ATLS WRITTEN REVIEW QUESTIONS ANSWERS LATEST A+ GRADED 100% VERIFIED

ATLS WRITTEN REVIEW QUESTIONS ANSWERS LATEST A+ GRADED 100% VERIFIED APPROVED BY: mater, pia ATLS Written Review ATLSStudyWRITTEN online at 1. 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. 2. 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. 3. Which brain lobes do the following hold: 1. anterior fossa: 2. middle fossa: 3. posterior fossa:: 1. anterior fossa: frontal lobes 2. middle fossa: temporal lobes 3. posterior fossa: lower brainstem and cerebellum 4. What are the 3 layers of the meninges?: dura mater, arachnoid mater 5. What does the dura mater adhere firmly to?: the skull. it is tough and fibrous 6. What layer of the meninges splits into two leaves as specific sites to enclose large venous sinuses? What do these sinuses do?: dura mater. these sinuses provide major venous drainage from the brain. 7. 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. 8. What are the arteries that lie between the skull and the dura mater (epidural space)?: meningeal arteries. 9. What is the most commonly injured meningeal artery and where is it located?: middle meningeal artery. Located over the temporal fossa 10. T/F: the arachnoid mater is fused to the dura mater?: FALSE: not attached. This produces a potential space for a subdural hematoma 11. In a subdural hematoma, what is the cause?: injury to bridging veins that extend from brain surface to the sinuses within the dura. 12. fills the space between the arachnoid and pia mater?: CSF. this cushions the brain and spinal cord. 1 / 12 compart13. What location of brain hemorrhage is frequently seen in brain contusion or injury to major blood vessels at base of brain?: subarachnoid. 14. The and contain the reticular activating system which is responsible for .: midbrain and upper pons state of alertness 15. What important function resides in the medulla?: cardiorespiratory centers. 16. What important functions are in the following brain segments: 1. left hemisphere: 2. frontal lobe: 3. parietal lobe: 4. temporal:: 1. left hemisphere: language center 2. frontal lobe: executive function, emotions, motor 3. parietal lobe: sensory function/spatial orientation 4. temporal: memory functions 17. What divides the brain into supratentorial and infratentorial ments?: tentorium cerebelli. (tent over cerebellum) 18. What is the physiology behind a blown pupil?: 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. 19. What is the tentorial notch/hiatus: this is where the midbrain passes through into the infratentorial compartment. 20. what part of the brain most commonly herniates through the tentorial notch?: Uncus (medial part of temporal lobe) 21. 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. 22. state: Ipsilateral/contralateral pupillary dilation associated with hemiparesis is the classic sign of uncial herniation.: ipsi contra 23. average ICP is mmHg.: 10 2 / 12 ATLS Written Review Study online at 24. The monro-kellie doctrine states that the total volume of intracranial contents must remain constant, because the cranium is : a rigid, non expandable container. 25. 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. 26. What is the equation for CPP (cerebral perfusion pressure)?: - CPP=MAP-ICP 27. in TBI, Every effort should be made to reduce , while normalizing , , and .: ICP MAP, oxygenation, intravascular volume 28. What GCS ranges for the following classes: 1. Minor 2. Moderate 3. Severe: 1. 13-15 2. 9-12 3. 3-8 29. What nerve palsy may occur with basilar skull fracture?: seventh nerve. 30. A GCS of is accepted definition of coma?: 8 or less 31. How do you assess a GCS of someone with asymmetric responses?: Use the best possible because this will be the best predictor of outcome 32. Basilar fractures of the skull usually require what type of imaging?: this requires CT with bone-window setting. 33. What are the typical clinical signs of basilar skull fractures?: rbital ecchymosis (raccoon eyes) 2. retroauriculor ecchymosis (battle sign) 3. CSF leak from nose or ears 4. 7th or 8th CN dysfunction (facial paralysis and hearing loss) 34. What should be a primary consideration for any patient with a skull fracture, especially a linear skull fracture?: hematoma. linear skull fracture increases likelihood of intracranial hematoma by about 400x 3 / 12 ATLS Written Review Study online at 35. What mechanism is common with diffuse axonal injury and what is the likely outcome?: these injury often occur with high velocity or deceleration injures. They appear as diffuse cerebral hemorrhage often between grey and white matter. These are associated with variable but often poor outcomes. 36. Epidural hematomas often occur in the area of the skull and result from a tear of the arteries.: temporal middle meningeal artery 37. What is the classic presentation of a epidural hematoma?: a lucid interval between time of injury and neurologic a deterioration. 38. What are more common brain injury: epidural or subdural?: subdural 30% epidural 0.5% 39. Subdural hematoma occur from tear of .: bridging vessels of the cerebral cortex 40. Contusion occur in % of TBI.They often occur in or lobes of brain.They may coalesce to form in as many as 20$%.: - 20-30% frontal or temporal intracerebral hematoma. 41. What is the imaging protocol for a patient with cerebral contusion?: get CT at presentation. then get another within 24 hours to assess for coalesced hematoma. 42. What factors would require a CT in minor brain injury?: 1. suspected open skull frac 2. basilar frac 3. >2 episode vomitting 4. pt older than 65 5. LOC >5 min 6. amnesia before impact of >30 min 43. How long after discharge should patient with mild brain injury be observed by friend?: 24 hours 44. What type of brain injury requires serial GCS?: ALL. minor. moderate. major 45. What imaging is done in all patient with moderate brain injury?: CT 46. What factor of ABCDE must be monitored closely in moderate brain injury?: Airway and breathing. rapid deterioration may occur. hypoventilation and hypercapnia may ensue requiring intubation. close monitoring in ICU is required. 4 / 12 ATLS Written Review Study online at 47. What should immediately follow the secondary survey in major/severe brain injury?: CT. REMEMBER: CT should never delay patient transfer 48. When assessing ABCDE of severe brain injury, when does DPL or FAST come before neuro exam?: if the systolic blood pressure cannot be brought above 100, DPL or FAST is done first as to assess source of hypotension 49. Spinal cord injury has what result in blood pressure?: hypotension. This may also occur in terminal brain injury with medullary failure 50. What needs to be cleared before Doll's eye testing is conducted?: cervical spine must cleared. 51. What tests should be performed before sedation?: GCS and pupillary rxn 52. 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: 5mm 53. What type of fluids should be used?: hypertonic (ringers lactate or normal saline). NO GLUCOSE. 54. What electrolyte abnormality is associated with brain edema and must be monitored?: hyponatremia 55. What are the physiologic consequences of PaCO2 >45? PaCO2 <30?: f PaCO2 >45 = vasodilation = inc ICP PaCO2 <30 (hyperventilation) = constriction = ischemia 56. What is the preferred PaCO2 in brain injury?: 35 mm Hg 57. 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 58. Does hypertonic saline lower ICP in hypovolemia? Does mannitol lower ICP in hypovolemia?: No NO 59. After administration of mannitol what should be monitored closely?: ICP! mannitol has a substantial rebound effect on ICP 60. What is the role of muscle relaxants (vecuronium or succinylcholine) in seizures with TBI?: NONE. these may mask tonic-clonic seizures and prevent anticonvulsant intervention (30-60 min of seizure = secondary brain injury) 5 / 12 ATLS Written Review Study online at n be done to e of body. 61. What meningeal tear would a CSF leakage of a head laceration indicate?- : dural tear 62. What is the treatment of any intracranial mass lesion?: Must be evacuated by neurosurgeon. transfer if not available. 63. 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?: need CT, Xray for trajectory, and angiography. leave the object in place. Removing the object lead to fatal vascular injury. 64. What clinical signs are the criteria for brain death?: GCS of 3, nonreactive pupil, absent brainstem reflexes, no spontaneous ventilatory effort 65. Which vertebrae is most susceptible to injury?: Cervical. NOTE: in peds this accounts for only 1% of vertebral injury 66. 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 C1 67. 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 68. When a dislocation-fracture of the vertebrae occurs, almost always the result is .: complete spinal cord injury 69. 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) 70. At what levels do the spinal cord begin and end?: begins at foramen magnum at terminal end of the medulla oblongata and end at L1 71. 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. 72. What function does the dorsal column have? What tests ca assess function?: position, vibration, light touch, all from same sid TESTS: positioning of bent toes/fingers, vibration with tuning fork. 6 / 12 ATLS Written Review Study online at can be done dy 74. What function does the corticospinal tract have? what tests can be done to assess function?: Motor power on same side of body TESTS: voluntary muscle contract or involuntary response to pain 75. What type of gastric tube should be placed when cribiform plate fx or mid face fracture is present?: orogastric. nasopharyngeal intrumentation is potentially dangerous 76. When fluids must be administered what is the best route, and which type of catheter is best?: -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) 77. What anatomical change is common in the third trimester of pregnancy?- : widening of the symphasis pubis 78. What pulmonary complication is common with blunt trauma and PaCO2 <35?: pulmonary contusion. 79. Chest tube is indicated for which of the following? -tension pneumo -hemothorax -ruptured bronchus -pulmonary contusion -mass hemothorax: All EXCEPT pulmonary contusion 80. What is the initial bolus for fluid resuscitation when a small child is in shock?: 20mL/kg ringers lactate 81. What are the chest tube blood volume output parameters that would require a thoracotomy?: >1500mL immediatley evacuated OR 200mL/hr for 2-4hrs NOTE: thoractomy is not indicated unless a surgeon qualified by training and experience is present 7 / 12 ATLS Written Review Study online at 73. What function does the spinothalamic tract have? what tests to assess function?: pain and temperature to opposite side of bo TESTS: pinprick and light touch 82. How can one determine the appropriate tube depth for pediatric intubation?: ETT tube size x 3 Ex: 4.0 ETT would be properly positioned at 12 cm from the gums 83. 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.- : 2-3 cm 84. 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 85. For a patient who is not breathing what intervention is indicated?: orotracheal intubation 86. 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 87. What is the acronym BURP?: backward, upward and rightward pressure used in external laryngeal manipulation with orotracheal intubation 88. what is the most common life threatening injury in children?: tension pneumothorax 89. What is the most common acid-base disturbance in the injury child and what is it caused by?: Respiratory acidosis caused by hypoventilation. 90. 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. 91. 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. 92. What is the main utility of ECG during resuscitation?: detecting rhythm abnormalities 8 / 12 ATLS Written Review Study online at 93. 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. 94. 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) 95. 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. 96. 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. 2. early initiation of crystalloid fluids due to moms compensatory mechanisms masking fetal distress associated with hypovolemia 97. T/F? Diaphragmatic breathing in a patient who is unconscious is not a sign of C-Spine injury: FALSE. diaphragmatic breathing=c-spine injury 98. What is used to evaluate a suspected urethral injury? What is used to evaluate a bladder rupture?: retrograde urethrogram cystogram 99. What are the abdominal structures that may not be detected on DPL?: - duodenum, ascending/descending colon, rectum, biliary tract, and pancreas 100. In a severe trauma where facial anatomy is distorted and an ETT cannot be placed, what is the next step to provide ventilation?: Next would be a transchricothyroid needle-jet insufflation. this is attached to high pressure oxygen, but can only be provided for around 30-45min due to CO2 accumulation. -the definitive after this would be a surgical chricothyroidotomy or an emergent tracheotomy. (emergent tracheotomy is not preferred because complication and time consuming) 101. What hold urine output be maintained at after a crush injury to prevent kidney injury?: 100 mL/hr 102. Is operation ever indicated in first hour after injury of multiple injured patient?: yes. especially if class 3 or 4 hemorrhagic shock is present 103. What class of shock are there NO clinical signs of inadequate organ perfusion?: Class I. <14% blood volume loss. (<750mL) 9 / 12 ATLS Written Review Study online at 104. What is suggested if chest tube placement for suspected pneumothorax results in incomplete lung expansion and air leak with bubbling? What imaging confirms?: This suggests tracheobronchial injury such as ruptured bronchus. -a second chest tube may need to be placed -this is confirmed with broncoscopy 105. Why do chest injuries have a high priority in the multiply injured person?: they often result in hypoxia 106. What is the physiology behind neurogenic shock?: loss of vascular tone 107. 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. 108. What would be expected on ABG abnormalities for pulmonary contusion?: PaO2 <65 mm Hg (sat <90) would suggest need for intubation and in the presence of flail chest is more suggestive 109. t/f vomitus in the posterior oropharynx suggests esophageal intubation.: false. signs include: epigastric fullness, absent end title CO2, absent breath sounds, audible borborygmi sounds over abdomen 110. t/f: major head injury rarely causes shock by itself: true 111. What are the vital signs to be expected when ICP increases?: decreased respirations and HR, increased systolic and pulse pressure 112. Urethral injury should be suspected in the presence of what three things?: 1. blood at the meatus 2. perineal ecchymosis 3. high riding or non-palpable prostate 113. What test is used to confirm the integrity of the urethra before a catheter is inserted?: retrograde urethrogram 114. What physical exam is essential before passing a urethral catheter: examine the rectum and perineum 115. What is the best guide for adequate fluid resuscitation in a burn patient?- : 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 10 / 12 ATLS Written Review Study online at 116. 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. 117. 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 118. What is one characteristic shared by all SURVIVORS of traumatic aortic disruption?: contained hematoma 119. What does x ray showing widened mediastinum and obliteration of the aortic knob suggest?: traumatic aortic disruption 120. 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) 121. What three X-ray views are most important for a person with multiple trauma?: c-spine, chest, pelvis 122. Pulse oximetry provides information about and but does not provide information about : 1. O2 sat 2. peripheral perfusion 3. adequacy of ventilation 123. Carboxyhemoglobin levels greater than % in burn patient indicate inhalation injury and require transport and/or intubation if transport is prolonged.: 10% 124. 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?: hypovolemic shock with fluids. NOTE: airway is OK because he is talking even though he complains of trouble breathing. 125. What is the most important principle in the early management of someone with TBI and increasing ICP?: prevent hypotension 11 / 12 ATLS Written Review Study online at 126. 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 127. 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 128. 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) 129. 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 -contralateral loss of pain/temperature sense beginning 1-2 levels down from lesion. 130. What is the primary concern in flail chest?: pulmonary contusion resulting in hypoxia 131. prevention of hypo perfusion and hypoxia are most important for optimal outcome in .: TBI 132. What imaging is required for a patient displaying basilar skull fracture: hemotympanum, raccoon eyes, CSF otorrhea, battle sign?: 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. 133. T/F: bony injury in pediatrics is more common than in adults?: FALSE: because bones are more pliable you will often find internal organ damage without overlying bone damage. 134. 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) 12 / 12 ATLS Written Review Study online at