Intern Year: Atls : Class Day One

Front 1

What is the primary survey?

**

Back 1

ABCDEs

Airway
Breathing
Circulation
Disability
Exposure

Front 2

In a trauma situation, what should be treated first

Back 2

Greatest threat to life

Front 3

anytime you come into a trauma pt what should you do? (2 things)

Back 3

Airway with c-spine protection

Universal precautions:
hat
mask w shield
gown
gloves (double glove, single gloving viral transmission is 67%)

Front 4

What are the 2 areas that are part of xray in resuscitation adjunct?

Back 4

Chest and pelvis

house the most blood

note: use FAST for abdomen

Front 5

what size needle is used for needle decompression

Back 5

14/16 gauge

2nd intercostal space mid clavicular line

aim down the pt

Front 6

What should you ask for from your ancillary staff upon start of a trauma?

Back 6

EKG
Pulse Ox
IV
BP
Draw Labs

Front 7

what is considered large bore IV?

how much fluid should initially be given in the trauma pt?

Back 7

14/16 gauge (you need 2!)

2L as fast as possible over 10 min

Front 8

if you are able to obtain a pulse at the following areas, what is the SBP?

Carotid:
Femoral:
Dorsalis pedis:

Back 8

Carotid: 60
Femoral: 70
Dorsalis pedis: 80

Front 9

if you are the only physician available in a trauma scenario, what are you going to likely do?

Back 9

transfer him out

Front 10

Describe the GCS and scoring

***

Back 10

Eye Response:

Eyes open spontaneously. +4
Eye opening to verbal command. +3
Eye opening to pain. +2
No eye opening. +1

Verbal Response:

Oriented. +5
Confused. +4
Inappropriate words. +3
Incomprehensible sounds. +2
No verbal response. +1

Motor Response:

Obeys commands. +6
Localizes pain. +5
Withdrawal from pain. +4
Flexion to pain (Decorticate). +3
Extension to pain (Decerebrate). +2
No motor response. +1

Front 11

give the GCS for the following scenario

localizes to pain
no verbal response
eyes open to pain

Back 11

localizes to pain: 5
no verbal response: 1
eyes open to pain: 2

Front 12

give the GCS for the following scenario

Eye opening to verbal command
inappropriate words
flexion to pain

Back 12

Eye opening to verbal command: 3
inappropriate words: 3
flexion to pain: 3

Front 13

give the GCS for the following scenario

Eyes open spontaneously
confused
withdrawal from pain

Back 13

Eyes open spontaneously: 4
confused: 4
withdrawal from pain: 4

Front 14

GCS score?

Extension to pain
incomprehensible sounds
eye opening to verbal commands

Back 14

Extension to pain: 2
incomprehensible sounds: 2
eye opening to verbal commands: 3

Front 15

quickest way to assess a pt in 10 seconds?

Back 15

ask the pt his or her name
and what happened

Front 16

Pregnant women have what important physiologic concern?

***

Back 16

if pt is on left side they will not get IVC compression

Symptoms of late pregnancy inferior vena cava syndrome consist of intense pain in the right hand side, muscle twitching, drop of blood pressure, and fluid retention

Front 17

what signs key you to progressive loss of airway

Back 17

stridor
anxious
hoarseness

Front 18

how can you assess the breathing part of ABCDE

Back 18

resp rate
chest movement
air entry
O2 sat

Front 19

What makes up the secondary survey?

What is an AMPLE history?

***

Back 19

Full H&P (do this after ABCDE, and when vitals are normalizing)

Allergies
Meds
Past illness/ Pregnancy
Last Meal
Events

Front 20

Which pts do I transfer to higher lvl care?

When should the transfer occur?

Back 20

those whose injuries exceed institutional capabilities

Airway and hemorrhage control are key
--consider this when surgery isn't available

Front 21

What is shock?

Back 21

inadequate tissue/end organ perfusion

AMS, anxiety
Cold diaphoretic skin
Tachycardia
Tachypnea
decreased urinary output (inadequate profusion to kidneys)

Front 22

Major cause of shock?

***

Others

Back 22

Hemorrhage ( Hypovolemic ) *** BLOOD LOSS

Nonhemorrhagic:
Tension PTX
cardiac tamponade
cardiogenic
Neurogenic
Septic

Front 23

Number one thing to do about shock?

Back 23

FLUID RESUSCITATION

2L of crystalloid wide open

2 large bore IVs

Front 24

Preferred access for giving fluids?

***

Back 24

2 large bore peripheral IVs

NOT CENTRAL LINE

Front 25

What is balanced resuscitation?

*** (? was on practice test)

Back 25

Permissive Hypotension

accept a lower than normal BP

Front 26

FFP dosage?

Back 26

10mL/kg

Front 27

750mL blood loss (15%) is what class hemorrhage?

symptoms?

tx?

Back 27

Class I

only symptom is slight anxiety (vitals will be normal)

tx: Crystalloid

Front 28

Amount of blood loss in Class I hemorrhage?

Back 28

up to 750mL

15%

remember: tx is crystalloid

Front 29

750-1500mL blood loss (15-30%) is what class hemorrhage?

Sx?

BP change?

Tx?

Back 29

Class II

Slightly anxious, tachy

Normal BP

Crystalloid

Front 30

1500-2000mL blood volume loss (30-40%) is what class hemorrhage?

Sx?

BP change?

Tx?

Back 30

Class III

Decreased BP

Need fluid and blood

Front 31

>2000 mL blood volume is what class hemorrhage?

Tx?

Back 31

Class IV

tx: right to blood and definitive control of bleeding

Front 32

When do you give blood? what class hemorrhage?

Back 32

Class III and above

aka 1500mL and above

if >2000 go right to blood

Front 33

pt loses 2200 mL blood is what class hemorrhage?

Back 33

IV

Front 34

pt loses 1700 mL blood is what class hemorrhage?

Back 34

III

Front 35

pt loses 1000 mL blood is what class hemorrhage?

Back 35

II

Front 36

If you get an Hemoglobin and Hematocrit right after trauma with blood loss, what would you expect?

Back 36

It should be normal

Front 37

HR > 120 is what class hemorrhage?

tx?

Back 37

Class III

Crystalloid and blood

Front 38

HR> 140 is what class hemorrhage?

tx?

Back 38

Class IV

BLOOD

Front 39

Class IV hemorrhage HR?

Class III?

Back 39

IV: >140

III: >120

Front 40

Major concern in head injury patients?

Back 40

PREVENT HYPOXEMIA

Front 41

how does the O2 dissociation curve change in shock

Back 41

in shock the O2 curve shifts to the right...

Front 42

Define the definitive airway

(objective-*?)

Back 42

Cuff tube in the airway

higher pressures, prevents secretions/vomi from trachea

Front 43

How do you know the airway is adequate

Back 43

Pt is alert and oriented

Pt is talking normally

No evidence of injury o the head/neck

You have assessed and reassessed for deterioration

Front 44

signs/sx of airway compromise?

(just for review i'd imagine)

Back 44

high index of suspicion
change in voice/sore throat
noisy breathing (snoring and stridor)
dyspnea/agitation
tachypnea
abnormal breathing pattern
low O2 sat (late sign)

Front 45

3 times to intervene in a pt with patent airway?

Back 45

Impending airway compromise (airway problem)

need for ventilation (breathing problem)

inability to protect the airway (disability)

GCS<8 INTUBATE

don't hesitate,.. couldn't think of more rhymes

Front 46

best way to displace the tongue during intubation?

Back 46

Jaw thrust

the tongue is the most obstructive thing when trying to intubate

Front 47

What is the LEMON mnemonic?

(there was a box saying to remember it)

Back 47

Look externally
Evaluate the 3-3-2 rule
Mallampati score
Obstruction
Neck Mobility

Front 48

What is the 3-3-2 rule?

Back 48

distance btwn the pts incisor teeth should be at least 3 finger breadths (3)

the distance btw the hyoid bone and the chin should be at least 3 finger breadths (3)

the distance btwn the thyroid notch and floor of the mouth should be at least 2 finger breadths (2)

Front 49

give the Mallampati classification:

soft palate, uvula, fauces, pillars visible

Back 49

Class I

Front 50

give the Mallampati classification:

soft palate, uvula, fauces visible

Back 50

Class II

Front 51

give the Mallampati classification:

soft palate, base of uvula visible

Back 51

Class III

Front 52

give the Mallampati classification:

hard palate visible

Back 52

Class IV

Front 53

Best predictor of tube being in the right place?

Back 53

visualizing it going through the cords!

others:
Watch the chest
Auscultation
CO2 detector/ ETCO2 monitor
Pulse ox
Xray

Front 54

Kirk's Highlights

-Focus on securing airway
-recognize the need to secure an airway
-correctly place the airway and adequately ventilate/prevent aspiration
-just because the gag reflex is present doesn't mean they don't need to be intubated
-maxofacial trauma: unstable midface can still be intubated (unstable jaw cannot)
-neck trauma: always think about vascular injury (hematoma precludes you from surgical airway)
-Hoarseness...look to tube

Back 54

not sure this is helpful or not...

Front 55

2 places where injuries are often missed that lead to death

Back 55

spleen and pelvis

Front 56

How do you determine if there is an abdominal or pelvic injury?

Back 56

DPL
FAST
PE (not very accurate)
CT

Front 57

what is diagnostic of injury to the bladder/urethra

Back 57

hematuria

note: its absence does not rule it out!

Front 58

Advantages of DPL?

Disadvantages?

Indications?

Back 58

advantage: Early dg, quick, 98% sensitive, detects bowel injury, no transport

dis: invasive, specificity is low, misses injury to diaphragm and retroperitoneum

indications: unstable blunt trauma, penetrating trauma

Front 59

Advantages of FAST?

Disadvantages?

Indications?

Back 59

adv: early dg, non invasive, rapid, repeatable, 86-97% sensitive, no transport

dis: operator-dependent, bowel gas and subQ air distortion, misses diaphragm, bowel, and pancreatic injuries

indications: unstable blunt trauma

Front 60

Advantages of CT?

Disadvantages?

Indications?

Back 60

adv: most specific for injury, 92-98% sensitive, non-invasive

disadvantage: cost/time, misses diaphragm, bowel, some pancreatic structures, TRANSPORT REQUIRED

indications: STABLE blunt trauma, penetrating back/flank trauma

Front 61

diagnostic study you should use for back and flank stab wounds?

Back 61

DPL, serial exams, or double/triple contrast CT

(they harped on this in the book a bit)

Front 62

indications for laparotomy? (blunt trauma)

(**?**)

Back 62

Hemodynamically abnormal with suspect abdominal injury

free air

diaphragmatic rupture

peritonitis

positive FAST, DPL, CT

Front 63

indications for laparotomy? (penetrating trauma)

(**?**)

Back 63

Hemodynamically abnormal
Free air
Peritonitis
Positive DPL, FAST, or CT
Evisceration

Front 64

what is usually the best strategy for GSW?

Back 64

Laparotomy!

Front 65

Important physiologic consideration in geriatrics

(probably know this, but they said it like 10x)

Back 65

low physiologic reserve

hypovolemic to begin with

Front 66

Initial management of pelvic fracture involves surgical consult and pelvic wrap.

What determines if the pt needs a laparotomy or angiography?

Back 66

Intraperitoneal gross blood

Front 67

Initial management of pelvic fracture involves surgical consult and pelvic wrap.

if intraperitoneal gross blood is present what does that indicate?

what if there is none?

Back 67

intraperitoneal blood present: Laparotomy

NO blood present: Angiography

Front 68

Flip to see abd/pelvis pitfalls

Back 68

delayed intervention for abd or pelvic hemorrhage

occult intraabdominal/retroperioneal injuries

back and flank wounds

repeated manipulation of a fractured pelvis

spinal cord injury

improperly applied pelvic wrap

skin necrosis from pelvic wrap

Front 69

danger of intubating a pt with a simple pneumo

Back 69

they are breathing hi pressure air and you can change a simple pneumo to a tension pneumo

Front 70

What are the immediately life threatening chest injuries

Back 70

Laryngeotracheal injury/airway obstruction
tension PTX
open pneumo
flail chest and pulmonary contusion
massive hemothorax
cardiac tamponade

Front 71

what is a flail chest

Back 71

multiple ribs fractured in multiple segments

gives paradoxical inspiration

when you inhale chest goes down

Front 72

define massive hemothorax

Back 72

1500 mL out of lung

Front 73

what 2 things can give tracheal deviation?

Back 73

tension PTX
hematoma of neck

Front 74

what type of acid base disorder will you see in a Tension PTX

Back 74

metabolic and respiratory acidosis

Front 75

What is the function of the dorsal columns?

*******TEST

Back 75

Proprioception, vibration, fine touch

crosses in the medulla

Front 76

What does it tell you when a patient is able to tell you he doesn't remember the accident and his leg hurts. GCS is 15

*******TEST

Back 76

Cerebral profusion is intact

airway is intact

Front 77

What do you do when a preggo is leaking amniotic fluid

*******TEST

Back 77

admit the pt

Front 78

pt is stabbed in the upper abdomen. What should you do first?

*******TEST

Back 78

Local wound exploration

(NOT FAST)

Front 79

you see a pt in neurogenic shock. What happens to their vasomotor tone?

if you see this question, just look for the starred answer

*******TEST

Back 79

Decreased

***RARE BELOW THE LEVEL OF T6

Front 80

When do you transfer a burn pt?

*******TEST

Back 80

>20%, face, hands, genitals, or airway involvement

Front 81

Elderly versus young

Who gets more subdurals?

who gets more cerebral contusions

*******TEST

Back 81

More subdurals: Old

more cerebral contusions: young

Front 82

where is CSF located?

*******TEST

Back 82

btw the arachnoid and pia

Front 83

What is cushnoid reflex?

*******TEST

Back 83

Hypertension
Bradycardia
Increased ICP

Front 84

more common dissection or aneurysm?

Back 84

disruption of aortic root

Front 85

80 pt with HR of 70, SBP of 70, bleeding profusely from scalp, what do you do first?

CT
Pressure on wound
or something else?

*******TEST

Back 85

Pressure on wound... this is due to the bleeding

hypotension in brain injury is due to blood loss

Front 86

what is usually the cause of hemothorax (what vessels)

Back 86

intercostal vein/artery

Front 87

What is a key component of treating rib fractures ?

(this was in the book too *?*)

Back 87

treat the pain without depressing their breathing

Front 88

symptoms of this include upper torso, facial, and arm plethora with petechiae secondary to acute temporary compression of the superior vena cava....what is this known as?

(*?*)

Back 88

Traumatic asphyxia (crush injury to the chest)

massive swelling and even cerebral edema may be present

Front 89

What is the number one thing that prevents successful BVM ventilation?

***

Back 89

The tongue

Front 90

If a patient is vomiting while on the board in c-spine precautions, what should you do?

Back 90

roll them on their side
maintain precautions
suction

Front 91

what is the equation for tube size in kids?

Back 91

(Age+16)/4

Front 92

What can estimate the size of a tube needed for intubation?

Back 92

the pts little finger or nostril

Front 93

In kids, what vital sign other than O2 sat can be a sign of decreasing O2

Back 93

bradycardia

Front 94

What constitutes a positive DPL on initial aspiration?

Back 94

20cc of fluid

Front 95

If you have a CXR that shows a pneumothorax, when can you just watch it and not intervene?

Back 95

<20%
STABLE
Not increasing in size

note: you must always TUBE a pt with TENSION PTX

Front 96

what causes pneumomediastinum?

Back 96

Esophageal tear or tracheal injury

this is when you have air that extends around the mediastinum and normally goes around the pericardium