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ATLS EXAM 164 complete solutions.
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. - ANSWER True
In the elderly population, what is decreased physiological reserve? - ANSWER 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.
Pre-existing conditions that affect morbidity and mortality include: - ANSWER cirrhosis, coagulopathy, COPD, ischemic heart disease, DM
What is the most common mechanism of injury in the elderly? - ANSWER Fall. Nonfatal falls are common in women and fractures are common in women who fall. Falls are the most common cause of TBI.
In the elderly population, what are risk factors for falls? - ANSWER advanced age, physical impairment, history of previous fall, medication use, dementia, unsteady gait, and visual, cognitive impairment
Most of elderly traffic fatalities occur in the daytime and on weekends and typically involve other vehicles. Why? - ANSWER 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.
True or False? Mortality associated with small to moderate sized burns in older adults remains high - ANSWER 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. - ANSWER this is true
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? - ANSWER bag mask ventilation, as it improves mask fitting.
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? - ANSWER 20- 40%
Functional changes in cardiac system include declining function, decreased sensitivity to catecholamines, atherosclerosis of coronary vessels, increased afterload, fixed heart rate (beta blockers)
- ANSWER 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 - ANSWER thus they are at increased risk for respiratory failure, increased risk for pneumonia, and poor tolerance to rib fractures
Functional changes in renal system include loss of renal mass, decreased GFR, and decreased sensitivity to ADH and aldosterone - ANSWER 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 - ANSWER 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) - ANSWER resulting in occult hypothyroidism, relative hypercortisone states and increased risk of infection
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 - ANSWER true
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...... - ANSWER respiratory failure may present insidiously in older adults.
The best initial treatment for the fetus is to provide optimal resuscitation of the mother. True or False? - ANSWER True. Also if xray examination is indicated during the pregnant patient's treatment, it should not be withheld because of the pregnancy.
What happens as the uterus enlarged and the bowel is pushed cephalad. - ANSWER 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.
Amniotic fluid can cause amniotic fluid embolism and disseminated intravascular coagulation following trauma if fluid enters maternal intravascular space. True or False - ANSWER True
By the third trimester, what is the complication of trauma to the pelvis of the mother? - ANSWER 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.
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. - ANSWER this is true
Physiological anemia of pregnancy - ANSWER 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.
Healthy pregnancy patients can lose 1200-1500 mL of blood before exhibiting signs and symptoms of hypovolemia. How can this manifest? - ANSWER this amount of hemorrhage may be reflected by fetal distress as evidenced by an abnormal fetal heart rate.
What are some of the lab changes in pregnancy? - ANSWER 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.
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. - ANSWER 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.
During pregnancy the heart rate increases to a maximum of 10-15 beats per minute over baseline by the third trimester. - ANSWER this heart rate must be considered when interpreting a tachycardic response to hypovolemia.
Blood pressure falls 5-15 mm Hg in systolic and diastolic pressures during second trimester, although it returns to near normal levels at term. - ANSWER some women experience hypotension when placed in the supine position due to the compression of teh inferior vena cava.
hypertension in the pregnant if accompanied by proteinuria may represent what? - ANSWER pre- eclampsia.
EKG findings in pregnant patient - ANSWER Flatted or inverted T waves in leads III and AVF and the precordial leads may be normal. Ectopic beats are increased during pregnancy.
Minute ventilation increases primarily due to an increase in tidal volume. Hypocapnia (30 mm Hg) is common in late pregnancy - ANSWER 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.
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. - ANSWER oxygen consumption increases during pregnancy and its important when resuscitating injured pregnant patients to maintain adequate oxygenation above 95%
In patients with advanced pregnancy, those that require a chest tube placement, where should the test tube be placed? - ANSWER it should be positioned higher to avoid intra-abdominal placement given the elevation of the diaphragm.
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? - ANSWER 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.
What does a normal fibrinogen level indicate in a pregnant patient? - ANSWER Fibrinogen level may double in late pregnancy and a normal level may indicate early disseminated intravascular coagulation
Most common cause of fetal death? - ANSWER 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.
Signs of uterine rupture - ANSWER 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.
Perform continuous fetal monitoring with a tocodynamometer beyond 20-24 weeks of gestation. - ANSWER 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
REMEMBER: maternal bicarbonate is low during pregnancy to compensate for respiratory alkalosis. - ANSWER 17-22 in pregnant patient. (non pregnant patient is 22-28)
Fetal heart rate is a sensitive indicator of maternal blood volume status and fetal well being. - ANSWER 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.
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. - ANSWER evidence of ruptured chorioamniotic membranes include amniotic fluid in vagina evidenced by a pH of 4.
Bleeding in 3rd trimester may indicate placental abruption and impending death of the fetus, a vaginal exam is vital - ANSWER 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.
Admission to hospital for pregnant patients: - ANSWER 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
With extensive placental separation or amniotic fluid embolization, widespread consumptive coagulopathy can emerge rapidly causing depletion of fibrinogen, other clotting factors, and platelets. - ANSWER immediately perform uterine evacuation and replace platelets, fibrinogen, and other clotting factors.
As little as 0.01mL of RH+ blood will sensitize 70% of Rh- women. - ANSWER All pregnany RH negative trauma patients should receive RH immunoglobulin therapy unless injury is remote from the uterus (isolated distal extremity injury)
Intimate partner violence in pregnant patient: - ANSWER 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
What is the difference between burns and other injuries? - ANSWER 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.
Always assume CO exposure in patients who were burned in enclosed areas. Patients with CO levels less than 20% may not show any symptoms - ANSWER 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.
Cyanide inhalation poisoning can occur in confined spaces and sign of potential toxicity is persistent profound unexplained metabolic acidosis. - ANSWER THERE IS NO ROLE for hyperbaric oxygen therapy in the primary resuscitation of a patient with critical burn injury.
American Burn Association states 2 requirements for diagnosis of smoke inhalation injury: - ANSWER 1. exposure to combustible agent
- 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.
The treatment of smoke inhalation injury is supportive. - ANSWER 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.
True or false: Clinicians should provide burn resuscitation fluids for deep partial and full thickness burns larger than 20% TBSA - ANSWER True. urine output monitoring is 0.5mL/kg/hr in adults and should be maintained at 30-50cc/hr to minimize over resuscitation
in a burn patient, cardiac dysrhytmias may be the first sign of hypoxia and electrolyte or acid base abnormalities. - ANSWER 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.
Tachycardia is a poor indication for resuscitation in the burn patient. - ANSWER 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.
True of false: Burn patients should get tetanus. - ANSWER true
Partial thickness burns - ANSWER 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)
Full thickness burns - ANSWER appear leathery and skin may be white or translucent or waxy white. surface area is painless to light touch or pinprick and generally dry
Compartment syndrome in burn patients: - ANSWER 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
compartment syndrome may be present with circumferential chest and abdominal burns - ANSWER 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.
Partial thickness burns are painful when air currents pass over the burned surface. - ANSWER 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.
Sympathetic blockade agents and vasodilating agents have shown to be effective in altering the progression of acute cold injury - ANSWER false
hypothermia is a core temp below 36C or 96.8F - ANSWER hypothermia can worsen coagulopathy and affect organ function.
Rhabdomyolysis can lead to metabolic acidosis, hyperK, hypoC, and DIC. - ANSWER Myoglobin induced renal failure can be prevented with intravascular fluid expansion, alkalinization of the urine by IV administration of Bicarbonate and osmotic diuresis.
For MSK trauma, loss of sensation in a stocking or glove distribution is an early sign of.... - ANSWER early sign of vascular impairment
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. - ANSWER an ankle brachial index of less than 0.9 indicates abnormal arterial flow secondary to injury or peripheral vascular disease
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 - ANSWER 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
Treat all patients with open fractures as soon as possible with iv antibiotics - ANSWER cephalosporins are necessary for all open fractures
operative revascularization to an avascular extremity is important to treat emergently. - ANSWER 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
High risk activities that can cause compartment syndrome include: - ANSWER excessive exercise
burns
severe crush injury to muscle
localized prolonged external pressure to an extremity
increased capillary permeability secondary to reperfusion of ischemic muscle.
Compartment syndrome is a clinical diagnosis and pressure measurements are only an adjunct to aid in its diagnosis. a pressure greater than 30 can cause anoxia. - ANSWER the absence of a palpable distal pulse is an uncommon or late finding and is not necessary to diagnose compartment syndrome.
Capillary refill times are also unreliable
weakness or paralysis of the involved muscle is a late sign and indicates nerve or muscle damage
the lower the systemic pressure, the lower the compartment pressure that causes compartment syndrome
risk of tetanus: - ANSWER wounds that are more than 6 hours old
contused or abraded
more than 1cm in depth
from high velocity missiles
due to burns or cold
significantly contaminated
ischemic tissue or denervated wounds
True or false? on page 162. To exclude occult dislocation and concomitant injury, x ray films must include the joints above and below the suspected fracture site - ANSWER true. unless life threatening, splinting of extremity injuries should be done during the secondary survey.
do not apply traction to patients with an ipsilateral tibia shaft fracture. - ANSWER true
Laryngeal Trauma presents as hoarseness, subcutaneous emphysema, and palpable fracture - ANSWER true. sounds of airway obstruction and include snoring, gurgling, stridor, hoarseness, cyanosis, agitation
tachycardia is diagnosed as > 100 in adults
160 in infants
140 in preschool aged children
120 in children from school age to puberty.
Tachycardia, muffled heart sounds, dilated engorged neck veins, hypotension and insufficient response to fluid therapy is what? - ANSWER cardiac tamponade, which is commonly caused by penetrating thoracic trauma, but can result from blunt injury to the thorax. Definitive treatment is operative intervention as pericardiocentesis is temporary measure.
Tension pneumothorax differs because it presents with distended neck veins and hypotension as well as absent breath sounds and hyperresonant percussion
Acute respiratory distress, subcutaneous emphysema, absent unilateral breath sounds, hyperresonance to percussion, and tracheal shift supports the diagnosis of???? - ANSWER tension pneumothorax. needle or finger decompression temporarily relieves this life threatening condition and follow this with a chest tube
isolated intracranial injuries do not cause shock, unless the brainstem is injured. A narrowed pulse pressure is not seen in neurogenic shock. - ANSWER The classic presentation of neurogenic shock is hypotension (due to loss of sympathetic tone) without tachycardia. A narrowed pulse pressure is not seen in neurogenic shock. The failure of fluid resuscitation to restore organ perfusion and tissue oxygenation suggest either continuing hemorrhage or neurogenic shock
Less than 15% blood loss. no change in HR, BP, pulse pressure, RR, urine output. - ANSWER this is class 1 hemorrhage and requires monitoring with base deficit of 0- -
15-30% blood loss. increase in heart rate. decrease in pulse pressure. BP, RR, urine output do not change
- ANSWER class II hemorrhagic shock. possible need for blood products, but mostly crystalloid fluid and base deficit of -2 to -6. anxiety, fear
31-40% blood loss. heart rate increase, respiratory rate increase, blood pressure decrease, pulse pressure decrease, urine output and GCS decrease - ANSWER class III and this is the least amount of
blood loss that consistently causes a drop in systolic blood pressure. blood products needed and base deficit is -6 to -
40% blood loss. heart rate increase, RR increase, BP decrease, pulse pressure decrease, urine output and GCS decrease - ANSWER MTP and base deficit is -10 or less
A chest xray must be obtained after attempts at inserting a subclavian or IJ to document position of line and evaluate for pneumo or hemothorax. - ANSWER do not use sodium bicarb to treat metabolic acidosis from hypovolemic shock
Hypothermia can be prevented and reversed by storing crystalloids in a warmer or infusing them through intravenous fluid warmers. - ANSWER blood products cannot be store in a warmer, but they can be heated by passage through intravenous fluid warmers. Fluids should be warmed to 39C or 102.2F before infusing them.
Massive fluid resuscitation with the resultant dilution of platelets and clotting factors (severe hemorrhage and injury results in consumption of coagulation factors and early coagulopathy) contributes to coagulopathy in injured patients. - ANSWER The response of elderly patients, athletes, pregnant patients, patients on medications, hypothermic patients, and patients with pacemakers or implantable devices may have different set of vitals in response to shock.
Older patients are unable to increase their HR when stressed by blood volume loss. A systolic BP of 100 may represent shock in an elderly patient. Due to medications, HR may not increase in the elderly population when in shock. - ANSWER Blood volumes may increase 15-20% in athletes, cardiac output can increase 6 fold and the rest HR can be 50. Trained athletes have a remarkable ability to compensate for blood loss and they may not manifest the usual way to hypovolemia, even with significant blood loss.
Patients suffering from hypothermia and hemorrhagic shock do not respond as expected to the administration of blood products and fluid resuscitation. IN hypothermia, coagulopathy may develop and worsen. - ANSWER When a patient fails to respond to fluid therapy one or more of these causes may be: tension pneumothorax, cardiac tamponade, undiagnosed bleeding, unrecognized fluid loss, acute gastric distention, MI, diabetic acidosis, neurogenic shock
Tracheobronchial injury will present with hemoptysis, cervical subcutaenous emphysema, tension pneumothorax, and/or cyanosis. - ANSWER A bronchoscopy can confirm the diagnosis, but these
pulmonary contusion can occur with rib fractures and flail chest (two or more adjacent ribs fractured in two or more places). - ANSWER initial treatment includes humidified oxygen, adequate ventilation, and cautious fluid resuscitation. definitive treatment includes pain control, adequate oxygenation
Blunt cardiac injury can present with hypotension, dysrhythmias, EKG changes, premature ventricular contractions, unexplained sinus tachycardia, AFib, bundle branch block, elevated central venous pressure without any obvious cause may indicate right ventricular dysfunction secondary to contusion. - ANSWER cardiac troponins can be diagnostic in an MI but have little role in diagnosing blunt cardiac injury. patients with a blunt injury to the heart diagnosed by conduction abnormalities are at increased risk for sudden dysrhythmias and need to be monitored for 24 hours.
Traumatic aortic disruption- most survive if they have an incomplete laceration near the ligmentum arteriosum. commonly caused by vehicle collision or fall from a great height. have a high index of suspicion if history has decelerating force. - ANSWER Look for widened mediastinum on chest xray, obliteration of the aortic knob, deviation of the trachea to the right, depression of the L mainstem bronchus, elevation of R mainstem bronchus, deviation of the esophagus to the right, left hemothorax, presence of the pleural or apical cap, fractures of the first or second rib or scapula, widened paraspinal interface, widened paratracheal stripe.
In a traumatic aortic rupture, heart rate and blood pressure control can decrease the likelihood of rupture. - ANSWER definitive treatment is surgery.
Diaphragmatic injury-displaced bowel, stomach, and nasogastric tube on left side. - ANSWER The appearance of peritoneal lavage fluid in the chest tube also confirms diagnosis
esophageal injury- clinical picture is a patient with a left pneumothorax or hemothorax without a rib fracture who has received a severe blow to the lower sternum or epigastrum and is in pain or shock out of proportion to the apparent injury - ANSWER presence of mediastinal air also suggests diagnosis and definitive treatment is direct repair of the injury.
injuries to the retroperitoneal structures are difficult to recognize because they occur deep within the abdomen and may not initially present with signs or symptoms of peritonitis. - ANSWER the retroperitoneal space is NOT sampled by DPL or FAST
physical exam findings suggestive of a pelvic fracture include: - ANSWER ruptured urethra, scrotal hematoma or blood at the urethral meatus, discrepancy in limb length and rotational deformity of a leg
w/o obvious fracture. use pelvic binder that is centered at the greater trochanters rather than over the iliac crests.
signs of urethral injury include: - ANSWER blood at the uretheral meatus, ecchymosis or hematoma of the scrotum and perineum. Palpation of the prostate gland is NOT a reliable sign of urethral injury.
a retrograde urethorgram is mandatory when the patient is unable to void, requires a pelvic binder, or has blood at the meatus, scrotal hematoma, or perineal ecchymosis. confirm an intact urethra before inserting a urinary catheter.
DPL: Aspiration of gastrointestinal contents, vegetable fibers, or bile through the lavage mandate laparotomy. Aspiration of 10cc or more of blood in hemodynamically abnormal patients requires laporotomy. - ANSWER performed rapidly, invasive procedure
sensitive for detecting intraperitoneal hemorrhage
low specificity
requires gastric and urinary decompression
not repeatable
a positive DPL is an indication for laparotomy
contraindications include previous abdominal operations, morbid obesity, advanced cirrhosis, pre- existing coagulopathy.
FAST - ANSWER noninvas and can be done rapidly
repeatable
does not assess retroperitoneal structures.
obesity can degrade images obtained by FAST
indications for a laparotomy: - ANSWER Blunt abdominal trauma with hypotension, positive FAST
hypotension with an abdominal wound that penetrates anterior fascia
gunshot wounds that traverse the peritoneal cavity
evisceration
