Study Guide for ATLS - Sample Chapters

Study Guide for the

ATLS Student Course Manual [Sample Chapters Only]

Dr. Ken Evans, MD

mcatest.wixsite.com/atls

Chapter 1

Initial 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&ury 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. Any patient *ho is "ool and ta"hy"ardi" is "onsidered to $e '''' until proven other*ise. in shock The definition of ta"hy"ardia depends on the patient%s a!e. +hat heart rate is "onsidered ta"hy"ardi" for infants, toddlerspres"hoolers, s"hool a!epre$us"ent, and adultsInfants > !", toddlers/preschoolers > #", school age/prepubescent > $", and adults > "" Copensatory e"haniss ay pre"lude a easura$le fall in systoli" $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 ay $e a$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 &er/. hypoxia

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Des"ri$e the Glas!o* Coa S"ale 0GCS.

A patient opens her eyes only to painful stiuli, utters inappropriate *ords, and lo"ali2es pain. +hat is her GCS s"ore+$ -%  'herefore, 01(  $2%2  " 3atients *ith a GSC of less than '''' usually re4uire intu$ation. 3 $


+hat inforation is in an 5AM3LE6 patient historyA  Allergies   edications 4  4)/4regnancy *  *ast meal +  +vents/+nvironment of in5ury +hen is this done6uring the secondary survey. 7ou should assue that any patient *ith ultisyste traua and altered level of "ons"iousness, or $lunt in&ury a$ove the "lavi"le, has *hat type of in&ury1ervical spine in5ury. in5ury. 8o* "an you "lear the C#spine *ithout ia!in!'he 17spine 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. 9ther*ise, *hen *ould C#spine fils $e o$tained6uring the secondary survey. survey. +hen should ost ia!es $e o$tained6uring the secondary survey. survey. 'here are a small number of exceptions 9see next :uestion. +hat ia!in! is done durin! the priary survey1<= and pelvis films 9both A4 views, and A(' scan. +hat should you do for every feale patient of "hild$earin! a!e4regnancy test.

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+hat possi$le in&uries *ould you suspe"t *ith a frontal ipa"t autoo$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. Si2e of needle for needle "ri"othyroidotoy$ gauge Si2e of needle for needle thora"entesis# gauge Si2e of needle for peripheral I:! gauge Si2e of needle for peri"ardio"entesis? gauge 9spinal needle

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Chapter ;

Sho"/

The ost effe"tive ethod of restorin! ade4uate "ardia" output and end#or!an perfusion is to restore venous return to noral $y lo"atin! and stoppin! the sour"e of ''''', alon! *ith appropriate '''' repletion. bleeding; volume Any in&ured patient *ho is "ool and has ta"hy"ardia is "onsidered to $e '''' '''' until proven other*ise. in shock 8ypotension is "aused $y ''''' until proven other*ise. hypovolemia Ta"hy"ardia is dia!nosed *hen the heart rate is !reater than '''' $eats per inute 0)3M in infants, '''' )3M in pres"hool "hildren, '''' )3M in "hildren fro s"hool#a!e to pu$erty, and '''' )3M in adults. !" @4 in an infant, #" @4 in a preschool7aged child, $" @4 in children from school age to puberty, and "" @4 in adults. Elderly patients ay not e

=rinary "atheters are !ood for assessin! renal renal perfusion and volue status. List > si!ns of urethral in&ury that i!ht prevent you fro insertin! one. @lood at urethral meatus, perineal ecchymosis, blood in scrotum, high7riding/non7palpable prostate, and pelvic fracture The ost "oon "ause of sho"/ 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 severity of sho"/. lactate Massive $lood loss ay produ"e '''' a"ute de"rease in the heato"rit or heo!lo$in "on"entration. only a minimal +hy i!ht you *ant a )air 8u!!er for a patient *ho sells of al"oholAlcohol ingestion causes vasodilation, which can lead to hypothermia. :as"ular a""ess ust $e o$tained proptly. proptly. This is $est a""oplished $y insertin! t*o lar!e#"ali$er 0iniu of ''''#!au!e in an adult peripheral intravenous "atheters $efore pla"eent of a "entral venous line is "onsidered. !7gauge ?esus"itation fluids should $e *ared to ;@ de!rees Celsius 01B.B o. Can you use a i"ro*ave oven to do thisBes, for crystalloids only 9but not for blood products. +hat thin!s are you loo/in! for *hen you perfor a di!ital re"tal e

8o* does sho"/ redu"e the total volue of "ir"ulatin! $loodAnaerobic metabolism 77> insufficient A'4 A'4 77> endoplasmic reticulum damage, then mitochondrial damage da mage 77> lysosomal rupture 77> sodium and CA CA'+= enter cells 9which swell and die 77> decreased intravascular volume +hi"h vasopressors should you use to treat heorrha!i" sho"/'rick :uestion. :uestion. Dever use vasopressors for hypovolemicshock 7 use volume replacement. 4ressors will worsen tissue perfusion perfusion in hemorrhagic shock. Appro
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8o* do you treat a "lass I heorrha!eBou donFt 9usually. 'ranscapillary refill refill and other compensatory mechanisms usually restore blood volume within $# hours. 8o* u"h $lood volue is lost *ith "lass II heorrha!e7%"& 9E"7"" m* in a E" kg adult. a dult. 8o* do you treat a "lass II heorrha!eHsually only with crystalloids. Su$tle CS "han!es su"h as an

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+hat is the differential dia!nosis for (non#responders( follo*in! fluid resus"itation Don7hemorrhagic 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. 8o* lon! "an an intraosseous 0I9 line $e /ept inIntraosseous infusions should be limited to emergency resuscitation and shoud be discontinued as soon as other venous access ac cess is obtained. 8o* should you position the patient *hen insertin! a su$"lavian or internal &u!ular line(upine, trendelenburg 9head down at  degrees to distend the veins and prevent air embolism, and turn the head away from you 9and only if the 17spine has been cleared. +here is an in"ision for a saphenous vein "utdo*n ade and ho* lon! should the in"ision $e'he saphenous vein can be accessed approximately  cm anterior and  cm superior to the medial malleolus. ake a $. cm transverse incision incision through the skin, taking care not to in5ure the vein.

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Chapter 

8ead Traua

Des"ri$e the Glas!o* Coa S"ale 0GCS. (ee page $. Bou need to know how to determine a patientFs 01( score :uickly  know it inside out. +hen "al"ulatin! GCS and there is ri!htleft assyetry in the otor response # *hi"h one do you use'he @+(' response 9better predictor than the worst response. Ideally, you *ant to *ait to perfor a GCS on a person *ith SE:E?E SE:E?E $rain in&ury until *hat@4 is normaliJed. 3atients *ith a GCS $et*een ; and F eet the a""epted definition of ("oa( or ('''' $rain in&ury.( severe +hat are the GCS s"ores for (inor( and (oderate( $rain in&uryinor is %7, oderate is 37$ +hat si!ns i!ht you see if a patient has a $asilar s/ull fra"ture4eriorbital ecchymosis 9raccoon eyes, retroauricular ecchymosis 9battle sign, otorrhea, and rhinorrhea. A fi
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moderate to severe headache, significant drug or alcohol intoxication, skull fracture, otorrhea, rhinorrhea, 01( remains K , nobody at home to observe patient. +hat is a (noral( IC3 in the restin! state" mm )g 9pressures > $", particularly if sustained, are associated with poor outcomes. The Monro#Kellie Do"trine des"ri$es "opensatory e"haniss to sta$ili2e pressure inside the "alvariu. +hat are the B ain ones-enous @lood and 1( decrease in e:ual volumes. Chen this is exhausted, exhausted, herniation can occur and brain perfusion will likely be inade:uate. 3reventin! hyper"ar$ia is "riti"al in patients *ho have sustained a ''''' in&ury. head 8i!h levels of C9 B *ill "ause "ere$ral vas"ulature to '''''. dilate 9to increase blood flow 7 (o you might want to hyper ventilate ventilate patients with brain in5uries. 7our patient has a dilated pupil and you *ant to !ive annitol on the *ay to the 9?. +hat is the dose".$ 7 ." g/kg I- rapid bolus. +hat *ould you *ant to do if a patient *ith a inor $rain in&ury failed to rea"h a GCS of 1> *ithin B hours post#in&ury, had L9C >in, is older than >, had eesis < B, or had retro!rade anesia ; inutesHrgent head 1' scan. +verything but the %" min of retrograde amnesia makes him high risk for needing neurosurgical intervention. +hat is the differen"e $et*een retro!rade anesia and antero!rade anesiaanesia'hese are terms easily confused. =etrograde amnesia is the inability inability to recall events that occurred before the loss of the before the trauma. Anterograde amnesia is the loss $


ability to create new memories after the the trauma. +hat t*o thin!s do you need to do first for everyone *ith a oderate $rain in&ury 0a""ordin! to ATLS al!orith. 'ransfer to a facility facility capable of definitive neurosurgical care, and $. Lbtain a head 1' scan 9however, this should not delay patient transfer. transfer. A AST s"an, D3L, or e<#lap should ta/e priority over a CT s"an if you "annot !et the $rain in&ured patient%s s)3 up to '''' 8!. "". If a patient has a systolic @4 over "" with evidence of intracranial intracranial mass 9e.g. blown pupil, assymmetrical motor exam, then a 1' would take priority. 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 0C33 is defined as ean arterial $lood pressure inus ''''. intracranial pressure 9144  A4  I14 8yperventilation *ill '''' IC3 in a deterioratin! patient *ith e
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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 ''''. In this settin!, a $olus of annitol 0'''' !/! should $e !iven rapidly 0over > inutes. euvolemic;  g/kg ?easons for a patient *ith ild trauati" $rain in&ury 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, leg , confusion or strange behavior, behav ior, 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. ear.

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Chapter @

Theral In&uries

Inhalation in&ury nesse"itates '''' and transfer to a ''''. intubation; burn center A hi!h inde< of suspi"ion for inhalation in&ury ust $e aintained, $e"ause patients ay not display "lini"al eviden"e for up to '''' hours. )y this tie, edea ay prevent non#sur!i"al intu$ation. $# Cir"uferential $urns of the ne"/ "an lead to s*ellin! of the tissues around the air*ay therefore, '''' is also indi"ated for these in&uries. early intubation Car$on ono
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+hat is the ain differen"e $et*een adult and infant )SA deterination for $urns+ntire head @(A for infant is ?&, whereas it is 3& for adults. Chest )SA is ''''. ?& )a"/ )SA is ''''. ?& Ea"h ar )SA is '''. 3& 9total 7 front and back Ea"h le! )SA for an adult is ''''. ?& 9total 7 3& front, 3& back Infant front or $a"/ of ea"h le! )SA is'''. E& 9total of each leg is #& If you add up the )SAs of the head, "hest, $a"/, ars, and le!s you !et @@ of total )SA. +hat does the reainin! 1 representrepresent'he perineum. 3artial or B nd de!ree $urns e

3artial or full thi"/ness $urns of !reater than '''' *arrants transfer to a $urn "enter. "& ?eferral to a $urn "enter is indi"ated forH 4artial7thickness and full7thickness burns on greater than "& @(A; 4artial7thickness and full7thickness burns involving the face, eyes, ears, hands, feet, genitalia, and perineum, as well as those that involve skin overlying ma5or 5oints; ull7thickness burns of any siJe in any age group; (ignificant electrical burns, including lightning in5ury 9significant volumes of tissue beneath the surface can be in5ured and result in rhabdomyolysis and acute renal failure and other complications; (ignificant chemical burns; Inhalation in5ury; @urn in5ury in patients with pre7existing illness that could complicate treatment, prolong recovery, recovery, or affect mortality 9e.g. diabetes; 1hildren with burn in5uries who are seen in ho spitals without :ualified personnel or e:uipment to manage their care; @urn in5ury in patients who will re:uire special social, emotional, or long7term rehabilitative support, including cases involving suspected child maltreatment and neglect. 8o* is frost$ite treated4lace the in5ured part in circulating water at a constant #"O1 9"#O until pink color and perfusion return 9usually 9usually within $" to %" minutes. minutes. 6o not use dry heat since there is a significant risk of burning the skin. 8ypotheri" patients are not pronoun"ed dead until they are ''''' and dead. warm Al/ali $urns are !enerally ore serious than a"id $urns, $e"ause al/alies penetrate tissues ore ''''. deeply

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Study Guide for ATLS - Sample Chapters

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