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ATLS 7th Edition - antwoorden
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ATLS 7th Edition - antwoorden
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Voorbeeld 3 van de 18 pagina's
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Voorbeeld van de inhoud
thATLS 7 Edition - answers
2 initial assessment 44 answers
1. d
Explanation: When possible trauma patients should be transported to a trauma center, especially if significant injury is
suspected or confirmed. A GCS < 14, respiratory rate < 10 breaths/min or greater than 29 breaths/min and a systolic blood
pressure < 90 mmm Hg all suggest potentially life-threatening injury and should prompt transport to a trauma center.
2. a
Explanation: The decision to transport a patient to a trauma center will depend upon many factors. Some situations that should
prompt transport to a trauma center include: ejection from auto, death in the same passenger compartment, pedestrian run over
or thrown, unrestrained passenger in a high speed MVA (speed > 40 mph, major deformity to vehicle such as > 20 inches,
intrusion into the passenger compartment > 12 inches, extrication time > 20 minutes, falls > 20 ft, rollover, pedestrian hit at > 5
mph or motorcycle crash traveling at greater than 20 mph or with separation from the bike.
3. d
Explanation: Some situations that should prompt transport to a trauma center include: flail chest, 2 or more proximal long bone
fractures (humerus, femur), amputation proximal (above) the wrist or ankle, penetrating trauma to the head, neck, chest and to
the extremities proximal to the knee and elbow, suspected open or depressed skull fracture, paralysis, suspected pelvic fracture,
combination trauma with burns and isolated major burns.
4. b
Explanation: Whether managing a medical or trauma patient the ABCs take priority. As soon as the airway has been evaluated
(and in practice simultaneously) protect the cervical spine.
5. d
Explanation: Definitive airway management is commonly indicated for trauma patients with tracheal/laryngeal fractures that
cause airway obstruction, GCS < 8 and nonpurposeful motor responses. Patients with mandible fractures who are protecting
their airway usually do not require emergent intubation. A respiratory rate > 29 breaths/min is concerning but does not
necessarily require intubation, especially if it is from a tension pneumothorax, massive hemothorax or pulmonary contusion.
6. e
Explanation: Airway management of trauma patients can be extremely difficult. If a trauma patient deteriorates following
intubation the most common reason would be improper endotracheal tube placement. Tube placement should be reconfirmed
by auscultating bilateral breath sounds and watching the chest rise and fall, using an end tidal CO2 detector, visualizing the
endotracheal tube through the cords and checking a chest X-ray. Other less common but potentially life-threatening causes of
deterioration following intubation include unrecognized laryngeal fracture, incomplete upper airway transection that becomes
complete following intubation, worsening pneumothorax or the development of a tension pneumothorax.
7. c
Explanation: Hemorrhage is the most common cause of preventable post-traumatic death.
8. d
Explanation: When a trauma patient is hypotensive suspect hemorrhage. If there is no visible evidence of external hemorrhage
suspect occult blood loss. Major sources of occult blood loss include hemorrhage into the thoracic or abdominal cavities,
hemorrhage surrounding long bone fractures (femur more commonly than humerous) or a pelvic fracture with retroperitoneal
hemorrhage. Neurogenic shock secondary to spinal cord injury is an uncommon cause of hypotension.
9. d
Explanation: Elderly patients, especially those on medications that may attenuate tachycardia such as beta blockers and
calcium channel blockers, children and athletes may not respond to hemorrhage in a normal manner, obscuring one of the
earliest signs of volume depletion.
10. a
Explanation: Rapid external hemorrhage is best controlled during the primary survey using direct manual compression.
Tourniquets can cause tissue injury and distal ischemia and hemostats can cause damage to veins and nerves.
11. e
Explanation: The GCS can help to determine a patients level of consciousness. The GCS measures eye opening, verbal and
motor responses.
12.
13. e
Explanation: The maximum rate of fluid administration is determined by the internal diameter of the intravenous catheter and
inversely by the length of the intravenous catheter. The size of the vein has less to do with the rate of fluid resuscitation than
these mechanical factors.
14. c
Explanation: Warmed crystalloid solution such as normal saline or Lactated Ringers, is the preferred initial intravenous fluid for
the resuscitation of trauma patients with hypotension. The ATLS textbook states that Ringer's Lactate solution is the preferred
initial crystalloid solution. The ATLS textbook states that normal saline the second choice because it has the potential to cause
hyperchloremic acidosis especially if renal function is impaired. Normal saline is, however, commonly used as the initial
intravenous fluid of choice at many trauma centers.
,15. a
Explanation: If a trauma patient requires blood emergently and there is not enough time to obtain matched type specific blood
unmatched type specific blood should be administered. If unmatched type specific blood is unavailable in a timely fashion O
negative blood should be administered. O positive blood is not a substitute for O negative blood, especially in a female patient
of child bearing age.
16. d
Explanation: Traumatic causes of PEA include cardiac tamponade, tension pneumothorax and massive hemorrhage with
hypovolemia.
17. d
Explanation: Urethral injury should be suspected if there is blood at the penile urethral meatus, perineal ecchymosis, a
nonpalpable prostate (high-riding prostate), ecchymotic srotum or blood suspected in the scrotum or a pelvic fracture. Do NOT
insert a Foley catheter if a urethral injury is suspected!
18. b
Explanation: Urethral injury is best diagnosed by a retrograde urethrogram. A Foley catheter should not be inserted if urethral
injury is suspected. Neither an abdominal/pelvic CT scan nor urinalysis are the test of choice for diagnosing urethral injury.
19. e
Explanation: Complications associated with nasogastric tube insertion include nasal bleeding, nasal injury, pulmonary
aspiration, vomiting, bradycardia and thankfully extremely rarely insertion into the brain via a fractured cribiform plate.
20. b
Explanation: Proper color change of an end-tidal carbon dioxide monitor following intubation confirms that the endotracheal
tube is in the airway. It does NOT comfirm proper placement in the airway or adequate ventilation. Blood in the endotraheal tube
would not give a false positive color change. Proper color change over time does rule out esophageal intubation.
21. a
Explanation: The pulse oximeter measures the percentage of hemoglobin saturated with oxygen. It does not measure the
partial pressure of oxygen dissolved in the blood, carbon monoxide or the adequacy of ventilation. Patients who are not
adequately ventilated may have normal pulse oximeter readings but very high partial pressures of carbon dioxide dissolved in
the blood (PaCO2)
22.
23. e
Explanation: The secondary survey (a complete examination) should not begin until the ABCs have been addressed, initial
resuscitative efforts have been instituted, life-threatening problems have been addressed (pneumothorax, cardiac tamponade,
rapid external bleeding) and the primary survey has been completed (patient fully undressed).
24.
Explanation: Patients with facial/maxillofacial trauma should be presumed to have potential injury to the cervical spine and
should have their cervical spine immobilized during the primary survey pending further examination and work-up.
25.
Explanation: Injury to the cervical vasculature (carotid arteries, vertebral arteries) can occur secondary to both penetrating
trauma and blunt trauma. Evaluation of the cervical vasculature can be performed using ultrasound, contrast enhanced CT and
MRI/MRA as well as angiography.
26. e
Explanation: Penetrating trauma to the neck associated with any one of the following: expanding hematoma, airway
compromise, arterial bleeding or a new bruit usually necessitates surgical exploration in the operating room. In addition patients
may also need direct and/or radiographic evaluation of the upper and lower airway (bronchoscopy), esophagus (esophagoscopy
and or esophagram) and the carotid arteries (angiography/CT with contrast/MRA).
27. b
Explanation: If it is unclear if a penetrating neck injury penetrates the platysma the best course of action would be to involve a
trauma surgeon. Exploration of the wound by untrained personnel is not recommended due to the risk of worsening or causing
injury.
28. e
Explanation: Injury to hollow viscus (small bowel) and the pancreas are often difficult to diagnose and may present days
following initial injury without antecedent signs or symptoms. Splenic rupture is usally diagnosed on the initial trauma work-up.
Delayed presentation of splenic hematoma may occur.
29. e
Explanation: Findings suggestive of tension pneumothorax include distended neck veins, hyperresonance to percussion,
decreased breath sounds, tracheal deviation and hypotension. Hypotension and distended neck veins are also a finding with
cardiac tamponade. Tension pneumothorax should be treated with needle decompression and tube thoracostomy (chest tube
insertion)
, 30. b
Explanation: Radiographic findings consistent with aortic rupture include widened mediastinum, blurring of the aortic knob,
rightward deviation of the trachea and esophagus, depression of the left mainstem bronchus, obliteration of the space between
the pulmonary artery and the aorta, widened paratracheal stripe, widened paraspinal interfaces, pleural or apical cap, left sided
hemothorax or fractures of the 1st or 2nd ribs.
31.
Explanation: Elderly trauma patients, especially those with underlying pulmonary insufficiency, can develop acute respiratory
distress with even minor chest injuries that would not be expected to cause problems in younger patients.
32.
Explanation: A high index of suspicion is needed, especially in pediatric trauma patients, in order to diagnose intrathoracic
injury. Since children have more pliable chest walls they may have significant intrathoracic injuries without significant external
evidence of trauma.
33. d
Explanation: Diagnositc peritoneal lavage (DPL) may be helpful in diagnosing intraperitoneal injury in severly injured trauma
patients with unexplained hypotension, abdominal pain and tenderness, and in those patients where a reliable abdominal
examination is difficult to obtain (neurologic injury and altered mental status)
34.
Explanation: A vaginal examination should be performed as part of the secondary survey, especially if there is acute onset of
vaginal bleeding following a traumatic event or the history and physical exam suggest a potential mechanism for gynecological
injury.
35.
36. d
Explanation: If there neurologic injury is suspected or confirmed in a trauma patient the patient?s cervical spine should be
immobilized with semirigid cervical collar. In addition the patient should be immobilized on a long spine board. A patient in a
semi-rigid C-collar on a long board will be maximally protected.
37.
Explanation: Adequate maintenance urine output for most adult trauma patients is defined as a minimum of 0.5 mL/kg/hour
38. a
Explanation: Adequate urine output for most pediatric trauma patients is a minimum of 1 mL/kg/hour. This is more than the
minimum maintenance urine output for adults of 0.5 mL/kg/hour. For pediatric trauma patients under 1 year old a minimum of 2
mL/kg/hour is recommended.
39. b
Explanation: The administration of pain medications for trauma patients in pain is an important part of their care. Patients in
pain should have their pain treated appropriately both before and after trauma surgeon evaluation.
40. c
Explanation: Severely injured trauma patients should usually have pain medications administered by the intravenous route. The
intravenous route provides the fastest onset of action, allows for easier titration to the desired level of pain relief and minimizes
oral intake which may become a factor if the patient is taken to surgery.
41. b
Explanation: The ?D? in the ABCDEs mneumonic of the primary survey represents disability: brief neurologic examination. The
?E? represents exposure and is a reminder to fully undress/disrobe the patient. Documentation is important and many trauma
patients may also be intoxicated.
42. b
Explanation: As soon as it is determined by either the emergency department physician or the trauma surgeon that a trauma
patient?s injuries exceed a hospitals treatment capabilities the process to transfer the patient to a trauma center with sufficient
treatment capabilities should be initiated. Ideally the emergency department physician and the trauma surgeon will make this
decision together. As long as appropriate transfer procedures are followed as outlined by the EMTALA law transfer of a patient
would not be an EMTALA violation. Good luck getting a trauma team from another hospital to respond to your emergency
department!
43. e
Explanation: In a trauma patient with potential or suspected cervical spine injury the chin lift or jaw thrust technique to open the
airway is preferred over the head tilt. The head tilt may result in further damage to the cervical spine.
44. a
Explanation: An open pneumothorax should be sealed.
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