ATLS Study Guide (Updated Study Guide for Year 2022/2023), Exams of Medicine

Download ATLS Study Guide (Updated Study Guide for Year 2022/2023) and more Exams Medicine in PDF only on Docsity! ATLS Study Guide Glasgow Coma Scale - Chance fracture - Transverse fracture through vertebra. In children usually associated with enterc disruption. Seen in motor vehicle accidents involving only lap belt. May be associated with retroperitoneal and Abdominal visceral injuries. Anterior hip dislocation - Flexed, abducted, externally rotated. Burst fracture - Associated with vertebral-axial compression injuries Posterior hip dislocation - Flexed, aDDucted, internally rotated Anterior shoulder dislocation - Squared off appearance Posterior shoulder dislocation - Lock in internal rotation. Ankle dislocation - Most are Externally rotated, with a prominent medial malleolus. FULL thickness (3rd degree) burn - Dark or white and leathery. Translucent white as well. Painless and generally "dry" Does not blanch with pressure. Very little swelling of burned tissue. Principle Life saving measures for patients with burn injuries include - -Establishing airway control -Stopping the burning. process -Intravenous access Factors that increase the risk for upper AIRWAY OBSTRUCTION in burns include: - - Burns to the head and face -Burn size and depth -Burns inside the mouth Partial thickness burn - Red remodeled appearance with associated swelling and blister formation. May have weeping or wet appearance and is painfully hypersensitive even to air current. Signs and symptoms and history that suggest INHALATION INJURY include: - These patients should be intubated. Inhalation injury is an indication for transfer to a burn center. Rule of nines - adult - The palm represents 1% of the body total surface area. Symptoms of carbon monoxide poisoning and respective levels - PaO2 does not reliably predict carbon monoxide poisoning because a CO partial pressure of only 1 mmm Hg results in a hemoglobin CO level of 40% or greater. Carbon monoxide has how many times greater affinity for hemoglobin than oxygen - 240 times. It displaces the oxyhemoglobin desaturated curve to the LEFT. Two criteria required for the diagnosis of smoke inhalation injury - -Exposure to a combustible agent -Signs of exposure to smoke in the lower airway, below the vocal cords, by bronchoscopy. Performing this action will help reduce neck and chest wall edema in patients with burn and inhalation injury. - Elevation of the head and chest by 30 degrees. IV fluid administration formula for burn victims - Indicated in burns involving over 20% of the body surface area. *(2-4 mL/kg of LR/NS) (weight in kg) (% area of burn); give 1/2 of this volume in first 8 hours. Remainder in over 16 hours. Large caliber, at least 15 gauge intravenous line should be introduced. Pitfalls for IV fluid requirements for burn victims. - These patients require greater fluid requirements: ~immolation injury ~pediatric burn victims ~concomitant blunt or crush injuries. Basic rules regarding IV fluids administration in burn victims - IV fluid Rate should not be based on the time of actual injury. In very small children, less than 10 kilograms, it may be necessary to add glucose to the IV fluids to avoid hypoglycemia. Any adjustment in IV fluid rate should be based on urine output. In an adult, urine output above 0.5 ml/ kilogram should result in reduction of IV fluid rate. 6. Bicarbonate space 17-22 (Compensatory metabolic Acidosis). A resting PaCO2 of 35 to 40 mm in the setting of pregnancy - may represent impending respiratory failure. Normal PaCO2 for a pregnant woman is between 25 to 30 mmHg Kleinhauer-Betke test - Maternal blood smear test which allows detection of fetal RBCs in the maternal circulation, indicates fetomaternal hemorrhage. Indication for Rh immunoglobulin therapy. Drugs to avoid in hypovolemia, head injured and intoxicated patients. - Benzodiazepines, fentanyl propofol, ketamine Initial Assessment components of seriously injured patient - Primary survey - 1. Airway maintenance with cervical spine protection 2. Breathing and ventilation 3. Circulation & hemorrhage control 4. Disability: neurological status 5. Environment/Exposure: completely undress the patient but prevent hypothermia Assume a CERVICAL SPINE injury in patients with BLUNT multisystem trauma, especially those with an altered level of consciousness's or a blunt injury about the clavicles. - IV fluid warming temperature in shock - 37 to 40°C Associated with aberrant conduction, premature beats, bradycardia. - hypoxemia, hypothermia hypokalemia. AMPLE history. - Allergies Medications Past illness/Pregnancy, Last meal Environment/events related to injury Frontal impact automobile collision: Bent steering wheel, Knee imprint dashboard Bulls eye fracture windshield - Cervical spine fracture Anterior flail chest Myocardial contusion Pneumothorax Traumatic aortic disruption Fractured spleen or liver Posterior fracture/dislocation of hip and/or knee Side impact automobile collision - Contralateral next sprain Cervical spine fracture Lateral flail chest Pneumothorax Traumatic aortic disruption Diaphragmatic rupture Fractured spleen/liver and/or Fracture of kidney, pelvis or acetabulum Rear impact automobile collision - Cervical spine injury Soft tissue neck injury Ejection from automobile - Ejection from the vehicle precludes meaningful prediction of injury patterns. Patient at greater risk from virtually all injury mechanisms. Motor vehicle impact with pedestrian. - Head injury Traumatic aortic disruption Blunt force to the neck or Traction injury from a shoulder harness restraint - Can cause carotid disruption dissection or thrombosis. Symptoms may develop late Auscultation of chest - Auscultate high on the anterior chest for PNEUMOTHORAX and at the posterior basis for detection of HEMOTHORAX Distended neck veins - Seen in Cardiac Tampanode or Tension Pneumothorax. Abdominal injury Patients with unexplained hypotension, neurological injury, impaired sensorium secondary to alcohol and/or other drugs, and equivocal or normal findings - Should be considered candidates for DPL, or FAST. If hemodynamically stable, CT scan of the abdomen Any increase in intracranial pressure can REDUCE cerebral perfusion pressure, and lead to secondary brain injury. - Complete cervical cord transection which SPARES the phrenic nerve, C3 and C4, results in... - Results in quadriplegia and ABDOMINAL breathing but paralysis of the intercostal muscles. Assisted ventilation may be required. Size of plastic cannula for cricothyroidotomy for jet insufflation - 12 to 14 gauge; 8.5 cm length LMA sizes - 3 for small female 4 for large female 5 for large male RANGES FROM 1 FOR NEONATE 5 FOR ADULTS Consider Use when you cannot extend the neck (c-collar in place) Laryngeal tube airway - Use when you cannot extend the c-spine (c-collar) CO2 capnography - Yellow indicates adequate CO2 levels, violet: too low Definition of Shock - Abnormality of the circulatory system resulting in inadequate organ perfusion and tissue oxygenation. Hemorrhage is the most common cause of shock in the injured/trauma patient. Earliest signs of shock - Tachycardia and cutaneous vasoconstriction. Tachycardia an infant - Greater than 160 beats per minute Tachycardia in a preschool child - Greater than 140 beats per minute Tachycardia in a school age to puberty - Greater than 120 beats per minute Tachycardia in an adult - Greater than 100 beats per minute. Significance of narrowed pulse pressure - Significant blood loss and involvement of compensatory mechanisms. What percent of body weight in kilograms represents the circulating blood volume of an adult (in liters). - 7%. Example, a 70 kilogram man's total circulating volume is 70 × 7% which equals 4900 ml. Class hemorrhage and hemodynamic effects. - Accurate lines of the sacrum - To treat an open book fracture of the pelvis - Life-threatening thoracic injuries that need to be addressed in the primary survey - Airway obstruction Tension pneumothorax Open pneumothorax Flail chest and pulmonary contusion Massive hemothorax Cardiac tamponade Most common cause of tension pneumothorax - Mechanical ventilation with positive pressure ventilation in patients with visceral pleural injury Flail chest - Flail chest radiograph - Initial treatment of flail chest - Adequate ventilation, humidified oxygen, fluid resuscitation. Later, analgesia. Short Term intubation and ventilation may be necessary. Local nerve block preferred over IV narcotics. MASSIVE hemothorax definition - > 1500 milliliters of blood or one third or more of the patient's total blood volume in the chest cavity. Neck veins can be distended (if concomitant tension pneumothorax) or flat (if blood loss results in hypovolemia). Treatment of MASSIVE hemothorax - Restoration of blood volume (crystalloid then type specific blood) and decompression of the chest cavity. 36 or 40 French chest tube required MASSIVE Hemothorax. Indications for thoracotomy: - If Greater than 1500 ml of fluid is immediately evacuated. Less than 1500 milliliters of fluid evacuated but continued blood loss of 200 milliliters per hour for 2 to 4 hours Beck's triad in cardiac tamponade - Venous pressure elevation, decline in arterial pressure, muffled heart tones. Kussmal's sign - Paradoxical RISE in central venous pressure with inspiration. Seen in cardiac tamponade. Resuscitative thoracotomy - Patients with PENETRATING injuries to the chest, pulseless, but with myocardial electrical activity may be candidates. Patients with BLUNT injuries to the chest, arrive pulseless but with myocardial electrical activity are NOT candidates. SIMPLE hemothorax - Less than 1500 milliliters of blood. Most common cause is laceration of an intercostal vessel or internal mammary artery or lung laceration due to penetrating or blunt trauma. Typical presentation of tracheobronchial tree injury - Hemoptysis, subcutaneous emphysema, tension pneumothorax; incomplete expansion of the lung after placement of a chest tube also suggests tracheobronchial tree injury. Confirmed by bronchoscopy. Treatment of tracheobronchial tree injury - Surgical. Most common findings in blunt cardiac injury - Multiple PVCs, unexplained sinus tachycardia, atrial fibrillation, bundle branch block, ST segment changes. Ligamentum arteriosum - Site of incomplete laceration in traumatic aortic disruption Radiologic signs on chest x-ray in traumatic aortic rupture that indicate the likelihood of major vascular injury - Widened mediastinum Obliteration of aortic knob. Deviation of trachea to the RIGHT Depression of left main stem bronchus Obliteration of space between the pulmonary artery and the aorta. Deviation of esophagus to the right Widened paratracheal stripe Presence of a plural or apical cap. Left hemothorax Fractures of first or second rib or scapula Traumatic diaphragmatic injury on the left. What action should you pursue - Insert a nasal gastric tube. If it appears in chest wall cavity on chest film the need for special contrast studies is eliminated. Suspect blunt esophageal rupture when you see the following - Left pneumothorax or hemothorax without a rib fracture History of a severe blow to the LOWER sternum or epigastrium. Pain or shock out of proportion to the apparent injury. Particulate matter in the chest tube after blood begins to clear. Presence of mediastinal air. Treatment of blunt esophageal rupture - Wide drainage of the pleural space and mediastinum, with direct repair of the injury through thoracotomy. Causes of subcutaneous emphysema - Blast injury. Airway injury. Lung injury. The emphysema itself is generally not treated but underlying causes need to be addressed and treated. Fractures involving ribs 1 through 3, sternum, scapula and clavicle can be associated with - Great vessel trauma or airway obstruction. Pneumothorax. Pulmonary contusion. Middle rib fracture, 4 through 9, can be associated with - Pneumothorax hemothorax pulmonary contusion. Fracture involving ribs 10 through 12 can be associated with - Hepatosplenic trauma Mediastinal widening - Great vessel injury Sternal fracture Thoracic spine injury. Mediastinal air - Esophageal disruption Tracheal injury Pneumoperitoneum. Air fluid level in the chest - Hemopneumothorax or diaphragmatic rupture. Disrupted diaphragm - Indicates adominal visceral injury X-ray findings in diaphragmatic ruptured - Elevation, irregularity or obliteration of diaphragm. Mass like density above the diaphragm. Air or contrast containing stomach or bowel above diaphragm. Pleural effusion. Fracture of the scapula - Great vessel injury, airway injury, pulmonary contusion. Sternal fractures are associated with - Myocardial contusion Great vessel injury Pericardiocentesis needle, size - 15 - 18 gauge, 15 centimeters length. repeat CT scan. (10 to 20% of these patients deteriorate and lapse into coma) Management of patients with severe brain injury GCS 3-8 - *CT Scan and admit to neurosurgical ICU *Therapeutic agents if needed including mannitol, hypertonic saline, moderate hyperventilation: PaO2 of ~35mmHg. *Repeat CT scanning as needed. *Intubation. A midline shift of 5 millimeters or greater on CT scan of the brain - Indicate the need for surgery to evacuate the blood clot or contusion causing the shift Indication for the use of Mannitol (1gm/kg) - Acute neurologic deterioration such as development of a dilated pupil, loss of consciousness, or hemiparesis in a severe head trauma patient. Patient must be euvolemic. Three main factors linked to a high incidence of late epilepsy in post traumatic patients - Seizures occurring within the first week Intracranial hematoma Depressed skull fracture. Diagnosis of brain death criteria - *GCS score of 3 *Nonreactive pupils *Absent brainstem reflexes (Doll's eyes, corneal, gag reflexes) *No spontaneous ventilatory effort on formal apnea testing NEUROGENIC shock is rare in spinal cord injuries below this level. - T6. Injury to this cervical spine level results in paralysis of the diaphragm - C3 thru C5 segments. Injury to the lower cervical upper thoracic spine results in paralysis of what muscles? - The intercostal muscles Definition of neurological level when discussing spinal cord injuries. - The segment of spinal cord that has normal sensory and motor function on both sides of the body. Central cord syndrome - commonly in hyperextension injuries in elderly with cervical spondylosis. Weakness in UE > LE, possibly loss of local pain/temperature. The motor fibers of the cervical segments are topographically arranged toward the center of the cord. Arms and hands are there for more severely affected. Anterior cord syndrome - Paraplegia and dissociated sensory loss with a loss of pain and temperature sensation. Dorsal column function is preserved. Poorest prognosis of the incomplete injuries. Brown-Sèquard syndrome - ipsilateral motor paralysis and loss of touch/vibration and contralateral loss of pain and temperature. Usually a result of a penetrating trauma. Atlanto-occipital dislocation - Not Common - < 1% all acute C/S injuries. Caused by severe traumatic flexion. Most patients die from traumatic brain injury. Atlas fracture - 40% of Atlas fractures are associated with fractures of the AXIS Occurs by strong vertical forces (e.g. Blow to head top or diving in shallow pool) fracturing the lateral masses and rupturing the transverse ligament. A fracture of the ring is a Jefferson fracture. Usually not associated with spinal cord injuries but are unstable. C1 rotary subluxation - Patient population: children & patients with rheumatoid arthritis. Patient presents with persistent rotation of the head. Axis Fractures - fractures of odontoid, forceful flexion or extensio Hangman's Fracture - fracture of both pedicles of C2 due to extreme hyperextension (incredibly unstable as dens pushes against brainstem). Involves the posterior elements of c2. The pars interarticularis C2 fractures. - Most are odontoid or hangman fractures. 20% of C2 fractures do not involve other one of these, however. C2 because of its unique anatomy is very susceptible to fractures. The most common site of cervical fractures - C5 Burst fracture - Due to direct axial load; retropulsion of fragments can injure the spinal cord; unstable. Thoracolumbar junction fractures T11 through L1. - Most often result from a combination of severe hyperflexion and rotation, and, consequently are usually unstable. Symptoms associated with lumbar fractures. - Bladder and bowel dysfunction, decreased sensation and strength in the lower extremities. Indication for flexion extension cervical x-rays. - When 3 view cervical spine imaging normal =To Detect occult instability. =Determine the stability of a known fracture such as a laminar or compression fracture Approximately 10% of patients with a cervical spine fracture have a second, noncontiguous vertebral column fracture. - Need to complete a complete radiographic screening of the entire spine in these cases. If on plain films of the cervical spine, no abnormality is identified, but the patient has evidence of a neurological deficit, order the following: - MRI scan to identify any spinal cord contusions,disruptions and paraspinal ligamentous and soft tissue injury. AP films of the spine - Detect distance between the pedicles Unstable fractures commonly cause widening of the inter pedicular distance. Lateral x-rays of the spine - The Delta P in suspected compartment syndrome - Equals the diastolic pressure minus the compartment pressure. If 30 or less the suggest patient has a compartment syndrome. compartment syndrome, however, is a clinical diagnosis. Clavicle fracture Scapular fracture Fracture / dislocation shoulder blade... Can be associated with..... - Major thoracic injury, especially pulmonary contusion and rib fractures. Displaced thoracic spine fracture can be associated with - Thoracic aortic rupture Spine fractures can be associated with - Intraabdominal injury Femur fracture can be associated with - Femoral neck fractures posterior hip dislocation Fracture / dislocation of the elbow can be associated with - Brachial artery injury Median, mode, and radial nerve injury. Posterior knee dislocation can be associated with - Femoral fracture Posterior hip dislocation Need this location or displaced tibial plateau fracture can be associated with - Popliteal artery and nerve injuries.