Correct answer: Class 2
Base excess and GCS have been added to the hemorrhagic shock table in ATLS 10. A base deficit ranging from -2 to -6 indicates class 2 shock.
Correct answer: Begin transfusing blood
ATLS 10 emphasizes the early administration of blood and blood products. Instead of 2L, a 1L crystalloid bolus is now administered. Simultaneously, you will be treating additional sources of bleeding and searching for unknown sources of ongoing bleeding, but while the patient is unstable, this will involve a FAST or DPL rather than a CT scan. You would also be re-examining the patient for tension PTX and other non-hemorrhagic causes of shock. This patient may need to be transferred and/or monitored invasively, but your immediate priorities should be to stabilize the patient by identifying and stopping the bleeding and replacing lost volume.
Correct answer: 1L bolus crystalloid
The initial fluid bolus in ATLS 10 has been reduced to 1L instead of 2L crystalloid because bleeding patients need the bleeding to stop and blood, so this is now the focus. If there is no improvement after the initial 1L fluid bolus, begin giving blood. Massive transfusion protocols are receiving a lot more attention. The other items mentioned may be indicated at some point during this patient's care, but he requires fluid resuscitation first.
Correct answer: A massive transfusion is defined as >4u pRBC in 1 hour.
ATLS 10 places a strong emphasis on blood and blood product transfusion. A massive transfusion is defined as the administration of more than 10u pRBC in 24 hours or more than 4u pRBC in 1 hour. The majority of patients who require blood transfusions do not require calcium supplementation. Although the ACS has published guidelines for developing an MTP, there is no universal MTP for all trauma centers. When uncrossmatched plasma is required, type AB plasma should be administered. When un-crossmatched pRBC is required, type O pRBC should be used.
Correct answer: A retrograde urethrogram is advised.
The prostate exam is no longer used as an indicator of urinary tract injury in ATLS 10 due to its inaccuracy. A retrograde urethrogram should be performed prior to the placement of a Foley catheter if there is a suspicion of urethal injury. If a FAST exam is performed, it should be performed prior to catheter placement or voiding so that the bladder is not empty during the FAST. Needle aspiration of a scrotal hematoma is neither recommended nor effective. Even if there is no blood at the urethral meatus or gross blood in the urine, a retrograde urethrogram should be performed if there are other signs of urethral injury such as scrotal ecchymosis or hematoma.
Correct answer: Fiber optic assisted intubation could be used.
Tracheobronchial injury is now classified as a potentially fatal condition in ATLS 10. If this injury is suspected, an extremely difficult airway is to be expected due to the nature of the injury. Fiber optic intubation with the tube placed below the level of injury or in the uninjured bronchus may be required. Bronchoscopy can confirm the diagnosis and help prevent the injury from worsening by intubating the patient blindly. Prior to inserting the gastric tube, the airway should be secured. Because there were no signs of tension PTX, needle decompression would not be necessary; however, the patient may require multiple chest tubes to control the air leak. After the primary survey, non-life threatening injuries are evaluated during the secondary survey.
Correct answer: Rotational Thromboelastometry is a point-of-care test that could help guide this patient's treatment.
ATLS 10 places a greater emphasis on coagulopathy, even mentioning the use of Tranexamic acid. The initial bolus is usually given over 10 minutes in the field, followed by an 8-hour infusion of 1g. Thromboelastography and Rotational Thromboelastrometry are both point-of-care tests that can help guide treatment for a potentially coagulopathic patient. Hypothermia raises the likelihood of coagulopathy. PLT, PT/INR, and PTT should be checked within the first 1 hour.
Correct answer: Class 3
Base excess and GCS have been added to the hemorrhagic shock table in ATLS 10. Rather than looking for anxiety, you will notice a change in GCS, which will begin to decrease at Class 3. Because neurogenic shock is caused by spinal injury rather than head injury, a change in GCS would not be an indicator of neurogenic shock.
Correct answer: This patient's target MAP is 60-70mm Hg.
A traumatic aortic rupture is suspected in this patient. CXR is ineffective for diagnosing or ruling out aortic rupture, and even a remote suspicion warrants further investigation. Proceed with CT if the patient is stable and can be treated at your facility. A short-acting Beta blocker is recommended for pain control as well as HR and blood pressure control (Esmolol). If beta blockade is contraindicated, a calcium channel blocker (Nicardipine) can be used, and if that does not work, Nitroglycerine or Nitroprusside can be used. The current scenario does not call for an ED thoracotomy. Upper endoscopy can diagnose or rule out an esophageal tear, but it cannot rule out an aortic rupture.
Correct answer: A 35-year-old woman with delayed-onset neck pain who can actively rotate her neck 45 degrees to the left and right.
The Nexus criteria and the Canadian C-spine Rues are both emphasized in ATLS 10, so review them both. The 12 year old boy has a high risk factor of falling from more than 3 feet; the 68 year old man, despite having a low risk factor of age >65; and the 42 year old woman has a low risk factor of a rear end collision, but being hit by a bus prevents it from truly being low risk; The 35-year-old woman has a low risk of delayed onset of neck pain and can rotate her neck 45 degrees actively both left and right on ROM testing, so she does not need imaging based on the information provided; the 23-year-old man has midline cervical spine tenderness and clearly needs imaging.
Correct answer: Resuscitation procedures may increase the risk of coagulopathy.
Tranexamic acid is recommended in ATLS 10 for severely injured patients who will require massive transfusions and are at risk of coagulopathy. The first bolus should be administered within the first 3 hours of injury. This could happen in a pre-hospital setting. It is then administered as an infusion over an 8-hour period in a hospital setting. We know that fluid/blood resuscitation can increase the risk of coagulopathy, emphasizing the need for massive transfusion protocols, and hypothermia increases the risk of coagulopathy, so warm rooms, warm blankets, and warm blood/fluids are still recommended.
Correct answer: The needle should be placed in the 5th intercostal space, just anterior to the mid axillary line, during needle decompression of tension PTX, according to current ATLS recommendations.
Because of the frequent incorrect placement of the needle too far medial in the field, the recommendation for needle placement in the 2nd intercostal space in the midclavicular line has changed in ATLS 10. The needle should be inserted into the 5th intercostal space, just anterior to the mid axillary line, according to current recommendations. A longer needle, such as an 8cm, has a better chance of entering the pleural space than a shorter needle and is therefore preferred. Patients with a small, occult PTX can be safely observed unless they are being transported by air or require mechanical ventilation, in which case a chest tube should be inserted. Tension PTX should be diagnosed clinically and treated right away rather than waiting for radiographic confirmation.
