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A comprehensive set of atls exam questions and answers specifically tailored for elderly and pregnant patients. It covers key physiological changes, risk factors, and management considerations for these patient populations. Valuable for medical students, residents, and healthcare professionals preparing for atls certification or seeking to enhance their knowledge in trauma care.
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aging is characterized by impaired adaptive and homeostatic mechanisms that caused an increased susceptibility to the stress of injury. Insults tolerated by the younger population can lead to devastating results in elderly patients."
physical impairment, history of previous fall, medication use, dementia, unsteady gait, and visual, cognitive impairment" "True or False? Mortality associated with small to moderate sized burns in older adults remains
"Spilled hot liquids on the leg, which in younger patients may re-epithelialize due to an adequate
"Airway-patients may have dentures that may loosen or obstruct the airway. If dentures are not
ventilation, as it improves mask fitting." "Functional changes in pulmonary system include decreased elastic recoil, reduced residual
are at increased risk for respiratory failure, increased risk for pneumonia, and poor tolerance to rib fractures" "Functional changes in renal system include loss of renal mass, decreased GFR, and decreased
insufficiency, decreased ability to concentrate urine, increased risk for AKI and urine flow may be normal with hypovolemia"
"True or false: Arthritis can complicate the airway and cervical spine. Patients can have multilevel degenerative changes affecting disk spaces and posterior elements associated with severe
"In elderly population, due to their changes in pulmonary system, placing a gauze between gums and cheek to achieve seal when using bag valve mask ventilation is okay. In addition, because
failure may present insidiously in older adults."
aging causes dura to become more adherent to the skull increasing risk of injury and older patients are on anticoagulant and antiplatelet medications." "Loss of subcutaneous fat, nutritional deficiencies, chronic medical conditions place elderly
evaluation and when possible early liberation from spine boards and cervical collars will minimize complications." "True or False: Fall prevention is the mainstay of reducing the mortality associated with pelvic
"The best initial treatment for the fetus is to provide optimal resuscitation of the mother. True or
patient's treatment, it should not be withheld because of the pregnancy." "An abrupt decrease in maternal intravascular volume can result in a profound increase in uterine
volume can occur resulting in a decreased hematocrit level. Thus, in late pregnancy a hematocrit of 31-33% is normal."
"Using a shoulder restraints in conjunction with a lap belt reduces the likelihood of direct and indirect fetal injury, presumably because the shoulder belt dissipates deceleration forces over a
pregnancy specific risks. Using lap belt alone allows for forward flexion and uterine compression with possible uterine rupture or placental abruption. Lap belt worn too high over uterus may produce uterine rupture."
15-30 degrees and elevate the right side 4-6 inches and support with a bolstering device to maintain spinal motion restriction and decompression of the vena cava." "Due to increases intravascular volume, pregnant patients can lose a significant amount of blood before tachycardia, hypotension, and other signs of hypovolemia occur. Thus, what do stable vital
distress and the placenta deprived of vital perfusion while the mother's condition and vital signs appear stable. Administer crystalloid fluid resuscitation and blood to support the physiological hypervolemia of pregnancy. vasopressers should be an absolute last resort in restoring maternal blood pressure as they further reduce uterine blood flow, resulting in fetal hypoxia." "Perform continuous fetal monitoring with a tocodynamometer beyond 20-24 weeks of
continuous monitoring for 6 hours, whereas, patients with risk factors for fetal loss or placental abruption should be monitored for 24 hours. RISK FACTORS ARE: heart rate > 110, an injury severity score >9, evidence of placental abruption, fetal heart rate >160 or less than 120, ejection during MV, and motorcycle or pedestrian collisions" "REMEMBER: maternal bicarbonate is low during pregnancy to compensate for respiratory
decelerations, absence of accelerations or beat to beat variability and frequent uterine activity can be signs of impending maternal and or fetal decompensation (hypoxia or acidosis) and should prompt immediate obstetrical consultation."
"If a DPL is to be placed in a pregnant trauma patient, place the catheter above the umbilicus using the open technique. Be alert to uterine contractions which suggest early labor and tetanic
chorioamniotic membranes include amniotic fluid in vagina evidenced by a pH of 4.5" "Bleeding in 3rd trimester may indicate placental abruption and impending death of the fetus, a
abdominal imaging can be done and radiation doses less than 50mGy are not associated with fetal anomalies or higher risk of fetal loss."
irritability, abdominal tenderness, pain or cramping, evidence of hypovolemia, changes in or absence of fetal heart tones and or leakage of amniotic fluid" "With extensive placental separation or amniotic fluid embolization, widespread consumptive coagulopathy can emerge rapidly causing depletion of fibrinogen, other clotting factors, and
fibrinogen, and other clotting factors."
pregnany RH negative trauma patients should receive RH immunoglobulin therapy unless injury is remote from the uterus (isolated distal extremity injury)"
burn size and depth, burns to the head and face, inhalation injury, associated trauma, and burns inside the mouth. Airway can become obstructed form direct injury such as inhalation injury, but also from massive edema resulting from burn injury."
circumferential neck burns, signs of airway obstruction, extent of the burn > 40%, burns inside the mouth, difficulty clearing secretions or swallowing, decreased level of consciousness," "Patient with inhalation injury are at risk for bronchial obstruction from secretions and debris and
airway tube"
lines with cross incision at the clavicular line and the junction of the thorax and abdomen usually relieve this problem. relieve circulatory compromise in a circumferentially burned limb by eschartomy and these escharotimies are not needed within the first 6 hours."
Do not break blisters or apply an antiseptic and application of cold compress can cause hypothermia. DO not apply cold water to a burn patient." "electrical burns are more serious than they appear on the body surface and extremities,
and can cause local thrombosis and nerve injury. So a severe electrical injury usually results in contracture of the affected extremity." "A clenched hand with a small electrical entrance wound should alert the clinician that a deep soft
forced contraction of muscles, doctors need to examine patient for skeletal and muscular damage, especially for fractures of the spine and rhabdomyolysis"
patterns may reflect cigarette burns or iron. Burns on the sole of the feet usually suggest child was placed in hot water. A burn on the posterior aspect of the LE and buttocks"
remember these burns can cause serious muscle damage without showing signs outright. Test urine for hemochromogen and administer proper volume. Assess for compartment syndrome and attach EKG leads as electrical injury can cause arrhythmias." "Frostbite is due to freezing of tissue with intracellular ice crystal formation, microvascular
edema are present w/o skin necrosis second degree: large clear vesicles accompany the hyperemia and edema with partial thickness skin necrosis. third degree frostbite: full thickness skin necrosis including muscle and bone with later necrosis
treatment is circulating water at constant 40 degrees C or 104F until pink color and perfusion return in 20-30 minutes." "In frostbite injury, warming large areas can result in reperfusion syndrome, with acidosis, hyperK
peripheral perfusion during rewarming." "Sympathetic blockade agents and vasodilating agents have shown to be effective in altering the
worsen coagulopathy and affect organ function."
Myoglobin induced renal failure can be prevented with intravascular fluid expansion, alkalinization of the urine by IV administration of Bicarbonate and osmotic diuresis."
"Knee dislocations can reduce spontaneously and may not present with any gross external or
ankle brachial index of less than 0.9 indicates abnormal arterial flow secondary to injury or peripheral vascular disease" "Blanched skin associated with fractures and dislocations can lead to soft tissue necrosis. The purpose of promptly reducing this injury is to prevent pressure necrosis of the lateral left ankle
dislocation or fracture is the presence of vascular compromise or impending skin breakdown, often seen with fracture dislocations of the ankle"
there is an associated fracture deformity, correct it by gently pulling the limb out to length,
hoarseness, cyanosis, agitation"
mallampati, obstruction, neck mobility" "Do not give a nasopharyngeal airway to someone suspected of having a cribriform plate fracture.
fracture" "A tube placed in the trachea with the cuff inflated below the vocal cords and the tube connected
definitive airway" "patients use the gum elastic bougie when vocal cords cannot be visualized on direct
80% of prehospital patients in whom laryngoscopy was difficult. A GEB inserted into the esophagus will pass its full length without resistance"
is suggested but not confirmed:
treatment as they worsen tissue perfusion. most injured patients who are in hemorrhagic shock require early surgical intervention or angioembolization to reverse the shock state. The presence of shock in a trauma patient warrants the immediate involvement of a surgeon." "An injured patient who is cool to the touch and is tachycardic should be considered to be in shock until proven otherwise. Massive blood loss may only produce a slight decrease in HCT/Hgb.
condition b/c compensatory mechanisms can prevent measurable fall in systolic pressure until up
to 30% of the patient's blood volume is loss. A narrowed pulse pressure suggests significant blood loss and involvement in compensatory mechanisms. tachycardia is diagnosed as > 100 in adults
160 in infants 140 in preschool aged children 120 in children from school age to puberty." "Tachycardia, muffled heart sounds, dilated engorged neck veins, hypotension and insufficient
commonly caused by penetrating thoracic trauma, but can result from blunt injury to the thorax. Definitive treatment is operative intervention as pericardiocentesis is temporary measure. Tension pneumothorax differs because it presents with distended neck veins and hypotension as well as absent breath sounds and hyperresonant percussion" "Acute respiratory distress, subcutaneous emphysema, absent unilateral breath sounds,
threatening condition and follow this with a chest tube" "isolated intracranial injuries do not cause shock, unless the brainstem is injured. A narrowed
of neurogenic shock is hypotension (due to loss of sympathetic tone) without tachycardia. A narrowed pulse pressure is not seen in neurogenic shock. The failure of fluid resuscitation to restore organ perfusion and tissue oxygenation suggest either continuing hemorrhage or neurogenic shock"
"15-30% blood loss. increase in heart rate. decrease in pulse pressure. BP, RR, urine output do not
mostly crystalloid fluid and base deficit of -2 to -6. anxiety, fear" "31-40% blood loss. heart rate increase, respiratory rate increase, blood pressure decrease, pulse
least amount of blood loss that consistently causes a drop in systolic blood pressure. blood products needed and base deficit is -6 to -10"
"what are these signs and symptoms describing? chest pain, air hunger, tachypnea, respiratory distress, tachycardia, hypotension, tracheal deviation away from side of injury, unilateral absence of breath sounds, neck vein distention, cyanosis (late manifestation), hyperresonance on
decompression or finger thoracostomy. place tube in afterwards" "pain, difficulty breathing, tachypnea, decreased breath sounds on affected side, and noisy
of an open pneumothorax. sterile occlusive dressing large enough to overlap the wound's edges and tap it securely on 3 sides"
hyperkalemia, hypoglycemia, hypothermia, toxins, cardiac tamponade, tension pneumothorax, thrombosis" "Massive hemothorax is suggested when a patient is in shock and has decreased breath sounds or
chest tube at the fifth intercostal space at the midaxillary line and you get a return of 1500mL or 1/3 or more of the patient's blood in the chest, that indicated the need for urgent thoracotomy. persistent need for blood is an indication for a thoracotomy. color of the blood is a poor indicator of the necessity for thoracotomy." "muffled heart sounds, hypotension, and distended necks veins may not always be present in cardiac tamponade. Kussmaul's sign (rise in venous pressure with inspiration when breathing spontaneously) is a true paradoxical venous pressure abnormality that is associated with
tension pneumothorax whereas presence of bilateral breath sounds is cardiac tamponade. FAST can identify cardiac tamponade. if FAST is unavailable, use echo or pericardial window. definitive treatment is surgery so thoracotomy or sternotomy."
injury, traumatic aortic disruption, traumatic diaphragmatic injury, esophageal rupture" "pulmonary contusion can occur with rib fractures and flail chest (two or more adjacent ribs
oxygen, adequate ventilation, and cautious fluid resuscitation. definitive treatment includes pain control, adequate oxygenation"
"Blunt cardiac injury can present with hypotension, dysrhythmias, EKG changes, premature ventricular contractions, unexplained sinus tachycardia, AFib, bundle branch block, elevated central venous pressure without any obvious cause may indicate right ventricular dysfunction
have little role in diagnosing blunt cardiac injury. patients with a blunt injury to the heart diagnosed by conduction abnormalities are at increased risk for sudden dysrhythmias and need to be monitored for 24 hours." "Traumatic aortic disruption- most survive if they have an incomplete laceration near the ligmentum arteriosum. commonly caused by vehicle collision or fall from a great height. have a
mediastinum on chest xray, obliteration of the aortic knob, deviation of the trachea to the right, depression of the L mainstem bronchus, elevation of R mainstem bronchus, deviation of the esophagus to the right, left hemothorax, presence of the pleural or apical cap, fractures of the first or second rib or scapula, widened paraspinal interface, widened paratracheal stripe." "In a traumatic aortic rupture, heart rate and blood pressure control can decrease the likelihood
"esophageal injury- clinical picture is a patient with a left pneumothorax or hemothorax without a rib fracture who has received a severe blow to the lower sternum or epigastrum and is in pain or
air also suggests diagnosis and definitive treatment is direct repair of the injury." "injuries to the retroperitoneal structures are difficult to recognize because they occur deep
urethra, scrotal hematoma or blood at the urethral meatus, discrepancy in limb length and rotational deformity of a leg w/o obvious fracture. use pelvic binder that is centered at the greater trochanters rather than over the iliac crests."
ecchymosis or hematoma of the scrotum and perineum. Palpation of the prostate gland is NOT a reliable sign of urethral injury.
"Duodenal injuries- a bloody gastric aspirate or retroperitoneal air on abdominal CT or radiograph
frontal-impact MVC and patients who sustain direct blows to the abdomen from bicycle handlebars." "Any early normal serum amylase level or an elevated amylase level does not conclude pancreas
hemiparesis and loss of pupillary response to light"
cerebral perfusion pressure. monroe kellie doctrine states that total volume of intracranial contents must remain constant because cranium is a rigid container incapable of expanding."
cerebral blood flow. GCS of 8 or less= severe brain injury GCS of 9-12= moderate GCS of 13-15= mild"
suspected open or depressed skull fracture any sign of basilar skull fracture emesis more than 2 episodes age > 65 anticoagulant use LOC > 5 minutes amnesia before impact"
temp 36- Glucose 80- Hgb > 7 PaCO2 35- ICP 5- pulse ox > 95 NA 135-145"
or glucose containing fluids because this can harm the injured brain) Avoid hyponatremia reversal of anticoagulants Hyperventilation to keep PaCO2 at 35-temporizing measure Mannitol-do not give to patients with hypotension"
warfarin: FFP, vitamin K, Prothrombin Complex Heparin or LMWH: Protamine Sulfate Direct thrombin inhibitors: Idarucizumab Rivaroxaban: N/A"
to the heart. Injury T6 and above can cause impairment of the sympathetic pathways. We get hypotension and bradycardia. Neurogenic shock is not reversed with fluid resuscitation alone. Vasopressors may be required. spinal shock refers to the loss of muscle tone (flaccid) and reflexes immediately after injury"
extremities occurring after a hyperextension injury, forward fall resulting in facial impact."
the anterior part of cord. paraplegia and bilateral loss of pain and temp. However, position, vibration, and deep pressure sense are preserved (sensations from dorsal columns). commonly due to cord ischemia"
Ipsilateral motor loss and loss of position sense and contralateral loss of pain and temp"
cirrhosis, coagulopathy, COPD, ischemic heart disease, DM"
Nonfatal falls are common in women and fractures are common in women who fall. Falls are the most common cause of TBI." "Most of elderly traffic fatalities occur in the daytime and on weekends and typically involve other
speeds and tend to drive during the day. Older people have slower reaction time, a larger blind spot, limited cervical mobility, decreased hearing, and cognitive impairment." "When preforming rapid sequence intubation, the dose of benzos, barbiturates, and other sedatives should be reduced to what percentage to minimize the risk of cardiovascular
"Functional changes in cardiac system include declining function, decreased sensitivity to catecholamines, atherosclerosis of coronary vessels, increased afterload, fixed heart rate (beta
cardiac ischemia, elevated BP at baseline, and increased risk of dysrythmias." "Functional changes to MSK include loss of lean body mass, osteoporosis, changes in joints and
intubation, risk of skin injury, increased risk for hypothermia, challenges in rehabiliation" "Functional changes in Endocrine system include decreased production and response to thyroxin
hypothyroidism, relative hypercortisone states and increased risk of infection" "Age related changes in the cardiovascular system place the elderly trauma patient at significant
Elderly patients have a fixed heart rate and fixed cardiac output, thus, their response to hypovolemia will involve increasing their systemic vascular resistance. Furthermore, since older patients have HTN, an acceptable BP may truly reflect a hypotensive state. A systolic BP of 110 is to be utilized as the threshold for identifying hypotension in patients 65 and older."
patients may look normal due to the medications they are on. Use lactate and base deficit to evaluate for evidence of shock" "poor hygiene, dehydration, oral injury, contusions affecting the inner arms, inner thighs, palms, soles, scalp, ear, nasal bridge and temple injury from being struck while wearing glasses, contact
presence of physical findings of maltreatment should prompt a detailed history. if history conflicts with findings, immediately report findings to authorities." "True of false: early activation of the trauma team may be required for elderly patients who do
an open tibia fracture in a frail elderly patient may become life threatening."
upper abdomen. As a result, the bowel is somewhat protected from blunt abdominal trauma, whereas the uterus and its contents (fetus and placenta) become more vulnerable. Uterus remains intrapelvic until 12 weeks and then at 20 weeks it is at the umbilicus, and at 34-36 weeks it reaches the costal margin." "Amniotic fluid can cause amniotic fluid embolism and disseminated intravascular coagulation
presentation, fetal head is usually in the pelvis and the remainder of the fetus is exposed above the pelvic brim. Pelvic fractures in late gestation can result in skull fracture or intracranial injury to the fetus. Also we can have a placental abruption due to its little elasticity and vulnerability to sheer forces." "During pregnancy the heart rate increases to a maximum of 10-15 beats per minute over
interpreting a tachycardic response to hypovolemia." "Blood pressure falls 5-15 mm Hg in systolic and diastolic pressures during second trimester,
experience hypotension when placed in the supine position due to the compression of teh inferior vena cava."
"Minute ventilation increases primarily due to an increase in tidal volume. Hypocapnia (30 mm