood is in the chest cavity to call it a "massive hemothorax"? - Correct Answer-1500 mL or 1/3 or more of the patient's total blood volume. (Some also define it as continued blood loss of 200 mL/hr for 2-4 hours- but ATLS does NOT use this rate for any mandatory treatment decisions). 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 soild 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% A blown pupil in a patient with a traumatic injury is caused by compression of which nerve? -Correct Answer-Superficial parasympathetic fibers of the CN III (occulomotor). What is a "normal" ICP in the resting state? -Correct Answer-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? -Correct Answer-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? -Correct Answer-Minor = 13-15, Moderate = 8-12 When calculating GCS and there is right/left assymetry in the motor response - which one do you use? -Correct Answer-The "BEST" response. (Better predictor than worst response) What signs might you see if a patient has a basillar skull fracture? -Correct Answer- PERIORBITAL ECCHYMOSIS (raccoon eyes), RETROAURICULAR ECCHYMOSIS (Battle sign), and otorrhea/rhinorrhea. What do you need to know about the GCS? -Correct Answer-EVERYTHING - Know it COLD! What things might require a person with MINOR brain injury get admitted? -Correct Answer-Abnormal CT (or no scan available), penetrating head injury, prolonged LOC, worsening LOC, moderate to severe HA, significant drug/alcohol intoxication, skull fx, oto/rhinorrhea, nobody at home to watch, GCS stays <15, focal neuro deficits. What would you want to do if a patient with a minor brain injury fails to reach a GCS of 15 within 2 hour post injury, had LOC >5 min, are older than 65, emesis x 2, or had retrograde amnesia >30 minutes? -Correct Answer-CT scan - Everything but the 30 min amnesia makes them HIGH risk for neurosurgical intervention (as would a basillar skull fx). What 2 things do you need to do first for everyone with a MODERATE brain injury (according to ATLS algorithm)? -Correct Answer-CT scan, admit to faciolity capable of definitive neurosurgical care (Moderate = GCS 9-12) High levels of CO2 will cause cerebral vasculature to _____. -Correct Answer-Dilate (to increase blood flow) - so you might want to HYPERventilate people with brain injuries. Ideally, you want to wait to perform a GCS on a person with SEVERE brain injury until what? -Correct Answer-BP is normalized A FAST scan, DPL, or ex-lap should take priority over a CT scan if you can't get the brain injured patient's BP up to ____ mm Hg. -Correct Answer-100 If a patient has a systolic over 100 with evidence of intracranial mass (blown pupil, unequal motor exam) THEN a CT would take first priority. A midline shift of greater than ___ often indicates the need for neurosurgical evacuation of the mass/blood. -Correct Answer-5mm Your patient has a dilated pupil and you want to give mannitol on the way to the CT scanner or OR. What is the correct dose? -Correct Answer-0.25-1.0 g/kg via rapid bolus A cast cutter should be removed to remove a trauma victim's helmet if there is evidence of a c-spine injury or if _____. -Correct Answer-the patient experiences pain or paresthesias during an initial attempt to remove the helmet. What are the signs of neurogenic shock? -Correct Answer-Vasodilation of lower extremity blood vessels - resulting in pooling of blood and hypotension. This loss of sympathetic tone may cause bradycardia or inhibit the tachycardic response to hypovolemia. How do you treat neurogenic shock? -Correct Answer-Judicious use of pressors and MODERATE fluid resuscitation. Too much fluid may result in overload and pulmonary edema. What is the most common type of C1 fracture? -Correct Answer-Burst fractures (Jefferson fracture) 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? -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). 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. When worn correctly, seatbelts reduce fatalities by ___%. -Correct Answer-65-70%, with a 10-fold reduction in serious injury.