ATLS Trauma in Special Populations 2 — Questions and Answers
Question 1: In a pregnant trauma patient at 28 weeks, what is the most important initial intervention to improve hemodynamics?
- Emergency cesarean
- Left lateral tilt of 15-30 degrees (Correct answer)
- Tocolytics
- Fetal monitoring
Correct answer: Left lateral tilt of 15-30 degrees
Left lateral tilt relieves aortocaval compression by the gravid uterus, improving venous return and cardiac output by up to 30%.
After 20 weeks, the gravid uterus compresses the IVC when supine. Left lateral tilt or manual uterine displacement is a critical ATLS modification. The best treatment for the fetus is adequate maternal resuscitation.
Question 2: An 80-year-old on warfarin with GCS 15 after a ground-level fall hitting their head. Most appropriate management?
- Discharge with precautions
- CT head scan regardless of GCS (Correct answer)
- Observe 2 hours then discharge
- Skull X-rays only
Correct answer: CT head scan regardless of GCS
Elderly patients on anticoagulants require CT after any head trauma regardless of GCS due to high risk of occult intracranial hemorrhage.
Cerebral atrophy stretches bridging veins. Anticoagulation prevents clotting. GCS may be initially normal despite significant hemorrhage. Reverse anticoagulation if hemorrhage found.
Question 3: A 5-year-old in an MVC has HR 150 but normal blood pressure. What does this suggest?
- Hemodynamically normal
- Compensated shock with up to 25-30% blood volume loss (Correct answer)
- Neurogenic shock
- Anxiety only
Correct answer: Compensated shock with up to 25-30% blood volume loss
Children maintain normal BP until 25-30% blood volume is lost, then decompensate rapidly. Tachycardia is the earliest sign.
Pediatric blood volume ~80 mL/kg. Fluid resuscitation: 20 mL/kg crystalloid boluses. Hypotension is a LATE sign. Capillary refill >2 sec, altered mental status, and decreased UO are additional signs.
Question 4: What modification to the primary survey is needed for pregnant patients beyond 20 weeks?
- Skip airway assessment
- Circulation before breathing
- Add fetal heart tone assessment after maternal stabilization (Correct answer)
- Reduce IV fluids
Correct answer: Add fetal heart tone assessment after maternal stabilization
After standard ABCDE and maternal stabilization, fetal assessment is added.
Also: left lateral tilt during C, Rh status determination, continuous fetal monitoring for 4-6 hours, watch for abruption. Key changes: 50% increased blood volume, 15-20 bpm higher HR, delayed gastric emptying.
Question 5: Elderly trauma patients have increased mortality primarily because of which factor?
- Higher spinal injury incidence
- Decreased physiologic reserve and pre-existing conditions (Correct answer)
- Increased pain sensitivity
- More penetrating injuries
Correct answer: Decreased physiologic reserve and pre-existing conditions
Diminished physiologic reserve across all organ systems plus pre-existing conditions and medications impair compensation and recovery.
Cardiovascular limitations, decreased pulmonary function, reduced GFR, medications masking shock signs (beta-blockers, anticoagulants), osteoporosis. Under-triage is a major problem in the elderly.
Question 6: What formula estimates the correct uncuffed ETT size for a pediatric patient?
- Age/2 + 4
- Age/4 + 4 (Correct answer)
- Weight/10 + 3
- Age/3 + 3
Correct answer: Age/4 + 4
Uncuffed ETT (mm ID) = (age/4) + 4. Cuffed = (age/4) + 3.
Always have tubes one size above and below available. ETT depth at lip = 3 x tube size. Modern practice increasingly favors cuffed tubes in children over 2 years.
ATLS Trauma in Special Populations 2
In a pregnant trauma patient at 28 weeks, what is the most important initial intervention to improve hemodynamics?