ATLS Questions and Answers: Initial Assessment and Management of Airway and Shock, Exams of Medicine

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Assessment/Management, Airway,

Shock) Questions And Answers

Patients with a GCS of less than __ usually require intubation. - correct answer 8 The "A" in ABCDE stands for __ - correct answer Airway with C-SPINE PROTECTION You should assume 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 be ___ until proven otherwise. - correct answer Hypovolemia When you don't have/can't get a BP, what 3 things should you look for when evaluating perfusion? - correct answer 1. LOC (brain perfusion)

2. Skin color (ashen/grey)
3. Pulse (bilateral femoral - thready/tachy)

Assessment/Management, Airway,

Shock) Questions And Answers

Elderly patients have a limited ability to __ to compensate for blood loss. - correct answer Increase HR Resuscitation fluids should be warmed to 39 degrees C (102.2F) - can you use a microwave to do this? - correct answer YES for crystalloids, NO for blood products List 5 signs of urethral injury that may prevent you from inserting urinary catheter. - correct answer 1. Blood at urethral meatus

2. Perineal ecchymosis
3. Blood in scrotum
4. High-riding/non-palpable prostate
5. Pelvic fracture Which arm should you NOT put a pulse ox on - correct answer The arm with BP cuff Name 2 anatomical things that can interfere with FAST exam. - correct answer Obesity, intraluminal bowel gas When should radiographs be obtained? - correct answer During secondary sruvery

Assessment/Management, Airway,

Shock) Questions And Answers

AMPLE patients history - correct answer Allergies Medications PMH/Pregnancy Last oral intake 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 trauma? - correct answer Blood, high-riding prostate, sphincter tone What should you do in every female patient? - correct answer Pregnancy test (childbearing age) Adult patients should maintain UOP of at least: - correct answer 0. mL/kg/hr, kids 1.0 mL/kg/hr Preventing hypercarbia is critical in patients who have sustained what kind of injury? - correct answer Head injury

Assessment/Management, Airway,

Shock) Questions And Answers

Where would you look at a patient if you suspect hypoxemia? - correct answer Lips, fingernail beds Patients may be abusive and belligerent due to __ (don't assume its drugs/alcohol/*******) - correct answer Hypoxia Can a patient breathe on their own after complete cervical cord transection? - correct answer Yes if phrenic nerves (C3-C5) are spared - this will result in abdominal breathing, intercostal muscles will be paralyzed though. Can you use an OPA in a conscious patient? - correct answer No, gag reflex would make them vomit Bougies are typically inserted blindly, how do you know you're in the trachea and not esophagus? - correct answer Clicks as distal tip rubs against tracheal rings, or will deviate R or L when entering bronchus (usually at 50 cm) What do you NOT want to hear when auscultating patient after placement of ETT? - correct answer Borborygmi - rumbles/gurgles suggesting esophageal insertion

Assessment/Management, Airway,

Shock) Questions And Answers

RSI dose for Etomidate - correct answer 0.3 mg/kg (usually 20 mg) RSI dose for succinylcholine - correct answer 1-2 mg/kg (usually 100 mg) How does etomidate affect BP? - correct answer It doesn't (shouldn't) have a significant effect on BP Ketamine will inc BP Propofol and thiopental will drop BP RSI dose of sux usually lasts about __ minutes - correct answer 5 What hypnotic/sedative/induction agent do you NOT want to use for a burn patient? - correct answer Sux - severe burns, crush injuries, hyperkalemia, or chronic paralytic/neuromuscular diseases: hyperkalemia risk O2 should flow at 15 L for needle cric and have a Y-connector for insufflation if possible. What size needle do you use for adults? kids? - correct answer Adults 12-14g, kids 16-18 g

Assessment/Management, Airway,

Shock) Questions And Answers

Cricoid cartilage is only circumferential support for upper trachea in kids, therefore surgical cric not recommended in kids under the age of __ - correct answer 12 yo In a "normal" patient without significant chest wall injury or lung disease, needle cric can provide adequate oxygenation for approximately how long? - correct answer 30-45 minutes For a patient with difficulty breathing, what things might you try before you provide a surgical airway? - correct answer Chin-lift, jaw thrust (NOT head-tilt when maintaining c-spine) OPA, NPA LMA, combitube ETT +/- bougie How do you size OPA? - correct answer Extending from corner of patients mouth to external auditory canal What should you do with the balloon on an ETT/LMA/Foley before you insert it? - correct answer Inflate it to check for leaks then deflate and insert

Assessment/Management, Airway,

Shock) Questions And Answers

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 Proper size ETT for an infant is ___ - correct answer Same size as infant's nostril or little finger (3 for neonates, 3.5 for infants 0-6, 4 for infants 6-12 month usually) What size cuffed ETT do you use for emergency cric? - correct answer 5 or 6 How do you calculate ETT to use for toddlers and kids? - correct answer Age/4 + 4 mm = internal diameter Shock is defined as abnormality of circulatory system that results in inadequate organ perfusion and tissue oxygenation. 4 different types: - correct answer Neurogenic Cardiogenic Hypovolemic Septic

Assessment/Management, Airway,

Shock) Questions And Answers

Most common cause of shock in injured trauma patient - correct answer Hemorrhagic Approximately __% of body's total blood volume is located in venous circuit - correct answer 70% Why does shock actually reduce the total volume of circulating blood? - correct answer Anaerobic metabolism -> can't make more ATP -> Endoplasmic then mitochondrial damage -> Lysosomes rupture -> Na and H2O enter the cell which swells and dies What vasopressors should you use to treat hemorrhagic shock? Doses?

• correct answer NEVER use pressors for hypovolemic shock - use volume replacement. Pressors will worsen tissue perfusion. Compensatory mechanisms may preclude a measurable fall in systolic BP up until __% of patients blood volume is lost. - correct answer up to 30% Any patient who is cool and tachycardic is considered to be in __ until proven otherwise - correct answer In shock

Assessment/Management, Airway,

Shock) Questions And Answers

Definition of tachycardia depends on the patient's age. What HR is considered tachycardic for infants, toddlers/preschoolers, school age/prepubescent, adults? - correct answer Infants > Toddlers/preschool > School age > Adults > Elderly patients may not exhibit tachycardia in response to hypovolemia because of limited cardiac response to catecholamines. Why else? - correct answer Beta blocker or pacemaker Signs of cardiac tamponade - correct answer Beck's triad: JVD ,muddled heart sounds, hypotension (resistant to fluid therapy) Likely tachycardic too Tension pneumo and cardiac tamponade may present with many of same signs. What will you see with tension pneumo that you will NOT see with tamponade? - correct answer Absent breath sounds and hyperresonance to percussion over affected hemithorax Immediate thoracic decompression is warranted for anyone with absent breath sounds, hyperresonance to percussion, tracheal deviation, __,

Assessment/Management, Airway,

Shock) Questions And Answers

and __ - correct answer Acute respiratory distress and subcutaneous emphysema Can isolated intracranial injuries cause neurogenic shock? - correct answer NO Calculate total blood volume in adult - correct answer 70 mL per kg of body weight 70 kg = 5 L of circulating blood (70x70 = 4900) Calculate total blood volume in child - correct answer Body weight in kg x 80-90 mL Blood volume of obese person is calculated based upon their __ body weight - correct answer ideal body weight Fluid replacement should be guided by ____, not simple by initial classification (Class I-IV) - correct answer Patient's response to intiial replacement How much blood volume is lost with Class I hemorrhage? - correct answer Up to 15%

Assessment/Management, Airway,

Shock) Questions And Answers

(donating 1 pint/500 mL is about 10% volume loss) Treatment of Class I hemorrhage - correct answer None (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 70 kg adult) Treatment of 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 Class __ hemorrhage - correct answer II How much blood volume is lost with Class III hemorrhage? - correct answer 30-40% (2000 mL) A patient with inadequate perfusion, marked tachycardia and tachypnea, significant mental status change, and a measurable fall in systolic BP most likely has a Class __ hemorrhage - correct answer III or IV - almost always require blood transfusion

Assessment/Management, Airway,

Shock) Questions And Answers

1st priority is stopping the hemorrhage Loss of more than __% of blood volume results in unconsciousness - correct answer >50% How much blood volume is lost with Class IV hemorrhage? - correct answer >40%, unless very aggressive measures are taken the patient will die within minutes A Class ___ Hemorrhage represents with smallest volume of blood loss that is consistently associated with a drop in systolic BP - correct answer III Up to __ mL of blood loss is commonly associated with femur fractures - correct answer 1500 mL Unexplained hypotension or cardiac dysrhythmias (usually bradycardia from excessive vagal stimulation) are often caused by ___, especially in children - correct answer Gastric distension How much crystalloid should you give an adult for initial fluid bolus? Kids? - correct answer Adults: 1-2 L

Assessment/Management, Airway,

Shock) Questions And Answers

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 blodo sooner rather than later) Each mL of blood loss should be replaced with __ mL of crystalloid, thus allowing for replacement of plasma volume lost into interstitial and intracellular spaces - correct answer 3 mL Blood on the floor + 4 more is a mnemonic for blood loss where? - correct answer Chest, pelvic, retroperitoneum (pelvis), thigh (femur) For children under 1 year, UOP should be __ - correct answer 2 mL/kg/hr Would patients in early hypovolemic shock be acidotic or alkalotic? - correct answer Alkalotic - resp alkalosis from tachypnea, followed later by mild metabolic acidosis in 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

Assessment/Management, Airway,

Shock) Questions And Answers

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: tension pneumo, tamponade, blunt cardiac injury, MI, gastric distension, neurogenic shock... True or False: Most patients receiving blood transfusions need calcium replacement - correct answer FALSE!