Barash Chapter 53- trauma Flashcards
The general approach to evaluation Acute trauma victim has three components:
Rapid overview: seconds, is pt stable, unstable, dying or dead ?
Primary survey: ABC, Neuro assessment, external injury ? TEE= Myo contractiliy, Volume, pericardial effusion, essential labs
Secondary survey: Detailed evaluation of each anatomic region, FAST( focused assessment with sonography ) , CT ( MDCT) , MRI, pulmonary
Why do a tertiary survey within 24 hours after trauma?
To potentially diagnose missed injuries during the initial survey
What are the difficult trauma related reasons for tracheal intubation?
Maxillofacial,
Neck
chest injury
cervicofacial burns.
Signs of upper and lower airway obstruction
Dyspnea cyanosis hoarseness strider dysphonia Subcutaneous emphysema hemoptysis
What physical findings may be present before symptom indicating airway obstruction and requiring specialized technique to secure airway?
Cervical venous distention ,
crepitation
Tracheal tug and/or deviation
Jugular venous distention maybe present before symptoms appear
What are the initial steps in airway management
Chin lift
jaw thrust
Clearance of the oral pharynx placement of an oral pharyngeal and nasal pharyngeal airway
in inadequately breathing patients Ventilation with his self inflating bag
In what type of brain injury is blind passage of a nasal pharyngeal airway or NG or nasotracheal tube avoided
Basilar skull fracture because the air we may enter the anterior cranial fossa
True or false airway assessment must include a rapid examination of the interior neck for feasibility of access to the cricothyroid Membrane
True
Why is tracheostomy not desirable in the initial phase compared to cricothyrotomy
Because it takes longer to perform
It requires Neck extension which may cause or exacerbate cord trauma in patients with cervical spine injuries
If a cricothyroitomy is in place for more than 2 to 3 days what should you do?
Conversion to a tracheostomy to prevent Laryngeal damage
What are the contraindications to cricothyrotomy
Younger than 12 years ( permanent laryngeal damage)
and suspected Laryngeal and Trauma( uncorrected airway obstruction)
Why does rapid sequence induction with cricoid Pressure in Trauma patients necessary?
I assume they’re full stomach
No time to reduce gastric content pharmacologically
Awake intubation with sedation and topical anesthesia as well can be done
What is the anesthesia approach for head, open eye, and contained major vessel injuries ?(3)
- Ensure adequate oxygenation in ventilation
- Deep Anesthesia
- Profound muscle relaxation before airway manipulation= they don’t buck cough or go hypertensive»_space; less Intracranial, intraocular, intravascular pressure elevation.
In head,open eye, or contained major vessel injuries, what can happen if you allow the patient to cough , buck or go hypertensive
- Herniation of the brain
- extrusion of eye contents
- dislodgment of a hemostatic clot from an injured vessel
If the patient is not hemodynamically compromised and has a head , open eye , or contained major vessel injuries how do you perform your anesthetic sequence
1.Preoxygenation and opioid loading
2.Large doses of IV anesthetic and muscle relaxant
Watch for :
Low BP»_space; ICP, Low CPP,
Is ketamine still contraindicated in patients with head or open eye injury?
Yes! Because of its potential to increase Intracranial and intra occular Pressure they used to avoid ketamine but because it maintains the systemic blood pressure it does not cause any big increase in ICP or IOP so nowadays it is used in those type of patients
Do use ketamine in patients with contained major vessel injury ?
No ! because by increasing systemic blood pressure it can cause dislodgment of a hemostatic plug initiating bleeding in vascular injuries
Can sux be used in head , open eye or contained major vessel injury ?
Yes ! As long as fasciculation is inhibited by prior with administration of adequate dose of nondepolarizing muscle relaxant
Or
just use ROC at 1.2 to 1.5 mg/kg = same onset as Sux of 60 seconds but will lasts 2 hrs
When comparing video laryngoscopy to direct laryngoscopy what is a disadvantage
Video shows longer intubation time resulting in decline of oxygen saturation to 80% or less in a lot of patients!
Most common cause of cervical spine injuries
- High speed MVA
- Falls
- Diving
- Gunshot
- Head injuries especially if low GSC = c spine injury
What are the complications associated with the C collar:
- Pressure ulcer
- Elevated ICP
- Compromise central venous access
- Airway management challenges if reintubation is needed
* once you establish airway r/o c- spine injury to clear the neck as soon as possible
What happens to blunt trauma induced C spine injury after admission
Worsening neurological deficits either because of delay in diagnosis or improper C-spine protection and/or manipulation
What indicates a low probability of C - spine injury
- No posterior midline neck tenderness and no focal neurologic deficit
- Normal level of alertness
- No evidence of intoxication
- No painful distracting injury
What is the Canadian C-spine rule for radiography after Trauma (which identifies Low risk patients)
- Is there any high risk factor mandating radiography :
≥ 65, dangerous mechanism , extremity paresthesia
2.Are there low risk factors that permit safe evaluation of the range of motion of the neck :
Sitting and Walking in ED, rear-end accident only , no immediate neck pain, no C spine midline tenderness .
- Can the patient rotate the neck laterally left and right for 45° in each direction without pain