ATLS EXAM

American Burn Association states 2 requirements for diagnosis of smoke inhalation injury:

1. exposure to combustible agent 2. signs of exposure to smoke in the lower airway, below the vocal cords, seen on bronchoscopy. A chest Xray and arterial blood gases should be ordered to evaluate the pulmonary status of a patient with smoke inhalation injury, but normal values on admission DO NOT exclude an inhalation injury.

A carboxyhemoglobin level greater than what percentage indicates a patient was involved in a fire and has inhalation injury?

10%

REMEMBER: maternal bicarbonate is low during pregnancy to compensate for respiratory alkalosis.

17-22 in pregnant patient. (non pregnant patient is 22-28)

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 depression?

20-40%

Physiological anemia of pregnancy

A smaller increase in red blood cell volume can occur resulting in a decreased hematocrit level. Thus, in late pregnancy a hematocrit of 31-33% is normal.

Tachycardia is a poor indication for resuscitation in the burn patient.

Adjust the fluid rate up or down based on the urine output and recognize that factors such as inhalation injury, age of patient, renal failure, diuretics, and alcohol can affect the volume of resuscitation and urine output.

As little as 0.01mL of RH+ blood will sensitize 70% of Rh- women.

All pregnany RH negative trauma patients should receive RH immunoglobulin therapy unless injury is remote from the uterus (isolated distal extremity injury)

The treatment of smoke inhalation injury is supportive.

Any patient with smoke inhalation injury and significant burns greater than 20% TBSA should be intubated. IF the patient's hemodynamic condition permits and spinal injury has been excluded, elevate the patient's head and chest 30 degrees to help reduce neck and chest wall edema.

Penetrating injury to pregnant women

As uterus grows larger, other viscera are protected from penetrating injury. Dense uterine musculature in early pregnancy can absorb significant amount of energy from penetrating objects decreasing their velocity and lowering risk of injury to other viscera. However, fetal outcome is generally poor with penetrating injury to uterus.

Do no equate blood pressure with shock in older patients

BP in older patients may look normal due to the medications they are on. Use lactate and base deficit to evaluate for evidence of shock

Compartment syndrome in burn patients:

Compartment syndrome can result from an increase in pressure inside the compartment that interferes with perfusion to the structures within that compartment. In burns, this condition results from a combination of decreased skin elasticity and increased edema in the soft tissue. A pressure > 30 mm Hg within the compartment can lead to muscle necrosis and once the pulse is gone it may be TOO LATE to save the muscle. so recognize the signs early: pain greater than expected and out of proportion to the injury pain on passive stretch of the affected muscle tense swelling of the affected compartment paresthesias or altered sensation distal to the affected compartment

How do you decontaminate burn areas?

Completely remove the patient's clothing to stop burning process, but do not peel off adherent clothing. Synthetic fabrics can ignite, burn rapidly at high temps and melt into hot residue that continues to burn the patient. brush any dry chemical powder from wound. rinse with copious amounts of warm saline irrigation or rinsing in a warm shower. once the burning process has been stopped, cover the patient with warm, clean, dry linens to prevent hypothermia.

Airway-patients may have dentures that may loosen or obstruct the airway. If dentures are not obstructing the airway, leave them in place for what?

bag mask ventilation, as it improves mask fitting.

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 burns and scalds. These are all signs of.......?

Elder maltreatment. The presence of physical findings of maltreatment should prompt a detailed history. if history conflicts with findings, immediately report findings to authorities.

Age related changes in the cardiovascular system place the elderly trauma patient at significant risk for being inaccurately categorized as hemodynamically stable.

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.

What is the most common mechanism of injury in the elderly?

Fall. Nonfatal falls are common in women and fractures are common in women who fall. Falls are the most common cause of TBI.

What does a normal fibrinogen level indicate in a pregnant patient?

Fibrinogen level may double in late pregnancy and a normal level may indicate early disseminated intravascular coagulation

EKG findings in pregnant patient

Flatted or inverted T waves in leads III and AVF and the precordial leads may be normal. Ectopic beats are increased during pregnancy.

Urinary system: what happens to the GFR, serum creatinine and urea nitrogen levels?

GFR and renal blood increases during pregnancy, whereas levels of the serum creatinine and urea nitrogen fall to one half of the normal pre pregnancy levels. Glycosuria is common in pregnancy.

By the third trimester, what is the complication of trauma to the pelvis of the mother?

by the third trimester, the uterus is large and thin walled. In vertex 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.

Always assume CO exposure in patients who were burned in enclosed areas. Patients with CO levels less than 20% may not show any symptoms

HA and nausea (20-30%), confusion (30-40%), coma (40-60%) and death (>60%). Cherry red skin color in patients may only be seen in moribund patients. Measurements of arterial PaO2 do not reliably predict CO poisoning b/c a partial pressure of only 1 mm Hg results in an HbCO level of 40% or greater. Pulse ox cannot be relied on to rule out carbon monoxide poisoning b/c we cant distinguish oxyhemoglobin from carboxyhemoglobin. A discrepancy between pulse ox and arterial blood gas may be explained by presence of carboxyhemoglobin.

Eclampsia

Maintain a high index of suspicion for eclampsia when seizures are accompanied by HTN, proteinuria, hyperreflexia, and peripheral edema in pregnant trauma patients. This can mimic head injury.

Patient with inhalation injury are at risk for bronchial obstruction from secretions and debris and they may require bronchoscopy.

Make sure to place an adequately sized airway tube

Flame injury is more evident than most chemical injuries.

Monitor IV lines closely to ensure they do not become dislodged as the patient becomes more edematous. Regularly check ties securing ET or NG to ensure they are not too tight.

Minute ventilation increases primarily due to an increase in tidal volume. Hypocapnia (30 mm Hg) is common in late pregnancy

Monitor ventilation in late pregnancy with arterial blood gas values. A PaCO2 of 35-40 mm Hg may indicate impending respiratory failure during pregnancy. Pregnant patients should be hypocapneic.

Rhabdomyolysis can lead to metabolic acidosis, hyperK, hypoC, and DIC.

Myoglobin induced renal failure can be prevented with intravascular fluid expansion, alkalinization of the urine by IV administration of Bicarbonate and osmotic diuresis.

Most of elderly traffic fatalities occur in the daytime and on weekends and typically involve other vehicles. Why?

Older people drive on more familiar roads and at lower 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.

Perform continuous fetal monitoring with a tocodynamometer beyond 20-24 weeks of gestation.

Patients with no risk factors for fetal loss should have 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

Loss of subcutaneous fat, nutritional deficiencies, chronic medical conditions place elderly patients as risk for hypothermia and complications for immobility.

Rapid evaluation and when possible early liberation from spine boards and cervical collars will minimize complications.

Cyanide inhalation poisoning can occur in confined spaces and sign of potential toxicity is persistent profound unexplained metabolic acidosis.

THERE IS NO ROLE for hyperbaric oxygen therapy in the primary resuscitation of a patient with critical burn injury.

What is the difference between burns and other injuries?

The biggest difference is that the consequences of burn injury are directly linked to the extent of the inflammatory response to the injury. The larger and deeper the burn, the worse the inflammation.

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 signs in a pregnant patient indicate about the fetus?

The fetus may be in 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.

After the 10th week of pregnancy, cardiac output can increase 1.0-1.5 L/min because of the increase in plasma volume and decrease in vascular resistance of the uterus and placenta.

The placenta receives 20% of the patient's cardiac output during the 3rd trimester. In supine position, vena cava compression can decrease cardiac output by 30% because of decreased venous return from lower extremities.

Amniotic fluid can cause amniotic fluid embolism and disseminated intravascular coagulation following trauma if fluid enters maternal intravascular space. True or False

True

True or False? Mortality associated with small to moderate sized burns in older adults remains high

True

True or false? Although the mechanism of injury may be similar to those for the younger population, data shows increased mortality with similar severity of injury in older adults.

True

True of false: early activation of the trauma team may be required for elderly patients who do not meet traditional criteria for activation

True. A simple injury such as an open tibia fracture in a frail elderly patient may become life threatening.

carefully observe pregnant patients with even minor injuries since occasionally minor injuries are associated with placental abruption and fetal loss.

True. AND to optimize outcomes for mother and baby, clinicians must assess and resuscitate the mother first and then assess the fetus before conducting second survey of the mother.

The best initial treatment for the fetus is to provide optimal resuscitation of the mother. True or False?

True. Also if xray examination is indicated during the pregnant patient's treatment, it should not be withheld because of the pregnancy.

True or false: Clinicians should provide burn resuscitation fluids for deep partial and full thickness burns larger than 20% TBSA

True. urine output monitoring is 0.5mL/kg/hr in adults and should be maintained at 30-50cc/hr to minimize over resuscitation

How do you dissolve a tar burn?

Use mineral oil

What are some of the lab changes in pregnancy?

WBC increases to 12000 and during labor can be 25000. Fibrinogen and other clotting factors are mildly elevated and PT and pTT are shortened, but bleeding time and clotting time are unchanged.

What happens as the uterus enlarged and the bowel is pushed cephalad.

When the uterus enlarges it pushes the bowel cephalad and the uterus lies in the 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.

Signs of uterine rupture

abdominal tenderness, guarding, rigidity, or rebound tenderness. Signs of peritonitis are hard to tell due to expansion and attenuation of the abdominal wall musculature. Other findings include abdominal fetal lie (oblique or transverse lie), easy palpation of the fetal parts because of their extrauterine location and inability to readily palpate the uterine fundus when there is fundal rupture. Xray evidence of rupture include extended fetal extremities, abnormal fetal position, and free intraperitoneal air.

In the elderly population, what are risk factors for falls?

advanced age, physical impairment, history of previous fall, medication use, dementia, unsteady gait, and visual, cognitive impairment

what 2 factors place elderly patients at risk for intracranial hemorrhage?

aging causes dura to become more adherent to the skull increasing risk of injury and older patients are on anticoagulant and antiplatelet medications.

In the elderly population, what is decreased physiological reserve?

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.

hoarseness, stridor, accessory respiratory muscle use, sternal retraction are signs of what?

airway obstruction. Clinical manifestations of inhalation injury may be subtle and may not show up within the first 24 hours. do not wait for the xray to show evidence of pulmonary injury or changes in blood gas because airway edema can preclude intubation and a surgical airway will be required.

Knee dislocations can reduce spontaneously and may not present with any gross external or radiographic anomalies until a physical exam of is joint is perfromed.

an ankle brachial index of less than 0.9 indicates abnormal arterial flow secondary to injury or peripheral vascular disease

Full thickness burns

appear leathery and skin may be white or translucent or waxy white. surface area is painless to light touch or pinprick and generally dry

Partial thickness burns

are characterized as either superficial partial thickness (moist, painfully hypersensitive, , potentially blistered, homogenously pink, and blanch to touch) or deep partial thickness ( drier, less painful, potentially blistered, red or mottled in appearance, and do not blanch to touch)

Treat all patients with open fractures as soon as possible with iv antibiotics

cephalosporins are necessary for all open fractures

compartment syndrome may be present with circumferential chest and abdominal burns

chest and abdominal escharotomies performed along the anterior axillary 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.

Abuse and burns

circular burns and burns with clear edges and unique 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

Pre-existing conditions that affect morbidity and mortality include:

cirrhosis, coagulopathy, COPD, ischemic heart disease, DM

Common mechanisms of injury include falls, MVC, burns, and penetrating injuries

common injuries in the elderly include rib fractures, TBI, pelvic fractures

electrical burns are more serious than they appear on the body surface and extremities, particularly the digits.

current can travel inside blood vessels and nerves and can cause local thrombosis and nerve injury. So a severe electrical injury usually results in contracture of the affected extremity.

For MSK trauma, loss of sensation in a stocking or glove distribution is an early sign of....

early sign of vascular impairment

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 contractions which suggest placental abruption.

evidence of ruptured chorioamniotic membranes include amniotic fluid in vagina evidenced by a pH of 4.5

High risk activities that can cause compartment syndrome include:

excessive exercise burns severe crush injury to muscle localized prolonged external pressure to an extremity increased capillary permeability secondary to reperfusion of ischemic muscle.

Sympathetic blockade agents and vasodilating agents have shown to be effective in altering the progression of acute cold injury

false

Frostbite is due to freezing of tissue with intracellular ice crystal formation, microvascular occlusion, and subsequent tissue anoxia.

first degree: hyperemia and 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.

Indications for early intubation in burn patients:

full thickness 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,

Partial thickness burns are painful when air currents pass over the burned surface.

gently cover the burn with clean sheets will decrease the pain and deflect air currents. 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.

Bleeding in 3rd trimester may indicate placental abruption and impending death of the fetus, a vaginal exam is vital

however, avoid repeating vaginal examination, CT abdominal imaging can be done and radiation doses less than 50mGy are not associated with fetal anomalies or higher risk of fetal loss.

hypothermia is a core temp below 36C or 96.8F

hypothermia can worsen coagulopathy and affect organ function.

Direct thermal injury to the lower airway is very rare and essentially occurs only after exposure to superheated steam or ignition of inhaled inflammable gases. Breathing concerns arise from what 3 general causes:

hypoxia, carbon monoxide poisoning, and smoke inhalation injury.

With extensive placental separation or amniotic fluid embolization, widespread consumptive coagulopathy can emerge rapidly causing depletion of fibrinogen, other clotting factors, and platelets.

immediately perform uterine evacuation and replace platelets, fibrinogen, and other clotting factors.

Factors that increase the risk of upper airway obstruction are:

increasing 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.

Intimate partner violence in pregnant patient:

injuries inconsistent with history, diminished self image, depression or suicide attempts, self abuse, frequent ED visits, symptoms suggestive of substance abuse, isolated injuries to the gravid abdomen, parter insists on being present for the interview and exam and monopolizes discussion

In patients with advanced pregnancy, those that require a chest tube placement, where should the test tube be placed?

it should be positioned higher to avoid intra-abdominal placement given the elevation of the diaphragm.

When interpreting x ray films of the pelvis in a pregnant patient, the symphysis pubis widens 4-8 mm and the sacroiliac joint spaces increase by the 7th month

keep this in mind

Failure to displace the uterus to the left side in a hypotensive pregnant patient

logroll all patients appearing clinically pregnant (second and third trimester) to the left 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.

Most common cause of fetal death?

maternal shock and maternal death. Placental abruption is second. Placental abruption is suggested by vaginal bleeding, uterine tenderness, frequent uterine contractions, uterine tetany, and uterine irritability (uterus contracts when touched). In 30% of cases of abruption, bleeding may not occur. Uterine ultrasound may be helpful in diagnosis, but is NOT definitive.

operative revascularization to an avascular extremity is important to treat emergently.

muscle necrosis begins where there is a lack of blood flow for 6 hours. is there is an associated fracture deformity, correct it by gently pulling the limb out to length, realigning the fracture and splinting the injured extremity. This maneuver can restore the blood flow

Fetal heart rate is a sensitive indicator of maternal blood volume status and fetal well being.

normal range for fetus is 120-160. abnormal heart rate, repetitive 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.

Anatomical alterations in the thoracic cavity seem to account for the decreased residual volume associated with diphragmatic elevation and chest x ray reveals increased lung marking and prominence of the pulmonary vessels.

oxygen consumption increases during pregnancy and its important when resuscitating injured pregnant patients to maintain adequate oxygenation above 95%

hypertension in the pregnant if accompanied by proteinuria may represent what?

pre-eclampsia.

Patient with electrical burn can develop for acute renal failure

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.

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 aging causes a suppressed heart rate response to hypoxia......

respiratory failure may present insidiously in older adults.

Functional changes in renal system include loss of renal mass, decreased GFR, and decreased sensitivity to ADH and aldosterone

resulting in drug dosing for renal insufficiency, decreased ability to concentrate urine, increased risk for AKI and urine flow may be normal with hypovolemia

Functional changes to MSK include loss of lean body mass, osteoporosis, changes in joints and cartilage, c spine degenerative changes and loss of skin elastin and subcutaneous fat

resulting in increased risk for fractures, decreased mobility, difficulty for oral intubation, risk of skin injury, increased risk for hypothermia, challenges in rehabiliation

Functional changes in Endocrine system include decreased production and response to thyroxin and decreased dehydroepiandrosterone (DHEA)

resulting in occult hypothyroidism, relative hypercortisone states and increased risk of infection

Blood pressure falls 5-15 mm Hg in systolic and diastolic pressures during second trimester, although it returns to near normal levels at term.

some women experience hypotension when placed in the supine position due to the compression of teh inferior vena cava.

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 great surface area and helps prevent the mother from flexing forward over the gravid uterus.

the deployment of air bags in vehicles does not appear to increase 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.

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 soft tissue

the only reason to forgo an xray exam before treating a dislocation or fracture is the presence of vascular compromise or impending skin breakdown, often seen with fracture dislocations of the ankle

in a burn patient, cardiac dysrhytmias may be the first sign of hypoxia and electrolyte or acid base abnormalities.

therefore an ECG should be performed for cardiac rhythm disturbances. Persistent acidemia in patients with burn injuries may be due to under resuscitation or infusion of large volumes of saline.

In frostbite injury, warming large areas can result in reperfusion syndrome, with acidosis, hyperK and local swelling.

therefore monitor the patient's cardiac status and peripheral perfusion during rewarming.

Healthy pregnancy patients can lose 1200-1500 mL of blood before exhibiting signs and symptoms of hypovolemia. How can this manifest?

this amount of hemorrhage may be reflected by fetal distress as evidenced by an abnormal fetal heart rate.

During pregnancy the heart rate increases to a maximum of 10-15 beats per minute over baseline by the third trimester.

this heart rate must be considered when interpreting a tachycardic response to hypovolemia.

An abrupt decrease in maternal intravascular volume can result in a profound increase in uterine vascular resistance reducing fetal oxygenation despite reasonably normal maternal vital signs.

this is true

Spilled hot liquids on the leg, which in younger patients may re-epithelialize due to an adequate number of hair follicles, will result in a full thickness burn in older patients.

this is true

Functional changes in cardiac system include declining function, decreased sensitivity to catecholamines, atherosclerosis of coronary vessels, increased afterload, fixed heart rate (beta blockers)

this results in lack of classic response to hypovolemia, risk for cardiac ischemia, elevated BP at baseline, and increased risk of dysrythmias.

Functional changes in pulmonary system include decreased elastic recoil, reduced residual capacity, decreased gas exchange and decreased cough reflex

thus they are at increased risk for respiratory failure, increased risk for pneumonia, and poor tolerance to rib fractures

True of false: Burn patients should get tetanus.

true

True or False: Fall prevention is the mainstay of reducing the mortality associated with pelvic fractures.

true

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 central canal stenosis, cord compression, and myelomalacia

true

External contusions and abrasions of the abdominal wall are signs of blunt uterine trauma.

true. Fetal injuries can occur when the abdominal wall strikes an object, such as the dashboard or steering wheel, or when a pregnant patient is struck by a blunt instrument.

A clenched hand with a small electrical entrance wound should alert the clinician that a deep soft tissue injury is likely much more extensive than is visable to the naked eye

true. patients with severe electrical injuries require fasciotomies. Electricity can cause forced contraction of muscles, doctors need to examine patient for skeletal and muscular damage, especially for fractures of the spine and rhabdomyolysis

Admission to hospital for pregnant patients:

vaginal bleeding, uterine irritability, abdominal tenderness, pain or cramping, evidence of hypovolemia, changes in or absence of fetal heart tones and or leakage of amniotic fluid