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ATLS Written Review WITH COMPLETE SOLUTIONS RATED A+
2025 LATEST UPDATE
What is the primary goal of treating TBI? How is this done? โ 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:
- anterior fossa:
- middle fossa:
- posterior fossa: - **1. anterior fossa: frontal lobes
- middle fossa: temporal lobes
- posterior fossa: lower brainstem and cerebellum** What are the 3 layers of the meninges? โ dura mater, arachnoid mater, pia mater What does the dura mater adhere firmly to? โ What layer of the meninges splits into two leaves as specific sites to enclose large venous sinuses? What do these sinuses do? โ 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?
- 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)? โ meningeal arteries. What is the most commonly injured meningeal artery and where is it located? the skull. it is tough and
middle meningeal artery.
FALSE: not attached. This produces a potential space for a subdural hematoma In a subdural hematoma, what is the cause? โ injury to bridging veins that extend from brain surface to the sinuses within the dura. fills the space between the arachnoid and pia mater? โ 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? โ subarachnoid. The and contain the reticular activating system which is responsible for
. โ midbrain and upper pons state of alertness What important function resides in the medulla? โ cardiorespiratory centers. What important functions are in the following brain segments:
- left hemisphere:
- frontal lobe:
- parietal lobe:
- temporal: - **2. frontal lobe: executive function, emotions, motor
- parietal lobe: sensory function/spatial orientation 4. temporal: memory functions** What divides the brain into supratentorial and infratentorial compartments? โ tentorium cerebelli. (tent over cerebellum) What is the physiology behind a blown pupil? โ blown pupil: dilation of pupil -CN III runs along the tentorium cerebelli. parasympathetic fibers that constrict the pupil run along CN III (oculomotor). When temporal lobe is herniated, it can compress these fibers. Unapposed sympathetic activity causes pupillary dilation. What is the tentorial notch/hiatus โ this is where the midbrain passes through into the infratentorial compartment. what part of the brain most commonly herniates through the tentorial notch?
**Uncus (medial part of temporal lobe)
- left hemisphere: language**
ip a rigid, non expandable does weakness occur on the same or opposite side of the uncal herniation? โ 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. โ contra average ICP is mmHg. โ 10 The monro-kellie doctrine states that the total volume of intracranial contents must remain constant, because the cranium is - The monro-kellie doctrine states that and may be compressed out of the skull providing a degree of buffering. โ 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)? โ CPP=MAP-ICP in TBI, Every effort should be made to reduce , while normalizing , , and
. โ ICP MAP, oxygenation, intravascular volume What GCS ranges for the following classes:
- Minor
- Moderate
- Severe โ **1. 13-
- 9-
- 3-** What nerve palsy may occur with basilar skull fracture? โ seventh nerve. A GCS of is accepted definition of coma? โ
What is the imaging protocol for a patient with cerebral contusion? โ 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? โ
**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? โ 24 hours What type of brain injury requires serial GCS?
- ALL. minor. moderate. major What imaging is done in all patient with moderate brain injury? โ CT What factor of ABCDE must be monitored closely in moderate brain injury? โ 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? โ CT. REMEMBER: CT should never delay patient transfer When assessing ABCDE of severe brain injury, when does DPL or FAST come before neuro exam? โ 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? โ hypotension. This may also occur in terminal brain injury with medullary failure What needs to be cleared before Doll's eye testing is conducted? โ cervical spine must cleared. What tests should be performed before sedation? โ 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 โ 5mm
What type of fluids should be used? โ hypertonic (ringers lactate or normal saline). NO GLUCOSE. What electrolyte abnormality is associated with brain edema and must be monitored? โ hyponatremia What are the physiologic consequences of PaCO
45? PaCO2 <30? โ 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? โ 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? โ No NO After administration of mannitol what should be monitored closely? โ ICP! mannitol has a substantial rebound effect on ICP What is the role of muscle relaxants (vecuronium or succinylcholine) in seizures with TBI? โ NONE. these may mask tonic-clonic seizures and prevent anticonvulsant intervention (30-60 min of seizure = secondary brain injury) What meningeal tear would a CSF leakage of a head laceration indicate? โ dural tear What is the treatment of any intracranial mass lesion? โ Must be evacuated by neurosurgeon. transfer if not available. for a penetrating object such as an arrow or screw driver into the skull, test should be performed and what should be done with the object? โ need CT, Xray for trajectory, and angiography. leave the object in place. Removing the object lead to fatal vascular injury. What clinical signs are the criteria for brain death? โ
Motor power on same side of body TESTS: voluntary muscle contract or involuntary response to pain What type of gastric tube should be placed when cribiform plate fx or mid face fracture is present? โ orogastric. nasopharyngeal intrumentation is potentially dangerous When fluids must be administered what is the best route, and which type of catheter is best? โ -peripheral route it preferred with antecubital or forearm. -if peripheral route is not accessable central vein access in any of the typical areas is acceptable. (in this case a short fat catheter should be used) What anatomical change is common in the third trimester of pregnancy? โ widening of the symphasis pubis What pulmonary complication is common with blunt trauma and PaCO2 <35?
pulmonary contusion. Chest tube is indicated for which of the following? -tension pneumo -hemothorax -ruptured bronchus -pulmonary contusion -mass hemothorax โ All EXCEPT pulmonary contusion What is the initial bolus for fluid resuscitation when a small child is in shock? โ 20mL/kg ringers lactate What are the chest tube blood volume output parameters that would require a thoracotomy? โ >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? โ 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. โ 2-3 cm
Fluid resuscitation of an infant begins with (amount and type). And then progresses to. (amount and type) โ 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? โ orotracheal intubation What should be used when vocal chords cannot be visualized on direct laryngoscopy? โ gum elastic bougie. in place when you feel clicks. can be inserted blindly beyond epiglottis What is the acronym BURP? โ backward, upward and rightward pressure used in external laryngeal manipulation with orotracheal intubation what is the most common life threatening injury in children? โ tension pneumothorax What is the most common acid-base disturbance in the injury child and what is it caused by? โ 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? โ 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? โ 40C (104F) should be done in whirlpool. not dry heat. What is the main utility of ECG during resuscitation? โ detecting rhythm abnormalities What does PaCO2 of 35-40 mmHg indicate in late pregnancy? โ 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? โ
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? โ they often result in hypoxia What is the physiology behind neurogenic shock? โ loss of vascular tone What is another name for Central Venous Pressure? When is it elevated?
- 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? โ 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. โ 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
- true What are the vital signs to be expected when ICP increases? โ decreased respirations and HR, increased systolic and pulse pressure Urethral injury should be suspected in the presence of what three things? โ **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? โ retrograde urethrogram What physical exam is essential before passing a urethral catheter โ examine the rectum and perineum What is the best guide for adequate fluid resuscitation in a burn patient? โ **urine output adults: 0.5mL/kg/hr
30kg: 1mL/kg/hr**
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? โ 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? โ contained hematoma What does x ray showing widened mediastinum and obliteration of the aortic knob suggest? โ traumatic aortic disruption What is the sensitivity and specificity of CT in aortic disruption? โ 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
- 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. โ 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? โ
Compare the specificity and sensitivity of DPL and CT in blunt abdominal trauma.
DPL- high sens (98), low spec CT - high sens (92-98), high spec (95)
