Chapter Review Questions for the
ATLS Student Course Manual
Dr. Ken Evans, MD
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Chapter 1
nitial Assess!ent Assess!ent and Mana"e!ent
A #ast$#utter should %e used to re!ove a trau!a vi#ti!&s hel!et if there is eviden#e of a C$spine in'ur( or if ))))). the patient experiences pain or paresthesias during an initial attempt to remove the helmet. The *A* in A+CDE stands for ))))))). Airway; however, always be cautious about and protect the cervical spine. spine. An( patient who is #ool and ta#h(#ardi# is #onsidered to %e )))) until proven otherwise. in shock The definition of ta#h(#ardia depends on the patient&s a"e. hat heart rate is #onsidered ta#h(#ardi# for infants, toddlers-pres#hoolers, s#hool a"e-pre%us#ent, and adults Infants > 1!, toddlers"preschoolers > 1#!, school age"prepubescent > 1$!, and adults > 1!! Co!pensator( !e#hanis!s !a( pre#lude a !easura%le fall in s(stoli# %lood pressure until up to ))))/ of the patient&s %lood volu!e is lost. %!& hat is the trau!a triad of death 'he trauma triad of death is the combination co mbination of hypothermia, coagulopathy, and acidosis. (evere hemorrhage in trauma diminishes diminishes oxygen delivery, delivery, and may lead to hypothermia. )ypothermia, in turn, turn, can halt the the coagulation cascade, which exacerbates the hemorrhage. (ince tissues are hypoperfused, anaerobic metabolism increases, causing the release of lactic acid and other acidic compounds. (uch an increase in acidity can reduce myocardial myoca rdial performance, further exacerbating tissue hypoperfusion. And so, the viscious cycle continues, ultimately ending in death ... unless someone trained in A'*( A'*( intervenes. A patient !a( %e a%usive and %elli"erent %e#ause of ))))), so don&t 'ust assu!e it&s due to dru"s, al#ohol, or that he is a 'er0. hypoxia
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Chapter 1
nitial Assess!ent Assess!ent and Mana"e!ent
A #ast$#utter should %e used to re!ove a trau!a vi#ti!&s hel!et if there is eviden#e of a C$spine in'ur( or if ))))). the patient experiences pain or paresthesias during an initial attempt to remove the helmet. The *A* in A+CDE stands for ))))))). Airway; however, always be cautious about and protect the cervical spine. spine. An( patient who is #ool and ta#h(#ardi# is #onsidered to %e )))) until proven otherwise. in shock The definition of ta#h(#ardia depends on the patient&s a"e. hat heart rate is #onsidered ta#h(#ardi# for infants, toddlers-pres#hoolers, s#hool a"e-pre%us#ent, and adults Infants > 1!, toddlers"preschoolers > 1#!, school age"prepubescent > 1$!, and adults > 1!! Co!pensator( !e#hanis!s !a( pre#lude a !easura%le fall in s(stoli# %lood pressure until up to ))))/ of the patient&s %lood volu!e is lost. %!& hat is the trau!a triad of death 'he trauma triad of death is the combination co mbination of hypothermia, coagulopathy, and acidosis. (evere hemorrhage in trauma diminishes diminishes oxygen delivery, delivery, and may lead to hypothermia. )ypothermia, in turn, turn, can halt the the coagulation cascade, which exacerbates the hemorrhage. (ince tissues are hypoperfused, anaerobic metabolism increases, causing the release of lactic acid and other acidic compounds. (uch an increase in acidity can reduce myocardial myoca rdial performance, further exacerbating tissue hypoperfusion. And so, the viscious cycle continues, ultimately ending in death ... unless someone trained in A'*( A'*( intervenes. A patient !a( %e a%usive and %elli"erent %e#ause of ))))), so don&t 'ust assu!e it&s due to dru"s, al#ohol, or that he is a 'er0. hypoxia
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Des#ri%e the las"ow Co!a S#ale 2CS3.
A patient opens her e(es onl( to painful sti!uli, utters inappropriate words, and lo#ali4es pain. hat is her CS s#ore +$ -% / 'herefore, 0( $2%2/ 1! 5atients with a SC of less than )))) usuall( re6uire intu%ation. 3 $
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hat infor!ation is in an 7AM5LE8 patient histor( A Allergies edications 4 4)"4regnancy * *ast meal + +vents"+nvironment of in5ury hen is this done 6uring the secondary survey. 9ou should assu!e that an( patient with !ultis(ste! trau!a and altered level of #ons#iousness, or %lunt in'ur( a%ove the #lavi#le, has what t(pe of in'ur( ervical spine in5ury. :ow #an (ou #lear the C$spine without i!a"in" 'he 7spine can be cleared clinically if the patient8 is awake, alert, and sober; has no distracting in5uries; has no neurological deficits referable to the cervical spine; has no midline neck pain or tenderness on palpation; and can flex, extend, and laterally rotate his head to both sides without pain. ;therwise, when would C$spine fil!s %e o%tained 6uring the secondary survey. hen should !ost i!a"es %e o%tained 6uring the secondary survey. 'here are a small number of exceptions 9see next :uestion. hat i!a"in" is done durin" the pri!ar( surve( <= and pelvis films 9both A4 views, and A(' scan. hat should (ou do for ever( fe!ale patient of #hild%earin" a"e 4regnancy test.
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hat possi%le in'uries would (ou suspe#t with a frontal i!pa#t auto!o%ile #ollision )ead trauma, cervical spine fracture, anterior flail chest, myocardial contusion, pulmonary contusion, pneumothorax, hemothorax, traumatic aortic disruption, fractured spleen and liver, posterior fracture"dislocation of hip and knee. Si4e of needle for needle #ri#oth(roidoto!( 1$ gauge Si4e of needle for needle thora#entesis 1# gauge Si4e of needle for peripheral < 1 gauge Si4e of needle for peri#ardio#entesis 1? gauge 9spinal needle
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Chapter =
Airwa( and
hat two pla#es would (ou loo0 at on a patient if (ou suspe#ted h(po>e!ia *ips and fingernail beds Can a patient %reathe on his own after #o!plete #ervi#al #ord transe#tion @es, if the phrenic nerves 9%7/ are spared 9% , #, / keep the diaphragm aliveB . 'his will result in CabdominalC breathing. 'he intercostal muscles will be paralyDed though. The proper si4e ET tu%e for an infant is )))). 'he same siDe as the infantEs nostril or littlefinger. 9usually siDe % for neonates; %./ for infants :ow do (ou #al#ulate what si4e ET tu%e to use for #hildren Internal diameter 9age " # 2 # mm hat si4e #uffed endotra#heal tu%e do (ou use for an e!er"en#( #ri#oth(roidoto!( / or . 5atients with tension pneu!othora> and patients with #ardia# ta!ponade !a( present with !an( of the sa!e si"ns. hat findin"s will (ou see with a tension pneu!othora> that (ou will not see with ta!ponade Absent breath sounds and hyperresonance to percussion over the affected hemithorax; and tracheal deviation away from the affected hemithorax. !!ediate thora#i# de#o!pression is warranted for an(one with a%sent %reath sounds, h(perresonan#e to per#ussion, tra#heal deviation, )))), and )))). acute respiratory distress and subcutaneous emphysema
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Chapter ?
Sho#0
The !ost effe#tive !ethod of restorin" ade6uate #ardia# output and end$or"an perfusion is to restore venous return to nor!al %( lo#atin" and stoppin" the sour#e of ))))), alon" with appropriate )))) repletion. bleeding; volume An( in'ured patient who is #ool and has ta#h(#ardia is #onsidered to %e )))) )))) until proven otherwise. in shock :(potension is #aused %( ))))) until proven otherwise. hypovolemia Ta#h(#ardia is dia"nosed when the heart rate is "reater than )))) %eats per !inute 2+5M3 in infants, )))) +5M in pres#hool #hildren, )))) +5M in #hildren fro! s#hool$a"e to pu%ert(, and )))) +5M in adults. 1! F4 in an infant, 1#! F4 in a preschool7aged child, 1$! F4 in children from school age to puberty, and 1!! F4 in adults. Elderl( patients !a( not e>hi%it ta#h(#ardia in response to h(povole!ia %e#ause of li!ited #ardia# response to #ate#hola!ines. h( else 'hey may be on beta7blockers, or have a pacemaker. hen (ou don&t have a %lood pressure, what are three thin"s to loo0 for when evaluatin" perfusion. 1. *evel of consciousness 9brain perfusion $. (kin color 9ashen face and grey extremities %. 4ulses 9bilateral femoral G thready and rapid hi#h ar! should (ou not pla#e a pulse o>i!eter 'he arm with a blood pressure cuff attached. Elderl( patients have a li!ited a%ilit( to )))) to #o!pensate for %lood loss. increase heart rate
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@rinar( #atheters are "ood for assessin" renal perfusion and volu!e status. List si"ns of urethral in'ur( that !i"ht prevent (ou fro! insertin" one. Flood at urethral meatus, perineal ecchymosis, blood in scrotum, high7riding"non7palpable prostate, and pelvic fracture The !ost #o!!on #ause of sho#0 in the in'ured trau!a patient is )))). hemorrhage +ase defi#it and-or )))) levels #an %e useful in deter!inin" the presen#e and severit( of sho#0. lactate Massive %lood loss !a( produ#e )))) a#ute de#rease in the he!ato#rit or he!o"lo%in #on#entration. only a minimal h( !i"ht (ou want a +air :u""er for a patient who s!ells of al#ohol Alcohol ingestion causes vasodilation, which can lead to hypothermia.
a! 2DRE3 in a trau!a patient Flood, tears, high7riding prostate 9in males, and sphincter tone. Adult patients should !aintain urine output of at least ))) Adults !./ m*"kg"hr 9children 1.! ml"kg"hr. H
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:ow does sho#0 redu#e the total volu!e of #ir#ulatin" %lood Anaerobic metabolism 77> insufficient A'4 77> endoplasmic reticulum damage, then mitochondrial damage 77> lysosomal rupture 77> sodium and A'+= enter cells 9which swell and die 77> decreased intravascular volume hi#h vasopressors should (ou use to treat he!orrha"i# sho#0 'rick :uestion. Jever use vasopressors for hypovolemicshock 7 use volume replacement. 4ressors will worsen tissue perfusion in hemorrhagic shock. Appro>i!atel( ))))/ of total %lood volu!e is in the veins. H!& hat ph(si#al si"ns su""est peri#ardial ta!ponade FeckEs 'riad8 K-6, muffled heart sounds, and h ypotension 9resistant to fluid therapy. Also likely is tachycardia. Can isolated intra#ranial in'uries #ause neuro"eni# sho#0 Jo. :ow do (ou #al#ulate total %lood volu!e in an adult H! m* per kg ideal weight. +.g. a H! kg person has about / liters of circulating blood 9H! x H! #,3!! m*. :ow do (ou #al#ulate total %lood volu!e in a #hild ?!73! m* per kg ideal weight. The %lood volu!e of an o%ese person is #al#ulated %ased on their )))) wei"ht. ideal luid repla#e!ent should %e "uided %( )))), not si!pl( %( the initial #lassifi#ation of he!orrha"e 2#lasses $<3. the patientEs response to initial fluid therapy :ow !u#h %lood volu!e is lost with #lass he!orrha"e Lp to 1/&. 6onating 1 pint, or M/!! m*, of blood is about a 1!& volume loss and would :ualify as class I hemorrhage.
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:ow do (ou treat a #lass he!orrha"e @ou donEt 9usually. 'ranscapillary refill and other compensatory mechanisms usually restore blood volume within $# hours. :ow !u#h %lood volu!e is lost with #lass he!orrha"e 1/7%!& 9H/!71/!! m* in a H! kg adult. :ow do (ou treat a #lass he!orrha"e Lsually only with crystalloids. Su%tle CS #han"es su#h as an>iet(, fri"ht, and hostilit( would %e e>pe#ted in a patient with a #lass )))) he!orrha"e. II :ow !u#h %lood volu!e is lost with #lass he!orrha"e %!7#!& 9$!!! m* in a H! kg adult. A #lass )))) he!orrha"e represents the s!allest volu!e of %lood loss that is #onsistentl( asso#iated with a drop in s(stoli# %lood pressure. III A patient with inade6uate perfusion, !ar0ed ta#h(#ardia and ta#h(pnea, si"nifi#ant !ental status #han"e, and a !easura%le fall in s(stoli# %lood pressure li0el( has a #lass )))) he!orrha"e. III or I-. 'hese patients almost always re:uire a blood transfusion, which depends on their response to initial fluid resuscitation. 'he first priority is stopping the hemorrhage. :ow !u#h %lood volu!e is lost with #lass < he!orrha"e ore than #!&. Lnless very aggressive measures are taken, the patient will die within minutes. Loss of !ore than ))))/ of %lood volu!e results in loss of #ons#iousness. /!& @p to )))) !L of %lood loss is #o!!onl( asso#iated with fe!ur fra#tures. 1/!! m* 3
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@ne>plained h(potension or #ardia# d(srh(th!ias 2usuall( %rad(#ardia fro! e>#essive va"al sti!ulation3 are often #aused %( )))), espe#iall( in #hildren. gastric distention :ow !u#h #r(stalloid should (ou "ive an adult as an initial fluid resus#itation %olus $ liters :ow !u#h #r(stalloid should (ou "ive a #hild as an initial fluid resus#itation %olus $! m*"kg 9may repeat and give as much as ! m*"kg. Fut, since children have a high reserve, they should get blood sooner rather than later. Ea#h !L of %lood loss should %e repla#ed with )))) !L of #r(stalloid, thus allowin" for repla#e!ent of plas!a volu!e lost to interstitial and intra#ellular spa#es. % m* *+lood on the floor and four !ore* is a !e!or( aid for sear#hin" for o##ult %lood loss where hest; abdomen and pelvis; retroperitoneum; and thigh. or #hildren under 1 (ear of a"e, urinar( output should %e )))) !L-0"-hr. $ ould patients in earl( h(povole!i# sho#0 %e a#idodi# or al0aloti# Alkalotic 7 respiratory alkalosis from tachypnea. 'hen metabolic acidosis from hypoxia ensues. *Rapid responders,* i.e. those whose vital si"ns return to nor!al 2and sta( there3 after fluid resus#itation li0el( have had a #lass )))) he!orrha"e. I or II *Transient responders* are asso#iated with #lass )))) he!orrha"e. II or III
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hat is the differential dia"nosis for *non$responders* followin" fluid resus#itation Jon7hemorrhagic causes, e.g. tension pneumothorax, pericardial tamponade, cardiac contusion, I, acute gastric distention, neurogenic shock, etc. Most patients re#eivin" %lood transfusions need #al#iu! repla#e!ent. True or false alse. :ow lon" #an an intraosseous 2;3 line %e 0ept in Intraosseous infusions should be limited to emergency resuscitation and shoud be discontinued as soon as other venous access is obtained. :ow should (ou position the patient when insertin" a su%#lavian or internal 'u"ular line (upine, trendelenburg 9head down at 1/ degrees to distend the veins and prevent air embolism, and turn the head away from you 9and only if the 7spine has been cleared. here is an in#ision for a saphenous vein #utdown !ade and how lon" should the in#ision %e 'he saphenous vein can be accessed approximately 1 cm anterior and 1 cm superior to the medial malleolus. ake a $./ cm transverse incision through the skin, taking care not to in5ure the vein.
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Chapter F
Thora#i# Trau!a
A patient arrives in the trau!a %a( intu%ated and there are a%sent %reath sounds over the left he!ithora>. here should (ou pla#e (our de#o!pression needle 'rick :uestion. 'his may not be a pneumothorax. or relatively stable intubated patients always suspect a right main stem bronchus intubation before attempting needle decompression. here would (ou insert a lar"e #ali%er needle to de#o!press a tension pnue!othora> 'hrough the $nd intercostal space in the midclavicular line of the affected hemithorax. or an open pneu!othora> 2su#0in" #hest wound3, air passes preferentiall( throu"h the #hest wall defe#t 2least resistan#e3 if the dia!eter of the defe#t is at least )))) the dia!eter of the tra#hea. $"% lail #hest results fro! !ultiple ri% fra#tures. +( definition, this would %e )))) or !ore ri%s, fra#tured in )))) or !ore pla#es. $ or more ribs fractured in $ or more places lail #hest is invaria%l( a##o!panied %( )))) whi#h #an interfere with %lood o>("enation. 4ulmonary contusion 7 do not over7fluid resuscitate these patients. +oth tension pneu!othora> and !assive he!othora> are asso#iated with de#reased %reath sounds on aus#ultation. 9ou #an tell whi#h it is %( ))))))). 4ercussion 7 hyperresonant with pnuemothorax; dull with hemothorax. +( definition, how !u#h %lood is in the #hest #avit( to #all it a *!assive he!othora>* 1/!! m* or 1"% or more of the patientEs total blood volume. (ome also define it as continued blood loss of $!! m*"hr for $7# hours 7 but A'*( does not use this rate for any mandatory treatment decisions. f a patient doesn&t have G or peri#ardial ta!ponade is not present Jo, the patient may be hypovolemic.
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hat si4e #hest tu%e !i"ht (ou use to eva#uate a !assive he!othora> N%? rench 7 inserted at the #th or /th intercostalspace, 5ust anterior to the midaxillary line. hat is Kuss!aul&s si"n A rise in venous pressure with inspiration while breathing spontaneously. It is a true paradoxical venous pressure abnormality associated with cardiac tamponade . :ow well do C5R #o!pressions wor0 on so!eone with a penetratin" #hest in'ur( and h(povole!ia Closed heart massageC for cardiac arrest is ineffective in patients with hypovolemia. 4atients with 4+J+'=A'IJ0 thoracic in5uries who arrive pulseless but with myocardial electrial activity 94+A, may be candidates for a thoracotomy in the +6. Are all patients with 5EA who have sustained a thora#i# in'ur( #andidates for an ED thora#oto!( Jo 7 Only 4+A with 4+J+'=A'IJ0 thoracic in5uries are candidates for an +6 thoracotomy. An ED thora#oto!( #an allow (ou to do what +vacuate pericardial blood, cardiac massage, direcly control hemorrhage, cross7clamp the descending aorta to slow blood loss below the diaphragm and increase perfusion to the heart and brain. or a patient with a trau!ati# si!ple pneu!othora>, what should (ou do +E;RE (ou start positive pressure ventilation or ta0e the! for sur"er( Insert a chest tube 7 positive pressure ventilation can turn a simple pneumothorax into a tension pneumothorax, so insert a chest tube first. Should (ou eva#uate a si!ple he!othora> if it is not #ausin" an( respirator( pro%le!s @es 7 A simple hemothorax, if not evacuated, may result in a retained clotted hemothorax with lung entrapment; or, if infected, develop into an empyema. A pneu!othora> asso#iated with a persistent lar"e air lea0 after tu%e thora#osto!( su""ests a ))))))) in'ur(. tracheobronchial 7 Lse bronchoscopy to confirm. @ou may need more than one chest tube before definitive operative management.
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hat radio"raphi# findin"s are su""estive of trau!ati# aorti# disruption idened mediastinum, obliteration of aortic knob, deviation of trachea to the right, depression of left mainstem bronchus, deviation of esophagus 9J0 tube to right, widened paratracheal stripe, fracture of 1st or $nd ribs, or scapula A de#eleration in'ur( vi#ti! with a left pnue!othora> or he!othora>, without ri% fra#tures, in pain or sho#0 out of proportion to the apparent in'ur(, and has parti#ulate !atter in the #hest tu%e, !a( have ))))))))). an esophageal rupture 7 a forceful blow causes expulsion of gastric contents into the esophagus, producing a linear tear in the lower esophagus allowing leakage into the mediastinum ra#tures for the lower ri%s 21$1=3 should in#rease suspi#ion for ))))) in'ur(. hepatosplenic h( are upper torso, fa#ial, and ar! plethora with pete#hiae asso#iated with #rush in'uries to the #hest 'emporary compression of the superior vena cava :ow does ATLS su""est (ou should review a #hest radio"raph 'rachea and bronchi, pleural spaces and parench yma, mediastinum, diaphragm, bones, soft tissues, tubes and lines. hat t(pes of penetratin" #hest wounds should alert the pra#titioner to the possi%le need for thora#oto!( 4enetrating anterior chest wounds medial to the nipple line, and posterior wounds medial to the scapula because of potential damage to the great vessels, hilar structures, and the heart, with the associated potential for cardiac tamponade. 9ou should for. :ow would (ou perfor! peri#ardio#entesis Obtain a inch, 1? gauge needle. 4uncture the skin 17$ cm inferior to the left xiphohondral 5unction at a #/ degree angle to the skin and aim towards the top of the left scapula. hat is a "ood wa( to 0now if (ou&ve advan#ed (our needle too far durin" peri#ardio#entesis and have entered ventri#ular !us#le +0 hanges 7 extreme ('7changes, widened P=(, 4-s, etc. ithdraw needle until +0 returns to baseline
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hat should (ou do with (our needle after (ou su##essfull( eva#uate %lood durin" peri#ardio#entesis If possible, use the (eldinger techni:ue to insert a 1# gauge flexible catheter. lose the stopcock and leave the catheter in place in case re7evacuation is needed. 'his is not a definitive treatment.
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Chapter
A%do!inal and 5elvi# Trau!a
Earl( #onsultation with a )))) is ne#essar( whenever a patient with possi%le intraa%do!inal in'uries is %rou"ht to the ED. surgeon hat are the indi#ations for pro!pt laparoto!( ree air, retroperitoneal air, or rupture of the hemidiaphragm. 4eritonitis. 4enetrating abdominal wound with hypotension. Flunt abdominal trauma with hypotension and a positive A(' or clinical evidence of intraperitoneal bleeding. Flunt or penetrating abdominal trauma with a p ositive 64*. 0unshot wound traversing the peritoneal cavity or visceral"vascular retroperitoneum. +visceration. Fleeding from the stomach, rectum, or genitourinary tract from penetrating trauma. ontrast7enhanced ' that demonstrates ruptured gastrointestinal tract, intraperitoneal bladder in5ury, renal pedicle in5ury, or severe visceral parenchymal in5ury after blunt or penetrating trauma. hat does AST stand for ocused Assessment (onography in 'rauma AST has a sensitivit(, spe#ifi#it(, and a##ura#( in dete#tin" intraa%do!inal fluid #o!para%le to )))). 64* hat are the advanta"es of AST =apid, noninvasive, accurate, and inexpensive means of detecting intraabdominal fluid that can be repeated fre:uently. hat are the four pla#es (ou should loo0 first when doin" a AST s#an ediastinum, hepatorenal fossa, splenorenal fossa, pouch of 6ouglas. a!e two anato!i#al #hallen"es that #an interfere with doin" a AST s#an Obesity and bowel gas 9since fat and gas attenuate sound waves. hat do (ou need to do +E;RE (ou do a D5L 2other than "ettin" instru!ents and !aterials to"ether and sur"i#all( preppin", et#.3 6ecompress the bladder and decompress the stomach.
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or patients with fa#ial fra#tures or %asilar s0ull fra#tures, "astri# tu%es should %e inserted )))) %efore doin" a D5L. orally hat is *ade6uate* fluid return when "ettin" D5L fluid %a#0 %!& D5L is #onsidered to %e ))))/ sensitive for dete#tin" intraperitoneal %leedin". 3?& D5L is indi#ated when a patient with !ultiple %lunt in'uries is he!od(na!i#all( unsta%le, espe#iall( when the( have ))))). hange in sensorium 9brain in5ury, +tO) or drug intoxication, etc., change in sensation 9spinal cord in5ury, in5ury to ad5acent structures 9pelvis, lumbar spine, lap7belt sign 9from seatbelt, or if patient is going for long studies 9', surgery, etc.. hat is the onl( A+S;L@TE #ontraindi#ation to D5L An existing indication for laparotomy. hat are so!e RELAT1! m* or 0I contents 9vegetable fiber, bile, feces, etc.. f (ou don&t "et "ross %lood upon initial D5L aspiration, what do (ou do ne>t for an adult or a #hild Adult8 1,!!! m* warm isotonic crystalloid intraperitoneally. hild8 same, but 1! m*"kg. hat para!eters would !a0e a D5L positive >1!!,!!! red cells"mm%, /!! white cells"mm%, or bacteria on gram stain.
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List three !ethods of he!orrha"e #ontrol. 4elvic stabiliDation, laparotomy, angiographic emboliDation. 9our trau!a patient needs an ur"ent laparoto!(, #an (ou ta0e the! to the CT s#anner first to evaluate in'uries Jo, if they need an emergent laparotomy, they are unstable 7 unstable patients should go to the O=, not the ' scanner. hat are so!e indi#ations for laparoto!( in patients with penetratin" a%do!inal wounds Lnstable, 0(, peritoneal irritation, fascial penetration. hat per#enta"e of sta% wounds to the anterior a%do!en do not penetrate the peritoneu! $/7%%& Do (ou need to operate on ever(one with an isolated solid or"an in'ur( Jo, not if they remain hemodynamically stable 9of all patients who are initially thought to have an isolated solid organ in5ury, Q/& will have hollow viscus in5ury as well. Does an earl(, nor!al seru! a!(lase level e>#lude !a'or pan#reati# trau!a Jo. Anterior-posterior for#es #ause ))))) %oo0 pelvi# fra#tures, and lateral for#es #ause ))))) %oo0 fra#tures. A48 open book; lateral8 closed book hi#h is less li0el( to have a life$threatenin" he!orrha"eH an open %oo0 or a #losed %oo0 pelvi# fra#ture losed book 7 the pelvic volume is compressed, so there is less room for blood to extravasate. hi#h are !ore #o!!on, open or #losed %oo0 pelvi# fra#tures losed book8 !7H!& 9open book8 1/7$!&; vertical shear8 /71/& 9ou need to do retro"rade urethro"raph( 5R;R to fole( pla#e!ent if there is ))))). inability to void, unstable pelvic fracture, blood at urethral meatus, 1?
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scrotal hematoma, perineal ecchymoses, or high7riding or mobile prostate.
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Chapter I
:ead Trau!a
Des#ri%e the las"ow Co!a S#ale 2CS3. (ee page $. @ou need to know how to determine a patientEs 0( score :uickly G know it inside out. hen #al#ulatin" CS and there is ri"ht-left ass(!etr( in the !otor response $ whi#h one do (ou use 'he F+(' response 9better predictor than the worst response. deall(, (ou want to wait to perfor! a CS on a person with SEed and dilated 2%lown3 pupil in a patient with a trau!ati# in'ur( is #aused %( #o!pression of whi#h nerve (uperficial parasympathetic fibers of the occulomotor nerve 9cranial nerve III. hat #riteria !a( !a0e ad!ission ne#essar( for a patient with !inor %rain in'ur( focal neurological deficits, abnormal ' 9or no scan available, penetrating head in5ury, prolonged loss of consciousness, worsening level of consciousness, moderate to severe headache, $!
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significant drug or alcohol intoxication, skull fracture, otorrhea, rhinorrhea, 0( remains Q 1/, nobody at home to observe patient. hat is a *nor!al* C5 in the restin" state 1! mm )g 9pressures > $!, particularly if sustained, are associated with poor outcomes. The Monro$Kellie Do#trine des#ri%es #o!pensator( !e#hanis!s to sta%ili4e pressure inside the #alvariu!. hat are the = !ain ones -enous Flood and ( decrease in e:ual volumes. hen this is exhausted, herniation can occur and brain perfusion will likely be inade:uate. 5reventin" h(per#ar%ia is #riti#al in patients who have sustained a ))))) in'ur(. head :i"h levels of C; = will #ause #ere%ral vas#ulature to ))))). dilate 9to increase blood flow 7 (o you might want to hyper ventilate patients with brain in5uries. 9our patient has a dilated pupil and (ou want to "ive !annitol on the wa( to the ;R. hat is the dose !.$/ 7 1.! g"kg I- rapid bolus. hat would (ou want to do if a patient with a !inor %rain in'ur( failed to rea#h a CS of 1 within = hours post$in'ur(, had L;C !in, is older than I, had e!esis > =, or had retro"rade a!nesia ? !inutes Lrgent head ' scan. +verything but the %! min of retrograde amnesia makes him high risk for needing neurosurgical intervention. hat is the differen#e %etween retro"rade a!nesia and antero"rade a!nesia 'hese are terms easily confused. =etrograde amnesia is the inability to recall events that occurred before the trauma. Anterograde amnesia is the loss of the ability to create new memories after the trauma. $1
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hat two thin"s do (ou need to do first for ever(one with a !oderate %rain in'ur( 2a##ordin" to ATLS al"orith!3 1. 'ransfer to a facility capable of definitive neurosurgical care, and $. Obtain a head ' scan 9however, this should not delay patient transfer. A AST s#an, D5L, or e>$lap should ta0e priorit( over a CT s#an if (ou #annot "et the %rain in'ured patient&s s+5 up to )))) !!:". 1!!. If a patient has a systolic F4 over 1!! with evidence of intracranial mass 9e.g. blown pupil, assymmetrical motor exam, then a ' would take priority. A !idline shift of "reater than )))) often indi#ates the need for neurosur"i#al eva#uation of the !ass or %lood. / mm Cere%ral perfusion pressure 2C553 is defined as !ean arterial %lood pressure !inus )))). intracranial pressure 944 A4 G I4 :(perventilation will )))) C5 in a deterioratin" patient with e>pandin" intra#ranial he!ato!a until e!er"ent #ranioto!( #an %e perfor!ed. lower n "eneral, it is prefera%le to 0eep the 5aC; = at appro>i!atel( )))) !! :", the low end of the nor!al ran"e. %/ mm hg 9#.H k4a +rief periods of h(perventilation 25aC; = of )))) to )))) !! :"3 !a( %e ne#essar( for a#ute neurolo"i# deterioration. $/ to %! mm )g Mannitol should not %e "iven to patients with h(potension, %e#ause !annitol is a potent os!oti# )))) and does not lower C5 in h(povole!ia. This #an further e>a#er%ate h(potension and, therefore, #ere%ral )))). diuretic; ischemia
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A#ute neurolo"i# deterioration, su#h as the develop!ent of a dilated pupil, he!iparesis, or loss of #ons#iousness, is a stron" indi#ation for ad!inisterin" !annitol, provided the patient is )))). n this settin", a %olus of !annitol 2)))) "-0"3 should %e "iven rapidl( 2over !inutes3. euvolemic; 1 g"kg Reasons for a patient with !ild trau!ati# %rain in'ur( to return to the hospital in#ludeH 6rowsiness or increasing difficulty in awakening patient, nausea or vomiting, convulsions, severe headaches, weakness or loss of feeling in the arm or leg, confusion or strange behavior, one pupil much larger than the other, peculiar movements of the eyes, double vision, or other visual disturbances, very slow or very rapid pulse, unusual breathing pattern, and bleeding or watery drainage from the nose or ear.
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Chapter
Spine Trau!a
hat are the possi%le !e#hanis!s that #an result in spine in'uries 4enetrating and blunt trauma, axial loading, flexion, extension, rotation, lateral bending, and distraction. Can (ou #lear the C$spine without i!a"in" @es. 'he 7spine can be cleared clinically if the patient8 is awake, alert, and sober; has no neurological deficits referable to the cervical spine; has no distracting in5uries; has no midline neck pain or tenderness on palpation; and can actively flex, extend, and laterally rotate his head to both sides without pain 9never do this passively. hat are the indi#ations for C$spine radio"raphs in a trau!a patient idline neck pain, tenderness on palpation, neurological deficits related to 7spine in5uries, altered *O, or intoxication. hi#h views should %e o%tained *ateral, A4, and open7mouth odontoid views. ith the proper views of the C$spine, and a 6ualified radiolo"ist, what is the sensitivit( for findin" an unsta%le #ervi#al spine in'ur( > 3H& 9' with % mm slices > 33&. Appro>i!atel( ))))/ of patients with a #ervi#al spine fra#ture have a se#ond, non#onti"uous verte%ral #olu!n fra#ture. 1!& Cervi#al spine in'ur( re6uires i!!o%ili4ation of the entire patient withH semirigid cervical collar, head immobiliDation, full7length backboard, and straps.
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Atte!pts to ali"n the spine for the purpose of i!!o%ili4ation on the %a#0%oard are not re#o!!ended if the( )))). cause pain hat is the !ost #o!!on t(pe of C1 fra#ture Furst fracture 9Kefferson fracture As lon" as the patients spine is )))), evaluation of the spine and e>#lusion of spinal in'ur( !a( %e safel( deferred, espe#iall( in the presen#e of s(ste!i# insta%ilit(, su#h as h(potension and respirator( inade6ua#(. protected n the presen#e of neurolo"i# defi#its, )))) or )))) is re#o!!ended to dete#t an( soft tissue #o!pressive lesion, su#h as a spinal epidural he!ato!a or a trau!ati4ed herniated dis0 =I; ' myelography Des#ri%e the !us#le stren"th "radin" s#ale used in ATLS.
A paral(4ed patient who is allowed to lie on a hard %oard for !ore than )))) hours is at hi"h ris0 for pressure ul#ers. $ hours 5artial or total loss of respirator( fun#tion !a( %e seen in a patient with a #ervi#al spine in'ur( a%ove )))).
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)))) sho#0 refers to the loss of !us#le tone and loss of refle>es seen after spinal #ord in'ur(. (pinal hat is neuro"eni# sho#0 (pinal cord in5ury 9(I 77> loss of sympathetic tone 77> vasodilation of blood vessels 77> pooling of blood 77> hypotension. (I may also cause bradycardia or inhibit the tachycardic response to hypotension. euro"eni# sho#0 is rare in spinal #ord in'ur( %elow the level of )))). ' hat is a !a'or differen#e in a ph(si#al findin" %etween h(povole!i# sho#0 and neuro"eni# sho#0 )ypovolemic shock8 usually tachycardic; neurogenic shock8 usually bradycardic. :ow do (ou treat neuro"eni# sho#0 Kudicious use of pressors and moderate fluid resuscitation. 'oo much fluid may result in fluid overload and pulmonary edema. )))) s(ndro!e is #hara#teri4ed %( a "reater loss of stren"th in the upper e>tre!ities than in the lower e>tre!ities, with var(in" de"rees of sensor( loss. entral cord )))) s(ndro!e is #hara#teri4ed %( paraple"ia and a disso#iated sensor( loss with a loss of pain and te!perature sensation. Dorsal #olu!n fun#tion 2position, vi%ration, and deep pressure sense3 is preserved. Anterior cord )))) s(ndro!e results fro! he!ise#tion of the #ord, usuall( as a result of a penetratin" trau!a. n its pure for!, the s(ndro!e #onsists of ipsilateral loss of !otor fun#tion 2#orti#ospinal tra#t3 and position sense 2dorsal #olu!n3, asso#iated with #ontralateral loss of pain and te!perature sensation 2spinothala!i# tra#t3 %e"innin" one to two levels %elow the level of the in'ur(. Frown7(R:uard
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Chapter J
Mus#ulos0eletal Trau!a
n addition to 7AM5LE,8 what other aspe#ts of the histor( are si"nifi#ant mechanism of in5ury, environment, prein5ury status, and prehospital observations and treatment. hat are the four essential #o!ponents of the ph(si#al assess!ent of MSK trau!a (kin, neuromuscular function, circulatory status, and skeletal and ligamentous integrity. E>tre!it( in'uries that are #onsidered potentiall( life$threatenin" in#lude )))) and )))). ma5or arterial hemorrhage; crush syndrome A tourni6uet !a( o##asionall( %e used if he!orrha"e is un#ontrolled %( dire#t )))) on the wound. pressure A properl( applied tourni6uet will )))) arterial flow. Occlude 9occluding only the venous system can actually increase hemorrhage hen !us#le is deprived of arterial %lood, ne#rosis %e"ins after a%out )))) hours. hours A fra#ture with an intrinsi# tenden#( to displa#e after redu#tion is #alled )))). unstable The appropriate use of )))) si"nifi#antl( de#reases the patients dis#o!fort %( #ontrollin" the a!ount of !otion that o##urs at the in'ured site. splints Should a le" %e #o!pletel( strai"ht when splintin" Jo, flexion of 1! degrees at the knee is recommended to lessen pressure on neurovascular structures.
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f a fra#ture and an open wound e>ist in the sa!e li!% se"!ent, the fra#ture is #onsidered )))) until proven otherwise. open 5atients with open fra#tures should %e treated with )))) )))) as soon as possi%le. intravenous antibiotics Crush s(ndro!e is also 0nown as )))). traumatic rhabdomyolysis E>plain #rush s(ndro!e rush in5ury of a significant muscle mass 9increase in S 77> release of myoglobin 77> may cause acute renal failure and disseminated intravascular coagulation 96I. Other effects are metabolic acidosis, hyperkalemia, and hypocalcemia. M(o"lo%in$indu#ed renal failure !a( %e prevented %( intravas#ular fluid e>pansion and os!oti# diuresis to !aintain a hi"h tu%ular volu!e and urine flow. t is re#o!!ended to !aintain the patients urinar( output at )))) until the !(o"lo%inuria is #leared. 1!! m*"hr A doppler an0le$%ra#hial inde> of less than )))) is indi#ative of i!paired arterial flow in the lower e>tre!ities se#ondar( to in'ur( or peripheral vas#ular disease. !.3 )))) s(ndro!e develops when the pressure within an osteofas#ial #o!part!ent #auses is#he!ia and su%se6uent ne#rosis. ompartment S(!pto!s of #o!part!ent s(ndro!e areH Increasing pain out of proportion to the stimulus, palpable tenseness of the compartment, asymmetry of the muscle compartments, pain on passive stretch of the affected muscle, and altered sensation 9e.g. paresthesia
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True or falseH The a%sen#e of a palpa%le distal pulse !a( %e relied upon to dia"nose #o!part!ent s(ndro!e. alse. 'he absence of a pulse is usually a late finding in compartment syndrome. The end results of untreated #o!part!ent s(ndro!e areH muscle necrosis, neurologic deficit, ischemic contracture, infection, delayed healing of a fracture, and possible amputation. +( L;;K at the patient, what findin"s !i"ht su""est a pelvi# in'ur( *eg7length discrepancy; hip rotation 9usually external hat is the pro#edure to salva"e a %od( part that was trau!ati#all( a!putated 'he amputated part should be thoroughly washed in isotonic solution 9e.g. =ingerTs lactate and wrapped in sterile gauDe that has been soaked in a:ueous penicillin 91!!,!!! units in /! m* of =ingerTs lactate. 'he amputated part is then wrapped in a similarly moistened sterile towel, placed in a plastic bag, and transported with the patient in an insulated cooling chest with crushed ice. are must be taken not to freeDe the amputated part. hat #hara#teristi#s of wounds in#rease the ris0 for tetanus (ignificant contamination, contused or abrased, > 1 cm deep, due to burns or frostbite, due to high velocity missiles, and > hours old. n order to dis#over o##ult in'uries not identified durin" the initial evaluation, it is i!perative to repeatedl( )))) the patient. reevaluate
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Chapter B
Ther!al n'uries
nhalation in'ur( nesse#itates )))) and transfer to a )))). intubation; burn center A hi"h inde> of suspi#ion for inhalation in'ur( !ust %e !aintained, %e#ause patients !a( not displa( #lini#al eviden#e for up to )))) hours. +( this ti!e, ede!a !a( prevent non$sur"i#al intu%ation. $# Cir#u!ferential %urns of the ne#0 #an lead to swellin" of the tissues around the airwa(N therefore, )))) is also indi#ated for these in'uries. early intubation Car%on !ono>ide has )))) ti!es the affinit( for he!o"lo%in as does o>("en . $#! or patients with C; poisonin", the half$life of C; is )))) when %reathin" roo! air, and )))) when %reathin" 1/ o>("en. # hours on =A; #! minutes on 1!!& O$ 5atients with C; levels less than ))))/ usuall( dont have an( ph(si#al s(!pto!s. $!& An( patient with %urns over !ore than ))))/ of the %od( surfa#e re6uires fluid resus#itation. $!& The pal!ar surfa#e of a patients hand represents appro>i!atel( ))))/ of +SA. 1& Adult head %od( surfa#e area 2+SA3 is ))))/. 3& 9i.e. entire head, front and back is 3& nfant&s head +SA is ))))/ 1?& 93& front, 3& back
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hat is the !ain differen#e %etween adult and infant +SA deter!ination for %urns +ntire head F(A for infant is 1?&, whereas it is 3& for adults. Chest +SA is ))))/. 1?& +a#0 +SA is ))))/. 1?& Ea#h ar! +SA is )))/. 3& 9total 7 front and back Ea#h le" +SA for an adult is ))))/. 1?& 9total 7 3& front, 3& back nfant front or %a#0 of ea#h le" +SA is)))/. H& 9total of each leg is 1#& f (ou add up the +SAs of the head, #hest, %a#0, ar!s, and le"s (ou "et BB/ of total +SA. hat does the re!ainin" 1/ represent 'he perineum. 5artial or = nd de"ree %urns e>tend into the )))), whereas full thi#0ness or ? rd de"ree %urns e>tend )))). dermis; all the way through dermis into and even beyond the subcutaneous tissue. :ow do (ou use the 5ar0land for!ula -olume of fluid in first $# hrs weight 9kg x & F(A burned x # Jote8 0ive half of this in ? hrs, then half over 1 hrs. e.g. H!kg x $/ x # H liters in $#hours. Jote8 Lse $/,B not !.$/ 0ive %./ * in first ? hrs, then %./ * in following 1 hrs. Are proph(la#ti# anti%ioti#s advisa%le 'here is no indication for prophylactic antibiotics in the po st7burn period. Antibiotics should be reserved for the treatment of actual infections. 'etanus immuniDation, however, should be up7to7date. %1
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5artial or full thi#0ness %urns of "reater than ))))/ warrants transfer to a %urn #enter. 1!& Referral to a %urn #enter is indi#ated forH 4artial7thickness and full7thickness burns on greater than 1!& F(A; 4artial7thickness and full7thickness burns involving the face, eyes, ears, hands, feet, genitalia, and perineum, as well as those that involve skin overlying ma5or 5oints; ull7thickness burns of any siDe in any age group; (ignificant electrical burns, including lightning in5ury 9significant volumes of tissue beneath the surface can be in5ured and result in rhabdomyolysis and acute renal failure and other complications; (ignificant chemical burns; Inhalation in5ury; Furn in5ury in patients with pre7existing illness that could complicate treatment, prolong recovery, or affect mortality 9e.g. diabetes; hildren with burn in5uries who are seen in ho spitals without :ualified personnel or e:uipment to manage their care; Furn in5ury in patients who will re:uire special social, emotional, or long7term rehabilitative support, including cases involving suspected child maltreatment and neglect. :ow is frost%ite treated 4lace the in5ured part in circulating water at a constant #!U 91!#U until pink color and perfusion return 9usually within $! to %! minutes. 6o not use dry heat since there is a significant risk of burning the skin. :(pother!i# patients are not pronoun#ed dead until the( are ))))) and dead. warm Al0ali %urns are "enerall( !ore serious than a#id %urns, %e#ause al0alies penetrate tissues !ore )))). deeply
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Chapter 1
5ediatri# Trau!a
hat heart rate is #onsidered ta#h(#ardi# for infants, toddlers-pres#hoolers, and s#hool a"e-pre%us#ent #hildren Infants > 1!, toddlers"preschoolers > 1#!, school age"prepubescent > 1$!. hat are (ou thin0in" if a #hild has %ro0en ri%s assive force and highly likely organ damage. (ince childrenEs ribs are very pliable, a great amount of force is re:uired to break them. 'here is often underlying organ damage without broken ribs. :ow should (ou insert an ;5A 2uedel3 in a #hild Lse tongue blade depressor and insert gentlywithout turning G otherwise there is great risk for trauma and resultant hemorrhage. 6o not do the 1?! degree rotation maneuvre. The nor!al s(stoli# +5 in #hildren #an %e esti!ated %( what for!ula 3! mm )g 2 9age x $ :ow do (ou esti!ate a #hilds total #ir#ulatin" volu!e ?! m*"kg hen sho#0 in a #hild is suspe#ted, how !u#h fluid do (ou "ive $! m*"kg warm crystalloid. ay need to repeat up to % times 9total of ! m*"kg, then consider blood products. ;pti!al @;5 for infants is ))) !L-0"-hr. $ m*"kg"hr 91./ m*"kg"hr for younger children, and 1.! m*"kg"hr for older children. hat would (ou see in an infant that would !a0e (ou suspe#t severe %rain in'ur( in spite of nor!al level of #ons#iousness Fulging fontanelles.
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Chapter 11
eriatri# Trau!a
)))) are the !ost #o!!on !e#hanis! of in'ur( en#ountered in older adults seen in trau!a #enters, and are the !ost #o!!on #ause of unintentional in'ur( and death a!on" the elderl(. alls Elderl( patients have a li!ited a%ilit( to )))) to #o!pensate for %lood loss. increase heart rate hat is a possi%le !ista0e a%out a %lood pressure of 1=-J in a J (ear$old !an Assuming that normal blood pressure means euvolemia. any geriatric patients have uncontrolled hypertension, and if their usual F4 is 1?!"1!!, then 1$!"?! is relative )@4Otension for them. re6uent use of !edi#ations, in#ludin" )))) and )))), #o!pli#ate assess!ent and !ana"e!ent. beta blockers; anticoagulants 9also calcium channel blockers, diuretics, J(AI6s, corticosteriods, hypoglycemics, psychotropics, etc. Rapid s#reenin" for )))) and su%se6uent #orre#tion of #oa"ulation para!eters !a( i!prove out#o!es. anticoagulant use h( would "eriatri# patients %e !ore sus#epti%le to intra#ranial he!orrha"e when there is in#reased spa#e around a shrin0in" %rain to prote#t the! fro! #ontusion Atrophic brains 77> stretching of the parasagital bridging veins, making them more prone to rupture upon impact. :ow well do "eriatri# patients do with non$operative !ana"e!ent of a%do!inal in'uries #o!pared to (oun"er people Jot as well G the risks of non7operative management are often worse than the risks of surgery.
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Chapter 1=
Trau!a in 5re"nan#( and nti!ate 5artner
5las!a volu!e in#reases durin" pre"nan#(, what happens to he!ato#rit It decreases due to dilution by plasma 9a hematocrit of %17%/& is normal in pregnancy. hat would (ou thin0 of a +C of 1, ina pre"nant wo!an Jormal. It can go up to $/,!!! during labor. A 5aC;= of ? to F in a pre"nant patient !a( indi#ate what Impending respiratory failure. 4aO$ is usually around %! due to hyperventilation due to increased levels of progesterone. 5re"nan#( results in a )))) fall in s(stoli# and diastoli# %lood pressures durin" the se#ond tri!ester. / to 1/ mm )g. Flood pressure returns to near7normal levels at term. hat should (ou alwa(s assu!e a%out a pre"nant patients sto!a#h 'hat it is always full. 0astric emptying time increases during pregnancy. +arly J0 tube placement is recommended. hat is the ti!e$fra!e for ad!inisterin" Rho"a! ithin H$ hours of the in5ury. True or alseH All Rh ne"ative pre"nant trau!a patients should %e ad!inistered Rho"a! alse. =hogam is not necessary if the in5ury is remote from the uterus 9e.g. distal extremity in5ury only. hen worn #orre#tl(, seat %elts redu#e fatalities %( )))/. /7H!&, with a 1!7fold reduction in serious in5ury.
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An a%rupt de#rease in !aternal intravas#ular volu!e #an result in a profound in#rease in uterine vas#ular )))), redu#in" fetal )))) despite reasona%l( nor!al !aternal vital si"ns. resistance; oxygenation Ad!ission to hospital is !andator( in the presen#e ofH vaginal bleeding, leakage of amniotic fluid pain or cramping, evidence of hypovolemia, uterine irritability, changes in fetal heart tones n the supine position, vena #ava #o!pression #an de#rease #ardia# output %( )))) / %e#ause of de#reased venous return fro! the lower e>tre!ities. %!& The uterus should %e displa#ed !anuall( to the )))) side to relieve pressure on the inferior vena #ava. left f the patient re6uires i!!o%ili4ation in a supine position, the patient or spine %oard #an %e lo" rolled )))) de"rees to the )))). 1/ degrees; left ndi#ators that su""est the presen#e of inti!ate partner violen#e in#ludeH In5uries inconsistent with the stated history; diminished self7image, depression, or suicide a ttempts; self7abuse; fre:uent +6 or office visits; symptoms suggestive of substance abuse; self7blame for in5uries; and partner insists on being present for the interview.
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