ATLS Chapters 4-6

Question

How should you position the patient before placing a subclavian or IJ line?

How long can you keep an IO line in?

Where do you want to make an incision for a saphenous vein cutdown and how long
should your incision be?
A patient arrives to the trauma bay intubated and there are absent breath sounds
over the left hemithorax, where should you place your decompression needle?
Where would you insert a large caliber needle to decompress a tension
pnuemothorax?
For an open pneumothorax, (sucking chest wound) air passes preferentially through
the chest wall defect (least resistance) if the diameter of the defect is at least ___
the diameter of the trachea.
Flail chest results from multiple rib fractures - by definition this would be ___ or
more ribs, fractured in ___ or more places.
Both tension pneumothorax and massive hemothorax are associated with
decreased breath sounds on auscultation, so you can tell which it is by _______.
If a patient doesn't have JVD, does this mean they don't have a tension pneumo or
tamponade?
By definition, how much blood is in the chest cavity to call it a "massive
hemothorax"?
What size chest tube might you use to evacuate a massive hemothorax?

What is Kussmaul's sign?

How well do CPR compressions work on someone with a penetrating chest injury
and hypovolemia?

Are patients with PEA who have sustained blunt thoracic injuries candidates for an
ED thoracotomy?
An ED thoracotomy can allow you to do what?
For a patient with a traumatic simple pneumothorax, what should you do BEFORE
you start positive pressure ventilation or take them to surgery for a GA?
Should you evacuate a simple hemothorax if it is not causing any respiratory
problems?
A pneumothorax associated with a persistent large air leak after tube thoracostomy
suggests a _______ injury.
What radiographic findings are suggestive of traumatic aortic disruption?
A deceleration injury victim with a left pnuemothorax or hemothorax without rib
fractures, is in pain or shock out of proportion to the apparent injury, and has
particulate matter in their chest tube may have _________.
Fractures for the lower ribs (10-12) should increase suspicion for _____ injury.
Why are upper torso, facial, and arm plethora with petechiae associated with crush
injuries to the chest?
How does ATLS suggest you should review a chest radiograph?
You should use a size 16 or 18 gauge 6" needle for pericardiocentesis. How do you
insert it?
What's a good way to know if you've advanced your needle too far during
pericardiocentesis and have entered ventricular muscle?
What should you do with your needle after you successfully evacuate blood during
pericardiocentesis?
For patients with facial fractures or basillar skull fractures, gastric tubes should be
inserted ____ before doing a DPL.
You need to do retrograde urethrography PRIOR to foley placement if _____.

DPL is considered to be __% sensitive for detecting intraperitoneal bleeding.

What are the four places you should look first when doing a FAST scan?
DPL is indicated when a patient with multiple blunt injuries is hemodynamically
unstable, especially when they have _____.
What is the only ABSOLUTE contraindication to DPL?

What are some RELATIVE contraindications to DPL?

When should you use an open SUPRAUMBILICAL approach for a DPL?

When doing a DPL, what INITIAL findings (not from lab) would mandate a
laparotomy?
If you don't get gross blood upon initial DPL aspiration, what do you do next for an
adult? For a child?
You've just put a bunch of fluid in the belly and aspirated more fluid for your DPL.
No gross GI contents or anything alarming are present, what QUANTATIVE things
would make the DPL positive?
Your trauma patient needs an urgent laparotomy, can you take them to the CT
scanner first to evaluate injuries?
What are some indications for laparotomy in patients with penetrating abdominal
wounds?
What percentage of stab wounds to the anterior abdomen do NOT penetrate the
peritoneum?
Does an early normal serum amylase level exclude major pancreatic trauma?

Do you need to operate on anyone with an isolated soild organ injury?

Which is LESS likely to have a life-threating hemorrhage - an open book or closed
book pelvic fracture?

Anterior/posterior forces causes _____ book pelvic fractures, and lateral forces cause
_____ book fractures.
Which are more common, open or closed book pelvic fracturs?
If a patient with a pelvic fracture is positive for intraperitoneal gross blood, a ex-lap
is warranted. What is your next move if that same patient is NEGATIVE for gross
intraperitoneal blood?
What do you need to do BEFORE you do a DPL? (Other than getting stuff together
and surgically prepping, etc...)
What is "adequate" fluid return when getting DPL fluid back?
A blown pupil in a patient with a traumatic injury is caused by compression of which
nerve?
What is a "normal" ICP in the resting state?
The Monro-Kellie Doctrine describes compensatory mechanisms inside the
calvarium to stabilize pressure - what are the 2 main/first ones?
Patients with a GCS of 3-8 meet the accepted definition of "coma" or "severe brain
injury." What are the GCS scores for "minor" and "moderate" brain injury?
When calculating GCS and there is right/left assymetry in the motor response which one do you use?
What signs might you see if a patient has a basillar skull fracture?

What do you need to know about the GCS?

What things might require a person with MINOR brain injury get admitted?
What would you want to do if a patient with a minor brain injury fails to reach a GCS
of 15 within 2 hour post injury, had LOC >5 min, are older than 65, emesis x 2, or
had retrograde amnesia >30 minutes?
What 2 things do you need to do first for everyone with a MODERATE brain injury
(according to ATLS algorithm)?

High levels of CO2 will cause cerebral vasculature to _____.

Ideally, you want to wait to perform a GCS on a person with SEVERE brain injury
until what?
A FAST scan, DPL, or ex-lap should take priority over a CT scan if you can't get the
brain injured patient's BP up to ____ mm Hg.
A midline shift of greater than ___ often indicates the need for neurosurgical
evacuation of the mass/blood.
Your patient has a dilated pupil and you want to give mannitol on the way to the CT
scanner or OR. What is the correct dose?
A cast cutter should be removed to remove a trauma victim's helmet if there is
evidence of a c-spine injury or if _____.

Answer
SUPINE, head down 15 degrees to distend neck veins and prevent embolism, only turn head away if
C-SPINE HAS BEEN CLEARED FIRST.
Intraosseous infusion should be limited to emergency resuscitation and shoudl be discontinued as
soon as other venous access is obtained.
The saphenous vein can be accessed approximately 1 cm anterior and 1 cm superior to the medial
malleolus. Make a 2.5 cm transverse incision through the skin and SQ tissue, careful not to injure
the vessel.
This may NOT be a pneumothorax, for intubated patients always suspect a right main-stem before
attempting needle decompression.
Into the 2nd intercostal space in the midclavicular line of the affected hemithorax.

2 per tiga

2 or more ribs fractured in 2 or more places

Percussion - hyperresonant with pnuemo, dull with hemothorax.

No, they might have a massive internal hemorrhage and be hypovolemic.

1500 mL or 1/3 or more of the patient's total blood volume. (Some also define it as continued blood
loss of 200 mL/hr for 2-4 hours- but ATLS does NOT use this rate for any mandatory treatment
decisions).
#38 French - inserted at the 4th or 5th intercostal space, just anterior to the midaxillary line.
A rise in venous pressure with inspiration while breathing spontaneously, and is a true paradoxical
venous pressure abnormality associated with cardiac tamponade.
"Closed heart massage for cardiac arrest or PEA is INEFFECTIVE in patients with hypovolemia."
Patients with PENETRATING thoracic injuries who arrive pulseless, but with myocardial electrial
activity, may be candidates for an ED thoacotomy.

NO - Only PEA with PENETRATING thoracic injuries should get an ED thoracotomy.

Evacuate pericardial blood, direcly control hemorrhage, cardiac massage, cross-clamp the
descending aorta to slow blood loss below the diaphragm and increase perfusion to the heart and
brain.
CHEST TUBE - positive pressure ventilation can turn a simple pneumo into a tension pneumo, so put
in a chest tube first.
YES - A simple hemothorax, if not fully evacuated, may result in a retained, clotted hemothroax with
lung entrapment or, if infected, develop into an empyema.
tracheobronchial - Use bronchoscopy to confirm, you may need more than one chest tube before
definitive operative management.
Widened mediastinum, obliteration of aortic knob, deviation of trachea to the right, depression of
left mainstem bronchus, deviation of esophagus (NG tube) to right, widened paratracheal stripe,
fx'd 1st/2nd ribs or scapula.
an ESOPHAGEAL RUPTURE - a forceful blow causes expulsion of gastric contents into the
esophagus, producing a linear tear in the lower esophagus allowing leakage into the mediastinum.
hepatosplenic

Temporary compression of the superior vena cava.

Trachea & bronchi, pleural spaces and parenchyma, mediastinum, diaphragm, bones, soft tissues,
tubes & lines.
Puncture the skin 1-2 cm inferior to the left xiphohondral junction at a 45 degree angle to the skin
towards the heart, aiming toward the top of the left scapula.
ECG Changes - extreme ST-changes, widened QRS, PVCs, etc... Withdrawl needle until ECG returns
to baseline.
Lock the stopcock and leave the catheter in place in case it needs to be reevacuated. If possible,
use the Seldinger technique to pass a 14 gauge flexible catheter over the guidewire. This is NOT a
definitive treatment.
through the mouth
inability to void, unstable pelvic fracture, blood at urethral meatus, scrotal hematoma, perineal
ecchymoses, or high-riding prostate.

98

Mediastinum, hepatorenal fossa, splenorenal fossa, pouch of Douglas.

Change in sensorium (brain injury/EtOH or drug intoxication), change in sensation (spinal cord
injury), injury to adjacent structures (pelvis, lumbar spine), lap-belt sign (from seatbelt), or if patient
is going for long studies (CT, ortho surgery...).
An existing indication for laparotomy.
Morbid obesity, advanced cirrhosis, preexisting coagulopathy, and previous abdominal operations
(adhesions).
PELVIC FRACTURES (don't want to enter pelvic hematoma) and ADVANCED PREGNANCY (don't want
to damage enlarged uterus).
Free blood (>10 mL) or GI contents (vegetable fiber, bile).

Adult - 1,000 mL warm isotonic crystalloid. Kid - 10 mL/kg

>100,000 red cells/mm^3, 500 white cells/mm^3, or BACTERIA (on gram stain).
No, if they need an emergent laparotomy they are unstable - unstable patients should NOT go to
the CT scanner!
Unstable, GSW, peritoneal irritation, fascial penetration

25-33%

NO
No - not if they remain hemodynamically stable (Of all patients who are initially thought to havea
ISOLATED solid organ injury, <5% will have hollow viscus injury as well).
Closed book - the pelvic volume is compressed, so not as much room for blood.

AP = Open Book, LATERAL = Closed Book

CLOSED BOOK - 60-70% (Open book 15-20%, vertical shear 5-15%)

Angiography

DECOMPRESS BLADDER, DECOMPRESS STOMACH

30%

Superficial parasympathetic fibers of the CN III (occulomotor).

10mm Hg (Pressures >20, particularly if sustained, are associated with poor outcomes).
Venous Blood & CSF (decreased in equal volumes, when this is exhausted, herniation can occur and
brain perfusion will likely be inadequate).
Minor = 13-15, Moderate = 8-12

The "BEST" response. (Better predictor than worst response)

PERIORBITAL ECCHYMOSIS (raccoon eyes), RETROAURICULAR ECCHYMOSIS (Battle sign), and
otorrhea/rhinorrhea.
EVERYTHING - Know it COLD!
Abnormal CT (or no scan available), penetrating head injury, prolonged LOC, worsening LOC,
moderate to severe HA, significant drug/alcohol intoxication, skull fx, oto/rhinorrhea, nobody at
home to watch, GCS stays <15, focal neuro deficits.
CT scan - Everything but the 30 min amnesia makes them HIGH risk for neurosurgical intervention
(as would a basillar skull fx).
CT scan, admit to faciolity capable of definitive neurosurgical care (Moderate = GCS 9-12)

Dilate (to increase blood flow) - so you might want to HYPERventilate people with brain injuries.

BP is normalized
100 If a patient has a systolic over 100 with evidence of intracranial mass (blown pupil, unequal
motor exam) THEN a CT would take first priority.
5mm

0.25-1.0 g/kg via rapid bolus

the patient experiences pain or paresthesias during an initial attempt to remove the helmet.