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A comprehensive review of the atls (advanced trauma life support) exam, covering key concepts and principles related to the management of traumatic brain injury (tbi). It includes detailed questions and answers, addressing various aspects of tbi, such as anatomy, physiology, clinical presentation, diagnosis, and treatment. Valuable for medical professionals preparing for the atls exam or seeking to enhance their knowledge of tbi management.
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What is the primary goal of treating TBI? How is this done? – preventing secondary brain injury. This is done by maintaining blood pressure and providing adequate profusion. After managing ABCDEs of TBI what MUST be identified if present? How is this done? – mass lesion that requires surgical evacuation is critical! this is done with CT. NOTE: obtaining a CT should not delay patient transfer to trauma center. Which brain lobes do the following hold:
T/F: the arachnoid mater is fused to the dura mater? –
does weakness occur on the same or opposite side of the uncal herniation? – OPPOSITE. the corticospinal tract of the midbrain is compressed and then crosses at the foramen magnum. state: Ipsilateral/contralateral pupillary dilation associated with hemiparesis is the classic sign of uncial herniation. – ipsi contra average ICP is mmHg. – 10 The monro-kellie doctrine states that the total volume of intracranial contents must remain constant, because the cranium is - a rigid, non expandable container. The monro-kellie doctrine states that and _ may be compressed out of the skull providing a degree of buffering. – CSF and venous blood. Once the CSF and venous blood reach a certain level of displacement the ICP rapidly increases. What is the equation for CPP (cerebral perfusion pressure)? – CPP=MAP-ICP in TBI, Every effort should be made to reduce , while normalizing , , and
. – ICP MAP, oxygenation, intravascular volume What GCS ranges for the following classes:
8 or less How do you assess a GCS of someone with asymmetric responses? – Use the best possible because this will be the best predictor of outcome Basilar fractures of the skull usually require what type of imaging? – this requires CT with bone-window setting. What are the typical clinical signs of basilar skull fractures? – 1.periorbital ecchymosis (raccoon eyes)
**2. retroauriculor ecchymosis (battle sign)
What type of fluids should be used? – hypertonic (ringers lactate or normal saline). NO GLUCOSE. What electrolyte abnormality is associated with brain edema and must be monitored? – hyponatremia What are the physiologic consequences of PaCO2 >45? PaCO2 <30? – f PaCO2 >45 = vasodilation = inc ICP PaCO2 <30 (hyperventilation) = constriction = ischemia What is the preferred PaCO2 in brain injury? – 35 mm Hg If ICP is rapidly increasing, what can be done while preparing for craniotomy? – hyperventilation. NOTE: this must be monitored closely and is only done very short periods at a time Does hypertonic saline lower ICP in hypovolemia? Does mannitol lower ICP in hypovolemia? – No NO After administration of mannitol what should be monitored closely? – ICP! mannitol has a substantial rebound effect on ICP What is the role of muscle relaxants (vecuronium or succinylcholine) in seizures with TBI?
GCS of 3, nonreactive pupil, absent brainstem reflexes, no spontaneous ventilatory effort Which vertebrae is most susceptible to injury? – Cervical. NOTE: in peds this accounts for only 1% of vertebral injury What nerve and cervical spine level would cause apnea and results in death in 1/3 of patient with upper cervical spine injury – phrenic nerve C At what age do cervical spine differences begin to normalize? at what age does cervical spine look like that of an adult? – marked differences in cervical spine occur until age 8 and steadily decline until age 12 when they are similar When a dislocation-fracture of the vertebrae occurs, almost always the result is.
complete spinal cord injury T/F: the thoracolumbar junction is extremely strong and rarely incurs injury? – FALSE: the flexible thoracic meeting the rigid lumbar make this area a common place for injury (15% of all spinal injuries) At what levels do the spinal cord begin and end? – begins at foramen magnum at terminal end of the medulla oblongata and end at L What is sacral sparing? – this is a sign of incomplete spinal cord injury where some sensation below an injury to spinal cord is preserved. In the case of sacral sparing, sensation and rectal sphincter tone is preserved. What function does the dorsal column have? What tests can be done to assess function? – position, vibration, light touch, all from same side of body. TESTS: positioning of bent toes/fingers, vibration with tuning fork. What function does the spinothalamic tract have? what tests can be done to assess function?
Fluid resuscitation of an infant begins with (amount and type). And then progresses to. (amount and type) – 20mL/kg Ringers lactate. (may give up to three of these boluses initially) For the third bolus consider PRBCs at 10mL/kg For a patient who is not breathing what intervention is indicated? – orotracheal intubation What should be used when vocal chords cannot be visualized on direct laryngoscopy? – gum elastic bougie. in place when you feel clicks. can be inserted blindly beyond epiglottis What is the acronym BURP? – backward, upward and rightward pressure used in external laryngeal manipulation with orotracheal intubation what is the most common life threatening injury in children? – tension pneumothorax What is the most common acid-base disturbance in the injury child and what is it caused by? – Respiratory acidosis caused by hypoventilation. What are the options to establish an airway when bag-mask ventilation and attempts at orotracheal intubation fail for a child? – LMA, or intubating LMA, or needle cricothyroidotomy.
- needle-jet insufflation is an appropriate temporizing technique for oxygenation but does not provide adequate ventilation. NOTE: surgical cric is RARELY indicated for infants an small children. usually it is an adoption when the cricothyroid membrane is easily palpable around the age of 12. A local area of frost bite should be rewarmed with what temperature and in what waY? – 40C (104F) should be done in whirlpool. not dry heat. What is the main utility of ECG during resuscitation? – detecting rhythm abnormalities What does PaCO2 of 35 - 40 mmHg indicate in late pregnancy? – impending respiratory failure. hypocapnia (around 30) is typical in late pregnancy due to inc tidal volume. Other than maternal death, what is the leading cause of fetal death? Symptoms? –
abruptio placentae (70%) suggested by vaginal bleeding, uterine tenderness, uterine contractions, uterine tetany, and irritability of uterus (contracts when touched) What type of monitoring should be initiated in fetus of gestation age >20 wks – continuous monitoring with tocodynamometer. monitor should be done for 6 hours with no symptoms, and 24 with abruptio symptoms. What are the two extra precautions during primary survey of pregnant woman? –
**1. uterus should be displaced manually to the left to relive pressure not he inferior vena cava.
NOTE: parkland is only for estimating and should be adjusted in accordance with urinary output. fluids should not be slowed at 8 hours if urine output is not adequate The LEAST likely cause of a depressed level of consciousness in the multisystem injured patient is a. shock. b. head injury. c. hyperglycemia. d. impaired oxygenation. e. alcohol and other drugs. - c hyperglycemia. For a patient bleed profusely from a wound not he medial thigh where should pressure be applied? – pressure should b applied directly to the wound. Do not apply pressure to the proximal femoral artery at the groin What is one characteristic shared by all SURVIVORS of traumatic aortic disruption? – contained hematoma What does x ray showing widened mediastinum and obliteration of the aortic knob suggest? – traumatic aortic disruption What is the sensitivity and specificity of CT in aortic disruption? – around 100%. NOTE: CT angiography should only be used to further identify site of disruption (not an initial test) What three X-ray views are most important for a person with multiple trauma? – c- spine, chest, pelvis Pulse oximetry provides information about and but does not provide information about -
**1. O2 sat
hypovolemic shock with fluids. NOTE: airway is OK because he is talking even though he complains of trouble breathing. What is the most important principle in the early management of someone with TBI and increasing ICP? – prevent hypotension For a trauma patient that requires a chest tube, the tube is placed and 1600mL of blood returns. What is the next step in management? – prepare for exploratory thoracotomy What are the symptoms with anterior crod syndrome? – paraplegia and loss of temperature and pain sensation, with preservation of position and vibratory senses and deep pressure sense. WORSE PROGNOSIS What are the symptoms of central cord syndrome? – disproportionate motor strength loss greater in upper extremities than lower with varying degree of sensory loss.(the arms and hands are most severely affected) What are the symptoms of Brown-Sequard syndrome? – Think of a cut from anterior to posterior of the cord.
**- ipsilateral motor loss, and loss of position of and vibratory sense