REVIEW FOR ATLS 2014 Name the adjuncts to the primary survey? !
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1. Electrocardiographic monitoring! 2. urinary catheter! 3. gastric catheter! 4. ventilatory rate! 5. ABGs! 6. Pulse Ox! 7. BP monitoring! 8. x rays!
! Name 3 likely causes of PEA on ECG?! !
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Cardiac tamponade! Tension pneumothorax! profound hypovolemia!
! A M P L E stands for ?! !
Allergies! Medications currently used! Past illnesses/Pregnancy! Last meal! Events/Environment related to injury!
! What are the 3 contraindication to the use of Succinylcholine?! ! Can precipitate severe hyperkalemia in:! 1. Burn victims! 2. Crush injuries! 3. electrical injuries”!
! Bag-mask ventilation can result in gastric distention, what are 2 complications associated with this?! ! 1. Vomiting and aspiration! 2. Stomach distention placing pressure on the IVC resulting in hypotension and bradycardia!
REVIEW FOR ATLS 2014 SHOCK!
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What 3 things define shock?! ! 1. Abnormal circulatory system function! 2. Resulting inadequate tissue perfusion! 3. Resulting inadequate tissue oxygenation!
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What is the first step in initial management of shock?! ! Recognize its presence.!
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What is the second step in initial management of shock?! Identify the probably cause of shock!
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What are the major types of shock?! ! 1. Hypovolemic (most often hemorrhagic in injured pt)! 2. Cardiogenic- Cardiac contusion, cardiac tamponade! 3. Obstructive - tension ptx or cardiac tamponade! 3. Neurogenic - spinal cord injury! 4. Distributive - septic, anaphylactic"!
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Most Common Cause of shock in injured patient?! Hemorrhage.!
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Formula for Cardiac Output (CO)?! CO(L/min) =! HR (beats/min) x Stroke Volume (mL/beat)!
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Name 3 parameters affecting stroke volume?! 1. Preload! 2. Afterload! 3. Myocardial contractility"!
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Earliest circulatory sign of shock?!! Tachycardia!
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What is the most effective method of restoring adequate CO and end-organ perfusion in shock?!! Restore venous return to normal -- stopping the source of bleeding + appropriate volume repletion!
REVIEW FOR ATLS 2014
! ! Describe the cellular pathophysiology of shock?! !
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Inadequate perfusion—> decreased O2—> switch to anaerobic metabolism—> inc. [lactic acid] —> metabolic acidosis—>—> loss of cellular membrane integrity & electrochemical gradient w/ release of pro-inflammatory mediators —> end-organ damage—> multi-system organ dysfunction!
! What are the 2 goals of treatment for hemorrhagic shock? ! ! 1. Definitive hemorrhage control! 2. Restore adequate circulating volume"!
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Patient's with hemorrhagic shock require vasopressors, T/F?! ! False; vasopressors further decrease tissue perfusion!
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What % of a patient's blood volume must be lost in order for systolic BP to change?! ! Up to 30% of a patient's blood volume; which is why it's so important to recognize tachycardia and skin color (compensatory mechanisms) in primary survey!
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A trauma patient is cool and tachycardic, what must be ruled out?! Shock!
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What are 5 parameters to pay attention to early in the primary survey in order to promptly dx shock?! 1. Pulse rate! 2. Pulse character! 3. Respiratory rate! 4. skin circulation! 5. pulse pressurer!
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A rapid deceleration injury to the thorax necessitates what?! ! Constant ECG monitoring in order to detect injury patterns and dysrhythmias! Name 5 common causes of non-hemorrhagic shock.! ! 1. Cardiac contusion! 2. Cardiac tamponade! 3. Tension pneumothorax!
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REVIEW FOR ATLS 2014 4. Neurogenic shock! 5. Septic shock! How do you differentiate between cardiac tamponade and tension pneumothorax?!! 1. Unilateral absence of breath sounds, ! 2. Tracheal deviation! 3. Hyper-resonance to percussion over the affected hemithorax!
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T/F, isolated intracranial injuries cause shock.! ! False; look for concomitant c-spine or upper t-spine injuries-->hypotension w/out compensatory tachycardia (2/2 loss of sympathetic tone)! How is neurogenic shock treated?! Initial fluid resuscitation-->failure of therapy-->continuing hemorrhage vs neurogenic shock-->CVP monitor!
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What is the typical blood volume of an adult? Child?! Adult = ~7% body weight (e.g. 5L in a 70kg pt)! Child = 8-9% body weight"!
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What guides volume replacement therapy in hemorrhagic shock?! Patient's response!
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Describe the spectrum of hemorrhagic shock?! !
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REVIEW FOR ATLS 2014
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What is the lethal triad?! 1. coagulopathy! 2. acidosis! 3. hypothermia"!
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In shock patients who fail to respond to initial fluid resuscitation, what must always be considered?! 1. Need for immediate definitive intervention! 2. Non-hemorrhagic causes of shock - blunt cardiac injury, cardiac tamponade, or tension pneumothorax"!
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What is type specific blood?! ! ABO and Rh compatible blood, readily available in 10 minutes!
! What are the levels of possible blood transfusion? ! !
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1. Cross-matched blood - fully compatible with all Ab, takes about 1 hr! 2. Type-specific - ABO and Rh compatible, takes about 10 mins! 3. O blood - make sure to use Rh(-) in females of child bearing age"!
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How does BP relate to CO in shock monitoring?!! BP = CO x SVR! Caveat: Increase in BP does NOT equate to increase CO, as SVR can account for this.!
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What are two locations which adequately reflect core temperature?! ! 1. Esophageal! 2. bladder”!
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REVIEW FOR ATLS 2014 HEAD TRAUMA!
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What is the primary goal of a patient with TBI (Traumatic Brain Injury) and what are 2 ways to accomplish this?! Prevent secondary brain injury --! 1. maintain adequate blood pressure to sufficiently perfuse the brain.! 2. maintain adequate oxygenation.! ! ! ! !
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What are the 2 classic findings in Uncal herniation?! ! 1. Ipsilateral pupillary dilation (compression of CN III PS fibers in the midbrain at the tentorial notch)! 2. contralateral hemiparesis (compression of cortico-spinal tract as it crosses at foramen magnum)"!
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What is the Monro - Kellie doctrine?! ! Because skull is rigid, it has a fixed volume. Therefore, mass lesions can initially force venous blood and CSF out of the skull and maintain ICP. Once this compensatory mechanism is maxed out, there is an exponential increase in ICP.! ! ! ! ! ! What is cerebral perfusion pressure defined as?!! CPP = MAP - ICP! ! ! ! ! What is a normal ICP?! ! 10 mmHg! ! ! ! ! What ICP is associated with poor outcomes?! ! >20 mmHg! ! ! ! ! What is the range of MAP during which autoregulation occurs?! ! MAP of 50-150 mmHg will maintain constant cerebral BF! ! ! ! !
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What are 5 ways to enhance cerebral BF and perfusion?! 1. Reducing elevated ICP! 2. Maintaining normal intravascular volume! 3. Maintaing a normal MAP! 4. Restore oxygenation/normo-capnia! 5. Evacuate traumatic mass (hemorrhage, clot) early! !
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If there is asymmetry when testing for the GCS, what is important?! ! Use the best motor response to calculate the score (most reliable predictor of outcome)! !
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REVIEW FOR ATLS 2014 A patient with cerebral contusions require what?! ! Repeat CT scans to evaluate for changes in injury pattern w/in 24 hours of initial scan -- up to 20% of patients show evolution of intra-cerebral hematoma or convalescent contusion w/ enough mass fx to require surgical evacuation! ! ! ! !
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Mental status changes in a drunk trauma patient are what until proven otherwise?! ! Brain injury! ! ! ! !
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What is a minor brain injury?! ! GCS of 15-13 ! What is a moderate TBI?! ! ! GCS of 12-9! ! ! ! What is a severe TBI?! ! GCS of 3-8! ! When do patients w/ a minor TBI require a CT scan?! ! 1. Clinically suspected open skull fracture! 2. Any sign of basilar skull fracture! 3. 2+ episodes of vomiting! 4. Pt 65+ yo"! ! ! ! ! ! ! ! ! ! What must be carefully avoided in moderate TBI patients?! ! 1. Hypoventilation! 2. Decreased ability to protect airway 2/2 depressed MS! AVOID NARCOTICS and HYPERCAPNIA! ! ! ! ! ! ! ! What level of midline shift indicates the need for surgical intervention?! ! A shift of >=5mm! ! ! ! ! What is the danger in treating a seizure patient with muscle relaxants alone?! ! Masked muscle contractions to not reflect the abnormal brain function -- can be devastating and MUST be treated with anti-seizure meds before NM blockade, if at all possible! ! ! ! ! What is the role of hyperventilation in TBI patients?! ! PCO2 should be maintained at low end of normal (35 mmHg - 45 mmHg)! Hypervent-->dec PaCO2 (25-30 mmHg)-->cerebral vasoconstriction—>decrease in ICP, HOWEVER prolonged periods of hyperventilation lead to ischemia-->devastating to already injured brain! Use hyperventilation in moderation and for as limited a period as possible!"! ! ! ! !
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REVIEW FOR ATLS 2014 Name 6 medical therapies for TBI.!! 1. IVF to maintain MAP! 2. Hyperventilation! 3. Mannitol! 4. Hypertonic saline! 5. Barbiturates! 6. Anticonvulsants"! ! ! !
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What is the role of anticonvulsants in medical therapy of TBI?! Can inhibit brain recovery-->use only when absolutely necessary! Phenytoin is currently acute phase DOC.!
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REVIEW FOR ATLS 2014
! ! ! ! ! THORACIC TRAUMA! !
What is the most serious aspect of thoracic injuries? How can it be treated?! ! Hypoxia - airway control and an appropriately placed needle or chest tube generally do the trick! !
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How is a tension pneumothorax initially managed?! ! Large caliber needle into second intercostal space in the midclavicular line of affected hemithorax! ! ! ! ! How is a tension pneumothorax diagnosed?!CLINICALLY! Do NOT wait for radiological evidence, treatment cannot be delayed!! ! ! ! ! How is an open pneumothorax treated?! ! Close defect with sterile occlusive dressing - securely taped on only 3 sides, to allow for a flutter-type valve effect! ! ! ! ! What is the initial treatment of a flail chest? (3)! ! 1. Adequate ventilation! 2. Humidified O2! 3. IVF - w/ careful monitoring to prevent fluid overload"! ! ! ! !
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What is the definitive treatment of flail chest?! 1. Ensure adequate oxygenation! 2. Administer fluids judiciously! 3. Provide analgesia to improve ventilation! !
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How are a massive hemothorax and tension pneumothorax differentiated?! ! Percussion - hyper-resonance = pneumothorax, dullness = hemothorax!
! Tracheal position - deviated in tension ptx, not common in hemothorax"! ! ! ! ! !
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REVIEW FOR ATLS 2014
! SPINAL CORD SYNDROMES! ! Central Cord Syndrome !
• Greater loss of motor strength in the upper extremities than in the lower extremities,! • Varying degrees of sensory loss. !
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Usually this syndrome occurs after a hyperextension injury in a patient with preexisting cervical canal stenosis (often due to degenerative osteoarthritic changes), and the history is commonly that of a forward fall that resulted in a facial impact. Central cord syndrome is thought to be due to vascular compromise of the cord in the distribution of the anterior spinal artery. This artery supplies the central portions of the cord. Because the motor fibers to the cervical segments are topographically arranged toward the center of the cord, the arms and hands are the most severely affected.!
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Anterior Cord Syndrome ! • Paraplegia ! • Sensory loss - pain and temperature sensation. !
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Dorsal column function (position, vibration, and deep pressure sense) is preserved. Usually, anterior cord syndrome is due to infarction of the cord in the territory supplied by the anterior spinal artery. This syndrome has the poorest prognosis of the incomplete injuries.!
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10! Brown-Séquard syndrome ! • ipsilateral motor loss! • Ipsilateral sensory (Position) loss! • Contralateral pain and temperature loss!
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Results from hemisection of the cord, usually as a result of a penetrating trauma. Although this syndrome is rarely seen, variations on the classic picture are not uncommon. Even when the syndrome is caused by a direct penetrating injury to the cord, some recovery is usually seen!
