17- Trouma & ER Refrence 2 + ِATLS Flashcards
1
Q
How is medical professionalism defined by the Royal College of Physicians?
A
It is defined as “a set of values, behaviors, and relationships that underpins the trust the public has in doctors”
2
Q
What is situational awareness?
A
It is the ability to perceive and respond to changes in one’s environment, involving detection, diagnosis, and prediction
3
Q
Can you provide an example of situational awareness in a surgical setting?
A
A patient undergoing a carotid endarterectomy shows signs of neurological deterioration upon clamping, which must be recognized and communicated to the surgeon for appropriate action
4
Q
What is decision-making in medicine?
A
It is the process of choosing a course of action from available options, balancing risks using new information and past experiences
4
Q
Is decision-making a dynamic process?
A
Yes, continual re-evaluation is necessary to assess the outcomes of previous decisions
5
Q
Does good situational awareness guarantee good decision-making?
A
No, although it is linked, good situational awareness does not guarantee good decision-making
5
Q
What are the four principles of ethical decision-making in medicine?
A
Autonomy, beneficence, non-maleficence, and justice
6
Q
What does autonomy mean in the context of medical ethics?
A
It refers to an individual’s right to self-determination, and doctors must respect this by providing information for informed decision-making
7
Q
What does beneficence mean in the context of medical ethics?
A
It describes actions carried out for the benefit of others, serving the best interests of patients at all times
8
Q
What does non-maleficence mean in the context of medical ethics?
A
It means “first do no harm,” patients should not be exposed to risks of harm without clear benefit
9
Q
What does justice mean in the context of medical ethics?
A
It refers to fairness and equality of treatment and access, including the allocation of scarce resources
10
Q
What is the concept of “double effect”?
A
It describes how an intervention can have both intended and unintended consequences, where an action with two opposite outcomes is morally justifiable if the intention is to achieve the good effect
11
Q
Can you provide an example of a clash of ethical principles in medicine?
A
A patient who is bleeding but refuses a blood transfusion due to religious beliefs, creating a conflict between autonomy and beneficence
12
Q
Should a patient’s autonomy be respected even if it conflicts with beneficence?
A
Yes, if the patient is mentally competent, their wishes should be respected to maintain autonomy and avoid deterring similar patients from seeking medical attention in the future
13
Q
What does task management entail?
A
It involves planning and prioritization to carry out work efficiently and effectively using available resources
14
Q
Is the ability to deal with stress and fatigue considered a non-technical skill?
A
No, it is not considered a discrete non-technical skill, but it influences each of the four domains
15
Q
What percentage of medical litigation is related to poor communication?
A
70%
16
Q
What are some reasons for initiating litigation in medical cases?
A
To correct deficient standards of care, find out what happened and why, enforce accountability, and gain compensation for costs of care
17
Q
What are some basic communication skills that healthcare professionals should be aware of?
A
Appropriate use of open, focused, and closed questions, avoiding leading and multiple questions, overcoming responses such as denial and blocking, and using empathic statements
18
Q
What are some communication problems in critically ill surgical patients?
A
Background obstacles to communication, such as patient illness and fear, busy staff, lack of concentration, operational fatigue, irritability, tension, confusion, distress, tearfulness, and high expectations
19
Q
What are some specific communication strategies for the critical care setting?
A
Provide explanations at each stage of care, explain the role of equipment, discuss upcoming interventions, and clarify the overall management plan. Use aids to orientation, such as readable clocks and name badges. Address acute confusional states through assessment rather than immediate sedation. Repeat questions and explanations, go back over the history, offer repeated explanations to reduce fear, and use check-backs to ensure understanding
20
Q
How can aids to orientation be helpful in managing confusion in critical care patients?
A
Photographs of loved ones and easy-to-read name badges can help patients with organic confusion maintain orientation
21
Q
Why is it necessary to repeat questions and explanations in communication with critically ill patients?
A
Patients may have difficulty recalling information from a single communication episode, so repeating questions and explanations ensures understanding
22
Q
What is the three-stage assessment process for addressing acute confusional states?
A
It is a process used to identify and address the underlying causes of delirium before resorting to sedative-type medications
23
What are some general principles for breaking bad news?
Consider the "set" including the environment and who will be present. Provide an introduction to the purpose of the conversation, discuss the details, and summarize the key points. Confirm patient permission to inform relatives. Understand intra-family dynamics to effectively communicate with relatives.
24
How can you initiate a conversation when breaking bad news?
Start with an open question like "What is your understanding of the present situation?" or "What have you been told so far?" This allows the patient or relative to share their perspective and expectations.
25
What should you do during moments of silence in a conversation about bad news?
Avoid the urge to fill the silence with your words. Allow time for information to be absorbed, and encourage a question and answer format where the patient and/or relatives can ask their questions.
26
Why is it important to use direct and understandable language when discussing difficult topics?
Using clear language, including difficult and emotive words when appropriate (such as "cancer" or "death"), helps patients face the reality of their situation and allows them to start dealing with it.
27
What are the communication issues that arise when there is a medical complication or error?
When a medical complication or error occurs, there are additional communication issues to address, such as breaking bad news, handling guilt, and addressing the fear of litigation.
28
What is the Duty of Candour and how does it relate to disclosing medical mistakes?
The Duty of Candour is a concept introduced in the UK that requires hospitals to inform patients if mistakes in their care have caused significant harm. As a trainee, it is important to recognize situations where a patient has experienced harm that would require disclosure under the Duty of Candour rules.
29
Why is it important to avoid criticizing the actions of others without careful consideration?
Criticism of others should be approached with caution, as it is easy to comment on something without knowing the full details. General Medical Council guidance emphasizes the importance of collegiality, and even innocent off-hand remarks or body language can imply criticism and lead patients to make complaints or seek legal advice.
30
What are traumatic stressors and how do they affect emotional reactions?
Traumatic stressors are events that create intense pressure or tension and are associated with negative emotions like fear and sadness. In some cases, the initial emotional reaction to these events can be so intense that the individual resorts to preventing or avoiding the painful feelings. This can involve avoiding places or objects that remind them of the trauma or suppressing emotions altogether.
31
What is post-traumatic stress disorder (PTSD)?
Post-traumatic stress disorder (PTSD) is characterized by a cyclical reaction of intrusive recollections and defensive avoidance. It occurs when the adaptive mechanism for coping with traumatic events is overwhelmed, and the emotions associated with the event are suppressed rather than declining. If left unresolved, PTSD can become chronic and disabling.
32
What are some symptoms of PTSD?
Symptoms of PTSD can include recurrent and intrusive distressing recollections of the event, including flashback episodes. These recollections can be triggered by cues that symbolize or resemble aspects of the traumatic event. Individuals with PTSD may also avoid thoughts or cues that activate memories of the event, and they may exhibit withdrawal, detachment, or signs of depression.
33
What are some common psychological difficulties that may occur in surgical critical care?
Traumatic life events in surgical critical care can trigger various psychological difficulties, including feelings of depression, anxiety, and even relapse of certain psychoses. It is important to assess the full range of psychological problems that patients may experience.
34
What are some common symptoms of anxiety in hospital patients with serious conditions?
Mild feelings of fear, apprehension, sadness, and emotional turmoil are common in patients admitted to the hospital with serious conditions. The clinical team's approach and communication with patients can greatly impact the level of distress experienced. Symptoms of anxiety may include autonomic symptoms like tachycardia and high blood pressure, as well as visible overbreathing, which can be a clue to the presence of chronic hyperventilation syndrome.
35
What are the core features of major depression?
Major depression is a common condition that often goes unrecognized. It is characterized by a low mood, loss of pleasure and enjoyment, reduced interest, hopelessness, helplessness, and pessimism for the future. There may also be biological features such as weight loss, impaired sleep with early-morning wakening, and a diurnal variation of mood that is worse in the early morning. In some cases, major depression may include mood-congruent delusions and hallucinations.
36
What are acute organic reactions and what are their characteristics?
Acute organic reactions, also known as confusional states or delirium, are short-lived disturbances characterized by confusion, clouding of consciousness, disorientation, and fearfulness. They may involve delusions, often persecutory in nature. Alcohol withdrawal and prescribed medication can be common causes, but they can also occur in the context of various medical conditions. Assessment of these reactions involves evaluating cognitive state, awareness of the environment, and identifying possible organic causes through a comprehensive assessment and review.
37
When should a referral to a psychiatrist be considered?
Referral to a psychiatrist may be necessary in situations where the diagnosis is uncertain or when there is a suspected psychiatric component. Extreme examples such as somatization disorder and Munchausen's syndrome occasionally occur in the surgical population, highlighting the complex interactions between physical and psychological processes that may require assessment. Referral is also appropriate and often urgent in cases involving the severity of the psychiatric condition or the level of danger associated with it, such as deliberate self-harm or the development of persecutory beliefs leading to thoughts of harm towards others. Psychiatrists can also provide guidance on consent for surgery, as they have specialized knowledge of the legislation related to treatment consent for psychiatric illness.
38
What are the "zones of change" described by Critchley?
The "zones of change" described by Critchley refer to three zones in which individuals position themselves based on their confidence with a situation. The comfort zone is where individuals feel secure and competent, while the high-risk zone presents significant challenges. The zone of development is the space in between where learning can occur. By attending the CCrISP course, trainees position themselves in this zone of development, gaining confidence in caring for critically ill surgical patients and taking more responsibility for patient care, which is essential for transitioning to specialty training.
39
What is the difference between a "change" and a "transition" in social psychology?
In social psychology, a "change" is a rapid event that happens to people regardless of their readiness. On the other hand, a "transition" is a slower, developmental process that occurs in people's minds when experiencing change. Viewing the move to specialty training as a transition allows individuals to prepare more fully by building upon the skills they have acquired during core training.
40
What responsibilities does a specialist registrar have during daily business ward rounds?
As a specialist registrar, one of the main responsibilities during daily business ward rounds is actively managing patients. This includes looking for and identifying problems, making decisions about patient management, and contacting the consultant when necessary. While the consultant may not conduct a formal ward round every day, the trainee must take an active role in patient care and communication. As experience grows, the trainee's scope for safe practice expands, but it is crucial to understand when decisions need to be made and who should make them throughout training.
41
What must a senior trainee be prepared to do in terms of their patients' progress?
A senior trainee must be prepared to overcome obstacles that block their patients' progress. This may require assertiveness, but it is important to exercise caution and avoid appearing aggressive to prevent alienation. Building strong working relationships with other key members of the multidisciplinary team is crucial in ensuring that patients receive the necessary treatment. Senior nurses, advanced nurse practitioners, outreach nurses, emergency theatre nurses, and radiologists are examples of individuals who can help facilitate the progress of patients.
42
What is one of the key skills required for doctors at any level of training?
One of the key skills required for doctors at any level of training is working within their limitations. This is especially important in the current climate of surgical training, where operative exposure during core training is significantly less than before. It is crucial to banish any feelings of dismay or inadequacy regarding surgical skills. As a senior trainee, you will quickly develop new operative skills and start feeling like a competent surgeon.
43
What are some basic communication skills mentioned in the glossary?
In the glossary, some basic communication skills are outlined. These skills include using an appropriate range of open, focused, and closed questions during data gathering. It is recommended to use the open question "Is there anything else?" as a final question when taking a history. The glossary also highlights the potential pitfalls of leading questions and multiple questions in checklist approaches to history-taking. Checking back and using a summary of the main features are mentioned as ways to confirm understanding and ensure an accurate history. Additionally, the glossary emphasizes the importance of empathic comments as a way to understand and acknowledge patients' emotional reactions.
44
What does "blocking" mean in terms of communication?
In terms of communication, "blocking" refers to not facing up to an issue or avoiding discussing it. An example of blocking is when a patient asks about potential complications of an operation, and the surgeon dismisses the question with a reassurance like "Don't worry, it'll all be fine." Another example is when a doctor informs a patient of a cancer diagnosis, and the patient denies the possibility by saying, "It can't be cancer, I feel too well." Blocking hinders open and honest communication about important matters.
45
What is "mirroring" in communication?
Mirroring in communication involves reflecting the tone of voice and body language used by the patient. For example, if a patient is speaking softly and timidly, responding in a similar tone can help establish rapport. Similarly, if a patient is sitting leaning forward, mirroring that posture can promote a sense of connection. Anti-mirroring, or doing the opposite of the patient's tone and body language, can negatively impact interactions. Mirroring is a technique that can enhance communication and understanding.
46
What are the differences between assertiveness, passivity, and aggression in communication?
In communication, assertiveness involves expressing honest opinions while respecting others, without needlessly hurting them. Passivity, on the other hand, involves suppressing honest opinions and not speaking up. Aggression is the use of excessive force or power, causing unnecessary suffering. It can manifest as either active aggression, such as violent or insulting speech, or passive aggression, such as emotional manipulation. Assertiveness is generally preferred as it allows individuals to express themselves honestly without causing harm. In assertive statements, the pronoun "I" is commonly used, whereas aggressive statements often use the pronoun "you" to blame or attack the other person.
47
What percentage of total hospital inpatients undergoing surgery are considered to be at high risk of adverse outcomes?
Approximately 15% of total hospital inpatients undergoing surgery, which amounts to around 250,000 patients, can be considered to be at high risk of adverse outcomes during their procedure.
48
Why is minimizing the risk associated with surgical procedures important?
Minimizing the risk associated with surgical procedures is vital to improve outcomes because high-risk patients account for 80% of deaths after surgery. The presence of any comorbidity increases the risk, and therefore, risk assessment plays a crucial role in improving patient outcomes. It is also important for comparative audit purposes, such as the National Emergency Laparotomy Audit (NELA) and the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) studies.
49
What are some challenges associated with existing risk assessment systems?
Existing risk assessment systems present challenges. Simple scales, like the American Society of Anesthesiologists (ASA) grading system, can be subject to varied interpretation among experienced medical assessors. On the other hand, more complex systems, such as the physiological and operative severity score for enumeration of mortality and morbidity (POSSUM), are often too complex for daily clinical use or have a retrospective element that limits their reliability in preoperative risk assessment.
50
How can coexisting diseases complicate surgical procedures?
Coexisting diseases can complicate even simple operations and increase morbidity and mortality. For example, a patient with a heart transplant who needs to undergo surgery for a cholecystectomy may face increased risks. The level of care required for such patients needs to be anticipated, and consideration must be given to transferring them to units with appropriate facilities. Additionally, expertise is needed to advise on preoperative optimization and perioperative management of individual comorbidities.
51
Why is it important to repeatedly assess high-risk patients throughout their hospital stay?
It is important to repeatedly assess high-risk patients throughout their hospital stay in order to minimize the risk of developing complications. While the concept of a "high-risk" patient is generally understood, it is crucial to recognize the specific factors contributing to that perceived risk and continuously reassess these patients to ensure appropriate care and intervention.
52
What is the metabolic response to injury?
The metabolic response to injury refers to the physiological changes that occur in the body following major injury, surgery, or severe infection. It occurs in two phases known as the "ebb and flow" phases. During the ebb phase, which lasts 24-48 hours, there is a neuroendocrine response to tissue injury and hypovolemia. Energy stores are mobilized, glucose concentration increases, and there is an increase in lipolysis. In the flow phase, which occurs after the initial phase, there is an increased metabolic rate and muscle catabolism. Protein catabolism affects skeletal muscle, and there is an increase in proteolysis and urinary excretion of nitrogen and creatinine.
53
What are some effects of the metabolic response to injury on glutamine?
The metabolic response to injury can affect glutamine in several ways. Intramuscular glutamine concentration is decreased due to increased efflux and possibly decreased de novo synthesis. Glutamine is an important fuel for immune cells, a precursor for glutathione (a free radical scavenger), and plays a role in nitric oxide metabolism and maintaining the gut mucosal barrier. After injury, the levels of glutamine may be compromised.
54
What is insulin resistance after injury?
Insulin resistance after injury refers to the reduced response of the body to insulin's anabolic effects. It can result in increased hepatic glucose production, lipolysis, and net efflux of amino acids from skeletal muscle. Insulin resistance is characterized by elevated plasma glucose and insulin concentrations that are inhibitory in uninjured individuals. Glucose uptake into skeletal muscle is also reduced, primarily due to impaired glucose storage rather than oxidation. Insulin resistance may be partly influenced by counter-regulatory hormones such as cortisol, adrenaline, and glucagon, as well as pro-inflammatory cytokines.
55
Which pro-inflammatory cytokines are correlated with insulin resistance?
Pro-inflammatory cytokines such as IL-6 in cancer patients, IL-1 in endotoxemia, and TNF in diabetes and obesity have been found to be correlated with the degree of insulin resistance. These cytokines can modulate insulin sensitivity and contribute to the development of insulin resistance in injured or septic patients.
56
What are the mediators involved in protein metabolism during the injury response?
During the injury response, there are mediators involved in protein metabolism. These include the induction of increased hepatic synthesis (IL-6 induced), increased microvascular permeability, raised plasma concentration of fibrinogen and C-reactive protein, and a decrease in plasma albumin concentration.
57
What are some counter-regulatory hormones involved in the injury response?
Some counter-regulatory hormones involved in the injury response are catecholamines (adrenaline), cortisol, glucagon, and antidiuretic hormone.
58
What are some pro-inflammatory cytokines involved in the injury response?
Some pro-inflammatory cytokines involved in the injury response are TNF-α, IL-1β, IL-2, IL-6, and IL-8. These cytokines mimic certain responses, but their plasma levels are not universally linked to injury, indicating their autocrine/paracrine function rather than endocrine function.
59
What are some medical disorders associated with obesity?
Obesity increases the likelihood of associated medical disorders such as ischaemic heart disease (especially central obesity), hypertension, oesophageal reflux, diabetes, obstructive sleep apnoea (OSA), osteoarthrosis, gallstones, varicose veins, and haemorrhoids.
60
What is the normal range for BMI?
The normal range for BMI is 20-25 kg/m^2.
61
How is obesity defined based on BMI?
Obesity is defined as a greater than 20% increase over the ideal body weight, which equates to a BMI over 30 kg/m^2.
62
What is considered morbid obesity?
A patient with a BMI over 35 kg/m^2 can be considered morbidly obese.
63
What is the STOP-BANG questionnaire used for?
The STOP-BANG questionnaire is a screening tool used to identify predictive factors for OSA. A value of 5 or more indicates the likely presence of OSA.
63
What is metabolic syndrome?
Metabolic syndrome is a collection of symptoms including central obesity, insulin resistance, dyslipidaemia, and hypertension. It significantly increases perioperative cardiac risk.
64
What is the impact of obesity on OSA (obstructive sleep apnoea)?
OSA is frequently undiagnosed but present in 10-20% of morbidly obese patients. If untreated, it can lead to heart failure and pulmonary hypertension. Predictors of OSA include male gender, older age, diabetes, hypertension, snoring, and large collar size.
65
What is recommended for obese patients requiring elective surgery?
For obese patients requiring elective surgery, preoperative weight loss should be recommended.
66
How is "elderly" defined in a social context?
In a social context, "elderly" refers to all individuals over the age of 65.
66
What challenges are faced in assessing functional capacity in immobile, morbidly obese patients?
In immobile, morbidly obese patients, many functional assessments, such as the shuttle walk test, may not be possible.
67
What is polypharmacy?
Polypharmacy is defined as the use of five or more medications regularly. It is common in the elderly patient population.
68
What is the purpose of audit in patient care?
The purpose of audit in patient care is to improve the care of patients by establishing a standard, identifying areas for improvement, implementing improvements, and evaluating the effects of implementation. It can also involve contributing data to national databases established by surgical specialty associations.
69
What are the two types of tests performed in preoperative assessment clinics?
The two types of tests performed in preoperative assessment clinics are relatively static tests, such as resting ECG or resting echocardiography, and dynamic (stressed) tests, such as exercise ECG or stress echocardiography.
70
What does cardiopulmonary exercise testing (CPET) assess?
Cardiopulmonary exercise testing (CPET) assesses the patient's cardiorespiratory system as a whole by progressively stressing them with a standardized test. It quantifies the patient's ability to respond to the metabolic demands of major surgery.
71
What does the anaerobic threshold measure in CPET?
The anaerobic threshold is measured in CPET and is used to triage patients into a perioperative care package appropriate for their degree of risk. An anaerobic threshold of at least 11ml/kg/min is considered necessary for major elective surgery.
72
What factors, other than cardiorespiratory reserve, are important in perioperative risk assessment?
In addition to cardiorespiratory reserve, factors such as age, nature of surgery, physiological systems, coexisting diseases (renal disease, neurological disease), immunological factors, haematological factors, endocrinological factors, hepatic function, and nutritional considerations are important in perioperative risk assessment.
73
What is the purpose of enhanced recovery after surgery (ERAS) programmes?
Enhanced recovery after surgery (ERAS) programmes, initially developed in colorectal patients, are used across the surgical spectrum to improve patient outcomes, length of stay, and patient satisfaction.
74
What are the basic principles of ERAS programmes?
ERAS programmes are packages of care that describe the patient journey from the decision to operate to discharge from the hospital after surgery. Adhering to all aspects of the package is crucial for success.
75
Why is CPET used in the preoperative phase?
CPET is used to quantify the risk associated with the surgery. It helps in informing discussions with the patient and planning postoperative requirements.
76
What is the goal of the preoperative phase in enhanced recovery programmes?
The goal of the preoperative phase is to ensure that patients are in the best possible condition for a smooth and quick recovery from their upcoming surgery. This involves accurately assessing and modifying the patient's comorbidities, controlling conditions like diabetes, cardiovascular and pulmonary disease, treating anemia, and encouraging smoking cessation.
77
What measures can be taken to promote early return of gut function in the postoperative phase?
Allowing oral intake of fluids and diet immediately after surgery, combined with measures to prevent postoperative nausea and vomiting, leads to early return of gut function. Early cessation of IV fluids and removal of other tubes also contribute to this goal.
77
What should be considered in terms of medication during the operative phase?
Medication to control postoperative nausea and vomiting is given at the time of induction. Intraoperative care includes prevention of hypothermia, goal-directed fluid therapy, and judicious use of vasopressors. Minimally invasive techniques are preferred, such as short and transverse incisions, avoiding postoperative drains and naso-gastric tubes, and considering local blocks instead of epidural analgesia.
78
What is the goal of the postoperative phase in enhanced recovery programmes?
The goal of the postoperative phase is to restore the patient's normal function as soon as possible. Daily goals for mobilization and tube removal should be set and met. Good pain relief should aim at restoring function rather than eliminating all pain.
79
What should be considered in terms of pain relief in the postoperative phase?
Good pain relief should prioritize restoration of function, such as deep breathing, coughing, and moving. Minimizing the use of opioid medication and utilizing other analgesics and local anesthetic techniques is important.
80
What should be done when a patient "falls off" the enhanced recovery pathway?
When a patient "falls off" the enhanced recovery pathway, they need to be managed differently, especially regarding fluid therapy, which should be used in a resuscitative manner rather than a restrictive manner.
81
What is the prevalence of diabetes mellitus in the UK population?
Diabetes now affects 4-5% of the UK population.
82
What are the risks of surgery for diabetic patients?
Even simple surgeries can be hazardous for diabetic patients. Surgical trauma can lead to hyperglycemia and ketoacidosis, poorly controlled diabetes accelerates catabolism and delays healing, and insulin and sulphonylureas can cause severe hypoglycemia.
83
What is the utility of preoperative glycated hemoglobin (HbA1c) values?
Good preoperative glycemic control, as directed by HbA1c concentrations, is associated with decreased morbidity and mortality, as well as shorter hospital stays.
84
What is the target HbA1c concentration for diabetic patients?
The target HbA1c concentration for diabetic patients is 6.5-7.5% or 48-58mmol/mol.
85
What is the association between HbA1c values and mortality in cardiac surgery?
HbA1c values of >8.6% or 70mmol/mol are associated with four-fold mortality in cardiac surgery.
86
What is the non-diabetic reference range for HbA1c values?
The non-diabetic reference range for HbA1c values is 4.0-6.0% or 20-42mmol/mol.
87
What HbA1c value is considered diagnostic of diabetes mellitus?
A diagnostic HbA1c value for diabetes mellitus is >6.5% or 48mmol/mol on repeated testing.
88
What HbA1c range indicates a high risk of diabetes?
A high risk of diabetes is indicated by HbA1c values in the range of 6.0-6.4% or 42-47mmol/mol.
89
What is the hallmark of poorly treated type 1 diabetes?
Diabetic ketoacidosis (DKA) is the hallmark of poorly treated type 1 diabetes.
90
What should be included in the simultaneous resuscitation and investigation of DKA patients?
Simultaneous resuscitation and investigation of DKA patients should include a 12-lead ECG, bacteriological cultures of appropriate fluids, cardiac enzyme determination, and ABG analysis.
90
What can cause DKA to occur in type 2 diabetes patients?
DKA can occur in type 2 diabetes patients when they are relatively insulin deficient and experience an intercurrent illness that stimulates counter-regulatory hormone secretion, especially glucagon.
91
What is the mortality rate of DKA?
DKA carries a mortality rate of 5-10% (50% in elderly patients with DKA precipitated by myocardial infarction or infection).
92
What are the consequences of raised circulating ketones in DKA?
The main consequences of raised circulating ketones in DKA are acidosis (both extracellular and intracellular), diuresis leading to electrolyte losses and dehydration, and nausea caused by direct stimulation of the chemoreceptor trigger zone in the medulla.
93
What is the initial treatment for DKA?
The initial treatment for DKA includes intravenous saline and insulin.
94
What fluid should be used for DKA patients?
0.9% saline (containing potassium when appropriate) is the fluid of choice for DKA patients.
95
When should Dextrose 5% be substituted for fluid in DKA patients?
Dextrose 5% should be substituted when plasma glucose has fallen to 10-14mmol/L to prevent hypoglycemia.
96
What is the difference between DKA and hyperosmolar hyperglycemic state (HHS)?
DKA is characterized by high ketone levels and metabolic acidosis, while HHS is distinguished by the absence of high ketone levels and metabolic acidosis.
97
What complications can occur in HHS?
Complications of HHS include thrombotic events such as stroke, peripheral arterial occlusion, deep vein thrombosis, and pulmonary embolism, due to increased blood viscosity.
98
What is lactic acidosis and when does it occur in diabetes mellitus?
Lactic acidosis is generated rapidly during tissue anoxia or when liver gluconeogenesis is impaired. In diabetes mellitus, it is a rare but fatal complication of biguanides (phenformin, metformin) that inhibit gluconeogenesis.
99
What are the treatment options for lactic acidosis?
Treatment options for lactic acidosis include intravenous bicarbonate (although it may aggravate intracellular acidosis), forced ventilation to reduce carbon dioxide levels, and dialysis to clear lactate and H+ and correct any sodium overload from bicarbonate infusion.
100
What is the mortality rate for lactic acidosis?
The mortality rate for lactic acidosis is high (>30%) due to coexisting organ failures.
101
What are common factors that predispose to hypoglycemia?
Factors that predispose to hypoglycemia include accelerated insulin absorption, exercise, hot environmental conditions, unfavorable factors relating to insulin administration (such as administering it too early, too much, or inadequate food intake), alcohol consumption, weight loss, loss of counter-regulatory hormones (Addison's disease, hypothyroidism, hypopituitarism, blunted glucagon secretion in long-standing type 1 diabetes), intestinal malabsorption, and renal failure (impaired insulin clearance).
102
What are the clinical events as blood glucose falls?
As blood glucose falls, the following events occur: at ~3.8mmol/L, adrenaline and glucagon secretion increase; at ~3.0mmol/L, hypoglycemic symptoms onset (note: some patients may have hypoglycemic unawareness); at ~2.8mmol/L, neuroglycopenia and cognitive impairment occur; and at <1.0mmol/L, coma can occur.
103
What is the recommended treatment if a patient is unresponsive to initial crystalloid therapy?
If a patient is unresponsive to initial crystalloid therapy, they should receive a blood transfusion.
104
When should tranexamic acid be administered in severely injured patients?
Tranexamic acid should be administered within 3 hours of injury in severely injured patients.
105
How is tranexamic acid administered in the field and in the hospital?
In the field, tranexamic acid is bolused, and in the hospital, a follow-up infusion is given over 8 hours.
106
What is the risk for severely injured trauma patients?
Severely injured trauma patients are at risk for coagulopathy, which can be further exacerbated by resuscitative measures.
107
What can mitigate the cycle of ongoing bleeding and further resuscitation in severely injured patients?
The use of massive transfusion protocols with blood components administered at predefined low ratios can mitigate the cycle of ongoing bleeding and further resuscitation in severely injured patients.
108
What tools can be used to avoid unnecessary imaging of the cervical spine in trauma patients?
The NEXUS (National Emergency X-Radiography Utilization Study) and Canadian C-Spine Rule can be used to avoid unnecessary imaging of the cervical spine in trauma patients.
109
What role does the team leader play in a trauma team?
The team leader supervises, checks, and directs the assessment, assigns roles and tasks to team members, and ensures a smooth transition from the prehospital to hospital environment.
109
What does the acronym MIST stand for in trauma assessment?
MIST stands for Mechanism (and time) of injury, Injuries found and suspected, Symptoms and Signs, and Treatment initiated.
110
What training should the team leader have?
The team leader should be trained in ATLS (Advanced Trauma Life Support) and the basics of medical team management.
111
What is the recommended size of the skin incision for a cricothyroidotomy?
The recommended size of the skin incision for a cricothyroidotomy is 2-3 cm vertical.
112
What caution should be taken during a cricothyroidotomy?
During a cricothyroidotomy, it is important not to cut or remove the cricoid and/or thyroid cartilages.
113
What do UK guidelines recommend for the insertion of a cricothyroidotomy tube?
UK guidelines recommend the use of a bougie to aid insertion into the trachea for a cricothyroidotomy.
114
What is the preferred site for adult intraosseous (IO) access?
The proximal humerus is the preferred site for adult IO access.
115
What preparation should be done if prehospital information suggests that the patient will require a definitive airway?
If prehospital information suggests that the patient will require a definitive airway, it may be wise to draw up appropriate drugs for sedation and drug-assisted intubation before the patient arrives.
116
How is massive transfusion defined?
Massive transfusion is defined as receiving more than 10 units of packed red blood cells (pRBC) in 24 hours or more than 4 units in 1 hour.
116
When should early resuscitation with blood and blood products be considered?
Early resuscitation with blood and blood products should be considered in patients with evidence of class III and IV hemorrhage.
117
What tools can be helpful in determining clotting deficiency and appropriate blood components?
Thromboelastography (TEG) and Rotational thromboelastometry (ROTEM) can be helpful in determining clotting deficiency and appropriate blood components to correct the deficiency.
117
What does the provider course emphasize regarding coagulopathy?
The provider course emphasizes recognition and reversal of coagulopathy secondary to medication.
118
How can early administration of blood products at a low ratio be beneficial?
Administering blood products at a low ratio of packed red blood cells to plasma and platelets can help prevent the development of coagulopathy and thrombocytopenia.
119
What type of fluids are commonly used for initial resuscitation in trauma cases?
Warm fluids, typically 1 liter, are commonly used for initial resuscitation in trauma cases.
120
What is the recommended administration of tranexamic acid in the prehospital setting for severely injured patients?
Tranexamic acid is typically administered as a 1 gram dose over 10 minutes in the field, followed by a 1 gram dose over 8 hours.
121
What are the advantages of IO access in the proximal humerus?
IO access in the proximal humerus is less painful and provides better circulation time.
122
What responsibilities does the team leader have in managing external hemorrhage and performing adjuncts?
The team leader ensures control of external hemorrhage and determines the timing for adjuncts such as chest x-ray, pelvic x-ray, FAST, and/or diagnostic peritoneal lavage (DPL).
123
How can tension pneumothorax be diagnosed when ultrasound is available?
Tension pneumothorax can be diagnosed using an extended FAST (eFAST) examination when ultrasound is available.
123
What is the algorithm for managing traumatic circulatory arrest?
The algorithm for traumatic circulatory arrest outlines the step-by-step approach to resuscitation in such cases.
124
What is the medical management approach for aortic rupture?
The medical management of aortic rupture involves the use of beta-blockers.
125
What is the recommended site for needle thoracocentesis in adults?
In adults, needle thoracocentesis is performed in the 5th intercostal space, just anterior to the mid-axillary line.
126
Where is needle thoracocentesis performed in pediatric patients?
In pediatric patients, needle thoracocentesis is performed in the 2nd intercostal space.
127
What is an alternative approach for emergency decompression of tension pneumothorax?
Finger thoracostomy is an alternative approach for emergency decompression of tension pneumothorax.
128
What is the recommended chest tube size for an acute haemothorax?
An acute haemothorax that is large enough to appear on a chest x-ray may be treated with a 28-32 French gauge chest tube (previously 36-40 recommended).
129
How can the likelihood of rupture of traumatic aortic aneurysm be decreased?
Heart rate and blood pressure control, achieved by using short-acting beta-blockers, can decrease the likelihood of rupture of traumatic aortic aneurysm.
130
When should open thoracotomy be considered?
Open thoracotomy should be considered when it will benefit the patient, and arrangements for safe transport to a skilled surgical facility should be made without delay.
131
Is palpation of the prostate gland a reliable sign of urethral injury?
No, palpation of the prostate gland is not a reliable sign of urethral injury.
132
What should the team leader do regarding the application of a pelvic binder?
The team leader must recognize the need to apply a pelvic binder and ensure its correct placement while continuing to evaluate the patient's response to resuscitation.
132
What should be considered for seizure prevention in patients with traumatic brain injury?
Seizure prophylaxis should be considered in patients with traumatic brain injury.
133
What are the mechanisms of blast injury from explosive devices?
Blast injury from explosive devices can occur through penetrating fragment wounds, blunt injuries from being thrown or struck by projectiles, and additional injuries to the tympanic membranes, lungs, and bowel related to blast overpressure for patients close to the source of the explosion.
134
What evidence-based treatment guidelines are introduced for traumatic brain injury?
Evidence-based treatment guidelines, including the BTF 4th edition TBI guidelines and the ACS TQIP best practices in the management of TBI, are introduced.
135
What is the recommended SBP range for patients with traumatic brain injury?
For patients 50 to 69 years old, maintaining SBP at >=100 mm Hg is recommended. For patients 15 to 49 years old or >70 years old, maintaining SBP at >=110 mm Hg is recommended. This is considered to decrease mortality and improve outcomes.
136
What is the evidence-based guideline regarding the use of seizure prophylaxis?
Seizure prophylaxis is introduced with evidence-based guideline level II A.
137
What medication is recommended to decrease the incidence of early post-traumatic seizures (PTS)?
Phenytoin is recommended to decrease the incidence of early PTS (within 7 days of injury).
137
Which medications are NOT recommended for late post-traumatic seizures (PTS)?
Phenytoin and Valproate are NOT recommended for late PTS.
138
Are early PTS associated with worse outcomes?
No, early PTS have not been associated with worse outcomes.
139
What replaces spinal immobilization?
Restriction Of Spinal Motion (ROSM) replaces spinal immobilization.
140
Are bilateral femur fractures a risk factor for complications and death?
Yes, bilateral femur fractures are a risk factor for complications and death.
141
What are the risks associated with bilateral femur fractures?
Patients with bilateral femur fractures are at higher risk for significant blood loss, severe associated injuries, pulmonary complications, multiple organ failure, and death.
141
What may be required to apply a traction splint?
More than one team member may be required to apply a traction splint.
142
Why is a complete secondary survey important in patients with bilateral femur fractures?
A complete secondary survey should be performed to ensure that injuries are not overlooked, as occult injuries are particularly common in patients with a depressed level of consciousness.
143
What is the recommended site for needle decompression in children according to PECARN criteria?
According to PECARN criteria, there is no change in the site for needle decompression in children, which is the 2nd intercostal space mid-clavicular line.
143
What is the recommended fluid resuscitation for patients with deep partial and full-thickness burns involving > 20% BSA?
Fluid resuscitation for patients with deep partial and full-thickness burns involving > 20% BSA is based on the Parkland formula: 2ml/kg/% TBSA for adults and 3ml/kg/% TBSA for pediatric patients. The fluid is administered as 50% in the first 8 hours after the burn and 50% in the subsequent 16 hours. Fluid should be titrated based on the adequacy of urine output, and fluid boluses should be avoided unless the patient is hypotensive.
144
When should packed red blood cells be considered in fluid resuscitation?
Packed red blood cells should be considered after the second or third bolus in fluid resuscitation.
145
What is the recommended fluid resuscitation for pediatric patients?
The recommended fluid resuscitation for pediatric patients is a 20ml/kg bolus followed by one or two additional boluses. Packed red blood cells (PRBCs) should be considered after the second or third bolus.
145
What is damage control resuscitation in children?
Damage control resuscitation in children refers to a strategy that limits crystalloid resuscitation and includes a 20 ml/kg bolus, 10-20 ml/kg of PRBCs, and 10-20 ml/kg of fresh frozen plasma and platelets as part of a massive transfusion protocol. It is important to note that no survival advantage has been demonstrated in the literature.
146
What should an adult trauma team provide when caring for injured children?
An adult trauma team caring for injured children should provide a trauma team leader with experience in the care of injured patients and familiarity with local medical resources available for pediatric care. They should also have a provider with basic airway management skills, access to providers with advanced pediatric airway skills, ability to provide pediatric vascular access via percutaneous or intraosseous routes, knowledge of pediatric fluid resuscitation, appropriate equipment sizes for different ages, strict attention to drug doses, early involvement of a surgeon with pediatric expertise (preferably a pediatric surgeon), and knowledge and access to available pediatric resources such as pediatricians and family medicine practitioners. Inclusion of the child's family during the emergency department resuscitation and throughout the child's hospital stay is also important.
147
Why is it important to debrief after a pediatric trauma case?
It is particularly important to debrief after a pediatric trauma case because team members and others present in the resuscitation room may be deeply affected by poor outcomes for children. Appropriate mental health resources should be available.
148
How do pre-existing conditions impact morbidity and mortality in pelvic fractures?
In pelvic fractures, mortality is 4 times higher in older patients compared to younger patients. There is also a higher need for blood transfusion even with stable fractures. Additionally, older patients experience longer hospital stays and have a lower likelihood of returning to independent lifestyles.
149
Which pre-existing medical conditions are associated with a higher risk of mortality?
Patients with cirrhosis, congenital coagulopathy, chronic obstructive pulmonary disease, ischemic heart disease, or diabetes mellitus have a twice as likely chance of dying compared to those without these conditions.
150
Why might early activation of the trauma team be required for elderly patients who do not meet traditional criteria for activation?
Elderly patients, even with seemingly simple injuries, such as an open tibia fracture, may quickly deteriorate and become life-threatening. Therefore, early activation of the trauma team may be necessary.
151
How can cardiac drugs, such as beta blockers, affect the interpretation of vital signs in hemorrhage cases?
Cardiac drugs, like beta blockers, can blunt the typical physiological response to hemorrhage, making it difficult to interpret traditional vital signs. The team member responsible for managing circulation must promptly notify the team leader of any minor changes in physiological parameters and assess for perfusion status to identify and manage catastrophic hemorrhage.
152
What is the primary mission of the trauma team when dealing with an injured pregnant patient?
Although there are two patients (the mother and the fetus), the trauma team's primary mission is to ensure optimal resuscitation of the mother.
153
What is the recommended approach for communication within the trauma team?
The trauma team can utilize the ABC-SBAR template to facilitate effective communication.
154
What indication suggests amniotic fluid leak?
A vaginal fluid pH of > 4.5 is an indication of amniotic fluid leak.
155
What should the trauma team leader do when the level of care exceeds the capabilities of the treating facility?
In such cases, the trauma team leader must work quickly and efficiently to initiate and complete transfer to definitive care.
156
What is the issue with performing CT scans at the primary hospital for trauma patients?
A significant portion of trauma patients transferred to regional trauma centers undergo CT scanning at the primary hospital, which leads to delays in transfer and redundant scans upon arrival at the trauma center.
157
What should the team leader prioritize in preparation for transfer to definitive care?
The team leader should ensure rapid preparation for transfer by limiting tests, particularly CT scans, to those needed to treat immediately life-threatening conditions that can be managed by specialists and facilities at hand.
