TLS MCQ #1 - 50% sure [Thoracic

trauma][ chest tube insertion]

Definition

ATLS MCQ #1

A 22 year old man is hypotensive and tachycardic after a shotgun wound to
the left shoulder. His blood pressure is initially 80/40 mmHg. After 2 liters
of crystalloid solution his blood pressure increases to 122/84 mmHg His
heart rate is now 100 beats per minute and his respiratory rate is 28
breaths per minute. His breath sounds are decreased in the left hemithorax,
and after initial IV fluid resuscitation, a closed tube thoracostomy is
performed for decreased left breath sounds with the return of a small
amount of blood and no air leak. After chest tube insertion, the most
approriate next step is

a) reexamine the chest
b) perform an aortogram
c) obtain a CT scan of the chest
d) Obtain arterial blood gas analyses
e) perform tranesohageal echocardiography

the answer is d ; but a website said a
(and a makes more sense to me. so i'll go with a)

info: chest tube insertion, p.108

the website:
http://translate.google.com/translate?hl=en&sl=nl&u=http://www.atls.nl/al
sg/atls.nsf/uploads/52D1762B14313442C125737500476755/%24FILE/Uitleg
%2520schriftelijk%2520examen.doc&ei=VoIXTLOdCZLQM_zFmasL&sa
=X&oi=translate&ct=result&resnum=1&ved=0CBYQ7gEwAA&prev=/sea
rch%3Fq%3D%2522after%2Bchest%2Btube%2Binsertion%2Bthe%2Bm
ost%2Bappropriate%2522%2Bnext%2Bstep%2Bis%26hl%3Den


Term
ATLS MCQ #2 - 75% sure
[Musculoskeletal trauma][Extremity
trauma]
Definition


ATLS MCQ #2

A construction worker falls two stories
from a building and sustains bilateral
calcaneal fractures. In the emergency
department, he is alert, vital signs are
normal, and he is complaining of severe
pain in both heels and his lower back.
Lower extremity pulses are strong and
there is no other deformity. The
suspected diagnosis is most likely to be
confirmed by

a) angiography
b) compartment pressures
c) retrograde urethrogram
d) Doppler-ultrasound studies
e) complete spine x-ray series

the answer is e.

info: can't find the info

--------
notes:
- angiography is found as CT
angiography, p.146, which focuses on
head traumas (not answer)
- compartment pressures are mentioned
on page 197 as intracompartmental
pressure measurements (not answer)
- retrograde urethrogram is not
mentioned in the book (or i couldn't
find it!)
- doppler ultrasound studies is not
clearly mentioned in the book (shit)
- X-ray evaluation is on page 166-168.
page 168 does say something that might
be seen as the correct answer.

Term
ATLS MCQ #3 - 100% sure [Trauma
in women]
Definition
ATLS MCQ #3

During the third trimester of
pregnancy, all of the following changes
occur normally EXCEPT a

a) decrease in PaCO2
b) decrease in leukocyte count
c) reduced gastric emptying rate
d) diminished residual lung volume
e) diminished elvic ligament tension


the answer is b.

info: page 261

Term
ATLS MCQ #4 - 100% sure [Head
Trauma]
Definition

ATLS MCQ #4

In managing the head injured patient,
the most important initial step is to

a) secure the airway
b. obtain c-spine film
c) support circulation
c) control scalp hemorrhage
e) determine the GCS score


the answer is a.

info: p.154

Term
ATLS MCQ #5 - 100% sure [Shock]
Definition

ATLS MCQ #5


A previously healthy, 70kg (154 pound)
man suffers an estimated acute blood
loss of 2 liters. Which one of the
following statements applies to this
patient?

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) his systolic blood pressure will be
decreased with a narrowed pulse
ressure (true)
e) his systolic blood pressure will be
maintained with an elevated diastolic
pressure


the answer is d.
info. page 61

Term
ATLS MCQ #6 - 100% sure [Trauma
in Women]
Definition
ATLS MCQ #6


The physiologic hypervolemia of
pregnancy has clinical significance in
the management of the severely
injured, gravid woman by

a) reducing the need for blood
transfusion
b) increasing the risk of pulmonary
edema
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

the answer is e.

info. page 261



Term
ATLS MCQ #7 - 75% sure [Thermal
Injuries][Injury Due to Burn & Cold]
Definition
ATLS MCQ #7


The best guide for adequate fluid resuscitation of the burn patient is

a) adequate urinary output
b) reversal of systemic acidosis
c) normalization of the heart rate
d) a normal central venous pressure
e) 4mL/kg/percent body burn/24 hours

the answer is a. (not sure..)

info: pg. 216-217

background:
The adequacy of therapy is confirmed by simple determination of
adequate urine output and of the haemoglobin and haematocrit levels.
The most important guide is the patients clinical response
source:
http://www.medbc.com/annals/review/vol_16/num_4/text/vol16n4p173.asp

Term
ATLS MCQ #8 - 100% sure [Shock]
Definition
ATLS MCQ #8


Establishing a diagnosis of shock must
include

a) hypoxemia
b) acidosis
c) hypotension
d) increased vascular resistance
e) evidence of inadequate organ
perfusion

the answer is e.

the info: p.58

Term
ATLS MCQ #9 - 100% sure
[Musculoskeletal trauma][Extremity
Trauma]
Definition
ATLS MCQ #9

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

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

the answer is: b

info is: p.79; in obvious external
bleeding section on table

background
- tourniquet can be found on p.194, 195.
they imply that you use a tourniquet if
you are choosing life over limb, and if
direct pressure isn't working. (p.195)

Term
ATLS MCQ #10 - 100% sure [Head
injury]
Definition
ATLS MCQ #10


For the patient with severe traumatic brain injury, profound hypocarbia
should be avoided to prevent

a) respiratory alkalosis
b) metabolic acidosis
c) cerebral vasoconstriction with diminished perfusion
d) neurogenic pulmonary edema
e) shift of the oxyhemoglobin dissociation curve

the answer is: c

info is: related info on page 136,137

--------
background info
Carbon dioxide is perhaps the most potent available modulator of
cerebrovascular tone and thus cerebral blood flow (CBF)
http://www.liebertonline.com/doi/abs/10.1089/089771501750055776?journal
Code=neu
-----------

Hypercarbia and hypoxia are both potent cerebral vasodilators that result
in increased cerebral blood flow and volume and, potentially, increased
ICP; thus, they must be avoided. Orotracheal intubation allows for airway
protection in patients who are severely obtunded and allows for better
control of oxygenation and ventilation.
http://emedicine.medscape.com/article/909105-overview
------------

Term
ATLS MCQ #11 - 100% sure
[Abdominal trauma]
Definition
ATLS MCQ #11


A 25 year old man is brought to a
hospital with a general surgeon after
being involved in a motor vehicle crash.
He has a GCS of 13 and complains of
abdominal pain. His blood pressure was
80mHg systolic by palpation on arrival
at the hospital, but increases to 110/70
mmHg with the administration of 2
liters of intravenous fluid. His heart
rate remains 120 beats per minute.
Computed tomography shows an aortic
injury and splenic laceration with free
abdominal fluid. His blood pressure
falls to 70mmHg after CT. The next
step is

a) contrast angiography
b) transfer to higher level trauma
center
c) exploratory laparotomy
d) transfuse packed red blood cells
e) transesophageal echocardiography

the answer is: c

info: page 12 - list

background info: none for now

Term
ATLS MCQ #12 - 100% sure [Trauma
in Women]
Definition
ATLS MCQ #12


Which one of the following statements
regarding abdominal trauma in the
pregnant patient is true?

a) the fetus is in jeopardy only with
major abdominal trauma
b) leakage of amniotic fluid is an
indication for hospital admission
c) indications for peritoneal lavage are
different from those in the nonpregnant
patient
d) penetration of an abdominal hollow
viscus is more common in late than in
early pregnancy
e) the secondary survey follows a
different pattern from that of the
nonpregnant patient

the answer is: b

info: page 265, i've marked it

background info: none yet

Term
ATLS MCQ #13 - 75% sure [Thoracic
trauma]
Definition
ATLS MCQ #13


The first maneuver to improve
oxygenation after chest injury is

a) intubate the patient
b) assess arterial blood gases
c) administer supplemental oxygen
d) ascertain the need for a chest tube
e) obtain a chest x-ray

the answer is: c

the info: can't find it!

background:



Term
ATLS MCQ #14 - 100% sure [Head
trauma]
Definition
ATLS MCQ #14


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 painful
stimuli. He does not follow commands,
but he does moan periodically. His right
arm is deformed and does not respond
to painful stimulus; however, his left
hand reaches purposefully toward the
painful stimulus. Both legs are stiffly
extended. His GCS Score is

a) 2
b) 4
c) 6
d) 9
e) 12

the answer is: d

info: p.138

background info:
i used my card on gcs for this.

Term Definition
ATLS MCQ #15 - 75% sure [Trauma
in Women]
ATLS MCQ #15


A 20 year old woman, at 32 weeks
gestation, is stabbed in the upper right
chest. In the emergency department,
her blood pressure is 80/60 mmHg. She
is gasping for breath, extremely
anxious, and yelling for help. Breath
sounds are diminished in the right
chest. The most appropriate first step is
to

a) perform tracheal intubation
b) insert an oropharyngeal airway
c) perform needle decompression of the
right chest
d) manually displace the gravid uterus
to the left side of the abdomen
e) initiate 2, large-caliber peripheral IV
lines and crystalloid infusion

the answer is: c

info is: p.87

background is:

Term
ATLS MCQ #16 - 50% sure [Initial
assessment and management] Review X
1
Definition
ATLS MCQ #16


Which one of the following findings in
an adult should prompt immediate
management during the primary
survey?

a) distended abdomen
b) glasgow coma scale score of 11
c) temperature of 36.5C (97.8F)
d) heart rate of 120 beats per minute
e) respiratory rate of 40 breaths per
minute

the answer is: e

the info is: page 79; topic on shock;
addresses distended abdomen, not RR
though :(

background is:

Term
ATLS MCQ #17 - 100% sure [Thoracic
trauma]
Definition
ATLS MCQ #17

The most important, immediate step in
the management of an open
pneumothorax is

a) endotracheal intubation
b) operation to close the wound
c) placing a chest tube through the
chest wound
d) placement of an occlusive dressing
over the wound
e) initiation of 2, large-caliber IVs with
crystalloid solution

the answer is; d

the info is: page 87

background is:


Term
ATLS MCQ #18 - 100% sure [Tetanus
immunization]
Definition
ATLS MCQ #18


The following are contraindications for
tetanus toxoid administration

a) history of neurological reaction or
severe hypersensitivity to the product
b) local side effects
c) muscular spasms
d) pregnancy
e) all of the above


the answer is: a

the info is: some related stuff on page
297

background info:
It is a contraindication to use this or
any other related vaccine after a serious
adverse event temporally associated
with a previous dose including an
anaphylactic reaction.
A history of systemic allergic or
neurologic reactions following a
previous dose of Tetanus Toxoid is an
absolute contraindication for further
use.
2,5


found a source

http://www.rxlist.com/tetanus-drug.htm

Term
ATLS MCQ #19 - 100% sure [Thoracic
trauma]
Definition
ATLS MCQ #19


A 56 year old man is thrown violently
against the steering wheel of his truck
during a motor vehicle crash. On
arrival in the emergency department he
is diaphoretic and complaining of chest
pain. His blood pressure is 60/40 mmHg
and his respiratory rate is 40 breaths
per minute. Which of the following best
differentiates cardiac tamponade from
tension pneumothorax as the cause of
his hypotension?

a. tachycardia
b. pulse volume
c. breath sounds
d. pulse pressure
e. jugular venous pressure

the answer is: c

info is: p.87 marked

background info:

Term
ATLS MCQ #20 - 100% short
[Pediatric trauma][Trauma in extremes
of age]
Definition
ATLS MCQ #20


Bronchial intubation of the right or left
mainstem bronchus can easily occur
during infant endotracheal intubation
because

a) the trachea is relatively short
b) the distance from the lips to the
larynx is relatively short
c) the use of tubes without cuffs allows
the tube to slip distally
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

the answer is: a

the info: p228 marked

background info:

Term
ATLS MCQ #21 - 100% sure [Thoracic
trauma]
Definition
ATLS MCQ #21


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, and 2 liters of crystalloid
solution are infused through 2 large-
caliber IVs. His blood pressure now is
60/0 mmHg, heart rate is 160 beats per
minute, and respiratory rate is 14
breaths per minute (ventilated with
100% O2). 1500cc of blood has drained
from the right chest. The most
appropriate next step in managing this
patient is to

a) perform FAST
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



the answer is: d

the info is: read p.90-91

background info:

Term
ATLS MCQ #22 - 100% sure [Airway
and ventilatory management] Review
X1
Definition
ATLS MCQ #22

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

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) attempt orotracheal intubation using
2 people and inline stabilization of the
cervical spine.
e) ventilate the patient with a bag-mask
device until his beard can be shaved for
better mask fit.

the answer is: d

the info is: related to anaswer p.33;
marked

background info is:

Term
ATLS MCQ #23 - 75% sure [Spine and
Spinal Cord Trauma]
Definition
ATLS MCQ #23

A patient is brought to the emergency
department 20 minutes after a motor
vehicle crash. He is conscious and there
is no obvious external trauma. He
arrives at the hospital completely
immobilized on a long spine board. His
blood pressure is 60/40 mmHg and his
heart rate is 70 beats per minute. His
skin is warm. Which one of the
following statements is true?

a) vasoactive medications have no role
in the 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) occult 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

the answer is: c

the info is: related topics on p.167; 161

background:


Term
ATLS MCQ #24 - 100% sure [Thermal
injuries][Injury due to burn & cold]
Definition
ATLS MCQ #24


Which one of the following is the
recommended method for initialy
treating frostbite?

a) moist heat
b) early amputation
c) padding and elevation
d) vasodilators and heparin
e) topical application of silver
sulfadiazine

the answer is: a

the info is: p.220

background is:
"4. Use moist heat (warm water) to
warm the casualty, rather than dry heat
(radiator or fire). Dry heat can cause
more damage."
source http://ezinearticles.com/?10-
Tips-For-Treating-
Frostbite&id=1666183

Term
ATLS MCQ #25 - 75% sure
[Musculoskeletal trauma][Extremity
trauma]
Definition
ATLS MCQ #25


A 32 year old man's right leg is trapped
beneath his overturned car for nearly 2
hours before he is extricated. On
arrival in the emergency departmnet,
his right lower extremity is cool,
mottled, insensate, and motionless.
Despite normal vital signs, pulses
cannot be palpated below the femoral
vessel and the muscles of the lower
extremity are firm and hard. During
the initial management of this patient,
which of the following is most likely to
improve the chances for limb salvage?

a) applying skeletal traction
b) administering anticoagulant drugs
c) administering thrombolytic therapy
d) perform right lower extremity
fasciotomy
e) immediately transferring the patient
to a trauma canter


the answer is: d

info is: related on p196-197

background is:

Term
ATLS MCQ #26 - 75% sure [Head
trauma]
Definition
ATLS MCQ #26


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

a) requires 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


the answer is: c

the info is: i can't find it

background is:

Term
ATLS MCQ #27 - 50% sure [Thoracic
trauma][Transfer to Definitive Care]
Definition
ATLS MCQ #27


A 22 year old man sustains a gunshot
wound to the left chest and is
transported to a small community
hospital at which surgical capabilities
are not available. In the emergency
department, a chest tube is inserted and
700mL of blood is evacuated. The
trauma center accepts the patient in
transfer. Just before the patient is
placed in the ambulance for transfer,
his blood pressure decreases to 80/68
mmHg and his heart rate increases to
136 beats per minute . The next step
should be to

a) clamp the chest tube
b) cancel the patient's transfer
c) perform an emergency department
thoracotomy
d) repeat the primary survey and
proceed with transfer
e) delay the transfer until the referring
doctor can contact a thoracic surgeon

the answer is:c

the info is: some reference can be found
btwn page 270 - 274

background:

Term
ATLS MCQ #28 - 75% sure [Head
trauma]
Definition
ATLS MCQ #28


A 64 year old man, involved in a high-
speed car crash, is resuscitated initially
in a small hospital with limited
resources. He has a closed head injury
with a GCS score of 13. He has a
widened mediastinum on chest x-ray
with fractures of left ribs 2 through 4,
but no pneumothorax. After infusing 2
liters of crystalloid solution, his blood
pressure is 100/74 mmHg, heart rate is
110 beats per minute, and respiratory
rate is 18 breaths per minute. He has
gross hematuria and a pelvic fracture.
You decide to transfer this patient to a
facility capable of providing a higher
level of care. The facility is 128 km (80
miles) away. Before transfer, you
should first

a) intubate the patient
b) perform diagnostic peritoneal lavage
c) apply the pneumatic antishock
garment
d) call the receiving hospital and speak
to the surgeon on call
e) discuss the advisability of transfer
with the patient's family

the answer is: c

the info is: related on p.123

background:

Term
ATLS MCQ #29 - 100% sure [Shock]
Definition
ATLS MCQ #29


Hemorrhage of 20% of the patient's
blood volume is associated usually with

a) oliguria
b) confusion
c) hypotension
d) tachycardia
e) blood transfusion requirement

the answer is; d

info is: page 61

background:

Term
ATLS MCQ #30 - 75% sure [??? deals
with intraosseous fluid resuscitation]
Definition
ATLS MCQ #30


Which one of the following statements concerning intraosseous infusion is
true?

a) only crystalloid solutions may be safely infused through the needle (NO)
b) aspiration of bone marrow confirms appropriate positioning of the
needle (POSSIBLE)
c) intraosseous infusion is the preferred route for volume resuscitation in
small children (NO)
d) intraosseous infusion may be utilized indefinitely (NO)
e) swelling in the soft tissues around the intraosseous site is not a reason to
discontinue infusion


the answer is: b

the info: random unhelpful info p.236


background:

"This route of fluid and medication administration is an alternate one to
the preferred intravascular route when the latter can't be established in a
timely manner especially during pediatric emergencies. When intravascular
access cannot be obtained in pediatric emergencies, intraosseous access is
usually the next approach."

". It can be maintained for 2448 hours, after which another route of access
should be obtained."
the info is:

"Furthermore, any medication that can be introduced via IV can be
introduced via IO."



source: http://en.wikipedia.org/wiki/Intraosseous_infusion

SOURCE OF DIRETIONS
http://docs.google.com/viewer?a=v&q=cache:Rxmq0CyxS64J:www.fchn.or
g/docs/northstar/EZ-
IO%2520directions.pdf+intraosseous+infusion+system+directions&hl=en&
gl=us&pid=bl&srcid=ADGEESj6FX7bjUc0C5D7KWUFeTb5TaPt3EGkL
CJOC9vBJGAdO4EXJTBlmph03TlX98ISaFNWzadJs_GpwYvP0plN2qaI
Un1G7arMl9863x6bVhEqWxirhWJBhP-QQ47-
Hjltels61jbo&sig=AHIEtbTUtqah8qhN5wrnat9mK5aa3zozoQ


Term
ATLS MCQ #31 - 100% sure [Head
injury]
Definition
ATLS MCQ #31


A young woman sustains a severe head
injury as the result of a motor vehicle
crash. In the emergency department,
her GCS is 6. Her blood pressure is
140/90 mmHg and her heart rate is 80
beats per minute. She is intubated and
mechanically ventilated. Her pupils are
3mm in size and equally reactive to
light. There is no other apparent injury.
The most important principle to follow
in the early management of her head
injury is to

a) avoid hypotension
b) administer an osmotic diuretic
c) aggressively treat systemic
hypertension
d) reduce metabolic requirements of the
brain
e) distinguish between intracranial
hematoma and cerebral edema

the answer is: A

the info is: page 142,143, #145
background: none for now

Term
ATLS MCQ #32 - 100% sure [Thoracic
trauma]
Definition
ATLS MCQ #32


A 33 year old woman is involved in a
head-on motor vehicle crash. It took 30
minutes to extricate her from the car.
Upon arrival in the emergency
department, her heart rate is 120 beats
per minute, BP is 90/70 mmHg,
respiratory rate is 16 breaths per
minute, and her GCS score is 15.
Examination reveals bilaterally equal
breath sounds, anterior chest wall
ecchymosis, and distended neck veins.
Her abdomen is flat, soft, and not
tender. Her pelvis is stable. Palpable
distal pulses are found in all 4
extremities. Of the following, the most
likely diagnosis is

a) hemorrhagic shock
b) cardiac tamponade
c) massive hemothorax
d) tension pneumothorax
e) diaphragmatic rupture

the answer is: b

the info is: p.91-92

background is:

Term
ATLS MCQ #33 - 75% sure
[Abdominal trauma]
Definition
ATLS MCQ #33


A hemodynamically normal 10 year old
girl is admitted to the Pediatric
Intensive Care Unit (PICU) for
observation after a Grade III
(moderately severe) splenic injury has
been confirmed by computed
tomography (CT). Which of the
following mandates prompt celiotomy
(laparotomy)?

a) A serum amylase of 200
b) A leukocyte count of 14,000
c) extraperitoneal bladder rupture
d) free intraperitoneal air
demonstrated on follow-up CT
e) a fall in the hemoglobin level from 12
g/dL to 8 g/dL over 24 hours


the answer is: e

the info is: some related info p.121
under solid organ injuries

background:

Term
ATLS MCQ #34 - 100% sure [Spine
and spinal cord trauma]
Definition
ATLS MCQ #34


A 40 year old woman restrained driver
is transported to the emergency
department in full spinal
immobilization. She is
hemodynamically normal and found to
be paraplegic at the level of T10.
Neurologic examination also determines
that there is loss of pain and
temperature sensation with
preservation of proprioception and
vibration. These findings are consistent
with the diagnosis of

a) central cord syndrome
b) spinal shock syndrome
c) anterior cord syndrome
d) complete cord syndrome
e) Brown-Sequard syndrome

the answer is: c

the info is: p.163

background:

Term
ATLS MCQ #35 - 100% sure [Spine
and spinal cord injury]
Definition
ATLS MCQ #35

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:

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) maintain inline immobilization and
establish a definitive airway

the answer is: e

the info is: related info p.27-28

background:
some info on flashcards for
tracheostomy indications (i.e. you don't
do it in emergency cases)

Term
ATLS MCQ #36- 100% sure [Thermal
injury][Injury due to burn & cold]
Definition
ATLS MCQ #36


When applying the Rule of Nines to
infants,

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


the answer is: c

the info is: p.223

background info:

Term
ATLS MCQ #37 - 75% sure
[Abdominal trauma]
Definition
ATLS MCQ #37

A 60 year old man sustains a stab
wound to the right posterior flank.
Witnesses state the weapon was a small
knife. His heart rate is 90 beats per
minute, blood pressure is 128/72
mmHg, and respiratory rate is 24
breaths per minute. The most
appropriate action to take at this time is
to

a) perform a colonoscopy
b) perform a barium enema
c) perform an intravenous pyelogram
d) perform serial physical examination
e) suture repair the wound and
outpatient follow up

the answer is: d

the info is: i can't find it

background: slightly helpful is
flashcards on kidney injury


Term
ATLS MCQ #38 - 100% sure [Trauma
in Women]
Definition
ATLS MCQ #38


Which of the following situations
requires Rh immunoglobulin
administration to an injured woman?

a) Negative pregnancy test, Rh
negative, and 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

the answer is: c

the info is: p.265

background is:

Term
ATLS MCQ #39 - 100% sure [Thoracic
trauma]
Definition
ATLS MCQ #39


A 22 year old female athlete is stabbed
in her left chest at the third interspace
in the anterior axillary line. On
admission to the emergency department
and 15 minutes after the incident, she is
awake and alert. Her heart rate is 100
beats per minute, blood pressure 80/60
mmHg, and respiratory rate 20 breaths
per minute. A chest x-ray reveals a
large left hemothorax. A left chest tube
is placed with an immediate return of
1600 mL of blood. the next
management step for this patient is

a) perform a thoracoscopy
b) perform an arch aortogram
c) insert a second left chest tube
d) prepare for an exploratory
thoracotomy
e) perform an chest CT

the answer is: d

the info is: p.90-91

background:

Term
ATLS MCQ #40 - 100% sure [Pediatric
trauma]
Definition
ATLS MCQ #40


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?

a) a flail chest is probable
b) a symptomatic cardiac contusion 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

the answer is: c

the info is: p.237

background:

Term
ATLS: What the actual course is like
Definition
ATLS: What the actual course is like


So my group just finished it too. We had a pretest which
we were suppose to take after reading the ATLS book.
Then took a two day course (half skills sessions, half
lectures) ending with a written test and standardized pt.
exam. I would be lying though if I said the main instructor
didn't help us out by quizzing us with very similar quiz
questions throughout the course. Was co-taught by
Trauma and EM attendings. All in all it was actually a
really good course!

http://forums.studentdoctor.net/showthread.php?t=736635

Term Definition

Term
ATLS: Who teaches and who takes the
course
Definition
ATLS: Who teaches and who takes the course


I'm pretty sure extenders can't be ATLS course
instructors (teach ATLS to physician and physician
extender students). They could become ATLS educators
(teach the instructor candidates how to teach ATLS to
other people-when I took the instructor course there were
even a few non healthcare educators).

They have special ATLS student courses where extenders
are allowed because the primary focus is on teaching
physicians (extenders can't be ATLS certified which is
why I think they can't be ATLS instructors), but if there is
an extender who wants the info taught in the class (let's
say you have a PA or NP that is on your trauma service, or
works in an ER where they might have to work with
trauma patients) they are allowed to take the course (but
not comprise more than 25% of the class).
-------------------
In our ATLS class there are some extenders (paramedics,
emergency room nurses & techs) who are auditing the
course. They do not take the exam but sit through all the
lectures and do the skills stations with us. All of the
instructors, however, are either EM or Trauma/CC
Surgeons.

-------------

Further reading of ACS website it does appear that to be
an ATLS Instructor one must be a physician (although I
cannot see where it says you have to be a surgeon or EM).

ATLS Educators are required to have a Master's or
preferably PhD or EdD.

--------------

My ATLS instructor certification expired around 2yrs
ago. However, my understanding is thus:

1. non-physicians "audit" the course
2. non-physicians that have audited the course can teach
components but are not ATLS instructor certified
3. I don't recall any restrictions on physicians having to be
surgeons to teach/be instructors. Granted, I believe
everyone in my instructor course was a "surgeon"... we
had ortho, ent, and neurosurgeons taking the instructor
course. I think in general, it just doesn't make sense for
someone that will not spend any significant time dealing
with traumas to beatls cert or atls instructor cert. I guess
an FP/pediatrician/etc.. could in the community do a bit of
ED/trauma type stuff. But, beyond that, I am not sure why
a hospitalist, radiologist, psych, etc... would spend the time
to that involved in ATLS.

---------------

I take atls every 4 yrs.
since 2008 pa's have been able to take ATLS and "fully
participate" in all stations and exams. my most recent cert
card says:
"emedpa" is recognized as having successfully completed
the ATLS course in it's entirety"
we pay full price for the course.($750)
if you fail the written or the practical you don't get a card.
ACS doesn't call that a cert card. everyone else does.
prior to 2008 we just got a cme certificate and a letter
from the program director stating that we met all course
objectives.
__________________
Emergency/Disaster Medicine P.A., EMT-P
23 Years working in EM

================


__________________

http://forums.studentdoctor.net/showthread.php?t=736635



Term
ATLS: Notes from the first day, 6/23/10
Definition
ATLS: Notes from the first day, 6/23/10




Introduction
Bill Elder

Tim Thomsen - trauma surgeon,
private practice 24 yers, UIHC 6 years
Kent Choi - trauma surgeon

- story of man who practiced the atls
monthly was had the algorithms and
management down pact!!
- the key point in that story is to
practice

A,B,C,D,E
Initial asessment
Injury -- primary survey --
resuscitation -- reevaluation -- detailed
secondary survey -- reevaluation --
optimize patient status -- transfer


Initial assessment and mangement
- Choi - trauma; trauma and critical
care UIHC - 10 yers
- 4 y/o MAVA, unresponseive, C-collar,
backboard, + bag-mask.
Objective: Primary and secondary
surveys, management resuscitation,
history, biomechanics of injury,
anticipate pitfalls
- use personal proective gear
- airway - ask a question

- Aproach every patient the same way --
in a systematic way
- Trauma in the elderly, pediatric
trauma (bigger head, airway is
anterior), trauma in pregnancy
- C-spine - inline stabilization -- don't
let them move it
- Pitfalls
- think about early intubation b/c
airway can get swollen and shut and
you can't intubate
- eg. motorcycle rider caught in a
laundry wire by the neck
- burn in a house
- think about equipment not working
- check your equipment

Breathing
- RR, chest movement, air entry,
oxygen saturation
- Pitfall: Iatrogenic pneumothorax --
20cm at the teeth is normal



Circulation
- other: base deficit, lactate - low
perfusion
- assess organ perfusion
- level of consciousness
- skin color and temperature
- pulse rate and character
- pulse rate and character
- control bleeding
- restore volume --> how do find goo
dmedicine
- reassess patient
- Pitfalls - elderly - atherosclerosis, keep
on bleeding; children -- bleed, but don't
drop BP; they bleed, squeeze their
vessels more

Disability
- GCS
- pupils
- observe for neurologic deterioration

Exposure/Enfironment
- avoid hypothermia
- eg. electric injury through heart? get
EKG, etc
- eg. electric injury through extremity?
worry about compartment syndrome


Resuscitation
- protect and secure airway
- ventilate and oxygenate -- etCO2,
ABG
- stop the bleeding
- vigorous shock treatment
- protect from hypothermia

Adjuncts to primary survey
- ivtal signs, EKG, ABGs, urinary
output, urinary catheters, gastric
catheter, pulse oximeter, etCO2, CXR,
pelvic x-ray, FAST, DPL

Do not delay transfer for diagnostic
tests
- use time before transfer for
resuscitation


SECONDARY SURVEY
- Start after primary survey
- restart with ABCDEs are reassessed
- Make sure vital functions are
returning to normal

Parts
- history
- PE
- Neuro
- Diagnostic tests
- Reassess

History
A
M
P
L
E

Head
- unconscious? brain vs intoxicated?
- always check every orifice, and/or
look inside
- seat belt sign: cardiac contusion,
mesenteric bowel injury,
- retroperitoneal injury they can bleed
but nt show signs
- rectum: gross blood, pelvic fracture
going into rectum, rectal tone
- pelvis
- Extremities - x-ray involved area joint
above and joint below
- places where you can have blood loss
but wont 'be able to see
- chest, abd, thigh, retroperitoneal,
scalp laceration, (very vascular, can
lose "3L of blood"

Brain injjry
- early neurosurgical consult

Spine
- feel whole spine, any step off
- steroid for spinal cord injury; if > 8hr,
no steroid; based on physician
preference

How do you minimize missed injuries?
- reassess pt over and over again


Pain management

Transfer
- make sure you have secure airway,
adequate IVs
- take care of also what might happen
on transport
- if hemorrhaging, abdominal
distension, operate at facilty, then send
them


Video
- get info from EMS
- assign roles
- ABCDE
- x-rays chest, pelvis
- secondary survey, ABCDE

NOTES
- Be respectful to EMTs
- get mechanism from EMTs
- don't be prideful
- what is your leadership life
- pay attention to the vital sign
- you may be asked to do
cricothyrodotomy
- answer back is very important
- reviewing what they've already done
- ask the team, have we missed
something?
- when you get tertiary center, have an
idea of why you're calling
- it's important to call out your findings
- go through things mentally, in a
systematic way. say it out loud.
- when things happen, everybody
should know about their roles



AIRWAY AND VENTILATORY
MANAGEMENT
- Miller - director of ED center

Airway
- ask them if they are short of breath
- If they can answer, airway OK
- burn/inhalation injury, look ok, then
decompensates 5 minutes later
- airway compromise
- if intubating, chin lift, jaw thrust
- nasoairway -- helps if you're having
problems bagging them
- possible difficult airway; mouth
opening, anatomy (beard, short, thick
neck, receding jaw, protruding upper
teeth
- Oral intubation
- cricoid pressure, suction, c-spine
- Plan for failure
- gum elastic bougie
- LMA/LTA
- Needle cricothyroidotomy
- surgical airway

Airway management
- preoxygenate
- cricoid pressure - just enough to push
cartilage, light pressure
- sedate (medazolam); try to get a look,
see if you can ge tan airway, then
paralytic (succinylcholine); speaker
uses etomodate b/c less CV effects,
EtCO2 monitoring; turns yellow

- Nebulized lidocaine works great -- you
don't have to already paralyze before
intubation
- aim 2 cm below the cord b/c if the
patient is not paralyzed, the cords move
if you barely touch it, then it goes up!
- left hand blad; right hand with thier
head; move the tongue; sweep the
tongue.
- Patients always have complications
when they head off the CT. Plan ahead
for complications





SHOCK
Shock
- What is shock? How to recognize
shock
- shallow rapid breathing
- cold, diaphoretic
- anxiety
- get the history, AMPLE
- hypovolemic
- cardiogenic -- EKG, etc. arrhythmia,
pump failure
- Neurogenic - below T4, above T4 -
hypotension
- Other: adrenal insufficiency, DKA

Determining the cause of bleeding
- FAST, DPL, physical exam
- x-ray

Treatment
- direct pressure/tourniquet
- pelvic binders
- angioembolization -- by IR guys who
can do that
- reduce and spling fractures -- "all
fractures bleed"

Management
- monitor response
- prevent hypothermia

Rapid responders
Transient responders
- make sure you're prepared for them
to get worse
Non-responders


Class I hemorrhage
Class II - can be obnoxious, fluids,
?blood
Class III
Class IV - have lots of blood ready!


Pitfalls
- athletes: bradycardia, hypotension --
their baseline. so they can look like non-
responders
- pregnancy: so don't put them on their
back
- Medications: B-blockers, Ca channel
blockers
- Pacemaker:
- Hypothermia:
- Early coagulopathy:
- blood pressure does not equate to
cardiac output
- misleading Hct/Hgb


THORACIC TRAUMA

Birsche - ED
- Most life threatening injuries are
identified during the primary survey.
- Injuries: tracheal injury, etc
- Airway obstruction
- signs: stridor, accessory muscle use on
inspiration, hoarsness, subcutaneous
emphysema from laryngeal tracheal
tear
- Tension pneumothorax
- don't wait for the neck vein to
distend!
- don't wait 'till cyanosis!

- Open pneumothorax
- Flail chest
- will need to intubate
- intubate
- if you have flail chest, likely will get
pulmonary contusion
- give analgesia so they can take full
breath
- but not so much analgesia that they
are unable to take full breaths
- - you have to be judicious with fluids
- pulmonary contusions get worse the
first 4 hours or so
- you might see them grunting + nasal
flaring -- suggests pulmoanry contusion

Massive hemothorax
- >100mL blood loss
- flat vs distended neck veins
- to OR
- sometimes will need to put in 2 chest
tubes
- get blood ready
- If put in chest tube, can get
destabilized b/c the might had been
tamponaded off, and now you've
disrupted that tamponade.

Cardiac tamponade
- low BP
- distended neck veins
- FAST exam

Resuscitative thoracotomy
- penetrating trauma, pulse in field, lose
it in ED
- blung trauma, loses pulse in ED
- do not do a blunt trauma with PEA.

Other
- blung esophageal rupture - endoscopy
- contrast swallow
- traumatic diaphragmatic injury
- traumatic aortic disruption
- blunt cardiac injury - cardiac
contusion, ectopy, PVCs, etc. abnl EKG
- tracheobronchial tree injury - CXR
doesn't chang eafter chest tube
- pulmonary consuion, intubate sooner
rather than later
- traumatic asphyxia (petechia,
swelling, cerebral edema)
- subcutaneous emphysema

Fractures
- ribs
- old people: if rib fracture, incrased
mortality with each increasing rib
fracture
- kids - worry about associated injuries


RANDOM
- If patient has cerebral edema, don't
use succinylcholine.


ABDOMINAL INJURY
- MVA, seat belt sign
- Blunt trauma
- ? mechanism to determine suspected
abdominal injury
- spleen, liver, small bowel
- put in NG tube to decompress
stomach
- urinary catheter
- Blunt Trauma
- indication for laparotomy in blunt
trauma
- physiology of pelvic binders
- pelvic fractures - wrap/binder

6.23.10 atls lecture

Term
ATLS: Notes from the second day:
Head Trauma 6.24.10
Definition
ATLS: Notes from the second day:
Head Trauma 6.24.10

HEAD TRAUMA
- scan them
- 58 y/o, fall, GCS 12, after admission,
deteriorates to 6
- ddx. head bleed, vs hemorrhage
somewhere
- i.e. could have both or none, or even
be intoxicated
- primary survey: "make sure that
when he comes in, you have a plan."
ATLS helps you manage the stress
- recognize injury, minimize secondary
injuries
- you need to have a plan. It could be
wrong, but you need to have a plan and
go with you. You can't teach someone
to have a plan. But you can correct an
incorrect plan.
- The head. It's a box. Keep it very
simple, and you can't get confused.
- Dural sinus filled with blood, so will
bleed a lot. It's just under the skull.
- Skull is very vascular. You can bleed
to death from a scalp injury.
- Cerebral blood flow -- can't measure
it directly; need to maximize it; what
you can tell is is it adequate vs
inadequate cerebral blood flow. based
on exam and vital signs. If MAP drops
to 40's to 50's, decreased perfusion,
decreased mental status
- With brain injury, autoregulatory
stuff is mesed up. so now it depends on
the systolic BP. -- you can control that.
- Mass effect
- Monroe-Kellie Doctrine
- head is a box;
- it has the brain, spinal fluid, and
blood
- any increase in any one of those will
mess things up
- first thing is to get rid of CSF (shunt
CSF); brain will compensate, and all of
a sudden it won't (like kids and their
BP)
- the braind then gets rid of venous
blood -- shunts venous blood out
- then arterial blood goes out -->
leading to infarction
- aftre that, the pressure goes up
exponentially, and once it does this, you
herniate

Intracranial pressure
- keep it below 20
- can MAP - ICP = CPP (check
equation)
- Keep BP around 100 for patients

- Hypotension is the biggest issue

- Cushing's response --> is to increase
ICP, CPP
- purpose is to keep CPP up. But if that
fails, you get decreased HR, and high
BP

- Keep their BP up
- Hypotension is the worst thing that
can happen for the head

Classification of head injuries
- cranial vault
- depressed/nondepressed
- open/closed
- open, bad. need to take to OR.

- Basilar
- with/without CSF leak
- if you can tell they have CSF, you
are the best doctor. It is hard to see
- with/without cranial nerve deficits
(double check)


Brain injuries
- Focal(ish)
- epidural
- subdural
- intraparenchymal

Diffuse(ish)
- concussion
- multiple contusions
- hypoxic/ischemic injury

Need to assess
- cervial spine fracture, carotid injury,
vertebral injury --> ischemia
- think abou the neck too for these
(above)


EPIDURAL HEMATOMA
- hit head
- look at side of the head
- the vessel is injured where it is
secured -- commonly, generally (think
aortic tear, meningeal artery, etc)
- can be rapidly fatal
- take to OR
- blood has iron, it's bright on CT
- dense stuff is bright. air is dark.
- epidural may have normal exam. see
CT with epidural

HERNIATION
- herniation is a clinical syndrome. If
you see a film, doesn't matter as much.
all about clinical syndrome.

SUBDURAL HEMATOMA
- if small, bone whiteness will hide it
- they don't die from the hematoma per
say
- they have underlying brain injury
(unlike the epidural hematoma)
because you have blood INSIDE the
brain
- if patient doing OK clinically, might
sit on it
- keywords: hyperdnesity, midline shift
- treatment: hemicraniectomy
- get a good neuro exam before you
intubate them


INTRACEREBRAL
HEMATOMA/CONTUSION
- these are proressive injury -- it evolves
over time
- pt can deteriorate quickly
- usually temporal pole and frontal area
- probably want to intubate before
sendimg them off

DIFFUSE BRAIN INJURY
- might not see the ventricals
- "things look tight"

GCS
- if giving GCS, can give the
components when presenting your
patient (patient had eye opening, etc)
- tell them what the patient is doing (not
the words decorticate, or decerebrate)
- need to memorize it

GCS 13-15
- neuro exam most important
- most people get head CT
- if head CT normal, no alcoholol/drug,
maybe send home

GCS 9-12
- CT scan all
- neuro exam
- watch them. could deteriorate

GCS 3-8
- neuro
- reevaluate

INDICATIONS FOR CT SCAN
- GCS <15 2 hours after injury
- p.142

MANAGEMENT
- ABCDE
- get GCS score
- pupils
- lateralization signs
- controlled ventilation
- goal: PaCO2 at 35mHg
- etCO2
- IV - euvolemia, NS or LR
- consult neuro
- mannitol
- use with signs of tentorial herniation
- can cause profound hypotension
- be careful before using this

Meds
- anticonvulsants, sedation, paralytics
(note that you do not use paralytics to
treat seizures!) duh
- use short acting paralytics
- sedation with propofol

Scalp wounds
- can staple it closed
- direct pressure
- can be badness in kids

Hyperventilation/mannitol -> don't
have to worry so much at university
hospital. can get to the OR quickly.


SKILLS STATION - HEAD TRAUMA

- for patient with increased ICP,
hematoma, when you intubate, put
them down hard, with intubation drugs.
200 succ (not 100), and 40 etomadate
(not 20)
- etomidate is a sedative
- if you don't hit them hard, they might
get increased ICP from the intubation
- call neurosurgery early so they can
come do a neuro exam before you
intubate
- call neurosurg early
- talk your plan to the team
- call out your findings
- primary just GCS mostly for
disability and crazyness
- intubate the bubbles -- facial injury,
airway obstruction
- make sure you resuscitation
- all the evals happen simultaneously
- quick primary survey, fix it,
secondary survey
- surgery intern in code, your job is to
do the lines

6.24.10 ATLS course, and head trauma
skills station too




Term
ATLS: Notes from the second day:
Spine Injury 6.24.10
Definition
ATLS: Notes from the second day:
Spine Injury 6.24.10


SPINE INJURY
- 38 y/o male, GCS 15
- suspect spine injury always
- mechanism of injury
- unconscious patient
- neuro deficit
- for pediatrics, pad them properly
cause kids have big heads
- p.169-170
- x-rays
- crosstable lateral films exclude 85% of
fractures
- If you add AP and odontoid views,
excludes most fracures
- 10% of patients with c-spine fracture
have a fracture somewhere else
- so look for other places of fracture
- get them off the board. pressure sores
can occur, esp in old, young
- how would you state the injury

Neurogenic shock
- high spine injury
- can develop airway problems too
- cervical or high thoracic
- give fluids first
- might need to give atropine b/c of
bradycardia
- some might need pacemaker b/c some
go asystolic (presenter story)

Spinal shock
- no hemodynamic issues

Consequences
- inadequate ventilation
- abdominal evaluation can be
compromised (no abd pain)
- occult compartment syndrome (see it
in M&M a lot)

Management
- keep BP>50
- maintain perfusion of spinal cord
(keep MAP>85 or normotensive); if
they are normally hypertensive, need to
keep their BP higher
- manage hypotension
- transfer for unstable fracture, any
neuro deficit (if outside hospital)
- preparation for transfer
- no studies have shown benefits of
steroids
- if you do use them, loading dose, run
for 24-48 hours
- some people do it, others don't
"when you are a resident, you just do
what you are told. but it doesn't mean
you can't ask questions or ask for a
valid reason for what you are doing."
- usually spinal shock occurs pretty
quickly, neurogenic shock occurs over
time, sometimes spinal shock occurs
before neurogenic shock
- remember, document your neuro
exam! b/c you have no idea what it was
before, and it's hard to note a change

atls lecture 6.24.10

Term
ATLS: Notes from the second day:
Musculoskeletal trauma 6.24.10
Definition
ATLS: Notes from the second day:
Musculoskeletal trauma 6.24.10



Musculoskeletal trauma
- splinting
- prevents further blood loss
- restore and maintain perfusion
- relieves pain
- stabilization
- rational for splinting
- secondary survey
- mechanism of injury
- time of injury - clean open fractures
within 6 hours
- concerns
- look for vascular compromise
- open fracture
- assess and manage vascular
compromize
- managing open fractures
- x-ray studies: a joint above and below
- Injuries causing compartment
syndrome
- crus injuries
- tibia, forearm
- vscular injury (bony injury likely
involved)
- cast, tight dressing
- burns

Symptoms of compartment syndrome
- pain on passive stretch
- etc
- p.196

Pitfalls

- MSK exam
- have them move their extremities
(instead of you doing it)
- put hand on iliac creast and push in
(not out; could make open pelvic
fracture worse!)
- pulses
- logroll, spine, step offfs
- medial part of leg is L3
- lateral part of arm is C5, and then you
go from thumb and around, so C6
thumb, C7 middle finger, C8 pinky, T1
left side of arm

- traction splint
- get to right length
- straps, adjust straps using good leg
- use it
- put ankle stirrup
- 2 straps above, 2 straps below knee
- while doing this, someone is pulling
traction
- you want to reduce the fracture
- when you release it, keep traction
while you pull the pin
- pain control
- pulse, sensation before and after

Vacuum splint
- used in the field
- does not reduce, just immobilizes
- pretty cool

Compartment syndrome
- can miss this
- often seen in m&M
- if you have lactate trending up, think
about this
- sedate patient before you do a
fasciotomy!!!

Vertical shear pelvic fracture

Open book fracture

Volume is like a cone; volume is
proportional to radius squared

Want to binder to be centered over the
femoral trochanters (NOT the iliac
crest!); while also at the same time you
should internally rotate the legs

Pelvic fracture
- legs, limb discrepancy
- look at the ring, follow the ring
- look at the SI (sacroiliac joints) for
widening
- look at acetabulum for acetabular
fracture
- look at pubic symphysis for open book
fracture (widened pubic symphaysis)
- look at rami for fracture
- look to see if there is symmetry
between structures on both sides
- cystourethrogram if blood in the
urethral meatus


MSK lecture, and MSK skills station/X-
ray station
ATLS lecture, 6.24.10

Term
ATLS: Notes from the second day:
Looking at spine x-rays 6.24.10
Definition
ATLS: Notes from the second day:
Looking at spine x-rays 6.24.10

C-spine
- adequate, see 7 cervical vertibrae
- look at alignment (A and C are most
important ones)
- look at bone for fracture or
dislocations
- cartilage
- dens
- extra axial soft tissue
- facets (usually if you hve a facet
problem, can't see it on x-ray)
- case: if the film is not adequate, get a
CT! can't rely on x-ray if not adequate

- odontoid view
- normal odontoid view
- c2 fracture
- hangmans fracture
- c4 fracture
- thoracolumbar fracture
- burst fraction
- in lower spine, do MRI most of the
time
- chance fracture

atls lecture, 6.23.10

Term
ATLS: Notes from the second day:
Thermal Injuries 6.24.10
Definition
ATLS: Notes from the second day:
Thermal Injuries 6.24.10


Thermal Injuries

Iowa
- burn injuries, house fires, industrial
fires
- more commonly see cold injuries

Burn patient
- intubate before you have to
- if you wait --> increased swelling --
intubation more difficult
- breathing -- difficult in chest wall
expansion
- house fire -- can get arsenic poisoning
('cause arsenic is in a lot of stuff!) so
keep that in mind, watch for symptoms

Inhalation injury p.212
- change in voice
- singeing

- biggest issues after burn is fluid loss
- best thing to use is urinary output
- palm of the hand is about 1%
- card that you hand when you scrub in
is about 1%
- 3rd degree doesn't hurt
- how much fluid to give? A lot!
- Parland formula: 50% first 8 hours,
50% last 16 hours. The time starts at
time of injury. So if pt arrives 2 hours
later, give first 50% in 6 hours.

Chemical burns
- wash them off

Electrical burns
- risk of myoglobinuria

You have to get your patients naked!

Criteria for transfer to a burn center
p.218-219

>10% BSA in <10 and >50 y/o
- etc
- p.219

Before you transfer, you must call the
transfer center!!

Frostnip
- no ice crystal formation
- get patient naked
- passive warming
- fluids, pain meds, tetanus, etc
- <35, call it hypothermia
- look hypothermic if palor, greay,
cyanotic,confused, shivering if early,
variable vital signs

Treatment
- warmed environment, blankets, and
IV fluids
- surgical rewarming techniques,
lavage, etc
- take care of ABCs


atls lecture, 6.23.10

Term
ATLS: Notes from the second day:
Pediatric trauma 6.24.10
Definition
ATLS: Notes from the second day:
Pediatric trauma 6.24.10


Pediatric trauma
- most common cause of death in kids is
injury
- when kids do badly, it's because of
respiratory problem most of the time
- kids have a big head -- so put padding
under the shoulder blades when they
are on the board (body on backboard,
head off of it)
- <4y/o, trachea is a cone, reaches a
point at the cricoid membrane; more
likely to get airway obstruction
- c-spine injury are often at C1,C2 at
the hinge where head meets neck
- SCIWORA - refers to plain films
- chest - prone to pulmonary
contusions, any chest trauma is going to
be significant
- abdomen: spleen and liver tend to be
below the costal margin; so you will see
lots of splenic and liver lacs
- a normal BP in kids is not reassuring
- when they do drop the BP, they are
near the end
- urine oiutput: 0-2 years, 1.5-
2mL/kg/hr
- kids lose heat fast. prevent
hypothermia.
- kids - larger tongue; high anterior
larynx; larger occiput, etc.
- Breslow tape, very important (said the
ED guy!!) only caries this and 2 other
things to work!
- kids do well when restrained in a seat
belt whereas adults can get jacked up
- Types of injuries, "superman
injuries" which is funny actually (not!)

A - obstructs easily;
- uncuffed ET tube; only need to put
the ET tube in like 1cm in or so; usually
no cuff before 6 y/o; not a fast rule
though

B - tension pneumothorax; avoid
barotrauma
C - vascular access; fluids and blood.
watch the HR, not the blood pressure
D - pediatric GCS score -- diffuse
swelling
E - gastric dilation; avoid heat loss

Intraosseus IV
- ideal spot is anterior tibia, but you can
put it in other places


Child abuse
- delay in care
- injury doesn't match with story
- story changes
- etc


atls lecture, 6.24.10