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ATLS Written Review FINAL EXAM 200 QUESTIONS &
DETAILED ANSWERS (WELL VERIFIED) ALREADY GRADED
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What is the primary goal of treating TBI? How is this done? **- CORRECT ANSWER
** 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? - CORRECT ANSWER >>> 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:
- anterior fossa:
- middle fossa:
- posterior fossa: - CORRECT ANSWER >>> 1. anterior fossa: frontal lobes
- middle fossa: temporal lobes
- posterior fossa: lower brainstem and cerebellum What are the 3 layers of the meninges? - CORRECT ANSWER >>> dura mater, arachnoid mater, pia mater What does the dura mater adhere firmly to? - CORRECT ANSWER >>> the skull. it is tough and fibrous
What layer of the meninges splits into two leaves as specific sites to enclose large venous sinuses? What do these sinuses do? - CORRECT ANSWER >>> dura mater. these sinuses provide major venous drainage from the brain. What is the midline sinus of of the brain that splits into two sinuses: bilateral transverse and sigmoid sinus? What side are these bigger on? - CORRECT ANSWER >>> The main sinus enclosed by the dura major is the midline superior sagital sinus. This splits into the sigmoid and bilateral transverse sinuses which are larger on the right side. What are the arteries that lie between the skull and the dura mater (epidural space)? - CORRECT ANSWER >>> meningeal arteries. What is the most commonly injured meningeal artery and where is it located? - CORRECT ANSWER >>> middle meningeal artery. Located over the temporal fossa T/F: the arachnoid mater is fused to the dura mater? - CORRECT ANSWER >>> FALSE: not attached. This produces a potential space for a subdural hematoma In a subdural hematoma, what is the cause? - CORRECT ANSWER >>> injury to bridging veins that extend from brain surface to the sinuses within the dura. _______ fills the space between the arachnoid and pia mater? - CORRECT ANSWER >>> CSF. this cushions the brain and spinal cord. What location of brain hemorrhage is frequently seen in brain contusion or injury to major blood vessels at base of brain? - CORRECT ANSWER >>> subarachnoid.
what part of the brain most commonly herniates through the tentorial notch? - CORRECT ANSWER >>> Uncus (medial part of temporal lobe) does weakness occur on the same or opposite side of the uncal herniation? **- CORRECT ANSWER
** 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.
- CORRECT ANSWER >>> ipsi contra average ICP is _____ mmHg. - CORRECT ANSWER >>> 10 The monro-kellie doctrine states that the total volume of intracranial contents must remain constant, because the cranium is ___ - CORRECT ANSWER >>> a rigid, non expandable container. The monro-kellie doctrine states that _____ and _____ may be compressed out of the skull providing a degree of buffering. - CORRECT ANSWER >>> 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)? **- CORRECT ANSWER
** CPP=MAP-ICP
in TBI, Every effort should be made to reduce ______, while normalizing ____, ___, and _____. - CORRECT ANSWER >>> ICP MAP, oxygenation, intravascular volume What GCS ranges for the following classes:
- Minor
- Moderate
- Severe - CORRECT ANSWER >>> 1. 13- 15
- 9 - 12
- 3 - 8 What nerve palsy may occur with basilar skull fracture? - CORRECT ANSWER >>> seventh nerve. A GCS of ___ is accepted definition of coma? - CORRECT ANSWER >>> 8 or less How do you assess a GCS of someone with asymmetric responses? **- CORRECT ANSWER
** Use the best possible because this will be the best predictor of outcome Basilar fractures of the skull usually require what type of imaging? - CORRECT ANSWER >>> this requires CT with bone-window setting. What are the typical clinical signs of basilar skull fractures? **- CORRECT ANSWER ** 1.periorbital ecchymosis (raccoon eyes)
- retroauriculor ecchymosis (battle sign)
- CSF leak from nose or ears
- 7th or 8th CN dysfunction (facial paralysis and hearing loss)
What is the imaging protocol for a patient with cerebral contusion? **- CORRECT ANSWER
** get CT at presentation. then get another within 24 hours to assess for coalesced hematoma. What factors would require a CT in minor brain injury? - CORRECT ANSWER >>> 1. suspected open skull frac
- basilar frac
2 episode vomitting
- pt older than 65
- LOC >5 min
- amnesia before impact of >30 min How long after discharge should patient with mild brain injury be observed by friend? - CORRECT ANSWER >>> 24 hours What type of brain injury requires serial GCS? - CORRECT ANSWER >>> ALL. minor. moderate. major What imaging is done in all patient with moderate brain injury? - CORRECT ANSWER >>> CT What factor of ABCDE must be monitored closely in moderate brain injury? **- CORRECT ANSWER
** Airway and breathing. rapid deterioration may occur. hypoventilation and hypercapnia may ensue requiring intubation. close monitoring in ICU is required. What should immediately follow the secondary survey in major/severe brain injury? - CORRECT ANSWER >>> CT. REMEMBER: CT should never delay patient transfer
When assessing ABCDE of severe brain injury, when does DPL or FAST come before neuro exam?
- CORRECT ANSWER >>> if the systolic blood pressure cannot be brought above 100, DPL or FAST is done first as to assess source of hypotension Spinal cord injury has what result in blood pressure? - CORRECT ANSWER >>> hypotension. This may also occur in terminal brain injury with medullary failure What needs to be cleared before Doll's eye testing is conducted? - CORRECT ANSWER >>> cervical spine must cleared. What tests should be performed before sedation? - CORRECT ANSWER >>> GCS and pupillary rxn A midline shift of _____mm or greater on the CT is indicative of need for neurosurgery to evacuate the clot or contusion causing the shift - CORRECT ANSWER >>> 5mm What type of fluids should be used? - CORRECT ANSWER >>> hypertonic (ringers lactate or normal saline). NO GLUCOSE. What electrolyte abnormality is associated with brain edema and must be monitored? - CORRECT ANSWER >>> hyponatremia What are the physiologic consequences of PaCO2 >45? PaCO2 <30? - CORRECT ANSWER >>> f PaCO2 >45 = vasodilation = inc ICP PaCO2 <30 (hyperventilation) = constriction = ischemia What is the preferred PaCO2 in brain injury? - CORRECT ANSWER >>> 35 mm Hg
What clinical signs are the criteria for brain death? - CORRECT ANSWER >>> GCS of 3, nonreactive pupil, absent brainstem reflexes, no spontaneous ventilatory effort
Which vertebrae is most susceptible to injury? - CORRECT ANSWER >>> 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 - CORRECT ANSWER >>> 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? - CORRECT ANSWER >>> 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 _____. - CORRECT ANSWER >>> complete spinal cord injury T/F: the thoracolumbar junction is extremely strong and rarely incurs injury? - CORRECT ANSWER >>> 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? - CORRECT ANSWER >>> begins at foramen magnum at terminal end of the medulla oblongata and end at L What is sacral sparing? - CORRECT ANSWER >>> 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? - CORRECT ANSWER >>> position, vibration, light touch, all from same side of body.
- ruptured bronchus
- pulmonary contusion
- mass hemothorax - CORRECT ANSWER >>> All EXCEPT pulmonary contusion What is the initial bolus for fluid resuscitation when a small child is in shock? - CORRECT ANSWER >>> 20mL/kg ringers lactate What are the chest tube blood volume output parameters that would require a thoracotomy? - CORRECT ANSWER >>> >1500mL immediatley evacuated OR 200mL/hr for 2-4hrs NOTE: thoractomy is not indicated unless a surgeon qualified by training and experience is present How can one determine the appropriate tube depth for pediatric intubation? - CORRECT ANSWER >>> ETT tube size x 3 Ex: 4.0 ETT would be properly positioned at 12 cm from the gums In pediatrics: once past the glottic opening, the ETT should be positioned __ to ___ cm below the level of the vocal cords and then carefully secured. - CORRECT ANSWER >>> 2 - 3 cm Fluid resuscitation of an infant begins with _______(amount and type). And then progresses to ______. (amount and type) - CORRECT ANSWER >>> 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? - CORRECT ANSWER >>> orotracheal intubation
What should be used when vocal chords cannot be visualized on direct laryngoscopy? - CORRECT ANSWER >>> gum elastic bougie. in place when you feel clicks. can be inserted blindly beyond epiglottis What is the acronym BURP? - CORRECT ANSWER >>> backward, upward and rightward pressure used in external laryngeal manipulation with orotracheal intubation what is the most common life threatening injury in children? - CORRECT ANSWER >>> tension pneumothorax What is the most common acid-base disturbance in the injury child and what is it caused by? - CORRECT ANSWER >>> 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? - CORRECT ANSWER >>> 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? - CORRECT ANSWER >>> 40C (104F) should be done in whirlpool. not dry heat. What is the main utility of ECG during resuscitation? - CORRECT ANSWER >>> detecting rhythm abnormalities What does PaCO2 of 35-40 mmHg indicate in late pregnancy? - CORRECT ANSWER
- the definitive after this would be a surgical chricothyroidotomy or an emergent tracheotomy. (emergent tracheotomy is not preferred because complication and time consuming) What hold urine output be maintained at after a crush injury to prevent kidney injury? - CORRECT ANSWER >>> 100 mL/hr Is operation ever indicated in first hour after injury of multiple injured patient? - CORRECT ANSWER >>> yes. especially if class 3 or 4 hemorrhagic shock is present What class of shock are there NO clinical signs of inadequate organ perfusion? - CORRECT ANSWER >>> Class I. <14% blood volume loss. (<750mL) What is suggested if chest tube placement for suspected pneumothorax results in incomplete lung expansion and air leak with bubbling? What imaging confirms? - CORRECT ANSWER >>> This suggests tracheobronchial injury such as ruptured bronchus.
- a second chest tube may need to be placed
- this is confirmed with broncoscopy Why do chest injuries have a high priority in the multiply injured person? - CORRECT ANSWER >>> they often result in hypoxia What is the physiology behind neurogenic shock? - CORRECT ANSWER >>> loss of vascular tone What is another name for Central Venous Pressure? When is it elevated? - CORRECT ANSWER >>> Basically the same as Right atrial pressure.
- Elevated in cardiac failure, tamponade, tension pneumo, disrupted thoracic aorta.
What would be expected on ABG abnormalities for pulmonary contusion? **- CORRECT ANSWER
** PaO2 <65 mm Hg (sat <90) would suggest need for intubation and in the presence of flail chest is more suggestive t/f vomitus in the posterior oropharynx suggests esophageal intubation. **- CORRECT ANSWER ** false. signs include: epigastric fullness, absent end title CO2, absent breath sounds, audible borborygmi sounds over abdomen t/f: major head injury rarely causes shock by itself - CORRECT ANSWER >>> true What are the vital signs to be expected when ICP increases? **- CORRECT ANSWER ** decreased respirations and HR, increased systolic and pulse pressure Urethral injury should be suspected in the presence of what three things? - CORRECT ANSWER >>> 1. blood at the meatus
- perineal ecchymosis
- high riding or non-palpable prostate What test is used to confirm the integrity of the urethra before a catheter is inserted? - CORRECT ANSWER >>> retrograde urethrogram What physical exam is essential before passing a urethral catheter **- CORRECT ANSWER
** examine the rectum and perineum What is the best guide for adequate fluid resuscitation in a burn patient? - CORRECT ANSWER
What three X-ray views are most important for a person with multiple trauma? - CORRECT ANSWER >>> c-spine, chest, pelvis Pulse oximetry provides information about _____ and ____ but does not provide information about ____ - CORRECT ANSWER >>> 1. O2 sat
- peripheral perfusion
- adequacy of ventilation Carboxyhemoglobin levels greater than ___% in burn patient indicate inhalation injury and require transport and/or intubation if transport is prolonged. - CORRECT ANSWER >>> 10% An 18-year-old man is brought to the hospital after smashing his motorcycle into a tree. He is conscious us and alert, but paralyzed in both arms and legs. His skin is pale and cold. He complains of thirst and difficulty in breathing. His airway is clear. His blood pressure is 60/40 and his pulse rate is 140 beats per minute. Breath sounds are full and equal bilaterally. He should be treated for what first? - CORRECT ANSWER >>> 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? - CORRECT ANSWER >>> 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? - CORRECT ANSWER >>> prepare for exploratory thoracotomy What are the symptoms with anterior crod syndrome? - CORRECT ANSWER >>> 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? - CORRECT ANSWER >>> 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? - CORRECT ANSWER >>> Think of a cut from anterior to posterior of the cord.
- ipsilateral motor loss, and loss of position of and vibratory sense
- contralateral loss of pain/temperature sense beginning 1-2 levels down from lesion. What is the primary concern in flail chest? - CORRECT ANSWER >>> pulmonary contusion resulting in hypoxia prevention of hypo perfusion and hypoxia are most important for optimal outcome in _____. - CORRECT ANSWER >>> TBI What imaging is required for a patient displaying basilar skull fracture: hemotympanum, raccoon eyes, CSF otorrhea, battle sign? - CORRECT ANSWER >>> CT! also age >65, GCS<15 2hours post injury, suspected depressed skull frac, committing more than two episodes, LOC >5 min, amnesia before impact (more than 30 min), dangerous mechanism. T/F: bony injury in pediatrics is more common than in adults? - CORRECT ANSWER >>> FALSE: because bones are more pliable you will often find internal organ damage without overlying bone damage. Compare the specificity and sensitivity of DPL and CT in blunt abdominal trauma. - CORRECT ANSWER >>> DPL- high sens (98), low spec CT - high sens (92-98), high spec (95)
