ANESTHESIA FOR TRAUMA Flashcards
define blunt trauma
collision between two objects (impact without broken skin)
* momentum is conserved, but kinetic energy is not, and does work on the objects in the form of deformation or conglomeration
define penetrating trauma
object pierces skin and enters body creating a wound
- missile decelerates transmitting kinetic energy to surrounding tissues
- because kinetic energy = 1/2 mv^2, VELOCITY is more important than mass in determining the amount of damage done
what is the primary survey of trauma?
KEEP CALM and ABCDE
- Airway maintenance w/ c-spine protection
- Breathing and ventilation
- Circulation and hemorrhage control
- Disability/neurologic assessment
- Exposure and environmental control
what are the pros and cons of propofol?
- pros: provides more muscles relaxation if need to intubate without use of NMBDs
- cons: profound cardiac depressant; severe reductions in systemic vascular resistance
what are the pros and cons of ketamine?
- pros: maintains BP in severely hypovolemic patients; increases sympathetic outflow; can produce sedation without respiratory depression
- cons: direct myocardial depressant; may increase ICP (contraindicated in traumatic brain injury), can produce vivid hallucinations (many trauma patients are already intoxicated)
what are the pros and cons of etomidate?
- pros: rapid onset, short duration of action; cardiovascular stable; may be particularly useful in traumatic brain injury where eve a single episode of hypotension is associated with poorer outcomes
- cons: does not provide good muscle relaxation by itself; inhibition of cortisol secretion (via 11-beta hydoxylase inhibition)
how should circulation and hemorrhage control be approached?
- 2 large bore PIVs (≥ 16g) vs. central access
- hypovolemic shock: STOP THE BLEEDING!
* thoracic cavity
* abdominal cavity
* pelvic fracture
* long bones
* external bleeding - tourniquets
- 2L of warm isotonic fluid, assess response, the BLOOD
how should pupils be assessed in trauma?
- pinpoint or blown?
* equal or unequal?
in what instances can pupil assessment be unreliable?
- in the presence of certain intoxicants
* in the presence of facial or orbital trauma
how is best eye response (E) graded on glasgow coma scale?
4 = spontaneous – open with blinking at baseline 3 = opens to verbal command, speech, or shout 2 = opens to pain, not applied to face 1 = none
how is best verbal response (V) graded on glasgow coma scale?
5 = oriented 4 = confused conversation, but able to answer questions 3 = inappropriate responses, words discernible 2 = incomprehensible speech 1 = none
how is best motor response (M) graded on glasgow coma scale?
6 = obeys commands for movement 5 = purposeful movement to painful stimulus 4 = withdraws from pain 3 = abnormal (spastic) flexion, decorticate posture 2 = extensor (rigid) response, decerebrate posture 1 = none
at what glasgow coma scale score is intubation indicated?
“less than 8 = intubate”
what is the approach for exposure and environmental control?
- complete removal of patient’s clothing
- warming of the OR
- bair huggers wherever possible
- warming of all fluids and good products
- temperature monitoring: esophageal or bladder
hypothermia –> coagulopathy –> acidosis –> hypothermia…
what are the advantages of FAST (Focused Abdominal Sonogram for Trauma)?
- faster than CT (2-5min)
- cheaper than CT
- no ionizing radiation
- no transport to CT scanner
- easy to rapidly repeat if patient decompensates
what position should patient be in for FAST?
supine – allows for free fluid to accumulate in dependent areas
* full bladder ideally for pelvic view
what are the transducer positions for FAST?
pericardial, right upper quadrant, left upper quadrant, pelvis
what is the protocol for penetrating chest wounds following Echo?
- positive echo –OR
- equivocal/ambiguous echo – pericardial window
- negative echo – observe
describe DPL (diagnostic peritoneal lavage)
- instrumental in diagnosing unstable blunt abdominal trauma
- small infraumbilical incision to place catheter
- instill 1L NS and allow to drain by gravity
- need return of 200-300ml for accurate interpretation
how is a positive DPL interpreted ?
- 100,000 red cells/µL
- 500 white cells/µL
- 175 units amylase/dL
- bacteria on Gram-stained smear
- bile
- food particles
how is an intermediate DPL interpreted?
- pink fluid on free aspiration
- 50,000-100,000 red cells/µL in blunt trauma
- 100-500 white cells/µL
- 75-175 units amylase/dL
how is a negative DPL interpreted?
- clear aspirate
*
describe damage control surgery
- arresting surgical hemorrhage (abdominal packing, interventional radiology and balloon tamponade)
- containing GI spillage
- temporary abdominal closure
- definitive repair and possible closure 6-48hr after initial injury
describe damage control resuscitation
- early blood product transfusion
- restoration of blood volume and physiologic/hematologic stability
- stop hemorrhage, restore blood volume, correct coagulopathy, acidosis, and hypothermia
- avoid physiologic exhaustion and metabolic failure
